Only connect! That was the whole of her sermon. Only connect the prose and the passion, and both will be exalted, and human love will be seen at its height. Live in fragments no longer. – E.M. Forster, "Howard’s End"
In 1992 at age 32, I found myself the director of a primary care geriatric department in Newark at a fabled but teetering hospital. I had just left my Boston training grounds and was fresh from geriatric fellowship. There I was, holding staff meetings, resolving disputes, and begging for resources and salary lines at a hospital that, several years later, was to be consumed by our arch competitor.
The director job turned out to be a wonder of clinical experience, academic rigor (morning report, directing a fellowship program), and exposure to the reality of what we then termed the “inner city.” We cared for patients who had never seen a primary care doctor. The “pathology” that walked in off the street was dazzling and tragic. We made the occasional house call to families so bereft that they not only lacked bus fare to make it in, but in one case, ate squirrels to survive. Twenty-eight years on, I am grateful that I took the job and that my gallant and wise wife helped me swallow my insecurities; we needed to move to New Jersey for family reasons and this was the job offer I received in the nick of time. I moved on to other work just before 9/11, mostly to a career in long-term care. Looking back, those eight years proved to be terrifying and also exciting, edifying, and essential to building the skills that would ultimately define my career.
After I came to grips with the day-to-day management as director, there was one hefty gap in my development and confidence. When a “VIP” of advanced years came into the office or was admitted to the hospital, it devolved to me to be asked (and expected) to become the primary attending. I would receive late-night calls from my laconic chair of medicine or my regal, World War II-foxhole-surviving president of the hospital. Owing to one part shyness and two parts insecurity, I was not able fully to embrace this role. I would, of course, buck up and pinch blood into my cheeks to look the part, but never with glee or purpose, and I’m sure it showed. At one point, by way of example, I was approached by a larger hospital system to come on board as their first geriatrician. I recall my interview with the cigar chomping and suspendered CEO, who said, “Young man, I want someone who will step up to the plate and be my guy exactly when I need him,” and I thought to myself upon escaping his lair, I will exactly not be that guy! So many years down the road, I now embrace the role of "top dog." As former medical director (now emeritus) of a large subacute rehab and nursing home, I take on the VIPs, the retired chairs of surgery, and retired CEOs of corporations without a second’s delay. I wish I could give my younger self a lesson in self-confidence. Or maybe it’s just age, but reflection and my lapels tell me otherwise.
According to literary critics, E.M. Forster’s dictum, “Only Connect,” has several levels of meaning. I take it here at the simplest level, that connections among humans are worth the detour and worth the wait. The clinical “two-minute drill” (apologies to quarterbacks Brady, Montana, and Marino) means that while getting a read on the field of play, I challenge myself to find something to connect me with the patient/person in front of me. Absent that, I have failed. What started as a thought experiment has become my framework and personal commitment. The performance of the H&P affords opportunity. Family history, social history, and living situation all provide the soil to cultivate a connection. I have even added to our EMR patient template “hobbies,” which has connected me on levels of music, genre of books, cards, sport teams, and even politics on occasion. In 1988, the standard musical genres preferred by our octogenarian residents were big band and opera. Now it’s more likely to be The Grateful Dead. Like in pediatrics where the connection is not only to the child but the parent, too, in geriatrics, my patient is not only the aged parent with CHF or chronic lymphocytic leukemia, but the child that may be well into their 60s or 70s. Connecting, only connecting, crosses the chasm of the clock.
Friends skilled in presenting have taught me the value of visual props used during a lecture or case discussion. While reducing a patient to a “prop” is deservedly taboo, bedside teaching applies the time-honored use of the visual to engrave in the learner’s mind a memorable symptom or finding. How many of us remember, even fondly, our first case of bulging jugular veins or spider angiomata or pursed lip breathing, the patient hunched forward to delay expiration and tug that last molecule of oxygen out of its alveolar redoubt?
Visuals are important for patients, too. There is, in some quarters, a rush to consign the gleaming white lab coat to the dustbin of medical apparel. This makes sense to halt the transmission of resistant bacteria carried on unwitting sleeves, or to dull the spur of “white coat hypertension” that confounds treatment. Let’s also not forget the power differential some see inherent in the white covering (though others find the coat a mark of professionalism as it was first conceived in the early 20th century in part to dress up our “art” in more scientific duds).
I have experimented with and repurposed my white lab coat and its bare lapels as a canvas to connect, “only connect.” Brady and the other star quarterbacks may parade their swooshes and logos on their uniforms; I proudly parade my pins as conversation starters for my two-minute drill. I have so many pins that I rotate them for equal air time, depending on what has been on my mind or where I have been in recent travels. Some time ago, I took a civil rights trip with my wife from Memphis to Montgomery and brought back a hagiographic Martin Luther King, Jr. pin, which now adorns my right lapel. Over on my left dangles “Mozart Forever.” Here’s how the two-minute drill goes down from scrimmage. I take the snap and enter the room: new patient and new family and my lapels are fluttering at full mast. MLK and Mozart pins ... incomplete pass, second down. Boston and Tanglewood pins, no takers yet? … Clock shows third down and 10 yards to go and one minute left. How about Hokusai’s Great Wave? ... nope, play whistled dead. Fourth down, Hail Mary pass ..."Pan-Can" pancreatic cancer purple ribbon pin. Tough guy son in room recognizes purple pin. He has a wife who just started chemo to “consolidate” before possible Whipple operation. Now the tough guy is tearing up and my patient (the dad) is not far behind. "Oh," I venture, "I may be a doctor, but let me tell you about my buddy who is now many years out from the same chemo and surgery." Completed pass! Move the chains … first-and-goal to go. Connect, hope, connect, repeat.
So here I am extolling the lab coat lapels and palaver pins that have widened my comfort zones and carried me closer to the end zone I thought I’d never reach. I’m sure pins and lapels will not work for everyone (and if you are wondering, I’m careful not to wear overtly political pins). Sharing this with you (the reader) and baring my earlier self-doubts and timidity are connections, too. For patients and families, might this be “TMI” and a bridge too far? We will have to see. Between here and there, though, we have bridges to build and friendships to forge. Maybe my next pin will read “Only Connect” and that will be a connection, too — or least my next play in overtime.
How do you find common ground with patients? Share your strategies in the comments.
Dr. Schor is a geriatrician specializing in long-term and post-acute care. He was medical director and attending physician at Daughters of Israel for close to 30 years and is now a Senior Medical Director at Optum Health. He is a new grandfather, an avid birder, and lives in Millburn, NJ.
Image by Joshua David Schor, MD, CMD, FACP
