Learning to listen in a resource-poor international setting: a medical student’s encounter with the power of narrative in
by Justin M. List, MAR
After talking with a woman who was living with HIV and caring for an HIV-positive child in the resource-poor community of Kawangware in Nairobi and completing a public health needs assessment for her, one of my medical school colleagues posed the following question to our volunteer group as we were working at the clinic: “What do I say to her at the end of the needs assessment when she asks me if I have hope that she’ll live?” I remained silent. How can I as a healthy, educated, middle-class medical student from the
Most members of the group had just completed their first year of medical school only days before we arrived in
For some of those interviewed, it was the first time they had ever felt listened to, as we found out from them or their translators. And hearing about the power of having a voice and feeling heard illustrated for me a learning point that I might have missed had I come to
I did learn some of the science of medicine, though, if not explicitly clinical. We used a needs assessment to acquire quantitative and qualitative data that—we hope—will serve the community through its analysis. But because we designed this trip from a public health perspective and left the stethoscope and Bates’ Guide to Physical Examination and History Taking behind, my education in the art of the medicine remained a key component of my experience in
I did not need to go to
Medical students working abroad in resource-poor, low-income settings will encounter a host of experiences and confront a variety of feelings, perhaps including some I have described. Students bring a rich array of experiences and feelings with them that affect their ability to truly listen to the content of the patient’s words, and it is to our benefit to explore these feelings before, during and after our international immersion. Like me, students may find themselves seeking clarification about how to incorporate international health care into their future careers after short-term, life-changing work. And medical students traveling abroad for the first time in their burgeoning professional capacity should be prepared to expect the unexpected despite extensive planning and pre-trip education; to experience complementary or conflicting feelings of duty, ignorance, education, helplessness and purpose all in a matter of days or weeks; to anticipate an unfolding lifetime of further professional and vocational reflection and action.
Remaining truly present and attentive may be the most difficult aspect of learning the art of listening in medicine, especially where unfamiliar contexts, cross-cultural issues and language barriers coexist. As physicians-in-training, we have a potentially easy exit—turning our focus to the rigmarole of the chart, looking down at the survey with intent, deflecting a consideration of the often difficult-to-comprehend social determinants of health or concentrating on the biomedical components of the present illness. For me, listening to these difficult stories took more energy at times than I could have imagined listening could possibly require. And yet listening is a skill that we as medical students must continue to practice consciously as we discover our personal limits in relation to our pursuit of justice and caring for patients holistically.
Listening is an end unto itself, but it is also a means and a beginning to addressing aspects of patients’ lives that lie outside but impact the biomedical context. In seeking out patient narrative, especially in international resource-poor settings, we must ask questions (in a culturally sensitive manner) to which we may fear to know the answers, answers that expose injustice yet open a new world of possibility to the patient and physician.
1. I want to acknowledge my partners and team members, Lisa Dunning, Kathy Hakanson, Mark Hakanson, Andrew Loehrer, Terri Parks and Jaime Sua, and Kathleen Harrison, Ph.D, Founder and Director of HARAMBEE (www.projectharambee.org). All of them opened themselves to the power of narrative through these needs assessment surveys and, through our shared stories from survey participant encounters, they provided me valuable insights.
Justin M. List, MAR, a former fellow at the American Medical Association’s Institute for Ethics, is a second-year medical student at