Prior to 1816, it was common practice for doctors to place their ears to patients’ chests to detect the workings of hearts, lungs and other organs.
That year, French physician Rene Laennec, who was uncomfortable placing his ear against the chest of a young female patient, invented the first stethoscope. Laennec’s stethoscope was around 12 inches long, but over time, the instrument’s tubing grew. In the 1830s, the flexible monaural stethoscope was introduced. It was around 16 inches long. Then in 1852, George Camman introduced the first binaural (for two ears) stethoscope, which was around 20 inches. Today’s stethoscopes are up to 30 inches long.
Born of one physician’s modesty, the most widely used medical instrument has become symbolic of the increasing distance between patients and their doctors.
In the 20th century, new tools helped clinicians assess the workings of their patients’ internal organs without having to be near them: cardiac rhythm monitors, echocardiograms, CT and MRI machines. Now, doctors and nurses routinely interact with their patients via the internet from virtually anywhere in the world. This activity became the preferred interaction for many during the COVID-19 pandemic. Technology provides opportunities to connect but not as completely as we do when we are person to person.
Now, because of COVID-19, when we provide in-person care, we cover our faces with masks. Our masks block viral transmission, but they can hamper direct communication. Seeing someone’s facial expressions is an essential part of information transfer. All it takes for a baby to smile is to show them your smile. But masks create distance between patients and their doctors. Important non-verbal communication can be lost.
The words medical professionals use also reflect a diminishing connection between patients and their caregivers. When I was in medical school, I read a letter submitted to the local newspaper from a worried mother who brought her child into the doctor for nosebleeds. Her child’s doctor told her that her son had epistaxis.
She did not ask the doctor what that meant and left the office concerned. Her letter was short. She asked what epistaxis was. The answer was even shorter: nosebleeds. Now, hundreds of websites help patients translate medical jargon into understandable words.
No laughing matter
Comedian George Carlin once made this issue the focus of a popular routine. He noted that, in WWI, we used “shell shock” to describe traumatic reaction to the experience of battle. In WWII, the condition came to be called “combat fatigue.” In the Korean Conflict, it was known as “operational exhaustion.” During Vietnam, the same phenomenon was changed to “post-traumatic stress disorder.” We now use this phrase for the effects of all types of trauma.
With time, the number of the words we used for the same condition grew longer and more clinical, eventually becoming utterly devoid of emotional content. The increase in syllables had the effect of insulating caregivers and other civilians from the unpleasant reality of the other person’s suffering, but the result has been to put more distance between clinicians and the people who rely on their help.
Today, because of deaths, despair, workforce shortages and social isolation brought on by COVID-19, large numbers of healthcare workers and those they serve will suffer PTSD. I would argue the majority of healthcare workers and first responders have “operational exhaustion,” which is a much better term for what is going on in healthcare facilities.
The gap between patients’ expectations and the care they receive has been growing for years, as is the difference between the ideals of healthcare professionals and the reality of day-to-day practice.
I see your heart
One remedy for this disturbing trend is for clinicians and their patients to take every opportunity to close the space that has grown between them.
For now, we cannot reduce that space physically, but we can reduce it figuratively and verbally. Figuratively speaking, we can bring our ears closer to each other’s chests so that we may hear each other’s “hearts.” Doctors can do that by taking the time to listen to patients’ concerns and personal stories, especially the stories of loss and powerlessness. Any one of these experiences may contribute significantly to their current condition.
Listening to patients and their families can help guide clinicians to more successful and satisfying decisions and better short-term and long-term outcomes. Equally, it is important for patients and their families to share with their doctors and nurses their stories and what meaning they derived from their experiences. This informs the clinicians about what is important to their patients and increases the chances that healthcare decisions are aligned with the person’s individual goals — goals for times they are in good health, and goals for when they approach the end of life.
Clinicians move closer to their patients’ hearts verbally when they ask open-ended questions about recent experiences and the emotions those experiences triggered. Patiently listen for answers without interrupting.
Use questions like, “It must have been very hard these last few weeks. Can you tell me how it affected you?” This approach is similar to how therapists initially approach clients with PTSD. They ask them to recall experiences but do so in a safe, supportive atmosphere.
Sometimes the origin of a word or a literal translation can lead us to surprising insights and metaphorical wisdom. The word stethoscope comes from the Greek “stethos” or breast, and “scope,” to look at or see, which taken together can be interpreted as, “I see your heart.” This simple phrase is a wonderful prescription for compassionate care and should be the core principle of all medical care systems.
In the last year, our world has lost too many lives, but, perhaps almost as sad, we lost countless untold stories. I am so fortunate to work where I do. I witnessed and heard remarkable stories from the community that is the Los Angeles Jewish Home. I saw the hearts of dedicated professionals entrusted with the care of a remarkable group of people who are our residents, patients, members and participants.
Shortening the distance between human hearts can reduce the emotional toll that this pandemic has caused. My efforts to do that combated my operational exhaustion.
The stories I learned from my patients are not lost. They are now my stories to tell.
May all those memories be a blessing.
Noachim (Noah) Steve Marco, M.D., is chief medical officer for the Los Angeles Jewish Home and the Brandman Health Plan. He is also the executive director of the Brandman Research Institute and the medical director of our IPA, LAJH Medical Associates.