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Missing the Gorilla

Teodoro, Nicholas, MPH

doi: 10.1097/ACM.0000000000002038
Teaching and Learning Moments
AM Rounds Blog Post

N. Teodoro is a fourth-year medical student, Columbia University College of Physicians and Surgeons, New York, New York; e-mail: nst2114@cumc.columbia.edu.

An Academic Medicine Podcast episode featuring this article is available through iTunes.

A man in a gorilla suit runs, completely unnoticed, past individuals intently passing a basketball. This “gorilla experiment” inspired a group of psychologists at Harvard to study this phenomenon, called inattentional blindness, in medicine. They found that expert radiologists who were asked to identify nodules on CT scans consistently failed to notice the large gorilla icon that appeared on the imaging scans. These surprising results demonstrate that when we face demanding mental tasks, we can miss salient, and ostensibly obvious, stimuli.

My first clinical encounters during medical school occurred under the mentorship of a diverse group of chaplains from different faiths. I discovered that chaplains pay a very particular kind of attention to patients. They focus much of their effort on what is happening in the moment. Chaplains use verbal and nonverbal cues to gauge where their patients are physically, spiritually, mentally, and emotionally. Their diagnostic tool kit is comprised of not just their senses but also their feelings and their curiosity. This approach helps them to build trust with patients, who then feel heard and cared for.

During one particularly potent encounter, I watched as one pastoral care provider listened to a young man, who was newly diagnosed with a neurological disorder, relate a substance-induced dream so intently that everyone in the room was on the edge of their seat. Instead of brushing off the discernible emotion this patient displayed, the pastoral care provider embraced it: “What happened next? What did that mean to you?”

His genuine interest and curiosity allowed this young man to speak so openly and so passionately of his drive to be a drummer and of his visible fear of losing that ability because of his diagnosis. In that moment, it was not only the patient’s mother who was in tears.

Not long after, I began interviewing patients with my physician–mentors, and I quickly found myself conflicted between my agenda and the patient’s. One patient, a middle-aged woman, was sleeping when a fellow medical student and I arrived. My preceptor nudged her awake and introduced us.

“So, um, what brought you to the hospital initially?”

“I have cellulitis.”

“You have cellulitis. Can you tell me more about what happened?”

She continued with her history of multiple hospitalizations, often self-identifying as a “long-term injection drug user”; a flash of emotion representing something much deeper than her physical symptoms was evident each time she used this phrase. We moved forward in the interview, review of systems, past medical history, medications, allergies. Even though she answered each question briefly, she still managed to find every opportunity to refer to her drug use.

I felt conflicted in this moment. I had my outline; I knew what information would enable me to correctly “work up” this patient. But she seemed to be calling for help. She was placing the gorilla right there in the room, repeatedly; one issue was underlying everything else in the interaction. Why then was I finding it so difficult to leave my “script”?

“I can see you are very concerned about your history of drug use. Will you tell me more about what you’re thinking?”

The atmosphere in the room quickly changed. I felt a different connection with her. She spoke about how her addiction affected her physical health and mental stability. She had tried for a long time to hide it from her family. When her two children eventually found out, they were angry.

As my classmate completed the remainder of the interview, I mentally paused to consider where the encounter had gone. I had my checklist of “pertinent” medical information. This patient was here for very specific health issues that needed to be addressed and treated. But if her addiction—a word she emphasized over and over—was so important to her, shouldn’t it be important to me as her care provider? I began to consider that perhaps there really is no separation between “chaplain questions” and “doctor questions,” because each set of questions is meant to provide care. Maybe, the real difference lies in how a chaplain listens to the answers.

Chaplains’ ability to be fully present and to embrace meaning enables patients and providers to move beyond a simple checklist encounter, where psychosocial issues are seen as human experiences rather than just another box to check. Creating this space, along with chaplains’ natural curiosity, allows them to gain valuable and actionable information from patients.

Early exposure to holistic patient care is crucial in medical training. In an increasingly science-heavy curriculum, medical students should experience the art of supporting and caring for those who are suffering. Hospital chaplains have developed a precious tool kit that, if taught across the board, would strengthen medical students’ preclinical training. Although they may not catch the nodules, chaplains are trained to never miss the gorilla.

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Acknowledgments:

The author would like to thank Dr. Chris Adrian for the opportunity to work with the pastoral care service and Chaplains Joel Berning, Seigan Ed Glassing, and Linda Golding for introducing him to the role of the chaplain in medical care and for their feedback on how to find more meaning in patient interactions.

Nicholas Teodoro, MPH

N. Teodoro is a fourth-year medical student, Columbia University College of Physicians and Surgeons, New York, New York; e-mail: nst2114@cumc.columbia.edu.

© 2018 by the Association of American Medical Colleges