Clinical Scenario
1. Anna: You’re making inpatient faculty rounds on a Friday afternoon. With you are three resident physicians and two medical students rotating on the otolaryngology–head and neck surgery service. Just as you finish seeing your patients, you receive a call from the daughter of one of your longtime patients informing you that her mother was admitted to the inpatient hospice unit yesterday and asking if you could stop by for a quick chat. Since you’re just one floor down, you direct the residents and students to follow you to see the patient. Anna is a delightful 84-year-old lady you’ve cared for over a two-year period who has malignant melanoma of the left posterior neck, requiring a wide excision of the melanoma and a unilateral neck dissection. Three months ago, she was found to have widely metastatic disease and has been under the care of the cancer center medical oncology team.
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December 2020As you enter the room, you and your team observe an elderly, gaunt, emaciated woman sitting elevated in her hospital bed. What isn’t usual about her appearance is that she’s wearing a red wig, bright red lipstick and nail polish, and a pink gown with a large red ribbon tied at the neck. As she recognizes you, she breaks into her characteristic cheerful smile, saying, “Oh, doctor, how kind of you to take time away from your busy day to visit.” Behind you, one of the medical students stifles a snicker at her bold appearance.
You approach the bed, and she painfully moves aside and pats the bed for you to sit beside her. “Doctor, you look so very tired,” she says. “Are you working too hard caring for patients to sit a spell with me?”
“Miss Anna, I would never be too tired to visit with you,” you respond. “Is there anything you need that I can get for you?”
“That’s just like you to ask about me when you’re helping so many people. How are you feeling?”
“I’m okay, thanks. Do you have much pain?”
“You’re so kind. I’m fine, really. Nothing to worry you about.” She pauses for a moment. “I’ll remember you for as long as I live.”
“Miss Anna, is it all right if I just stay a while and talk?” you ask. “I don’t want to tire you out.”
“Doctor,” she says, “I have all the time in the world for you. Tell me all about your life and family—I’m a very good listener. Never forget that family is the most important thing in life, and good friends are blessings.”
2. Dennis: You’re staffing the ENT Clinic at the local VA medical center. The junior resident presents the next patient to you after the interview and initial examination. Dennis is an 89-year-old gentleman who has an upper lip lesion that’s been growing over the past four to five years. The resident presents the pertinent aspects of the patient’s history, as well as the head and neck examination findings. When you enter the exam room, you see an elderly, distinguished-appearing gentleman, clean shaven with a neat military haircut, dressed in a clean workman’s shirt and neatly pressed work pants.
Our patients are more than just their disease—they are parents, spouses, and children, all struggling to find meaning in their lives and achieve some level of happiness and health.
As you shake his hand and introduce yourself, you notice he’s missing the distal fingertips of his right hand, and you observe atrophy of the helices of both ears, findings the resident may have missed. Indeed, there is a lesion on the upper lip, which on closer inspection with a dermatoscope appears to be a classic basal cell carcinoma. However, before you discuss the diagnostic and management options of the lesion, you inquire of the patient what happened to his ears and fingertips. He looks at you quizzically. “Frostbite,” he answers.
“What were the circumstances?” you press.
“Are you interested out of curiosity, Doc, or do you have a theory?”
“A little of both, I guess.”
“You been in the military, doc?”
When you answer “yes,” he asks, “Any combat deployments?”
“Two,” you answer.
“Okay, then. Marines, Chosin Reservoir, Korea, November 27 to December 13, 1950, then as a forced guest of the Chinese Communists until I escaped.”
(You sneak a closer look at the electronic health record and see that Marine Gunnery Sergeant Dennis was awarded the Navy Cross, the Silver Star, the Purple Heart, and the Prisoner of War Medal.)
“It’s a great honor to meet you, Gunny,” you say. “For the sake of this young resident, what lessons have you learned during your time in active service?”
“Every human life has meaning. Every life deserves respect and dignity. Be courteous to others. And you keep persisting, no matter what, to the end. Believe in a Higher Power, because we can’t do it alone. And, don’t complain when life gets hard. That’s when we learn what we’re really made of.”
What ethical lessons have these patients taught their doctors?
Discussion
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Too often we take for granted the impact our patients have on our lives and fail to learn valuable humanistic lessons from them. Certainly, we’re quite aware of their undoubtedly important contributions to our knowledge of pathophysiology and normal vs. abnormal findings. Yet, we don’t always appreciate that what we learn from them about human nature can be of equal value with what we learn medically.
We live and work in the realm of human beings. We make recommendations to, and facilitate shared decision-making with, individuals who are emotionally and cognitively complex and face complicated challenges in their life’s relationships—just like us. Perhaps the most important lessons we can learn from our patients are related to humanism, where our observations of their human interactions and behavior provide invaluable information we need to care for them. The revered patient-physician relationship, so fundamental to the entire notion of caring for others, can be a mirror reflecting our own capabilities and failings.
My first impactful lesson in respect for patients as people occurred in my gross anatomy class, where my professor (a physician and international anatomist) taught that individuals should always be respected, in life and in death. My cadaver was himself a former professor of anatomy at a major medical school in the Midwest who had donated his body for our learning as a final act of educational generosity. At every dissection session, we were reminded that, as future physicians, we were expected to understand that our patients, in life and in death, provide an unbelievably rich opportunity to learn about not only the intricacies of the human body, but also their humanity.
Each patient contact, even during short interactions, adds to our growing appreciation of the complexity of human nature, emotions, and communication. In medical school and during residency, we learned about disease from the microscopic to the macroscopic. But learning about human nature takes a lifetime of experience and exposure.
Some of our education about human nature and communication is subliminal, not quite on the surface enough to verbalize or quantify. The rest can be measured and is informative, if we take the time to listen, observe, and interact.
Our patients are more than just their disease—they’re parents, spouses, and children, all struggling to find meaning in their lives and achieve some level of happiness and health. They are us, and we are them. We care for easy and difficult patients, and we share human fragility with them. The more we understand their presentations of anger, sadness, fear, happiness, and other human emotions, the more empathetic and capable we can become as physicians. We can learn directly from our patients what we’re doing well and where we need improvement.
The ethics of professionalism identify a number of traits and virtues that are expected to be exemplified in physicians’ personal and professional lives. These include, in part, excellence, compassion and caring, empathy, honesty, moral courage, kindness, judgment, selflessness, and humanism. The practice of medicine is just that—practice. While the majority of these exemplary traits are inculcated early in our lives, there’s still plenty of room for improvement and expression through the years. How patients view us, how they respond to us, and how they show us where we need to improve all have fundamental value. Our patients can make us better people and physicians if we listen, observe, contemplate, and improve.
Humility, in the sense of listening more than talking, is part and parcel of a virtuous approach to patient care.
In the two clinical scenarios, each patient taught us something valuable about human nature. Anna is dying, yet her focus during the encounter wasn’t on herself, but rather on the physician. What a brave and resilient person! She shows us the human capacity for dignity at the end of life. Her appearance with the wig, lipstick, fingernail polish, and pink nightgown demonstrates that she’s in charge of her life even to the end, not allowing her impending death to change her approach to living. (There’s also a lesson to be learned by the medical student who subtly derided her appearance.) How our fellow human beings face death and dying presents an opportunity for us, as physicians and people, to respond to them in more appropriate and personal ways, with which we previously may not have been comfortable. Anna also teaches us to pay attention to our own and our loved ones’ wellness, for someday we will be where she is. She reflects our own mortality and helps us cope through her demonstration of moral courage and autonomy. Life is fragile, but worth living in full to the end.
Dennis also teaches us about how to deal with indescribable challenges in life—surviving combat in Korea, fighting alongside brothers-in-arms and watching them die, suffering frostbite, being captured and tortured, and enduring and escaping a prisoner of war camp. He demonstrated the highest level of personal courage and perseverance as a soldier. Many combat veterans are reticent to readily tell their stories to anyone except fellow veterans; humility comes from a well-placed and well-discharged sense of duty. Listening more than talking is part and parcel of a virtuous approach to patient care. In Dennis, we recognize strength in the face of adversity, and a commitment to the ideals of honor, duty, and country.
When we actively and empathetically listen to patients, we’re able to better understand who they are as human beings and then apply that knowledge to the care we offer them. The successful physician-patient relationship depends upon our ability to use the art and science of medicine to properly care for patients. What we can learn from them about human nature and dealing with illness is best learned not from textbooks, but from our listening to, observing, and understanding them throughout our entire careers.
I extend my personal and professional gratitude to all of my patients encountered over my 50-plus years as a physician for what they’ve taught me about life, living and dying, and how to be a better physician and human being. I couldn’t have done it without them.
Dr. G. Richard Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.