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The Sound of Silence in Medicine

My mother bought The Little Prince for me when I was nine years old. It’s nearly twenty years later, and that book is dog-eared and heavily underlined, its cover marked by countless coffee mugs like rings in a tree—and is currently nestled on my nightstand even as I’ve transitioned into life in medical school.

In it, Antoine de Saint-Exupéry states a simple truth: “Le langage est source de malentendus”—language is the source of misunderstandings. So much of what I do on a daily basis in trying to become a competent physician revolves around communication: conversing with colleagues, talking with patients, and interacting with instructors. These exchanges all have different purposes. Sometimes I am trying to glean new bits of information, be it about the Krebs cycle, someone’s smoking habits, or the nutritional benefits of an all-ramen diet in grad school. Sometimes I am focused less on what people are saying and more on why they’re saying it, trying to understand their motivations and feelings through the ebb and flow, the tone and meter of the conversation. But sometimes, in my most-poignant interactions, we say absolutely nothing at all.

Three illustrative instances come to mind, each representing a time when I learned the limits of my words and the limitless nature of the need for humans to connect. Let’s name the players in this drama the Boxer, the Albanian, and the Dying Man. The first was shrouded by a dark room, the second by a darkened mind, and the third by a darkening future.

The Boxer looked as you might expect—a bit top-heavy, with ropy muscles rippling along his arms, and ears pressed nearly flat against his head. He was only 25, but already had three children and two jobs, one managing a restaurant and the other working his opponents over in the boxing ring. A group of us students had been assigned to conduct comprehensive interviews with individual patients, and I had already struck out three times with patients who were either asleep or in isolation. I poked my head into room #4 and saw that the lights were out and the curtains drawn over the windows and around the bed near the door. Stepping softly over to the window bed, I quietly asked the patient if he was open to being interviewed and he nodded his assent. I asked him if I was pronouncing his surname correctly, and my question was again met with a nod. After my next few questions were met with similar silent nods, shakes, and shrugs, I asked if he was concerned that we might be disturbing his roommate. He typed briefly on his cell phone and then showed me a note that read, “My jaw is wired shut.” Great.

The Boxer had been admitted with a broken jaw after being attacked from behind by a drunken assailant with a baseball bat. My first inclination was to inquire briefly about the incident, ask if he was comfortable, and then politely excuse myself and move on. But then I saw the Boxer’s eyes. The lower half of his face was fixed in expressionless stasis, but his eyes were looking at me with a mixture of excitement, embarrassment, and pleading. That look made me realize that I had a decision to make. Was I going to make the expedient, and technically appropriate, choice that would help me fulfill my purpose for being in the hospital that day, or was I going to take the opportunity to empathize properly and comfort someone who was obviously in a state of great distress? The look in the Boxer’s eyes made my decision for me.

The Albanian was 80 years old, with a shock of snow-white hair and his bedsheets pulled up right under his chin—the spitting image of Kilroy. He had suffered a stroke two weeks prior and was in the hospital after coughing up blood one evening. He spoke nary a word of English, and the little that he said in Albanian (translated by his daughter-in-law), when he furtively surfaced from behind his linen shield, suggested a compromised mental state. A crooked sign taped above his bed declared him to be legally blind, which might explain why he hardly made eye contact with me throughout our interview, except for two instances when he gave me looks that I cannot forget. Let me explain.

I asked the daughter-in-law about his home life, especially about the difficulty her father-in-law experienced in being the primary caregiver for his sickly wife, something that would be impossible for him to do from that point on. The Albanian reached out to grab her wrist and asked her what we were talking about. When she told him, he rolled back over to face me, looked me straight in the eye, and said something to the effect of, “Why are you bothering with me? I’m not good for anything anymore. Leave me alone and go help someone else.” He rolled away and refused to look at me again for quite a while. He would sporadically check in on what was being said, and the interview progressed to its conclusion. I closed my notebook and stood up, put my hand on his arm, and, with the help of his daughter-in-law, repeated falteringly, “Ndjeheni më mirë, dhe më intereson për ju”—feel better, and I care about you. The Albanian looked up in surprise with what seemed to be delight twinkling in his eyes, and I turned and left the room.

The Dying Man had an orchid on his windowsill. It sat in a simple terra-cotta pot and had once been a deep, rich purple, but now it was withered and shriveled, and served only as a resting place for my eyes when I couldn’t face the Dying Man anymore. I can see the palliative-care facility where he lives from my kitchen window, and I visited him every Saturday afternoon. Our first conversation was about Tolstoy, the Metropolitan Opera, and the South Island of New Zealand. Our second was about his pioneering work during the outbreak of AIDS, the best place to buy homemade pasta in the Bronx, and the Vietnam War. Our third was about death and dying. I had helped prepare deceased people for burial and performed anatomical dissections, but I had never been looked in the eye by death before. I hadn’t expected it to look so alive.

The Dying Man would hold my gaze with his hazel eyes and tell me about his life, what he thought would happen after he died, and what it all meant to him. Over time, I saw his muse shift from Minerva to Morphine. He became tired, distracted, and listless, and the man I had grown to love and respect retreated behind glassy eyes and sunken cheeks. But we still sat together, and communed when we couldn’t communicate. I would look at him, then my orchid, then back again, thinking about everything he told me about his life—how he had consistently stood up and fought for what he believed in, had lived a selfless life in the service of others at the risk of his own health and reputation, and had embraced every opportunity to explore the depths and heights of everything a beautiful man can mine in a lifetime. In those silent hours, I saw the Dying Man transform from a person into an idea. I lost him two months ago, and I miss him so much that I still feel the loss in my throat and chest when I think of him. I sit at my kitchen table and look out the window at the building where he lived; I feel his eyes on mine again, and there’s a question in them. Always the same question. A question the Dying Man spent a lifetime answering. His eyes ask me, “What are you living for?”

I began by saying that so much of what I do as a medical student is to try to communicate. For the longest time, communication meant choosing my words carefully in order to say precisely what I meant. But the Boxer had no voice.

For the longest time, communication was a means of understanding and being understood. But the Albanian could not understand.

For the longest time, communication meant building a connection for the future. But the Dying Man was no more.

What these three men taught me is that as humans, we all crave essentially the same things: connection, purpose, and meaning. The Boxer wanted someone to spend time with, the Albanian wanted someone to care about him, and the Dying Man wanted someone to teach. All I did was sit. I sat and listened…and felt…and laughed…and cried…and thought…and comforted…and validated…and consoled…and wondered…and dreamed. And that was enough.

Saint-Exupéry spoke another truth: “On ne voit bien qu’avec le cœur”—one sees clearly only with the heart. These three extraordinary individuals opened their hearts, if not always their lips, to me, and taught me that I will only ever really begin to understand my patients, or for that matter anyone, when I learn to listen with my heart as well as my head. I must certainly become the best clinician I can be. But I must also sit and listen and feel and laugh and cry and think and comfort and validate and console and wonder and dream. And maybe that will be enough.

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