Lynette Chiu | Writer + Strategist
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Observing Clinical Encounters at a VA Hospital

In the first semester of the Narrative Medicine Masters program, students shadow a clinician for several hours and observe the less technical elements of every interaction with patients—body language, interpersonal dynamics, and manner of speaking—and then submit a descriptive account of the experience, including what we noticed and what it was like to be a presence in the exam room.

The following is my account of visiting the VA medical center in the Bronx. I have anonymized the doctor and the patients.

The hospital is outfitted with metal detectors. I locate Dr. A, who provides primary care to homeless and non-homeless vets, and sees his patient populations on separate floors. He tells me that some staff are in favor of keeping the two groups separate, but one of the doctors would like to integrate them. I don’t know if there are administrative advantages to keeping them divided, but as Dr. A notes, the current set-up stigmatizes the homeless.

Most people in the building, and in Dr. A’s office, wear something marking them as vets, such as patches on their jackets, an army T-shirt, dog tags, a Navy baseball cap. I imagine there is a shared understanding among people who have experienced the rigor of training, the stripping off of one’s identity through crew cuts and boot camp that prepares them to be remade as soldiers. I don’t know if they don these items because they make up most of their wardrobe, or they are very proud of having served, or they simply want to be identifiable to others like them.

I sit by the examining table while Dr. A sits at his desk and each patient takes a chair against the wall. We form a triangle. Patients can’t see me from the waiting room, and they each pause for a split second upon realizing I’m there. Patient 1 is direct, amicable, and curious. Dr. A runs through his many medications with him, and the man leans in, intent and engaged. He pushes against his cane and states that his most recent medication is a narcotic, and he felt the opiates worked better.

“All we have to do is get you a new back, and you’re good to go,” concludes Dr. A.

“Yep, that’s it!” says Patient 1, looking my way and smiling.

Patient 2 is more erratic in mood, by turns relaxed, resigned, and restless. He is in pain, and choosing to stay in pain because he doesn’t want surgery. He has refused even flu shots for years, and he both laments his situation and expresses his frustration in bursts that are a mix between aggressive and jocular.

“I got a heart murmur, and I’m stressing about it,” he says.

“Why?” asks Dr. A.

“I wish I didn’t have it!”

The man notices every time Dr. A repeats a question, saying “You already asked me that!”, and I wonder if his shifting presentation is throwing off the doctor as much as it is me. Throughout, I’m not sure if it will remain a respectful exchange. While seated, Patient 2 alternates between sitting back with his head against the wall, where his words sound more brazen, and leaning forward in a more protective pose when he is feeling more defensive. He does not look the doctor in the eye when discussing his weight gain. His body appears healthy, strong, and not overweight, but he has put on almost 20 pounds in four months.

“The shower was cold this morning,” he snarls. “I was mad as hell.”

He keeps mentioning a box that is burdening him. It turns out to be a cardboard box that he has left in the waiting room, about 3 feet square, containing a comforter, pots and pans, and other items. Dr. A goes to investigate and immediately sets out to figure out how he and his staff can help him, maybe rig up a different way to carry it that won’t strain his already pained body. The mood is collaborative. 

The computer is a character throughout the consultations, holding records of prescriptions given by other doctors, and acting as another authority in the patient’s care. Based on the computer’s record of past visits, Dr. A suggests a basic check be done to “humor the computer” and with another patient says he is going to measure his cholesterol “for the computer’s sake”. He does not come off as pushy for re-visiting something that was checked fairly recently; he can pass it off as the computer’s mandate instead of his, and not leave much room for the patient to protest.

I’m surprised by how fluent the patients are in the vocabulary of medications and ailments. Most of them know exactly the number of milligrams they are taking of each pill and what classification of drug it is. They’re wary of becoming dependent, and I imagine worn out from the sheer amount of prescriptions they’ve sampled. “Methadone?” says Patient 2. “I’d rather take an Oxy.”

The patients primarily acknowledge me in moments of levity, and I validate the exchange with a smile, a non-verbal “yes, that was funny.” Dr. A asks Patient 1, who is using nicotine patches, if he thinks he has really quit. “Well, it depends on my mood, you know?” He appeals to me with a grin.

I am grateful and puzzled by how on the whole, the patients do not act self-conscious about their ailments or medication regimens in front of me. Neither the doctor nor I make clear that everything in the visit will remain confidential and anonymous, and I am taken by how comfortable most of them seem with my being there in spite of that. The patients don’t make any eye contact with me while being examined—and that is a relief. Patient 1 looks blankly at the far wall while lying on his side and I am careful not to look right at him, just a couple feet away. He seems far more vulnerable here, lying prone with a doctor lifting his shirt, than when he was sitting in the chair. I don’t want my gaze to heighten the tension that arises when a clinician begins to look for answers on the body. There’s an inherent fear of a discovery, or sudden pain, and when nothing dramatic happens, there’s an exhalation.  

Patient 3 doesn’t have many of his front teeth left, and chemo has affected his right hand and the left side of his jaw. He’s learning to do everything with his left hand, and is having trouble tying and untying his shoes. Dr. A kneels down to work on the knots and helps get the patient’s shoes and socks off. The exchange feels tender.

I can’t tell what is going on with Patient 3, but Dr. A is talking in terms of how to manage his pain “to where you can live with it.” He wonders if medical marijuana could help. The man speaks at length about his life, and Dr. A listens. He had a full scholarship to USC before he joined the Navy, still always cheers for USC football, and he comes from a family of soldiers who served in WWI, WWII, and Korea. “World War II vets live like 90 years, and Vietnam ones are dying off of cancer,” he notes.

At one point, one of the doctor’s staff members shoves a piece of paper vertically through the door.

“High tech delivery system,” quips Dr. A.

They return to Patient 3’s biography, the election, and his current situation.

“I don’t want to be loopy, lie in bed the last days of my life,” the man says. Outside of the talk about his pain, he is jovial throughout the exchange, laughing with ease. His life is coming into focus for me: his grandchildren in California, witnessing the L.A. riots, the time he was ordered to learn the Marine anthem while holding up two buckets of sand.

“That sounds like a scene out of a movie!” exclaims Dr. A. “But you had to live that.”

In the waiting room, Patient 2 is back, ready to go back out into the world with his box. He’s managed to pull together something to ease his journey.

“I’m going to give you props,” says Dr. A.

“You should give me money!” Patient 2 says. He leaves soon after.

As Dr. A escorts me out, he mentions that Patient 3 has metastatic prostate cancer. “It’s metastasized to his bones, so I indulge him more. He has six to twelve months expectancy.”

It feels desperately unfair that he will be gone soon, and the only request he had of Dr. A was to get him some shoes that didn’t need to be tied.