When you follow a doctor around and observe what she does at work, it’s termed “shadowing.” You are more than a shadow, though; a patient doesn’t look at a shadow with distrust or trust. But a patient looks at you and acknowledges you when he or she is answering a doctor’s questions. Like any person in a conversation with multiple people, the patient includes you even if you yourself don’t speak. A patient looks you up and down and asks you questions when the doctor steps out for a moment. And you smile back, and try to answer and ask questions back without being intrusive.
It’s an unequal scenario. You’re presumably healthy and just there to watch people come and present their problems; they’re there because something has been bothering them. She urinates too little too frequently; he can’t stop sleeping in; she wants to get pregnant but her husband is vacillating about it; he has pain when he lifts his right arm; his diabetes is getting out of control again; he has a common cold; she has an uncommon cold. While a patient narrates his or her problems to the doctor, glancing at me every once in a while, I try to make eye contact and strike a balance between smiling but also looking concerned. Time abroad has taught me that, at the very least, even a wordless crinkling of the eyes can form trust.
In some ways, you can hear more as a shadow than you might as the real doctor. While a doctor is busy coding conditions and medications onto the patient’s electronic medical record, clicking away on the keyboard, or taking the patient’s pulse, all you have to do is observe and listen. In this way, it’s hard not to catch things.
Most memorable was the time an Ethiopian man came in for a cold.
“It’s strange,” he says, smiling and sniffling. “In Ethiopia if I got sick I would go running. Running was my medicine. After one long run my sickness would be gone.”
He smiles more.
“Here, the sickness stays. It stays even after three days of running by the Charles. Why, I wonder?”
He is a new patient, and the doctor asks him questions about his life while performing a routine checkup—breath and lung sounds, heart rate, blood pressure, reflexes, ears. He moved here from Ethiopia a year ago; his family is back at home. He used to be a sociology professor. Here, he is a clerk at a convenience store. Parallel universes; and while we are checking out items at our local convenience stores, we probably only ever see one of them. I was humbled.
As the doctor looks inside his left ear, the patient says:
“Ah, that one has no hearing. A cadre shot his rifle right next to it 20 years ago. I guess it could have turned out worse, eh?” he chuckled.
The word “cadre” threw me off for a second, but my eyes widened as I registered this. How could they not? And yet his partial deafness wasn’t his primary complaint, it was just an event in his history. His primary complaint was a common cold, and so he was going to be okay, I suppose. Or as okay as you could be, leaving your home country just a year prior, in a new place with new customs and without your whole family. As he left, he wished me luck on my studies.
I’m not sure that this happens with every doctor—that patient details surface unbidden, or that the doctor herself even cares. With this doctor, she devotes swaths of time to each patient, always starting with conversation, never a blunt question-and-answer session. She remembers patients fondly, no matter how belligerent or even aggressive they might have been. She takes the “annoying” ones, the “strange” ones, the tired, poor, huddled masses. One woman pulls up an extensive Yahoo! Forum thread about IBS—from this thread she has wrangled bits of information she takes as fact: she must have so-and-so disease, she eats too much cocoa powder. The doctor listens. In the end she doesn’t broach the subject of the Yahoo! Forum thread, she gives her own medical assessment and advice—but the mere act of listening and acknowledging helps the patient. The patient is visibly calmer and happier at the end.
I attended a panel on the humanities and medicine recently, and one of the speakers from the Columbia Narrative Medicine program mentioned that her mentor had a policy of not taking notes while seeing a patient. She would go so far as to “sit on her hands” in order to refrain from taking notes, and instead just listen and engage in the conversation.
In our past week of EMT class, we’ve been learning how to do patient assessment. It turns out EMTs do not just show up at the scene, pull out oxygen masks or a stretcher, and start treating. When they are dispatched, they know very little about the reasons for dispatch or patient condition. Think of how little you can convey in an emergency 9-1-1 call, especially if you yourself didn’t see the accident happen. Thoroughly assessing the patient takes time, and even a kind of algorithm, in order to come out with successful treatment, transport decisions, and verbal or written reports. We were literally given a flowchart to follow in order from section to section and have acronyms within each section to remember what to ask, what to do, and in what order.
It is tempting, with this flowchart, to hold the flowchart in hand and study it while attempting to assess a patient (in our case right now, a mock patient). There is so much information to assess within the unrelenting ticking of time for any given emergency victim that it’s tempting to write stuff down. But we are cautioned to write as little down as possible. Pretend that the patient is spewing blood onto your gloves and you can’t touch a pen. Try to remember everything. Be able to adapt to asking follow-up questions even while following the flowchart. Analyze changes in vitals even as you ask more questions and continue the conversation. And make the patient feel comfortable enough to answer your questions, without promising them anything. It is a huge faux-pas to say, “Everything will be alright”—you don’t know that! You have to be objective but caring.
This particular skill set reminds me of something else I’ve spent oodles of time doing—reporting. In journalism, you can’t write every little thing down. You don’t always have the luxury of recording conversations. It’s best to get quotes right the first time, and you can’t be flippant about your facts. You have to probe to get answers that you want, but you can’t be too blunt or annoying about it. You have to adapt the way you ask questions for the person you are talking to. Just because you know a bunch of jargon, it doesn’t mean everyone else has to know it too. There is a delicate balance between intrepid, questioning reporter and soothing, conversational reporter that you have to traverse, which changes depending on where you are, how much time you have, and what you’re trying to find out. You have to direct the arc of the conversation without making it seem like you have a direction. You have to ask questions without referring to a pre-set list every five seconds. You can’t suffer bouts of time-outs to frantically write down everything the interviewee says and risk losing that precious eye contact for too long. And after the interview is over, you have to be able to parse the scribbles in your memory as well as the ones on your paper in order to construct a cohesive and useful narrative. What details do you include, and in what order? What news is most relevant and interesting for people to hear first? Like the “lede” in a news article, as a medical professional you need to make some order out of symptoms, for yourself and more importantly for whomever you are transferring the patient to. As our EMT instructor read over my mock patient narratives and pointed out what information was superfluous, what was lacking, and where I could be more concise, I had a flashback to sitting in a newsroom and discussing how to rearrange my words and thought process with one of the editors. Like in the objective process of news reporting, as an EMT it is important to file your judgments aside in the grander scope of attempting to convey factual and relevant reality. Who would have thought doctoring and reporting could be so similar?
Maybe not enough people think that. No career advisor has told me that medical schools value journalism experience. But shouldn’t they? It is hard to teach an aspiring doctor how to listen, how to filter information, how to ask the right questions at the right moments, how to convey information to another doctor, and how to construct an objective narrative. It is hard to sit an aspiring reporter down and teach him or her that as well. It is only the uncomfortable moments—that time you mildly harangued Drew Faust at midnight during a rainy power outage, or that time you racked your brain for what to ask Ted Kennedy while trying to not get visibly excited that you were interviewing a Kennedy, or that time you listened patiently to a young man complaining about the causal relation of university expansion to town rat infestations, or that time you pitched a story that you cared about in a way to make people who didn’t care about it suddenly realize they did—only those get you through to being competent. The most direct route is the circuitous one. Doctors get there the same way, I assume—by practice. But maybe practice can start early on, in other walks of life, beyond being the silent, smiling shadow in the corner. Maybe medical schools should parse applications for great storytellers. Maybe some already do? The art of telling a story is an interesting undercurrent that I never recognized in medicine, back in my non-pre-med days. This is ground that can’t be covered in physics, chemistry, organic chemistry, or biology. But it is an important science.
I remember when the doctor I shadowed had to leave to make a phone call, and told me I could look through the information for the upcoming patient appointments while I waited for her. Each tab in the electronic system contained a profile of a different patient, a compilation of medical facts to create a health biography. There were multiple authors—different doctors and referrals, some entries quoting the patients, some more descriptive, others dry. There were pages of prescription medications with factual explanations for why they were taken—schizophrenia, headaches, lupus, diabetes, a heart condition. I was fascinated by this collection of short stories, some 50 years old, some one year old. These stories are living documents, snowballing with time, dependent on both the whims of the body of the patient and the whims of the doctor. The patient is the narrative, but the doctor crafts it. For that to be successful, the doctor has to believe in the power of reporting and the idea that every patient has a story worth telling.