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Teaching and Learning Moments

Taking Time

Rausch, Evan MD

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doi: 10.1097/ACM.0000000000001417
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Intern year is hard. After a long month working in the ICU and a longer month on wards, I started overnight shifts in the emergency department. The room overflowed with beds parked three deep as nurses and doctors squeezed between them. I grabbed a chart and went to the next patient. A nursing home had transferred the eighty-something-year-old woman for unclear reasons, and I began asking questions to try to elicit a specific symptom from her. While the emergency room buzzed around me, I waited through her slow responses. It was a sharp jolt as I shifted speeds. My mind lurched forward, bursting with diagnoses: urinary tract infection, dementia, GI bleed. I became more frustrated as she took her time. I wanted to move on. I had patients to see. But as she talked, I settled in and for the first time really looked at her—her tightly wound head wrap; her skin that bronzed at the curves of her cheeks but darkened in the creases; her wide, alien eyes. She was clever, toying with me as I went through the interview, sneaking in details about her life, letting me know she was still sly.

I thought back to medical school when I took a course on narrative medicine that included weekly trips to the Metropolitan Museum of Art in New York. Although I usually walked through the rooms aimlessly and only stopped briefly when something caught my eye, for this class, we had to focus. The Met became our three-dimensional textbook, with clearly defined chapters that taught us how to look at art. Before this class, I often took in dozens of pieces, possibly even hundreds in a single visit to the museum. On these days, though, we would get to six. That was the point. By slowing down and forcing yourself to stare, the works of art expanded in your mind. They stewed and grew. We went far beyond “I love this one” or “I don’t get it” and began to notice how each of us perceived different aspects of the same work, how each of us interpreted the same data in a different way.

The parallels to practicing medicine were obvious from the start. In a pragmatic sense, it was an exercise in focus and strengthening our powers of observation. A leaf may be green, but if you look closely you see strokes of yellow or an undercoat of blue—the reality behind the label. Similarly, it takes a careful eye to spot small changes in a patient’s skin or in how she moves. Focusing on one piece of art intensely only made it more interesting, expanding in your mind, becoming more complicated the more you saw. A patient interview can be the same. It’s the difference between a large clinical trial and a case study. The data may come from the large series, but when face-to-face with a patient, that can seem hopelessly reductive. Allowing one patient to fill your mind complicates her case, but ultimately it piques your interest in her story and leads to a better relationship between patient and doctor.

I still steal a few hours when I can to go to New York’s collection of museums and galleries. I used to treat such visits as an escape, but now they feel more like a way of thinking. As busy as the day can get, I hope to keep these techniques with me and remember that each patient warrants my full focus. Back in the emergency department, the patient continued her story, telling me about her past as she slowly explained what brought her in. I sat back for the show and let her reveal the brushstrokes beneath the life.

Acknowledgments: The author wishes to acknowledge Gail Halaban, instructor of the visual arts narrative medicine course at Columbia University College of Physicians and Surgeons, and Deepithman Gowda, associate professor of medicine at Columbia University Medical Center.

Evan Rausch, MD

Copyright © 2016 by the Association of American Medical Colleges