It was a Wednesday morning. The air was crisp. The sun graced us with brilliance. I made my way to the emergency room where I was working for a two-week period on the cardiology consult service. There was much to learn, and I relished every opportunity to hear a murmur, to help diagnose a STEMI and to rush the patient to the cath lab for what I understood was a life-saving procedure. The learning experience was thrilling. My neurons were firing happily.
When I walked to the coordinator and asked if there were any cardiology consults for the team, she handed me one. I made my way to the consultant station with the patient’s chart and began decoding all the pieces of relevant information, writing them down meticulously according to the system I had developed.
This was a 65-year-old retired gentleman who was living at home with his wife. He was known to have dyslipidemia, coronary artery disease, hypertension and atrial flutter. My next instinct was to look at the ECG. There it was: the beautiful yet ominous atrial flutter with its regular, monomorphic waves between every QRS complex. Poorly controlled with medication, I assumed. I re-read the reason for consult: “sudden onset dysarthria, disequilibrium and weakness.”
I flipped to his list of medications. He had a cardiologist, surely he was anticoagulated, I thought to myself. He wasn’t. My heart sank a little. I quickly logged into the computer system to see if he had had any imaging and what his blood tests showed. There it was: a CT head, no contrast, read by the on-call radiologist. “Large cerebellar stroke…” A lump formed in the back of my throat. I do not recall what his blood tests showed. I gathered my papers and walked toward his bed, my feet suddenly feeling elephantiasis-like. I stood at the foot of the bed and took a deep breath before introducing myself. His dysarthria was too pronounced to communicate. His dizziness too severe to open his eyes. He lay there, helpless, with wires linking his chest to the cardiac monitor and IVs poking into the veins in his arms. I knew that he was well outside the window of intervention for stroke by now. Suddenly, my heart felt too heavy for my thorax to carry.
Upon discussing the case with the staff cardiologist, we had come to the conclusion that this gentleman had, in fact, had a large stroke as a result of his atrial flutter, which was poorly controlled and for which he was not preventively anticoagulated. There was no mystery to solve; this was as clear as the sun reflecting its light onto the fresh layer of snow just beyond these doors. My thoughts ran back to the Swiss Cheese Model that we were taught ad nauseam, whereby errors can be prevented at so many different levels by different people and systems before they reached the patient. It would be easy to point at his treating cardiologist and place the blame on him or her. However, pointing fingers and throwing the blame on others is rarely the solution to any problem. I wondered how something this crucial slipped through the cracks.
The sadness trickled in afterwards, catching me off-guard.
This could have been so easily prevented! I thought to myself. How are we going to break this down to his family? I felt as though we, the medical community, had failed this gentleman.
I remembered how my patients often guided me towards what we could do for them. All we had to do was listen, attentively, completely present and aware at that moment, all other preoccupations left behind. I wondered how many hints, clues and conversations were brushed off or missed by physicians, nurses, pharmacists as they were too distracted, too rushed, too preoccupied by their looming to-do lists and long lines of patients to be seen.
Perhaps, just perhaps, errors such as the one I described can be prevented if we actively pay attention. To err is human as they say. Making a mistake is easy, as I have learned thus far during my clerkship experience, particularly if you have the power a physician is given. With that power comes a hefty responsibility towards our patients and at times towards their families as well. With this responsibility comes the steep learning curve of clinical experience.
This was a reminder that active listening and being truly present and aware during the time we spend with our patients are crucial to our work as physicians and, I would posit, essential to our clinical approach. In fact, I believe these are some of our most powerful tools. The past several months of clinical exposure have also taught me that this mindfulness, being fully aware of ourselves and of the patient, is more than a tool — it is a potent antidote.
I recall a woman in her fifties who was admitted on the surgical floor for diffuse, severe chronic abdominal pain. She was extensively worked up, all to no avail. There was a small part of her that had lost hope, dreading the prospect of living a life with such excruciating pain and no clear answers. I was reassessing the patients on the service in the early afternoon when I came to her bed and began to ask the routine questions. Something about her demeanor urged me to stop asking questions so routinely and to simply ask how she was really faring. I was inclined to shift my approach from screening for problems that would need immediate fixing, such as a bowel obstruction, to an approach where I took her entire experience into consideration by recognizing her suffering. At that moment in time, she simply needed a safe space to voice her concerns and to express her fear, anger, pain and frustration. It took a conscious choice to listen attentively, to be present with her emotions, to acknowledge them and to respond to her compassionately without judgment. Afterwards, although she continued to endure the pain, it appeared as if a weight was lifted off of her chest. Perhaps she finally felt understood and emotionally safe with the team that was caring for her. Perhaps, at that stage, more than a diagnosis, this is what she needed to begin healing the emotional turmoil that comes with infirmity.
Time has revealed to me the privilege that is learning from my patients, for they are the most influential of teachers. I pray that I may continue to grow and to learn from my patients as I actively listen to them, fully aware, present, and mindful of their whole-person experience, all without judgment. I believe that therein lies the power and the essence of my ability to help my patients embark on their journey towards healing.