Mr. H’s reticence was unexpected, but his silence was not. He was a 58-year-old gentleman with laryngeal cancer status post laryngectomy, and I was the intern admitting him for newly diagnosed aspiration pneumonia. He had a pen and clipboard at his bedside but seemed genuinely uninterested in human conversation. In response to my questions, he invariably pointed to “Should be in the chart” or “Don’t care,” which he had scrawled earlier on his clipboard. He was cordial but never betrayed a trace of emotion, not even when he gestured for me to pause so he could use his tracheostomy suction catheter.
Mr. H’s unwillingness to communicate persisted the following day, a behavior I found a bit unsettling but admittedly was a gift to my busy prerounding routine. I agreed with my attending physician’s suggestion that long-standing depression—not something that could be reversed as an inpatient—was the most likely cause for his terseness. The following day, I saved Mr. H for last, hoping to zip in and out of his room quickly in time for rounds. But when I went to hand him his clipboard as a formality, I noticed that his pen had gone missing. For something of seemingly little import, I was surprised to see his look of pure panic when I could not find his pen on the floor or in his bed. I reflexively offered him my own pen instead, the four-color contraption I had been using throughout my intern year to organize my thoughts and checkboxes. He appeared intrigued, briefly clicking through all four pen colors while I examined him. After I explained the day’s plan, he turned to a new page on his clipboard and clicked the pen to red before asking: “How much for this pen?”
Did he really think I would have charged him? I explained that the pen was his to keep, and he thanked me in blue. Our conversation unexpectedly switched to full throttle, and he peppered me with questions interspersed with unpredictable pen clicks between sentences. The pen appeared to have physically energized him, a finding I confirmed when we weaned him off supplemental oxygen that same afternoon. We discharged him the following day with a gastrostomy-compatible antibiotic regimen, and I happened to be at the nurses’ station as he was leaving. He smiled and wrote out “Thank you for the pen!” in blue on the discharge paperwork that I had typed out earlier. His nurse had already reviewed the paperwork with him, and he had evidently paid careful attention. Normally a boring-looking black-and-white document, his discharge paperwork had been brightly annotated in black, blue, green, and red.
Thinking back to Mr. H’s case, I wince at his bold request to purchase my pen, but I also wonder what I can learn from our interaction. A laryngectomy is as life-altering as it is lifesaving, and paper provides a poor substitute for the inflection inherent in the human voice. Converting Mr. H’s clipboard into a multicolor canvas allowed him to regain some control over his voice’s timbre and proved to be the key to successfully connecting with him. I’ve since realized that it is not just the literally voiceless who stand to benefit from conversational colors. In a broader sense, this connection represents the transition away from invoking only the black and white of imaging results and clinical documentation when talking to patients. Take the patient who instantly brightens when you ask about the loved ones from his get-well cards or smartphone background, or the patient who relishes the opportunity to relay a few pearls about her profession outside of the hospital. The colors we create in those cases are metaphorical, but the silence they eliminate is very real. The pens themselves may be cheap, but the voices they enable are priceless.
Acknowledgments: The author wishes to acknowledge Mr. H and the rest of his clinical team.
Rahul Banerjee, MD
R. Banerjee is a resident physician in internal medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; e-mail: [email protected]