“Where is the lub-dub?!”
Something was terribly wrong, at the earliest possible moment in my medical career. It was a moment of crisis for me on an otherwise ordinary weeknight more than a decade ago. Just after I had begun medical school, the medical equipment salesman had brought his wares to our classroom one fall evening. Every one of my medical school classmates was testing out otoscopes, ophthalmoscopes, and stethoscopes. Here I was–the recipient of a new, highly starched white coat with my name embroidered on it–and I couldn’t hear my own heart beat! There must have been a terrible mistake when they had admitted me to medical school, I felt certain.
Embarrassed and not a little insecure, I found a classmate nearby who pointed out that I had put in the stethoscope earpieces backwards. I turned the stethoscope around, and to my great relief, there were my heart sounds. At last I could hear the “lub-dub” that my professors told me to listen for. Thus began my career in cardiac auscultation (from the Latin auscultare, meaning “to listen”)–rather inauspiciously.
A dozen years later at the Upper Cardozo Health Center in Washington, DC–where I practice primary care pediatrics and internal medicine–many of the families I care for are members of the working class, uninsured or underinsured, and are either immigrants or are the children of immigrants. Their stories–indeed, their heart cries–have challenged my auscultation skills, and they expose some important shortcomings in my repertoire of diagnostic and therapeutic tools.
Laura is the Salvadoran mother of David, a five-year-old boy with severe asthma. She cannot bear to tell her wheezing son that his Guatemalan father was detained two days ago and is scheduled to be deported soon. So she confides in me, bursting into tears as soon as she steps into the exam room. “What should I do?” she asks desperately. “My son keeps asking, ‘Where is daddy?’ I cannot tell him what happened, but neither do I want to lie to him.”
How do I auscultate the sound of a heart that is breaking? What diagnosis should I make? This is no mere asthma exacerbation. And what treatment should I recommend? An inhaled bronchodilator medication is wholly insufficient. The best I can come up with is to write a simple letter addressed “to whom it may concern,” outlining David’s health concerns and the potential impact of the loss of his father.
Santos is a 36-year-old married father of two who works in the kitchen of a local restaurant. One day he tells me that he cannot cope with the fact that for the first time, he forgot to call his eight-year-old son back in El Salvador on his birthday. In fact, the stress of being physically disconnected and apart from his children bothers him so much that he cannot sleep at night, and he suspects that it is straining his already fragile marriage. A mere prescription for medication is unlikely to solve Santos’s problems. Active listening, or reflecting back his concerns to him in his native Spanish, may be a helpful, if humble, start. But it is incomplete. My stethoscope is rendered nearly useless.
When patients approach me with psychosocial concerns, oftentimes I feel unprepared to evaluate and treat them in a manner that truly comprehends or attends to the cries of their hearts. It is easier for me to latch on to my stethoscope than it is to hear out their concerns directly by being fully present, just as it is easier to define their problems in medical terms (palpitations, insomnia, asthma exacerbation, or adjustment disorder), than it is for me to put into practice the adage of the 19th-century German physician Rudolf Virchow, who said that “physicians are the natural attorneys for the poor.”
In this era when as a clinician I tend to be driven to distraction (text and e-mail messages, phone calls, and pages abound; the electronic health record diverts my eyes from the patient and onto the screen), it is possible to hurriedly rush through dozens of patient encounters in a given day–yet still run late for almost every one of them!
Recently I found hopeful insight in the advice of the late Russian Orthodox archbishop and physician Anthony Bloom, from his 1970 book “Beginning to Pray.” He writes of his work with patients on pp. 88-89:
You can simply be concerned with the person or task that is in front of you, and when you have finished, you will discover that you have spent half the time doing it, instead of all the time you took before; yet you have seen everything and heard everything…
Once you have learned not to fidget, then you can do anything, at any speed, with any amount of attention and briskness, without having the sense of time escaping you or catching up with you. It is like the feeling…of…when you are on holiday, with all your holiday ahead of you. You can be quick or slow, without any sense of time, because you are only doing what you are doing…
It is time to focus on the person in front of me. I’m all ears.
Dr. Ryan Buchholz practices primary care pediatrics and internal medicine at the Upper Cardozo Health Center in Washington D.C.