There is something deeply satisfying about hitting the right note on the violin.  On the rare occasion when my left hand is perfectly positioned and my bow arm is applying the perfect amount of pressure on the violin string, the resulting note that resonates from the wooden belly of the instrument is, for lack of a better word, perfect.

My favorite piece that I performed with my youth orchestra was the fourth movement of Mahler’s Symphony No. 5, Adagietto.  I spent hours practicing my part.  Repetition was critical.  Over time, the black dots and lines on the sheets of music became familiar patterns that guided my rehearsed finger and arm movements.  The music made sense.

Medicine made sense to me in a similar way in the classroom.  Cancer, for example, was a set of words and concepts that, through repetition, could be mastered.  From the elegantly designed cellular mechanisms to the carefully outlined treatment algorithms, cancer was a discrete body of knowledge that could be built upon and neatly applied.  With all these advancements in modern medicine, I felt armed and ready to combat this destructive foe.

The first cancer patient I took care of in the inpatient ward was a veteran who was diagnosed a few months earlier with early stage pharyngeal cancer.  An unfortunate string of events that followed – a bowel obstruction, an exploratory laparotomy – resulted in delays in treatment.  He was admitted for a newly discovered pleural effusion.  My team moved quickly to formulate a treatment plan.  Prognosis may be poorer with this possibly metastatic cancer, but still fair.  Our team was optimistic that our plan was going to deliver good results.

Nevertheless, it became progressively difficult to carry out our plan.  Hospital services became overbooked, resulting in delays.  The patient became irritated and would not cooperate with the physical therapist, which precluded him from gaining enough strength to tolerate treatment.  A personal feud developed with his sister that resulted in her threatening to stop taking care of him at home.    Communication with our team also started to break down.  We were frustrated that the plan that we had laid out were being broken apart against what we saw as senseless barriers.  We had the tools to treat his cancer!  But our voices were drowned out by noise from sources beyond our control.  Stopping by his room during morning rounds became a chore that was followed by jokes about schemes for getting him off our service.  He lingered on the ward as the patient who nobody wanted to see.

***

I was excited for the first day of orchestra rehearsal because the violins opened the piece with a beautiful melody, one that I had exhaustively practiced to perfect.  As the conductor lifted his baton, we all raised our bows in unison and played our hearts out.  What ensued was a cacophonous mess.  The cellos and were being too loud!  I could barely hear the violin melody over the rumbling cello accompaniment.  The violinists gave each other exasperated looks.  The conductor stopped us and shook his head. 

I showed up to the inpatient ward similarly excited because I had the opportunity to apply the knowledge that I had spent so many hours perfecting in the classroom.  But that sense of clarity quickly broke down as the realities of patient care complicated what seemed to be straightforward solutions to disease.  It became frustrating to deal with all these issues, especially when it was the patient himself who was in the way.  The ensuing struggle resulted in a path towards the deterioration of a caring relationship that was paved with only good intentions.  The barrier to humanism in medicine, ironically, came from human imperfections that obstructed an increasingly perfect science.  The patient became a mere obstacle to our goal of treating his disease.

“You need to listen to each other,” our conductor told us.  “Violins, you have a beautiful melody.   But listen to what the other instruments are saying.  That is how you will understand the music.”  We took these words to heart.  Gradually, we learned to listen to each other more than we listened to ourselves.  The cacophonous sounds eventually melted into harmony.  We created music. 

Modern medicine has empowered physicians with increasingly perfected tools to fight disease.  Yet, the practice of medicine is not a solo endeavor.  It is an unfinished symphony performed unrehearsed without a conductor.  We all too often find ourselves frustrated when we, while trying to do our jobs, get drowned out by other voices beyond our control.  And when these voices come from the patient, the hazyboundary between treating the disease and caring for the patient become sharpened.  But what if we listened a little harder?  Can we make some sense of each other’s voices to find harmony?

***

I had some extra time one afternoon to check up on my patient.  He was lying in bed, a cachectic man with wrinkles and gray hair that made him appear much older than his age of 52.  The steady hiss of the humidifier for his tracheostomy site remained the only sound in the room; he did not appear to notice or care that I was there.  Instead of just doing my usual two minute exam and leaving, I pulled up a chair by his bed and sat down.  Neither of us said anything over the next ten minutes, but he did not gesture for me to leave either.  While I was looking away towards the window, I heard a breathy voice behind me.

“I’m not afraid of dying.  I used to work in a hospital, you know.”

I turned around, surprised.  For the first time, I saw a sad, not exasperated look on his face.  We chatted a bit more before I had to leave.  Not much changed after that conversation; the delays and obstacles to treatment were still there.  But from that day on, everything just made a little more sense to me.

Ron Li is a medical student.