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Leaning In

Reisman, Anna MD

doi: 10.1097/ACM.0000000000000468
Teaching and Learning Moments

Dr. Reisman directs the Standardized Patient Program, Teaching and Learning Center, Yale University School of Medicine, New Haven, Connecticut; e-mail:

My patient’s small apartment was hot and loud. She closed the door behind us, waved a jiggly arm toward the couch, and flicked off The Price Is Right. I had brought two medical students on this home visit so they could practice talking to a real patient. Before this visit, they had only interviewed actors who pretended to be patients.

The female student’s voice was soft. “Good morning. I’d like to ask you some questions. First, how are you feeling today?”

“Can’t hear you!” The old woman pushed her large glasses up her nose.

The student leaned forward and raised her voice a 10th of a decibel. “How … are … you … doing … today?”

The old woman smiled and shrugged. The student paused, as she had been taught, to give the patient a chance to talk.

Silence. The old woman nodded politely. The student grinned back, then turned to us, uncertain. I asked the students what they thought was going on.

“Maybe she doesn’t have much else to say,” ventured the interviewer.

The other student asked, in a low voice, “Is she, maybe, demented?” His classmate bobbed her head in eager agreement, and my heart fell. Soon, they might be writing off all old people who don’t immediately answer a question as “pleasantly demented.” It’s a catchphrase that describes placid old people who don’t protest when their blood is drawn or fidget during a physical exam, or who smile and nod when asked questions but don’t really answer them. Plenty of students, not to mention full-fledged doctors, give up on attempting a real conversation once they reach this point.

I told them that it was too soon to draw conclusions.

“Ma’am?” The student was trying again. “How long have you lived here?”

“Can’t hear you!”

“You have to yell,” I told the student. “I know it’s hard to believe that it’s okay, but you have to give it your all.”

Face flushed, she amped it up a notch. “How long have you lived here?”

My patient cupped a hand over an ear and shook her head.

I squatted next to her, my mouth an inch from her beige hearing aid. “Can you hear me now?” I hollered.

“Yes, indeedy.”

“Your turn,” I said to the student. She looked dubious but knelt by the old woman and politely shouted her question.

It worked. “Five years!” the old woman announced.

The student’s eyes widened. Emboldened, she shouted again into the old woman’s ear. “Where did you live before you moved here?”

And just like that, with a little lean and a loud voice, they had connected. The patient showed the student some photos of her family members and shared memories of fishing with her husband, who had died a few years earlier. The student asked about her diet, the old woman pulled out the dining room menu, and together they discussed the healthiest options.

Watching them, I felt a swell of pride—for a few moments of initial awkwardness, we were getting a good payoff. The art of communicating with the very old can be tricky, and it often doesn’t come naturally to young medical students. Miss Manners may recommend a respectful distance when addressing an elder, but it’s not going to work if the elder can’t hear you.

A real smile, an eye-twinkling one, had lit up the old woman’s wrinkled face. The students were smiling too, and so was I, because they were starting to learn that a polite smile was not a sign of comprehension or confusion.

It was an invitation.

Anna Reisman, MD

Dr. Reisman directs the Standardized Patient Program, Teaching and Learning Center, Yale University School of Medicine, New Haven, Connecticut; e-mail:

© 2014 by the Association of American Medical Colleges