Wednesday, March 17, 2010

Learning to Listen

I'm exhausted. Physically and emotionally exhausted. I exist on cereal, soda, and however many gluten-free snack bars I can stuff into the pockets of my white coat. I haven't exercised in a week. I haven't slept adequately in two. My feet are on fire, accompanied by 1+ pitting edema up to the mid-tibia. My vasculature, my brain, my soul -- all of them resisting the reality of my new life.

I stopped dreaming that My First Patient was going to die. Not because he necessarily got better (as alluded to in my previous post, "getting better" = upgrading to lifelong dialysis -- so I guess, yeah, he got better). But because I'm now helping to also take care of My Second Patient, and I simply don't have the emotional resources to obsess over two people. How do people have practices? How do people have children?

My Second Patient is an elderly woman with congestive heart failure, chronic kidney disease, hypertension, and a slew of the other usual suspects, and came in on Monday with progressively worsening shortness of breath and fluid buildup. Our job is to a) help her breathe better, and b) figure out whether to blame the kidneys vs. the heart vs. some other entity. Three days later, she still can't breathe too well (even on oxygen!), and we haven't been able to get rid of much fluid with diuretics.

The worst part is that she lives 2 hours away (this is the closest big hospital), far away from her husband or anyone else who can be here to hold her hand. So I do.

I am so attached to this lady that it's sick. I've come thisclose to snuggling her. I also came thisclose to slapping my senior resident who marched into her room yesterday, leading our amusing-looking pack of lapdogs, poking and prodding her while spouting frightening jargon. When I returned to her room later to "translate" (from Medical to English), her eyes were red and moist. She had been crying.

I, too, am tearful often around this lady. Not because we have the "intimidated, confused, and alone" thing in common, which we do. I get tearful because she makes me feel like I might actually one day be a decent doctor. When I am forced (by my conscience) to explain test results and treatment plans (presented completely differently than the residents do: "today we're going to do x to you" doesn't exactly do wonders for one's locus of control) at the level of some fuzzy grey zone between sub-technical and respectful-lay (perhaps resembling Wikipedia-level medicine -- i.e., how most medical students learn anything that makes sense), I appreciate that I don't suck at it. I get nonstop practice at tetering on that fine line between "neutral" and "non-neutral." Everything matters here. Your tone, your facial expressions, your body language. The moments you create for people might actually be some of the only human interactions for the day. Their singular insight into "what's going to happen to them" that day, or ever. These moments matter. You can't butcher them or rush them. Or skip them (as My First Patient was about to be whisked off to the OR to have a catheter placed for dialysis, I asked whether any of his real doctors had told him. I nearly puked when I heard the answer.).

Today on rounds, my attending called out a senior resident for his ineffective nonverbal communication skills. It was a resident I actually like, who is actually pretty gentle and friendly with patients -- doesn't interrupt, is pleasant and reassuring. But my attending called out for the way he interviews patients while standing up, towering over them, with his arms crossed against his chest. I was very moved. Moved because FINALLY, for the first time on this rotation, someone called attention to everything I've been complaining about since I got here. Somebody finally said this wasn't ok. But the thing was, the resident didn't take this feedback constructively. Instead, he argued of the merits of "asserting one's self" with a patient, setting boundaries, "letting them know how it is." He didn't drop the "c bomb," but I thought he was going to.

"There's room for compassion sometimes..." he began. "But sometimes you just need to let the patient know that you're calling the shots."

This is who they leave me alone with, to teach me how to be a doctor.

My attending didn't bother to argue. I assume he chalked it up to a lost cause. But since he still had the floor, he continued.

"Sometimes you don't need to say anything at all. Sometimes you just listen. Everyone has a story."

One of the upshots of a) knowing relatively little about what's wrong with really sick people and how to fix them (or at least how to apply the stuff I know), and b) having relatively few responsibilities besides showing up early, hanging around late, and undergoing the various humiliating rites of passage associated with third-year med student life, is that I have all the time in the world to figure out other ways of being useful. I've found that my 'usefulness niche' is to listen to people's stories -- to look them in the eye, smile, and shut the hell up.

It's amazing what people tell you when you shut up.

I've created a construct of "listening quotient" -- how much listening will I do during any one enounter. The LQ is calculated on the basis of several factors: a) the look in a person's eyes -- are they scared? are they lonely? are they confused?; b) has any other human being interacted with him or her lately?; c) if I were in his or her place, how much and in what capacity would I want me there?; d) what is my purpose: data acquisition, comfort/assurance, interview practice, etc?.

Today, for example, I was tasked with performing a rectal exam on My Second Patient. I'd never performed an unsupervised rectal exam before, nor had I performed a rectal exam on a patient who didn't show up for an annual physical expecting to have one. I entered her room, and found her short of breath and distressed after experiencing an adverse drug event. Seriously? A rectal exam in the middle of this? Game over. So because I had the time, and because I did genuinely want to understand what she had experienced (so that I could relay it back to my team), and because I wanted her to feel like she had been heard, and because the LQ earned by knowing that I was about to impose discomfort, awkwardness, and potentially pain, we chatted for a good half hour before I explained why we were recommending (if it were ok with her) that I perform a rectal exam. I apologized profusely, etc. etc. about the nature of the exam, and helped her to roll over into the most appropriate (and comfortable, as I can attest via my experience as a patient) position. As a 400+ lb. woman, it was a challenge to attend to her modesty, comfort, and self-consciousness while helping her get into position. I'm not sure that I did a good job. And when it was all over (post-tissues: I ALWAYS give tissues; my doctors never did), we chatted again for another half hour. The blood I saw on my sample earned an even higher LQ, anticipating what I might one day have to tell her.

Tonight before I went home, I went in to check on My Second Patient. We went over some of her test results (good), and the plan for the next day (hopeful). She told me that her husband was visiting shortly (great!). And then, all of a sudden, she started bawling. I touched her arm.
"I'm so scared..." she said. My hand remained on her arm. I said nothing.

"Thank you. You make me feel so much better. You come with me to all my scary procedures, and you teach me about what's going on."

It's amazing what people tell you when you shut up and listen.

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