Learning to Listen.

Abstract

I felt a small thrill looking at the rows of short, starched coats beside me. “Keep your white coat thin so patients' stories may touch you,” instructed our welcome to medical school speaker. It was a thoughtful sentiment, but not one that particularly resonated with me at the time.And so, I progressed. From preclinical, to clinical, to residency training, I examined, prescribed, and sutured. But mostly, I listened. Increasingly, the symptoms and how they fit into diagnostic and treatment flow charts clicked neatly into place. Each specialty had its bread-and-butter complaints. My efficiency improved alongside my clinical confidence. And, I admit, the stories became more opaque. The person behind the pelvic pain in a 20-minute patient visit became quieter. I needed to collect information and focus so that I could triage, diagnose, and implement. I began practicing with an agenda, one that was well-intentioned, borne from time constraints. Lost in what was becoming routine, I slowly drifted away from the patient's experience.Then I had a patient with a surgical complication. An expected one, one specified in the consent form. But it haunted me. She haunted me. Weeks turned to months, and I found myself still waking early, thinking about her. As my husband dozed on next to me, I wondered what it might be like to manage spreadsheets rather than organs. I thought a lot about harm, consent, the risks of surgery. And about surgical training. About the lights so bright in the OR. About the attending who snapped when I wasn't prepping the patient quickly enough. About when I was frozen holding a foley, focused on managing an overwhelming panic about complications that could happen. I thought about the patient's tattoos, the small talk we had made before starting the case. Each time in the OR I wondered when I might harm. I did harm.How do you face yourself in the mirror when you know you have harmed someone? Can I trust myself again? Can others trust me? The next time I performed that same surgery, I pretended that the complication had never happened. Afterward I went to a call room and laid my head against the door, and closed my eyes. I obsessed over her postoperative course, hovering over vitals and hemoglobins.I became hypervigilant. I listened with renewed intensity, eager to not miss problems, eager to fix. I operated with fresh eyes and practiced more. I took more time with my patients and learned more about them. I thought more about how symptoms affected their lives. I thought more about how a surgery recovery would affect their work schedules. I thought about trying to breastfeed with incisions.Months later, I was working alone one weekend. The census was high and I was stretched thin. A girl on our list had a one-liner that was hard to forget. Her suffering and long-term ramifications were devastating. My role in her care was limited: I did not participate in her surgeries or manage her course. I knew her story, but I did not know her. Yet I found myself thinking of her while tucking into a dessert of toasted sweet meringue on a bed of tart raspberry purée. There was something so delightful, playful, frivolous even, about this dessert. It was the kind of thing any child would love. It felt so indulgent to be allowed this kind of joy that typifies youth. I thought, she should be playing and enjoying this kind of dessert.Driving through the forest that night, I was mesmerized by the tall pines, each perfectly coated with fresh snow. Drawn into wonder and natural beauty, I again thought of her and wondered, did my white coat get too thin?Then I became the patient in the gown. I fit perfectly into the little treatment flow chart boxes. Each step of care was medically and biologically sound, but my outcome also was not as expected. I would have made the same decisions as the clinician.There was no particular “ah-ha” moment for me. I started listening in earnest. Even in compressed patient time slots, I made room for patients to tell me how and why, not driven by fear now. The nuances of decision-making and counseling gradually gave more meaning to doctoring. I thought about patients and how my sense of responsibility and duty in medicine was tempered by factors outside of my control. I thought about patients, like myself, that do not respond as expected. About the progression of disease we believe should have responded or the cure we didn't predict. There is so much weight for us to hold. Now as I don my full-length white coat, I hope to keep it thin.