“Sticks and stones can break my bones, but words can never hurt me.”  I learned this saying when I came to America, but before that, I learned a different story.  A wood cutter got lost in the forest, it was getting dark and cold.  He met a bear, who offered him to come to his den.  The man entered and said “It stinks in here!”  The next day the woodcutter was getting ready to leave, when the bear asked him to hit him on the head with his axe.  The man was reluctant, “But you were so generous, so hospitable,” he pleaded, “I don’t want to hurt you.”  The bear threatened to eat him if he didn’t, so the man took his axe and swung, leaving a huge gash in the bear’s head.  Years passed.  One day the man saw the bear in the woods again.  ”How is your head?” the man asked. “The wound on my head has long since healed,” the bear said, “but the words you said still hurt.”

In medicine we aspire to fix your bones when broken by sticks and stones, and we do not always succeed.   Yet often it is our words that leave the most lasting impression, long after the physical wounds have healed.

As doctors, we can be callous and insensitive.  It may be because we’re sleep deprived and stressed, or because, in our view, your family member is not that sick compared to the others who are actively dying right now, or because of a myriad of other reasons that are just not your problem when you are the one in the intensive care unit worried about someone you love.

“The doctor hardly spent any time with my father,” an upset family member wrote in the patient satisfaction survey, “he spent the whole day in the room next door where the patient was dying.”

A colleague was telling me about the patients in the ICU whose care I would take over for the night before going home.  One patient was an elderly man who was not waking up, nothing left to do but wait and see if he recovers.  As we were talking, this man’s wife walked up to the desk and locked eyes her husband’s doctor.  ”Is he going to speak?” she asked.

“I haven’t heard him say a word since he’s been here,” my colleague said quickly.  Assertively.

“He opens his eyes when I speak to him,” she said uncertainly. It was a question.

“I know,” my colleague said.

She paused for a beat and then slowly her face crumpled, her eyes welled up, she made a sound then turned and walked away to cry.  My colleague turned to me and his face said what does she expect from me? I said nothing.  But I thought our patients should expect so much more.  He finished telling me about the other patients.  I could’ve followed her then, but what would I have said?  Was she even still in the hospital?

People who come to the doctor, whether in the clinic or in the ICU,  come in a time of crisis.  Even a routine diagnosis for the doctor may be unexpectedly terrible news to the patient.  “You have emphysema” is delivered evenly, because, well, the fact of the matter is that you have smoked for 60 years and you have been coughing most of that time, and surely someone else has said it to you already? It’s in your chart.  You’ve been calling it “smoker’s cough,” and we just called it by its medical name.   To us, it is surprising that you are surprised.  But for the patient, it is the first time he recognizes that he is on the same journey as the mother he spent a decade caring for, watching her die slowly.

Sometimes, we say things and we think we are being kind or charming.   ”You look too good to be here,” a security guard in the children’s emergency room said jovially to my five-year-old when we were checking in, and I was ready to punch him.  Have I said this to patients before?  It was well-intentioned: you are doing well for being in the intensive care unit, you are going to be one of the lucky ones who walk out, and you will walk out soon.  But did they hear it, as I did right then in the children’s emergency room, as a dismissal.  You’re not sick enough to be here — you’re wasting our time and resources, you should go home. You’re not suffering very much at all.  

It works the other way, too. A kind, simple word, can mean so much.  ”You did the exact right thing,” the nurse practitioner in the emergency department said to me after looking at my son’s swollen hand and I exhaled a sigh of relief as if a weight I didn’t know I was carrying was suddenly lifted.  Did I really? I wondered, and although I was not quite sure whether to take him at face value, I held on to his words.  I wasn’t the world’s worst mother, and what mother couldn’t use that reminder when accompanying her child to the emergency room?

We come to medical care in times of vulnerability, and often things that seem benign  sound cruelest.  Because, doctors are not trying to be hurtful, just honest.  Doctors are not trying to be tone deaf, but sometimes they don’t hear the way the words tumble out in the same way their patients do.

Denitza Blagev is a pulmonary physician who blogs at mybetterdoctor.