Throughout my palliative care elective I picked up a lot of valuable communication and interaction skills through observation of my preceptor. There were things that he would do, that I felt, indirectly let the patient know his attention was undivided and completely devoted to them. For example, as soon as he entered the room, he would remove his stethoscope from around his neck and lay it down on the table. Furthermore he would grab a seat and sit down comfortably before beginning his interview with the patient. I felt that these little gestures showed the patients that he was there only for them.

Also, he always emphasized to me, that although these patients are very sick and bed ridden, they have an entire history behind them. He felt it was important to gather that information so that we could get to know the “person” rather than the “patient”. So before getting into medical issues, he always asked about their occupation, where they came from, about family members etc. Patients always seemed to enjoy telling their life story and all the eventful things they had gone through in the past.

He also made sure to acknowledge their suffering and pain. He felt sympathy was not enough, and that empathy was integral. He taught me that empathy was the ability to acknowledge and understand a patient’s grief and suffering. Many people believe empathy is the ability to feel one’s pain, however he emphasized that we can never totally understand or know someone else’s pain but we can acknowledge their pain.

In addition to the above, he made physical gestures as well. If someone was in pain or in emotional distress he went on to hold their hand. From my observation, it seemed to soothe the patients and it appeared quite comforting.

As stated above, I had observed my preceptor closely. I vividly remember his interactions with patients and it was inspiration. I hope that I am able to take forth what I had seen and learned from and use that, not only in my practice, but in my day to day life interactions with people. 

It has been a week since I have started working with the Save a Child's Heart Foundation in Holon, Israel. So far, I have met children from Tanzania, Ethiopia, El Salvador, Angola, West Bank and Palestine. The children are of all ages, the youngest being one week old. None of them speak a language I understand so we communicate by drawing pictures, with sign language, or by tone of voice. Most of all though, these children hold my hand, hug me, and just need affection. Many of the older children are in Israel without their parents and come with their hospital's nurse. They are scared, confused, and homesick and what they need is reassurance.

This has truly been a lesson in the importance of communication and I now realize that speaking the same language or speaking in general does not matter. There are many ways to communicate other than speech and sometimes just human touch is what a patient needs.

Reflection:

In my clinical experiences since Save a Child's Heart, I have further developed an understanding of nonverbal communication in the clinical setting. A positive patient interaction not only requires clarity when speaking, but also has to do with the tone of voice, body language, and attitude during the encounter. Moreover, I have found that in emergency and critical care, physicians often use humour as well as nonverbal reassurance such as comforting touch (within the limits of professionalism). I have seen how effective these interactions can be especially when patients are distraught and on the verge of a breakdown. As I observe different physicians in various clinical settings and personally experience patient interaction, I am able to learn which techniques I would like to adopt and enhance throughout my medical training. Aside from collecting clinical knowledge, I feel that acquiring communication skills has been an important aspect of pre-clerkship clinical electives.

Every now and then, I find a humbling reminder that to be an effective communicator, one must exceed the bounds of words.

Words are, in essence, binding.

By that statement, I do not mean to imply that words are a replacement for a signed agreement; or that words are to be taken at face-value as verbally spoken contracts continuously falling from our tongue onto others' ears. No.

By the binding of words, I am referring to the bounds they place on our emotions. Words ask us to put what we're feeling into a communicable context that is somehow supposed to accommodate for our indescribable emotions. Words provide us with a prison in which to place our deepest thoughts and most moving stories and express them to others in ways that are meant to convey the same meaning we authentically feel.

In both a literal and figurative context, many things are beyond words.

One moment, in particular, stands out amongst the rest. This isn't a moment, per se, but a person. A beautiful six year-old boy with Down's Syndrome, severe developmental delay, and Acute Lymphoblastic Leukemia who came into my life about 4 months ago.

His name is M.

He looks up at me with big eyes and a curious smile. He doesn't say much, but when he does, it's usually the name of his favourite animal or a call to "mommy".

I was matched to M through the CHEO Buddy program at the University of Ottawa. This opportunity has been the best experience of my Medical School endeavour thus far, and I don't believe my experience here would feel complete without him.

Stepping in to meet M and his family for the first time, I was immediately greeted with respect and gratitude. Slowly learning sign language in order to meet M’s communicative needs, I have developed quite a remarkable non-verbal relationship with a six year-old boy in but a few short months.

It was a Tuesday afternoon, when I visited M in his Hospital bed, that it happened.

Showing him different animal puppets and signing their names, he touched my hand and said "Kahlah".

Kayla.

He said my name. With all the effort he could muster to sound out the letters and put them together. M said my name.

It is moments like these where I realize being a communicator is truly beyond words. I hear my name on a daily basis, from the classroom to my home-life, to talking on the phone. I have read and written my name in every e-mail, text, and test I've ever endured. But one simple attempt to say my name, from a six year-old boy who barely speaks at all, was enough to give me pause and bring me to tears.

"Yes, M", I say, choking back the urge to burst into hysterics, "my name is Kayla."

A smile comes across his face and he leans his head in for a kiss.

"Human vocabulary is still not capable, and probably never will be, of knowing, recognizing, and communicating everything that can be humanly experienced and felt." - Jose Saramago

As part of the cardiology block, we had a simulated clinic session dealing with risk factor management and modification. I soon discovered that, firstly, the patient had a whole range of cardiovascular risk factors and, secondly, he had just suffered a heart attack and had no intention of taking it easy and modifying his lifestyle. After reading over the case before entering the patient’s room, I devised an approach that involved choosing one or two risk factors to be modified, rather than all of them, in order to encourage the patient’s compliance with these changes. The assumption being that in this case very small changes would be a good start towards making behavioural changes based on the patient’s interests over a number of visits. However, my interaction with the patient did not go entirely as planned. After less than ten minutes of discussion, the patient did not want to talk anymore and simply wanted to be told that he could return to work. In an effort to do my best to explain to him the medical consequences associated with his lifestyle and the heart attack he had just suffered, I continued the discussion for longer than he would have liked. What happened next took me by surprise; he got so angry that he did not even want to shake my hand at the end of our conversation. This simulated clinic session was the most difficult one I have ever had, to the point where I can honestly say it was the greatest communication challenge I have experienced to date in medicine. It upset me, and I was grateful to the physician who stayed to talk with me after the session. I learned, in a very tumultuous way, that it is absolutely critical to pay close attention to the subtle signs that patients exhibit during the course of the medical interview. I must be able to recognize very easily the signs of a patient’s discomfort and frustration in order to avoid a traumatizing outcome like the one that just occurred during this simulated clinic session.