The Silence

The following is a post I wrote in medical school that I never published.


“C’mon,” my resident called out to me, “Let’s go do something.”

“Ok,” I replied as I half-jogged to catch up with her.

It was a slow night in Labor & Delivery. I wasn’t doing much. Most of the patients I saw that night during Night Float (shift from 5:30 PM – 7:00 AM) were patients in triage with various complaints. Most were women who had been feeling contractions that day. I think most were sent home that night because they weren’t yet in labor. (Labor is defined as contractions plus cervical change. Since they had contractions without dilation of their cervix, they were not going through active labor.)

The resident and I walked to triage. The nurses had told us that there was a patient in triage who was still in the early part of her 2nd trimester. She came in complaining of decreased fetal movement. The experienced ones on the unit didn’t think much of it. They wondered if she had even felt movement before this time as it was early in the pregnancy. But the patient was here; and so we went to see her.

As we walked into the room the nurse was trying to find fetal heart tones with the handheld Doppler Ultrasound device. (A Doppler Ultrasound is a handheld device that allows one to hear the fetal heartbeats.) She muttered something about the equipment in the room not working, about her doppler’s battery running out. She could not pick up any heart sounds; her probes were met with silence. This should have been my first warning sign. The nurse then left the room to allow us to do our exam.

Our patient was lying in her hospital bed. Her husband stood by her side. Their toddler sat in a chair, amusing himself with a toy. The patient explained to us that she understood it was early to feel movement. But she had started feeling movement a couple weeks ago. However she noticed that it was significantly less a few days ago. That day, though, she had felt none. She wondered if it was just because she wasn’t noticing it. After all, we often advise expectant mothers to sit still in a quiet place when they try to do “kick counts” because it is easy to block the movement out when the baby is still small.

The resident fired up the ultrasound machine and started probing. She was going to try to assess for fetal heart rate since the nurse hadn’t been able to with the Doppler.

“There’s the head,” she said as she pointed it out on the screen. She continued moving the probe around, sliding it over the jelly-covered belly. I thought I recognized the chest wall, but I was so bad at looking at ultrasound images that I didn’t think much of it when the resident kept moving.

“I usually find it really quick. But maybe the baby is turned away,” she told the couple. Again, throughout the ultrasound, only silence.

My resident then turned to me, “Can you call Dr. A on the unit? She might be better at this.”

Dr. A was our senior resident — less than a year away from becoming an attending. It made sense that she would be better at this. But this was also my second warning sign.

I left the room, but instead of getting on the phone, calling the unit secretary, and asking for Dr. A, I ran to the unit myself. I didn’t want to waste time. Besides, since I didn’t know the unit’s extension, I figured I could run to Dr. A faster than I could call.

When I returned with to the room with Dr. A, she politely introduced herself and replaced the resident at the ultrasound machine. She took her turn at the machine. Within a minute, though, she turned to the resident and quietly asked her to page the attending physician on call. And there, accompanying the silence, was warning sign number three.

The resident and I walked out. She paged Dr. B. In the hospital, they don’t like paging the attending unless absolutely necessary — especially when it is at night.

I was surprised at how fast Dr. B came. I remember thinking that the call room must be really close.

Dr. B, the resident, and I walked into the patient room. Dr. B introduced herself as the supervising physician and took over for Dr. A at the ultrasound machine. After a little bit she turned and asked us to turn the lights back on.

“I’m sorry,” she began as she looked at the patient and her husband, “there is no heartbeat.”


I don’t know if I still remember the mother’s face. I think I do. But it isn’t a very clear picture in my head. I didn’t want to stare as the tears started streaking down her face so I looked away. It was tough. Labor and delivery is usually a unit of such joy. The patient’s are generally young and healthy. They leave with brand new bundles of joy.

But that night, instead of joy and new life, I came face to face with silence.


Can We Really Understand Our Patients?

The following post originally appeared on Medscape’s The Differential on January 12, 2011.


Knowing I had recently completed a rotation in OB/GYN, a friend asked me how they (medical schools) make male medical students understand what their pregnant patients feel like. It was an interesting question. And it got me thinking about understanding what our patients go through – no matter their age, or sex, or condition.

As medical students, there is not much discussion about how our patients feel. Sure, there are classes about human suffering. But these classes deal with generalities. Each patient experiences their condition in their own unique way. To draw upon the obstetrical cases, telling a woman that she is pregnant can be met with a variety of responses that range from fear and dread to joy and elation.

I once heard Dr. Wil Alexander say, “The moment a symptom occurs, a story begins.” Those words seemed so profound at the time that I wrote the idea down and saved it. Each patient who walks through the hospital doors is more than a symptom. They are more than a diagnosis. They are more than a disease. They are human beings who have a story – a story that is just waiting to be told.

The question that my friend raised, regarding how male medical students are made to understand the experiences of their pregnant patients, made me realize that there is little done to help us understand our patients’ experiences. But I am okay with that. Because each experience is too individual to explain away with a blanket statement. It is impossible for anyone to know exactly how another feels.

The important thing, in my opinion, is for us to connect with our patients and convey that we acknowledge that they are going through a difficult or trying situation and to offer ourselves as they cope with it. It can be something as simple as giving them permission to be candid about their raw emotions – the frustrations and fears that build up – in a safe environment where no one will betray their trust or judge them or treat them any differently because of it.

It would probably be a good thing if we could understand exactly what our patients were experiencing. It would probably help many of us with our empathy. But without that ability to understand perfectly the experiences of our patients, we are left with the ability to accept perfectly the experiences of our patients. And I suspect that for most of them, this much is enough.


Random Thoughts at 6 AM

It’s 6 AM here. I feel like taking a shower. It would probably make me feel more awake. But the problem is that I don’t want to be awake. I want to be asleep.

I’ve been up since 1:30 AM. The plan is to keep studying for a few more hours and then go to sleep. I am bummed that I don’t get to wake up today and turn my clocks back one hour (Daylight Savings Time is today).

I need to be at the hospital by 5:30 PM today. As luck would have it, I’m scheduled for two days of “night float” just days before my shelf exam. So today and tomorrow I will be arriving at the hospital by 5:30 PM and staying until 7 AM.

No beds. No naps. Just hanging out on the Labor and Delivery unit in case something goes down.

I’ll be silently hoping for “quiet” nights. Because the nurses will pounce if I say something like “quiet” on the unit. It’s supposedly bad luck.