My last column told the stories of two patients from whom I learned important lessons about gratitude and compassion. In this column, I share stories about patients who taught me critically important lessons about truly listening and the power of acceptance.
Samantha — or Sam, as she preferred to be called — was a young surfer recovering from a serious car accident, and Paul a young father with cancer. Although I cared for each many years ago, what they taught me remains as vivid today as ever.
Their lessons are proof that the bond between patient and physician is special, and why what we learn from those for whom we provide care stays with us long after we have forgotten the lectures we heard and the textbooks we read.
Racing through hospital rounds
I first met Sam when I was a second-year resident at Stanford University, rotating through the orthopedic service. She was a 16-year-old surfer from Santa Cruz with a bit of an attitude — athletic, with a deep bronze tan and straw-colored hair bleached by the sun.
One night, as she drove her car up the winding road from the beach to her home in the hills, the vehicle careened off the road. She fractured a dozen bones in her arms, legs, back, and pelvis.
Sam needed surgical repositioning for some of the fractures and traction for the bones that could not be safely put back into place. Traction involved inserting stainless steel pins through the broken bones, attaching the pins to a series of weights and pulleys, and keeping her on strict bed rest in the hospital for three weeks. Once the constant pull of the weights moved the bones into their original anatomical positions, we would apply a full body cast and send her home.
Rounds on a surgical service begin at 6:00 a.m. and need to be complete by 7:30 a.m., when surgery begins in the operating room. With 20 patients to see each morning, speed and efficiency are essential. Most of the time is devoted to the sickest patients. These are the ones who had surgery most recently, and those with complications such as pneumonia, wound infections or major bleeding. All others get a very brief visit.
After a week in the hospital, Sam was stable medically and surgically. As a result, our team of doctors rarely stayed with her longer than a minute or two on our morning rounds. Six or seven of us — attending physician, residents, and medical students — would walk into her room in unison. We would stand halfway between the door and her bed. One of the students would read from the medical chart and report that Sam had no fever, update us on the most recent x-rays, and describe the current position of the bony fragments. The resident responsible would turn to her and say, “Everything is going great.” Then, as though we had choreographed the movement, we would turn as one and leave.
A problem beyond broken bones
After a week of these cursory daily rounds, Samantha surprised us. Just as we turned to leave, she said, “There’s moss growing under my leg cast.” This got our attention. We huddled around her bed, pulled back the sheets and began to fire questions at her. “When did you first notice it?” “Are you having any pain?” “Does it itch or burn?” As we peered closely under the cast, we could see that no moss was actually growing under her cast. Sam quickly admitted to having put it there.
She had asked her younger sister to go into the forest near their home and bring her a thatch of green moss. Earlier that morning, she had inserted the moss under the edge of her cast, her intention to teach us a lesson. “You stopped asking me how I was doing,” she said, “and what I was feeling. I didn’t know what else to do to get your attention.”
From that day forward, each of us doctors made certain we said good morning to every patient on our service and asked how they were doing. And even more importantly, I learned to inquire before I left the room, whether in the hospital or the office, if there was anything else they would like to tell me or anything I had forgotten to ask.
Those few extra minutes during which I listened intently to my patients have paid remarkable dividends. Dozens of times, I have diagnosed problems that I would have missed, and long before they would have become serious. And by listening to stories from hundreds more, I have learned a great deal about people and gained valuable life lessons.
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When the professional turns personal
Paul came to see me with a dark, pigmented spot on his shoulder that his primary care physician worried might be a melanoma. Paul was an artist, thirty years old, recently married, with his first child on the way. I explained the relatively minor procedure I would need to perform to determine the diagnosis. He told me the word melanoma terrified him and asked whether I thought that was the diagnosis. I explained that I couldn’t be sure until the pathologist had the chance to do the necessary microscopic evaluation. I knew Paul would spend three or four sleepless nights until he found out the answer.
When the pathology report came back, the diagnosis confirmed his worst fears. The melanoma was relatively thick, and his prognosis poor. For most cancers, the mortality rate correlates with the extent to which the tumor has spread. For melanoma, the major prognostic factor is the thickness or depth of the lesion. The surgical procedure would require a wide excision, skin grafting to close the wound and removal of the lymph glands under the arm, the first place the tumor cells would spread.
Paul joked that he was glad he had a left-sided cancer, since he painted with his right hand, and no matter how debilitating, his surgery would not interfere with his art. Of course, he understood there was nothing funny about his situation. His humor was my first clue to his resiliency.
In most cases, the doctor-patient relationship stays professional. But sometimes, it becomes personal. And ours became personal. Paul and I looked forward to our conversations in the office. I would always reserve extra time, knowing that after we addressed his medical issues, we would chat for at least another 15 minutes about life, family and what we hoped for in the future.
Shortly after the birth of his son, I had to give Paul the sad news that his cancer had spread to his lung. I explained that chemotherapy would slow its progression, but a cure was not possible. As he had done with everything about his disease, he understood and accepted the facts and the implications. For the next several months, his oncologist provided most of his care, so I rarely saw him as a patient. But he always sought me out and updated me on his life and his family. We shared an interest in growing fruits and vegetables in our yards, and invariably he would bring me a juicy tomato or peach.
I was saddened to watch as the tumor spread and his condition worsened. One day he came to my office and asked to talk. He had brought with him a present for me: a self-portrait he had sketched with charcoals. On the back he had written, “Life ends and we should enjoy each day.” And in his joking style, he had added, “You will never be a good farmer, but if you work hard at it, you might become a great physician.”
He concluded, “Please do this for your patients and for me.”
With tears in my eyes, I hugged him and thanked him for the beautiful picture and the inspiration. Sometimes the most difficult part of being a physician — and the most important — is accepting our limitations and letting go.
Paul eventually died. I stored his drawing of himself in a cardboard box. Unfortunately, in one of my many moves, it was lost. But I’ve kept with me the lesson Paul taught me about the need for acceptance. I carry it in my heart wherever I go.
How our patients make us better
As a surgeon, I marvel at the beauty of the human anatomy, and experience tremendous fulfillment in performing technically successful surgical procedures. And as a physician, I’ve felt equally immense pleasure in caring for my patients, and cherish all they have taught me.
If I am far from an exemplar of gratitude, compassion, listening and acceptance that these four teachers have imparted, they are not to blame. Thanks to what each of them taught me, I am a far better surgeon and person than I otherwise would have been.
Robert Pearl is a physician and CEO, Permanente Medical Groups. This article originally appeared in Forbes.
Image credit: Kaiser Permanente
