I read Milan Kundera’s The Unbearable Lightness of Being in transit, mostly. A friend had given me the novel for my 25th birthday, and I doggedly carried it with me everywhere in the hope of completing it. It surfaced at predictable times: on a bullet train between Tokyo and Kyoto the summer before residency; on the train journey home to see my family on my first scheduled vacation as an internal medicine resident. The quickly worn pages occupied the parenthetical clauses of my life; the unobtrusive characters and spaces nestled between more pressing passages that demanded attention without pause.
![Figure](https://www.cmaj.ca/content/cmaj/190/3/E82/F1.medium.gif)
Image courtesy of Photoslash/iStock
I revelled in this fact. Kundera speaks directly to his readers through bracketed insights, in which he breaks any illusions of separation between reader and material, and appeals for the reader to be transported into the world of Communist-run Czechoslovakia. However infrequently, I would transiently float out of my body and attempt to decipher the world of Kundera’s characters. My greatest hints were provided between sporadic semilunes. Describing the fortuitous meeting between two of the novel’s lovers, Kundera reveals in parentheses: “(the crew of her soul rushed up to the deck of her body).”1
Sitting there in a postcall fugue on the train home, I envisioned my first two months of residency as they would be illustrated by punctuation. How would I write these months? Tears, I thought, would be ellipses … each dot a drop. Perhaps they would sound like the echo of weighted information when it finally falls; the sound of a denouement, the sound of suspension, the sound that barely escapes one’s lips when news is finally relayed. After all, words have gravity. Periods would hang solemnly in the air with the ring of finality. Sometimes we would acknowledge their presence, other times not. Exclamation marks would be peppered throughout: the cacophony of a telemetry monitor beeping in the thick of the night, the code blue announcements unfailingly eliciting adrenaline-driven leaps to action.
Parentheses, however, would dominate. In my quieter moments, I would reflect that this was ironic; within the controlled chaos of the hospital, within the “hums” and “aahs,” hidden moments were omnipresent. If you blinked, you might miss them.
You see, I almost did.
As a first-year resident, I adopted my own version of what one of my staff later dubbed the medical hello. These were motions that I felt were necessary, at the bare minimum, upon seeing a patient in hospital. I’d inquire about pain, breathing, ambulation, oral intake and bowel movements. Apologetically, I would poke and prod and recite lines all too familiar.
“Okay, Ms. Smith, if you just relax and turn your neck this way, I’m going to look at how full your tank is.”
“What do you mean, my tank?”
“It’s a vein in your neck that connects to your heart. It tells me how well hydrated you are!”
From the foot of the bed on this particular day, I looked for the double waveform of the internal jugular vein, convincing myself it was in fact 3 cm above the sternal angle. I exposed the chest wall, listened to the heart, mimicked deep inhalations as I auscultated the lungs, plunged deep into the abdomen with icy hands, and then exposed ankles to look for edema or clots. My motions had the automaticity of a well-rehearsed actress attending her millionth dress rehearsal while belying the awkwardness of a novice unconfident in her execution.
Then I motioned to leave.
“But wait!” Ms. Smith called. “Can I go for a hair appointment tomorrow?”
I stopped in my tracks. Why not? We arranged a day pass for the following day. Ms. Smith appeared relieved; she didn’t care if I knew how many times she’d pooped, but she did want her hair (normally well coiffed) to be in good shape for her family’s visits.
I almost missed this — and I almost missed many other things.
On reflection, much of my first two months of residency were lived in the in-betweens, the moments I might not have caught had I not been compelled to pause. Between my medical hellos were innumerable actions and interactions that occurred within brackets. These were not the task-oriented items I documented in my daily progress notes, but the wishes that my patients may have needed to express most. The grasp of a hand on my wrist, trying to catch me before I left the room so that I could reposition the bed more comfortably. The reinstitution of a tray so that someone could complete the breakfast I had just interrupted. The diligent nurse calling me back: but had I looked at the patient’s new rash? (He’d been scratching all night.) The 96-year-old patient awaiting rehabilitation whom I’d routinely drop in on, if only to hear about his desires to travel again to Spain.
It was in these moments that I came to know my patients — not by their absence of heart murmurs, but by their existence as humans, with limitations and desires and fear and hope. It was outside their rooms, outside our scripted interactions, that I’d celebrate their progress most.
I recall a patient with an exacerbation of chronic obstructive pulmonary disease whom I’d admitted and whom we couldn’t seem to wean off nasal prongs. Every day, he persisted at using his incentive spirometry machine, often proudly indicating to me how far his deep, deliberate breaths could cause the yellow piston to tunnel toward the top of spirometer’s column. One day, I spotted him near the nursing station, off nasal prongs, independently doing a lap of the floor. He gave me a large, toothy grin and I reciprocated with a huge smile and thumbs-up. Afterward, I rushed off to lunchtime teaching.
On this train ride home, this first of many vacations I will look forward to, I realize that the way in which I come to understand my patients is not wholly unlike the way in which I attempt to grasp the lives of fictional characters whose lives could not be further removed from my own. Perhaps this is empathy. Just as I will never understand the life of a fictional barmaid photographing the events in Prague during the 1968 Russian invasion, I do not delude myself into believing that I can truly understand the trials of my patients, many of whom have never known the privilege that I have. The fictionalization through reference to Kundera does not dilute the point; I do not pretend to be equipped with the knowledge that only lived experience can truly provide, regardless of circumstance. However, I can pause to read the brackets; I can pause to try.
I can read the hints that Kundera deliberately included to lessen the distance between myself and the characters he created.
I can linger at the end of a patient’s bed to see if there is anything I’ve missed. For so much in the hospital happens within these bracketed moments — the ones we almost neglect. I’m trying to be better about finding them, about doing more than simply acknowledging that they exist.
Early on during residency, you are no longer a simple spectator, but a character in someone else’s play. The ability to write others’ narratives carries enormous responsibility and privilege, and I can only hope that a deeper appreciation of the day-to-day parentheses will not lead my own pen astray.
Footnotes
This article has been peer reviewed.
The patients depicted in this article are fictional.