I tested Julian today.
I knew nothing about him – no medical notes, no brief, just a name and profession; ‘doctor’,
Level 3 cognitive batteries contain a multitude of cognitive tests, including but not limited to word lists, digit spans, figure copy, immediate and delayed recall, language and fluency tests, visuospatial tests, a STROOP task, and three emotional tests. It took us 2.5 hours to get through all of it.
Two and a half hours is a long time, and I feel like I got to know Julian in this time. He didn’t tell me anything about himself, and he didn’t have to. I’ve been on a neuropsych placement at a hospital for a couple of months now, and in this time I’ve come to understand the cognitive battery testing to be a strange space – quite removed from everyday interaction, more intimate than acquaintances and more formal than friendship; a space where it’s appropriate to divulge the discrepancies between your brain and your mind to a person who is actively hoping to pick up on any such turmoil.
I haven’t administered many batteries yet; I believe today’s was my fourth. However I have administered countless single tests, such as the MoCA, ACE and OCS on numerous patients, in the ward and clinics alike. However despite my meager experience, I am coming to understand that the depth of interaction that can be achieved during a battery far surpasses that of a single test. With each test, each stumble, each nervous laugh, each small confusion and realisation and pause, I felt us settle deeper into a steady rapport with one another, and during those 2.5 hours I came to like him a lot. I feel that this was mutual; when he left, Julian told me that the experience of testing had been extremely beneficial and that he was glad he had done it, and he shook my hand and thanked me for my time.
I have encountered this a lot in my short time working as a neuropsychologist; people tend to be grateful and warm towards me, above and beyond what would be expected or even considered appropriate for a formal testing setting. I feel that this may be due to my title as ‘assistant’; I am shielded from any discontent felt towards ‘the system’, for the patients and I are all under an unspoken agreement that this is out of our collective hands, and furthermore, that I actually suffer as they do, and am ‘on their side’. I am finding and seeing that patients and assistants of clinicians are natural allies – I can do nothing to sway the decisions of my supervisor, however I can vehemently empathise and genuinely enjoy spending time I am not being paid for explaining and guiding frayed patients and family members through their medical pathways.
Julian struck me as warm. I knew he was a doctor – as soon as I met him in person, I wanted him to be my doctor. He was quick to laugh, and took enjoyment wherever he could – particularly in the WAIS block design, in which we concurred should be a game in it’s own right, and in utopia would be given to children. He complained of and demonstrated self-awareness of short term memory problems, despite far outperforming the majority of patients I’ve seen so far. He is clearly and intelligent man, but what made this so easy to perceive and receive was the way in which he reacted to less than perfect performance. He invariably performed well enough to reach the end of all subtests, meaning that he encountered the hardest questions. When he was stuck, for example in the final WAIS arithmetic questions, he did not waste time, he did not panic, he did not stall – but most significantly, he did not attribute his failure to answer the question in the time limit to an external source. He did not complain or question the test perimeters; he simply stated that he ‘couldn’t get that one’, in flat affect; neither skittish nor shamed nor grudging.
Julian stated that he found having the tests administered to him enlightening – during his time as a clinician he remembered administering a few MoCAs, and was intrigued as to how many tests there were, and how one chose which ones to administer to which patients. I explained as well as my limited knowledge, experience and time would allow; despite the fact that he is significantly older, more knowledgeable and successful than I am, he listened to my explanation with genuine interest and heeded what I said. I am unsure if this is entirely or partly due to Julian’s temperament, but it has made me wonder as to the power dynamics at play during testing. For the first time in my life, I am the professional with the clipboard behind the desk asking the questions, having all the answers, knowing when the press and when to be still, when to increase the pace and when to let the patent take their time. This experience is remarkable. Being a psychology student, you cannot help but to come across the classic social obedience to authority literature; Milgram, Zimbardo, Asch – and so I was already aware that such things as possessing a name badge, knowing where I was going and introducing myself as ‘neuropsychologist’ was going to elevate me in the eyes of my fellow humans, but the experience of this phenomena is much more subtle and evocative than I had expected. When I am in a work mindset and a patient asks me something, I feel that I am much more likely to know the answer than if the same question were to be asked to me on the bus home. When I am at work, I am expected to know things, and I expect myself to help people – and so I do. I automatically present myself and interact with people in this context, and they generally follow my lead, even in situations such as this, when they are vastly more experienced and knowledgeable than I.
This is particularly marked in situations that I am not familiar with – in this battery, there were a couple of subtests that I had never administered before, and have received no formal training for. Thus, I have not refined my ‘patter’ pertaining to those subtests, and was not as quick or as confident in their handling. However, in occasions like these, I have found that the patients either do not pick up on my hesitation or are unconcerned if they do – the context so heavily implies that I know what I’m doing, that it is actually quite difficult to appear as anything other than competent. I have also been mildly disturbed to notice that when administering subtests I am not familiar with, I am much more personable – more likely to use the time between tests to make conversation, to build rapport, to ask follow up questions, whereas in subtests that I now know off by heart, I reel off my established brief and that is that.
I have also become concerned and saddened at the rate in which I forget patients – I see so many, so many people in so many places, that it is hard to remember any one case. And yet patients do affect me, oftentimes profoundly – every day. I wanted to take this opportunity to speak from a place where Julian’s presence is still present in the forefront of my mind; a reflective state, perhaps, in which I am acutely aware of the complexity of the dynamics between tester and testee.
Julian’s a brilliant man, and I’d like him to be my doctor.