JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 7, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2014.0064
Begging To Be Heard Paul C. Rousseau, MD
Dear Editor: When my wife was dying, the only thing physicians had to offer was presence and listening. Yet, no physician sat down and allowed her the privilege of speaking. Not one. Perhaps they were afraid or uncomfortable. After all, how do you peer into the soul of a woman with days to weeks to live and two young daughters pleading for her life? Or perhaps they were busy with time constraints, limited work hours, relative value units, and the bureaucracy of medicine. Or perhaps they were hardened, the burden of too many patients in too few hours relegating her story to a demanding annoyance of commitment and time that was best avoided. As I think back, many of the physicians were young, and while knowledgeable about disease and technology, they were still learning of the hallowed ground at the bedside. Informatics had molded their character and approach to medicine, their intimacy often with a computer rather than a patient. After all, intimacy is easier with a machine—there are no emotions or unknown answers. Her story was likely a mere distraction, tangential to the pathogenesis and clinical management so ingrained in medical care.1 However, what my wife experienced is not uncommon—I see it every day. It’s an unintentional neglect of bedside skills, forgotten in a hurry to attend to other urgencies that have changed the practice of medicine. It’s also akin to a bedside adolescence for younger physicians, their narrow experience not yet appreciative of the revered importance of the bedside encounter. Jerome Groopman indirectly addressed this bedside adolescence in an essay about his first child’s sudden illness and a visit to the emergency room. As the surgical resident was taking the history, an intern bounded into the examining room asking, ‘‘What have you got in here? What is it? A good case?’’ Groopman became incensed and told the intern to get out. The hurt of hearing his son called a ‘‘good case’’ was just too much to bear.1 However, as Groopman looked back on that seminal encounter many years later, he reflected on the changes that seem to occur with the passage of time. He wrote, ‘‘It is as if medicine at this stage of my life has split into two streams—a current of marvelous biology and an undertow that pulls at the soul.’’1 Groopman’s thoughts are important. Maturity brings a clinical reverence for the bedside that derives not only from the learning of medicine, but also from the wisdom
of age and the wounds of loss. Maturity also brings a more personal connection to the patient, as mortality stares back like a reflection in the mirror. So are young physicians condemned to ‘‘a current of marvelous biology’’ absent of nonclinical bedside skills? I think Groopman is correct to a point, as the introspection of age cannot be denied—there are things that are only realized through experience. It’s like an older surgeon who knows when watchful waiting is better than the cold steel of a scalpel. In addition, Mounica Vallurupalli, a student at Harvard Medical School, lamented in a recent perspective about the lack of understanding of the nonmedical aspects of patient care. She wrote, ‘‘We learn about how disease affects the body at the most fundamental molecular level, yet our training deemphasizes the ways in which illness and suffering affect others.’’ She continued, ‘‘This omission is particularly unfortunate because our understanding of suffering is so fundamental to the quality of the care that we give.’’2 That said, and in spite of the challenges noted by Groopman and Vallurupalli, I still believe young physicians can begin to develop a more humanistic approach to the bedside encounter with the right mentors and the right environment, two influences that nurture not only clinical acumen, but medical humaneness. However, medical humaneness has become difficult to find in contemporary medicine, as nonclinical skills are increasingly devalued. I wonder why we still need an x-ray or a blood test to feel as though we’re doing something clinical. Why must sitting and listening to a patient feel so empty and so undervalued—why can’t we feel as though listening is doing something? And why must technological bunkers of computers and cell phones be the valued norm of care, rather than sitting bedside and sharing the suffering of the patient?3,4 We have become distracted, even dependent, on technology. As Abraham Verghese notes,4 the patient has become invisible—unseen and unheard. The patient in the bed is merely an icon for the real patient, the one in the computer—the iPatient. Even chart notes have become monotonous and diuretic, peeing out words with little information other than billing necessities. It seems we have wandered from the bedside and lost the art of medicine. And that is troubling, as sitting bedside and listening forges a rich connection between physician and patient, fostering a caring and deeply personal relationship. Listening also acknowledges and allows the grief that accompanies the
Palliative and Supportive Care Program, Medical University of South Carolina, Charleston, South Carolina.
751
752
betrayal of one’s body and the losses of illness. It’s this betrayal and loss that segregates patients from a healthy society, but sitting bedside and listening helps bring them back and cradles their grief. So we must do better, in spite of the strain of modern-day medicine and the neglect of medical humaneness. We must give time at the bedside and allow stories to be told, so that what matters is heard and there is witness to life. The hearts touched will beat much calmer, and our lives will be much richer. We all have a story, and we all want to tell that story. We want it to be heard, and we want it to resonate. It helps with healing, and it helps when the burden is too heavy to carry alone.5 The doctors of old understood this, for they had no antibiotics, morphine, or other modern medicaments. They only had the bedside, where they sat, held hands, waited,3 and in the end, listened.
LETTERS TO THE EDITOR References
1. Groopman J: A great case. N Engl J Med 2004;351:2043–2045. 2. Vallurupalli M: Mourning on morning rounds. N Engl J Med 2013;369:404–405. 3. Rousseau P: Presence. J Clin Oncol 2010;28:3668–3669. 4. Verghese A: Culture shock: Patient as icon, icon as patient. N Engl J Med 2008;359:2748–2751. 5. Gawne-Kelnar G: Listening. Palliat Support Care 2013;11: 531–533.
Address correspondence to: Paul C. Rousseau, MD 81 On The Harbor Drive Mount Pleasant, SC 29464 E-mail: [email protected]
Begging To Be Heard Paul C. Rousseau, MD
Dear Editor: When my wife was dying, the only thing physicians had to offer was presence and listening. Yet, no physician sat down and allowed her the privilege of speaking. Not one. Perhaps they were afraid or uncomfortable. After all, how do you peer into the soul of a woman with days to weeks to live and two young daughters pleading for her life? Or perhaps they were busy with time constraints, limited work hours, relative value units, and the bureaucracy of medicine. Or perhaps they were hardened, the burden of too many patients in too few hours relegating her story to a demanding annoyance of commitment and time that was best avoided. As I think back, many of the physicians were young, and while knowledgeable about disease and technology, they were still learning of the hallowed ground at the bedside. Informatics had molded their character and approach to medicine, their intimacy often with a computer rather than a patient. After all, intimacy is easier with a machine—there are no emotions or unknown answers. Her story was likely a mere distraction, tangential to the pathogenesis and clinical management so ingrained in medical care.1 However, what my wife experienced is not uncommon—I see it every day. It’s an unintentional neglect of bedside skills, forgotten in a hurry to attend to other urgencies that have changed the practice of medicine. It’s also akin to a bedside adolescence for younger physicians, their narrow experience not yet appreciative of the revered importance of the bedside encounter. Jerome Groopman indirectly addressed this bedside adolescence in an essay about his first child’s sudden illness and a visit to the emergency room. As the surgical resident was taking the history, an intern bounded into the examining room asking, ‘‘What have you got in here? What is it? A good case?’’ Groopman became incensed and told the intern to get out. The hurt of hearing his son called a ‘‘good case’’ was just too much to bear.1 However, as Groopman looked back on that seminal encounter many years later, he reflected on the changes that seem to occur with the passage of time. He wrote, ‘‘It is as if medicine at this stage of my life has split into two streams—a current of marvelous biology and an undertow that pulls at the soul.’’1 Groopman’s thoughts are important. Maturity brings a clinical reverence for the bedside that derives not only from the learning of medicine, but also from the wisdom
of age and the wounds of loss. Maturity also brings a more personal connection to the patient, as mortality stares back like a reflection in the mirror. So are young physicians condemned to ‘‘a current of marvelous biology’’ absent of nonclinical bedside skills? I think Groopman is correct to a point, as the introspection of age cannot be denied—there are things that are only realized through experience. It’s like an older surgeon who knows when watchful waiting is better than the cold steel of a scalpel. In addition, Mounica Vallurupalli, a student at Harvard Medical School, lamented in a recent perspective about the lack of understanding of the nonmedical aspects of patient care. She wrote, ‘‘We learn about how disease affects the body at the most fundamental molecular level, yet our training deemphasizes the ways in which illness and suffering affect others.’’ She continued, ‘‘This omission is particularly unfortunate because our understanding of suffering is so fundamental to the quality of the care that we give.’’2 That said, and in spite of the challenges noted by Groopman and Vallurupalli, I still believe young physicians can begin to develop a more humanistic approach to the bedside encounter with the right mentors and the right environment, two influences that nurture not only clinical acumen, but medical humaneness. However, medical humaneness has become difficult to find in contemporary medicine, as nonclinical skills are increasingly devalued. I wonder why we still need an x-ray or a blood test to feel as though we’re doing something clinical. Why must sitting and listening to a patient feel so empty and so undervalued—why can’t we feel as though listening is doing something? And why must technological bunkers of computers and cell phones be the valued norm of care, rather than sitting bedside and sharing the suffering of the patient?3,4 We have become distracted, even dependent, on technology. As Abraham Verghese notes,4 the patient has become invisible—unseen and unheard. The patient in the bed is merely an icon for the real patient, the one in the computer—the iPatient. Even chart notes have become monotonous and diuretic, peeing out words with little information other than billing necessities. It seems we have wandered from the bedside and lost the art of medicine. And that is troubling, as sitting bedside and listening forges a rich connection between physician and patient, fostering a caring and deeply personal relationship. Listening also acknowledges and allows the grief that accompanies the
Palliative and Supportive Care Program, Medical University of South Carolina, Charleston, South Carolina.
751
752
betrayal of one’s body and the losses of illness. It’s this betrayal and loss that segregates patients from a healthy society, but sitting bedside and listening helps bring them back and cradles their grief. So we must do better, in spite of the strain of modern-day medicine and the neglect of medical humaneness. We must give time at the bedside and allow stories to be told, so that what matters is heard and there is witness to life. The hearts touched will beat much calmer, and our lives will be much richer. We all have a story, and we all want to tell that story. We want it to be heard, and we want it to resonate. It helps with healing, and it helps when the burden is too heavy to carry alone.5 The doctors of old understood this, for they had no antibiotics, morphine, or other modern medicaments. They only had the bedside, where they sat, held hands, waited,3 and in the end, listened.
LETTERS TO THE EDITOR References
1. Groopman J: A great case. N Engl J Med 2004;351:2043–2045. 2. Vallurupalli M: Mourning on morning rounds. N Engl J Med 2013;369:404–405. 3. Rousseau P: Presence. J Clin Oncol 2010;28:3668–3669. 4. Verghese A: Culture shock: Patient as icon, icon as patient. N Engl J Med 2008;359:2748–2751. 5. Gawne-Kelnar G: Listening. Palliat Support Care 2013;11: 531–533.
Address correspondence to: Paul C. Rousseau, MD 81 On The Harbor Drive Mount Pleasant, SC 29464 E-mail: [email protected]
