Looking

Caroline Wellbery, MD, PhD
Department of Family Medicine, Georgetown University, Washington DC (Fall 2014)

 Image of a magnifying glass by Kit
Photography by Kit

I have always been an observer, something that comes so naturally to me that when I notice the absence of this skill in others, I am sometimes taken aback. “How could you not see that?” I ask, not always endearingly. To the credit of those non-observers I am thinking of, there are many ways of noticing, so parsing the nuances of a political speech may be just as attentive a skill as sizing up at a glance the mood of everyone in a room. Besides, there is an important difference between mere perception and how we put our knowledge to use. Having a keen eye without the chance to bring our observations to life can be frustrating—which is why many observers become artists, and why in turn some writers and artists choose to intensify their impact by becoming doctors as well.

One of my residents told me this story. He had a teacher in medical school whom everyone worshiped for his skills at the bedside. This teacher specialized in intensive care, where patients are often too ill to communicate. For the most part, intensivists make medical decisions on the basis of monitors and machines, but this particular teacher insisted on the importance of clinical observation. Thus he always examined his patients from head to toe, removing the sheet that covered them, turning them side to side, commenting on their color, the rise of their chest and the upstroke of the arteries in their neck. He always gathered around him a group of trainees and involved them in this meticulous process. One of his critically ill patients had been in the intensive care unit for a long time, obtunded and on a ventilator. Every day, this teacher stopped at the patient’s bedside, examined him, made adjustments on the various dials, and had little to say about progress. This routine went on day after day, week after week. Then, one morning on rounds, the doctor informed his cluster of residents and students that the man would recover. “He’ll wake up tomorrow,” he predicted. The others stood slack-jawed, frowning at the ventilator settings, the blood work results, the heart rate and blood pressure. As far as they could tell, nothing had changed. But the doctor had folded down the patient’s bed sheet and pointed to the man’s ankles. “Do you see how they’re crossed?” he asked. “A sick man doesn’t cross his ankles.” Indeed, the next day, his patient opened his eyes and began to improve. He was soon well enough to be discharged from the intensive care.

Nowadays we devote less energy to looking at our patients than relying on machines to interpret their maladies. Plenty has been said about this dependence on technology, which trains us to see only what we expect using conventional rules. Our automatic response to familiar visual cues can become a symptom of automaticity in general. There are reasons to counteract this. By learning to see, we learn to notice; and by learning to notice, we become vibrant and aware. We open our minds. We see nuances. The invisible becomes visible. We cultivate our potential as diagnosticians.

How can we hone our observational skills? Many medical schools give students an opportunity to take an art observation class in a local museum, where they spend their sessions looking closely at paintings. The idea is that this sort of attention will translate into clinical acumen. But why not make this a universal assignment? Art can train us all to see.

Not long ago, I went to watch a film called “Museum Hours.” This film is all about looking, and the film’s main locale, the museum, is a home for the eye. The camera lingers on all sorts of details, not only of paintings; in pairing what goes on in the art works with parallel scenes outdoors, it shows how careful art observation enables us also to see ordinary objects that usually go unnoticed. Doorways, or clouds, or birds, for example. What I found particularly interesting is the filmmaker’s suggestion that the stories in which we immerse ourselves, the stories of what we are doing, where we are going, what we want—all these stories that accompany our daily action get in the way of observational clarity. So in order to make this point, the filmmaker deliberately does away with the plot, and in doing so, lets us know that plots distract us from noticing what is really there. He sets up two plot lines only to smother them at the earliest convenience. A middle aged woman living in Canada receives a call. Her distant relative, in Vienna, has fallen into a coma, and it appears there is no other next of kin. So the Canadian woman gets on a plane to attend to her cousin. This could lead to all kinds of interesting stories about struggle with illness, or insight into the relatives’ relationships. But nothing of the sort happens, because the cousin remains in her unexplained coma throughout the entire film. She even dies in the end, but it is safe to say that this plot line is in fact, already dead on arrival. In a secondary plot, the Canadian woman visits a famous Viennese art museum and there befriends one of the museum guards. They start having conversations together and soon go out for the evening. The viewer hopes a romance is budding for these two lonely people, but no luck. The guard reveals in passing that his male lover “is long gone.” So we know that here too is a narrative dead end—no relationship can evolve between them, no exciting story which would force a transformation or lead to complications. These plot disruptions set the stage for the slow-paced close looking that follows for the rest of the movie and explains why the woman next to me in the theater fell asleep and eventually even snored softly until the credits went up.

Close looking is work. I heard of one teacher who took her students outside to spend an hour looking at a patch of grass. When we want to convey how deadly boring an experience is, we say it was like watching grass grow. But the point is that much is actually happening in that grass, and we can extrapolate from there, little by little, to see what is happening elsewhere and everywhere.

Close noticing, groomed by watching grass grow, is, perhaps, what intuition is. I went to a conference once, where one of the bonding activities was to bungee jump from a high platform in the domed, multi-tiered hall. Eleven of us signed up, and I was the first to jump. After I touched ground, I stood watching the others take their turn above, adjusting the harness, taking a deep breath, making jokes, crossing themselves prayerfully. I told a person who happened to be standing next to me that you can tell a lot about a person by the way the prepare for this jump—whether they are secure, anxious, exhibitionistic, and so forth. About one jumper following protocol who calmly adjusted his harness, practiced a knee bend, looked both unruffled and earnest, I said: He has had a protected childhood but the rules in his household were rather strict. When he came down, my companion made me go up to the jumper and repeat to him what I had said about his childhood, and the jumper said, yes, that is pretty accurate. These were not profound insights on my part, but merely based on the compressed information derived from a critical moment.

Psychics use this skill, I imagine, in precisely the same way, except that instead of just guessing about an individual’s past, they imagine how the subtle behavioral cues they observe in their client might also influence the future. It is not that they are clairvoyant, as they would like us to think. If someone projects a personality that is difficult but suggests interest in self-improvement, a psychic might say: Marriage will come to you, but only after a series of problematic relationships. The psychic as a keen reader of human nature takes into account not only the client’s body language and other unconscious revelations but also his or her wishful thinking. Thus extrapolations for the future are rooted in the client’s personality and a basic knowledge of what he or she wants to hear.

Doctors are not psychics, but if they are experienced observers, their intuitions may seem clairvoyant at times. I have a colleague who diagnosed a woman’s rectal bleeding as cancer. The case was unusual, because the patient was far younger than most cancer patients, and because her hemorrhoids suggested another, more plausible reason for her bleeding. True, sooner or later almost any doctor would have reached the correct diagnosis. But my colleague ordered the appropriate confirmatory test on the first visit, and to this day cannot give a rational reason for her suspicions.

While we can’t force intuition, we can train it by becoming students of the eye and improving our vision. In this way, we can boost our instinctive responses with evidence. Different techniques for noticing abound, and do not always have to engage the retina. Listening and imagining can guide us along the same route. For example, the Buddhist-based drills of mindfulness encourage sensory awareness by having us pay attention to our physical selves. My personal favorite teaching tool is poetry. If folks cringe at the thought of poetry, it may in some cases be because poetry can be difficult and impenetrable. But partly it’s because poetry forces you, like the movie “Museum Hours,” to slow down to a crawl, often without a story to sustain interest. That is one way poetry packs its punch. So, like savoring a single grape over a period of ten minutes, a mindfulness technique, savoring the quintessential images of poetry can transform our way of seeing. Take, for example,  Franz Wright’s “scarlessly closing like water” or the “tall blue starry strangeness of being here” phrases which address our disappearance from this earth and our struggle for meaning. What medium, if not poetry, can tackle such weighty issues and condense them into word nuggets like these? When we take them out of our pockets and unfold them, they become wings.

Ironically, poetry seems to lend itself to today’s sound bite culture. What is poetry, if not a high-brow form of Twitter? Poetry should be admired for its economy of expression. But unlike Twitter, which disappears in an endless drone of voices, poetry means to arrest us, to make us stop in our tracks. It is a bell that wakens the silence. Poetry makes us see things. It turns us into witnesses. Take Mary Sullivan’s poem, in which she invites her friends to notice precisely her dying.

Write to my friends.
Tell them what time of day or night
I died and what the weather was.
Tell them, the color of the walls…
Describe the quality of light in the room…

She goes on to ask them to note who was present, what her bodily shape looked like, how her last breath sounded, whether there was in insect in the room. Why is this noticing, this witnessing so important? It’s because one of the most important gifts a human being can wish for is to be seen. It’s what an infant’s drifting eyes seek in harnessing the mother’s regard. It’s what children shout for when they perform their tricks in the swimming pool. It’s what lovers want in their moony, reciprocal gaze. It’s what patients need when they’re sick and dying. Simply to be held in the embrace of careful looking is essential, life-affirming, healing and comforting. Was the lingering eye of the camera in “Museum Hours” a caress? Yes it was. Purposeful looking is a spiritual practice. Over time, it begins to look more and more like love.

 


CAROLINE WELLBERY, MD, PhD, has practiced Family Medicine and taught medical students and residents for a long time. She has established an arts-in-medicine fellowship for physicians wishing to apply their artistic talents to teaching and patient care, and serves as Associate Deputy Editor for the American Family Physician journal. She has published several essays in JAMA’s Piece of my Mind and another, “Living well before we die,” has been featured in Hektoen International.