When Words Fail: Love’s Rightful Place in Medicine

• patient-provider relationship
• countertransference

My parents never said “I love you” when I was a child. Chalking it up to a different culture or a different love language, I didn’t think much of it until I noticed my friends’ interactions with their parents. Every morning drop-off at school, or delivery of chocolate milk while playing video games seemed to be flourished with those darling, intimate words. I distinctly recall one evening standing in the dark outside my parents’ bedroom—hand on doorknob and heart aflutter—thinking, “Just ask them already. Mom and dad, do you love me?”

Set against that backdrop, I think I surprised even myself when, 22 years later, I told my very first patient, “I love you.” Felix^a was a punchy 89-year-old, who had been hospitalized for severe shortness of breath while playing in the county horseshoe competition semi-finals. For the 3 days I buzzed about him—inspecting here, palpating there—he would never let me forget that I was the one keeping him from that championship trophy.

As a fresh 3rd-year medical student, I had never spent much time in hospitals, and honestly had no idea what to expect. Classmates had convinced me I’d spend most of my day swimming through the electronic health record or preparing for rounds rather than actually working with patients. With expectations of frenzy, I was pleased to find that, though my minutes with patients were brief in absolute measure, time and space seemed to stretch around me.

I found myself entering into a daily rhythm that felt oddly familiar, and somehow tender. I was struck in noticing that, each morning, I set out to visit my person. To sit at the edge of their bed and ask, “How did you sleep?” and “Have you eaten?” To notice the passing breath—where it flowed and stagnated, and when called for, to match a heavy sigh with my own. To be thoughtful in how and where I laid my hands. To slowly page through the chapters of one’s life, day after day, grandkid after grandkid, in joy and sorrow both. And the sweetest of all—listening to the heart, a time to peer within, though with closed eyes.

Aortic…pulmonic…tricuspid…mitral. These felt like the darling, intimate interactions most people only encounter in life’s moments of quiet serendipity. In the fuzzy light of Sunday mornings, watching their newborn’s passing breath; listening to a partner’s heartbeat. It felt a lot like love.

My face glowed scarlet as soon as I heard the 3 words spill out of my mouth. (Though I don’t think you could tell under 2 face masks and a face shield.) I gulped, hoping I hadn’t crossed a line at literally my first time working with a patient. Felix didn’t say a thing, but seemed to give a knowing nod. He’d be discharging later that day, to an empty horseshoe pit, and I think we both knew that the chances we’d cross paths again were slim. Somehow, in that moment, love was the closest thing I had to a “right” word. No, this wasn’t the love borne of brotherhood, not an emblem of romance nor of country. It was something else altogether.

Those who read this may scoff at the idea of having, much less expressing, true love for patients. Perhaps it is a hallmark of my level of training—being far too green to know any better, or to have developed a more judicious capacity to attenuate my emotions.¹ Even so, that my words cohered before I even became aware of what was an “appropriate” patient interaction suggests that my feeling was rooted somewhere deeper, somewhere essential. A primitive reflex.

I’ve sat with the experience for months, turning it around in my head like a smooth river stone. Was it stupid? Was it the truth? And most of all, was it wrong? In Felix’s case, my words ended up not causing issue—but it was important to recognize how easily it could have gone another direction. There is a profound intimacy to be found in the patient-provider relationship, and so too there is a responsibility to hold to account the power differences intrinsic to the roles of “the sick” and “the healer.”

What surprises me most is that regardless of what I should have said, I sincerely believed the words. The 3 years of training I’ve undergone provide testament to the notion that medicine is primarily the application of critical reasoning and the scientific approach to improve human health. But maybe more often than we’d like to admit, we pedestal objectivity at the expense of the subjectivity that originally beckoned us to the healing professions: our impulse to look out for our fellow human beings. To tend to the injured and reticent. To love.

People may use different labels to describe this principle, but I see no problem subscribing to the word love. Although love is often cast with a broad brush in English, transcultural concepts such as chesed, maitrī (mettā), or agape may more appropriately speak to the care we offer patients,² these perfect strangers we come to know from the inside out. Feminist scholar bell hooks wrote that when love functions as a core motivation informing daily actions, it has the power to create transformative social change.³ We can claim a similar “love ethic” in medicine too, rather than shy away from it under the pretenses of professionalism.⁴ By choosing love, we affirm that the lives of our patients are intrinsically, intimately bound together with our own. By choosing love, our daily clinical practices manifest as the direct extension of a greater purpose, rather than the constrained measures of an indifferent health care machine.

These meditations drew me inwards, back to that 8-year-old, barefoot in the dark at his parents’ doorknob. How special he would feel to hear those 3 words. I think about that kid as he turned around, deciding it was far too scary to ask. He would go on to grow up and learn there are actually many ways to convey “I love you,” and in his parents’ case, it was voiced with resounding clarity. Sometimes, it was just offered with a different parcel of 3: “Have you eaten?” Other times it rested quietly at the edge of his bed, his mother a bleary-eyed protector against monsters in the closet.

I have grown more than I thought possible during medical school. Yet even so, I still feel like that little boy in all of his innocence and naivete, swapping pajamas for ill-fitting scrubs. I’d like to think that my words to Felix were ghost-written by that kid—a genuine but feeble attempt to convey that which dwells beyond the limits of our English language. Or perhaps even the human one. Using mere words to contain this transcendent care we have for those entrusted to us is akin to stargazing through a microscope lens. So, I think it is time I stop trying.

What I recognize now is that my parents actually taught me something precious, long ago: how to give voice to love, without words. Though my heart still flutters each time I put hand to doorknob, I know I enter with a miraculous version of love—one that asks nothing in return, seeks only to witness and ease the life of another. It’s impercptibly quiet, but it still speaks. Tucked in between OPQRST.^b Through the eye crinkles that permeate our face shields. In how we sit on the edge of that bed.

I think it’s there. In that sublime silence, we begin to heal.

• © 2022 Annals of Family Medicine, Inc.