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nonverbal signals and fleeting glimpsesof emotion — telling clues that theycan then follow up on. “That expres-sion lets the patient know not only thatyou’ve understood what they’ve said,but you have understood on a deeperlevel,” Haidet says.

He notes that many doctors work-ing at inner-city public hospitals learnto achieve a level of connection andunderstanding in a short time.

“They’re very good at getting centredand being in the moment with thosepatients,” he says. “They listen deeplyand co-construct the narrative with thepatient.”

It’s not a one-way street. Haidet also

notes that patients need to be assertive— and studies support that theory. Inmany cases, “interventions were associ-ated with improved physician andpatient communication behaviors.”3

In reviews of Haidet’s course, doc-tors remarked that while most of whatthey learned wasn’t new to them, thematerial allowed them to enjoy theirpractice much more.

Fateema Sayani BJMusic criticOttawa, Ont.

REFERENCES1. Haidet P. Jazz and the ‘art’ of medicine: improvi-

sation in the medical encounter. Ann Fam Med2007;5:164-9.

2. Beckman HB, Frankel RM. The effect of physicianbehavior on the collection of data. Ann Intern Med1984;101:692-6.

3. Rao JK, Anderson LA, Inui TS, et al. Communica-tions interventions make a difference in conversa-tions between physicians and patients: a systematicreview of the evidence. Med Care 2007;45:340-9.

Box 2: Clinical exercises

1. “Mastering space”

For the next two weeks, pick onetime when the patient is finishing asentence. Wait for at least 10seconds before saying anything. Ifthe patient talks before 10 seconds,follow up on what they say. Watchfor the times when the patient sayssomething unexpected or profound.

2. “Cultivating ensemble”

For the next two weeks, say asentence that begins with: “So,what I’m hearing you say is… ” Dothis once with every patient. Aftertwo weeks, do it when it feels right.Experiment with different ways ofsaying the phrase.

Box 1: Suggested listening

• Now’s the Time, Sonny Stitt (altosaxophone) from Stitt Plays Bird(Atlantic/Warner)

• All Blues, Miles Davis (trumpet)from Kind of Blue (Sony/BMG)

• Giant Steps, John Coltrane (tenorsaxophone) from Giant Steps(Atlantic/Warner)

• Waltz For Debby, Bill Evans (piano),Scott LaFaro (bass) from The Bestof Bill Evans (Fantasy Inc.)

Books

A commentary on the truth

The orange wire problem and other talesfrom the doctor’s office

David WattsUniversity of Iowa Press; 2009.186 pp $25.00

Writing reflective essaysabout clinical experiencesis a complex endeavour

that can appear deceptively simple. It is not always easy to balance

fidelity to the facts with the imperativeto maintain patient confidentiality.There are the ethical questions of whatbenefits are accrued, and to whom, andwhat the risks might be. There is thematter of choosing your audience anddeciding how best to speak to them.

The number of physicians who writedespite these difficulties is quite strik-ing and while not everyone possesses

the same degree of skill, there is gener-ally an earnest quality to the writingthat suggests an effort to understand,and to share, truth.

San Francisco, California, physicianDavid Watts takes this task seriously.As well as authoring several books onmedicine, he is a poet, musician, andtelevision personality. In the preface toThe orange wire problem and othertales from the doctor’s office he writesthat he is striving “not so much to doc-ument as to approach a truth that goesbeyond nonfiction and dares to flirtwith the realm of mystery.” As such astatement would suggest, this is anambitious book.

In 26 short narratives, Watts pro-vides sparse sketches of encountersbetween doctor and patient. Most of theclinical scenarios will be familiar tophysicians, but Watts imbues them withimportance and significance. He bringshimself deeply into the encounters andD

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Thirty years ago, in my secondyear psychiatry, I suffereddread during on-call at Douglas

Hospital. The hospital, set on 170 acresbetween Montréal’s Lachine Canal andthe St. Lawrence River, had more than1000 mental-health patients. I was thesole on-call, responsible for every-thing: medical crises, dressing andsuturing wounds, monitoring infec-tions, drug reactions and attempting tosedate violent and suicidal patients. If Ididn’t know what do, I read manuals,spoke to nurses, called the staff psychi-atrist and waited for the patient to getbetter — or worse.

On this particular on-call evening,the hospital was marooned by a violentblizzard. Lights flickered, broadcastswarned of whiteouts, falling powerlines, school closures and airplanedelays. Outside, the maelstrom roaredand trees snapped; inside, the hospitalwas still and my beeper mute. By 11:30,the evening nurses were asleep in spareward beds; night staff who were unableto reach the hospital remained house-bound. Unable to sleep, I threw on myboots and coat and trudged knee deep insnow as the savage sky whitewashedthe earth. When I returned to my room,I crept into bed, sniffed my clean sheetsand sank into a deep sleep.

An hour later, the irate head nursephoned. A patient, sleepless for morethan two days, threatened to leave. Where

was I? My beeper was dead. Hurriedly Idressed and marched through a sombreunderground tunnel to a locked ward andwas informed about Sophie. I reviewedher chart, met with the head nurse andchecked my psychiatric manual.

Sophie was on lithium, valium andthousands of milligrams of chlorpro-mazine. Nothing touched her. “Watch

out,” the head nurse warned. “She’ssly, foxy.”

“Finally, a nice doctor,” a comelyblonde in a hospital gown greeted uswith a Lauren Bacall voice. “Sillynurse,” she grinned. “Doctor, you’llsend me home now?”

“I would like to talk to you.”“You can take me home.”Sophie spoke dry-mouthed and

rapidly. Her eyes sparkled like icicles. “The staff are worried you haven’t

slept.”“I sleep when no one is looking,”

she winked. “You can sleep with me.”After a fruitless talk with Sophie, the

nurse and I walked into the hall. “Puther in a quiet room,” she advised. Feel-ing cruel, but knowing the nurse wascorrect, I explained the move to Sophie.

“Get out!” she cried. She hurledinsults. She kicked the door. “I don’ttrust you!”

“Sophie hasn’t taken liquids for overa day — she’s too hyper,” the nurse said.

We returned with a cup of gingerale. Sophie flung it at us. As we left Iheard her ranting tearfully, poundingthe walls. “She’s getting more manic,”the nurse said.

I found a new copy of Freedman &Kaplan (1975) on the ward andreviewed drug treatment. There were notmany options. “Now what do I do?”

“Sedation,” the head nurse said. Iwaited a half-hour during which time

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does not back away from sharing hisown emotions, whether he is dealingwith a patient’s insurance company ortalking to the physician caring for hisown dying mother.

Description is kept to a minimum.Dialogue flows without quotationmarks. At times this makes it difficult totell whether words are spoken by thepatient or the doctor, and the linebetween communication and internalreflection is indistinct. It’s a style ofwriting that differs from the norm

among books written by doctors: Itkeeps the reader slightly off-balance andcompels attention. Yet the book itself iseasy to read and not without humour,despite its lofty ambitions.

There is a line in the book whereWatts tells one of his patients: “A doc-tor is supposed to share not just truthbut wisdom, which, if you will, is acommentary on the truth.” This goalcan apply not only to clinical situa-tions, but also to the process of writingcreatively.

Bravery is one of the virtues we don’toften talk about in medicine, but it takesa special sort of courage to be presentwith a patient’s pain, to hold the experi-ence long enough to examine it and thento bare one’s soul in the commentary onthe truth.

This is a book that aspires to be notonly brave, but wise.

Lara Hazelton MDPsychiatristHalifax, NS