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Skin in the Game

Branch, William T. Jr MD

doi: 10.1097/ACM.0000000000001068
Teaching and Learning Moments
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W.T. Branch Jr is Carter Smith, Sr. Professor of Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; e-mail: Wbranch@emory.edu.

Author’s Note: The name and details in this essay have been changed to protect the identity of those involved.

We entered the room and opened the curtain. Sitting with rigid posture to avoid painful movement was Henry, a 24-year-old African American man with widely disseminated cancer. He was here to have his pleural effusion tapped. The three adults sitting at his bedside looked up. I felt self-conscious. My personal goal was to model compassion in front of my housestaff, but I didn’t yet know this patient and his family. Henry had just arrived on the floor.

I asked, “Are you relatives?” They nodded. Bending close so I could speak softly to Henry, I asked, “Okay if they stay while we talk?” “Yes,” he mouthed and nodded.

The 50-ish woman on my right rose. Her strong voice expressed dissatisfaction, “I’m his mother. You all keep asking about his ‘comfort.’ We don’t want just ‘comfort.’ We want him to get better. Get something done!”

Responses flashed through my mind. Say something empathic. Say you understand. But these responses felt formulaic. Intuitively, I visualized a response. Be genuine, answer her question. So I said, “You want him to get better and so do we. First, I need all the facts. Give me time to confer with his oncologist about the chemotherapy, so that I know for sure what we can do. Then I promise I will explain things to you.” It sounded a little lame, but it was the truth.

I could hear the insecurity in my voice. My response was met with silence. For that moment, we came out of our different roles, and we entered the scene together. Henry’s mother broke the silence.

“That will work,” she said. We all relaxed. My team went back to work assessing the patient’s clinical needs.

Henry’s mother pushed me to respond from the heart. I modeled not intricate communication skills but honest facts and genuine feelings. I too had skin in the game, and we had faced the situation together.

As we left I thought, we need to mold our learners’ hearts as well as their skills. The question was how.

As we continued the rotation, I noticed a change. The house officers began listening more to their patients. They began to ask about and meet their patients’ needs and requests. I don’t think their actions were a response to the care I modeled. Maybe they wanted to show me they were good doctors. Maybe, though, the changed atmosphere went to something deeper—their choice to do the right thing. We were in this together.

Here’s an example of this change. A 60-ish woman was admitted for diverticulitis. She made clear that she expected to be discharged within three days. After two days, severe tenderness persisted. Our intern and resident learned that she planned to visit her sick son in another city. They had established a rapport by listening to her. Later, when she was not improving, they gently explained that she could develop complications, and she agreed to further intravenous antibiotics.

These house officers folded kindness and concern naturally into their work. They were on their way. Their hearts were being molded. We as a team had joined together to do the right thing.

Their kindness and decency to their patients was elegantly simple. They reminded me of a colleague who, when asked why he strove to be humanistic, replied, “I hope this isn’t too simplistic, but I believe in treating others as I would want my family or myself to be treated.” Such authentic actions comfort patients, and they reward physicians with the feeling that their work is worthwhile.

William T. Branch Jr, MD

W.T. Branch Jr is Carter Smith, Sr. Professor of Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; e-mail: Wbranch@emory.edu.

© 2016 by the Association of American Medical Colleges