One morning, the residents picked an elderly woman who was admitted for “social” reasons: she had been evicted from her apartment, had nowhere to go, and showed up at the hospital emergency room, destitute and confused, with little in the way of medical illness. Her answers to questions were monosyllabic. Her medical history was sparse, her family was gone, and she seemed to have no interests. Fitzgerald wasn’t getting anywhere. Finally she asked the patient if she had ever been hospitalized.
“Yes, I broke my arm,” she said.
“How did that happen?”
“A steamer trunk fell on it.”
Fitzgerald persisted; answers slowly unfolded. The patient was emigrating from Ireland to the United States. The boat lurched. It had hit an iceberg. The name of the boat—you guessed it.6 In the same essay, Fitzgerald told another story about a resident who noted a scar in a patient’s groin. The patient said that he had been bitten by a snake there. “How did that happen?” Fitzgerald asked. The resident said he didn’t know. As Fitzgerald noted, the imagination can run riot with possibilities.
While Fitzgerald’s stories relate to knowing the patient as a person, curiosity is also essential to the technical aspects of care. Several years ago, on my first day of a much-needed vacation, I was trying to unstick the quick-release lever on a bicycle seat post. The lever snapped and the rusty broken end impaled the muscle at the base of my left thumb. It was a deep wound. After stitches and a week for the swelling to go down, I still had numbness on the outside (radial side) of the thumb. The hand surgeon explained to his resident (and me) that nerve injury on the radial side of the thumb was less important than on the ulnar side of the thumb because the ulnar side was needed for a pincer grasp—turning screws and handling instruments. Thus, they would not plan any further tests or interventions. They didn’t think to ask what I actually do with my hands. For me, doing physical examinations, typing on a computer, and playing the harpsichord are everyday activities that require sensation on the radial side of the thumb. I rarely use a pen, a screwdriver, or a scalpel. As an assertive patient, I objected. They changed their plan and, fortunately, the numbness resolved.
In medicine, feeling not-too-certain leads good clinicians to dig further, to explore the archaeology of each person’s illness. Social psychologist Ellen Langer recommends that we consider “facts” as merely provisional or contextual—what’s true today in Rochester, New York, might not be true tomorrow—or elsewhere. Facts come to us from our primary senses (“I saw it with my own eyes,” etc.) and also through spoken or written language. Any trial lawyer or astute clinician knows better than to accept these primary data as irrevocably true.
Faith Fitzgerald, in her article on curiosity, tells a story of a medical student who presents a patient on rounds as having “BKA times two.” In medical jargon, BKA stands for “below-the-knee amputation.” Fitzgerald saw the patient and noted two feet sticking out from under the sheets—warm, pink, hairy. Even seeing the patient with Dr. Fitzgerald, the student failed to notice that the patient had feet until she pointed it out. The student was flummoxed, rendered speechless. He said that he reported BKA because it said so in the chart. Apparently, a transcriptionist made an error on a discharge summary. Instead of typing DKA (diabetic ketoacidosis), she typed BKA. The error was carried through several hospital admissions. Once a patient is assigned a diagnosis, whether it be a disease (asthma, for example) or a personal characteristic (e.g., “difficult,” “noncompliant”), that diagnosis tends to stick, and it takes what seems like an act of Congress to remove it from the patient’s profile.7 It shuts down consideration of alternatives.
In medicine, curiosity about people is not merely a nicety. A spirit of inquiry, interest, and wonder is good for patients—and fundamental to excellent care—because clinicians then see them in all of their richness and complexity. Adopting an attitude of being not quite certain can release clinicians from the tyranny of categories, or at least soften their edges. They see patients as humans, not merely case studies. Curiosity can help clinicians choose the right treatment; asking someone how he spends his day can help me know whether taking a pill three times a day is realistic or if a once-daily dosing (at slightly higher cost) is better. A deep interest in people is the basis for empathy and understanding. Curiosity, like attention, has a moral dimension: it inspires care that respects and engages with patients’ needs, wants, preferences, and values.8
FUZZY TRACES
In primary care practice, patients typically present with early and subtle signs of illness, making a diagnosis more difficult. Appendicitis in its early stages can seem just like an ordinary stomachache. Pneumonia and heart failure may be hard to distinguish from one another. An allergic reaction and a staph skin infection may look alike. Some diseases have early signs and symptoms that are just too subtle to detect, but are obvious in retrospect. Sometimes it doesn’t matter if the diagnosis is delayed, but at other times an early diagnosis is critical.
As a family physician, I see many children in my office with cold symptoms, often the victims of some virus. However, every once in a while, a child with symptoms similar to those of a virus has something more serious—pneumonia, meningitis, even leukemia. In those situations, often something doesn’t feel quite right to me. I feel a sense of unease. My brain is on high alert, yet the accompanying feelings are visceral and hard to describe—I just don’t feel comfortable inside. Sometimes I wake up in the middle of the night, worried. Perhaps I told a mother to bring her child back in a week; now that seems too long. These visceral feelings draw upon and also inform what philosopher Michael Polanyi calls “tacit knowledge”9 (that which we know but find difficult to describe) and what psychologist Valerie Reyna calls “fuzzy traces” (memories that carry the gist of a situation but are often fuzzy about details).10
What happens next is particularly important; it would be so easy to ignore the feeling and move along to the next task. But I’m curious when a patient “looks sick.” I can explore it, unpack it, and examine it more closely. Perhaps the child is a bit pale or is clinging to his mother more than I’d expect. Perhaps I know that his mother doesn’t schedule office visits unless something is really wrong—and she’s usually on the mark.
When being curious, this sense of unease piques my interest in the patient. I am attuned in a way that invites further exploration, often before I can characterize why—perhaps in the same way that a sommelier can first identify a great wine and only later finds the adjectives to describe it. Clearly, these impressions are informed by my clinical expertise; I would not have been able to make fine distinctions between “sick” and “really sick” prior to having gone to medical school, just as a sommelier needs to have learned a vocabulary to distinguish different types of grapes and styles of winemaking. From discernment comes curiosity, and then greater discernment. Curiosity is more than mere experience; it links heightened attention (“Something’s not quite right”) with self-awareness (“I’m feeling uncomfortable”), knowledge (“This situation could be dangerous”), and exploration (“I wonder what’s going on”).11
A BAD DAY
Curiosity suffers when we feel befuddled and besieged. Alexis Brown and I had met just once before, not quite three weeks earlier, shortly after she had been hospitalized with a myocardial infarction—a heart attack. Alexis was only forty-two years old and had considered herself healthy and fit. Today she was scheduled for a complete physical.
The visit started with an initial greeting and a general inquiry about her concerns.
“Things are okay.”
“How do you feel you’ve been recovering since the heart attack?” I asked.
“I didn’t have a heart attack.”
I was taken aback. “I don’t understand. I thought we’d gone over that.”
“They did the first test and it was normal, then a few hours later they told me it was abnormal. Then they told me there was no blockage.”
Suddenly, doubting my memory, I paused. �
��Could I check the note your cardiologist wrote?” I wanted to be certain, beyond doubt.
I found the note from the cardiologist. Sure enough, the EKG tracing showed ST-wave changes characteristic of a myocardial infarction. The blood troponin levels were initially normal, then elevated four hours later, indicating heart damage. So far, pretty typical for a heart attack. Her cardiac catheterization didn’t reveal fixed blockages in any of her coronary arteries. This was unusual, surprising. However, the right coronary artery went into spasm during the test, transiently blocking blood flow—a characteristic of Prinzmetal’s syndrome, an uncommon condition and even more rarely a cause of a heart attack. My notes indicated that I had discussed all of this with Ms. Brown the last time and she had seemed to understand. I was sure I was right. But now, it was as if the prior discussion hadn’t occurred.
I asked about exercise.
“I’m not exercising.”
“Why is that?”
“They never told me what I could do to prevent this from happening again.”
“And medication? I see that they prescribed lisinopril and metoprolol to prevent future heart damage.”
“I read the side effects and I’m not taking them.”
I was growing annoyed, frustrated. We reviewed her lab tests. Cholesterol good. Stopped smoking in the hospital, none since. Doesn’t drink. I tried to plow through.
“So, maybe we should do the physical exam. Here’s a gown; I’ll be back in about two minutes.
“I don’t think I want a physical today.”
“Okay, we can wait if you like. I was reviewing your chart and noticed that you don’t have a flu shot on record. Can I offer you one?”
A hesitation. “No, I don’t think I want it.”
“Can I ask why?”
“I don’t think I will get the flu.”
The more she protested, the more I pushed, offering things, services and recommendations. I had no interest in why she might be acting the way she was.
“I just don’t want it,” she said.
Now I felt under attack. I thought, “Why the hell is she coming in today, anyway? To torment me?” I was running late already and had no patience for what I perceived as stonewalling.
Perhaps you see this situation more clearly than I did at the time. I didn’t welcome her perspective. I was impatient with her lack of cooperation, not seeing that my impatience was the flip side of my need to be an authority, in charge. I just wanted to push ahead with my agenda and get this increasingly unpleasant visit over with. She had seemed so reasonable during our first visit, and now this. To reassert control I started on a quiet rampage, “I thought that we agreed that you’d come in for complete—” Not being able to finish my own sentence, I stopped abruptly. An awkward silence.
Then, I smiled at myself. I realized that she was not making me annoyed, that my own mind was creating this sense of annoyance because I desired something (a docile, agreeable patient) that was not in the offing. Call this a mindful moment. I realized, with a calm equanimity, that I was trying to push her into compliance and that I was serving my own need to have the visit follow a particular protocol. My breathing had become shallow and I had an almost insatiable desire to sigh. I had been tensing my legs as if preparing to bolt. I wanted to get out of there. I hadn’t been curious about how Alexis Brown saw the situation nor about what she felt she needed. I had had no interest in examining my contribution to—and her experience of—our breakdown in communication.
Here, the sense of unease finally roused my curiosity. I inquired, not having any idea how she might respond, “Can I ask you, how are we doing here? I’m not sure what you were hoping for today.”
“We’re doing okay.”
There was another silence, this time less awkward and more expectant.
“I’m the one who’s in control here. I know my body and I don’t need a physical.”
“That’s really important. You want to be in control. I understand that to mean you want to know what’s going on so that you can be in charge of your health. Is that right?”
“Yes.” We had arrived somewhere. She had a few questions, all germane to her illness and its treatment. I still felt uncomfortable.
“So how should we leave things? Normally I’d see someone back a couple of times in the first few weeks after a hospitalization, but it’s up to you. You could come back in a week, a month . . .” I expected her to say that she’d call when she needed to and that I’d never see her again.
“How about two weeks.”
I was stunned.
“You’re the first doctor who explained things.”
“I’ll try, but you let me know when we go off course.” I meant it; I did need her help.
“Okay, see you then.”
The next week a note from the cardiologist indicated that she was doing well and was content taking her medications.
TRAVELING IN PACKS AND PRACTICING ALONE
While curiosity is often spontaneous, sometimes it takes effort, especially when things aren’t going well. As communication was breaking down with Ms. Brown, I didn’t want to be curious; I just wanted to get out of there. Physiologically, the stress of conflict activated my three-way fight-or-flight-or-freeze switch—not my curiosity switch. I wanted to place the responsibility and blame for malfunctioning communication on her. How easy it would be to say that she was “in denial” or “noncompliant,” leaving a fractured relationship unaddressed and a serious disease untreated. I needed a way of bringing myself back to the present, to engage with her in a more productive way. This took an additional minute or two of time and some additional mental effort, but likely saved me hours down the road.
I tried to dissect what had happened. As I became aware that my breathing was shallow and that I had been tensing my legs, I had a “fuzzy trace” moment—something was amiss but I couldn’t put my finger on it. I then noticed the associated emotions—feelings of restlessness and frustration. At first I tried to push those sensations and emotions away, then realized that they were a useful signal. What I was doing wasn’t working, and the clue came from feelings in my body. I listened to the signals coming from within and used those signals as triggers to become more curious, to slow down and inquire further, even though I was feeling annoyed. While it could have happened sooner (I became curious after having tried several other options!), this subtle transition was instrumental in achieving a positive outcome.
Achieving a transition like that—transforming discomfort into curiosity—takes practice, both in the clinic and outside. One exercise that can be particularly useful is the “body scan,” popularized by Jon Kabat-Zinn in his Mindfulness-Based Stress Reduction programs. The body scan is not a relaxation exercise; rather, it’s an awareness exercise.12 Participants are guided through awareness of each part of the body, noting its position in space, tension, relaxation, or other pleasant or unpleasant sensations. When “scanning” the abdomen and chest, the attention is drawn to movement—of the breath, the viscera, and the heart. Sometimes I’ll experience a strange sense of unfamiliarity and novelty—for example, when I first noticed that I habitually hold my left shoulder more hunched than the right. Simply noticing and exploring bodily sensations—without trying to change them—lets you observe more fully. Paradoxically, practiced inaction can lead to action. In the clinic that day, a brief taste of that practiced awareness was essential in switching from frustration to inquiry.
Well-functioning clinical teams can also promote curiosity. A palliative care nurse-practitioner colleague routinely explains to patients when we arrive with a group, all in white coats, “We travel in packs for protection.”13 While it’s an attempt to make humor out of a potentially threatening situation, there is some truth in it. Several sets of eyes and ears, in a well-functioning team, extend the senses and sensibilities of any one individual. A team member might say, “Did you notice she’s looking a bit yellow?” or “She seems to be more confused today than yesterday,” or “I don
’t think that we’re all on the same page.” A new observation then leads to doubt, reconsideration, and revision of our impressions. Observant teams stimulate an infectious curiosity.
However, as clinicians, we often practice alone. Even in the hospital, after rounds, I visit patients by myself. In my family medicine office, a patient arrives and the door is shut. It’s just me and the patient—and possibly a family member or two. No one is watching. Almost no one has directly observed my practice in thirty years—except the occasional medical student. In those situations, curiosity has to start with me. If I’m being mindful, I am curious about the patient and I am curious about my own experience. In a way that is informative and not self-indulgent, I notice what captures my attention as I go about my work, whether I find it pleasant or unpleasant, interesting or annoying. I am “preparing to be unprepared”; I practice what Ellen Langer calls “soft vigilance,” an open, receptive awareness, actively looking for something that is new, unexpected, or interesting.14 Soft vigilance is a relaxed awareness. It is different from hypervigilance—trying to focus on every detail at every moment. Soft vigilance is energizing, whereas hypervigilance can be exhausting. Soft vigilance informs and prepares me to pay attention in a different, more open way.
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