Abstract
Editor's Note: Though Dr. Rosenblum's book presents reflections from a physician's point of view, the lessons are universal and apply equally to the practice of nursing. In keeping with the theme of this issue of Creative Nursing, this book is the story of Dr. Rosenblum's own journey. This review was originally published in The Advisor, the Journal of the National Association of Advisors for the Health Professions (Vol. 26, No. 3, September 2006, pp. 40-41) and is reprinted by permission.
Once I started to read A Time to Hear, A Time to Help: Listening to People with Cancer last year, I could not put it down. Though published in 1993, its wisdom and lessons are timeless.
The book reminded me so vividly of the best parts of medicine, the relationships with patients. Being privy to their stories, having the opportunity to learn from their wisdom and be a part of their drama, the awe-inspiring ways in which patients and their families handle serious illness, the need to avoid jumping to premature conclusions about diagnosis or motives (“clear thinking unclouded by prejudice”), dealing with “difficult patients” when the issue is really “difficult doctors” or “difficult systems,” recognizing the role of uncertainty—all of these themes are important lessons to pass on to those interested in becoming good physicians. And primary among them is the importance of time and listening carefully in an engaged fashion. Doctors who don't take the time to listen, really listen, don't know what they are missing, not only in clues to diagnosis, but also in the joy of being a doctor.
Though Dr. Rosenblum's book presents reflections from a physician's point of view, the lessons are universal and apply equally to the practice of nursing.
What makes the book, written with love of patients and of the profession, so appealing are the patients ‘and physicians ‘stories and the honesty of the author's reflections. Daniel Rosenblum describes the richness of the doctoring experiences, and, when warranted—often—he is critical of the care, even his own. But when he criticizes, he provides a remedy: what exactly went wrong and how to fix it. Mistakes in reasoning and communication can be as devastating as surgery gone badly.
Those who consider medicine as a career and life's work because they are tantalized—and maybe seduced—by the technology or by the excitement of the emergency rescue of a patient from the brink of disaster, may find that these attractions wear thin over time, for much of medicine is pretty straight-forward. For some, this revelation may make the career seem routine. For others, like oncologist-teacher Daniel Rosenblum, every day and every patient, even absent the story-book, ER-like moments, bring opportunities for significant intervention and making a real difference, and for enriching the life of the physician.
During Dr. Rosenblum's career serving patients, he also taught at Harvard and Georgetown University Medical Schools. I was privileged to learn from him in 2005 when he spoke to an audience of health care professionals and validated the importance of engaged listening and careful, precise communication in being an effective clinician. The earlier one learns these lessons from experienced teachers and good role models, the better.
The insights did not come immediately to Dr. Rosenblum, who described his professional journey: “Years ago, when I was more committed to the science of medicine than the need to care for frightened humans, I had fought to suppress my anger with people whose anxious confusion frustrated my need to acquire information.” (p. 119)
But he reflected continually on the experiences of his practice—the transactions and relationships with his patients and their families and with his colleagues—and he learned not only about his patients, but also from them. In a sense, this book is also the story of his journey toward greater wisdom and professional growth, a model for aspiring physicians.
Here are some of those timeless lessons, validated over and over:
On the importance he attached to effective communication: “I respected her right to decide, but I believed, if she decided not to take chemotherapy, I had failed to present the facts clearly.” (p. 63)
On the importance of attending to details in the patient's story: “I make assumptions when I should ask questions. I trust my own superficial observations when I should probe deeper by listening to my patients ‘concerns about themselves.” (p. 123)
On the importance of taking sufficient time to listen and reason carefully: “Instead of encouraging conversation…we often abbreviate it in the interest of performing objective tests [which] can be misleading. Subjective observations, properly interpreted, remain our most sensitive instruments in the diagnosis of most medical problems.” (p. 180) Even with the newer laboratory tests and scans, the patient's story and a careful physical examination are still the most productive initial pathways to accurate decisions about diagnosis and treatment.
On the importance of respecting the patient's individual life story and needs: “Rather than adapting her life to fit my medical recommendations, she made me adapt my medical recommendations to her life.” (p 68)
On the importance of empathy, putting oneself in the other's shoes: “Both of us [the author and his colleague who shared the care of a patient] were aware that the difficulty of our work paled in comparison to the struggles of our patient.” (p. 96)
On the importance of presence, of not abandoning the patient even after specific therapy has failed: “My chemotherapy may not have helped her, but her frequent visits to my office did.” (p. 92)
On how physicians can contribute to the chaos of illness: “We act as if the mental suffering produced by too much medical information, technical language, refusal to answer questions, controlling behavior, impatience, confusing directions, lengthy delays, excessive fees, failure to return telephone calls, inaccessibility, delegation of tasks which should be done by physicians, and inadequate preparation of patients for side-effects and complications were not our responsibility…. Only when we doctors feel as much concern for the human anguish we created as we do for blood loss or infected wounds will this form of denial begin to erode.” (p. 171).
On the need to recognize one's limitations: “Among my colleagues, certainty is usually a sign of ignorance.” (p. 194) A really good physician reasons carefully, makes a decision, and then steps back and asks, “Is there yet another way to look at this?”
On what it really means to be a doctor: “I must be willing to sit, to wait for permission to speak, to deliver information at a comfortable speed, to emphasize what is important without abolishing hope, to allay undue anxiety, to resolve confusion.” (p. 271)
On regarding patients as teachers: “[To be the sort of physician I wanted to be], I had to be willing to learn from my patients. Like other practitioners who love the art of medicine, I found my patients to be willing teachers…. Given the time to talk and an attentive audience, people in distress can be remarkably articulate.” (pp. 282, 285) (One of my own patients told me, in no uncertain terms, “I am the professor of myself.”)
The biology and the technology of medicine are fascinating, challenging and continually evolving, no question about it. But when one complements those parts with all the dimensions of the physician-patient relationship, then medicine becomes an extraordinarily fulfilling career. For a worthwhile insight into what the practice of medicine is like at its best, and as a text for a course on the human, non-technical parts of medicine and on the physician-patient relationship, I highly recommend A Time to Hear, A Time to Heal. The stories in it are touching and the lessons are timeless.
The difficulty of our work paled in comparison to the struggles of our patient.