The Least of These: Reading Poetry to Encourage Reflection on the Care of Vulnerable Patients

INTRODUCTION

How do we encourage medical students, residents, and physicians to reflect critically and empathically on the plight of vulnerable patients? Exposure alone may not be sufficient, as some evidence suggests that contact with such patients leads to more negative attitudes in trainees.¹ A series of 16-line poems² (11 total, 3 quoted below) by physician-poet Rafael Campo offers provocative material that can easily be integrated in discussions of both novice learners’ and experienced doctors’ clinical interactions with the underserved and other vulnerable groups. Campo’s poetry tackles the intersection of social and medical issues in addressing topics such as alcoholism, child abuse, sexual abuse, domestic violence, drug abuse, AIDS, racial prejudice, homelessness, and homophobia. It compels the reader’s gaze to linger on patients who have been discarded and devalued in the health care system. In almost all the poems, the doctor fails the patient, not necessarily medically, but certainly humanely. These are powerful pieces, viscerally painful to read, that hold up a mirror to all the wrong turns that doctors (and society) can take in interacting with vulnerable populations. Each of these mini-narratives can be a starting point for medical readers to develop a detailed awareness of how indifference, negative judgment, and overt prejudice can manifest in clinical encounters and explore ways of expressing attitudes and behaviors exemplifying values different—and better—than the ones on display in these works. Used as a basis for discussion, not to condemn physicians but to better understand how easily they can yield to detachment, indifference, objectification, even contempt, these readings can deepen learners’ awareness of attitudinal and behavioral pitfalls in clinical practice, and redirect them to alternative ways of perceiving and acting.

TEXT¹

VI. S.W.

Extending from her left ear down her jaw,

The lac was seven centimeters long.

She told me that she slipped and struck her face

Against the kitchen floor. The floor was wet

Because she had been mopping it. I guessed

She’d had to wait for many hours since

The clock read nearly midnight; who mops floors

So late? Her little girl kept screaming in

Her husband’s thick, impatient arms: he knocked

Three times, each time to ask when we’d be done.

I infiltrated first with lidocaine.

She barely winced, and didn’t start to cry

Until the sixteenth stitch went in and we

Were almost through. I thought my handiwork

Was admirable. I yawned, then offered her

Instructions on the care of wounds. She left.

V. John Doe

An elderly white male, unresponsive.

Looks homeless. Maybe he’s been here before.

No chart. No history. His vital signs

Were barely present, temperature was down

Near ninety, pressure ninety over palp;

The pulse was forty, best as they could tell.

They’ll hook him up to a monitor before

They warm him up. I didn’t listen to

His lungs—I bet I’d hear a symphony

In there. I couldn’t check his pupils since

His lids were frozen shut, but there were no

External signs of trauma to the head.

They found this picture of a woman with

Two tiny kids still pinned inside his coat.

It’s only three a.m. The night’s young. If

He’s lucky, by tomorrow he’ll be dead.

X. Maria

This G2, P1 gives us a confusing

History. It sounds like she’s been pregnant

Approximately thirty weeks, although

She can’t recall her last LMP. No pain,

But bleeding for about two days. Of course

She hasn’t had prenatal care, and God

Only knows where the father is. She works

Two jobs that keep her on her feet all day.

She’s been in the United States six months,

And doesn’t speak a word of English. Bet

You she’s illegal. Cervical exam

Is unremarkable, the os is closed.

I think we need an ultrasound to tell

Us more. Besides a look at the placenta,

We need some confirmation of her dates.

Her uterus can tell us more than she can.

CONTEXT

In “S.W.,” a bare-bones presentation of intimate partner violence, the patient makes all the traditional excuses and the doctor makes all the classic mistakes. Even the resident doubts his patient’s narrative, but he is too tired or too indifferent to question it further. The resident notices a great deal about the patient, including the suspiciousness of her history of present illness, the agitation of her daughter, the impatience and aggressiveness of the brawny husband, and eventually his patient’s tears. But interpreting or acting upon the meaning of this information is apparently beyond this physician’s scope. In a final irony, the physician provides the patient with wound care instructions for the laceration, but ignores the far more serious emotional and psychosocial wounds that abuse has inflicted on her. This poem is useful in focusing learners’ attention not only on the signs of interpersonal partner violence, but more importantly on what factors can make a resident not care whether a patient is in fact abused. At various points as the poem develops, student physicians or their more experienced counterparts can brainstorm different ways of responding to the patient that might lead to a different final outcome.

“John Doe” describes an elderly man, apparently homeless, who has almost frozen to death. Yet to the treating resident, this patient’s tragic misfortune is not a significant event. He’s seen it before. Throughout years of street life, probable trauma, and certain deprivation, the patient has somehow retained a picture of great significance, one that suggests critical dimensions of a former life. The doctor notes the picture, but withholds comment. As in the first poem, he sees the fact, but not its meaning. In the last line, the resident cynically asserts that the patient would be better off dead. Although we do not learn how the physician is able to so quickly and efficiently determine the relative absence of value in a life, we have the feeling he’s reached such conclusions before. “John Doe” can profitably be read as a cautionary note about how quickly doctors can objectify their patients, how easily they can ignore what might be most important in a patient’s life, and how simple it can become to make professionally inappropriate and morally corrupt judgments about another. It also raises valuable questions about how to treat a patient who can make no protest, who has no defender except the moral conscience of the physician.

“Maria” is cast in the form of a case presentation. It describes the uncertainty and frustrations of a cross-cultural medical encounter from the perspective of a cynical, emotionally distant resident. One of its most interesting aspects is the seemingly objective language of medicine that the resident employs. Yet the poem makes obvious that such language can easily become riddled with biases and assumptions. Such stereotypic and prejudicial phrasing illustrates how bias can contaminate the veneer of neutrality, and makes medical readers more conscious of their own speech and that of others. Then there is the issue of the resident’s clinical stance itself. The resident accurately assesses the medical situation, and properly recommends an ultrasound. But where is his empathy for a woman who is bleeding at 30 weeks, cannot speak the dominant language of the emergency room, who is alone and likely afraid? Reading this poem encourages learners to explore the value of empathy and perspective-taking, especially when working across cultures, and to consider how expressing these qualities might affect the encounter.

Taken as a whole, these poems confront learners with the disturbing relational consequences of physicians who, although prepared to address the medical needs of their patients, are unable to see or hear their humanity. They focus on vulnerable patients, whom physicians may believe they can afford to dismiss and sometimes even despise without consequence. Instead of adopting a position of empathy³ and compassionate solidarity⁴ toward such patients, these doctors intentionally or unintentionally abandon them emotionally if not medically, allowing the technology of bio-medicine to shield them from the messy human complications of medicine.

Yet the poems beg the question, what makes physicians behave in such a manner? Based on their evident emotional exhaustion and depersonalization, one might deduce that the residents represented are suffering from burnout.⁵ Such awareness can lead to reflective conversations about work conditions, role models, self-care, and the moral choices overworked and overburdened physicians must make, often on a moment-by-moment basis, in the execution of their clinical practice. By examining different ways of being, medical readers can become more aware of assumptions they have absorbed about certain kinds of patients, and can begin to decide in a more conscious manner how they wish to interact with such patients in the future.

QUESTIONS FOR DISCUSSION

1. Why are “vulnerable” patients also vulnerable to emotional and relational neglect? How might this neglect be remedied?

2. Does the objectivity of the residents depicted serve any useful purpose? How can physicians achieve an appropriate balance between emotional distance and caring?

3. What are possible strategies for engaging with residents like those portrayed in the three poems?

4. How can you prevent and/or address similar problematic attitudes and behavior in your own clinical interactions?