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Can’t talk now

Yale Medicine Magazine, 1999 - Winter


A student reflects upon life on the wards and looks for ways to improve communication.

I met him in the emergency room. As a third-year student, I now performed many basic procedures on a daily basis but this case was a first for me. The physical examination was unremarkable until I discovered a large, bleeding, irregular mass where his prostate should have been. From that moment, I knew the man had cancer.

Subsequent work-up confirmed diagnosis, metastatic rectal carcinoma, but what disturbed me most was that, as far as I could tell, nobody informed the patient for over 36 hours. Yet in that time he was subjected to a series of rectal exams by grave-faced physicians. A biopsy and CT scan were performed to confirm suspicions. Within 10 minutes of my discovery, we were already detailing his poor prognosis—but only outside the room and among ourselves. The hard work of informing the patient was deferred, and I cringe to think how the gravity of our countenance and the flurry of our activity tortured his imagination.

~ ~ ~

It happened every morning during “lightning rounds.” Sheepishly we stood by as the resident hurled questions at the case in the bed while jabbing her fingers into its abdomen in a cruelly ritualized abstraction that passed for a physical exam. It did not matter that the case could not understand the questions. The case had pancreatitis and the resident already knew the story. It did not matter that the case told a different story when the resident rushed away. It did not matter that we all averted our eyes, afraid to confront the fear, confusion and suffering in the case’s face. It did not matter that I was guilty by association each time the resident transformed our “team” into a pack of marauding wolves.

~ ~ ~

The anger was palpable. It was 2 a.m.—and they all knew what was coming. Starting with me, they would spend the rest of the night answering the same questions repeatedly as they made their way through the emergency room, medical admitting and finally up to the cancer unit. They were tired of rehearsing the story of their father’s nine-month decline into disseminated lymphoma with the first incorrect diagnosis, the second correct and devastating diagnosis, the three less-than-perfect surgeries, and the unexplainable complications. They could not understand why they had to rehearse the details already contained in his chart. They were fed up with doctors who seemed not to listen. They were exhausted by the disease. They were angry at me before I even entered the room.

As a medical student, I had the luxury to dedicate 60 minutes to this family. As they vented their frustration, the anger started to cool, and they left the emergency room satisfied that at least one person had listened. I worry that the structure of post-graduate training will not permit me this luxury when I am a house officer.

~ ~ ~

It puzzled me at first. It seemed odd and a little annoying that a fellow medical student would publically grill me with detailed questions after my presentation. After inquiring about my topic the day before, she had apparently done some homework. I concluded she must be a very diligent, if slightly over-eager, student.

Two weeks later I inquired about the subject of her impending presentation. I was dumbstruck when she said, “You made the mistake of telling me your topic. I’m not that stupid.”

Disturbing stories such as these are rare in my experience, but I suspect most physicians and medical students would have similar vignettes to share. Medical education is full of dedicated people with the best of intentions, but with regrettable frequency the system grows larger than the individuals within it, and the human touch is all too easily lost—if only temporarily. Each of these four stories is just a snapshot of many days and nights, but I think each illustrates a breakdown in communication. As a medical student, I was disturbed by my own role in this broken communication, but more disturbing to me was that the medical team rarely discussed these troubling experiences.

I never expected the third year to be easy. I was prepared for the long hours and the intellectual demands, but what challenged me most was learning to work within the social and professional environment of clinical medicine. All our energy was devoted to mastering the vast body of medical knowledge. We rarely took the time to reflect on what we were doing. Morning rounds were business only. Mealtimes were filled with didactic lectures in darkened amphitheaters. We discussed facts—hard data verifiable by experiment. We spent great energy on rounds to present an impenetrable facade which succeeded if it anticipated and answered all the questions of the senior physician.

There was no place for vulnerability, exposure, uncertainty or the admission of incomplete knowledge. As a result, there was no place to address the ambiguous forces that would make us reluctant to convey a diagnosis such as cancer. We were never able to expose our frustration with a system that does not always succeed in listening to the suffering of patients.

As I spoke with fellow students, I found that they shared my sense of isolation in their own struggle to interpret the experience of clinical medicine. To address this need, I met with seven other fourth-year students to organize a series of dinner-discussions that we hoped would provide a forum for the type of open and honest reflection mis-sing from our own third-year experience. So far, attendance has been sparse. Students explain that they are too busy. However, one-on-one discussions confirm that many students recognize the need to reflect together on our own development as physicians. We are still feeling our way, but in the next months we will meet with faculty and students to redesign the forum. With a little luck, we just might find a way to catalyze a new type of conversation that is both compelling for our growth and convenient for our schedules.

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Linda Z. Mowad, R.N.
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