“Your intern shot 50 questions at me non-stop, it made me dizzy. I’ve never heard anyone talk this fast before.” A patient in the Emergency Room told my senior resident, after I left the room to write the admission note. Although English is my second language, I talk faster in English than in my native tongue (Mandarin Chinese). I suspect being in medicine has a lot to do with it.

In residency, night shifts were my favorite rotations. As the intern, we carried the admission pager (1 in 3 admissions in the hospital came to us), our own pager (which is usually non-stop going off), and the OB delivery pager (we delivered all the babies at night). Our attendings were not in-house, leaving just the senior resident and the intern to do all the admissions, and handle all medical issues that came up at night for the patients in the hospital on our team. So night shift meant maximum autonomy, but fast-paced hands-on learning. You get so good at multi-tasking and getting things done so fast, as to not fall behind on all the pages, therefore leaving the day-shift team no mess to clean up. And you still want to go home to sleep on time, so you can come back to do it all over again the next night. It was nerve-racking, but exhilarating.

This training pushed the speed of my speech to its zenith: in order to get things done fast, I had to talk fast, and talk non-stop. If there was room to breath, I was probably slacking. The “awkward silence” was the enemy to efficiency and productivity.

Another reason for my talking fast and excessively is, paradoxically, my language barrier. I have a very subtle accent, not enough to be detected if the grammar, choices of words, and the sentence structures are correct and customary to American English; but enough to be detected if the above criteria were not met. Sometimes, people put up a “mental block” when they sense that the speaker is a “foreigner”, compromising communication. “I’m sorry, what?” People would say from behind the mental block, even though to another person, the speaker is perfectly understandable. While I am proud to be who I am, and genuinely think that all accents are equal, I try to avoid this kind of obstruction. If I talk fast enough, and pack enough content into what I say, I leave less room for miscommunication.

The fast and furious style of talking stuck with me until recently, when I started to slow down.

“Do you think there is a sadness in Luz’s eyes?” I asked my medical assistant after I left a teenage patient’s room. Luz’s mother brought her in for sports physical, which usually is a very quick and easy visit. I assess if the patient is physically healthy enough to participate in sports for a year, and I provide a doctor’s note to the school.

“Yes, doctora, she looks like she could cry.” My medical assistant confirmed. We nodded to each other and understood the plan. We went back to the room and asked the mother to come to the nursing station for the sports letter, and explained to her that, as a routine practice, I always talk to teenage patients alone after the physical exam. Luz’s mom didn’t protest, and left the room.

“Luz, you look sad, is everything OK?” I asked.

Silence. Luz avoided my gaze. So I moved a little closer to her. “Do you feel safe at home?”

She said nothing.

“Is anybody mean to you in school?” I guessed again, growing weary of the awkward silence. I could sense my brain started to turn faster and faster, to search for possibilities and come up with more questions to fill the void.

Luz said nothing, still looking down. Somehow, even her body seemed like it totally stopped moving, like she was frozen in place.

“Is anybody calling you names? Are you parents getting along? Has anyone touched you inappropriately? Are you eating? Are you vomiting? Do you hurt anywhere?”

Nothing. No words. No movement. Is she even breathing?

As my frustration grew, I found myself leaning more and more toward Luz. In the meanwhile, without actually moving, her existence leans away from me, further and further as I darted more questions at her.

“Your intern shot so many questions at me, it made me dizzy.” The ER patient’s words suddenly came to mind. Was that what Luz was thinking? Perhaps, instead of dizzy, I asked too many questions too fast, it made her want to escape the room?

This thought made me swallow my next question, and moved a little away from Luz. As I took a deep breath, I noticed that Luz took a deep breath with me, too.

A few months ago, I was trying to bring my therapist up to speed about what was going on in my life that disturbed my mental balance. After I finished, I looked at her and expected some equally enthusiastic response. But instead, she said: “do you notice what your breath is doing right now?”

“What is my what doing?” I puffed my shallow breaths. Oh, that. I smiled and inhaled deeply, creating a little space for myself as I did now for Luz.

“Luz, I am going to step out and bring somebody to help me, OK?” I asked. I finally admitted to myself that I was not going anywhere with her, if not making it worse. I needed help. We needed help.

Luz nodded. It was the first time she actually responded to me in some way.

I left room, and called the behavioral health counselor for help. “There is something going on with this kid, and my gut tells me we should try to find out, but I couldn’t get her to talk to me.” I looked at the time and counted how many patients behind schedule I was at this point, feeling frustrated and defeated. “I gotta move on to the next patients,” patients who actually wanted to talk to me, sometimes who couldn’t stop talking to me, I thought to myself, “can you please come and help me?” I pleaded.

A few patient visits later, I found the counselor waiting for me at my desk. “How did it go?” I asked, barely looking up from my computer, typing furiously to write a note. This was when I realized there was silence, again. It was not her words, but the pause in our conversation that drew my attention. So I stopped typing, and looked up.

“Good and bad.” She said. “Luz told me her story. But we need to call the authorities.”

As it turned out, Luz’s mother had a frequent visitor who was sexually abusing Luz each time he came over. And this had been going on for years. She hadn’t told anybody until now, creating an enlarging gap in her relationship with her mother. We immediately got our social services department involved, informed the mother, and completed our mandatory reporting.

“But how did you get Luz to open up to you?” After quite a bit of running around, I finally found time to ask the burning question. The counselor must have found the right question to ask, and I wanted to know what it was. Maybe it wasn’t just the right question, but the right tone, the right gestures? Maybe there was a light touch on the back, maybe they spoke Spanish to each other? How was she able to build a therapeutic relationship with a traumatized child who wouldn’t open up?

Sensing my eagerness to learn the “secret” to her “technique”, the counselor giggled, and said: “I just sat there with her until she talked.”

Of course! It was the darn silence. The thing that I had been trained to be so uncomfortable with, was actually the most therapeutic in this case. It showed Luz that we had no agenda, no prepared questions or answers. We were ready to listen whenever she was ready to talk. But in the meanwhile, we were not afraid to sit in silence, and create some space that she can breath and lean into.

To be honest, I am still not great at providing the therapeutic silence in my exam rooms. But I imagine it’s like any other “technique” we use: practice makes perfect. These days, I remind myself to “notice your breath”. And I slow down when it becomes too shallow.