Moments That Matter

Our patients are often our most powerful teachers. One of mine was Robby, a middle-aged former stock car racer I met while scribing who had completed treatment for rectal cancer a decade prior. The doctor and I entered his examination room prepared with a note and a plan. Robby always greeted us with a smile. I was used to being the silent ghost in the corner, typing away, but he made me feel like an old friend. He had a knack for finding humor in everything. I was tracking the passage of time during this appointment not by my watch hands, but by Robby’s hearty laugh. Twelve or 13 Robby-laughs later, after confirming there were no changes to his health, the appointment seemed to be concluding. Orders had been placed and the note was nearly finalized. I was already thinking about our next patient. Then Robby said, “I have one more thing,” in a quieter voice. His smile wavered, then disintegrated. He broke eye contact and whispered, “My son Marco just died.” The room went silent. Robby had spoken so quietly we almost missed it. His words hovered in the center of the room like a black hole, sucking in air. The 3 of us were in a vacuum, none breathing for fear of disturbing the sudden solemnity of the moment. The doctor walked over to Robby, reached under her face shield, and wiped away a tear. She hugged him, her first patient hug in months, and said, “I’m sorry, Robby. I’m so sorry.” Robby let out a shaky half-sob, then gave the doctor a small smile. He began talking about Marco. We listened. Robby began at the end and ended at the beginning. Marco had found a career and mellowed out. Before that had been teenage rebellion and tattoos. He had been a shy, quiet child, and difficult for Robby to relate to. While Robby spoke, his body stayed with us, but his mind went elsewhere, to another time. Slowly, air seeped back into the room. First hesitantly, then with gusto, Robby’s laughs returned, too. His face was still wet with tears, but their paths were interrupted by his smile. We took a collective breath and the appointment ended with another hug. Robby sent handwritten letters after every appointment. This time he thanked the doctor for “taking care of me—all of me.” Her listening and hugs had been comforting during the sharp sting of grief. This visit kept replaying in my head. It was an example of the doorknob phenomenon, when patients wait until the last possible moment to utter crucial new information. Usually, these revelations are about symptoms. In this case, it was a deeply personal tragedy. Robby had given us the gift of vulnerability. On reflection, I realized he had given us another gift: a lesson. He made me think about restructuring visits to identify crucial personal life events earlier. Robby taught me to open appointments with open questions. It can mean the world to patients if the first questions you ask leave room for them to answer personally or medically. For example, I started asking, “How are you doing?” instead of “How are your symptoms?” because that opens the door equally to talk about their daughter’s upcoming wedding or their peripheral neuropathy. Critically, it signals to patients that you care about them holistically and want them to have agency in the conversation. By asking these questions, we populate our notes with fuller pictures of our patients, less impersonal and autocompleted. As medical professionals, it is tempting to cultivate a razor-sharp focus on symptoms and diagnoses. Robby helped me realize our former approach was like a racehorse with blinders: fast, but risking missing something important. In the rush, we almost missed providing emotional support—something else patients like Robby come to us for. Robby left one more gift, just for me. He closed his letter with a message: Brian, I pray you will be a doctor like this one day, one who cares so deeply for your patients. Watch and listen for our signals. We are telling you what we need. Meet us where we are in these moments that matter most. All the best. Einkauf, Freja K. Ekman, and Basil M. Baccouche for their generous feedback and support

Art · Nothing · Visual arts · Empathy and Medical Education · History · Medicine · Philosophy · Psychology