The better angels of our nature
Ethan Stonerook
Abstract
Figure“Though passion may have strained, it must not break our bonds of affection. The mystic chords of memory, stretching from every battlefield and patriot grave to every living heart and hearthstone all over this broad land, will yet swell the chorus of the Union, when again touched, as surely they will be, by the better angels of our nature.” —Abraham Lincoln, First Inaugural Address It's a tricky business to bring two strangers together these days, each bearing the weight of their own story. In a time when we seem increasingly at odds with our neighbor, it may be even more complex between clinician and patient. How soon after we enter an examination room does our patient know if we really see them, if we are there to care for them? How many seconds of eye contact, or speech, or quiet does it take? One study found that the average person can predict medical malpractice lawsuits after listening to 40 seconds of an initial encounter between patient and surgeon.1 What if we narrowed down the window to just the first 2 seconds: the knock on the door, our countenance, our first words to the patient? On a Thursday morning in January, I knocked and entered a procedure room to perform a lumbar puncture (LP) and administer intrathecal methotrexate to a woman I had never met. Two mornings a week, I am the “procedure guy” in the cancer center, running from room to room carrying a stack of consents and bone marrow biopsy and LP kits. On each consent is a sticky note with enough information to first do no harm. This one reads, “42 yo F, no AC, plts 147K, AML in CNS.” In my rush, I omit the long, deep breath outside the door, a pause I learned in PA school. I open the door as I knock and lead with an automatic, “Hi Ms. B, how are you?” Ms. B. is Black, slight of frame, seated in a typical examination room chair. Younger than I expected (for a fraction of a second, I remember I am middle-aged now). Her legs are crossed at the ankles, black tennis shoes tucked under the seat of the chair. Her hands grip the front edge of the seat with her arms locked straight. Her head hangs low. “I'm okay,” she says. My automaticity is interrupted, and I wonder. Is she dejected? Aloof? She doesn't seem cold, or distant. The tone was earnest, albeit quiet. It's a feeling I recognize. Where is that feeling? It feels like I just set it down, a set of keys on some nearby counter. There it is. Discouragement. She is discouraged. And then I see her posture in a new light. She is Rodin's “The Thinker,” but only if he were woken up for a moment, given 2 seconds to consider the modern world, and then frozen back in his bronze. A mere second has passed. How amazing the amount of data we can process in a second! Even in oncology, I rarely get a discouraged response like this. What else may be troubling her? Something beyond cancer? Everyone here has that. Something in her voice assumes I was involved, that I ought to know. Were we all involved? It feels like the response you would get at a funeral when greeting an old friend: “How have you been?” “Well, considering the obvious, I'm okay.” A shared acknowledgment that something communal has happened to us both. I reconsider for another half-second and finally see the picture clearly. Something has happened to us. Is she seeing what I am now seeing? Thousands of people rushing up the steps of our Capitol building, carrying weapons and hateful signs. The police officers brave enough to put up a defense are being beaten back. Items are being thrown through glass. In one image, two portraits of statesmen hang on adjacent walls: on the right, Senator Charles Sumner, an abolitionist from Massachusetts; on the left, Vice President John C. Calhoun, an adamant defender of slavery. In between them is a living man carrying a treasonous flag. I have finally caught up to the whole clinical situation. I am not just a man standing with a procedure kit, waiting to put chemotherapy into a woman's spine. I am a neighbor with a shared citizenship, who can carefully place chemotherapy in a spine that is discouraged, yet strong, both of us bearing the weight of these images. At the 2-second mark, I speak again. “I'm sorry, I need to back up, and acknowledge what happened yesterday in Washington D.C. It's devastating, and it's a lot to carry. How are you?” Ms. B tilts her head to the side, finally making eye contact with me. She offers a slight smile. “Thank you. I'm okay.”