Listen and Learn

In the fourth month of internship I can say for sure that I've learned one thing well: Humility. Well maybe two, to listen and I might just learn something.

Reality has set in. Months of 10-hour shifts, forever chiming beepers, and up-all-night calls addressing 3:00 AM chest pain and shortness of breath is a like a sucker punch in the gut to a wise-eyed, clean-pressed white coat wearing optimist. It's not the patients or even addressing their concerns. My patients have come to the emergency department or have been admitted to the hospital. They're concerned, and I'm happy to address their problems and hopefully relieve their fear.

Here's the rub; I'm afraid I don't know what I'm talking about. Sure I can explain basic things, and I'm a pro at viral coughs, nausea and vomiting, and runny noses. The simple stuff; I can handle that. It's the complicated, subtle presentations (and sometimes the not-so-subtle case that slips right through my brain without matching some once-remembered pattern from an amalgam of medical school lectures, thick books filled with illustrations, and a couple short months of experience) that give me fits. I present diagnostic and therapeutic plans that are sometimes more guesses than blueprints for discovering and prescribing appropriate medicines for maladies. For instance just last night in a young child with a throat injury, I wanted to order a lateral x-ray of the neck. I was concerned about the little guy's airway patency. Nevermind he was kicking and screaming as I examined him, prying his mouth open with a tongue blade and the help of both mom and dad holding an arm and leg each, trying to look in the back of his throat. If I'd considered that physical exam finding, I'd have surmised my two-year-old's airway was most certainly open and breathing was more than adequate. However, a lateral radiograph of the neck was the right test to order. I just wanted it for the wrong reason. Concern was well-placed as he should be evaluated for the possiblity of air in the retropharyngeal space (the soft tissue behind the airway in front of the spinal column). Sure enough, he'd punctured the back of his throat and was taken to surgery the next day. I'd ordered the right test, for the wrong reasons. When I present and end up posing more questions to my attending (supervising) physician that I answer in the same 6 sentences, I try to remember that there's a reason this process takes 11 years, and it's not because it's easy.

I'm becoming a better question asker every day. The secret part of asking medical questions is that it's not always the words you use or the volume of discussion that matters but the way you ask things, or the order you use, or maybe the intonation of your voice and emphasis that will unlock the hidden history that a patient just hasn't considered previously.

Patients with real organic pathology don't often want to lie. There is the rare case they're embarrassed or frightened by something about doctors or the hospital or circumstance. More often when patients lie, they do it poorly. So poorly, that it's not hard to discern the truth from fiction. Even mediocre listening debugs a malingerer quickly.

I hope I'm listening better too. With so many resources in the form of nurses, attending physicians, fellow residents, there are so many people to learn from that are interested in teaching. I just have to make myself ask, and sometimes that's harder than making myself ask for directions at a road-side gas station.

Hopefully I'll continue to develop my clinical recognition skills, start to know both the right tests and right reasons, and continue to listen when I ask questions at the right time in the right way. And maybe I've learned a second thing: to listen. Listen to my attendings, my teachers. They sought teaching positions accepting less money than elsewhere because they relish the chance to teaching me. They must think there's something important about this process. One of my emergency medicine attendings likes to remind me that emergency medicine residency is a three-year process, not an immediately attained destination. He quips, "You're being impatient like my 12-year-old daughter. You don't have to be perfect, Andy. You want to do everything perfectly too soon. It's your third month."

Maybe it seems like I want to be perfect, but mostly I don't want to hurt anyone or endanger them. If I can pull that off sometime soon, I think I'd be happy. So I'll remember a usually all-too-obvious fact, I don't know everything and I more often feel like I don't know anything. I'll listen to my bosses, the nurses, my patients - everyone who might want to teach me something. If I Listen to my patients, to hear how they feel, what's been going on that has them worried, and why they've come to the emergency department at 3:16 AM with a toothache, maybe that will be a good start and a big step on this evolving process of residency training. They must need something. Right?

--Andrew Jacques ('05)