Anything else?

Do you always feel comfortable asking your doctor all of your questions?  I thought I did, until late one summer, when my legs suddenly started to itch.  It began on the lower aspects of both shins and spread steadily, up to my knees, then my thighs, and then my arms, with little pink bumps.  The itching was moderate, I could still get through my day, but I didn’t know what it was.  After a few weeks I made an appointment with dermatology.

I was a model patient—told my story in chronological order, all the pertinent details laid out neatly for the resident who saw me first.  I made his job easy; he appreciated that.  We both surmised that it probably wasn’t anything serious, maybe viral, and would likely resolve with time and some steroid cream.  The attending entered several minutes later, having heard the story outside of the exam room.  We all agreed on the diagnosis and treatment, easy-peasy.  I felt proud for keeping their clinic on schedule.

Then I suddenly remembered other bumps on my hands that I had always wanted to ask a dermatologist about.  Present for years, there were just a few—pinhead or smaller, round, translucent nodes on my palm, which would always grow back a few days after I pinched them off.  I showed them to the attending doctor and asked what they were.  He said they were nothing, and that I could just live with them.  And that was that.  I only realized later how unsatisfied I felt.  What were they?  What caused them?  What should I expect, would they ever go away?  I just wanted to know, to learn.  He didn’t really answer my question (though I suspect he thought he did), and I felt too sheepish to ask anything more, as if I were wasting his time.  I can’t blame him entirely—he was not intentionally dismissive or rushed; actually he was perfectly pleasant.  But something made me shut up when I really wanted to engage him.  It fascinates me to this day: I am a doctor; I gave my doctors what they needed from me, and could not get what I needed for myself.  The rash resolved with ointment and my hand bumps persist.  I still regard them with annoyed curiosity, and remember that encounter.  It was humbling, to be sure.

By contrast, my kids’ allergist regularly invited me to ask questions.  He knew my background, and explained things to me in a collegial way.  He would then speak to my kids in language that they could understand.  I always came prepared for his appointments, a list of events and questions in hand.  Toward the end of every visit he always asked, “Anything else?”  No, we’re good.  Some more small talk, follow up plans…  “Anything else?”  Umm, no, thanks, I think we got it.  Prescriptions, parking validation…  “Anything else?”  Really?

At first I started to wonder, ‘Am I missing something?  Is he hinting at me?  What else, there must be something else, think, woman!’  And, ‘Does he have some kind of tic?’  Then I realized: He made an intentional practice of making it safe for patients to ask questions. He understood how patients got tongue-tied in his presence, and made repeated, conscious efforts to untie us.  Brilliant!  Maybe it cost him a few extra minutes each visit, maybe not.  His sincere interest in my concerns, though, earned him my trust and respect.  As a fellow physician, I know the value and rewards of that.  And now I ask my own patients often, “Anything else?”

Beyond the Rant

For the better part of 20 years, I have had the humble privilege of working with medical students.  Whenever I spend time with them, I learn at least as much as I teach, and I come away inspired.

This day was no different, and I will never forget it.  We gathered in the stark conference center for a day-long communication skills workshop—physicians, nurse practitioners, residents, and medical students.  The facilitators came from the Alan Alda Center for Communicating Science; if you ever have a chance to learn from them, I highly recommend it.  I could almost palpate the group’s shy, tense, anticipatory excitement—this was a high-potential learning situation.  After time-travel role playing, imaginary ball-throwing, and Zip-Zap-Zopping with abandon, we relaxed into the liberated format that is improv-based learning.  That’s when I experienced an unqualified quantum leap in consciousness.  It came in the form of a rant.

The instructions:

Partner A: Rant rant rant, HARD, about something that really makes you angry—that truly enrages you, nothing small.  Not allowed to make it up, must be honest, let loose.  Yell, stomp, swear, etc., for two minutes straight.

Partner B: Listen, be present, no talking.  Introduce A to the group afterward.  The catch:  At no time during the introduction should the group be able to tell what A ranted about.

I paired up with Erik, a fourth year medical student.  I did the rage gods proud as I cursed and flailed for two full minutes about the victim mentality.  Your parents ignored you?  Your boss is a jerk? You’re stuck in a dead-end job in a crime-ridden city, hovelled in a grungy apartment with no view, and it’s all someone else’s fault?  Suck it up!  And on it went.  Erik stuck with me through it all, looking me straight in the eye and never flinching.  He introduced me thusly:

“This is my friend Cathy.  Cathy believes strongly, with her whole being, that each and every person has the strength and capacity to overcome any adversity, and lift himself out of whatever situation holds him back.  She believes in people, and wants to see them succeed, no matter what the circumstances.”  Nailed it.  What a powerful thing, to have someone distill and give voice to my core value, and after I had just raved like a lunatic, no less.  I had never met Erik before that exercise, and I felt an instant bond.  He saw me, and showed me a part of myself that I had not seen before. I am proud to know him.

Often when we witness ranting, we pile on and trigger an avalanche of mutual self-righteousness, or we unwittingly invalidate the person by arguing a counterpoint.  The practice of listening beyond the rant, hearing the core value, and then reflecting it, serves a higher calling.  It connects, validates, and settles.  It offers the ranter a mirror, an opportunity for self-reflection and awareness.  If we practice consistently, on each other and ourselves alike, we can hardly help but emerge transformed.

The Best of Both Worlds

I met my husband my second day on campus at Northwestern University, 1991. He started one year ahead of me; I met him in the bookstore. He was an established  molecular biology major, having years of laboratory research experience behind him already. I, too, decided to major in biology, but with a concentration in physiology. The micro and the macro–that may describe us in a nutshell: Both awed by the mysterious and yet completely logical ways of the body—the ultimate integrated system—but from opposite ends of the spectrum. We trained at the University of Chicago, that mecca of hard core basic science. Research and discovery of the fundamental mechanisms of disease—much of it at the molecular level—still thrills him, and leaves me positively lethargic. Show me how people transform health through relationships and beliefs, how the mind and body are connected in ways we cannot measure—that seizes my attention.

Today my husband specializes in orthopaedic tumors and joint replacement, and I do primary care. Much of his professional world consists of binary decision making: operate or not, the experiment proved the hypothesis or not. I like exploring multiple solutions for a particular problem, withholding judgment, and trying one approach at a time. Personally, he likes to be alone; I love people, the more the better! He makes decisions based largely on data and devoid of emotions, whereas I root my decision trees firmly in how I feel about the issue at hand. I seek color, texture, and meaning in everything around me; his needs are pragmatic, functional, and stoic.

And yet, what seems contrasting and opposed turns out to be, in every sense of the word, complementary. For the most part, we both balance objective and empathic information when making decisions. But when my emotions run high and objective data look fuzzy, he points out the practical implications of my choices. When he faces decisions that impact relationships, I help him identify core values that lead him to settle on one side of an issue with confidence. When both people in a relationship are free to be fully themselves, without fear of judgment or ridicule, their differences, and respective strengths, hold each other up.

The most interesting conversations we have about work revolve around teaching.  As a surgeon, his primary charge is to prepare his trainees to be technically excellent in the operating room, to carry out patient care decisions with confidence and resolve. Nobody wants a wishy-washy surgeon. My teaching focuses on fostering empathy, role modeling excellent listening skills, and showing students that no matter what specialty they choose, their patients will always need to feel seen, heard, understood, and cared for. In primary care, the old saying, “They won’t care how much you know until they know how much you care,” has explicit meaning. I like to think that because of me, my husband models more mindful interpersonal skills for his residents and students. And because of him, I try always to incorporate evidence and concrete, goal-oriented rationale in my decision making. We influence each other for the better.

The long-standing tension between surgeons and non-surgeons remains a fact of life in medicine today.  Stereotypes peg internists as ruminating and indecisive, and orthopaedists as dull-witted, mallet-wielding carpenters. This territorial, oppositional culture can be insidious and damaging.  How can we do best by our patients if we cannot get along ourselves?  In our ‘mixed’ marriage, I see us bridging this gap.  I hope it translates to better patient care. For ourselves, at least, it makes for interesting dinner conversation and a shared love for our work. And we would not have it any other way. Footnote: I first published this post on the American Holistic Medical Association blog in 2012.