Letting Silence Into the Patient Encounter Allows the Provider to Learn

Letting Silence Into the Patient Encounter Allows the Provider to Learn

Anne Katz, PhD, RN, FAAN

Mar 06, 2018

As the patient talked, I found myself nodding my head. In so many ways, she was just like me. Highly educated, a professional, a woman who had worked hard and long to get where she was. And then cancer took it all away, or at least that’s the way she described it. She was diagnosed with metastatic cancer one year ago and finally had time to take a breath after the rigors of surgery, radiation, endocrine manipulation therapy, and chemotherapy. Nothing seems to have gone right for her; she was hospitalized with febrile neutropenia twice during the months of chemotherapy, she has osteoporosis and has had to stop the winter activities that she loves because of the dangers of falling on the ice. She is depressed and anxious and, for the first time in her adult life, completely unable to control what happens to her.

As we talked I could see how difficult it was for her to keep from crying. Patients often cry in my office; I keep a box of deluxe tissues on the table and a small garbage receptacle nearby. Her husband sat in the other chair, seemingly unable to offer comfort to her. In the moments when she stopped talking and struggled to keep her composure, he sat silent, unwilling or unable to break the heavy silence in the room. She described how painful it has been to give up the career she loves and how difficult it is to fill the empty days. She doesn’t have the concentration to read, and it’s been so long since she read for pleasure and not for work that novels and biographies just don’t hold her interest. It feels like a cheap replacement for the work-related reading she used to do, always under pressure but she loved the intensity of it. Her social circle is small because she didn’t nurture her friendships when she was so busy with work and travel. She always thought that she had time to reconnect with friends before she retired. But then the cancer happened and she didn’t have time to prepare; the cancer happened so quickly and she had no time to think or to plan. It just happened to her and took so much away. The list of her losses flowed from her mouth and her sorrow was palpable.

I didn’t try to stop her or to speak words of comfort or encouragement. What is there to say in the face of someone’s suffering that isn’t trite or unhelpful? Perhaps this was the reason for her husband’s silence—he didn’t have the words to say. A therapeutic technique I learned long ago is the value of silence in getting the patient and/or their partner to talk. Human beings are generally uncomfortable with silence and if we, the professionals, can just keep quiet, the patient will speak first and break the silence. This is when people often speak their true feelings in an attempt to fill the gap in conversation. Health care providers have a tendency to talk a lot; we are trained to ask questions, to give information, to provide advice and guidance. Silence uses up time and makes us nervous so we talk and talk and talk, often not allowing the patient or their family members to get a word in. And then we finish talking and we ask the patient if they have any questions. In the moment, many patients don’t know what to say, never mind being able to formulate a question. Yes, we encourage our patients to write down their questions ahead of any appointments and some of us allow time for this. But clinics are busy and the flow of patients seems to never ebb. So we have a myriad reasons to fill the silence.

But if we just stop and let the silence fill the room we can learn so much from our patients. They can teach us about what we value by what they have lost. We can learn from them about how to accept change and uncertainty, even if they struggle with these. They can show how the plans we all make for our careers and our future can explode when cells run amuck. They can prepare us for the very worst day by allowing us to share their present. I have always loved words and I make my living from using them with care in the clinical arena and with rigor in my writing and editing. But the most valuable lessons I have learned are when I have held my words and allowed the patient to speak. I don’t have any way to “fix” her situation. My role is not to prescribe or cut or irradiate but just to listen, to allow the silence to take over the space until she fills it again. This may be an uncomfortable place for many to be but for me, silence truly is golden.


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