We are happy to announce the this years winners of the Student Ascona Awards 2015.

1. Sean Tan — Ireland

2. Khloe Frank — USA

3. William Brierley — England

The award ceremony took place on the 8th of September 2015 in Metz — France

Please find the essays of the three winners below:

 

TUESDAYS WITH MRS FOX

Sean Tan

 

 

The first Tuesday-meeting Mrs. Fox

 

I’m just here to finish this assignment. I really don’t want to do this. I hope this ends soon.

 

Those were the only words that crossed my mind as I was being driven to a house in a suburb of Belfast. This was the first family attachment session that was being carried out. First year medical students had to participate in this activity. It involves two students paying weekly visits to interview an assigned patient, and then writing a report on it. In my case, the weekly visits were scheduled every Tuesday. 

 

My friends were looking forward to the first patient contact we will be having. It made them feel like real doctors: being in charge of a patient, interviewing them, taking down past medical histories. This wasn’t a lecture anymore, and the reality of dealing with patients excited everyone. This was like a proper inauguration into medical school! 

 

My emotions were the antithesis of the positive feelings everyone else had. I was worried, uncomfortable, nervous and extremely reluctant to participate in this activity.

 

First of all this was not a simulation and I was about to interact with a real patient. My partner and I would be responsible for conducting all the sessions with this patient. I have only stood on the sidelines as I shadowed doctors around the hospital, never interacting with patients. And now I had to be responsible for one? How was I going to do it? 

 

Furthermore, I am from Malaysia and I was still having trouble understanding the culture and the accent of Northern Ireland. At times it was hard enough interacting with the local students here. However now I had to interact with someone who was a lot older, hidden away in a suburb I have never heard of. This patient has probably never interacted with foreigners before. Wasn’t there going to be an immense cultural barrier? Would I even be able to understand what my patient was saying? Wasn’t it going to be incredibly hard to communicate to someone who was…. so different?

 

On top of that, I was going to be digging up a painful past and that would involve my patient exposing herself emotionally. Wasn’t it going to be incredibly awkward? How was I going to react if this complete stranger started becoming emotional? What if I said something offensive and hurt my patient?

 

At the time, I thought the only thing that was going to help me endure this, was viewing my patient, and this entire activity as an assignment I had to get out of the way. I am just going to ask a few questions, write down what my patient says, finish everything as soon as I can, and everything will end quickly. All I have to do is to treat my patient as another assignment.

 

I’m just here to finish this assignment. I really don’t want to do this. I hope this ends soon.

 

The 20-minute cab ride seemed too short as my family attachment partner-Katie, and I arrived at the home of our assigned patient. It was a one-story brick house painted red and white. We rang the doorbell and with an electronic buzz, the door was unlocked. We found ourselves inside a cozy living room.

 

“I’m in here!” The voice came from the first room on our left. Without knowing what to expect, I walked in with my attachment partner.

 

A table lamp was the only source of light in the room, causing it to seem shadowy. There were so many things in the room, which made it seem smaller than it already was. Various items such as boxes of medication, fruits, bags of crisps and newspapers were arranged into stacks around a bed that was pushed against a wall. On the bed sat an old lady, who beamed at us as we walked in.

 

After exchanging pleasantries, we found out that her name was Mrs. Fox and she was 80 years old. She had a magnificent head of white hair that drooped down to her shoulders. Her grey eyes seemed to twinkle with joy. Yet those eyes seemed…forlorn, as if she has witnessed a great tragedy. 

 

This woman radiated warmth and youthful energy, so much so that even the wrinkles etched into her countenance seemed to smoothen out and fade away. The smile that she was wearing was bright enough to light up the dim room we were in. Even though Mrs. Fox was bedridden, it didn’t stop her from expressively waving her arms and shaking her legs as she conversed with us. 

 

Her voice had a strong quality, which befitted her strong personality. Her voice was firm, loud, and merry. I was relieved to find that I could understand what she was saying, even though she had one of the thickest Northern Irish accents I have heard so far.

 

Despite possessing the heart and spirit of an 18 –year old, her body couldn’t be further from that age. There was swelling around her arms and legs, and evident varicose veins. She was obese, and her range of motion was very restricted. What made her immobility worse was the fact that she was hooked up to an oxygen tank, indicating the state of her respiratory system. 

 

After giving each of us hugs with strength that no one would believe she possessed, Katie and I sat down on the armchairs in the room. Mrs. Fox was delighted to accommodate and welcome us into her home.

However, even though Mrs. Fox was such a lovely individual, the negative emotions that I had prior to meeting Mrs. Fox didn’t leave me. In fact, it only seemed to get worse. It was as if all my worries and doubts I mentioned before seemed to materialize in the form of this stranger in front of me. I just wanted to avoid the difficulty of interacting with someone who was completely different, someone whom I didn’t know. I also thought that it was going to be terribly awkward if things turned emotional. So I retreated into myself.

 

During family attachment sessions, one of us would be the interviewer who asked questions, and the other would write down notes. Even though I hated writing down notes, I volunteered to do it because I wanted to avoid interacting with Mrs. Fox. I just sat in silence, mechanically writing down whatever she said. I would occasionally glance up and smile, but that was the extent of my communication with Mrs. Fox. 

 

Frankly, I don’t remember much of that session because I was so emotionally disconnected from what was happening before me.

 

Everything passed in a blur, and at the end of it all I thought was:

I’m just here to finish this assignment. I really don’t want to do this. I hope this ends soon.

 

The second Tuesday- learning how to empathize 

 

It was a cloudy day, which perfectly reflected the troubled and gloomy mood I was in as I arrived for the second family attachment session. I was already uncomfortable being here, and now it was my turn to interview and actually talk to the patient. However no matter how reluctant I was, I knew that this was inevitable. 

 

We found ourselves back in the same dimly lit room, with the same bright cheerful patient. The only difference was I would have to be the one talking. Even though it was cold, I still felt the sweat on my palms as I nervously flipped open my notebook and asked her the first question I had prepared.

 

On that fateful Tuesday I started off by asking Mrs. Fox about her past medical history. She told me that she had COPD, which explained the oxygen tank, but that wasn’t all. Mrs. Fox was recently diagnosed with chronic lymphocytic leukemia and diabetes. On top of all that she had experienced strokes, ischemic heart disease, multiple miscarriages, a total hysterectomy and depression.

 

As Mrs. Fox told me about the seemingly inexhaustible list of diseases she had, I noticed that her eyes started tearing. Her voice and her hands started to tremble. The suffering she has endured, and was still enduring is something that most people wouldn’t be able to fathom. What she has been through has certainly left a mark on her. Yet, despite all that pain, this courageous woman still had the strength to laugh and smile.

 

Although one of the worries I had was that the situation would turn emotional, I didn’t feel any discomfort or awkwardness. I just felt a sudden pang of despair for what has happened to her and all I wanted to do was to comfort her. Without realizing what I was doing, I instinctively reached over and held her hands to comfort her. She grasped mine with a strength and firmness that could have only been forged by the crucible of trials that she has been through. 

 

I didn’t know what to say. How could I convey the anguish I felt on her behalf? What could I say to make things better? I looked into her eyes and told her the only words that could adequately express what I felt. “ Mrs. Fox, I am so sorry.”

 

“Thank you.” She said, giving me a warm and gentle smile.

 

The smile she gave me was a smile that I had seen many times before. It was the same smile that my late father gave me as I held his hand while he was in pain from chemotherapy .It was the same smile that my late grandmother gave me when she had to endure session after session of radiotherapy. It was the same smile that my grandfather gave me even as his mind was degenerating due to Alzheimer’s.

 

It was the smile of someone who knew the sorrow of suffering. It was the smile of someone who knew that amidst the fiery furnace of life, there were still many good things to hold on to. It was the smile of someone who knew that even though they had to bear the burden of their afflictions, the love that they had for others, and the love that others had for them would see them through the storm.

 

At that moment it dawned upon me that suffering and pain transcended race, religion, age, culture, status or nationalities. There is no difference between any individual when faced with diseases and afflictions. Different people struggle with different kinds of pain, but the fact remains that all of us know what it means to be hurt. Because of this, all of us can identify with one another and understand each other. 

 

So, it didn’t matter that Mrs. Fox was of a different race, or age, or culture. It didn’t matter that I was a medical student, or that she was a patient. She has suffered the loss of her health and time. I have suffered the loss of my father and beloved relatives. We knew how it felt like to be in pain and agony. We were the same.

 

I no longer saw Mrs. Fox only as an assignment I had to get out of the way, or as a stranger that I didn’t want to communicate with, or as a patient that I didn’t know how to deal with.

 

I saw before me, someone I could identify with. I saw someone who has tasted the bitterness of life, just as I had.  I saw someone who never gave up, and still hasn’t given up even after all she has been through. I saw in her the face of my father, my grandmother, my grandfather, and all those who have been hurt or are still hurting. All I wanted to do was to help her in any way I could, and I wished with all my heart I had the power to take away the hurt she went through.

 

I think that Mrs. Fox understood that something changed inside of me as I retuned her smile, and firmly but gently squeezed her hand. We continued talking about her past medical history, but I realized that I just learnt something far more important.

 

Empathy: the ability to identify with another person and share their feelings. That’s what I just learned to do, to empathize with my patient. Wasn’t this one of the most important traits for a doctor to have? Although I shouldn’t pour too much emotion into each patient when I become a doctor, I should learn to place myself into the shoes of my patients and identify with their suffering.  Only then will I be motivated to provide the best care I can, for the sole purpose of helping my patients. As the good book says: do unto others what you want others to do unto you.

 

As I made my way home, my mind was still reeling from the paradigm shift I experienced. I came here thinking that there wasn’t much to learn. I have never been so wrong, in all my life.

 

The third Tuesday – learning the importance of empathy

 

The environment and the people were the same, however my attitude towards these Tuesday sessions had changed. I came on this Tuesday with an open heart and a receptive spirit, knowing that Mrs. Fox was going to teach me what I could never learn in a classroom.

 

The question that Mrs. Fox had to answer for this session was: What is your opinion on the healthcare system? 

 

It turned out that Mrs. Fox was extremely reluctant to go to the hospital, or even to the general practitioner she was registered with. She would try everything in her power to understand what was wrong with her and try to find her own solutions. Contacting the doctors was the very last thing she would resort to.

 

Naturally we wondered what has been causing such reluctance and asked her about it. Due to the myriad of medical conditions she had, Mrs. Fox has been in and out of the hospital for decades. However as the years went by, she noticed a change in the way doctors treated their patients.

 

Mrs. Fox said that the doctors many years ago treated patients with a greater sense of respect and dignity. She felt safer when they treated her, even though medical knowledge back then was nowhere as advanced as it is now. 

 

The later generations of doctors that treated her intimidated her. She couldn’t really understand what was going on because they would use medical jargon when they spoke with her, making everything sound extremely scary. What made things worse was that the doctors assumed she knew nothing about the diseases that she had. This treatment made her feel like a stupid old lady who was ignorant, when in actual fact she was very knowledgeable about her afflictions.

 

Mrs. Fox felt like a statistic. Doctors would refer to patients not by name, but by their medical problems. For example: they wouldn’t say “Mrs. Fox” in bed 14, but they would say, “ strangled ovarian cyst” in bed 14. It made her feel like she wasn’t a person, but just another case to be solved. The culmination of this impersonal and condescending treatment eventually scared her away from the hospital. 

 

“But I have my medications, my prescriptions, I am perfectly all right!” She said as she gave us her usual radiant smile. Katie and I couldn’t help but smile as well, as we hugged her goodbye.

 

However my feelings were far from happy as I reflected on what Mrs. Fox said.

My initial attitude towards Mrs. Fox was exactly the same as the doctors she disliked: She was just another case, another assignment I had to get out of the way. It worried me that I saw another human being only as a box I had to tick off my to-do list.

 

This made me realize the importance of empathy. Doctors have to deal with so many cases and patients every single day. So much so that patients are at risk of being categorized as “chores” or “tasks” that have to be finished up. I’m just a medical student and I’ve already experienced treating my patient as an assignment I had to complete. What was it going to be like when I will deal with dozens upon dozens of patients every single day?

 

What was going to prevent me from committing the same mistake? Empathy.

 

Being able to identify with my patient and view things from their perspective will remind me that every patient that comes to me for help isn’t a disease but a person. A person who has feelings, who has worries, and who is in need of my help.

 

With this reminder, I will be able to treat my patients with the respect and consideration that they deserve. I won’t carelessly use medical jargon when speaking with them, because from their point of view it is scary. Patients are more than just their disease. I won’t refer to patients according to their medical conditions, but by name. I won’t treat my patient like a lifeless statistic or a mundane duty, but I will treat them as a person, addressing their concerns and insecurities.

 

Knowing that I am human, vulnerable to committing errors in patient-doctor helps highlight the importance of empathy. Possessing empathy will be crucial in allowing me to assess how I treated my patients and learn from my mistakes. This was certainly food for thought, and it kept my mind chewing for quite a while.

 

The fourth Tuesday- learning the importance of support 

 

“Who lives in the pineapple under the sea? SpongeBob Squarepants!”

 

Those were the words that greeted Katie and I as we arrived for our weekly meet-up with Mrs. Fox. The television in the living room was displaying SpongeBob in all his glory, which puzzled me since Mrs. Fox can’t leave her room.

 

The answer to my bewilderment came in the form of a 5-year-old boy, who was sitting in front of the television.  He was so motionless I didn’t notice him at all!

 

As Katie and I greeted Mrs. Fox and sat down, I asked Mrs. Fox who that young boy was.

 

“Oh, that’s just my grandson! My two sons came by to take care of me for the day and deliver my favorite crisps to me!” She said with a gleeful smile. “They just left to do a bit of shopping. They should be back any moment now!” At that exact moment the doorbell rang. ”That must be them now” she said as she buzzed them in.

 

Two big burly men came into the room holding massive bags of groceries. They each cracked a smile identical to the one Mrs. Fox has. There was no denying that they inherited it from her.

 

“Is my mum giving you any trouble? She’s getting a bit old now, might be a bit senile.” The first son said, with a mischievous twinkle in his eye.

 

“Yea, off her rocker these days” the second son added, chuckling to himself.

 

“Get out of here ya wee brats!” Mrs. Fox told them as she doubled-over in laughter. They walked away, leaving Katie and I laughing just as much.

 

Mrs. Fox told us that she had 9 children: 4 sons and 5 daughters, all of whom took turns taking care of her or just keeping her company. It was apparent that she had a very close relationship with her children from the way she interacted with her sons. Dozens of pictures displaying her children, grand children and great grand children emphasized the love she had for her family.

 

Coincidentally, for this session we discussed the source of Mrs. Fox’s support during the hardships she experienced. Unsurprisingly it turned out to be her family.

 

On top of the seemingly inexhaustible list of diseases and the miscarriages she had, Mrs. Fox told us that one of her daughters passed away at the age of 8 from leukemia. The loss of her husband at the age of 63 made the situation look bleaker than it already did.

 

When Mrs. Fox felt like she couldn’t go on any longer, her family was always there to support her. For all these years they have stood by her, encouraging her, loving her. They would joke around with her, helping her laugh even when she knew that the worst was yet to come. They would keep her company, allowing her to hold on to hope when she felt like the clutches of despair were too strong. At times when Mrs. Fox felt like all was lost and she was about to give up, all she had to do was remember the faces of her family members.

 

The love that Mrs. Fox’s family has for her can only be described as steadfast. Becoming bedridden didn’t deter her family from assisting her; in fact it only served to increase the concern and care her family provided. The children made sure to visit her in turns, ensuring she wasn’t alone. Even the grandchildren were involved. One of her grand daughters constantly drops by to help Mrs. Fox clean the house.

 

Whenever Mrs. Fox needed something form a store, there would always be one of her children available to help her get it. No matter how busy her children were, they always took the time to ensure she had everything she needed.

 

With such a loving and caring family, no wonder Mrs. Fox always had a reason to be joyful amidst such trying circumstances. Mrs. Fox couldn’t contain the happiness she felt when she spoke about her family. She enthusiastically told us the names of all her grandsons and great- grandsons as well, showing us their pictures, telling us the Christmas gifts she planned to buy for them, grinning and laughing while she did so.

 

Seeing the strength Mrs. Fox received from having such a loving family, made me realize how important it is for a patient to have pillars of social support that they can fall back on.

As a future doctor it is imperative that I learn to identify the physical disorders of patients. However it is also important I find out if they do have any form of social support. That’s why in history taking sessions from patients medical students are required to ask if the patient is living with anyone or if they are receiving any form of support.

Possessing a strong form of social support has a profound impact on the attitude of a patient. Mrs. Fox and her family perfectly illustrate this statement.  Having such an encouraging form of social support has prevented her from giving up in the face of adversity.

The attitude of a patient towards his or her illness greatly influences the outcome of treatment. If a patient has a positive attitude and is determined to do everything possible to get better, this greatly increases the likelihood of recovery. Conversely when a patient looses hope and gives up, there will be detrimental effects on a patient’s health.

Having a close form of support helps ease the burden of a patient. Mrs. Fox can’t perform daily tasks because she is bedridden, but her family helps take care of everything she needs. Having an intimate network of caregivers also ensures a patient’s safety. If an emergency occurs and the patient is unconscious, there will be someone available to get appropriate assistance.

Besides thinking about the importance of social support for patients, witnessing the loving dynamics of Mrs. Fox’s family reminded me of my own family back in Malaysia. Being part of a family is one of the greatest blessings I have ever had. Knowing that there are people who genuinely love you just as much as you love them is one of the greatest gifts of life. It made me miss my mum and my sister more than I already did.

Upon returning home that day, the first thing I did was pick up the phone and call home.

The final Tuesday – learning the importance of thankfulness.

 

I’m just here to finish this assignment. I really don’t want to do this. I hope this ends soon.

 

Those were the words that crossed my mind when I first visited Mrs. Fox.  At that time, the final visit was what I was looking forward to. I thought it would bring me relief, signifying the release from a commitment I didn’t want.

 

And yet here I was, entering Mrs. Fox’s room for the final session, and all I wanted was more time. I didn’t want this to end. During these past few weeks, I have not only enjoyed the company of a wonderful person, but I have learned how to be one as well. Mrs. Fox has taught me what no lecturer could, making me a better person without even meaning to.

 

How ironic. I was reluctant to come, and now I was reluctant to go.

 

The atmosphere in the room was as gloomy as the clouds outside the window.

My heart was heavy as I sat down and looked at Mrs. Fox.  Her brilliant smile seemed to be dimmed by the sadness she felt. Looks like I wasn’t the only one who was reluctant to say goodbye.

 

Katie and I decided to ask Mrs. Fox if she had any advice she would like to give us, anything she thought would help us in the future.

 

Mrs. Fox looked into the distance, furrowing her eyebrows as she did so. After carefully considering the question, she finally said these words:

 

“Always be thankful. No matter how bad the situation looks, there will always be something to be thankful for.”

 

Life hasn’t been easy for Mrs. Fox. She told us there were days where the darkness of life seemed to envelope her, eliminating any glimmer of hope. There were days where the harsh reality she had to face threatened to push her sanity beyond the point of no return.

 

It was during those moments that Mrs. Fox learned the importance of counting her blessings and being thankful. When she started to do that, she realized although there may be monumental difficulties, there are still many good things in life to be grateful for. Being grateful changed her outlook on her current situation. The obstacles she faced seem less daunting, knowing that there is more to life than her problems.

 

The first among many things Mrs. Fox gives thanks for, is her family. She has a loving family that unconditionally loves and supports her. They cook for her, clean her, and tidy up her house. Without them she would have to be moved to a care home.

 

 

Mrs. Fox feels thankful that being bedridden has not limited her access to healthcare. Her general practitioner and respiratory nurse regularly call to check on her. All the medications she needs are delivered to her by the pharmacy. The district nurse comes to her home every Thursday to make sure Mrs. Fox is all right. The nurse takes a blood sample at the end of every month for hematological examinations and the Belfast City Hospital Hematological department will review the results with her over the phone.

 

She feels that she is extremely well cared for. If she needed help at anytime it was just a phone call away.  The hospital, the nurses, her family and even the social care workers could be contacted at anytime.

 

The house she lives in, the food she eats, the clothes she has, Mrs. Fox is thankful for all of it. 

 

What Mrs. Fox said convicted me. When I do come across problems, all I do is complain and grumble. When a complication occurs it becomes my focal point, and the only thing I feel is irritation.

 

My problems are so petty in comparison to what Mrs. Fox is facing. Whatever I have faced is trivial compared to the catastrophes she has had to deal with. However she has learned how to be thankful in whatever situation she is in and I haven’t.  Shouldn’t I, a healthy young person be doing that more readily?

 

I think that this does not only apply to me, but to most of the people in generation Y and Z. We do not know how fortunate we are. Possessing health, shelter, food, peace, families and an education seems to be taken for granted. At the slightest hiccup we feel as if we have lost the world, when we actually have so much.

 

We do not realize that many of the things we get, are privileges that less fortunate people do not get to enjoy.  We have so much to be thankful for, and yet we are blind to it. It is time that we learn to see that, and be content with our allotted portion in life. Contentment will allow us to be joyful, even when we encounter difficulties along the way.

 

The sunlight that entered the room grew progressively dimmer, and I realized that it was time to go. Mrs. Fox knew it was time to part ways as well. All of us just sat in a comfortable silence for a few moments, enjoying each other’s company.

 

In that momentary lull of conversation, I felt so thankful that I was a part of a life-changing experience. I started off this family attachment scheme with a heart of stone, hardened by my own fears and concerns. Mrs. Fox gently brought down the inhibitions and walls I built around myself. She taught me about empathy, love and thankfulness. She taught me how to become a better doctor and more importantly, a better person. 

 

Inevitably all good things must come to an end, it was time to go. Katie went to say her goodbyes to Mrs. Fox before I went up to Mrs. Fox to hug her goodbye. Her eyes were moist with tears even though she was doing her best not to cry. I gently held her shoulders and gazed into those wise grey eyes as I thanked her from the bottom of my heart.

 

“Thank you Mrs. Fox”

 

“What for dear?” she asked, with a slight tremble in her voice

 

“ You have taught me so much, changed me without even knowing it. You made me a better person, helped me realize how to become a better doctor, and its people like you that inspire me to study medicine. So thank you Mrs. Fox, because I thought I was here to know more about helping patients, but you helped me.”

 

Mrs. Fox smiled while wiping away the tears she couldn’t hold back. She hugged me for as long as she could before kissing me on the forehead. 

 

I smiled at her for the last time, leaving behind a part of me in the dimly lit room I so reluctantly stepped into weeks ago.

 

Where do I go from here?

 

After my encounter with Mrs. Fox, the mindset that I have when I approach patients has changed in a few ways:

 

A heightened sense of awareness

This refers to an awareness of how a patient thinks and feels. 

 

I knew that it was important to be conscious of how the patient views the doctor-patient interaction. However this was just head knowledge. The inconsiderate words and actions of doctors was what drove Mrs. Fox away from hospitals. This made me realize the enormous amount of influence a doctor had on a patient’s emotions.

 

Sometimes medical professionals approach a patient only looking for the pathological problem. This focus makes it easy to forget that a patient is more than their disease. Only honing in on the biological problem without a consideration of how the patient feels and thinks can cause the patient to view the doctor- patient relationship as cold and impersonal.  As Mrs. Fox has mentioned sometimes patients can feel as if they are just a statistic, treated as a task rather than a person. 

 

The patient can feel intimidated. If a patient is already worried about a disease, this cold and distant treatment, with a pure focus on the disease will only aggravate the patient’s consternation.

 

Witnessing the effect that doctors had on Mrs. Fox will be a constant reminder to view any situation from a patient’s perspective. This will allow me to carefully consider how my words and body language are affecting my patient. Hence, my patient won’t feel scared or distant, only the warmth that comes from a human touch.

 

Humility

After reflecting on my attitude I had when I first met Mrs. Fox, I realized I was quite prideful. I didn’t think that meeting a patient had anything to offer me, and that the family attachment scheme was a pointless waste of time. 

 

My pride hardened me to the point where I didn’t even consider the amount of suffering Mrs. Fox may have been through; all I cared about was finishing my assignment. Hearing about the crucible that Mrs. Fox has been put through, made me realize how disrespectful and prideful I was. After adopting a more receptive and humble mindset I managed to learn so many things form her.

 

So the next time I approach a patient, I will do so with respect and humility. They may be walking through, or have walked through the valley of the shadow of death and have many things to teach me.

 

Equal treatment

The main reason I was uncomfortable with meeting Mrs. Fox was because she was so different from me. She was of a different age, a different race and of a different culture. This difference made me think that interacting with her would be too difficult. As it turned out, I managed to connect with her just fine.

 

What I learned is that I shouldn’t let any pre-conceived notions I have about a person affect how I treat him/her, especially if it’s my patient. I shouldn’t be too quick to jump to conclusions about a person, because I can be completely wrong.

 

 A doctor has to help everyone equally, regardless of age, race, culture or religion. If I met my patient for the first time and judged him/her based on appearance or any other characteristic, this might affect how I treat that patient.

 

I shouldn’t focus on the differences between my patients and myself, but view them as a fellow human being who needs my help, and treat them as such.

 

How future medical training might enhance the state of awareness in medical students.

 

 

 Workshops instead of lectures 

 

In my university there were quite a number of lectures about patient- doctor interactions. They were very good, but I think workshops that actively engage the students would be more beneficial.

 

During a lecture, all that a student does is sit down and listen. Most of the time the information is not processed because there is no active thinking involved. In a workshop with activities such as poster presentations and discussions, the active involvement of medical students will allow the information to stick.

 

Attachments 

 

The family attachment scheme I participated in was a great way to learn about a patient’s experience. However I felt that it was too short, a few additional weeks would have definitely helped paint a more complete picture of Mrs. Fox’s life.

 

Perhaps attachments should also be done with patients who are located in the hospice or a care home. The experience of patients in those locations would be different from someone living in their own home. This will help medical students witness a variety of patient experiences.

 

Patient-conducted sessions

Another way we can change medical education in the future is by receiving suggestions from patients. They would be the ones with the best ideas about how to raise the state of awareness of medical students, because they are the ones who are on the receiving end of health care.

 

Lay people who have been patients could be invited to view how patient awareness sessions are conducted, and they could be asked to give feedback. Meetings between medical education staff and a selected group of such reviewers could be arranged to discuss improvements in this area. Online forums could be created for anyone to give suggestions at any time. Suggestion forms could also be given out to patients who are willing to fill them out. 

 

 

 

My First Prescription: The Power of Words, Uncertainty, and Reflection

Khloe Frank

 

For first year students at the University of Washington School of Medicine, the Introduction to Clinical Medicine course is a welcome reprieve from the natural sciences that dominate the rest of the schedule. In this class, we learn about how to interact with patients, and we practice doing patient interviews at the local hospital; essentially, we get to focus on the aspects of medicine that made most of us want to become doctors in the first place, which are sometimes forgotten amidst the hours of memorizing G-protein pathways and examining slides under a microscope. For the patient interviews, we are assigned to small groups with mentor doctors who read our interview write-ups and give us feedback. They advise us on how to ask difficult questions, deal with challenging situations, and be efficient in our time with the patients.

One Tuesday morning in December, after a late night of studying for first semester final exams, I was rather tired and feeling envious of my classmates who were not in Interview Group C and would have the luxury of sleeping in. Recalling the excitement I had felt the morning of my very first patient interview, I tried to channel that enthusiasm. This was my fourth practice interview, however, and I was becoming somewhat disenchanted with the routine of bombarding these patients with such an exhaustive list of questions without being able to benefit them in a noticeable way. For this day’s interview, we were adding the Review of Systems section, which brought the total list of questions to around 50 or more.

 

Nevertheless, I put on my white coat, grabbed my pen and notepad, and walked the two blocks from my apartment to the hospital. The nurse organizing our interview assignments gave each student a slip of paper with a patient’s name and room number, and I headed to the sixth floor to find my patient, Sarah (whose name has been changed here to maintain confidentiality).

 

Sarah’s room was dark when I entered, but she was lying in her bed awake. I began introducing myself as I washed my hands at the sink. “Hi, are you Sarah? My name is Khloe, and I am a first year medical student. Are you still willing to do a patient interview with me this morning?”

 

“Oh yes,” replied Sarah. Noticing that I was standing at the sink, she pointed toward the corner of the room and suggested, “You can pull up one of those chairs over there.”

 

I asked Sarah if she was comfortable, and she assured me that she was. Then I briefly explained that our interview would be confidential, and that although some details would be shared and discussed with my student group, Sarah would remain anonymous. Finally, we began what would become a lengthy interview that would take me in a direction I had never been before.

 

I started with the typical question, “What brings you to the hospital today?”

 

“Well,” Sarah said, “I have lung cancer.” I felt myself come to attention at the mention of cancer, as I am considering a career in oncology. I had yet to interview a patient with cancer in this hospital, and we were on the pulmonary floor, so I had not expected that this would be the day. Yet here I was, sitting beside a woman who was coping with a disease that I actually knew a little bit about, and which I was extremely interested in coming to understand further. I looked at Sarah more closely in the dim light, and saw that she was very thin, although I had hardly noticed it at first because her personality was so robust.

I waited for Sarah to go on. “I have some lumps in my lungs, and they metastasized to my brain, too.” She paused as I wrote a few frantic notes to catch up. “So I had surgery with the gamma knife to get those, and now I am doing chemotherapy to help with the rest.” I nodded in acknowledgement as I added these details to my notepad as well.

 

“You know, I’m almost 82 years old,” Sarah exclaimed suddenly, “but I take care of everything. My husband has dementia, so I’ve spent the past 10 years caring for him – doing all of the driving and all of the work around our house.”

 

“Wow,” I replied, “that’s very impressive.”

 

Sarah continued, “But I had to come to the hospital after the chemotherapy because I was feeling so bad . . . well, it wasn’t the chemo actually; it was the anti-nausea medication that they made me take.” She sounded almost apologetic about having to leave her husband to come to the hospital. I made a mental note to ask more about Sarah’s home life later, but I was already getting a picture of a woman who was capable and selfless despite her age and ailments. She reminded me of my grandmother, a woman I very much admired. For the moment, however, I wanted to find out why the anti-nausea medication had brought Sarah to the hospital.

 

“Can you tell me more about that?” I prompted.

 

“Well, after the gamma knife surgery, I started chemo. I guess the surgery had to be first . . .” she drifted off, seemingly trying to remember why.

 

“When was the gamma knife surgery?” I asked.

 

“Let’s see,” Sarah began counting backward until she concluded, “about a week and a half ago.” I wrote that down as she continued, “And then I started the chemo last week, on Wednesday. They gave me the chemo and some anti-nausea medication through the IV because I didn’t have a port yet. I’m supposed to get that on Thursday, I think . . . but I’m not sure if they’ll still be able to do it now that my blood is clotting too much. I don’t know; maybe they will do the chemo by IV again.” I continued making notes as Sarah explained, “Anyway, the doctor told me that I would need to take an anti-nausea medication on ‘Day 4’, which I thought was three days after the chemo since the day of chemo should be ‘Day 1’, but my daughter thought that would be ‘Day 0’. Turns out I was right, so I was supposed to take the anti-nausea medication on Saturday.” I hurried to jot down all of these details so I could organize them later, and in the midst of this mess of scribbling, I found a brief moment to marvel at Sarah’s ability to keep track of so much despite all that she had been through so far.

 

Sarah waited for me, and then went on, “My first doctor told me to take the anti-nausea medication on Saturday no matter what, even if I was not feeling nauseous. But I felt fine, so we called in to ask, and the doctor on-call said I didn’t have to take it if I felt okay.” I was beginning to get the sense that Sarah had talked with many different doctors over the past few weeks and had not had more than one or two encounters with a single one.

 

Sarah forged ahead, “Well, I generally don’t like to take medication if I don’t need it, so after talking to the on-call doctor, I didn’t want to take the anti-nausea medication . . . but my daughter was very worried, and she thought I should do what the first doctor said. So I took it. And that was where my problems began.” It amazed me that even amidst the challenges following her cancer diagnosis and her confusion over the treatment plan, Sarah seemed more focused on easing the worries of those around her than concentrating on her own problems. Later, when I asked Sarah what her greatest stressors were as part of the Social History questions, she told me “I worry about my family worrying about me. Other than that, my life is good.”

 

“So what happened after you took the anti-nausea medication?” I prompted.

 

Sarah told me that she had become constipated and had severe cramping in her abdomen, making it difficult for her to eat. She also had begun to feel sick and dizzy, so the next day (Sunday), she went to the Emergency Room. A CT scan showed that Sarah had developed blood clots in her lungs, and she was admitted to the hospital to be treated for that. She was also given hydration and stool softeners, and one day after admission, the cramping ceased and Sarah’s appetite returned. Two days after admission, on the day of my interview with her, Sarah was told that her blood work looked good and she would be released in the afternoon. I was glad to hear that she was feeling much better.

 

“Well, thank you for that information; it is really helpful,” I said, preparing to get a few more details and clarifications in order to complete the chronology of her History of Present Illness. “Can you tell me now about how you were first diagnosed with cancer?”

 

“About two months ago,” Sarah recalled, “I went to my primary care doctor because I had lost a lot of weight . . . I probably should have gone in sooner, but I was busy taking care of my husband and playing the organ at church functions, so I didn’t.” Sarah told me that CT scans had revealed a large primary tumor in her right lung, with small nodule metastases to her left lung, and “19 small lumps” metastasized to her brain. She told me about an awful episode of hyponatremia that had brought her to the ER shortly after this diagnosis, attributed to hormonal abnormalities caused by her tumors. Somewhere along this train of thought, as she described how terrible she had felt during the hyponatremia, Sarah reassured me, “I’ve had a very good life, though. I am happy with how it has been.” It sounded like she had thought about this deeply and these were her genuine feelings, which made me glad for her.

 

Back when I had been preparing for medical school admissions interviews, particularly the challenging role plays that are notorious at the University of Washington School of Medicine, I decided to learn more about how to give supportive end-of-life care. I found a video of a lecture by the renowned cancer surgeon Dr. Atul Gawande (author of Complications: A Surgeon’s Notes on an Imperfect Science), in which he explains that initially, he was not very good at talking with patients about end-of-life care. Therefore, Dr. Gawande sought out a doctor who was more adept with these situations and asked her to summarize the most important topics to cover. They came up with a list of four questions to ask and discuss with each patient:

1) Do you know and understand your prognosis?

2) What are your goals for things that would you like to do as time runs short?

3) What are your fears about what is to come?

4) How much are you willing to compromise, enduring additional suffering for the possibility of added time?

 

In the video, Dr. Gawande emphasizes that these questions should not merely be discussed in a single meeting, but rather be addressed repeatedly as part of a continuous conversation throughout the provision of end-of-life care. So far in my studies, this was the only concrete training I had experienced regarding end-of-life care. It seemed like a valid method to me, both for informing how best to support and treat patients through this difficult time, and for evaluating how they are coping with their disease and prognosis. I recognized that, as a student, I would mostly be doing the latter, but I thought it was important for understanding Sarah’s health. So I started working on question 1.

 

“Do you know what type of cancer you have?” I asked Sarah.

 

“No,” she said, sounding surprised, as if she was realizing this for the first time. “I don’t remember them telling me that.”

 

“Well,” I offered, “You might want to ask your oncologist at the next appointment – Thursday, right?”

 

“Oh yes,” Sarah nodded, “I should ask her that this Thursday.”

 

“Okay,” I continued, “Did your oncologist tell you if your cancer was curable or treatable? Did she talk about the difference?”

 

“No,” Sarah said, sounding surprised again. “But that sounds important.”

 

“Okay,” I replied, “That might be another good thing to ask your oncologist on Thursday.” I tried to keep my tone very nonchalant and non-judgmental so that Sarah would not feel panicked as we started to uncover how much she did not know about her condition.

 

When I asked Sarah if she had discussed her fears and goals with any of her doctors yet, she told me again that she was very content with how she had lived her life. She just wanted to spend the time she had left enjoying her family. Sarah said she had very few major concerns, but she reiterated that she was mostly worried about her children worrying about her, and she also realized suddenly that she needed to finalize her legal affairs. 

 

“Alright,” I said, “Maybe you can start working on that stuff when you are out of here and feeling better. But it sounds like overall you have things figured out pretty well and you’re very content. Is that accurate?” Sarah nodded.

 

I then transitioned into some of the questions for the Past Medical History section. We talked about Sarah’s history of immunizations, preventative medical screenings, surgeries, and major illnesses. Then I moved to some questions about her health habits. She did not smoke or drink alcohol. When I asked about her diet, Sarah told me that she did not eat much meat. “Do you think I am getting enough protein, especially now that I am undergoing chemotherapy?” Sarah asked me, “And are there foods besides meat that I can eat to get more protein?”

 

At this moment, it became clear that in the process of having to do a complete interview with Sarah and cover all of the mandatory topics, we were bound to come across even more unanswered questions regarding Sarah’s current health, treatment plan, and prognosis. The great irony of being a medical student, I began to realize, is that you often have the unique opportunity to spend an almost unlimited amount of time with patients – getting to know them and the details of their health in extreme depth – while simultaneously being severely limited by a lack of medical expertise.

 

Looking at the small, kind woman shrouded in the linens of the hospital bed before me, I wondered if she would remember any of her mounting list of questions on Thursday. I knew that first year students were not supposed to give medical advice without supervision, and I was very aware that I did not know enough to even want to try to give Sarah medical advice or educate her about cancer or nutrition. But I wanted to do something to facilitate some continuity in her care so she could get answers. I felt isolated from Sarah’s healthcare team – her primary care provider and her various oncologists. As far as I could tell, my interaction with Sarah was limited to this one session of just the two of us. Then suddenly, an idea popped into my head.

 

“You know what, this is getting to be a lot of questions,” I said, flipping to a blank page at the back of my notebook, “Let me write them down for you as we think of them. Then you’ll have a list all prepared to ask your oncologist on Thursday so you don’t forget.”

 

“Oh yes,” Sarah responded, “that would be great.” As I began to write out the questions, Sarah suddenly noticed how dark the room was. “My goodness,” she said, leaning up on one arm to reach the control panel for the lights, “You have been writing in the dark!” She hit the button, and the room filled with light. I had not wanted to disturb the relaxed atmosphere and trouble Sarah with turning on the light, and she refused to allow her weakened state to prevent her from making my task easier; in that moment, I felt a connection with Sarah, recognizing our shared instinct to hold the comfort of others above our own.

 

As we made our way through the questions of the Social History section, Sarah and I came across several more questions for her to ask her oncologist. Mostly, Sarah wanted to know more details about how her prognosis and treatment plan would affect her ability to enjoy time with her family. Seeing as I was just as ignorant as Sarah regarding many of these issues, it began to feel like we were partners on the same quest – both striving to better understand Sarah’s situation. It reminded me of an article I had read in the Introduction to Clinical Medicine course, which portrayed the patient interview as a “joint construction of narrative” in which the doctor and patient collaborate to co-author an account of the patient’s experience of illness. This process begins when the patient shares their perspective with the doctor, telling the story of why they came to the hospital and why they are worried about their health. The doctor identifies missing pieces and unanswered questions in the patient’s narrative, and then offers information that allows the patient to improve their story and make better sense of what is happening to them. In this way, the patient and doctor together create a more accurate account of the patient’s experience of illness. They construct a joint narrative. I felt like I was doing that with Sarah, except that instead of directly offering her information, I was offering her a way to identify the information she needed so that she could get it from her oncologist later.

 

In asking about her Social History, I also discovered that Sarah had spent her life teaching people to play the piano and organ, that she loved her church and had strong support from her network of church friends, and that visiting with her two-year-old granddaughter was a huge highlight of Sarah’s life at this time. These details about Sarah made her even more endearing to me.

 

Just as I was finishing the last section of questions, the Review of Systems, Sarah’s breakfast was delivered to the room on a cafeteria tray. “Oooh, would you mind bringing that over to my bedside table?” Sarah asked me, clearly excited. “I just got my appetite back yesterday, and I am so hungry!” I brought the tray over, and a nurse who came in right at that time helped me move the bedside table to where Sarah could comfortably reach it. Her deep gratitude for this simple act made me feel certain that Sarah rarely allowed others to do things for her.

 

Looking at the clock, I suddenly realized that our interview had been going on for nearly 90 minutes, and I was getting tired. I could not imagine how exhausted Sarah must have been. There were a few more questions I could have asked to be thorough, and I am sure that Sarah would have held off from eating for a few more minutes to help me get all of the information I needed. But I had a sufficiently complete interview, and when Sarah asked me if we were almost done, her voice sounded so hopeful for this to be the case that I could not help but smile and say, “I think that’s actually everything, Sarah. Thank you for volunteering to do this! It is such an important part of the learning experience for us students.” I flipped to the back of my notepad and ripped off our page of questions, “And here is this.” I handed it to her.

 

“Thank you,” said Sarah, “You are going to be a great doctor.”

 

I felt very flattered by this comment. Due to the singular nature of the student-patient practice interview relationship, I then said what I knew would be my last words to her, “Thank you, Sarah. Take care of yourself!” I think I meant that more sincerely that I had perhaps ever before. Take care of yourself, I thought, don’t worry so much about everyone else. 

 

I walked back to the assignment room to summarize my interview experience for the nurse who gave out the assignments, and as I walked, a feeling of warmth surged through my body. Sarah’s medical condition was sad, but her spirit was not. I was so glad to see that she had come to terms with death, that she was satisfied with the life she had lived, and that such a sweet person was at peace with the world in the face of fighting cancer. For the first time, I felt like I had actually helped a patient during one of the practice interviews. I had finally been a part of the joint narrative that we discussed in class. Little did I know that I also had just given what could be considered my first prescription for a patient: a sheet of paper that offered hope and provided a sense of direction – a treatment of words.

 

As Thursday approached, I thought about Sarah’s upcoming appointment with her oncologist. I still felt good about having been able to ensure some continuity of care and help Sarah organize her thoughts, but I also began to feel a bit uneasy about the sheet of paper with the questions. I had given it to Sarah, and it was now completely out of my control. What if her oncologist was insulted by the fact that a first year medical student had given Sarah these questions to ask? What if the oncologist had already discussed these issues with Sarah and thought that I was getting involved in places that I should not? Were my actions unprofessional? Had I overstepped my role as a student?

 

Each semester, the first year students get to do a clinical preceptorship. My first preceptorship was in Hematology/Oncology, which meant that once a week, I got to spend a few hours in the afternoon working with a medical oncologist as she saw patients. As a first year student with minimal knowledge of the field, I had a unique solidarity with the patients in that our perspectives of these interactions were similar; both the patients and I were unfamiliar with terms and concepts that the oncologist used every day, and both the patients and I depended on the oncologist to give us a picture of what lay ahead. As a student, I was able to talk with the oncologist after each appointment, getting answers to questions that had not been addressed and clarifying points that had been confusing. The patients, however, were not privy to these discussions, and sometimes I felt like the stories we had created with them were left incomplete. On the other hand, I had a very limited view by only participating in a few appointments every week, making it difficult to determine whether these unfinished details were neglected indefinitely or addressed at times when I was not present.

 

Most of the patients I saw came to the oncologist to receive chemotherapy, so we would look at their blood work and talk with them about how the past week or two had been before deciding whether or not they could endure another round of treatment that week. We also had patients who came in to see the results of a scan after a couple months of treatment, and we often had the pleasure of telling these patients that their cancer was under control and that they could stop treatment for the time being and go enjoy life.

Then there were the patients who had a little “N” marked next to their names, meaning “new patient.” Interactions with these people were often challenging, but not in the way I originally anticipated. For a few patients, the news that they had cancer was a complete shock, totally overtaking their composure and blocking their ability to process anything we said beyond the diagnosis. This was the scene I had expected. Most new patients, however, had already either been diagnosed with cancer at a hospital or had the possibility suggested by their primary care provider before being referred to us. In these situations, the most challenging aspect seemed to be giving them the most pertinent information in the short time we had together, as their lives were thrown into utter chaos. These patients usually needed to start treatment right away, and many of them did not live in the city; thus, the appointment time was spent discussing the treatment procedure and plan, referrals to surgery or radiation oncology, housing, transportation, and other logistics. The oncologist often told them whether their cancer was curable or treatable, but sometimes it did not seem that the patients understood the nuances of this vocabulary to the extent that we did.

 

Often, we did not have time during these appointments to delve into discussions of the kind that Dr. Gawande had recommended in his video, even with our patients who had terminal cancer. Most surprisingly for me, the patients hardly ever initiated these conversations when we failed to do so. I did not know if this was because they did not want to discuss these matters with us, because they were in denial, or because they did not understand their prognoses. The oncologist frequently would make implicit comments like, “Go home and enjoy some time with your family,” or, “This is your vacation week from chemo; go do something you love!” It was often unclear to me, however, if they had more direct conversations about end-of-life priorities at appointments for which I was not present, or if they never had these conversations at all. Perhaps they did not need to in some cases, as patients may have preferred to seek out religious leaders, family members, and friends for these emotional conversations. As a first year student who had observed only snapshots of clinical medicine and grasped only bits and pieces of the methods for the practice of medicine, it was difficult for me to discern the best action for a doctor to take in a given situation. I spent a fair amount of time puzzling over this predicament of uncertainty, wondering if there even was a truly “right” thing to do in these situations and if my actions for Sarah had been right. There was nothing more I could do at this point, however, so I tried to move on. I busied myself with the write-up of my interview with Sarah.

 

Three days after I submitted my write-up online, I received written comments from my mentor in the interview group, Dr. S. She complimented the strong aspects of my write-up, made some suggestions for ways to improve, and then noted that in light of my tendency to build strong rapport with my patients and conduct a patient-centered interview, it was likely that patients would continue to share their unresolved questions and concerns with me. Dr. S suggested that we meet to discuss strategies for dealing with patients who bring up resolved issues, as Sarah had. We set a date to meet after final exams were over.

 

A week and a half later, after being tested on cell physiology, histology, and human behavior, I walked downtown to Dr. S’s office, unsure of what awaited me. I had gotten the sense that she genuinely admired my compassion for the patients, but I also felt that she was going to tell me that there was something wrong about what I had done for Sarah. I could not express exactly why I felt this; I could not think of a specific rule I had violated, nor could I think of an alternative action that I clearly should have taken. In my gut, however, I had felt some discomfort with my actions when reflecting on them after my interview with Sarah. Maybe there was a better way to accomplish my goal of helping Sarah address her unresolved questions and concerns so that her treatment and the remainder of her life could be as good as possible for her. I hoped that Dr. S’s strategies would allow me to achieve this for future patients.

 

Dr. S welcomed me into her office and started by clarifying some of the medical inconsistencies she had noticed in my write-up about Sarah. For example, it was unlikely that all 19 of Sarah’s brain metastases had been targeted and destroyed, even though Sarah had told me that the gamma knife surgery was “successful” and that she thought that meant that all of her brain tumors were gone. This was a common situation that I had encountered before: often times, patients have an inaccurate understanding of their disease, and it is not clear whether this is due to poor explanations by the healthcare team, confusion and misunderstanding on the part of the patient, or a combination of both. One time a patient had confidently told me that his doctor had diagnosed him with a damaged disc of the “T14” vertebra, when I had just learned in Anatomy that the thoracic vertebrae only numbered up to 12. Another student in my interview group had once had a patient tell her that she was in the hospital for a stroke; as they began going through the patient’s symptoms and treatment regimen, however, the student realized that the patient had actually had a heart attack. Because our patient interviews were just for practice, we never saw the patients’ charts or talked with their care teams; we simply reported what they told us and what we observed. As Dr. S explained a few more inconsistencies in Sarah’s report of her disease, I realized that my sense of Sarah’s lack of understanding and limited continuity of care may have been on target.

 

Next, Dr. S showed me some statements that essentially described what I had done for Sarah. They were excerpts from the handbook for third year medical students in the Family Medicine rotation, describing how the medical student should work with the patient to create an appropriate treatment plan while focusing on the patient’s unique needs. We had received a lecture on the “patient-centered interview” in the Introduction to Clinical Medicine course, and the professor of the Human Behavior course had taught us about motivational interviewing. I suddenly realized, however, that we had been introduced to these concepts without fully being taught how to do them proficiently and how to identify when we should or should not incorporate these ideas into our interactions with patients. I had felt very inspired when learning about the patient-centered interview and motivational interviewing, so it seemed natural that I wanted to incorporate these concepts into my approach to medicine. Dr. S acknowledged this, but went on to say, “Do you see how, in the act of writing these questions for Sarah and giving them to her on a sheet of paper, you essentially gave her a prescription? Do you see how you treated her with your words?” I thought about this and then nodded in agreement.

 

The problem was, I was not a third year medical student. I was not part of a medical team, and Sarah was not my patient for anything beyond our 90 minutes together for the interview. “Words are powerful,” Dr. S emphasized, and we discussed some of the unintended consequences that could have resulted from my actions, many of which I had already imagined in horror. Dr. S assured me that the worst I could have done was insulted and annoyed Sarah’s oncologist, and that my actions were not likely to harm Sarah in any way. This made me feel lucky, as I had this opportunity to learn from a mistake that was not costly for the patient. I felt driven to improve my professionalism in order to better uphold the honor and privilege that comes with wearing the white coat.

 

Dr. S helped me see that I was headed in the right direction by focusing on the patient’s needs during the interview, but that I still lacked some of the skills and knowledge that a third year student needs to be effective. More importantly, I was not a steady member of the healthcare team, as third year students are. Dr. S helped me see that in any given situation, I need to assess my role in the greater context of the medical team and the healthcare system. I need to consider the repercussions of my actions. In my interaction with Sarah, I had been there as a student to practice interviewing her.

 

“So what should I do, then,” I asked, “to address Sarah’s needs without overstepping my role as a first year student and drawing out unintended consequences with my involvement?” Dr. S offered some examples of alternative actions I could have taken. I could have checked with Sarah to see if her oncologist had given her a notebook or handbook with a page for questions and then suggested that she write down her questions as we discovered them. Another option would have been to find a nurse on the pulmonary floor, tell her that my patient had many unanswered questions, and ask her what the hospital healthcare team’s protocol was for dealing with this; most likely, the nurse would have either answered Sarah’s questions herself or communicated them to Sarah’s oncologist directly. These ideas had not occurred to me before, and I was glad that my meeting with Dr. S yielded some possible solutions that would allow me to help my future interview patients while staying within my professional boundaries as a first year student.

 

Dr. S and I also had an interesting conversation about continuity of care and how to maintain its integrity for patients like Sarah, who may be dealing with five or six different doctors over the course of only a few weeks. Again, Dr. S pointed out the need to consider the big picture and analyze one’s role on the healthcare team; this understanding will inform how best to advocate for the patient and improve the continuity of their care. Dr. S also noted the importance of always giving your patient the hope of something, whether it is the hope of curing their disease or the hope of being able to support them through the last days of their life. I began to relate this to our discussion of continuity of care and wonder, “How do you support your patient with hope as a team?” This relates to my experience with Sarah because I realized that healthcare providers must work and communicate as a team in order to create a joint narrative that allows them to understand the patient’s unmet needs and address them effectively.

 

A couple of years ago, I was exposed to the concept of “leaning into discomfort.” It is an idea that has been mentioned in various books about teamwork and careers, as well as in a Ted Talk by Dr. Brene Brown about the “power of vulnerability”. Leaning into discomfort means that one acknowledges when a situation makes them feel uneasy, and instead of shying away from that feeling, they push back against it and confront it directly. One examines the discomfort to determine why they are feeling it, and in doing so, one learns more about oneself and about the situation at hand. This concept is applicable to life in general, as well as any career. When I learned about the practice, I immediately saw its relevance in the field of medicine. Medical interactions between doctors, patients, students, and families, are complex and multi-faceted, a conglomeration of biological, technological, social, psychological, political, and emotional factors; often there are no clear right answers, no universal protocols for how to confront challenging situations. As a result, medicine is full of moments of discomfort. Acknowledging these moments is vital for medical students and doctors to learn and improve, to make progress as individuals and as a field.

 

When I think about the uncertainty I felt after my interaction with Sarah, I realize that it is something I will continue to experience throughout my career. As a student or a doctor, I will find no shortage of resources – papers, lectures, models, and theories – explaining the best ways to interact with my patients within the healthcare system. But it is impossible for a person to know everything, and often even to be certain of what will produce the best outcome in any given situation. It is important to be aware of these limitations. Inevitably, I will have to look at each patient who comes before me and do what I think is best based on what I know at the time and what I feel is right in that context. After that, I must acknowledge that I do not and cannot know everything, and that there may be something better I can do in the future. Thus, as I go through medical school, I will continue to reflect. As I make my way through the clinical rotations of third and fourth year, the residency that will follow, and finally, my career, I will reflect with colleagues and mentors, and I will reflect within myself, in order to learn and improve so that I can truly do my best for my patients.

 

My encounter with Sarah was unexpected, and I went into it with the few relevant tools that I had and the minimal experience of three previous patient interviews. Our interaction was characterized by the way it was confined to the two of us, trying together to create a narrative of Sarah’s experience with cancer that made sense to us both, and working to identify the gaps in our information and gather what we needed to write the next pages of her story. In my time with Sarah and the days I spent reflecting on it afterward, I came to recognize the power of my instinct to slow down with my patients and create the joint narrative; it is through this process that I can come to truly understand how each patient experiences their illness. And with this understanding, I will develop stronger connections with my patients and better be able to treat them in the future with medical advice and interventions, and in the present with the appropriate words in cooperation with their medical team.

 

Sarah taught me that even when I least expected it, I had something to offer to a patient – something besides medical expertise. Someday, not too far in the future, I will be a doctor. I will be much busier, with more patients and less time. I will know more about medicine, and I will finally be able to give my patients medical advice and treatments. But what I must not forget, in the light of my newfound position and expertise, is how to use the simplest tools. It was the basic acts of listening and caring that allowed me to reach out to Sarah and become a partner in her experience so that I would be able to treat her with my understanding, my support, and my words. Sometimes, those may be the things that a person needs most.

 

 

Daniel

Willian Brierley

 

 

It all began through a window. A small, square window. Looking through from the bright hospital corridor, dim light came through from the room behind. If you were with me and saw what I saw, you’d have made out a cot. Angular and clinical – not a thing for a child. As your eyes begin to adjust, you can begin to see more of the room. A bed, lower on the floor, with a bigger figure sitting on it. I’d turn to look at you, to share a feeling of trepidation. And then I knock on the door.

 

The patient’s name was Daniel. I’d first met Daniel, a 14 month old boy with bronchiolitis, during a ward round on the pediatric ward of a busy East London hospital. It was early winter, and the ward was a cacophony of different coughs. As 4^th year medical students, we were trying to commit to memory the different sounds and the illnesses they signified, like eager birdwatchers recording new species. 

 

“The thing is with Daniel though”, the doctors said in hushed tones before we entered his room, was that he had Down’s syndrome and was awaiting major heart surgery to correct the atrial and ventricular septal defects that would otherwise kill him.

 

I didn’t have time to process all this information, and what it meant, before we entered the room, in a bustling flourish. As a medical student, my clinical years had become an exercise in expanding the two-dimensional descriptions of diseases and their presentations in textbooks into three dimensions. I was about to experience the patient who has taught me the importance of this the most.

 

Daniel was lying listlessly in the cot. Nasal prongs gave him the air his congested lungs were desperately trying to process. Like a good medical student, I noticed the signs of respiratory distress that I knew I could be asked about, as his little chest heaved under the work of breathing. 

 

Beginning to settle into my surroundings, my eyes rested on Daniel’s face. Most noticeable was his dark storm of curly hair, a face that was unusual, but as my medical student brain was coming to terms with, didn’t look like the face of a child with Down’s. His mother was by his side. There were dark rings orbiting her tired, gentle, anxious eyes. As the doctors went through the barrage of questions their role demanded, I remember her calmness and the almost tangible bond between her and her son. 

 

But as all this was going on, there was a part of me that was feeling a current rushing underneath this technical, professional exchange. There was something more that my intuition wanted me to learn from, a story that I did not yet know, but part of me wanted to be told.

 

When I returned later in the day to speak to Daniel’s mother Serafina, I had already begun to sketch a mental picture of their situation. As I peered in that window, I tried to empty my mind of any preconceptions before I greeted Serafina. 

 

The room was hot, stuffy and cramped with equipment and belongings. I knew they’d both been there for days now. Daniel was starting to get better, and we discussed how he’d ended up in hospital. Serafina spoke with devotion about her son, and she transmitted her love for him with every description of him. With every minute that passed I understood more and more the bond between them. It was the two of them. They were in this together.

 

Serafina kept on talking, and I listened. I mentally put aside my plan to run through a formulaic medical clerking and we settled into each other’s company. Daniel lay in his mother’s arms being bottle fed. She described how Daniel was the youngest of her three children, how she juggled being a full-time mother with all the hospital appointments that they’d been through together after the discovery of his heart defect. The eagerness of her speech let me know that she was grateful of the company. As the story of how Daniel had ended up in hospital this time around came to an end, my head was full of questions that I wanted to ask, but wasn’t sure how to broach.

 

Throughout our exchange, the descriptions of devotion, I could sense the ghost of the word ‘but’. That there was a difference between how she was admirably coping with the situation she found herself in, and the reality of how things may have been if she’d had a choice in the matter.

 

“So when did you find out that Daniel had Down’s syndrome?”, I asked. I remember her smile. It was wistful, as she fleetingly looked to the floor before getting up and shuffling wearily back over to the cot to put Daniel back to bed.

Serafina explained to me how she had turned down the opportunity to be screened for Down’s syndrome during her pregnancy with Daniel. She told me that it had been offered by her family doctor, but she had declined: she had felt that it wasn’t necessary. 

 

She vividly described the moment that the doctor took the consent form and tore it up, before tossing it in the bin. In hindsight, a trivial moment for the doctor had become charged with significance for Serafina, symbolic of a turning point in her life. That was the day, she said, that her life had changed. 

 

There was a pause that suspended between the two of us as Serafina looked into the middle distance. I wasn’t quite sure whether she was lost in reverie or something less pleasant. As I waited for her to resume, I realized that I was entering a place of memories and emotions for Serafina that was delicate and still coalescing. I sensed that I had to tread carefully. 

 

She started again, this time to tell me about when Daniel had been born. Serafina told me that she had felt something was different compared to her previous two births. She’d noticed that it had taken longer for her to be handed her baby after delivery than with her other two children. That there had been whispered conversations around her before, after the briefest of contact with Daniel, her husband and new child had been taken away to an adjoining ward. 

 

I began to feel that loneliness, that claustrophobic closing-in sensation of something happening, but only to you. The loneliness of a situation that only you can understand. A moment where life disembarks from its supposed course and is shunted into the unknown. I could see her there: exhausted, people around her talking about her, but not to her. The sense of something happening, impending. But that has not fully taken form yet, not yet understood. The fear.

 

A moment in life that was supposed to be joyous had become a hinterland of uncertainty. An investigation would have to be made before any diagnosis could be considered. But that would take time, and what could anyone say to Serafina? It made me think of times in my life when, like Serafina, I’ve been in situations where I’ve experienced the insidiousness nature of uncertainty and how it burrows into your wellbeing. I thought to myself, as I would many times throughout our exchange, how could I have handled the situation better if I had been the doctor in that situation?

 

I reflect now, that this is the crux of medicine. As healthcare professionals, we have the privilege of being alongside people at the most momentous periods of their life. To be a guide, to assist and to explain the things not understood along the way. And, as was the case when Serafina talked to me, sometimes just to be company along the way.

 

She explained that she was eventually given Daniel to hold again. She said his hair was as wild and beautiful as it was when I met him. It was what she noticed first and what she noticed the most. “But, when I put him against my chest to feed, I knew. I just knew. Something was wrong.” I asked what. “Floppy, he was just floppy. I didn’t need anybody to tell me anything then, I already new there was something wrong with him”. 

 

The medical student part of me acknowledged that hypotonia at birth was one of the cardinal signs of Down’s syndrome. But the rest of me was just thinking how terrified Serafina must have been to know that something was wrong with her child, but not understand what. She was eventually told by a consultant that Daniel was being investigated for some congenital abnormalities that might indicate a condition, and that it was likely this was Down’s syndrome. 

 

At this point, she said, she started to notice other features. His eyes were almond shaped, with characteristic epicanthic skin folds. But she had eyes like this, she protested, and I agreed. His nose was flatter than normal too, as she began to intently study her newborn’s face. 

 

With the lens of a potential medical diagnosis now fixed to her eye, she couldn’t help look at her beautiful new baby boy not as a proud mother, but as a clinician trying to decipher the code written into his body. It was the beginning of her struggle to reconcile the child she loved with the interpretation that he was in someway defective.

 

She remembers a nurse coming over to her as she held Daniel. Serafina was obviously worried. She turned to the nurse for some kind of understanding. The nurse had said “Are you God? Well, if you’re not, there’s nothing you can do” before squeezing her shoulder. She describes it as a moment of tenderness, words that meant something to her at a time that she needed comfort. 

 

As I listened, my own silence was beginning to weigh on me. I knew the importance of allowing the patient time and space to speak, and that by not interrupting people will naturally offer all the information needed. And I had the time, I was happy to. 

 

But as Serafina opened up to me more and more, I felt increasingly compelled to even the emotional status quo somehow. I felt the need to reassure, to comfort. But unlike the nurse she’d just mentioned, I didn’t have the words. I was frightened of talking for the sake of it. For something crass, or patronizing to tumble out of my mouth if I opened it.

 

I was imagining her position, but my powers of empathy seemed to barely touch the situation that she was describing. How could I offer anything to her that she had not already discovered for herself? So I endeavored to keep on listening.

 

She told me how they had been left, finally, the two of them. Alone in a room to rest. She was worried, confused. Serafina smiled as she told me how Daniel had been sleeping, but as she looked at him, he opened his eyes. He had intently peered at her, and held her gaze. 

 

She felt that he was telling her what she needed to hear: I’m fine, I need you: it’s us now. It was another moment that she was drawing on to help her make sense of what had happened. A narrative that stitched events together retrospectively, giving meaning and sense to what was unintelligible at the time. It seemed that this was part of her healing.

 

At various points as we spoke, she would digress from her story to tell me how much she loved her son, how special he was. How he had shown so much spirit. How the research she’d done had shown her that of all the genetic mutations that Down’s syndrome belongs to, that it was one of the few compatible with life. How special her son was. 

 

I knew that she meant it. But her declarations of love were so emphatic that they almost sounded like protestations aimed at convincing me, or maybe even herself. I could see that she was wrestling with conflicting emotions: her love for Daniel and what that bond would mean for her future, too.

 

I could feel the story of her life coagulating and forming around us as she continued talking. In reflection, my own story, the way I make sense of things was beginning to become intertwined with Serafina’s. I began to use her experience to reflect more and more about my future role as a doctor and how to handle moments like she was describing.

 

There were times when she talked, and times when she would pause. I’d hold myself back from saying anything. I had begun to understand that these fallow moments had a latent power of their own. Serafina would form an image in her head, something would take shape that pierced her consciousness. And then she would tell me. There is one, in particular, that I now too will always remember. “I look now sometimes at a picture of me on my wedding day. I look so happy”, she said “And I think ‘You don’t know anything’, everything is not how you think it is”. 

 

I realized that my eyebrows must have raised. She looked at me expectantly. All I could do was ask her ”Why?” 

 

Serafina told me how she had realized that how she saw herself then, just a few years before, was completely different to herself now. The experience of having a baby with Down’s syndrome had made her question her own values, priorities and the way she saw the world. She had been confronted by her own prejudices through questioning the attitude of others towards Daniel. Where she had once been judgmental, she was now open-minded, where she had once been self-absorbed she was now selfless.

 

I asked about how she saw other people perceived Down’s syndrome. She felt that rather than being abnormal - diseased in some way - Daniel was just a variation of normal. He was meant to be here. She told me how vivacious he was, how much he had changed her life for the better. How he had made her grow, mentally and spiritually. How loved he was by his brother and sister, his father. 

 

What Serafina was describing to me was the conflict of living with illness. Daniel would need support for the rest of his life, she knew this. When they were in hospital, Daniel became reduced to a constellation of signs and symptoms. His future became a treatment plan. But as far as his family was concerned, he was Daniel. The boy with the beautiful smile and indomitable spirit. Serafina had alluded to her hopes that he would go to University. She joked that the girls would love his hair. 

 

I was reminded of what Susan Sontag had written, that we are all born with dual citizenship, members of “the kingdom of the well and the kingdom of the sick. Although we all prefer to only use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place”

 

For Serafina and Daniel, this duality lay between his condition, that in some ways restricted him, and his individuality. But there was also an internal conflict that I was sensing in Serafina. A reconciliation of the way she would have judged a child with Down’s syndrome before Daniel, and the way she felt about it now. How these things aren’t clear cut – Daniel’s condition, a negative in some ways had actually been an epiphany in Serafina’s own development. 

 

Serafina recounted to me an encounter she’d had with Daniel when she’d presented to the Emergency department. A doctor had asked her if she’d undergone pre-natal testing for Down’s. When she’d said no, there had been a reaction from him. Subtle, but that she’d picked up on. Something in his response had let slip that he’d thought she’d made a mistake. This had hit her particularly strongly.

 

And, it hit me too. I could see how, in some minds, she’d made a mistake. Maybe Serafina even felt this herself at times. Myself, I don’t know what I would decide if I was ever presented with the dilemma of knowing that my unborn child had Down’s syndrome. There is no black and white in such a situation. There is no right answer. 

 

As Serafina’s journey towards a wiser more enlightened self had illustrated, grayness rules in medicine. ‘Good’ and ‘bad’ are often hand in hand. To be able to navigate the grayness between these two poles seems to underlie a lot of decisions I will have to make in the future.

 

The emergency doctor had projected his own values onto another person’s life, and his reactions had belied this. I was viscerally being shown the importance of self-awareness: the discipline of knowing when preconceptions are entering your mind and how to put them to one side. 

 

Throughout our exchange, I knew that language would betray any prejudice that was hiding in my mind. Just as Serafina had been forced into an epiphany of understanding, my own outlook and beliefs were now being scrutinized.

 

Working as a medical student in East London, my education has benefited from the kindness of patients who have taught me. Patients like Daniel teach me what it really means to have a condition. That Down’s may not look like it does in the textbooks. That some conditions will make you challenge ones own notions of what it means to be on the other side of the illness/ health divide. The power of pathologising a condition. And how deep the repercussions are for the person that is told that, from now on, their name will be qualified with a condition. A label that reduces them and diminishes their individuality. I digested my time with Daniel and Serafina as I left them to rest.

 

I was questioning my own role as a medical student. Was I just prying? Did Serafina really want me there? She was talking to me because I was there, but I wasn’t sure whether she was confiding in me, or venting to me how she felt about the established way of thinking. Which as a medical student I surely represented? 

 

A medical student often inhabits a liminal space. Looking towards the kingdom of medicine and all its titled inhabitants, but no longer looked upon by others as a ‘layperson’. It can be a strange world. Often lonely, sometimes overwhelming as the two worlds exert their pull as you pass between the two. Learning the custom and language of medicine, so that you can be accepted. But often wincing when you hear its strange tongue being spoken to an uncomprehending patient. 

 

I was understanding my role, as a conduit between these two worlds. A diplomatic passport that allowed me to pass freely between the kingdoms of the well and the ill. Grasping this idea helped me shape my relationship with Daniel and Serafina. Inhabiting the grey area has its advantages. As this was becoming clear to me, these worlds were about to clash in a way that was going to challenge me even further. 

 

Daniel and Serafina had never been far from my mind in the day that followed, before I again found myself outside that small window. This time, I was joined by fellow students and a consultant on a teaching round. 

 

I stayed on the periphery as our teacher started asking Serafina questions about why Daniel had ended up in hospital. I found myself moving closer to Daniel as the exchange gathered pace, gently placing my hand on his chest, a gesture of reassurance for me as much as him. This time, looking in to this room felt different, I was observing rather than communicating. The questions were pointed rather than open. Our teacher was talking, but Serafina was quiet. I felt an air of anticipation in the room that was beginning to build into tension.

 

And then, we veered into the realm of Daniel’s condition. The doctor began pointing out what he called the ‘dysmorphic’ features that were associated with Down’s syndrome. As he pointed out Daniel’s flat nasal bridge, his single palmar crease, I began to feel more and more uncomfortable. To my shame, I tried not to look at Serafina. I didn’t need to look, I knew how this was making her feel. 

 

As a group, we had entered as students under the veil of goodwill that comes with learning. But we were now acting like dispassionate scientists: analyzing Daniel and reducing him into a taxonomic list of features so that we could classify him.

 

 

To the defense of the doctor who was leading us, I have great respect for him. I found him to be a wonderful and caring doctor in every other exchange I encountered him in. I just don’t think that he was aware of how insensitive his approach was. He had spent so long in the domain of medicine, that he was able to lapse. Part of him had become immune to the effect that his words could have on others. 

 

I can’t think of any other reason why he chose to conclude his examination with the words “But children with Down’s syndrome are very happy, we like them, they are cheery people”. Everything in his face and his body said that he meant this with kindness and paternal reassurance. But with those words, I could see Serafina’s composure begin to crumble. 

 

We left, and there was little time to reflect before we entered the next room, and I had to examine a patient in front of the group. Later, when I met my colleagues for lunch, they told me they’d bumped into a crying Serafina in the corridor. She’d told them to never speak to a patient in the way that she’d just been subjected to. They said that she had cancelled the next day’s appointment with the heart surgeon who was to operate on Daniel.

 

I felt terrible. Guilty that I had stood by and watched as the scene had unfolded. Yes I was a medical student, there to learn and do as I was instructed. But I was also an individual. I felt I had betrayed myself by not speaking out against what I thought was wrong. I was ashamed of myself. I was ashamed that medicine had been used to legitimize a form of discrimination that had really hurt someone.

 

I excused myself from the table to go and find Serafina. I didn’t know what I was going to say, I didn’t even know if it was appropriate, but I felt a responsibility to speak to her. 

 

I was aware that I had possibly become too involved emotionally in this case. I felt protective towards Daniel and Serafina. But as I rushed through the long corridors, I scanned myself, and I trusted that my response was appropriate. I resolved to myself that I was not there to make myself feel better about the situation, I just wanted to make sure that Serafina was alright.

 

Serafina talked, I listened. She told me how much she hated the word ‘dysmorphic’, how dehumanizing it was. She’d felt humiliated by the exchange that had just happened, but she was also angry. I could sense this anger was steeling her, pushing her further along in her journey, settling her temperament. Although she’d been crying, I could see that she was bouncing back: this experience was feeding the resilience that had become her lifeline.

 

I wasn’t sure what to say, apart from to be honest. I tried to explain that my superior had been well-meaning, but agreed that his choice of language had been insensitive. It was difficult to navigate being honest with trying not to betray my teacher, who I did not want to overly-criticize. 

 

The situation was making me acutely aware of how the profession I was entering would test me time and again in situations like this. How responsibilities to patients and to profession were concurrent, but could pull in different directions. That the knot of such contradiction would lie in my hands. It would ultimately be up to me to untie such conflicts in a way that was equitable.   

 

I wanted to make things alright, but I knew that this was beyond my powers. As Serafina talked and Daniel smiled and gurgled, unwitting to the situation around him, all I could do was to keep them company through this moment. She reassured me that she had rearranged the appointment with the heart surgeon, and that she was simply looking forward to Daniel being discharged so that they could return home. To have a normal family life again, where Daniel was just Daniel, and not a patient. To be humanized again, is how it felt.

 

The one comment I dared to make, picking my words exquisitely carefully, was an observation on something Serafina had said to me the day before. I reminded her that Daniel was very much meant to be here, he had overcome much placed in his way, already. That somehow he had come through the genetic lottery, the screening process, and now this recent hospital admission. He was very much surviving, and he was obviously enjoying being here. I suggested, without trying to overly-reassure her, that this would stand him in good stead for the future and the impending operation. I thanked Serafina and Daniel for the great deal that I had learned from our time together.

 

I left them for the last time, in the room that I’d first encountered them when I  looked in through that small window. Our encounter had changed the way I would see people with conditions like Daniel’s in a deeply felt way. 

 

My mind was drawn back to something that had happened to me in my first week of medical school at Barts and in London, nearly 4 years before. As part of our induction process, we were allowed into the hallowed pathology museum at the top of our medical school building. 

 

The sense of ceremony was heightened by the grand surroundings of ancient glass cabinets containing medical relics. There was an institutional smell of polish and decay, as we were led towards the tour’s climax. The most famous exhibit, and a figure who had become emblematic for the medical school, was the hunched skeleton of Joseph Merrick. The man who is remembered as ‘The Elephant Man’.

 

I remember standing there, studying his skeleton. He stands, naked, unable to object to the casual scrutiny of passers-by. His right side droops, as if it had been melted by some fierce heat. It gave him the impression of cowering. As if the weight of all the attention and the corrosion of all the sneering insults he must have endured had combined to physically deform him. 

The most poignant item on display was the pillbox shaped cap that he wore in public, to obscure his face in order to avoid the public gaze that was to become the source of his fame and survival, but also of great suffering. 

 

I thought about how incongruous this was. That this man Joseph Merrick should still be known as ‘The Elephant Man’ by the institution which still homes him. That he should be defined by a name which caricatured his disfigurement. How discordant this was within the politically correct world in which his remains now inhabited. A time in which he would be understood as having a rare genetic overgrowth disorder, probably Proteus syndrome. Instead his name has become shorthand for the ugly and strange, in a betrayal to the celebrated mind that once inhabited his famous body.

 

Joseph Merrick often quoted poetry at the end of his letters:

 

‘Tis true my form is something odd

But blaming me is blaming God

Could I create myself anew

I would not fail in pleasing you.

 

If I could reach from pole to pole

Or grasp the ocean with a span

I would be measured by the soul’ 

 

 

My experience with Daniel had reminded me that the prejudices felt by Joseph Merrick over a century ago still reverberated today. That medicine can often be clumsy, cruel even. Defining individuals by their condition sacrifices their humanity. That the way we perceive others is in fact a reflection of ourselves, and that without a self-awareness to our approach, we can unwittingly hurt others.

 

I had been shown how powerful the words we choose to define others are, especially coming from the perceived position of authority that doctors often occupy. How they can empower someone, or oppress them. 

 

In terms of communicating with patients, I had learned that communication has the ability to frame a way both doctor and patient views a condition, and that this perspective is a powerful therapeutic tool.  

 

The principle of ‘narrative medicine’ had been demonstrated to me firsthand. The idea that by listening to a patient, being empathic and attempting to inhabit their story is key. I had felt uncomfortable at times, giving myself to the story that was unfolding around me. But I did feel that I had helped Serafina in some way. By listening, I was helping construct a space in which she was making her own sense of things. 

 

She was empowered to make her own narrative. To understand things in a way that allowed her to gain ownership over what was happening to her and Daniel. This principle of narrative medicine is something that my experience with Daniel has turned into an ethic. One that I will endeavor to uphold and keep at the forefront of my mind. When I am tired, busy, short of time as a junior doctor. To always try and find time to give a patient the opportunity to have someone to listen and engage with them.

 

My experience showed me how this principle not only benefits the patient, but also enriches the clinician, as they build their ‘empathy bank’. The accrual of this repository of experience helps a clinician to relate better to future patients. And it also gives them a deeper understanding of pathology as they grasp a feeling of what it is actually like to have the condition that they explore. I feel that these experiences are especially powerful as guiding principles to be aware of for any medical student who wants to develop, and by doing so be enriched as an individual.

 

I had experienced what it was like to hold that passport to the ‘other’, to be one of the refugees that medicine seeks to repatriate to the land of wellbeing. I had felt how alienating it was to be marginalized by a condition, and how much harm this could cause. I vowed to always keep an understanding of this liminality within me. That an important part of being a good doctor is to not forget what it is like beyond medicine, what it is like to occupy the feelings that those who visit hospital inhabit.

 

And I had been cautioned that medicine is not separate to the world ‘outside’. It is there to sustain the world we live in. Although it can feel like rarified air at times, I must breathe deeply, and bring my feet back on the ground in order to relate to the patient in front of me. I understand that this will guide me through many challenging interpersonal exchanges. 

 

Looking back as I write this, I am grateful for how this experience has made me grow as a person and as a clinician. Medicine is a mirror which forces you to examine yourself as you examine others. I will always try and keep this reflection in mind before I gaze though the next small window into another person’s life.

 

Names have been changed of all parties involved in this story and precautions taken to avoid any identifying features