When There Are No Words: Interpreting Patients’ and Families’ Subtle Messages

I had the privilege of going to the National September 11 Memorial & Museum in New York City a couple of years ago. As you enter what feels like a sacred space, there is a sequence of photographs of people reacting to the smoking Twin Towers. The photos are of individuals of all races, ages, and ethnicity. In nearly every photo, the person staring up at the tower has a hand clasped over his or her mouth in shock. It was not until I saw that photo display that I appreciated that that particular expression of shock and dismay transcends all human differences — race, age, gender. There was something else, too: I did not need a verbal explanation to understand what those people were feeling.

It is December 2017. I live in Los Angeles, and we are in the middle of a firestorm of wildfires. When I opened the paper that morning the front page had several pictures showing the destruction, yet the photo that caught my attention was of a woman standing and looking at the flames. Her hand was clasped over her mouth.

Sometimes what someone says with body language is clear.  However, sometimes it is not, and we need to do a little exploring.

Rebecca Saxe, PhD, is a cognitive neuroscientist in the department of Brain and Cognitive Sciences at MIT. She explains in a TED talk that beginning at approximately age 5 years we begin to learn to think about what another person is thinking.¹ To do so, we follow cues and then put them into the context of the situation. Dr Saxe’s work focuses on a specific small area of our brain, the right temporoparietal junction specifically tasked with figuring out what other people are thinking. The ability to process this information is based not on body language but on an understanding of circumstances. Her work is far more nuanced than I give credit here, but in an oversimplified explanation, it gives credence to the saying, “I know what you are thinking,” in part because we know what we’d be thinking in that instance.

CASE

Recently I was part of a family meeting in a patient’s hospital room. Maria had repeated hospitalizations for complications from her cancer and cancer treatment. She was on the precipice of complications from her treatment outweighing the possible benefits, and it was time to review her current medical situation. One look at her and it seemed obvious that, at least for the moment, she was not a candidate for more chemo.

Maria’s physician sat close to the head of the bed to discuss the situation with her. He was clearly engaged, nodding his head at all of the right times and genuinely focused on her. Sam, her husband, sat on the window seat.  He was not in the doctor’s visual field, though he was in mine.