This article has been de-identified to protect the anonymity and confidentiality of the patient in the story. Any matches in names or circumstances to other real patients are entirely coincidental.
“I’m just afraid I’ll never get better,” said Mr. X, dejectedly.
“Why do you feel that way?” I asked.
My question opened the Pandora’s box of Mr. X’s life. Rarely had I heard such devastating stories, from his recurrent violent childhood abuse to his persistently debilitating medical conditions. His life had been one trial after another. I began to understand why he was so fearful that his current medical problem would never improve.
Over the next half-hour, with many nods of sympathy, shakes of my head in empathetic disbelief, and angry tenses of my jaw behind my mask, I heard the most intimate and harrowing details of Mr. X’s life. But the most surprising detail was yet to come.
“Have you ever talked through this with a therapist or doctor?”
“No,” said Mr. X. “I rarely talk about these things with anybody. What I’m doing now is not normal. I don’t tend to want to talk about it.”
I was floored. Mr. X had been regularly receiving medical care for most of his adult life because of his litany of health issues. But beyond brief mentions of his childhood abuse, he had never disclosed the extent of his trauma with anyone who could treat him — until now. With me. And as a medical student, I couldn’t even treat him.
“May I ask why you decided to share this with me today?” I asked.
“I guess I feel safe right now. You seem like a very kind person. So I think I can trust you,” he replied.
Mr. X’s words once again stunned me, as they implied that he didn’t feel safe enough to share this information with any of his doctors before. Yet this information was vital to his care, as unresolved distress from traumatic life experiences greatly contributes to complex pain syndromes. With Mr. X's permission, I shared all of this with his physician, who was my preceptor that day. I could tell that he understood the seriousness of the matter and spoke with Mr. X about it. It reassured me to know that Mr. X’s life story was finally beginning to receive rightful attention in his care.
I took Mr. X’s reticence to share his story with his doctors to be an indictment of modern health care in the United States. A reimbursement-based medical system in which primary care doctors are monetarily incentivized to see more patients in less time was not conducive to uncovering the depths of Mr. X’s heartache. There was barely enough time to just take a cursory history, perform a physical examination, review his labs, and discuss additional testing and treatment.
I have gleaned that many doctors are willing and wanting to hear their patients’ life stories and address their emotional needs, especially as they pertain to present health issues. But they are constrained by external factors that pressure them to refer patients with “complex” psychosocial problems to psychiatrists or social workers. But if patients do not feel safe with their current providers, why would they trust their referrals?
As a medical student, I am only scratching the surface of what day-to-day interactions with patients look like. Sometimes I am disappointed and enervated by the increasingly transactional nature of the patient-physician relationship. I wonder how I will commit to the heart of patient care when hounded by modern technocratic medicine, which interrupts face-to-face conversations between patients and doctors with excessive machines, algorithms and electronic medical records.
There is, however, one indispensable lesson that Mr. X taught me: While we cannot immediately mitigate the external impedances to patient care, we can always recognize and resolve the internal impedances within ourselves. Had I decided to ignore Mr. X’s subtle comment that his condition might never improve, I would not have asked him to tell me why he felt that way. I could have quickly reassured him and steered the conversation “back on track” to his medical diagnosis. And after he began to open up about his trauma, I could have decided not to ask whether he had previously shared this with any of his doctors. But since he kept sharing, I was comfortable to continue asking, and trust began to emerge between patient and medical student. Although I could not offer him any real medical care, I could advocate for him, as I did by informing his doctor that day. Could that be the care he really needed?
We hear in medical training how empathetic listening is so important to patient care. I have wondered what real difference this theoretical reality makes to patients beyond their level of satisfaction. Can empathetic listening influence hard outcomes, like health care utilization, morbidity and mortality, or does it serve primarily to make patients feel warm and fuzzy inside? And does this even matter?
Mr. X answered both questions for me. Even if empathetic listening yielded no detectable differences in hard outcomes, the tears he shed and the relief I saw in his eyes from feeling like someone truly cared about him was enough evidence of its value for me. And when I asked him if he’d be open to exploring these issues further with a therapist — something he hadn’t wanted to do before — he hesitated but said he was open. At that moment, I think that meant a lot.
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