As I progress through my medical career, I must make time to listen

I am four months into my third year of medical school.  The third year is the first clinical year, when students spend most of their time in the hospital, interacting with patients and working as part of the medical team.

Our deans told us at the beginning of the year that we would be talking with patients more than anyone else on the medical team; we would serve as advocates for our patients’ wants and needs.  They said that although our medical knowledge is still novice in comparison to the doctors above us, the patients commonly remember the students more than anyone else.

It comes down to time.  The residents and attending physicians have several patients to see each day, and they only have time to briefly visit the bedside to elicit key information that affects patient care.

We are the lucky ones, we were told, we third year medical students. While our resident is busy managing more than a dozen patients – most of whom have multi-systemic, complex problems – we are beginners, entrusted to manage a handful of patients at a time.  As beginners it takes us more time to think through algorithms of management and treatment options.  A handful of patients is plenty.  Having only this handful allows us to really get to know our patients as people – to sit at their bedsides and hear their stories, beyond the details that affect their care.

Today was our “call day.”  I am rotating through internal medicine. Every fourth day, our team is on call.   Our team consists of one attending physician (boss), two resident physicians (doctors in training after medical school), and two medical students.  On call day, our team accepts new patients who present to the emergency department and need to be admitted to our service.  Being on call is always chaotic and always interesting, as we rush around interviewing patients and figuring out what is wrong with them and how we can help.

This morning, I was assigned to a middle-aged man, Jack, who had presented during the night with worsening back and hip pain.  I rushed to the fifth floor and opened his chart.  My job was to read what other doctors had written in their notes, and then to talk to the patient and perform a history and physical exam.   Afterwards, I would present my findings to one of the residents.

Jack was diagnosed with liver cancer one year ago that had rapidly spread to his pelvis and spine.  An MRI (magnetic resonance imaging) was performed in the emergency department last night to look for cancer in his spine and pelvis.  An MRI is an imaging test used to visualize structures inside the body.   MRI provides high-detail images of soft-tissue structures in the body, which makes it a good imaging choice for specific structures and diseases, such as the brain, muscles and certain types of cancer.   Because the purpose of Jack’s imaging was to look for the spread of cancer, an MRI was the appropriate choice.

The MRI revealed a new mass in Jack’s spinal cord.  The neurosurgeons wanted to operate to remove the mass and prevent compression of the spinal cord, which could cause paralysis.  I opened the MRI document on the hospital computer and scrolled through the images until I noticed an unusual round mass in the lower portion of the spinal cord.  The medical student part of me noted the size and location of the mass, and thought about what structures might be affected by the spreading cancer.  The human part of me felt hopelessness and compassion for this poor man, who I knew had a very poor prognosis.

The surgery, the neurosurgeon’s note explained, would not cure his cancer.  It was only a way to prevent the spinal cord compression, thus relieving his pain and possibly preventing paralysis in his legs.  It was a way for him to have a better quality of life before his inevitable death secondary to this terrible disease.

I had no other patients to see that morning, and I had three hours before I had to meet with my team for rounds.  I reminded myself of the message from my deans:  I am the lucky one; the one who gets to spend more time with my patients, hearing their stories, and getting to know them beyond their status as patients with diagnoses, but as real people.

I spent the next three hours sitting and talking with Jack.  As a medical student, I gathered a detailed past medical history and history of his current illness.  As a human being, I formed a bond with a dying man, getting to know him and listening to his story as he wanted to tell it.  I learned about his childhood: how he was educated in a monastery as a teenager, and how he became a Buddhist monk.  I learned how he traveled to different countries as a medical assistant, birthing babies and giving medicine to those in need.  I learned how he eventually moved to the US to receive higher education.  I learned about his wife and three children, and how he likes to drink beer socially with his friends.

I learned about his diagnosis with hepatitis, most likely because of a needle stick during his involvement as a medical assistant.  I learned about his MRI just one year ago that was given as a screening test because of his hepatitis status.  At that time, he had no symptoms of any kind, and the doctor told him he had a tumor in his liver that needed surgery.  I learned about his pain after surgery, and how he was told that his cancer had spread to his pelvis.  And now he was here, a man of great accomplishments, with worsening pain and a worsening prognosis.

A man who had raised three children and supported his family, now reduced to a sick patient in a hospital gown, eating hospital food, totally dependent on his doctors and nurses.  A man who had defined himself in so many ways, was now being defined as a 53 year old man with liver cancer metastasized to his pelvis and spine.  The other details faded to gray to the busy doctors with too many patients.

But not to me – I am the lucky one.  With question after question, and time to spare, I was able to learn about his upbringing, about his fight with cancer during the past year, and about the lessons he learned through his life and how they applied to his current situation.  Buddhism, he explained, teaches that a person has no true belongings.  For if something belonged to a person, it would do as he said.  But nothing behaves that way, not even one’s own body.

“Hair,” he continued, “if it was up to us, hair would always stay black, but instead it turns to gray, or maybe falls out completely…  It is the same with the rest of my body, and my liver.”

“But I still went through with the surgery last year – I was not ready to accept this fate!  I was not ready to believe that my body did not belong to me.  It seems I still have much to learn.”

I tucked away my pen and paper and continued to listen to his story and absorb his wisdom.

He went on, sharing his thoughts and feelings, his worries and concerns, and his outlook on his terminal illness.  A dying monk from a different world, taking the time to teach and reflect with a young medical student – it was extremely powerful.

I am the lucky one, to have the time to stop and listen.  To bring that background information back from the gray and into the light, to invite Jack to tell his story.  And I can only hope that by doing my part, I am helping him in some way through his difficult struggle.  And for that, I am thankful to play my part, and eager to fulfill this important role as we take care of patients on our medical team.  As I progress through my medical career, I must continue to make time to listen, not only as a physician gathering information from patients, but as a human being listening and learning as I hear other people’s stories.

Gregory Shumer is a medical student. This post originally appeared in The Doctor Weighs In

It was written as part of a narrative medicine curriculum at Georgetown University School of Medicine, taught by Margaret Cary, MD. Her students’ stories reflect the depths and the heights of medical school; most importantly, the stories reflect the magic and wonder of becoming physicians.

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  • http://www.facebook.com/profile.php?id=1611638692 Wyvonia Woods Harris

    When the word “listening is in the title, I know the article will place me in a learning experience. Thanks to the author.

  • http://www.facebook.com/thatsananna Melissa Hausman Oltman

    So good – thank you.

  • http://twitter.com/NancysPoint Nancy’s Point

    While you might be one of the lucky ones, I think that man was lucky, too, having you attend to his needs so compassionately that day. Time and listening are two great gifts any doctor can give their patients.

  • http://www.facebook.com/STINGER64 Stephen Ray Mitchell

    Greg, You did listen to your mentors and especially to Jack. Enjoy the ride.
    You have already managed to see the reward among the painful privacy of suffering. You will bring much joy to patients like Jack in your career!

    Ray Mitchell, MD

  • James deMaine

    Wonderful post.  Your are intuitively following the great teachers of patient care such as Francis Peabody who said,  “the secret of the care of the patient is in caring for the patient.”  If you have time, please read this RWJ Honor Lecture about Peabody: http://www.ramcampaign.org/pages/docume/riza_bylined_article.pdf

  • petromccrum

    Others should follow your example. What a wonderful post. 
    Good luck in your medical career.  Need more doctors like you.

  • janiceamancuso

    Gregory, you essay touched me deeply. Beautifully written. Do you know about 
    http://www.pulsemagazine.org/? The 6/1 posting was by Alan Blum, MD, a family physician for 35 years. At different ends of the career spectrum, you both have much in common. I hope you never forget your experience with Jack. I will keep the wisdom you shared close by; hopefully it will become part of the fabric of my being.
    janice

    http://oslersymposia.org/ - Doctoring in the 21st Century: Embracing the Challenge, Oct 2012

  • http://profile.yahoo.com/KNZ22VMISM6D26MXSJ4PKMGXXM James

    I attended a retreat called “The Art of Presence” in Assissi, Italy put on every summer by the George Washington Institute of Spirituality in Healthcare. I vowed to spend a small time with each of my patients sitting quietly, being present. I find it takes no longer to complete my day and feel much is gained. Every patient is our teacher, we simply have to listen!

  • http://www.tryingtobeamedicalstudent.blogspot.com/ TTBAMS

    What a wonderful post. And a good way to remind medical students that we should enjoy and make the most of our current experiences, not just continually focus on our qualified future and how our lives will be better when we are doctors. However once we are doctors we no longer have the time for the privelege of the experience such as yours with Jack.

    TTBAMS

    Tryingtobeamedicalstudent
    http://www.tryingtobeamedicalstudent.blogspot.com

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