Silence and Humility

Chief complaint. History of present illness. That was it. I had been a bit nervous, 30 minutes into our Practice of Medicine course, after realizing that I would be seeing patients just weeks after receiving my white coat. At first, I had attempted to quell this nervousness by focusing on the low stakes. But, owing to my therapeutic contributions (or lack thereof), I then faced an even more unsettling conundrum while approaching my patient’s door: With minimal medical knowledge at hand, what could my classmates and I possibly learn from our first patient interviews? No matter. By the time I had formed this question in my mind, I was entering the room of Mr. L., an older man sitting on a bedside chair, covered in a blanket and staring out the window. “Hello, Mr. L.,” I said. “How are you doing? My name is Aldis. I am a first-year medical student.” He looked at me quizzically. I wondered what he was thinking but did not take the time to find out, largely because I had been repeating a clinical mnemonic used to assess a patient’s pain—OPQRSTAAA (onset, position, quality, radiation, severity, timing, aggravation factors, alleviating factors, and associated symptoms)—in my mind for the previous 20 minutes, and I was intent on dutifully shifting to “O,” for onset. “So, Mr. L., can you tell me how your symptoms started?” “Well,” he began. And so ensued a long narration which I struggled to keep track of—a web of times, places, frustrations, symptoms, and confusions. Preparing each subsequent question while he answered the one before it, I tried desperately to avoid awkward pauses, lest he take the moment to realize I had no idea what I was doing. Yet as Mr. L. continued his list of physiological ailments, my mind began moving in a different direction, posing questions not listed in my preparatory materials. What did this man fear? I wondered. What mattered to him? It was a curious direction to take, but I had grown increasingly certain that Mr. L. was unhappy, and not merely in the way that anyone sick and in the hospital is unhappy. Having exhausted my abounding knowledge of OPQRSTAAA, I asked him what was wrong. “I was so healthy for so long,” he said forcefully, yet solemnly, looking through the window. “That sounds ... incredibly frustrating,” I replied. Incredibly frustrating? It was certainly how I would have felt, but the phrase left me almost embarrassed, wishing I could offer more than, as those gifted in the art would call, an empathic statement. But then Mr. L. replied, “It is incredibly frustrating!” and swung his head back toward me. For the first time, I saw genuine despair seep through the cracks of his stalwart exterior. His eyes widened, his brows ascended to mid-forehead, and his voice echoed in the room. He was frightened. “What are you most worried about?” I asked him. “I ... I’m not sure my life will be worth living.” And we were quiet again. Perhaps the question of whether someone else’s life was worth living was of prime importance in my classmates’ minds that morning, but until that point, I had been far more concerned with how I looked, how I would manage the morning session, and whether, in my nervousness, I qualified as tachycardic. Now, in the unavoidable silence, I was forced to consider Mr. L., his mind, and world. I was forced to move beyond myself, and in that movement, understand that a medical education meant far more than the acquisition and demonstration of clinical knowledge. It meant, at times, the silent and humble witness of the life, and suffering, of another human being. And as far as witness went, there was something powerful about meeting Mr. L. so early in my training that I could not delude myself into thinking I had any grand wisdom to offer. Empty of all but myself, I was forced to see this man not for his symptoms, but as a complex, life-loving, fear-laden human being. And in that recognition—that silent opening for feeling and connection, making room for his vulnerable confession—I felt the existence of a knowledge and healing beyond histories and treatment. As I approach my clerkship year, I hope always to seek for that knowledge and healing, however briefly, amid the struggle and uncertainty of my work and my patients’ lives. Lives that are so much larger than illnesses and complaints.

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