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March 30, 2016

People : Communication

                                                                                                                                      Stormur Cottages, Iceland. August 2015 

Integrating primary care and mental health services is an interest of mine, and is one of the main things that drew me to the clinic where I work, which has on-site psychiatric services. As a result, in addition to the depression and anxiety that is common in any primary care practice, I see many patients with schizophrenia and bipolar disorder.

I've always appreciated the importance of caring for the physical health of these patients, and have had enough experience at the county hospital during my medical residency to have a sense of the difficulty of doing so. Being able to see these patients regularly in a full time primary care practice has given even more context.

I've learned to adjust how I communicate depending on how a person presents their own words and how they receive mine. Sometimes, though, there's no anticipating.

My medical assistant always asks patients the reason for their visit prior to them seeing me, so that I have a sense of their priorities. For one patient, a man with schizophrenia who I hadn't met previously, she said to me, "I'm not sure why he's here. I think a routine exam. He doesn't say much."

As a person whose work entails asking a lot of questions, I've gotten into a habit of defining people by how they answer them. Are they direct and concise?  Do they actually answer the question? Do they tell stories that date years before the setting of the current question?  Do they care that I hear everything or do they find simply talking therapeutic? This helps me figure out how to gather information and have a conversation without running too much over time, and how to offer the kind of interaction the person seeks from their doctor.

I've noticed that there is a subset of patients with schizophrenia who give the shortest answers possible to answer a question. Their expression is muted, from their condition or from the medications used to treat it, I'm not sure. I've yet to find the best tools for eliciting more from my questions, other than giving patients a lot of time to answer.

This particular patient does take a long time to respond, often taking a full minute before responding to yes or no questions. Sometimes he doesn't respond at all. Trying to make up for the lack of detail in his responses, I ask more questions. He smiles and gives a small laugh after each one, and because he does this so regularly I can't tell if it means whether he sees humor in everything or that he's aware that his expression is limited.  I remember that this is a strategy my dad used when speaking to his customers. Because he knew he couldn't speak English as well as them, he laughed a lot as a way to connect and show engagement despite not being able to converse.

In an especially long pause between these exchanges, the patient looks at me in earnest and surprises me. He asks me a question.

"Do you find it hard to make friends?"

I can't remember what we were talking about before he posed this question, but I do know that it isn't related to his question, at least not on the surface or in a way that my mind can understand. But more than any of my questions, his question opens him to me.

He doesn't start miraculously telling me narratives about his feelings and his life, but his sentences become longer and he waits for my reactions. He becomes not just a part of the conversation but the driver of it.

And with his own question, this man tells me more about loneliness, aging, and isolation than I could have heard with a hundred answers to my questions.

At some point in the conversation we return to medical questions. After I explain some results of laboratory tests to him, he smiles at me and says, "Do you have any pets?"

Taking the cue from before, I'm no longer surprised and go with the flow of this new direction he's given the conversation. He doesn't answer my questions about whether he has pets and which animals he likes, but he listens to me talk about how I would love to have a dog but our landlord won't allow us to have one. I tell him how my brother used to have the most amazing cat, who had the personality of a dog, and how I loved him so much because he was so needy and affectionate, and how I wanted to keep him when my brother was looking to give him away, and how crushed I was when my landlord wouldn't let me. He doesn't respond with any comments or the social cues we've learned to use to tell let others know we're listening--he doesn't nod his head or say, "hm."  But I end up talking more about myself than I can last remember doing with a patient (it's usually not part of patient-centered care to share this much about yourself).

When I come home that night, instead of just writing about the interaction like I might usually do in order to reflect, I write questions. Things I'd like to ask people I know.  Things I'd like to ask strangers. Things I'd like to have people I know ask me.  Things I'd like strangers to ask me.  And more than considering whether I had immediate responses, I find that the process of figuring out what I want to ask--of others and of myself--opens a means of connection that I'd left unpruned for too long.


  1. It's so wonderful to hear about how a patient, by him asking you a question back, opened up new possibilities of connection within yourself. I'm curious about the kinds of questions you are asking.

    1. Maybe I will do a follow up with these questions! I'm sure we all have similar ones, and would be interesting to see the connections between what we think on our own.

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  2. I love the idea of writing down questions of all the things you described. I have been toying with the same idea, as a means to foster deeper connections to the people around me, and now you've reminded me to do that and see what happens.

    PS Love that you're writing again xx

    1. Thanks for reading! We're always developing in parallel and I like this shared community to see what happens with each other...would love to hear what you process ;)

  3. Love how beautifully this is articulated! As someone who was very shy as a kid (and still struggles with shyness!), I too have always found it more comfortable to ask people questions than to talk about myself. It's definitely been a mechanism for me to connect with others without feeling judgment about myself or what I have to say. So interesting (and comforting!) to hear this is maybe a more universal human tool/truth :)

    1. I've always appreciated your questions. You are one of the best conversationalists I know! Thanks for your thoughts, as always.

  4. Kim, this is beautiful. When I was sharing with you that one time about my migraines, I was struck by how well you listened and asked questions. I'm not sure if I said this out loud to you but I remember thinking how adaptive and patient you must be with your patients. You so clearly explained that here. I love the idea of doing a follow up with those questions. Can't wait to read more.

    1. Thanks Christine--you always make conversation easy and comfortable so I appreciate the feedback from someone as attentive and thoughtful as you. It's not always so easy for me to stay patient in the moment, so it's good to keep the goals in mind ;)


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