ReflectiveWriting:AMedicalStudent’sGuide

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ThisguidewasinspiredbyDr.SarahdeLeeuw’smedicalstudentworkshopReflectiveWriting:It’snotjustaboutwritinginyourjournal.Ithascometogetherasaproductofhergenerosityandpatienceinsharingherworkshopmaterial,suggestions,edits,andardententhusiasmforreflectivewriting.TheFacultyofMedicineismostfortunatetobenefitfromDr.deLeeuw’sexpertiseandsupport.

CONTENTS

WHATisreflectivewriting? 2WHYisreflectivewritingrequired? 3Great,whatdoIneedtoGETSTARTED? 4HOWshouldIstructuremyreflections? 5HOWwillmyreflectionbegraded? 6TheMeritsofReflection:AUBCMedicalStudent’sPerspective 7STUCKstaringatablankpage?:Tips&ExercisesinReflectiveWriting 8Trouble‐Shooting 17WheremightIPUBLISHmyreflections? 18UBCMedicalStudentReflectiveWritingSamples 19References 35Contributors 37

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DeeplyreflectivecontemplationcanbeincreDeeplyreflectivecontemplationcanbeincrediblyintimidatingatf irst,diblyintimidatingatf irst,

then incredibly l iberat ing.then incredibly l iberat ing.

WHATISREFLECTIVEWRITING?Itallstartswithreflectivethinking,whichcanthenbetranslatedintoanymediumthatinspiresthesethoughtstogrow.Inthecaseofreflectivewriting,thatmediumis(youguessedit)writing.Writingapersonalreflectioninvolves:

1. Thinkingbackonaspecificevent/idea/concept.2. Analyzingthistopicthoughtfully(fromdifferentperspectives;

withrespecttopre‐existingknowledge/attitudes).3. Thinkingcarefullyaboutwhatthistopicmeanstoyou

personally,bothatthepresenttimeandaspartofyourfutureprofession.

ReflectivewritingisNOT:o fictiono anobjectivejournalisticorscientificseriesoffactso argument‐driven(e.g.anargumentativeessay)o novelesqueo aresearchpapero technicalreportingorwritingo ascreenplay

ReflectivewritingneedNOTbe:o aconfessionofallthedetails

ofyourpersonallifeo deeplyprofoundo fullofemotionand/orpathoso spiritual

Ahelpfulanalogyforreflectivewriting:

Reflectivewritingisthepracticeof“holdingamirror”uptosomething.ButNOTjustlikethis–thisissimplyanobjectivereflectionofanevent.

Likethis!Youneedtoplaceyourselfinthesituation–delverightintoitandsubjectivelyconsideryourrole,worries,views,andunderstandingsinrelationtothereflectedimage.…Thenconsiderhowyoumightprojectknowledgegainedfromthispastexperienceintothefuture.

Definition: reflective, adj. and n.: That proceeds from or is the result of careful thinking, typically influenced by recollection of one’s past experiences; considered, measured.

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WHYISREFLECTIVEWRITINGREQUIRED?

Connections.Writereflectivelytodiscoverandexploreconnections–withyourpatients,yourcolleagues,andyourself.Inturnyou’llcultivateanunderstandingofpatients,andamindfulnessofyourownmentalandphysicalwellbeing.Development.Writereflectivelytoexploreyourfeelings–andperhapseventounearthhiddenandunfamiliaremotions.Writetovent.Toexploremistakes.Tolearnfromthemandmoveon.Clarity.Writereflectivelytoassemblefragmentedthoughtsintoacohesivewhole.Forceyourselftoarticulatethosenascentideasskirtingtheperipheryofyourmind.Strivetomaketheseemergentthoughtscleartobothyourselfandyourreader.Innovation.Writereflectivelytokeepyourcuriousmindontheedgeofrevelation–tonotmissanopportunitytoexploreanystrokeofinsight–tostimulateideasforbetterpracticeandcollaboration.

Theproblems[inmedicaleducationandpractice]aresystemic:mismatchofcompetenciestopatientandpopulationneeds;poorteamwork;persistentgenderstratificationofprofessionalstatus;narrowtechnicalfocuswithoutbroadercontextualunderstanding;episodicencountersratherthancontinuouscare;predominanthospitalorientationattheexpenseofprimarycare;quantitativeandqualitativeimbalancesintheprofessionallabourmarket;andweakleadershiptoimprovehealth‐systemperformance. –Frenketal.2010,TheLancetWe[maybe]abletousethehumanities’intricateandsympatheticknowledgeaboutthehumanconditionaswellasitsabilitytoexaminepluralistic,experimentalknowledgetohelpensureamorallysensitive,narrativelysound,anddeeplyprofessionalclinicalpractice. –Shapiroetal.2009,AcademicMedicine

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GREAT,WHATDOINEEDTOGETSTARTED?Soyou’vebeentoldtodosomereflectivewriting.TherearethoseofyouforwhomthismeansflashbackstoHilroyruledexercisebookswhereyoudocumentedyourweekendactivitiesorfuturecareergoalsinexchangeforpastteachers’redcheckmarks.Thereareothersofyouwhomayhavecontinuedscribblingdownaccountsofexperiences,hopes,andexotictravelsintobrown‐coveredrecycled‐papernotebooks.Andthentherearethoseofyouforwhomrecordingobservationsinyouruniversitylabjournalsisthefarthestyou’vecaredtoventureintotherealmofreflectivewriting.Reflectivewritingisapersonalexperience–thefirststeptowhichisopeningyourmindtotheexperienceandfindingamediumthatworksforyou.Whatisamedium,youask?Simplyput,itiswhateverformofpresentationbestinspiresyoutodelveintoyourexperiencesandexploreyourthoughtssurroundingthem.Writing,sketching,sculpting,photography,music–thereisanendlesslistofpossibilities.Buthowdoyouknowwhichonesworkbestforyou?Thatquestionisalittletrickierandrequiresyoutodosomepersonalandopen‐mindedexploration.Manyofyoumayalreadybefamiliarwithapreferredmedium.You’relookingforthatmomentwhenyou’restrummingyourguitarandimpressyourselfwithsomedeep‐soundinglyrics.Orwhenyou’rebloggingtheobjectivedetailsofsomeexperienceandsuddenlysurpriseyourselfbytypingaprofoundthought.Orwhenyouaren’tsurewhatyouremotionsarewhenyoupickupyourpaintbrushorcamera,butendupproducingapiecethatevokesquiteastrongtoneormood.Inallofthesecases,allowingyourselftobecomeimmersedinamediumleadstotheemergenceofemotionsorthoughtswhichyouevidentlypossessed,butuntilthatpointwereunawareexisted.Allowingyourselftobecomeconsciousofthesethoughtsletsyoufurtherexplorethem,andsopermitspersonaldevelopment.Butwritingisn’tmymedium!Presumablybecauseitconstitutesthemostoutwardlyunambiguouspresentationofinformation(asopposedtoaphotographorpaintingwhosemessageisintheeyeofthebeholder)writingisthemediuminwhichDPAShastraditionallyrequestedreflectionsbedone.Thatisnottosaythatstudentsshouldbediscouragedfrompracticingreflectioninothermedia–infact,DPAStutorsarethrilledtohavecreativesubmissionsinwhatevermediabestinspiretheirstudents.Forstudentswhohavenotidentifiedapreferredmediumthough,writingisanexcellentplacetostart.Allmedicalstudentspossesstheskillstowrite(objectively,atleast),sowithalittlehelpfromthisguidewehopethatwithouttoomuchfrustrationyouwilllearntohoneyourwritingalittletoallowsomehelpfulpersonalthoughtstosurface!THINK:Whatsuppliesmakemewanttowrite? WherecanIfindsomealonetimetoreflect?o ahard‐coveredblank‐pagenotebooko aruledcoilbooko loose‐leafpapero scribblingthoughtsonscrappapero colouredpens!o mylaptop/tablet/phone

HowdoYOUprefertorecordyourthoughts?

o morning,evening,middleofthenighto mydeskbythewindowintheafternoonsuno sittingonthebeach/intheforest/bythepoolo typingonmyiPadonalongbusrideo sippingalatteatStarbuckso passingtimeontheferry

WhereareYOUinspiredtowrite?

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HOWSHOULDISTRUCTUREMYREFLECTIONS?Whilethereisno“right”waytostructureaprivatepersonalreflection,whenitcomestopolishingupacollectionofyourpersonalthoughtsforsharingwithatutoritmayimproveclaritytointroduceasemblanceofstructure.Bynomeansdoyouhavetodothis.Thefollowingformatissimplyasuggestion,whichsomestudentsmayfindhelpful.Trydifferentthings.It’syourreflection.FigureoutwhatworksforYOU!YOURGOAL?Toletyourreadershareinyourpersonalprocessofdiscovery.1.DESCRIPTION Whathappened? Becreativehere!Writeinfirstpersonorthirdperson,froma

medicalstudent’sorpatient’sperspective,inpresentorpasttense,ordosomethingcompletelydifferent–whateverletsyoutellthestorybest!Insteadofgivingastraightforwardaccountyoumaywishtoopenwithananecdote,narrative,orquotationtotransportyourreaderintothescenario.Butdon’tstophere!–Remembertoexploreandexplainthiseventinthenexttwosteps…

2.INTERPRETATION Whatinparticularissignificantabout

theevent/ideayouhavedescribed?Doesthismakesensegivenyour

previousexperience?Orareyouexperiencingsomethingnew?Whatarepossiblereasonsforwhatyouhaveobserved?

Howisthisevent/ideasimilartoordifferentfromothers?

Focusonreflectinguponjustthemostsignificantpartsoftheevent/ideayou’vedescribedinthepreviousstep.Writeaboutwhatwasmeaningful,useful,uncomfortable,whatyourthoughts/feelingswere,whatyouquestioned,whatyounowrealizeinretrospect,…Begenuinehere!Don’tbeafraidtorevealerrors,weaknesses,andanxietiesinadditiontoyourstrengthsandsuccesses.Trytoexplorewhymayhaveleadtotheseshortcomingsandhowtheymightbeimproveduponinthefuture.

3.OUTCOME/FUTUREIMPLICATIONS Whathaveyoulearned/whatwillyou

takeawayfromthisevent/idea?Howdoesthisapplytoyourfuture

profession?Arethereareasinwhichyouarestill

uncertain?

Reflectingforwardisjustasimportantasreflectingback!

Reallythough,anythinggoes!Reflectivewritingcanbe:

o poetic–prose,free‐verseo essayo creativenon‐fictiono well‐researchedo illustratedo …thelistgoeson!

Therules?Thereisonlyoneruletoreflectivewriting: IthastoreflectYOU. …you–yourthoughts,feelings,emotions,worries,etc.–arethesubjectofthenarrative …youneedtosituateyourselfinrelationtowhateversubjectyouareengaging

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HOWWILLMYREFLECTIONBEGRADED?Sincethereisnorightorwrongtoapersonalreflection(remember,theonlyruleisthatithastoreflectYOU),youwillnotbejudgedonhowyouchoosetopresentyourreflection.Rather,youwillbemarkedonthedepthofthoughtyouhaveputintoreflecting–thesubjective,ratherthantheobjective.Hereistheexactgradingrubricthatwillbeprovidedtoyourtutor–noticethatitissufficientlyflexibletoaccommodateanymediaofyourchoice.Ifyouhaveanyquestionsaboutgrading,don’thesitatetoapproachyourtutor!

Category Mastery Satisfactory NeedsImprovement

Self‐reflectionandintrospection

Seekstounderstandconceptsbyexaminingopenlyyourownexperiencesinthepastastheyrelatetothetopic,toillustratepointsyouaremaking.Demonstratesanopen,non‐defensiveabilitytoself‐appraise,discussingbothgrowthandfrustrationsastheyrelatedtolearninginclass.Risksaskingprobingquestionsaboutselfandseekstoanswerthese.

Seekstounderstandconceptsbyexaminingsomewhatcautiouslyyourownexperiencesinthepastastheyrelatetothetopic.Sometimesdefensiveorone‐sidedinyouranalysis.Askssomeprobingquestionsaboutself,butdonotengageinseekingtoanswerthese.

Littleself‐disclosure,minimalriskinconnectingconceptsfromclasstopersonalexperiences.Self‐disclosuretendstobesuperficialandfactual,withoutself‐reflection.

Reflection

Reviewspriorlearning(pastexperiencesinsideandoutsideoftheclassroom)indepthtorevealsignificantlychangedperspectivesabouteducationalandlifeexperiences,whichprovidefoundationforexpandedknowledge,growth,andmaturityovertime.

Reviewspriorlearning(pastexperiencesinsideandoutsideoftheclassroom)withsomedepth,revealingslightlyclarifiedmeaningsorindicatingasomewhatbroaderperspectivesabouteducationalorlifeevents.

Reviewspriorlearning(pastexperiencesinsideandoutsideoftheclassroom)atasurfacelevel,withoutrevealingclarifiedmeaningorindicatingabroaderperspectiveabouteducationalorlifeevents.

Curiosity

Exploresatopicindepth,yieldingarichawarenessand/orlittle‐knowninformationindicatingintenseinterestinthesubject.

Exploresatopicwithsomeevidenceofdepth,providingoccasionalinsightand/orinformationindicatingmildinterestinthesubject.

Exploresatopicatasurfacelevel,providinglittleinsightand/orinformationbeyondtheverybasicfactsindicatinglowinterestinthesubject.

Independence

Educationalinterestsandpursuitsexistandflourishoutsideclassroomrequirements.Knowledgeand/orexperiencesarepursuedindependently.

Beyondclassroomrequirements,pursuesadditionalknowledgeand/orshowsinterestinpursuingindependenteducationalexperiences.

Beginstolookbeyondclassroomrequirements,showinginterestinpursuingknowledgeindependently.

Transfer

Makesexplicitreferencestopreviouslearningandappliesinaninnovative(newandcreative)waythatknowledgeandthoseskillstodemonstratecomprehensionandperformanceinnovelsituations.

Makesreferencestopreviouslearningandattemptstoapplythatknowledgeandthoseskillstodemonstratecomprehensionandperformanceinnovelsituations.

Makesvaguereferencestopreviouslearningbutdoesnotapplyknowledgeandskillstodemonstratecomprehensionandperformanceinnovelsituations.

Initiative Completesrequiredwork,generatesandpursuesopportunitiestoexpandknowledge,skills,andabilities.

Completesrequiredworkandidentifiesopportunitiestoexpandknowledge,skills,andabilities.

Completesrequiredwork.

Rubricadaptedfrom“FoundationsandSkillsforLifelongLearning”c/oAssociationofAmericanCollegesandUniversities.

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THEMERITSOFREFLECTION:AUBCMedicalStudent’sPerspective

Astackofjournalssitsonthebottomshelfofmybookcase.Ofdifferentcoloursandsizes,onewater‐damaged,mostwithbrokenspinesandtatterededges,thepagesofthesebooksholdmydeliberatefour‐year‐oldlop‐sidedletters,mymiddleschoolmicroscopicprinting,mycurrentlazyscrawl,andeverythinginbetween.Whatbeganwithmypreschool‐agedselfscribblingoutafewlineseacheveningtosatiatemyacademic‐orientedparentshasevolvedintonearlytwodecadesofjournalentries,reflectingoneverythingasmundaneasgroceryshoppingtovividdescriptionsofsomeofthemostsignificantmomentsinmylife.ThefirsttimeIheardanEdwardSharpeandtheMagneticZerossong.GrowingaDicentraspectabilisplant.ThedayIgotmyguitar.ThefirstcutImadeintoacadaver.Diggingtothemiddleoftheearthinmysandbox.Myfirstdayofuniversity.Watchingsnowfall.Standing230mbelowgroundincompletedarknessatCarlsbadCavernsNationalPark.Feelinglikeakidplayingdressupinmystethoscopeandwhitecoat.SippingteawhilewatchingstoopedricepaddyfarmersinLongsheng,China.Calculatingthedistancesbetweenemissionspectroscopicbandsofhydrogen.MygrandmothergivingmeanEnglishmintfromherpurse.ReadingHighTideinTucson.Reflectingonsuchexperienceshasnotonlyservedasanobjectiverecordofwhattookplace,buthasalsoallowedmetoretrospectivelyexploremythoughtsandfeelingssurroundingtheevents.Itisoftensurprisingwhenasimpleeventtranslatesintoseveralpagesofmusingsinmyjournal.Tomethisisthevalueofreflectivewriting–thattheactofformulatingone’sthoughtsontopapercanrevealintrospectiononalevelbeyondwhichthewriterrealizedshepossessed.Assuch,reflectivewritingenablesustobecomemorethoughtful,mindful,andconscientious.Asawhole,itwouldseemthatincreasingourskillsinthesethreeareaswouldleadtoanincreasedcapacitytoempathizewithothers–orattheveryleast,wouldfacilitateabetterunderstandingofwhatothersmightbeexperiencing.Inorderforpeopletoderivesuchbenefitsfromreflectivewriting,theymustenterthepracticewithanopenmind.Withapoorattitudeorskepticismtowardsthetask,onewouldbeinclinedtoresisttheflowofthoughtsontopaper.Ratherthanthecascadeofthoughts,eachinspiringthenext,thatmakesreflectivewritingsoenlightening,theresistantindividualwouldfindthetasktobeslow,frustrating,andultimatelyawasteoftime.UnfortunatelythisistheattitudeIhaveencounteredamongstmanyofmymedicalschoolcolleaguessurroundingreflectivewriting.Perceivedasanoneroustask,manystudentsprocrastinatewritingreflectionsuntilthelunchhourimmediatelybeforethereflectionisdue,onlytodistractedlyspilloutafewsuperficialthoughtswhilewillingthewordcounttoinflatetotheassignedminimum.Thesestudentswhosubmituninspiredreflectionsonlong‐pasteventsareinevitablytheoneswhowillcriticizethepracticeofreflectivewriting.IappreciatethatDPASencouragesstudentstopracticereflectivewritingandwouldliketoseemorestudentsapproachthetaskwithanopenmindandpositiveattitude.Inpeopleofouragegroup,itseemsthatjournal,letter,andemailmodalitieswhichpermitonetoformulateablockofthoughtsarebeingdisplacedbytheworldofdisjointed140‐characterthoughtsnippetsofTwitterandtextmessaging.Itisimportanttoengagesuchapopulationinreflectivewriting,inorderforittodevelopintoahabituponwhichtheycanrelythroughouttheircareers.IwouldliketoseeDPAScontinuetopromotereflectivewritingasastrategytofacilitatephysicianmindfulness,andtomakeitsvalueapparenttostudents.

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STUCKSTARINGATABLANKPAGE?Herearesometipsthatyoumayfindhelpful.We’vealsoincludedsomeexercises–weencourageyoutogetoutapencilandtrythemyourself!o Areyouamargindoodler?Goahead–draw,diagram,anddoodleinyourreflections!o Leavelargemargins–soyoucangobackandlabelthingsforquickreference(e.g.noteson

particularthings,stories,goals),orsothatyoucanrecordfurtherfeelingsornotesthatdon’toccurtoyouuntilyourereadyourreflectionatalatertime.

o Pictures,quotations,articles–includetheminyourreflections!Theyaregreatinspirationstoget

youthinking.o Grammarandspelling?Forgetaboutit!–Heck,youdon’tevenneedtowriteincomplete

sentences.Justgetthethoughtsdownasspontaneouslyastheycometoyou.Youcanalwaysgobackandeditafterwardsiftherearepartsofyourwritingthatyouwouldliketopolishupforotherstoread.(Butforprivatewriting,there’snoneedtogobackandeditatall!Remember,it’syourreflection–youmaketherules.)

o Getitalldown!–Whenyoustartwriting,don’tbediscriminativeaboutwhatyouputdownonthe

paper.Scribbledownwhateverthoughtsflitacrossyourmindanddon’tworryaboutorganizationuntilafterwards.Acommoncauseofstaring‐at‐that‐blank‐pagesyndromeisthinkingtoodeeplyaboutgettingdownsomethingprofoundandsupremelyorganized(medstudentsareallperfectionistsatheart,right?)–inwaitingforthisonedeepthoughttostrike,youmissoutonexploringsimpler,potentiallyhelpfulthoughts.Yourprivatejournalshouldbelikeyourdeskdrawer–youknow,thedrawerwhereyouhavetorummagethrougholdpencils,sparehighlighters,arainbowofpost‐its,acrumpledteabag,andhalf‐usederasersanytimeyouwanttofindasparepieceof0.5mmlead?It’syourownprivatespacefilledwithunpolishedoddsandends,fromwhichyouoccasionallyselectacouplepiecestobringoutinpublic.Asfortherestofthedrawer,noonewilljudgeitstidiness–youmayaswelltossinthattri‐colouredpenyoufoundinthedepthsofyourbackpacksincewhoknows,itmaybejustwhatyou’relookingforinthefuture.

PRIVATE PUBLICAboveisonemodelofthereflectivewritingprocess.Asyoucansee,themajorityoftheprocessisapersonal,privateendeavour–itisnotuntilthefinalstagethatsomethingpresentableemerges.Probablyoneofthemostcommonmistakesinreflectivewritingisforstudentstofearorleaveinadequatetimeforthemessyprivatestagesofreflection,wantingtoskipstraighttoproducingapolishedpiecerightfromtheget‐go.Thisisnotthepurposeofreflection–itisthroughthedevelopmentofarefinedideafromamessofthoughtsthatyouwillfindyoudiscoverthemost,anditisthisprivateprocessthatwillbemostworthwhile.

o Thehere&now–Ifyou’restuckstaringatablankpage,beginningwithatimeorplacemayhelpjumpstartyourreflection(e.g.OnarainyThursdayafternoonIstoodinanemptybusshelter,whitecoatovermyarm,nervouslycheckingmywatch.).

a private mess of ideas

a couple of these ideas leave you thinking…

refining & revision of your thoughts…

a final public product!

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o Beyourself–Embracethefreedomofbeingabletobecompletelyhonestwithyourfeelings.Reflectionsareprivate.Thereisnoneedtoappeaseanyoneelse.Itisimpossibletomakea“mistake”inyourwriting.

o Say“I”–Forgetaboutthe3rdpersonpassivevoiceyourlabinstructorshavedrilledintoyour

academicwriting!Committoyourfeelingsandwriteinfirstperson.o ...Ortakeastepback–andfromtimetotimewriteaboutyourselfin3rdperson,perhapsto

contemplateapatient’sperspective.1stperson

Describeabriefpatientencounter(e.g.percussingoutaliver,givingavaccination,etc.)fromyoursubjectivepointofview,asamedicalstudent.

3rdpersonNowstepoutsideofyoursubjectiveexperienceandimaginehowapatientwoulddescribethesameencounter.

o “Mylifeistooboring.There’snothingworthwritingabout.”Sowhat!–Recordyourday‐to‐day

thoughts,nomatterhowmundaneyouthinktheyare.There’snopressuretowritesomethinginspirationalorclevereverytimeyoupickupyourpen!Writefreely.Noself‐criticismallowed.

o Ventaway!–Thesafe,criticism‐free,privatepagesofajournalaretheperfectplacetoget

frustrationsandfearsoffyourchest.You’llfeelbetteraftergettingitdownonpaper.Trustme.o Butdomorethanrant…–Onceyou’veairedyourfrustrations(nowwasn’tthatsatisfying?!)don’t

leaveitatthat–taketheopportunitytoreflectuponwhyyoufeltthewayyoudidandsuggestimprovements.Takethehighroad:learnfromtheexperienceandmoveon!

o Resistanceisfutile.–Youneverknowwherereflectivewritingmaytakeyou.Somedaysthis

journeymaybeprofound;othertimesyou’llfeellikeyou’vereachedastandstill.Regardless,trytomaintainanopenmindandexpecttosurpriseyourself.

o Useimagesandmetaphors.–Noonesaidyouhadtosticktothedryacademicwriting.o Commit–Inthebusyworldofmedicine,it’salltooeasytoshoveasidesomethingastrivial‐

seemingasjournalwriting.Youmightonlydoiteveryfewweeks,waitinguntilyouarestruckbysomethingthat,inyouropinion,issufficientlymeaningfultowarrantreflection.Instead,trytogetintothehabitofwritingdownafewlineseveryday.Perhapsrecordonethoughtonthemostsignificanteventofyourdaybeforeyougetintobedeachnight,orwritedownonegoalforthedayaheadwhileyouwarewaitingforyourcoffeetobreweachmorning.Simplydevelopingthehabitofgettingyourthoughtsontopaperisastarttotrainingyourmindtoreflectonaregularbasis. …Trythe“7‐DayChallenge”onthenextpage!

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7‐DayChallenge!Eachnightforaweekstopbeforegettingintobedtowritedowntheonemostsignificanteventofthepastday.Writeatleastonesentencetodescribewhythateventwasnoteworthytoyou.Monday:Tuesday:Wednesday:Thursday:Friday:Saturday:Sunday:

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5StepstoaReflectionYes,comingupwithareflectionisthiseasy.Don’tworryaboutbeingprofound–thisisanexerciseforyourselfonly–justputdownthefirstthingsthatcometomind!1. Comeupwith3(unrelated)

“objective”anddescriptivesentencesaboutyourpresentenvironment.(e.g.Iamtwirlingmygreenhighlighter,tryingtofocusonreadingaboutreflectivewriting.)

1.2.3.

2. Comeupwith3(unrelated)sense‐baseddescriptivesentencesaboutyourpresentenvironment.Avoidtheuseof“I”andtrytobaseeachsentenceonadifferentsense.(e.g.WarmraysofyellowSeptembersunstreambetweentheslatsofmywindowblinds.)

1.2.3.

3. Comeupwith3(unrelated)sentencesaboutyourpresentenvironmentwhereyouuse“I”andanemotionallydescriptiveword(ortwo).(e.g.Despitemyexpectationsthatreflectivewritingwouldbetouchy‐feelyandsomethingthatIcouldn’tdo,I’mrealizingnowthatitmaynotbetoohard.)

1.2.3.

4. Comeupwith1summativesentenceaboutyourpresentenvironmentthatalsoprojectsintothefuture(use“I”).(e.g.Inaquietpleasantenvironment,withastrongcupoftea,Ithinkitcouldbecalmingtopracticereflectivewritingfromtimetotimethroughoutmymedicalcareer.)

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5. Takeasamplingofyoursentencesandputthemtogether.Youcanbecreativeinhowyoustringthemtogether.Addtowhatyouhaveiftheinspirationstrikes!

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o Capturethemoment.–Usewordsmuchlikeacameratofreezeamomentintime.Thecacophonyofthewaitingroom.Theblindingsterilityoftheoperatingroom.Thewhirofacastsaw.

Say“cheese”!

Jotdownabriefword‐photoofyourcurrentenvironment.(You’llstarttoseedetailsofyourenvironmentthatyounevernoticedbefore!)Inspiration:WilliamCarlosWilliams(1883‐1963)wasanAmericandoctorandwriter.Inhispoem“TheRedWheelbarrow”hecapturesasimpleimage:

somuchdependsuponaredwheelbarrowglazedwithrainwaterbesidethewhitechickens.

(www.urthonaessays.wordpress.com)

o Then“Photoshop”thatimage!Whileanobjective“snapshot”descriptionofaneventmakesa

greatstart,don’tmaketherookiemistakeofleavingyourreflectionatjustthat.Makesureyougoontoputyoursubjectiveself–yourthoughts,feelings,personality–intothepicture.Thisiswhatbringsareflectiontolife!

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FirstsWalkingoutofthegrossanatomylabafterdissectingtheheart,afirst‐yearmedicalstudentcommentedonheraweoftheexperience:“Therearesomany‘firsts’inmedschool–Imean,otherpeoplehavetheirown‘firsts’thatthey’llremembergrowingup–butoursarethingslike‘thefirsttimeIheldahumanheart’.Sometimesitjusthitsmehowluckyweare.”Indeedyou’veprobablyrealizedbynowwhataprivilegeitistobeenteringthemedicalprofessionandtohavethetrustofcompletestrangersinaffordingyouthese“firsts”.Fromthefirsttimeyouheardaheartmurmur,tothefirsttimeyougaveaninjection,tothefirsttimeyouscrubbedintotheOR,youhaveacareerof“firsts”aheadofyou,whichjusthappentomakewonderfulsubjectsforreflection.Brainstormalistofmedical“firsts”whichyouhaveexperienced.Youcanaddtothislistastimegoeson.Chooseoneofthesemeaningfulexperiencesandmakeitthesubjectofareflection!

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Me:HereandNowThisexerciseissimple.Therearenowronganswers.Weaskthatyousimplygivesomethoughttothequestionsbelow,thentuckthispageawayinasealedenvelope.Afteryourfirsttwoyearsofmedicalschool,onthecuspofclerkship,weencourageyoutolookbackontheseanswersandreflectuponyourpersonalchangesandgrowth.Whatthing(s)doyoufeelareyourstrengths?Whatthing(s)doyoufeelareyourweaknesses?Ifyoucouldchangeonethingaboutyourself,whatwoulditbe?…Andhowwouldyoudoit?Whatwasthemostsignificanteventinyourlifeoverthepastyear?Inwhatwaysdoyoufeelyouhavechangedoverthepastyear?Whatdoyouvalueinyourlifenow?Whatareyourdreamsandgoals(short‐andlong‐term)?TODAY’SDATE:

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Howdoyoufeeltoday?Anyonecanreflect!Onanything!Here’sanexercisetoconvinceyouofthis.Allyouneedtodoisthinkbackonyourday(oryesterday,iftodayisyettounfold)…Jotdownatimeyoufeltgoodtoday.

Jotdownatimeyoufeltfrustratedtoday.

Pickanyoneofthefeelingsonthenextpageandjotdownatimeyourfeltittoday.Whatisonethingyouwouldchangeaboutsomethingyoudidtoday?Whatisonethingsomeonedidthatimprovedyourday?

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(http://www.angiogram.com/feelings.html)

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TROUBLE‐SHOOTING!Whenaskedwhattheyfoundmostproblematicaboutstudentreflections,DPAStutorsrespondedwiththefollowing:

TheProblem TheSolution!overlyoptimisticreflections

Takeoffthoserose‐colouredglasses–reflectionsshouldnotbeartificiallyoptimistic.Whennegatives,doubts,oranxietiesstarttoemerge,youknowyou’vedelveddeeplyintotherealmofpersonalreflection.Keepinmindthatsomeofthemostilluminatingreflectionsresultfromtheprocessoffailure,fromwhichlessonsarelearned.Disappointmentsareinevitableinlifeanditiscriticalthatyouincludethemintheprocessofreflecting.

overlypessimisticreflections

Anentirelynegativereflectionisjustasconcerningtotutorsasanentirelypositivereflection.OneofAlbusDumbledore’spearlsofwisdom:“Happinesscanbefoundineventhedarkestoftimes,ifonlyonerememberstoturnonthelight.”Sure,reflectivewritingwasn’tquitewhathehadinmind,butthepointstandsthatifyoulookhardenoughwithinyourself,youwillfindsomethingpositivetoincorporateintoyourreflection.Byallmeans,ventaboutthepast,butdon’tforgettoprojectsomethingconstructiveforthefuture!

solelyobjectivereflections

Remember,simplyholdingupamirrorjustgivesobjectivedetails.It’suptoyoutostepbehindthemirrorandplaceyoursubjectiveselfintothereflection.

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WHEREMIGHTIPUBLISHMYREFLECTIONS?Firstoff,congratulationsonnotonlymasteringtheskillofreflectivewritingbutbeingwillingtosharepubliclywhatmaybeverypersonalthoughts.Variouspublicationswelcomenarrativemedicinesubmissions–herearesomeyoumaywishtolookinto,severalofwhichhavepreviouslypublishedworksubmittedbyUBCmedicalstudents:

o UBCMedicalJournal(UBCMJ)o CanadianFederationofMedicalStudents(CFMS)AnnualReviewo DalhousieDepartmentofPsychiatryAnnualStudentWritingCompetition(Octoberdeadline)o TheIntima:AJournalofNarrativeMedicine(ColumbiaUniversity)

Asfoodforthought,hereisanexcerptfromTheIntima’ssubmissionguidelines(www.theintima.org):TheIntimapublishesoriginalcontributionsthatrelatetothetheoryandpracticeofnarrativemedicine.

Non­fictionPerhapsnowhereinliteraturedoesthewrittenwordholdmorebountythanthenarrativeexperience.TheIntimawelcomessubmissionsofclinicalresonancefromapersonal/familial/professionalperspective.FictionTheabilitytolookatexperiencesfromadistanceallowswritersandtheirreaderstocapturetheessenceoftheintimateexperienceinanewframe.There‐issuingofthoseexperiencedscenescapturesandre‐examinestheimpactofhealthcareviatranslation.PoetryPoetryevadesstrictdefinitionandaccordingly,thissectionmaycontaindiverseformsofwriting.Authorswillsubmitpoemsthattheybelievespeaktothethemesofnarrativemedicine,andthepoetryeditorwillchooseseveralpiecesthatpoignantlyandvividlyrepresentdiverseviewpointsonthetopic.AcademicNarrativemedicineisanewlyrecognizedentity,seekingtoreinforceandre‐definetheinterfacebetweenpatientandphysician,caregiverandpatient,patientandfamily,allthosewhoselivesaretouchedandalteredbytheexperienceofillness.Methodology,essay,practicumexperience;allservetoshare,educate,andpromotetheskillsandhorizonsofthepracticeofnarrativetechnique.FieldNotesTypicalstylesofwritingtobefeaturedwillincludedescriptive,exemplification,andnarrativeessaysthathighlightthepersonalexperiencesandfirst‐handaccountsofprovidersimplementingnarrativemedicinetechniquesandstrategiesintheirwork.Also,participantsinnarrativemedicineworkshopsandprogramscansubmitnarrativeessaysthatdescribetheirexperiencetakingpartinsuchactivitiesandtheoutcomesoreffectspostinvolvement.StudioArtTheIntimawelcomespainting,photography,orothervisualrepresentationofnarrativesasopportunitiestoexploreboundariesofhealth,wellness,andthepoweroftelling.MultimediaTheIntimaChannelfeaturesaudioorvisualrecordingsthatexplorethemesinnarrativemedicine.

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UBCMedicalStudentReflectiveWritingSamples

You’re WHAT?! “The next one’s interesting,” the nurse called out to me as she passed by. “70 year old woman, thinks she’s pregnant. Probably dementia, if you ask me.” My eyebrows shot up incredulously as I turned to thank her. Recomposing my face into the neutrally friendly, calm demeanor I was learning to associate with professionalism, I knocked and entered. Across the room sat Meredith, wearing copious amounts of make-up, large flashy rings on her wrinkled hands, and a wig of dark red hair that nearly hid her age. She fidgeted in her chair, staring at me, her eyes having darted towards the door as soon as it had creaked open. I introduced myself and began the interview, “What brings you to the office today, Meredith?” She replied, “I think I must be pregnant, because I’ve been having all the symptoms of pregnancy. And just so you know, I have five children, so I know what it feels like.” She paused, daring this young first year medical student to challenge her. I asked her to describe her symptoms. “I feel bloated, and I’m always nauseous, and I threw up a few times,” she rattled off, “I’m also getting lots of cramps in my uterus, and I have to pee a lot too. I’m telling you, I don’t know how, but I’m pregnant!” I paused, caught in the moment between trying to remain engaged in the conversation, thinking about what could possibly be going on, and pressuring myself to ask an intelligent next question. Was this dementia? Did she just want to become pregnant? Or was I about to witness a new world record? I noticed Meredith watching me closely. As the confused pause got longer and longer, I blurted out the first thing that came to mind, “Ok, so when’s the last time you had, er, intercourse?” “Three days ago” My eyebrows shot up again before I could stop them. She continued, “About six months ago, I met my current boyfriend, and we’ve been madly in love ever since.” “That’s great!” I offered, a bit weakly. “When do you think you got pregnant?” “Well, all my symptoms started about a month ago,” she replied. “My boyfriend and I also had sex around then, so maybe that’s when it happened.” “….Maybe” I replied, avoiding her gaze, which had never left mine. After confirming that she was indeed post-menopausal, I glanced up at the clock, surprised to see that more than five minutes had already passed. Anxious to gather more information before my preceptor came back, I asked in rapid succession, “Did anything else change a month ago? Your diet? Your bowel habits? The color of your urine?” “No,” she replied curtly each time. “I took a pregnancy test which was negative, but I want the doctor to give me another one.” “Ok I’m sure we can arrange that,” I replied quickly. “Do you have any previous medical conditions, and are you on any medications?” “I have diabetes and hypertension. I’m taking pills for both but I don’t remember what they are. Isn’t the doctor coming in soon?” Right on cue, my preceptor strode in, signaling like a buzzer that my time to solve the case was up. Meredith immediately turned her attention away from me and greeted her doctor, a note of relief in her voice. My preceptor glanced down at the chart, turned to me and asked me to present my patient. Tentatively, I began, “Meredith is a 70 year old woman who has one month history of nausea and vomiting, uterine cramps, bloating, and urinary frequency. She believes she’s pregnant.” I paused, searching my preceptor’s face for any clue. Glancing up from the chart, my preceptor asked, “Did you ask her whether she’s on any medications?” Meredith answered for me, “Yes, I’m on two high blood pressure medications, one diabetes medication, and the cancer medication you gave me last month”

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“Oh, what’s the cancer medication for?” I interjected. “My breast cancer,” she replied. My preceptor explained to both of us that Tamoxifen, the medication prescribed for Meredith’s recent recurrence of breast cancer, was the likeliest cause of her symptoms. Meredith’s requested pregnancy test was negative, and with a laugh and a sigh of relief, she thanked both of us for seeing her and left the office. Afterwards, my preceptor turned to reassure me, “Meredith probably doesn’t share her breast cancer diagnosis with everyone, so don’t feel bad.” I nodded, wondering if she might have chosen to confide in me, if I had focused less on solving the clinical puzzle, and more on the confused, near-panicked woman who thought she was going to have to give birth again.

Just a Stranger on the Bus Rays of late-September sunlight flood the crowded Mount Pleasant Funeral Home as second year Island Medical Program students read the final lines of a Johnny Hathcock poem:

Weep not for me, though I be gone. I shall not really die.

A diverse crowd fills the hall’s wooden benches: from the wide-eyed baby sitting in his father’s lap to the elderly couple clutching Kleenex in the front row, people of all ages have gathered for the UBC Faculty of Medicine’s 2010 Donor Memorial Service. I stand against the wall in the overflow room to the side of the main hall, amongst a crowd of fellow first year medical students. Their neatly pressed suits and respectful stance would not suggest the revelling of less than twelve hours past at the first year medicine toga party. As the first lines of the medical students’ a cappella group’s Irish folksong ring out into the hall, I watch a snowy-haired couple in the second row dab their eyes. A minute of silence is observed to respect the cadaver donors. After twenty minutes the families shuffle slowly to the front of the hall to each receive a potted chrysanthemum and card written by a second year medical student. We watch from the overflow room, exchanging whispered thoughts on the brief ceremony. I make small talk with a fellow classmate as I try to recall his name from the 255 I have been attempting to learn over the past several weeks. Sweat beads on his forehead in the warm and crowded room; everyone complains of the heat. We fall silent and smile at a silver-haired lady who walks over to ask if we are “the medical students”. Her voice breaks as she tells us that her father was a doctor and that we have an amazing future ahead of us. She apologizes for being emotional and thanks us profusely; we thank her in return.

As she walks away I cannot help but wonder what she is thanking us for. Does she know that we have completed exactly three weeks of medical school? That it was only two days ago that I figured out which way my stethoscope earpieces should be directed to avoid putting it on backwards? Minutes later an elderly man tells me that his father is one of the donors, and jokes that his dad, who never had a post-secondary education, saw donation as his chance to go to university. As was the lady who thanked us earlier, this gentleman appears to be very pleased with us.

It feels undeserved to receive such respect from strangers upon mere mention of our chosen profession. As of my birthday five days ago I am no longer a teenager, but still feel overwhelmed by the social responsibility already encroaching upon us. New experiences have been coming at us quickly over the past few weeks, and we have a lot to learn between now and the day when wearing our white coats and stethoscopes no longer feels like a game of dress-up.

As we mingle in the crowded reception room, balancing paper plates of fruit and Styrofoam cups of coffee, I watch the family members, wondering who, if anyone, is here for the person we currently have wrapped in white sheets in the sub-basement anatomy lab. We know only that our cadaver is a 102-year-old female—the oldest donor this year. Any children she may have had would now be elderly themselves.

As of three weeks ago I had never seen a dead person or even attended a funeral. Then came the first day of medical school, when I found myself making an incision into a dead lady’s back with my

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classmates doing the same on the 52 other bodies around me. As we were told on the first day of gross anatomy, it is not normal to be in a room with 53 dead people. It seems that to avoid being unnerved by this, it is easier to regard the cadavers in the gross anatomy lab as bodies, rather than as people. With the cadaver’s face covered and body shrouded with sheets, only exposing the region currently being dissected, the uneasy student can detach the technical work from the human being in an almost surreal setting. Some students prefer it to be this way—when offered the opportunity to look at their cadaver’s face they choose not to do so. During the third lab when some of our group members decided that they were ready to see our cadaver’s face, I joined them to look upon the face of the person from whom we had the privilege of learning.

Indeed, it is a privilege to work with cadavers. Yesterday, holding our cadaver’s heart in my hands, I examined the valves and chordae tendineae—structures as perfect as those drawn in our Gray’s Anatomy textbook, even after 102 years of constant work. Being able to look at the inside of a person’s heart—an organ that has been beating through every experience in their life—is a remarkable feeling, and drew all of us closer to the lady behind the body on our table.

And so, as I stand on the crowded B-line bus headed back to UBC, I think about what I have had the privilege of experiencing over the past few weeks and about the new weight of social responsibility that accompanies. Though in gross anatomical terms I am in no way distinguished from the old man in a paint-speckled jean jacket, the Chinese lady knitting a scarf, or the skateboard-carrying teenager whose iPod I can hear from two rows away, I realize that these people may be my future patients; under the pretence of my profession I am no longer the ordinary person standing beside them on the bus, but a professional who they can trust with their problems, secrets, and, ultimately, life. It is humbling to realize the confidence which complete strangers have in me, as I begin my education in this interesting field.

We grow We turn from our past, we leave it broken; we start to weave new tales, unspoken Our canvases dry, our brushes wet but what to draw? What forms to set? A golden day? A stormy night? it is our choice, it is our right. Our right? Well, yes, it seems that way

but we’re not the ones who have all the say For above our bodies there appears an good old friend and pupeteer Who tweaks the strings, just slightly, though to turn our courses, to and fro. It may seem futile, grueling at times caught, entangled amidst these lines An evil force, you dare argue well, no, that simply isn’t true! You struggle, you fight, you scream aloud but are you quite so strong and proud? For if you look, you’ll see at last

that where you go and where you’re cast It is not off the course you choose but just a path you thought a ruse.

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But fear not, child, let down your guard for where you’re going, isn’t far. It may seem dire, it may seem dark your life’s newest black mark Shall we take the chance? Accept the dare? or will we cower when we get there? Avoid the new; proclaim it dead and you will never get ahead What’s that, you say? You still resist, that which the pupeteer insists? I’m sorry, dear, what else to say but you may not have it just your way So shriek to me, cry out your pain just know that it will be in vain You fought it so, you tried your best and yet, you still must face this test You’re angry, you say? Well I’m not shocked you thought your fate was all but locked May you, for once, accept this trial and meet it not with fear, but guile Self-riteousness; the curse you wield it cannot, now, remain your shield You bare it so, you show it off to those at whom you’d sooner scoff And now, you think, this is not fair? The pupeteer, he does not care.

Life Choices Shaun: Alright, just one more DPAS assignment then I can focus on the exams. Shaun reads the selected case for his Ethics presentation... Shaun: Hmm. Alright, a person with ALS wants to live out her life until she is no longer able to function, at which time, she would like assistance in ending her own life with the help of her doctor. Logic: She makes a good point here. People without disabilities are able to end their own lives. By not allowing her to receive help in doing so when she is completely disabled, that is somewhat prejudice. Morality: Really? Do you honestly think that it’s right for anyone to be able to end their own life? Shaun: I suppose I don’t really think that. But I have to think about what is better for my patient, right? By saying “no”, I am allowing my patient to suffer. By saying “yes”, I am allowing her to die. Logic: Exactly. It’s a weight of quality vs. quantity of life!

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Morality: Take a step back here. By saying “no”, you don’t KNOW if your patient will suffer. By saying “yes”, you are not simply letting her die, you are KILLING her! Logic: People kill deer they have hit on the side of the road to prevent suffering. We actively euthanize pets when they have gotten to a point of suffering from illness or age. Is this really any different? Morality: Of course it’s different! We are talking about human life here! Logic: Yes, and we are also talking about human suffering! We cannot neglect that fact. Shaun: If I end up doing this, perhaps I’ll be doing my patient a service, but what about the rest of society? What about her family? Logic: When she has become disabled, she will be a burden on them. She has said she does not want to do that to her family. Morality: What about how much they love her? Is it really within your rights to rip that away from other people? Do you really think you should be the one making the decision for this family? Shaun: So we’re back to quantity vs. quality and now, burden vs. love? I can’t say that I am enjoying this as much as I thought I would. Am I really going to have to do this all the time? This isn’t standard is it? Logic: If it is, then you’d better be prepared to deal with it. Start right now. If you were talking to this person right now, if they were suffering in front of you, would you really refuse to help? Shaun: Well, no, of course not. Morality: You don’t have to refuse to help her! You just have to refuse to kill her! There isn’t all that much to think about here, is there? Honestly, can you think of nothing else to do but to help take her life. Shaun: I guess I can. I mean, I don’t know what I can do at this point, but there must be something that might be useful to do. Logic: And go against the wishes of your patient? What about patient autonomy? Aren’t you obligated to adhere to your patients’ wishes to the best of your ability? This would cover autonomy, non-malificence, beneficence. What more do you need? Morality: Maybe you need a bit of heart! This isn’t just an isolated thing. Sure, if you read a black and white list, maybe you’re doing the right thing, but is that really all you should do? Shouldn’t you think for a second at least what the far reaching issues might be? Do you really think that that is the RIGHT decision? So what? You’re a big doctor now? What gives you the right to deal out death? Who put that power in your hands? Shaun: Maybe I should go to bed and think about this a little later... Logic: Look, you know that you won’t be able to let this person suffer. The only logical choice is say “yes, you don’t deserve to have to live like that, I will help you”. Would YOU like to live like that? What would you want to do? Shaun: I guess... Yeah, when you put it that way. It does make sense. I suppose that I would feel like I should help them to end their life. I don’t think I’d want to be in that state either. Alright, yeah, my decision

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would be to help this woman to end her life when she became too debilitated to do it herself. And besides, this isn’t a real situation. It isn’t like I’m actually doing this, right? Morality: Whatever helps you sleep at night...

Ngo Ah Ma Suo Ga Ngo ah ma suo ga repeats the Chinese lady, leaning on the examination table with a tired look on her face. Her brother nods in agreement as the elderly Chinese doctor leans forward to make a note on the chart. The small, windowless examination room is crowded with the doctor, sister, brother, a female caretaker, and the patient herself—a silver haired, frail, elderly Chinese lady wearing a bewildered expression and casting anxious glances at my classmate and me as we stand in the doorway in our new white coats, stethoscopes on our shoulders, and SOAP forms at the ready. I glance from my partner’s SOAP log, which he is filling out at a feverish pace as the interview unfolds before us, to my own blank sheet, and regret not paying better attention in Cantonese school. I catch the odd word—milk, sleep, bathroom—but have to wait for the doctor’s translation. Ngo ah ma suo ga—“mother is crazy” say the sister and brother of the elderly lady in the chair. She watches them indifferently, seemingly oblivious to this comment. “She just wants attention.” The doctor directs a question towards the old lady, who stares blankly in return. “She can’t hear you. She will not wear her hearing aids.” The questions are redirected to the caretaker. The sister and brother continue to interject. I give up on trying to follow the Cantonese conversation and resort to sneaking glances over my partner’s shoulder at the English notes he is scribbling in his clipboard. It is elucidated that the elderly lady has been complaining of headaches each evening, just as her caretaker finishes her work shift and prepares to depart. The doctor asks for clarification on the nature of these headaches, but is unable to get a clear description of the pain from the family members or caretaker, who continue to insist that the old lady is fabricating the pain as a means of extending the caretaker’s work day. The doctor probes this hypothesis. “How often do you visit your mother?” “Once a month.” The exchange continues for another fifteen minutes; all the while the elderly Chinese lady remains quiet and fidgets with her cardigan buttons. The elderly Chinese lady was the first patient I encountered at my first family practice preceptor visit during my fourth week of medical school. This experience in particular served as my introduction to two of the subjects addressed during the past DPAS block: linguistic and cultural diversity, and vulnerable populations. Spending the next four Thursday afternoons in this Richmond preceptor practice, seeing primarily ethnic, senior patients, exposed me to many instances of both. Linguistic diversity was particularly visible in my preceptor’s practice, ranging from various Asian languages to Spanish. A professional translating service was never employed; instead, it was common for an older non-English speaking patient to be accompanied by a child who did know some English. As in the case described, this often resulted in a narrated or edited relaying of information. While family members seemed eager to share their thoughts on the illness, collecting useful “FIFE” data from the actual patient often presented a challenge when all conversation was filtered, in both directions, through the family member. “Can you increase the dose on mother’s sleeping pill prescription?” “Rather than increasing the sleeping pill dose, you might try giving her a cup of warm milk before bedtime to help her sleep.” “No, no, we’d prefer the pills. With the milk someone would have to help her to the bathroom during the night.”

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The elderly lady does not participate in this conversation. This exemplifies one danger of communicating through family members—although they know and understand the patient better than would a professional translator, they may have their own ideas of how treatment should proceed and advocate for these rather than allowing the doctor to explore alternative options with the patient. As it is often the older generation in ethnic Canadian families that has difficulty communicating in English, this group constitutes a vulnerable population. If my preceptor’s practice in Richmond is at all representative of the extent of cultural diversity in the Lower Mainland, these non-English speaking seniors account for a fairly substantial portion of patients. While many of these elderly patients may originate from cultures that foster close family relationships and endow children with the responsibility of caring for their aging parents, it is likely the case that these same cultures emphasize a sense of pride that might dissuade seniors from seeking medical help. Growing up with some Chinese influence, I am aware that “losing face” or dishonouring one’s family is a particularly prevalent fear amongst the older generation. This might lead to a propensity amongst traditional Asian families to downplay their problems, and a reluctance to discuss family issues—particularly psychological disorders—with a Caucasian doctor. As such problems might traditionally be dealt with within a family, this population might not seek medical help out of fear of instigating trouble, a suspicion or distrust of western medicine, or simply the worry of not being able to communicate in English. In addition to linguistic diversity, cultural diversity was apparent in the manner in which my preceptor interacted with his patients. Rather than initiate friendly small talk, the Chinese doctor was to the point, which was efficient but seemed a little curt. The patients, however, seemed receptive to this approach, which goes to show that the superfluous and idiom-ridden sentences native English speakers construct might seem unusual and inefficient to cultures where it is acceptable to be more brusque. Canada being such a culturally diverse country, it benefits medical students to experience interacting with patients of various backgrounds, in order to become sensitive to the unique challenges linguistic and cultural differences may present. In addition, we should challenge ourselves to identify vulnerable patients outside of the stereotypically defined categories. Developing awareness of both cultural and linguistic diversity and vulnerable populations will afford us a better understanding of our patients and provide a different perspective on their problems that may allow us to better resolve their medical concerns.

The Experience of Trauma

My grandfather never talked about the three years he spent in a Nazi concentration camp, that is, unless he had a bit too much to drink. I can remember one night many years ago when he bought a big bottle of wine to celebrate my cousin’s Bhatmitzvah. Since my cousin and I were both only 13 at the time, he had most of the wine himself. Then, he started to talk about the past. He told us that, when he was our age, his teacher called him to the front of the class, slapped his face, called him a dirty Jew, and told him not to come back to school. A few months later, Nazi soldiers came to his home and made him watch while they shot his dog. When he was 15, those same soldiers came back, this time to take him to an extermination camp in Poland called Treblinka. Every morning, he and the other prisoners were made to stand in a line and every fifth person was shot. Miraculously, my grandfather was never number five. Somehow, he managed to escape from the camp. When he was hiding in the forest, the Russian army found him and he stayed with them until the end of the war. Then, he went home and started medical school. My grandfather’s story taught me about the resilience of the human spirit. He went through the worst situation a person can endure and remained strong enough not only to survive, but to become a doctor only a few years later. I grew up believing that his desire to thrive despite the obstacles was innate to everyone and, therefore, any kind of psychological trauma could be overcome with enough effort. Recently, I met someone that challenged this assumption. While I was doing my family practice rotation, I was asked to take the medical history of a woman I will call Krystal who was suffering from an extremely debilitating anxiety disorder. When I lead her into the examining room, she insisted that I leave

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the door wide open because she was claustrophobic. She sat curled up in a ball, speaking very quietly and never making eye contact.

Krystal said that, one year ago, she was taking the elevator to work when it malfunctioned. For half an hour, the elevator went up and down the 40 story building with Krystal trapped inside. She said that, since the incident, she was scared all of the time. She reported trouble sleeping and a fear of leaving her home. She had not returned to work since the event and complained that she was not getting enough workers’ compensation. While Krystal was telling me her story, I felt a disconnect between what I was saying and what I was feeling. I was careful to convey that I understood how Krystal’s elevator experience could lead to her anxiety but, truthfully, I had a very difficult time empathizing with her. I could not understand how my grandfather could have gone through three years of starvation and forced labour while watching hundreds of other Jews being killed everyday and still come out less traumatized than Krystal who spent 30 minutes on an out-of-control elevator. I felt the urge to blame Krystal for her anxiety. Admitting this urge to myself made me feel cruel and insensitive; I questioned whether I had the right disposition to help Krystal. It did not take long for me to recognize that if I acted on my true feelings, I would be perpetuating the stigma of mental illness by blaming the victim. I did not have nearly enough information to make any kind of judgment about this woman. I let Krystal talk and tried to keep my mind as open as possible. Soon, I got a fuller picture of her experience with trauma. Krystal was sexually abused as a child and that may have predisposed her to an anxious personality. She may already have been standing on the boundary between mental health and mental illnesses when she walked into the elevator that day and the stress of a chaotic elevator ride pushed her over the edge. The day I met Krystal was the day I realized that I had to change my assumptions about how people deal with trauma. Each person has different genetic predispositions, brain chemistry and past experiences that can influence how a given trauma is experienced and what kind of lasting impression it will have. Perhaps my grandfather was not disabled by the psychological burden of being in the camps because he came from a stable, loving home and was blessed with an optimistic outlook on life. Conversely, Krystal’s history of sexual abuse may have exacerbated how she experienced the elevator malfunction. In my future contacts with anxious or depressed patients, I will try to avoid making automatic assumptions and keep my mind as open as possible so that I can allow myself to really hear how the person got to where they are now.

It’s All Palliative Dr. S. makes minute adjustments to the rectangular irradiation frame she has drawn upon the image of a femur on her computer screen. The image is blurry: all I can see is the bright electron lucent shape of a bone against a dark background. Beside Dr. S. is a previous scan, which shows a dark metastatic region on the femur. “That’s what we’re looking for,” she tells me. She adjusts the viewing frame a little more. I stare hard at the image, trying to see the metastasis and wishing I had paid better attention in radiology. It turns out Dr. S. cannot see the metastasis either. “I think it’s around here…it must be,” she muses, dragging the rectangle a little larger, “You can’t be a perfectionist. This is all palliative anyways.” I have heard that line more often that I would have liked today: “This is all palliative anyways.” In my seat beside Dr. S. in the darkened control room, I feel like I’m in a recording studio. Rather than affording a view of musicians though, the window in front of me shows an unusual scene. Atop a metal and glass platform lies a frail looking elderly lady; see looks very small, dwarfed by the large linear accelerator looming above her. I cannot see her face, as a white plastic mesh mask, molded to fit her facial features exactly, has been placed over her face and screwed tightly into the metal platform beneath her. I wonder whether she feels claustrophobic or afraid, caged and unable to move. I watch as red laser spots dance over her head in the darkened room. It is essential that she remain completely still during the irradiation of her eye cancer, as an off-target beam could cause instant blindness. I see the glint of the patient’s eyes

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through the mask as Dr. S. tattoos rectangular radiation field outlines onto her body with a black permanent marker. After adjusting irradiation frames on the lady’s femur and eye, Dr. S. moves on to target a dark area on her left seventh rib. On the full-body scans I can see similar dark areas within other ribs, though twenty minutes earlier when I palpated the lady’s anterior chest, she did not complain about pain elsewhere. This particular spot had been a bit sore: “We may as well give it some radiation while you’re here. It’s a long drive from Qualicum,” Dr. S. tells the patient. Dr. S. explains to me that she probably wouldn’t treat a local patient so radically, but as the Victoria Cancer Centre is the only place on Vancouver Island providing radiation therapy, considerations must be taken for patients living farther north on the Island, especially those with mobility issues who do not travel to Victoria frequently. “This is all palliative,” she tells me again, seeming to have heard my unspoken concern for radiating so non-specifically on this frail patient. Although this is my first day of shadowing radiation oncologists at the BC Cancer Agency’s Vancouver Island Centre, I have already seen my fair share of red, raw peeling skin and blisters on fatigued and nauseous patients—all side effects of radiation cancer therapy. After being exposed to such reminders of just how powerful radiation therapy is, I expected that the radiation field planning process would be very meticulous, taking absolute care to irradiate only the cancer while avoiding healthy tissue. In contrast to this impression, it seemed almost careless to be marking out radiation fields by dragging rectangles over what seemed to be vast swaths of femur, in this hopes of “roping in” the invisible metastasis. “It’s all palliative,” I thought, grimly. This patient most likely will die within a few months, so it does not matter if healthy bone is radiated, so long as the cancer cells are killed to ease her pain. The bright, beautiful décor and cheerful volunteers bustling around the building distract from the distressing associations I imagine many people have with the BC Cancer Agency. As I offer a box of Kleenex to a mother and daughter who are in tears, I can’t help but think of how many families have been in this position, receiving what could potentially be the worst news of their life, in this very office. This is the first time I have been around such upset patients; crying patients still make me uncomfortable, as I haven’t really figured out what I can say or do to comfort them. The radiation oncologists I am shadowing are very calm around upset patients. Dr. O. explains that it is important to always be sensitive towards patients. Regardless of how rushed he is, he forces himself to sit down upon entering an examination room, even for the shortest of exchanges, just to ensure that he gives patients a fair amount of time and attention. Dr. O. teaches me to place a reassuring hand upon a patient’s shoulder—something my clinical skills tutor would never condone. I get the impression that oncologists have a closer relationship to their patients than some other specialists might, as they are the doctors cancer patients place their full trust and hope in over many months or years. In fact, a cancer patient I saw yesterday at my preceptor’s office did nothing but praise her radiation oncologist and proceeded for ten minutes to tell me funny stories about everything from his fashion sense to wife and children. Indeed, before Dr. O. and I walk into the examination room to see our first patient, he stops to remind me that these patients are particularly vulnerable—they have complete trust in us and therefore will be uninhibitedly open—and that is something that we must never abuse. Upstairs in her office, Dr. S. shows me radiation plans she is working on with the dosimetrists in the medical physics department. Precisely mapped out and analysed with advanced computer software, then tested with a run-through on a “phantom” of diodes, these plans are a far cry from the quick rectangular dose fields she had drawn out on the palliative patients this morning. This is the mathematical, objective view of radiation therapy I took away from my four-month work term in the BC Cancer Agency’s medical physics department last summer. Back in July, as I stood at the linear accelerator aligning flasks of cancer cells in the radiation field, I recall having the realization that the metal platform onto which I was placing my flasks had held a cancer patient all but thirty minutes earlier, receiving the same treatment that I was administering to my cell experiment. I often carried my cell flasks past these patients in the waiting room, but it was not until now, shadowing the radiation oncologists, that I have had the privilege to see the human aspect of radiation therapy, and the illness rather than the disease. While from a physics perspective a tumor is a geometrical conformation of cells whose ideal radiation plan may be calculated objectively, from a

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medical perspective the “it’s all palliative” patient context provides sufficient reason to abandon the math and irradiate on instinct. It has been most interesting to experience both viewpoints.

While I was applying for medical school, I felt pressured to give the admissions committee the impression that I intended to eventually specialize in family practice. Even though I was aware of the nationwide shortage of physicians in all specialties, it seemed that the lack of general practitioners (GPs) was causing the greatest concern. Now that I am in medical school, my feeling of being nudged towards family practice has only become stronger. I think the reason why medical schools are now motivated to mold the majority of their students into GPs is because society is recognizing the essential role that those physicians play. When I imagine the Canada’s medical system as a bicycle wheel, I see GPs at the centre and all other specialties along the spokes. This is because GPs are the primary and most responsible physicians, the ones who organize care for their patients. Also, by being able to see their patients regularly over an extended period of time, they are in the best position to catch illnesses early, which improves outcomes and reduces the need for expensive interventions. Thinking about it this way, I can certainly understand why so many Canadians are distressed about not being able to find a GP. My medical school has good reason to be nudging me towards general practice. However, a whole lifetime of experience is pushing me in the opposite direction. My mother is a GP and, until recently, she had her own private practice. I think she is a wonderful doctor and her patient clearly adored her, yet some of the things she has told me make family medicine seem like an unattractive career choice. For example, she had a very difficult time finding a locum in the last few years of her practice so it was nearly impossible to get time off work. Another common complaint of hers was that there was a large amount of paper work that has to been done, such as filling out disability forms or work absence forms, and the pay for that work was very little. She also told me that many of her patients would go to walk in clinics for simple complaints such as a runny noise but would save the really difficult medical problems for their GP. What disturbs me the most about family medicine is the idea of being on call as GP. Most patients expected a diagnosis and treatment over the phone. When my mom was on-call, she not paid for providing this service but was fully responsible if she said anything incorrect. This seems very unfair to me since the nurses at the nurses’ hotline do essentially the same thing but get paid for it. In general, most of what my mom has told me over the years about her job have been good things but, for some reason, these negative examples stand out in my mind far more. When I think about what type of specialty I would like to go into, I feel as if I am being push both towards and away from family practice. I recognize the dire need for family doctors and I see how much my preceptor seems to enjoy her work. At the same time, I am put off by things I have heard from my mother about family medicine. I find this dissonance to be confusing and unnerving. While I was reflecting on this issue, I called my mother and asked her what she would do if she could live her whole professional life over again. She said that she would still go into medicine and still be a family doctor, but that she would not go into solo private practice because there was not enough professional support for her to fall back on. Sure enough, when she said this, I remembered times in my childhood when I was so sick I could not go to school and she could not stay at home to take care of me. Instead, she took me to work and made a bed for me under her secretary’s desk. Perhaps if she had had a partner, he or she could have filled in for her for the day. When I am a doctor and my children are sick, I hope my practice will be flexible enough for me to stay home with my children if they need me. I recognize that the situation for GPs may have changed since my mom retired. I am hopeful that if they have not changed yet, they might in the future. Things have been getting progressively better for doctors. For example, few residents have to be in the hospital for 36 hours in a row now, which was not the case when my grandfather was in training. I have come to a two major conclusions based on my mother’s experience with family practice, one that extends to the entire Canadian medical system and another than affects only myself. The first is that if Canada wants more doctors to go into (or stay in) family practice, it must recognize and address the major concerns of GPs. For example, GPs should be paid to be on call just as nurses are paid to monitor the

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nurses’ hotline. Also, the billing system should be changed so that family doctors get paid more to handle the complicated cases that are left over after the simple cases are dealt with by walk in clinics. On a more personal note, I have decided that family medicine is not off the table for me as a future specialty. In the next few years, I will be attentive to any changes in the Canadian medical system that affect GPs and I will continue to keep my eyes and ears open while I am shadowing my preceptor in her practice. I am already anxious about choosing the right specialty but the only that I can do now is be open to all experiences and learn as much as possible.

A Night In The ER

At 9:55 pm on Friday night I pull up next to a lone car in the patient parking lot of the Saanich Peninsula Hospital. Surrounded by daffodil fields and acreages, this hospital does not quite share in the hustle and bustle of the Jubilee or Victoria General. Certainly on this Friday night it feels deserted. When I arranged to shadow Dr. M. on his ER night shift I wasn’t quite sure what to expect. Seeing as my only exposure to Emergency thus far has been from television dramas and belaboured newspaper editorials on wait times, part of me did expect to walk into a world of harried doctors and disgruntled patients. At the least, I did not envision the empty, darkened waiting room I stepped into that Friday night. “4-3” calls a nurse to Dr. M. as he walks past. I spend a moment contemplating what this could possibly mean. Some kind of ER jargon? Nope. Not even close. It’s the score of the Canucks-Blackhawks game (and probably the reason behind the empty waiting room). I listen as Dr. K., who is just finishing his shift, briefs Dr. M. on a handful of patients that have been admitted, and a few more who are waiting in examination rooms to be seen. They seem to be pretty typical cases: a few people with pain, and one lady with shortness of breath. Dr. M. hands me the first chart—21-year-old male, abdominal pain—and points me to Bed 5: “Go get started!”. I walk up to the curtained-off bed, prepared to fire off my arsenal of clinical skills pain questions. But the curtain is drawn closed. What’s the protocol for entering a curtain? I can’t very well knock on it. Fortunately one of the patient’s friends is on his way out and pulls the curtain open, solving my problem. I introduce myself to the patient, but his other friends are in the way so I can’t get around the bed to shake his hand. Oh well. Where to stand? There’s no room at the head of the bed. I put the chart and my clipboard on the high table at the foot of the bed and settle on questioning the patient from there. Too impersonal? I don’t know. I ask a few questions. No family history, just cut to the chase. Chief complaint? Affected area? Time of onset? Severity on a scale of ten? Oh wait, the triage nurse has already done all that. It’s all here on the chart. Nevermind. Okay, more specific questioning. How about FIFE? “What do you think might be causing this pain?” I query. “Contractions. He’s in labour.” interjects a friend. “I’m Facebooking that!” laughs another. Next thing I know he’s got his iPhone out, taking a picture of his hospital-gowned friend. I try again: “Any ideas?”. Appendicitis is brought up. Quick. Think. Where’s the appendix? McBurney’s Point. One third of the distance from the ASIS to the umbilicus? Sounds about right. But wait, isn’t appendicitis pain first felt referred to around the umbilicus? Better ask about that. “No, it’s just on the right side.” Okay. There’s embarrassed mention of constipation. But doesn’t the chart say most recent bowel movement was “a few minutes ago”? It does. It’s a good reminder though: abdominal pain may be something gastrointestinal. Better ask about stool. Any changes in the past few days? No. His friends are laughing. Stool any different from normal? No. I’m embarrassing the patient. Blood in stool? No. More laughing. “Sorry, I’m really immature,” he apologizes. Time to report back to Dr. M. But where’s the chart? Oops. Left it by the patient’s bed. Go back to get it. Not thinking straight and it’s only 11 pm! Looks like it’s going to be a long night.

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“You’re forgetting something,” Dr. M. tells me. I guess, incorrectly. “There are two important things in emergency medicine: one, is the patient well or unwell?; two, do we need to send them to a bigger hospital?”. How could I have missed that? This patient is well, joking with his friends, not seeming the least bit sick—something so obvious I forgot to even mention it. Over the next few hours I learn that emergency medicine is all about details—picking up on small bits of information that may not seem significant to a first year medical student, but are pertinent clues to the detective work involved in determining how to help the patient. Could the red streak down this patient’s arm be related to the IV he received five days earlier? What developed first, the redness or the pain? In the ER, it seems that making a diagnosis is less critical than stabilizing a patient. Especially in the middle of the night, when lab and x-ray technologists are not around to provide diagnostic results, simply providing a patient with codeine may be the most productive immediate action towards alleviating their distress. While making a diagnosis may not be paramount, there are often cases in which decisions must be made without delay (it is “Emergency”, after all). This is where the “team” aspect of emergency medicine comes into play, in contrast to the isolated family practices to which we have so far been primarily exposed. The next patient Dr. M. and I see is my first encounter with a more serious health problem, requiring imminent treatment, and an example when acting quickly could significantly impact an outcome. A middle-aged woman, on warfarin for deep vein thrombosis and pulmonary emboli, is at the ER with a severe headache. A CT-angiogram has revealed intracranial bleeding. The doctor debates sending her to Victoria, and telephones another physician who has previously encountered the patient for further insight. Though Dr. M. says that phoning physicians at home in the middle of the night is no way to make friends, it is important to use all resources at your disposal to collect information on a patient. While he is on the phone, a nurse is drawing blood and administering morphine. Next, the lab technologists are called in to run blood tests. The collaboration between these different professionals ensures that what could potentially be a tense and disorganized situation is approached as smoothly as possible. While a lack of disembodied limbs and traumatic head wounds shattered my television-derived ER illusion, my experience at Saanich Peninsula was anything but dull. Seeing a diversity of patients of different ages and backgrounds, and being under the pressure of having to fit pieces of history, physical examinations, ECGs, tests, and scans together in a limited amount of time, made each patient encounter both exciting and challenging. While the initial approach to taking the history of the presenting complaint might begin much like a family practice visit, the opportunity afforded by the ER environment to perform immediate diagnostic tests, take therapeutic initiatives, and monitor their results right away provides greater short-term satisfaction, albeit at the expense of the long-term patient relationship valued in family practice. Perhaps Dr. M. has found the ideal compromise: see long-term patients as family doctor, and work a weekly ER shift for a change of environment.

Women in Medicine

I am part of a family that is practically overflowing with doctors. My father is a urologist, my brother is a gastroenterologist, and my mother and grandfather are both general practitioners. Understandably, the discussions at our weekly family dinners rarely stray far from medicine. This week, we talked about the increasing proportion of women in medicine. My brother rightly commented that female doctors tend to work fewer hours than their male counterparts and, unless the medical schools start churning out many more graduates, the country-wide doctor shortage will only get worse. Ordinarily, this kind of talk would send all the doctors at the table into a frenzy about the inadequacy of the Canadian health care budget but, instead, the discussion took a different turn. As I and the other women cleared the dinner table, the men began to proudly compare the length of their work days. “I often start work before 7:00am and get home after 7:00pm.”

“I am on call more days than not. I might have to leave at any moment to deal with an emergency.” “When I was a resident, my shifts were 36 hours long. Sometimes, I would not leave the hospital for a week!”

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Amongst the boasting, I detected the slightest whiff of chauvinism. If they were willing to work so hard at their jobs, why weren’t the female doctors willing to do the same? I took this as my cue to step in.

“You may work long hours but, when you come home, you can relax. Most working women actually have two jobs, one in the office and one at home. Taking care of a family and a household can be a full time job.”

My brother scoffed and said that housework is not an excuse anymore because men are more involved with household chores now than ever before. Apparently, he has not noticed all the women cleaning up the dinner table while all the men sat talking. “Housework aside,” I replied, “What about having babies? No women could work as hard as you do when she is nine months pregnant or has a new born baby that she has to breast feed. Taking on that kind of responsibility effectively puts one’s career on hold.” Then I asked all of them, “If everything in your lives had been exactly the same except you were women, when in your career’s would you have decided to have children?” I was met by silence. In spite of all that they had to say about women in medicine, not one of them had considered this question before. Ever since that evening, I have been wondering how I will be able to accomplish the seemingly impossible feat of being a good doctor, a good mother and a good wife all at the same time. Right now, I have no partner and no children and, thus, I have the luxury of being able to focus exclusively on my career. However, I know that one day I will also want to have a husband and children who will no doubt force me to take some of my time and energy away from medicine. I am already anxious of the multiple demands that will be placed on me in the years to come. There seems to be a culture in medicine that compels doctors to work themselves to the breaking point. Long hours, high stress and sleep deprivation are, at best, considered the norm and, at worst, considered points of pride. I am glad that medicine is becoming an increasingly female dominated profession. Perhaps women, with their many responsibilities outside of medicine, will bring the importance of self-care and balance into the profession. I have been warned many times that medicine is a jealous mistress but I hope that, by the time I am in practice, she will have become a little less insecure.

One of the main reasons I chose to pursue a career in medicine is because medicine is such a broad field. All physicians can find their happy niche in the profession if they are open to exploration. At this early stage in my training, exploring seems to mean broadly surveying the pros and cons of as many of the big medical specialties as possible. In assessing the merits of each specialty, the focus is on the competitiveness of the residency program, how many years of training will be involved, and how much the doctors get paid once they are fully trained. While I agree that all of these things are very important to consider when making career choices, I am just a little worried that my colleagues and I will forget to fully consider how the lifestyles associated with these various specialties will fit with our personality types. In fact, at our age, I wonder how well any of us could accurately describe his or her own personality. So far, medical school has placed plenty of emphasis on career exploration but very little on self-exploration. It is very likely that that this focus will shift over the next few years, but I have always been impatient when it comes to planning my future. After a few weeks in the anatomy lab, I very quickly came to the decision that I would probably prefer a medical specialty to a surgical specialty. I already knew that I enjoyed facilitating psychosocial healing, so I starting looking into specialties like psychiatry and oncology because they involve working with patients who are probably experiencing intense emotions. However, neither of these specialties are without their drawbacks. Psychiatry seems like a lonely profession, composed of mainly one-on-one therapy with patients and very little interaction with other colleagues. I also wonder how working with psychologically disturbed people everyday for years would affect my own mental health. Oncology is a fascinating and complex field, but I now believe that I was drawn to the specialty primarily by a desire to help people deal with their emotional, rather than physical, reactions to cancer. Since I am not passionate about the science behind cancer, I doubt that oncology would be the right niche for me. I went through this type of thought

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process with many other specialties too over the past few months but nothing really leapt out at me. Last week, the topic for our family practice lecture was “palliative care”. I had volunteered at Victoria Hospice for two years so I was excited to hear more about this familiar subject. The lecturers were general practitioners from various parts of the province who were highly involved in palliative medicine. They spoke about delivering bad news, relieving pain, and comforting grieving patients and family members. I got the impression that these doctors truly understand the art of medicine. I remember Victoria Hospice as a uniquely beautiful and sincere place. When people are dying, all of the masks that they have been hiding behind come off and they become their true selves. By volunteering at hospice, I was able to witness their great highs and even greater lows as they went through the major transition of coming to terms with their mortality. While walking home at the ends of my shifts, I almost always felt calm and grateful. The palliative care lecture last week brought all those memories and feeling back again. When I reflect on my experience at Victoria Hospice and what I learned in last week’s lecture, I feel a strong sense of purpose and belonging. Based on the very little that I know so far, I believe that palliative medicine is the right fit for me. I think I would function best in an environment like hospice that highly values communications skills, sensitivity and compassion. I feel that I have a healthy attitude towards death that would protect me from becoming overly saddened when my patients reach the final stages of dying. Further more, I believe that working in palliative care would give me perspective; I would be more grateful for the blessing in my life and less likely to ruminate over the petty annoyances of every day life. I still have a lot of time to learn about medicine, about myself, and about how the two can fit together before I have to make any major career choices. However, one thing that I know about myself already is that I like to have a plan. Without at least a tentative idea of where I am headed, I feel anxious. Therefore, I am grateful to have palliative medicine as a goal, even if it is only a temporary one. Over the next few years, I will probably change my mind many times but I am confident that I will eventually find an area of medicine that fits me best.

I had a plan when I rolled my bike through The Village on campus. I was going to buy a bottle of wine, eat some sushi, then go to my friend’s birthday party and present her with the newly acquired bottle of wine as a present. When I got to the liquor store, there was a man standing just outside the door. He appeared to be in his mid 40s. Even though he had a full beard and was wearing many layers of mismatched old clothes, he looked very thin. He asked me if I could spare some change. I gave my usually response, “no, sorry,” and walked into the store. It is best not to get involved with people like him. After all, he probably just wanted the money to buy drugs or alcohol. Why else would someone be begging for money instead of checking into a shelter to get out of the cold?

I passed the man again on my way to the sushi restaurant. I became very aware of how warm and clean my coat was compared to his and the thought made me uncomfortable. I sat in the restaurant trying to enjoy my yam tempura roll but I was preoccupied with guilt. Just a few days before, a guest speaker was invited to one of my “soft” afternoon classes. She invited the students to ask her anything at all; nothing we said could be considered “politically incorrect”. It came out that she had been homeless for a part of her life because she could not afford rent. Her poverty was not due to addiction. Her youth and inexperience made it difficult to find a stable job and she had no family to fall back on. I asked her why she did not stay in a shelter. She gave me two reasons: 1) she had a shopping cart full of belonging that the shelter would not let her bring inside and she was afraid that it would be stolen, and 2) most shelters would not let her stay long enough for the welfare process to be completed so she would have had to be homeless for a period of time even if she did check into a shelter.

I started to imagine how I might feel and what I might want if I suddenly became so poor that I could not afford rent. I would probably be cold and hungry. I would want a warm place to stay and something to eat and I would be so grateful if a stranger offered me those things. I could not give shelter to the man by the liquor store, but I could offer him food. I bought another yam tempura roll and went back to the man who was stilling begging for money. The conversation that ensued was not at all what I expected.

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“Sir, are you hungry?” “Why do you ask?” “I brought you some food.” “What is it?” “It is yam sushi.” “Oh. I think I’ll pass.” I could not make sense of what had just happened. Why would this obviously hungry homeless man refuse my food? I quickly made up my mind that my friend would get wine AND sushi for her birthday and then I left to catch my bus. I lay in bed that night thinking about my encounter in the Village. What had I done wrong? What should I do next time someone on the street asks me for money? How do I stop this negative experience from clouding my judgment of all homeless people? I came to the conclusion that I had made too many assumptions about the man by the liquor store. When I ignored the man’s request for change, I assumed he would use the money to fuel whatever addiction he had. When I brought him the sushi, I assumed that he was hungry and that he would appreciate some food. In other words, when I decided to treat him as I myself would want to be treated, I effectively made the false assumption that this man was just like me. Just because I would jump for joy if I were begging for money in the cold and someone offered me a yam tempura roll does not mean that everyone would. While it is entirely possible that my first assumption, that he was waiting to gather enough money to go into the liquor store and get some alcohol, was correct, I did not have enough information to make that call. Perhaps the first thing I should have done was asked why he needed the money and if he was hungry. This experience has left me believing that empathy is more than just putting yourself in someone else’s shoes and acting accordingly; it is about seeing the world through their eyes. This was an important lesson for me to learn. In the future, I want to be able to see the world through my patients’ eyes rather than mistake my perspective for theirs. To do this, I must be curious about them and able ask the right questions.

The Value of Good Communication I sat in the waiting room holding an open magazine in my lap. Even though I had not read a single word in the past ten minutes, I kept turning the pages. All the other patients sitting around me seemed to be doing the same thing. Everyone looked nervous, though perhaps that was just because I was projecting my own emotions on them. I had been waiting to see this specialist, the very busy and important Dr. K, for a consultation for almost a year. Now that the day was finally here, I was both relieved to finally be getting some answers and scared about what those answers might be. I heard a man’s voice from down the hallway call my name inquisitively. It was Dr. K. Contrary to my preconceptions of what a “hot shot” specialist should look like, he was not wearing a starched white coat nor a stern expression. Dr. K was dressed casually but professionally and he was smiling sincerely. He greeted me with a handshake and then led me to a small, neat exam room. Once we were both seated, he asked if I was comfortable. Given that I was as comfortable as I possibly could be under the circumstances, I nodded. Dr. K began by telling me what he had learned about me from the referral he had received from my family doctor. Without referring to his notes, he recalled all the pertinent details of my condition from memory. I had not said a word about my medical concerns to Dr. K and yet I already felt somewhat understood. Dr. K and I spent the next few minutes discussing all aspects of my medical condition. Since he knew that I was a first year medical student, Dr. K used terminology that was suitable for my level of education, which made me feel respected but not overwhelmed. When it came time for the physical exam, Dr. K explained the process both before and during the exam. After the exam, he told me his impressions of the physical findings. The news was not as good as I had hoped for, but he reassured me that there were good treatment options available. Then, he explained

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my condition and the treatment options in great detail by drawing anatomical pictures on the fresh strip of paper that was lying on the exam table. It took some time for me to wrap my head around all the new information, but thanks to the visual aids, I started to understand. He did not rush me. Once I assured him that I did not need any more clarification, he told me to go home and take some time to think about what I wanted to do next. Dr. K reminded me that even though he had given me his recommendation, the final decision belonged to only me. Before I left the office, I shook Dr. K’s hand and told him how grateful I was that he would be handling my case. For the first twenty-four hours after my appointment with Dr. K, I thought only about the information he had given me and what I was going to do with it. It wasn’t until the second day that I started to think about HOW Dr. K had given me that information. Only then did I begin to appreciate the quality of the interaction I had had with him. I went back to my clinical skills notes from last semester and realized that Dr. K had followed the Macy Model of Effective Doctor-Patient Communication perfectly. The Macy Model outlines the skills a physician should demonstrate at each step of the doctor-patient interview to ensure good communication. Last semester, I had glossed over the Macy Model in just enough detail to act out the steps in my graded patient interview. The steps seemed either obvious (“review the patient’s chart before the interview”) or kitschy (“elicit the patient’s concerns and feelings; acknowledge their frustrations”). Needless to say, I did not take the model very seriously.

The Macy Model was far more meaningful when I saw the process in a real-life setting and, most importantly, from the position of a patient. The experience gave me a deeper understanding of the impact each skill can have on the patient’s impression of the doctor. For example, I previously assumed that the reason doctor’s should review the chart before meeting with the patient is to become well informed about the given patient’s overall medical history and, thus, be better able to understand the current presenting complain in the appropriate context. In other words, the main purpose behind reviewing the chart was to improve clinical diagnosis and treatment decision. However, when I realized that Dr. K had taken the time to thoroughly review my case before meeting me, I did not feel any more reassured that he would arrive at the correct diagnosis than I had while I was in the waiting room. Instead, it made me feel valued and cared for. Without me saying a word, I felt that Dr. K had already taken the time to listen to my concerns. As another example, Dr K’s detailed explanation of my condition and the available treatment options (along with the helpful drawings) made me feel empowered to make an informed choice about my body.

Whether Dr. K knew about the Macy Model or not, he followed all the steps perfectly and each one made me trust him more. I had always had the impression that many specialists who were highly in demand lost their ability to communicate effectively with patients because they felt they were too busy to take the extra time necessary to do so. However, I do not think that Dr. K spent much more than twenty minutes with me in total, which means that good communication and efficiency are not mutually exclusive. I learned a great deal from Dr. K, both as a patient and as a budding doctor. I have a new appreciate of the value of the skills outline in the Macy Model and I will do my best to adhere to them in my future practice.

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Contributors

FacultyDr.SarahdeLeeuwDr.GaryPooleDr.CatherineAndersonJenniferKong

MD2014AliaDharamsiAdeleDuimeringAndrewJefferyJoshuaLaiDeannaSinghShaunvanPel