The Space to Listen

The Millers were a box set. He came from Iowa farmland, joined the Navy to see the world, and ended up in San Diego. She was a farmer's daughter who followed her husband where the Navy sent him. After his service as a Machinist Mate, Mr. Miller found employment in San Diego's aerospace industry, helping build the machines that would define an era. Mrs. Miller raised their four children. 

Tall and improbably vertical for his 92-years, he was a skin cancer factory. No sooner did I cut one out, another would appear. They came to appointments together and, like good Midwesterners, the Millers always began by asking about my family — my wife’s name pronounced impeccably and the name and ages of my children recalled accurately. Only after this ritual would we discuss the reason for their visit. 

Mr. Miller, who had applied his conscientiousness to the Atlas rocket program, approached his medical treatment with identical care. When I explained treatment options, he would nod with the focused attention of someone who had once calibrated instruments that could not afford to fail. 

Mrs. Miller was short, her hair styled in what the beauticians call a Poodle Cut, making it impossible to not think of Lucille Ball when I saw her. During these consultations, she spoke rarely. When I prescribed imiquimod cream for her, it was Mr. Miller who documented the instructions in a small notebook he carried for such purposes, his handwriting as precise as technical drawings. 

Then came a Tuesday in October when Mrs. Miller appeared alone in my exam room. My stomach dropped as I assumed the worst. "No, he's here," she said, noting my expression. "We had trouble parking, so he dropped me off." The relief I felt dissipated when I opened her chart and saw the diagnosis: recurrent breast cancer. 

"I'm sorry to see that," I said. "How is your treatment going?" 

"I'm not treating this one," she replied. The words hanging there. 

"Oh, I see," I said, though I didn't. 

"Do you know who Christopher Hitchens is?" she asked. The question was like a non-sequitur dropped from a random exam room above us. Christopher Hitchens, the British-American essayist, was an improbable subject for this 89-year-old great-grandmother. I confirmed that yes, I was familiar with his work. 

"I've been listening to his podcasts," she said. Given that Hitchens had been dead for a decade, I wondered if she had dementia. She then added, as if reading my concern, "Not recent, of course. I'm listening to his lecture recordings from when he was alive." I struggled with a bizarre image of Mrs. Miller, earbuds in place nodding along to Hitchens atheistic provocations. 

"I believe there is nothing after this," she stated, referring to life with the same directness with which one would decline ordering dessert. "And I'm glad of that. I've had better fortune than most and have had my fill. And now I'd like to die as I choose." 

At that moment, I realized my error. For years, I had categorized Mrs. Miller as gracious, but simple, uneducated, a woman who deferred to her husband's judgment because she lacked confidence in her own. This was attribution bias in its purest form — assuming that her behavior stemmed from internal factors rather than the context of a 70-year marriage with its own established patterns and protocols. Now, sitting alone in my examining room, she revealed herself as erudite, intellectually curious, courageous. Not “just” a housewife, but a woman of substantial thought. A woman who deferred to her husband of seven decades not from intellect's absence but by her choice. 

The parking situation extended conversation through Hitchens, mortality, and the secular leanings of our founding fathers. She spoke with the clarity of someone who had considered these matters deeply. "It's triple negative," she said of her cancer, "and I've failed treatment already. I don't want to spend the rest of my days throwing up. Why me? Well, why the hell not? Hitchens would say." 

Our conversation extended beyond the allocated time before returning, as custom dictated, to regards for my family and career. We concluded with our usual "I’ll see you back in 6 months," though both of us understood the uncertainty in that promise. 

Exam rooms with their clinical-blue lighting and steely Mayo stands help keep us from sliding into our emotional selves, but sometimes we slide. All day that day I felt the double grief of her likely limited future visits and the years I'd spent not fully seeing her. 

In medicine, we learn to see what's visible — lesions, symptoms, signs. Mrs. Miller taught me to look for what isn't: the hidden lives that patients carry with them, revealed only when we create a space to listen. Godspeed, Mrs. Miller. I hope to see you again. 

(The names and details here have been changed for confidentiality). 

Jeffrey Benabio is chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on X.