When residents report on patients, I emphasize repeatedly that although the history and many aspects of the mental status examination are undeniably important, I think of the gaze, our patients’ and ours, as particularly important. Some of our gazes must serve as a diagnostic tool, but much of them are a point of connection to patients, and I am reminded of a much earlier experience, when I was a medical student.
I had been assigned to work in the pediatric oncology clinic, and on one of those days, I was asked to evaluate a young girl, about 9 years old, who had come in with her parents for evaluation of her malignant astrocytoma. The attending physician prefaced my going into the room with just the slightest comment, insinuating that the visit was perfunctory and that she was not doing well at all. As I entered the examination room, the parents were seated rather still, with a somewhat hunched posture, conveying a level of fatigue, their very cushingoid daughter nearby. I explained that I was a medical student and would be first examining their daughter, to which the mother nodded as if to say "yes" but did so very reflexively. And her husband, a good bit more solemn in expression, never said anything. Thereafter, with ophthalmoscope in hand, I bent over, in a sense brushing past the child’s gaze for the sake of looking into the back of her eyes.
For all of the times one is told of a cardinal feature of one disease entity or another, it is a shock to finally see something as bold as the feature itself in unbridled form. There in the back of her eyes was the most glaring example of papilledema I had ever seen, and it was startling. I almost had to back away for a bit to reconsider what I had seen, as if to ponder its veracity only to approach again to convince myself that it was so. But in likely just as short an amount of time, I knew in the most exacting of terms that I had seen what other students and doctors had been observing and that it spoke clearly of disease, deterioration, and pending death. The ophthalmoscope having translated to a virtual crystal ball, I was looking at evidence of a child who would soon expire.
As I backed away from the girl, righting myself somewhat slowly, she scanned my face, somehow in search of the answer to which we, as doctors, were so directed. "What is happening to me?" she seemed to say. She stood so passively, her long hair shrouding her swollen face, quietly licking her lips very anxiously and fidgeting a bit, exuding enormous fright and vulnerability. I felt entirely overwhelmed, and my inclination was to hold her, although I didn’t. Because I couldn’t convey anything good, I averted my gaze a bit toward her parents, who simply looked back, the mother’s eyes scanning me slightly. And then the mother smiled, just slightly and rather weakly, I would add, conveying that she already knew the answer. I recall stumbling over a few words to explain the findings.
"Well, uh…there is still swelling. I, uh…I think that my attending will be right in."
It was impossible to know what else to say. For what felt like a very long time, our silence persisted, and we simply exchanged glances. That was all. We transcended ophthalmoscope readings to now speak silently of the balance between life and death. I’m not sure that words would have done it nearly enough justice, perhaps only proving cluttering, disturbing a reverence for our collective struggle.
Without a doubt, the young girl has passed away by now, her parents devastated by her death. They can look at photos of when she was younger, colors entrapped in a photo gel that speak of a time when everything seemed just so much brighter, but they are undoubtedly crushed under the weight of her absence. In many respects, I am crushed by her absence, too, and I also write this as a long-overdue eulogy to her, but I can no longer exchange gazes with them to tell them so. Our gazes can now only be directed within, to help us reflect on all that we’ve seen and felt.
Certainly sans implements, one has to face patients and tell them in so many words, gaze included, what our eyes have allowed us to see. You, as the reader, are currently using your own gaze to read prose conveying something of what I’ve seen and felt, expectantly devoid of the exact experience of what I saw in a certain moment of time. One is thereby solely reliant on descriptive prose, an amalgamation of words, as a means of conveyance of sight, but it can feel a bit lacking. Although we place an enormous emphasis on verbal expression, and it is vital, some conduit to connection with patients, words will sometimes be faltering, nondescript, laundered, or simply beside the point. This does seem to speak, as it were, to the impasse of words alone, written or spoken, not encompassing enough of the human experience. When I emphasize gaze to residents, therefore, it is with the hope that it will be more far-reaching than simple use of a diagnostic gaze and an admonishment to not be solely reliant on the exchange of words. Our interchanges with patients extend much beyond verbal expression. If we really allow ourselves to look within, our gazes and those of patients will reveal some very hidden and profound feelings, and they will serve a pivotal role in empathic connection. Sometimes, we may simply have to speak in silence. We hope our eyes will say it all.
Address correspondence and reprint requests to Dr. Benjamin, UCDMC, 2230 Stockton Blvd., Sacramento, CA 95817; firstname.lastname@example.org (e-mail).