The playwright and actress Anna Deavere Smith stands in the well of Fitkin Amphitheater musing about how patients and doctors manage to communicate under pressure when she slips on a white coat and transforms herself into Yale physician Asghar Rastegar, M.D. “I have looked at every single patient as being a phenomenal new experience,” says Smith, using Rastegar’s words and his Farsi accent. “Excited to walk in that room. Oh yeah, oh yeah, no question about it. Phenomenally excited. Every time, every time, every time.”
Moments later, Smith portrays another doctor, Forrester A. Lee Jr., M.D. ’79, HS ’83, a cardiologist and the school’s assistant dean for multicultural affairs, who calmly and deliberately describes how medical training itself can block vital avenues of communication. “When you’re listening to a patient tell you things that you have to integrate into a whole body of knowledge you have, it’s hard to listen well, because your mind is trying to filter out what they’re saying. And consider alternate diagnoses and so forth. So you’re really not listening; you’re trying to solve the puzzle ... and so it just sort of goes by you that they said something very, very important. You didn’t hear it.”
Sitting down in a chair, Smith becomes a patient, speaking with a trace of a Southern accent. She is Frankie Harris, a woman with HIV who has been treated at Yale.
“I didn’t trust anyone. Doctors wasn’t listening. I had to fight, I had to advocate for myself to get doctors to listen to me. I had to learn to say, ‘What’s the side effects of this?’ Learn to say ‘No, I’m not takin’ that, give it to someone else, let someone else try it first.’ ... I am very conscious and very responsible for other people’s health when it comes to my virus. And I says [to the doctor] ‘Look, before you examine me put some gloves on. I have the virus.’ She went out of the room and she never came back. She never came back.”
The physicians who crowded into Fitkin for medical grand rounds in mid-November had not come to hear a colleague discussing a disease but rather to watch an outsider make a case for the potential richness of doctor-patient communication. Playwright and actress Anna Deavere Smith used the words of physicians and patients from the Yale community to create Rounding It Out, a 90-minute examination of how doctors and patients view one another.
The recipient of a MacArthur Foundation fellowship for creating a new genre of documentary theater, Smith has appeared in film and on television in The American President, The West Wing and The Practice but is best known for her solo stage performances depicting communities in turmoil. In Fires in the Mirror: Crown Heights, Brooklyn and Other Identities, Smith portrays two dozen real people, from city bureaucrats to housewives, to explore the 1991 clash between black and Jewish residents of Crown Heights. In Twilight: Los Angeles, 1992, she examines the riots sparked by the Rodney King verdict.
A less obvious crisis brought Smith to the medical school: the erosion of intimacy between patient and physician. In 1997 Ralph I. Horwitz, M.D., chair of the Department of Internal Medicine, and Rastegar, the subject of the opening scene and the department’s associate chair for medical education, had been discussing how to train novice doctors to listen better. When they heard Smith speak on campus on Martin Luther King Day in 1998, “it struck us that she is probably the best listener we had ever seen,” Rastegar recalls. And so Smith came to Yale last summer and fall to interview 21 physicians, nurses, and patients and their families to create what she calls “a first draft,” weaving together excerpts from the interviews with her own commentary and songs sung by Lynette Dupre and Suzzy Roche. In Fitkin and again the next day in Harkness Auditorium, Smith performed for packed houses that included the five physicians and six patients whose words she spoke from the stage. Noting that “the intimacy of transactions is dissolving” in our society, she told the audience: “I am stunned to learn here that a patient-doctor interaction is assumed to happen in 15 minutes. That would have to be a kind of haiku. Are the doctors prepared for that? The patients?”
In her portrayal of Horwitz, Smith brings to life the physician’s conflict between work and personal life. “For a long time medicine took the view that if you perfected yourself as a physician, you would have a full and complete life. That everything else would fall into place. That the perfect doctor would be the perfect person. And there’s nothing more arrogant. And nothing less true. ... You’re hearing this from a person that spends far too little time at home with my family.”
Smith’s journey through the medical school and hospital took her again to Lee, as he described the excruciating wait for a heart. “All the kinds of encouraging and supporting things the patient wants to hear from me largely center around ‘When am I going to be transplanted?’ And it’s the one question I cannot answer. ... Most of my patients will tell you I am very quiet, I don’t have many words.” He describes telling an African-American patient that he needed a new heart. “And he looked at me and said, ‘They don’t transplant black people,’ and I looked at him and I said, ‘You’re kidding, do you really believe that?’ And he did. So it was a very, very joyous day in my life to walk into his room and say: ‘We have a heart for you today. Believe it.’ ”
Smith portrayed Associate Dean Ruth Katz, M.P.H., J.D., recalling her treatment for cancer. “As much faith as you have in this place, every time they give you chemotherapy ... I had a friend there with me to make sure the bag of chemotherapy with that stuff in there that they were about to pump into me was exactly what I was supposed to get. No more. No less.” In a moment of comic relief, Katz recalls the day an oncology fellow reported that Katz’s chart had been lost and that he had to take a new history from the very beginning. He came to the question of her occupation and learned that Katz was associate dean of the medical school. “Now he looks up and he said, ‘At this medical school?’ And I said, ‘At the Yale School of Medicine.’ He found my files within a half an hour.”
The last patient portrayed on the stage was Karina Danvers, a woman with HIV: “People think that just because you have a terminal illness, or chronic or whatever they want to call it, all of a sudden every day is just precious and wonderful. I still beep my horn when somebody’s at the red light for too long.” She pauses. “I wish sometimes people would feel sorry for me. Ya know? Because it’s really tough living this ... I am a young woman ... dying.”
The presentation was “an affirming reminder of how valuable and privileged our connections with patients are,” said Stephen J. Huot, M.D., Ph.D., HS ’87, associate professor of medicine. “It was wonderful to see humanity as part of medical grand rounds.” First-year medical student Michael Shapiro said watching Smith portray Yale doctors made him ask himself again how well he listens. “Anna Deavere Smith in essence was holding a mirror up to the audience and saying, ‘Look at you, look at what you’re doing.’ ”
Shapiro’s classmate, Jenny Yiee, said that by inviting Smith to campus, the medical school administration had validated Yiee’s belief that doctor-patient communication is vital. Some students, Yiee said, believe that understanding science is more valuable than understanding patients. They regard the required first-year course known as “The Doctor-Patient Encounter” as a “blah-blah-blah class,” saying, “Let’s go study biochem now.”
Musician Roche, formerly of The Roches, said she felt elated after performing a script about medicine for an audience of physicians. “It’s what theater could really be. Instead of big stars and People magazine, it could be relevant to people’s lives in their own community.”
For third-year resident Christopher Ruser, M.D., Rounding It Out served as an antidote to the effects of residency. “I think residency has a tendency to depersonalize patients because of pressures, time limitations, fatigue. Watching Smith reminds us why we chose this career. ... We are privileged to be able to sit in a room and hear everything, to find out what their illness means to them as a complete person.” Seeing the senior physicians depicted by Smith gave him hope that as he becomes more adept at reaching diagnoses, he will increasingly find ways to use the patient interview to become acquainted with the whole person. Because of the performance, Ruser said, “I would go in and really try to understand the person who was in that bed, and not just what I had to do for the patient in the next 24 hours.”
Smith said in an interview that she’d come to understand that “the diagnostic procedure with a patient could by necessity—particularly for a younger doctor—require that they not see the whole person.” She hoped her work would help doctors “reflect on how, over time, to allow the whole person and the person who’s being inspected [by the physician] to both live.”
Establishing that kind of connection with a patient is essential to good care, according to Rastegar. “People recognize quickly if you see them as a whole human being or are just treating them as a disease. Despite all the wonderful therapeutic modalities we have developed, there are many diseases we cannot cure. So our role is helping them adjust to the illness and go on with their life. You need to know the whole person to do that. It’s in a marriage between scientific understanding and understanding of the human being in his or her totality that we can provide the best care.”
Smith’s presentation and her discussions with students and house staff were part of what Horwitz describes as “a larger effort to refocus attention on the medical profession’s civic responsibility.” Her visit was funded by a bequest from Daniel James, a patient and friend of Horwitz who died in 1998. Horwitz hopes to find money to bring Smith back to campus periodically, to continue the discussion begun last fall.
Smith has not decided whether she will develop Rounding It Out into a full-fledged theatrical production. That depends in part on finding a grant to support the project. She describes the work as, “at best, an offering. I wanted it to be a provocation and a cause for conversation.” Rastegar said Smith’s visit has, indeed, made “a different kind of dialogue totally acceptable, a discussion of the patient’s narrative and their view of their illness.”
The experience of having her story told in a public forum was fulfilling for patient Frankie Harris, whose painful account of being pimped by her mother made some people in the audience cry. “There was a time I felt that I was always alone, and there was a time that I felt that I deserved all that happened to me. It was healing to let go of the blame and let go of the shame.”