It had been a typical Monday morning at the teaching practice where I see patients, though patient flow was chaotic as we implemented a new registration system. I was running a few patients behind and regretting that my patients had to wait so long. Mrs B was next. I had assumed her care several months before. A 70-year old retired licensed practical nurse with diabetes, hypertension, and recent leg edema, Mrs B always seemed well-informed and on top of things.
This time I was concerned because her serum creatinine had risen far above her baseline. I informed her, and she seemed surprised that there would be any problem with her kidneys, even though her creatinine had hovered around 1.3 mg/dL for several years. Her previous physician had ordered a renal sonogram last year, which she had understood to be normal. We discussed, in a matter-of-fact way, the possible causes of the decline in kidney function and decided to repeat the laboratory tests and a urinalysis. We also anticipated what would be involved in further work-up if the laboratory results confirmed the change in her creatinine level.
I shuffled papers in the chart to review any previous evaluation and her medication list, struggled with a new laboratory requisition sheet, and checked on her routine monitoring for diabetes and last mammogram. I was already past the 15 minutes allotted for her visit. Mrs B answered all my questions clearly and confidently. Just as I was about to hand Mrs B the laboratory orders and appointment slip and pick up the chart to leave, I stopped, put everything down, and looked her in the eye.
“Mrs B, I rushed so much to take care of everything today—we talked about the kidney problem rather quickly. How are you feeling about all this?”
“Scared to death, Doctor, scared to death,” she said, without blinking an eye. “Everyone in my family has kidney trouble—my mother, my uncle. I have 2 sisters on dialysis.” Her eyes filled with tears.
“Then you’ve been dreading this?” I asked.
What was it that made me pause to ask that key question about how she was feeling? I had been close to walking out the door without grasping how worried she was. Yet I did pause, for those few seconds of silence, to look once more at the patient, to connect. We took a few more minutes to talk about her fears. I assured her that I would let her know the results promptly, and that I anticipated an early consultation with a nephrologist. She left the office looking somewhat relieved, expecting to wait several days for the results.
Later that week, I returned to the office for some patient follow-up and chart review. One of our medical assistants asked me to handle an authorization and referral for a vacationing colleague. It was for an ultrasound-guided breast biopsy for a patient whose mammogram revealed a lesion. The patient was a 68-year-old woman in good health who I didn’t know. Not wanting to write the referral without checking with the patient, I called her at home and had the following conversation.
“Hello, Mrs M, this is Dr Townsend. I work with Dr P, who is on vacation. I understand you had to go back to the hospital to get some other x-rays of your breast.”
“Yes, Doctor,” she said, a Caribbean lilt in her voice.
“Did they tell you they had seen a spot, a lump that needs a biopsy?”
“Did they schedule the biopsy?”
“Yes, Doctor, next Tuesday.”
“Is that OK with you? Do you understand what they are going to do?”
“And you’ll be able to go?”
“I’ll write the referral for Dr P and everything will be set.”
“And I’ll tell Dr. P when he gets back.”
After a brief silence, I was about to say good-bye when I asked one more question, perhaps in hopes of getting an answer beyond the deferential, “Yes, Doctor”.
“Mrs M, are you worried about this?”
“Oh, yes, Doctor”, a near-sob in her voice.
“You’re worried you have cancer?”
“Have you told anyone about this?
We talked for a few more minutes, about how mammograms help us find cancers early and whether she could talk to a family member or friend about her worries. She promised to talk about it with her daughter, and I promised to call the radiologist to learn more about what they saw on her mammogram. I urged her not to worry alone. Later on that day, I called Mrs M to let her know that the radiologist said the lesion was very small.
In our busy practice lives, we can easily miss the worry beneath the surface of our conversations with patients. As a family doctor, confident of my skills in integrating inquiry about psychosocial issues in routine care and committed to training young physicians in this model, I was surprised that I had come close to ignoring this key dimension in these 2 encounters. Had I been misled by the competence of Mrs B or the reserve of Mrs M? Had my use of closed-ended questions, seemingly appropriate for a simple telephone call or for discussing laboratory results, limited what the patients could tell me? Was I distracted by the confusion and delays in the practice that first day, or was I simply hurrying because I was running behind? Did my intention to make a brief stop at the practice to do “just a few things” limit my openness to clues from Mrs M?
Yet I did pause to ask the one last question, the one that allowed these patients to reveal their worry. A psychologist colleague always reminds us that including just one question on the psychosocial dimension in every visit is likely to pay off. I’ve found her advice to be true over the years. Even when hurried and hassled, the visit feels incomplete without making room for that final check-in with the patient about the meaning or impact of what we’ve said. Silence, pauses, eye contact, a last question—these ingrained habits serve as a check on a premature end to the visit and assure a connection with the patient.
We often worry that such questions will open Pandora’s box, the one opened by that much-maligned goddess who, in Greek mythology, unleashed all the ills of the world. Truly, we physicians are messengers of Pandora’s problem-filled world. We connect patients to that world, almost as immediately as aches and pains do. In a way it is our job to open Pandora’s box—we question, we probe, we order tests, we name risks, we raise issues patients would just as soon leave alone. We play Pandora. We connect patients to their illness. We can’t avoid it. It’s what we do.
Yet our curiosity and our questions can lead to insights into the patient’s world that help us to share worry and isolation or to mobilize support from family and friends. In this regard, it is interesting to recall that after Pandora opened her box, letting loose all that chaos, she managed to shut it just in time to prevent hope from escaping. As physicians, by connecting to patients through simple personal questions, we connect them to hope. In small ways, our attention to patients’ unspoken fears helps to maintain that emotional quality, hope, so essential to well-being. And hope springs not only from positive prognoses and reassurance that we may be able to offer, but also from the power of patients’ own reflections, their ability to name fears and to solve problems, and their willingness to ask for help from others. In Greek, after all, Pandora means “all gifts.” We, too, are endowed with gifts as a result of our training, the diagnostic tools and treatment options at our disposal, an ever-expanding medical and scientific knowledge, and the wisdom gained through experience, which we offer to patients. By opening Pandora’s box, we make room for listening, for reflection, and for putting things into perspective, and with our gifts, we open doors for healing.
We should embrace Pandora’s curiosity and her courage. Perhaps we need not fear opening Pandora’s box, but rather we should fear leaving it shut.
I want to offer a final note, having just returned from a gathering of the leaders of our discipline at the Association of Departments of Family Medicine winter meeting. I believe this moment is precious and unique in medicine, when mounting evidence documents the value of family medicine and primary care in keeping people healthy and in reducing mortality. We will have many new tools at our fingertips in the coming decades, including medications tailored to individual genetic patterns, ever more amazing imaging techniques, and less-invasive approaches to surgery. Yet, the processes of care upon which family medicine is built and the relationships that ensue may be our most powerful tool of all. As my new Dean* notes, “Listening is the cornerstone of medicine.”
Let us raise our collective voice in support of a system of care that makes room for listening—to patients, to each other, and to communities.
I wish to acknowledge Henry Geisinger, MS, for his interpretation of Pandora’s story and his contribution to the framework of this essay, and Darwin Deen, MD, Paul Gross, MD, Rose Guilbe, MD, and Eliana Korin, DiplPsic, for their helpful comments and insights. I am grateful for those who shared family medicine’s gifts with me and showed me the path to becoming the physician I could be. Among the many teachers and colleagues who taught me how to listen are Lucy Candib, Herb Fendley, Joanna Shapiro, Carl Meier, Barbara Franzblau, Hal Strelnick, Eliana Korin, and Chinita Fulchon.
Conflict of interest: none reported
*Bob D’Alessandri, MD, President and Founding Dean, The Commonwealth Medical College, Scranton, Pennsylvania.
Die Buchse der Pandora (Pandora’s Box) (1929 Germany 110 mins)
Source: BFI Prod Co: Nero-Film Dir: G.W. Pabst Scr: Ladislaus Vajda, based on the plays Der Erdgeist and Die Büchse der Pandora by Frank Wedekind Phot: Günther Krampf Ed: Joseph R. Fieseler Art Dir: Andrei Andreiev, Gottlieb Hesch
Cast: Louise Brooks, Fritz Kortner, Franz Lederer, Carl Goetz, Alice Roberts, Kraft Raschig
Lulu’s story is as near as you’ll get to mine.
– Louise Brooks (1)
There is no Garbo! There is no Dietrich! There is only Louise Brooks!
– Henri Langlois (2)
It is easy to see the great films of the short-lived Weimar Republic (1919–33) as haunted and spectral – the artistic expression of a society on its last legs. Their very brilliance seems inseparable from a brittle fragility, as if the extremes toward which they were reaching with an almost breathtaking speed would inevitably result in the backlash that followed, and the flight of their makers into exile or silence.
What makes G W Pabst’s 1929 film Pandora’s Box (Die Büchse der Pandora) so astonishing is the non-moralistic candour of its ambiguous sexuality and the electrifying presence of a 22-year-old American actress named Louise Brooks. Based on two plays by Frank Wedekind (1864–1918) (3), the film is a completely modern creation, not the mélange of music hall and tragedy that Wedekind wrote (only later to be labelled “expressionist”); concentrating on the amorous exploits of Lulu, available to seemingly everyone but possessed by no-one, who manages to bring all of her suitors, male or female, to grief.
Pabst was an acutely intelligent director who, in 1928, was already famous for his handling of actors. He had cast a virtually unknown Greta Garbo in his 1925 film The Joyless Street (Die Freudlose Gasse), which convinced Hollywood of her star potential. For the role of Lulu, he reportedly tested and turned down every available actress until he saw Louise Brooks in Howard Hawks’ A Girl in Every Port (1928) and asked to borrow her from Paramount Pictures (4). He clearly saw something in Brooks that matched his vision of Lulu, but her casting proved more apt that probably either of them could have anticipated. During filming in Berlin, Pabst gave her a chilling warning: “Your life is exactly like Lulu’s, and you will end the same way” (5).
Encapsulating the plot of the film makes it sound unbelievably lurid: when the wealthy Peter Schon attempts to break off his affair with Lulu so that he can wed a respectable socialite, his plan is foiled when he is caught by his fiancée with Lulu in flagrante delicto. Deciding to marry Lulu instead, Schon discovers on their wedding night that she has seduced his son, Alwa. He gives her a pistol and orders her to shoot herself. She refuses to take the gun from him but in an ensuing struggle Schon is shot dead. Lulu is tried and convicted of murder but escapes the courthouse during a riot when one of her friends activates the fire alarm. Together with Alwa, a lesbian countess and a circus strong man, Lulu escapes by ship eventually to reach England’s East End where she must resort to prostitution. It is there, on a foggy Christmas Eve, that Lulu meets her fate at the hands of Jack the Ripper.
What prevents all of this from teetering over into burlesque is Louise Brooks, who delivers what is surely one of the greatest examples of naturalist acting on film. As Brooks explained to Kenneth Tynan: “I was simply playing myself, which is the hardest thing in the world to do – if you know that it’s hard. I didn’t, so it seemed easy. I had nothing to unlearn.” (6) Brooks was also a trained dancer and her every movement in the film, from her swoon in the courtroom to her languid, tired last walk up the stairs to her London garret, is sensuously balletic.
The film was photographed by Gunther Krampf, who had filmed Murnau’s Nosferatu in 1922. Through his subtle use of filters and key lights, he gives Brooks’ startling beauty an iridescence, her lacquered black hair starkly contrasted with the shimmering whiteness of her costumes, as if she were nothing more than a gem-like surface to reflect or refract the light around her.
The film wasn’t received in Germany with much sympathy, which puzzled Brooks. In her memoir, Lulu in Hollywood, published near the end of her life in 1985, she pondered:
Berlin had rejected its reality when we made Pandora’s Box and sex was the business of the town. At the Eden Hotel, where I lived in Berlin, the café bar was lined with the higher-priced trollops. The economy girls walked the streets outside. On the corner stood the girls in boots, advertising flagellation. Actors’ agents pimped for the ladies in luxury apartments in the Bavarian Quarter. Race-track touts at the Hoppegarten arranged orgies for groups of sportsmen. The nightclub Eldorado displayed an enticing line of homosexuals dressed as women. At the Maly, there was a choice of feminine or collar-and-tie lesbians. Collective lust roared unashamed at the theater. In the revue Chocolate Kiddies, when Josephine Baker appeared naked except for a girdle of bananas, it was precisely as Lulu’s stage entrance was described by Wedekind: “They rage there as in a menagerie when the meat appears at the cage.”(7)
- Quoted in Kenneth Tynan, “The Girl in the Black Helmet”, Show People, Simon and Schuster, New York, 1979, p. 294.
- Tynan, 1979, p. 303.
- Wedekind’s American mother actually named him Benjamin Franklin!
- Recounted by Paul Falkenberg, one of Pabst’s assistants, to Brooks in 1955. Louise Brooks, Lulu in Hollywood, Knopf, New York, 1982, p. 95.
- Brooks, 1982, p. 105.
- Tynan, 1979, p. 276.
- Brooks, 1982, p. 97.