I am part of a writer’s group and together we are doing a 12-week course on how to write a lyrical essay. The first week’s assignment is called “Shimmers and Shards,” and the goal is for us to pay close attention to our environment, notice something “sticky” that grabs our attention, and then describe it in less than 40 words. Shimmers are those things that make us feel good or hopeful, while shards are more painful or challenging images or objects. This task is way easier said than done. We are not supposed to jump into interpretation or metaphor and are not supposed to assign meaning or start to make a story in our minds. The goal is to just describe what we are seeing/hearing/smelling/tasting, in concise, literal language.
This is very much like the initial contact a physician has with a new patient. We pay close attention to what words the patient uses in his or her effort to describe their sense of unwellness, and to initially hold back making any meaning out of their disclosure. To wait in the pregnant pause for more information. There is a risk of something called “premature closure,” which is deciding too early in the discovery period what the patient’s diagnosis may be, fitting it into a pattern one may have seen thousands of times before. This has the potential of shutting off the trickle of additional information that may steer the physician in the right direction and can lead to serious diagnostic errors. Waiting for the patient’s story to unfold is not easy for physicians, for so many different reasons. We interrupt patients an average of just 11 seconds into the patient encounter. 11 seconds. We are pressed for time, always, and start making a mental list in our mind immediately of what can explain a patient’s symptoms. We want to fix things. To decrease suffering. To move on to the next patient.
During our training we are taught that most of the time we can diagnosis a patient’s illness by paying close attention to what’s called the “HPI – the history of the present illness.” There are many acronyms medical students use as a reminder of what questions to ask the patient while their story is unfolding. OPQRST is one. O is for onset - when the symptom started. P is for palliative or pejorative - what makes the symptom better or worse. Q is for quality of the or description of the symptom – sharp, dull, pulsating, hot, cold, etc. R if for radiation, does the body sensation move to any other location. S is for severity - on a scale of 1 -10 how severe is this symptom. And T for timing - is there a time of day, month, year that this symptom emerges? It's like we are dropping crumbs for the patient to follow, leading them down a path. A story that starts to form in our mind the moment the patient opens their mouth to answer the first simple question: What is bothering you today?
If the practice of medicine allowed us the time to let the patient tell the story in their own words, at their own pace, we could answer the OPQRST questions forming in our minds by just paying close attention to what words the patient choose to use in explaining their suffering. By listening, pausing, and giving the patient more than 11 seconds. We could also notice how they hold their bodies while sharing their history, taking note of the potent non-verbal cues, the tone and pitch of their voice, and the cadence of their words.
This is something I have the privilege to do with my patients most of the time, as I work in the inpatient hospital and not in a clinic where patients are scheduled every 10 or 15 minutes, waiting in rooms and watching the clocks. On the inpatient ward I can spend as much or as little time with a patient as I need to take care of them, as long as I don’t have too many patients I am responsible for. I can see them more than once if needed. I can attend to the sickest ones first. I can talk to family members and see the patients doing their therapies in the gym. I have time to collaborate with other members of the healthcare team, the case managers, nurses, and therapists. It’s what I love about my job.
I have found a place in medicine where I can look for shimmers and shards in my patient’s recovery journeys. I celebrate the joys with them as they occur: the return of movement in their hand after a stroke. The decrease in pain in their broken hip. The improvement of their sleep after medication adjustments. The resolution of their infection or constipation. I also empathize with their setbacks and frustrations. The lack of quick recovery after a stroke that paralyzes their arm or leg. The increase in pain in their broken limbs as their activity level increases. And the great sorrow they experience as they recognize life will never be the same.
I try so hard to give my patients the space and time to tell me their own story, in their own words, at their own pace. It’s my favorite time of day at work. When I sit down to listen and pay close attention to the patient. And I continue to have faith that I will find a place to work where I can practice medicine in this way. A place where I can be in alignment with my values. A place where quality is more important than quantity. A place where I do not feel pressured to interrupt the patient after only 11 seconds.