Meanings

Can we ever understand each other? Know what is being asked of us? It’s not just a medical problem; it’s universal, I suspect. And it’s one that entails far more than simply comprehending the meaning of a word in both its denotative (definitional) as well as its connotative (secondary, or evocative) usage. It involves apprehending -truly appreciating – whatever is intended in the communication.

In a sense it is often a relational concept: we are linked in a sort of symbiosis and inherent in that is the empathetic interpretation of what is being conveyed. Friends potentially have this: Don’t listen to what I say; hear what I mean. We all hope for this, I think -especially when things are hard to express, when words fail, as it were. When we need the other person to grasp something we cannot adequately articulate, we are at a loss -or perhaps more accurately, at a disadvantage- in terms of receiving their help or advice. Words, large or small, can be impediments.

And this is particularly salient in medical encounters where both unfamiliarity with appropriate terminology as well, perhaps, as embarrassment, conspire to camouflage the reason for the visit. Where you say pain, but really mean cramp, or perhaps irregular -referring to your menses, for example- when you actually mean totally unpredictable, or maybe that you’ve even stopped trying to keep track of them… Where cancer could mean something you think your grandmother had -but nobody would talk about it with you- or that in fact it’s what you think you have but are afraid to verbalize it. Heavy is what your periods are not -even though you are anaemic- because they’ve always been like that, and so were your mother’s: They are normal, doctor

I realize this is not usually a major obstacle to doctor-patient relationships, because over time doctors learn to listen to what is not being said; the encounter is frequently more valuable than the words in it -no matter how descriptive. It is also why it is often so difficult to address problems over the phone.

Through the years, I have struck by the need not only to be a good listener, but a good and careful observer. There is as much meaning in silence as in conversation; as much information in examination as description. Words are susceptible to challenge, or misinterpretation; unimportant ones can be uttered with emphasis, significant ones mumbled sotto voce. Comfort level is privileged and not summonable at will. Words escape from the top of the tongue, or are inadvertently trapped behind the teeth; meaning is sometimes a prisoner to safety -be it cultural, or personal. And it can be as unpredictable as the weather; as fickle as a mood…

So then, how can we understand each other -especially in moments of crisis? How can we ensure that others know what we intend -what we need to convey? Is it as simple as choosing the right words, the right syntax? Is it a vocabulary issue, or something more complex? More profound? From the doctor point of view, I would argue for the latter; I think that the essence that underscores all communication, that underlies all meaning, is engagement: being present in the situation at hand; imbedded in the message -both obvious and covert, intended and accidental; alert to context; aware of the unspoken. Words, after all is said, are just drawings in sound; to understand, to really comprehend, we must listen with more than our ears, see with more than our eyes. To listen fully, we must hear.

It is not an arcane prescription, not something requiring years of training; it is what we all attempt when we truly care; it is what is missing when we do not… And absence of the effort is something Shakespeare noticed so many years ago (Henry IV part II):

It is the disease of not listening,
the malady of not marking,
that I am troubled withal.

Touch

Several years ago, I noticed a lump in my neck; I was no longer young, and I was terrified. The differential diagnosis was given to me by a colleague I greatly respected, but I had not expected the presentation to be so matter of fact. I don’t know what I had anticipated, but somehow there was a gap between her words and my condition, between her and me, I suppose. That something so important to me could be offered as mere words seemed inadequate. Incomplete. When I looked into her eyes hoping I had misheard, I could see the compassion and the empathy, but it was more like reading a story in a book: the information was there, the meaning clear, but it required an effort on my part to extract it. The story, in other words, was incomplete.

And then she did something that I will always remember -something that for me, proved I had gone to the right doctor: she reached across and touched the hand I had placed on her desk to steady myself. That little gesture of reassurance, that small reminder of the link we all share was enough to see me through that day. And it taught me something about medicine -no, about humanity. About Life.

Words are sometimes simply not enough; explanations, however thorough, are often incomplete.

There’s something magical about touch. I saw a patient in the office on whom I had recently operated. After asking her the usual questions about how she was feeling now that her much-anticipated and dreaded surgery was over, she settled back in her chair with a smile.

“You know, doctor,” she said, placing her hands on my desk for emphasis, “Everybody was so nice in the hospital… I never imagined it would be like that.”

I smiled in return, thinking she would comment on how thoroughly we had discussed the procedure the day after surgery, or the care we had taken to alleviate her pain… Maybe the smiles we had brought to her on our twice-daily rounds… Our constant reassurance, our patience in answering her questions… Our willingness to listen to her. “A hospital can be a frightening place, can’t it?” I said, more as a statement than a question.

She nodded. “Especially at night when all the visitors and doctors have left. It’s a time when you’re all alone in the darkness and those scary thoughts of cancer and bleeding and infection come swirling around like bees to a hive. I remember lying there, staring at the ceiling and worrying. I was wide awake despite the pain medications and a nurse came in to see how I was doing. She was young -about my granddaughter’s age maybe; I hadn’t seen her before. I guess she thought I would be asleep, but when she noticed my eyes were open, she came over to the bed. And you know the first thing she did?”

I could see a tear beginning to form in one of her eyes, so I leaned forward to show her I was listening.

“She took my hand and held it. And you know, for the first time in there, I realized I wasn’t alone. Somebody, a stranger, noticed that I was afraid and came over to comfort me. She didn’t say anything; she didn’t have to…”

There is a dark corridor we all must walk; touch is often inappropriate, damaging. And yet it can be therapeutic, a bridge between the empty, cold empire of words and the warm land of feeling, understanding and empathy. It is an opportunity for communication that can not be taught, only felt -the word itself a testament to its importance. No, I’m not advocating a radical new approach to medicine, an ill-advised crossing of the line. And I’m not so naive as to believe that it is always necessary as proof that a concern has registered. But a hand briefly resting on a shoulder on the way out of the door is sometimes okay, don’t you think?