Your Voices

Compiled by Jeff Forster, Editor

On Byron

"From the foot of the bed, my eyes inched slowly toward the stubbly, disheveled face of Byron, my first patient on the first day of my first year as an intern. He had been in the hospital for a long time; folks in the Department of Medicine joked that he should be nominated for Teacher of the Year.

I looked at my patient, a frail, old, frowning, cachectic, 95-pound man. He stared at the muted television, forgoing eye contact with any of the figures hovering around his bed.

I asked softly if I might listen to his heart. He shrugged. As I lifted his shirt, I didn't have to count intercostal spaces to locate his point of maximal impulse; it was pounding right before my eyes.

All the pages written about medicine were not going to be helpful. I needed to develop communication, nurture trust, and eventually feed this weak man in order to start managing his endless problem list.

After sifting through three volumes of previous hospitalization and discharge summaries on Byron, I approached him again, without white lab coat and stethoscope. It took about 20 minutes, but he finally made eye contact.

Over the next few days, I slowly broke the ice by listening to his war stories. I made time to wheel him to the lobby so we both could enjoy the sun. He'd talk about his sons, whom he loved, and his grandchildren, whom he adored, and describe all the lonely Father's Days he'd spent with a six-pack.

I found out that he liked peanut butter and jelly sandwiches and root beer. This was easy enough to arrange, even within the VA bureaucracy. Astonishingly, he started to gain some weight, and became strong enough to lift himself out of bed. One day, out of the corner of my eye, I caught him smiling.

At the time of discharge, he stretched out his thin hand and shook mine. "Thank you for listening," he said.

'Congratulations,' my senior resident said. 'What did you learn? CHF? Sodium imbalance?'

'The usual bread and butter medicine,' I replied.

What I really wanted to say is that while caring for Byron, I learned that we are all born with the skills to begin effective communication: talking and listening. Once these skills are mastered and a trusting alliance formed, we may practice the art of healing.

Three months later, I stepped into a crowded hospital elevator. As the doors closed, I heard a soft voice from the back: 'Good morning, Dr. Gupta.' I looked back and saw a clean-shaven man wearing a volunteer badge on his faded blue tee shirt.

I smiled. 'Good morning, Byron.' "

Pankaj Gupta, internist, Framingham, MA

On med school graduations, then and now

"At Ali's medical school graduation, the young doctors walked up to the stage and were greeted with a hearty handshake. And then, to my amazement, the professor of their choice gave them a big hug. This outward display of emotion was unheard of in my day. It is a symbol of what our profession desperately needs today.

This was my first medical school graduation since attending my own, decades ago. To gain freedom from their Russian-dominated homeland, Ali and his family had walked from Kabul, the capital of Afghanistan, through the dangerous Khyber Pass to Pakistan. My wife and I became their stateside sponsors.

At Ali's graduation, the dean of the college said he knew there were some graduates who even now had serious doubts about becoming a doctor. He told them it was okay to have doubts. He said he had changed his mind several times in his career, and he reminded the graduates that the medical school staff was ready and willing to take phone calls from graduates who might want to talk about their careers. He said it was good—and necessary—to take time off from a busy schedule. And he advised them to step back periodically throughout their lives to reassess their goals and plans.

My graduation was not at all like Ali's because I would have remembered such a heartfelt talk by the dean. In my day, we felt intimidated and dehumanized by our professors. Any outward display of emotion was not well tolerated. We were permitted one emotion: fear.

Ali and his classmates were not only permitted to be human, but were actively advised to do so, and encouraged to listen to their souls. Be a human being first, then a doctor. Listening to the dean, and looking at Ali, I knew that the future of medicine was in very good hands."

John N. Haswell, ob/gyn, Sarasota, FL

On obesity, and being obese

"I find myself in the unenviable position of discussing obesity from two perspectives—that of treating physician, and that of patient. I've been battling the bulge intermittently throughout my life. I feel like I've had weight on and off my body more often than a snake sheds its skin.

I never once lost weight or progressed toward health because a clinician bawled me out or ridiculed me. Accusing me of gluttony, laziness, or lack of willpower only arouses feelings of embarrassment and inadequacy, and does nothing to motivate me to lose weight. If you wouldn't ridicule a patient for his hypertension, don't criticize him for his obesity.

Obesity is a medical problem, not a character issue. I believe most obese patients would give just about anything to get their problem under control. It is an uncomfortable and embarrassing way to live.

How can physicians treat their obese patients effectively?

• Show simple and genuine concern. When a doctor asks me, 'How can I help you with this problem?' I feel validated as a person and able to tackle a weight loss program.

• Don't be stingy with praise; recognize even a small achievement as a difficult task well accomplished. A little reinforcement goes a long way.

• Avoid scolding and reprimanding over setbacks. Help the patient work through these tough spots by pointing out that tomorrow provides another chance to start over.

If a physician feels disgusted with a patient because of body size, I would suggest there is indeed a character issue—the physician's, not the patient's."

Louise E. Frazee, FP, Myrtle Beach, SC

On the most powerful medicine: a doctor's words

"I've had the misfortune of being hospitalized twice in the past year. The experiences of recovering from pancreatitis, a cholecystectomy, and repair of a ruptured patellar tendon have given me an opportunity to reflect on what it means to be a doctor.

I had excellent clinical care, but the demeanor and confidence of my doctors were just as important to my recovery. While it is satisfying to treat an illness successfully, it is even more satisfying to experience the profound human moment between doctor and patient.

The emotional numbness that has developed in modern medicine—the sheer volume of patients, the onslaught of bureaucratic hassles—can cause us to lose the human focus. Every time I enter an exam room, I need to remember that this is likely the most crucial encounter my patient will have that day. Our conversation will probably be repeated to family and friends, who will evaluate every word and nuance. To be remote and cavalier can be destructive.

If I project compassion and confidence, my patient will have a greater chance for improvement. I try to ask about the patient's family or job or otherwise connect on a personal level. Patients notice; they are wishing, hoping, and listening, and my words are indeed powerful medicine. Words have the power to make patients feel they're in good hands, that they're going to get better. Even when the course of illness is not smooth, they need to know I am alongside them all the way.

When I cannot offer a treatment, there is only one thing left to offer: myself. If I can lend some of my strength, compassion, and emotion to the moment, the patient and family are incredibly grateful. That's where my greatest amount of professional gratification comes from, one patient at a time. Some of my most grateful patients, in fact, are the ones I've had the least to offer. It is not only my expertise as a physician my patients need, but my kindness and humanity, as well."

Mark Wesselman, oncologist, Albuquerque

 

Jeff Forster. Your Voices. Medical Economics 2001;5:114.