Date: Sun 11/30/2003 6:00 AM
Random Thought: Bedside Manner

It is cold out there this morning! Mid-twenties!! The air had a slight chill that was akin to liquid nitrogen. I thought for a time or two that I was going to be quick frozen. By the time I came in from my walk my skin was the same color as my Carolina Blue grubbies. I quickly lunged for the warmth of a steaming cup of fresh brew. It was to no avail. My ice-cold hands quickly turned it into ice coffee! Now I know how Midas felt.

Talking about a deep chill is a good lead-in to two interesting and interconnected pieces about the less than warm temperatures of traditional medical bedside manners that I've just read. The first was Geoffrey Kurland's MY OWN MEDICINE: A DOCTOR'S LIFE AS A PATIENT. It's interesting. Kurland, an accomplished pediatric pulmonologist, stricken with leukemia, talks of his revelation of how doctors are present at and involved in emotionally charged moments throughout their careers. Yet, with unacceptable rarity they are not trained to listen, to be empathetic, to be sensitive, to create rapport, to generate trust, to just plain talk, to be human. They may have great medical skills at opening up people, but far too many have weak people skills that close people up. Kurland describes his own sense of diminishment, devaluation, disempowerment as a patient at the hands of his medical colleagues. He talks about how the attending physicians ignored what's fundamentally important and meaningful to him as a human being. I wonder what wondering we academics would be led into if one of us published MAKING THE GRADE: A PROFESSOR'S LIFE AS A STUDENT?

The second piece I read was an old article discussing how the national medical licensing exam will include on a trial basis examining "patient encounters." It seems that there is a push in some quarters of the medical profession to transform a major complaint into a major concern. That is, there is an attempt afoot to establish a balance in a science-heavy curriculum with a "best friends" training to forge vital connecting and supportive relationships between two human beings known as patient and physician. The Licensing Board is devising what I call a testy test in bedside manner.

If I remember my history of science, it once was, before the time of scientific and technological innovation, before the likes of Jenner and Lister and Pasteur and Koch and penicillin and Pfizer, that all doctors generally had to offer was compassionate listening. Then, the empathetic patient concern model of warm caring went by the wayside as it was replaced by the chill of an unemotional disease treating model. Doctors substituted what I'll call "presence" with antibiotics and surgical "procedures" rather than balancing the two into a healing wholeness. Yet, recent studies show that good communication leads to good clinical practice and better outcomes for patients. Patients want to talk; they want to be respected; they want to be noticed and heard; they want doctors to care about them as individual human beings. Other studies show that doctors can learn a lot about a patient's malady, as well as about a patient's needs, by listening to the patient.

Now, take the words, "physician" and "patient," and replace it with "teacher" and "student." There you have it. Not much difference too many times in too many places. Communication qualities such as listening carefully, making eye contact, touching, noticing body language and showing empathy, being understanding and sympathetic may sound like emotional fluff to many intellectual-oriented academics. But, as my good friend, Alex Fancy, would say, they're really the right stuff. After all, compassion, empathy, sympathy are attitudes or spirit made flesh and bones. That bears repeating: in academics so many are so far into their heads and subjects that they are so far removed from the essential and integral human element in education. They so often underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to touch and turn a life around. It bears repeating because it only takes one person who truly and caringly sees and listens to turn a life around.

Anyway, I had an impish, perhaps treasonous, thought. What if such a test in bedside manners was part of our examination for our academic degrees. Wouldn't it be interesting. Let's be honest. In a people business such as is education, too many of us just don't have the people skills. Most of us have not been trained in such skills. Many of us see ourselves in the information discovery and/or delivery and transmission business rather than in a people serving business. For too many, their future is not really at stake, their job is not really on the line, and their prestige doesn't really depend on their relationship with students. So, such skills are superfluous.

If nothing else, it doesn't take a proverbial rocket scientist to know that patients who feel rapport with a doctor are more likely to do better medically. We've all been there. I know I have. A few years ago, as an out-patient I had what I call "open hand surgery." It sounds more dramatic than mundane carpel tunnel surgery. Anyway, the prep nurse was one of those Dorothy's house should have hit. As she man-handled me, I kept looking around for her broom. Boy, did I want to throw water on her so she'd melt. I am sure she was technically competent, but she had the bedside manner of a hungry tiger about to pounce on a delicious lamb. She was abrupt, stone faced, cold, distant, unreassuring, and harsh. Let's just say that I was, to say the least, not a relaxed happy camper as I went under. She might as well have been an unfeeling robot. I experienced an infantilization. (how is that for a made-up word) I felt slighted, overwhelmed by a harrowing, alienating, and frustrating feeling of aloneness, helplessness, and diminishment.

Ever come out in an out-patient recovery room. I had this amnesic, almost panic, attack, "Where am I?" The place had the look and smell of a morgue. Unnatural and noxious scents of antiseptic and anesthesia heavily fragranted the air. There were bodies all around me. I knew I was dead. Slowly, as the fog began to clear, I cursed that wicked witch in white whose unruffled manner made my last minutes on earth unpleasantly tense, uncertain, unsettling, and frightening. Then, I felt a soft, caring touch on my hand. I heard a soothing, caressing, angelic voice softly whispering in my ear. "Dr. Schmier, everything went well. Your wife is outside in the waiting room. I told her you'll be out in a short while. You'll be with her very soon. Just close eyes and rest. Don't worry. I'll be here and I'll take care of you. Everything will be fine......" My panic disappeared, my muscles relaxed, and I gratefully closed my eyes. I may have had a thin line of a slight smile on my face.

Now this nurse I am sure was just as technically competent as the first, but unlike the first, she wore a halo instead of a cone hat; she understood she was as much, if not more, in the people business as in the medical business.

It's no different in academics. Studies, and my professional experience, show that students who feel a rapport with a professor, who are a member of a supporting and encouraging classroom community, who are respected and trusted and cared about are more likely to reach out for their as yet hidden potential. The most basic of all human needs is the need to understand and be understood. Why can't so many of us understand that?

There is a Native American saying: speak only half as much as you listen. I'm not sure most academics even listen half as much as they speak. Yet, seeing eyes and listening ears mean a seeing and listening heart; they mean being aware; they mean taking an intense and sincere and caring interest in what is being said; they mean hospitality, respect, appreciation, nurturing, and wonder; they mean being open to something new about a new person; they mean not being preoccupied with what to say when the other person stops; they mean an intense silent conversation; they mean not acting like Alice's hare, even if you are in a hurry; they mean knowing beneath the spoken words is their meaning; they mean knowing that words have no meaning, people who speak the words have all the meaning; they mean paying close attention to whom a person is; they mean creating deeper silences in yourself; they mean not talking to yourself while the person is talking; they mean getting the ears, eyes, mind, and heart operating at the same speed; they mean not judging, labeling, analyzing, diagnosing, prognosing before the person is finished; they mean not having prejudiced notions, preconceived opinions, cynical attitudes, suspicious feelings; they mean creating a safe place for whatever is said; they mean surrendering yourself to the needs of others. Seeing and listening are acts of love, for you make yourself accessible, you give yourself, you make yourself vulnerable, to someone else's words and feelings. They mean a continuing form of embrace.

Let me offer a medical scenario. You have severe stomach cramps. Your family members rush you to the emergency room. The physician reluctantly leaves his other more glamorous treatments, has never seen you before, doesn't make eye contact, doesn't display any empathy, doesn't listen carefully, shows little sensitivity, doesn't notice body language, doesn't have a record of your medical background, doesn't get one, doesn't examine you, doesn't answer your questions about your symptoms, doesn't create rapport and trust, doesn't honor your feelings, and doesn't communicate clearly. The doctor is rude, condescending, abrupt, inattentive, and, like Alice's hare, has no time for unnecessary "small" talk however necessary and "big" such talk may be to you. Yet, in the literal wink of an eye, like Flash of the comic books, he or she utters a precise "I know exactly what's wrong" diagnosis, prescribes a specific drug, offers an exact prognosis, and is off in a whirl and blur.

What kind of doctor would you think this person was? Ready to chase after an anbulance chaser? Isn't this exactly what too many of us academics so often do when we enter a class, especially one of those uneducational, depersonalizing large classes, and more especially those unprestigious, non-professional, mere "bread-and-butter," huge first year survey classes where we more often than not give mere lip-service to a humanities curriculum? The students lose, have stripped from them, their individuality, identity, and their humanity. Let's admit it. Most of us academics in higher education were not trained as classroom teachers. Most of us are groping amateurs, although many are educating themselves and seeking on-the-job training. But, even then, too many of those struggling to up-grade themselves are concentrating mostly on technology and technique concerned with transmitting the subject material. Like medical school students, most of us weren't trained in bedside manner, communication skills, and student encountering. Far too many of us haven't learned about learning or haven't applied what we've learned about learning. Most of us are still far more consuming talkers rather than see-ers and listeners.

Now, is there hope for those who don't or won't recognize that academic performance on both sides of the podium is behavior driven? Sure there is. We have to take the time to learn how to see and to listen. But, that isn't the same as learning new technologies or methods or techniques. It can work if we work long and hard at it. It may look easy, but not talking or doing, just seeing and listening is not simple. The greatest barrier in learning how to see and to listen is the illusion that so many of us have created that convinces ourselves that we already do it--and do it well. And, we casually dismiss students with a "what do they know," when they say we don't. I know. I did it.

I am a recovering talkoholic. I now know that it's harder to stay awake than you think. I now know that it's harder to stay alert than you think. I now know that it's easier to be in a daze than you think. I now know it's so easy to ignore the human details. I didn't now that or want to know that when I was hooked on orating. When I was addicted to talking, trust me, silence was my enemy and I didn't listen or see most others. I was too busy wanting to be seen and to be heard. I was too busy to notice that there were others in the classroom. I was so shut up in myself I couldn't shut up. I was so untrusting of myself and others than I didn't trust the silence of just seeing and listening. And, I wasn't really listening to what I was saying about myself and students. I was saying that I didn't really want to participate in those around me regardless of my pronouncements to the contrary. Then, after my epiphany in October, 1991, I started learning that the highest development of seeing and listening is seeing and listening to myself. I started to take a long and honest look at myself. I started to think about why I saw and listened at little as I did, how I saw and listened to what little and to few that I did, and understood what it takes time to change old habits. I started working hard and long to learn how to be still, to see and to listen, to get into a routine where nothing is routine, to find that place where everything and everyone has a special place, to become mindful--and grateful--for the everyday things in everyday life, to cherish the extraordinary value in each ordinary person. It was a herculean effort of will and perseverance. It was slow. Small steps. There were setbacks. Many colleagues saw my need for changing as a sign of weakness. Some still do. Some felt threatened by my transformation. Some still are. Nevertheless, I continued to hear the call of authentic selfhood and true presence. It was a journey inward, downward, and outward. Slowly, I began to understand that the less my mouth spoke, the more my heart spoke; and the more my heart spoke, the more my life spoke. I also began to understand that as I learned to truly see and listen, I was opening myself to my experiences and living in community with others. I was becoming attuned to what was not yet visible in me and others, to what was seeking to emerge, and to what was weaving that emerging spirit into the flesh and bone and behavior of myself and each student.

To keep my eyes and ears, as well as my heart, open and to see the wonderful sacredness in the ordinary, each day I engage in at least one of three exercises. One exercise, in which I asked participants in a recent workshop to engage, I call "water journaling." It's simple. From the moment I get out of bed, I consciously look for and see, hear and listen to water in any place, at any time, in any form: saliva in my mouth, tears in my eyes, the toilet, the shower, the steam, the sink, the toothpaste, the shaving cream, the fishpond, the cup of coffee, the dishwasher, the puddle in the street, the fountain on campus, the vapor in the air, etc. etc. etc. You get the point. I then make a brief journal entry of each time I hear water, see it, and feel it. Try it. I am always amazed at how this simple exercise sharpens my senses and hones both my awareness and mindfulness, and how it becomes almost impossible to ignore the usually ignored. The second exercise I often do is to slowly, ever so slowly, play with a raisin (a blueberry or strawberry in season), roll it in my fingers and feel every ridge in every detail, stare intently at, wonder about its origin as a succulent grape, magnify its shriveled patterns, take it to my nose and deeply inhale it's smell, let it sit on my tongue, feel the rushing flow of saliva, play with it, and let my tongue and palate and cheek and gums and teeth feel every line in every wrinkle. The third exercise is simply to just sit down and draw a picture with the intent awareness of something I'm looking at. It forces me to take notice of the horde of ordinarily unnoticed extraordinary and tinniest but important of details. All three exercises are a form a form of meditation, for as I sensitize and focus myself to that single raisin or to water or to the particulars of a scene, I prepare myself and renew my habit to be aware of, to be mindful of, to appreciate, and to focus intently on each immediate moment and person. And so, over the years, I've developed the habit that when I walk across campus, down the halls, into a classroom, or into a workshop room, I see and listen to nothing but "sacred ones." And believe me when I say the more "sacred ones" you delight in, the more people you consider to be a reason for comfort and joy and blessing, the more blessed joy will comfort you.

The medical examing board recognizes that poor communication leads to poor clinical practice and poorer outcomes for patients. If we teachers do not understand ourselves as communicators, we won't accept that our first responsibility is to be effective see-ers and listeners. Let me put it this way. If you don't sincerely care about the person as a sacred individual, you won't truly want to take the time and make the sincere effort to see and listen; and if you won't take the time and make the sincere effort to see and listen, you won't get to know the student; and if you really don't know a student beyond knowing a name, you won't appreciate a student; and if you don't appreciate a student, you won't truly understand a student; and, if you don't understand a student, you will tend not to have high regard for and tend to disregard him or her no matter what you say. Then, your academic diagnosis, prescribing, and prognosis will fall back on labeling, on too often existing impersonal, disconnected, disrespectful, distorting, and denigrating stereotypes, assumptions, and preconceptions. And when the student doesn't do what you demand or expect, you'll put all the blame on him or her while exonerating yourself.

To paraphrase Pearl Bailey, for a student to talk to a teacher whose door is closed is enough to tie the devil up in knots. No, the best way to understand and deal with students is not to talk about them, it is to see and listen and stay intently aware and mindful of each of them. Now you may not see eye to eye with a student, but listening ear to ear and seeing heart to heart will have a far better chance of unleashing potent forces of change and transformation seldom dreamed of.