A Case Study of Conversation Surrounding a Compassionate Silence

• Patient: “Because it’s swollen. It’s pushing-”
• Clinician: “That’s how we know that we punch ourselves or stick ourselves or something, right, when we cut ourselves cutting vegetables in the kitchen or something. But definitely there could be a nerve component inside and [name] makes a very good point because – and with the swelling in the lymph nodes you have – we have nerves in that area. And if it’s swollen and it’s pushing on those nerves then.”
• Patient: “Yeah, it’s swollen.”
• Clinician: “Then that’s what’s shooting that, you know those.”
• Patient: “Yeah, it feels like that. It feels like it wants to burst-
• Clinician: “Right, the burning pain, the shooting pain.”
• Patient: “Yeah.”
• Clinician: “You know those are very characteristic terms used for neuropathic pain.”
• Patient: “Hopefully, well like you said a couple of them disappeared in the past couple of weeks. They just melted and [sound effect].”
• Clinician: “The lymph nodes?”
• Patient: “Well the-”
• Clinician: “Or the lesions?”
• Patient: “The lesions and I’m just hoping that the rest will follow suit. And.”               
• Clinician: “Yeah so between that, I mean the radiation has a long half-life.”
• Patient: “Yeah.”
• Clinician: “Uhm, so it could be radiation effects still, or it could be the chemotherapy effect.”
• Patient: “Yeah.”
• Clinician: “Yeah.”
• Patient: “Okay.”

• Patient: (deep sigh)
• Clinician: “A lot going on.”
• Patient: “I’m really tired of [crying]. I’m tired of crying about it. I’m tired of it all.” 
• Clinician: “I know, I wish there were things I could say differently.”
• Patient: “I’m just going to go through it.”
• Clinician: “Are there things that you can – that you think would help make it a little less hard for you to go through?”
• Patient: “Well I do – I do have a lot of support from my church and from friends and family. I just have to keep my head on straight and look at the right things and think about the right things. Think positively.”
• Clinician: “It’s okay not to though.”
• Patient: “In my head.”
• Clinician: “It’s okay to have those moments.”
• Patient: “Well I mean I do and when I feel sorry for myself and start crying. But I mean I’m choosing to think positively about it. That the chemo’s going to work and it will bind all this back down again like we did before. So this is where you have to go in your head. Yeah. In the meantime, yes, it does suck. Ah.”

During the 5 minutes before the Pause, the clinician is explaining the treatment options for neuropathic pain, and asking the patient about her symptoms. The conversation revolves around levels and location of pain and the subsequent pain management. Medications are suggested for future use, and the conversation leans toward the effects of previous sessions of radiation. The entirety of the 5 minutes discusses pain and pain management.

During the 5 minutes following the Pause, the focus of the conversation pivots towards individual experience and emotions, as well as the contemplation of personal values. The patient expresses frustration, and cites the support of friends and her church as making the process easier for her. The patient expresses a positive outlook as being a primary aim. There is no further mention of treatment from the clinician during this time.

During the 5 minutes before the Pause, there are two conversation speakers. The clinician is talking more than the patient. The clinician speaks on average more words per conversation turn, as well as dominating the information flow within the conversation. There are several occurrences of overlapping speech.

During the 5 minutes following the Pause, the patient speaks on average longer per turn. The patient initiates the direction of the conversation and dominates information flow. The clinician adds minimal information to the conversation. Instead the clinician reiterates and supports the patient’s statements, with a few prompting questions. There are no occurrences of overlapping speech.