Sitting for Picasso: Surprise and the Art of Medical Education

We will be wearing our famous street faces, anonymous as trees. Suddenly you will see me, you will blink, hesitant, then realize I have not looked away. For one brave second we will stare openly from borderless skins... From “Eye to Eye” by Naomi Shihab Nye I had seen Mr. Armstrong several times in my Internal Medicine outpatient practice at the Veterans Affairs Medical Center. He was a very pleasant gentleman— 53, homeless and living on the street, with an array of common chronic medical conditions including hypertension, hypercholesterolemia and chronic obstructive pulmonary disease. Our visits were generally filled with challenges related to things such as diet, stress and medication adherence. I mostly did my best to manage these problems while trying to stay on time. In my clinical world he was a homeless person with a problem list. Then one day he came into see me looking much better—he had moved into the Veterans Affairs Domiciliary. He had his own room and regular meals, not to mention medication monitoring. My job was much easier, and the visit was much more efficient. A few months later he had left the Domiciliary and had his own apartment in the community. He was happy and feeling well. Somehow in the midst of my routine visit management he found an opening to wake me up. “You know, it was really discouraging to be homeless, on the street. It was a dark time for me. Kind of like Picasso’s Blue Period.” I am not an art historian, but I have made the rounds of some interesting museums, often wearing an auditory guide at the behest of my wife. So I know something about Picasso and his “Blue Period.” Meanwhile, Mr. Armstrong, my formerly homeless person with a problem list, was not supposed to know or care about Picasso and his Blue Period. Borrowing from Naomi Shihab Nye’s poem—I could not look away. Everything changed. I asked him about his interest in art, and he told me how much he loves to go to museums. The visit was no longer than when I had struggled with his adherence—but more importantly, I was not so aware of the time. When I saw him next I asked him about museum visits, and he proceeded to talk about an exhibit of Greek sculpture. We shared a moment outside of medical algorithms, anonymity slid away, he did fine medically and I am telling his story today. How often does that happen? Not enough. Why not? It is complicated. We worry about time, and we let ourselves be satisfied with single stories, stereotypes— he was a “homeless person.” It was too easy to let that be his only story, to not listen or ask for other stories. In a memorable TED talk in 2011, the talented Nigerian author Chimananda Adichie describes “The Danger of the Single Story” and the power imbalances that are part and parcel of this truncated way of perceiving the world. Time turns out to be our all-purpose excuse for a laundry list of shortcomings, including sitting down and listening for more than 1 story. Open-ended questions, questions that we do not know the answer to, threaten to unravel our schedules and the management of our days. But as much as we invoke the constrictions of minutes and hours, time is far from the well-defined organizational structure that we make it out to be. There is no question that circumstances, including a doctor sitting rather than standing, can alter the perception of time. And we “make time” when we view the investment as important or unavoidable. There are moments in our days when the ticking stops, when time disappears— these have been described as “Kairos” time. Literally translated as “God’s Time,” we experience this most often when we notice something, something that makes us think or imagine. The miracle of our children as they sleep, the splendor of a winter morning, the story of a remarkable patient. They are the times we remember, which make up for all the anxiety over seconds and minutes (“Chronos” time). All in all we make assumptions about time and we allow time to manage us. We can do better. So how can we “find Picasso” more in our daily practice lives? I suggest 3 things. First, always sit down. Second, ask. And third, welcome surprise. It is hard to imagine having a serious conversation with a friend or relative looking down or looking up. Sitting is a powerful signal—“I am ready to listen to you. I care about what you have to say. I have time for you.”