The “Non-talker”
Cesar Rodriguez
“I’m going to have to keep sending you in for my tough non-talkers” she said. I had just come back from speaking to one of her patients: a 47-year-old woman with back pain, headaches, and Meniere’s disease who told me I reminded her of her son – mostly, I think, just because of the long hair. I walked out and presented to my preceptor who was pleased I had been in there for 25 minutes because she had been able to see 2-3 patients in the time I saw one.
It was near the end of the day on Friday, we had 3 patients left, and that was when she told me she was sending me in to see one of her newest, “non-talkers.” A new patient to her, this was a 27-year-old man with prior history of alcohol abuse for over 10 years and questions of depression and anxiety. I was, of course, quite hesitant.
“Will he even want to talk to a student?” I asked her – a veiled, albeit poor attempt at getting out of a situation I felt woefully unprepared for.
Dr. H chuckled, “I think you’ll be fine, and if he doesn’t want to talk to you, don’t take it personally.”
She was right. I couldn’t let my hesitation preclude me from providing this patient an opportunity to express himself and to experience my first real attempt at counseling a complex patient who lacked any physical manifestations of disease. I told her I would do my best and sat down to read his history on the EMR. I opened her note from his last visit to read about a 27-year-old male with history of alcohol abuse, 4 prior OUIs, jail time, AA meetings not attended, a family history of alcohol abuse, and a lost driver’s license.
I stood up and paced back and forth across the office, pretending I couldn’t find the room just to work off the nerves some more. Finally, I found the room, and entered.
For 45 minutes I spoke to this young man who will be known as Charlie. From the beginning I tried my hardest to provide a safe space for him with a non-judgmental attitude and as much compassion as I could muster. We spoke about everything. He told me how hard everything had been roughly 2-3 months ago. I asked him why. He told me two things: firstly, his girlfriend of one year had broken up with him out of the blue. Second, one of his close friends had died from a rapidly progressive pancreatic cancer that took him so suddenly my patient didn’t have the chance to say goodbye. At this point my vision was getting blurry and I had to pretend to look at the light above us to pray my own tears wouldn’t come down in front of him (I’ve always thought I’m too fucking emotional for this job) and I started with the death of his friend.
I gathered that he had a very strong support system, that he was able to go to the wake and funeral, and that to my surprise, this event did not seem to be what was bothering him the most.
I started slowly making my way to his breakup. When he seemed comfortable discussing how she had dumped him, why she did it, and how utterly meaningless he felt after the break up, I changed my tone. Instead of asking medical questions I commiserated with him just like I remembered my own pediatrician had done with me when I told him of my first break up in high school. Instead of asking medical questions I validated his feelings by acknowledging how awful relationships can be. How hard they are.
“I know how much they fucking suck sometimes” I told him.
He laughed at me when he heard me swear but more importantly, I could see him start to relax. His shoulders came down, he sat differently in his chair, he even looked at me differently. The connection was there, and it was not built on piles of ABGs, cardiac function curves, or pulmonary function tests, but on a bed of emotional maturity, respect, humility, and understanding – the real pillars of medicine.
Our conversation about his break-up allowed me to circle around to what I needed clinically to discuss: his drinking. By the time I got around to asking him about it, he confided in me that while his drinking had gotten worse post break-up, his crisis had been potentiated by another factor as well: he had, for the first time, contemplated suicide one night (or in our medical lingo, had “suicidal ideations”). When he told me this I automatically ran through my head scenarios in which I had seen Dr. H deal with this and I asked the same questions. He expressed to me that while the thoughts had scared him, they had also allowed for certain other thoughts that had been simmering within him to bubble up to the surface: “I’m depressed.” He began to unravel the nigh-impossible journey of depression self-medicated by alcohol, but he did so on his own volition. He had been ready to discuss this I think, he just needed someone to ask and to meet him halfway.
By the end of our 45 minutes we were able to get to a point together where he felt comfortable discussing anti-depressive medication and was even open to the idea of one-on-one counseling. When I walked out of the room, emotionally exhausted, I went to present to my preceptor and told her “I don’t have a by-the-book presentation, is it okay if I just tell you what we talked about?” to which she replied “of course.” We both walked back in to talk to him, she was able to build off the bridge I constructed, and prescribed him an anti-depressive and referred him to a counselor of his choice.
For the first time in a long time, I felt like we had done something really good. I had done something really good. Under the constraints of a system that only values physical disease and incentivizes physicians to look at patients as singular units of pathophysiological mechanisms, we had still been able to provide this patient a real human interaction. To anticipate the counter-argument, one can say that there is no feasible way to spend 45 minutes with each patient (and to be fair, I think the only reason this worked is because my preceptor was able to finish her patients while I spent 45 mins with one) and they would be right. But if anything this experience reminded me of the power of multi-disciplinary teams, and more importantly, the undying significance and importance of our humane people skills that form the baseline of our profession. Nowhere in those 45 minutes did I do something that a person who was not a second year medical student could not do.
The world of medicine is fraught with science, problem solving, facts to memorize, disease processes to recognize, standardized exams to prepare for, flashcards to make, and money to be spent on [insert resource book here]. But in this world we cannot forget that for all its rules and tribulations, the only language that matters, and will continue to matter, is compassion.
Cesar Rodriguez is a fourth-year UMass medical student applying into Internal Medicine. This piece is from an experience during his second year.
