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

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 2 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 3 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 2 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. 2 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 2 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 4 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 min, 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 2 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 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 min 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. 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 5 or 6 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 2 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 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.