Question

There are two reflective essays from MED students during their third year internal medicine clerkship. One student sees each connection to a patient as like the individual brush strokes of an artist and the other sees gratitude in a patient with an incurable illness and is moved to gratitude in her own life. (WORD COUNT 500)

1. Reflect on both essays and then choose one and describe how the student grew from the experience.

2. Then explain what you learned as a result of your reflection and how the lesson(s) will influence your future patient physician relationships.

Reflection #1

Georges Seurat’s A Sunday on La Grande Jatte is one of the most iconic paintings of the nineteenth century. His chromoluminarism and pointillist technique is lost from the distance; only when you look closely can the details of each brush stroke be admired. I caught myself admiring this work when visiting The Art Institute of Chicago just prior to the start of our clinical years. The excitement, perspective, and chaos of the various exhibits foreshadowed what the upcoming year would bring. Early into my medicine clerkship, I was assigned to follow Miss Jones, the patient in room 601. While she had a history of leaving against medical advice (AMA) on prior admissions, these three letters were not limited to her discharge summary. She was found to have a positive antimitochondrial antibody in the workup of her abdominal pain and pruritus. On my first day of meeting Miss Jones, her room was as chaotic as the art exhibit. The interview seemed never-ending--filled with interruptions from consults to vital checks to breakfast orders. While both our general appearances would be deemed as “mild distress” for various reasons, we each took a sigh of relief as we made it to the conclusion of the interview. I was disappointed in myself, having felt like I did not truly connect with this patient. When she mentioned her dog in passing, I got excited and asked his name. “Let’s just get on with it,” she replied. Certainly not the patient-physician relationship I was hoping to foster. Day-by-day, her labs started to come back, providing us with more pieces of the puzzle to solve her case. Cholestatic liver patterns, elevated cholesterol, and a +AMA found in a fortysomething year old female? This classic test question was now being played out in real life. UWorld prepared me for recognizing patterns in labs; but it does not tell you how it will change the world of the patient with the diagnosis. Each new result or team update was a chance to solve the puzzle of getting to know Miss Jones. No longer was she “the patient with suspected PBC,” she was the tea-drinking, yoga-loving bookworm who happened to have been diagnosed with primary biliary cholangitis. When our team officially told the news, she nodded her head and we parted ways to finish rounds. When I went back to see her, she was scared, tearful, and frustrated. I re-explained our findings and plan. We tried the teach-back method but she remained overwhelmed and confused. One could argue that a 50,000 foot view of medicine is pattern recognition of illness scripts; but I believe it's the details that keep people’s passion sustained despite years of practicing. It is understanding your patient in the context of their disease. Just as Seurat thoughtfully juxtaposed dabs of color to create his optical masterpiece, we as physicians must learn to carefully juxtapose the art and science--the patient and the disease--to truly appreciate the wonders of our craft. Seraut believed in dividing colors into its components-- a concept called chromoluminarism. The thought being you can never perfectly recreate the same shade of purple by mixing red and blue. In medicine, the same principle holds true- despite the same disease process, no two hospital stays are alike. The explanation given to Miss Jones about her diagnosis might have been acceptable to the next patient but it did not accommodate her learning style. That night I pondered about how to convey what was going on. No longer did I feel like a student- I was the teacher. The next day I went to 601 with markers and paper in hand. I started drawing pictures of the anatomy of the biliary system. Her face lit up as she conveyed to me that she was a visual learner. Miss Jones and I spent the afternoon going over everything from the different measurements in a liver function panel to the metabolism of bilirubin. Finally, the day came when my progress note read “disposition: home.” As I entered room 601 for the final time, I saw my friend Miss Jones. She took my hand-- thanking me for everything I had done, which pales in comparison to how much she did for me. We discussed her relief after months of pain and uncertainty of not having a diagnosis. Instinctively I said, “You’re a trooper.” “Trooper,” she paused and smiled. With a glisten in her eyes, looked up, and said, “Trooper--that’s my dog’s name.”

Reflection #2

Gratitude is an interesting thing – just as lighting a candle from another previously lit one gives rise to a second bright flame without diminishing the original one, gratitude is an emotion – no an attitude towards life – that seems to give a person the capacity to continually pour from their cup while also simultaneously filling it. This is quite paradoxical. And yet, as future doctors, it is the quintessential question for us – how can we give and give to others while continuing to draw meaning and becoming recharged through our interactions without burning out? Just this last week, I had a patient, let’s call her Mrs. Smith. She is an 82 year old female, very thin and frail in appearance who was diagnosed with acute myeloid leukemia. This was a lifechanging diagnosis our team presented all treatment option. She listened intently, asking all the pertinent questions about prognosis, treatment, and recovery. Finally after explaining that she and her husband had talked about these kinds of issues she said, “I’m 82 years old and I just want to enjoy what time has been given to me with my family… “If I make it through the holidays, then great. If my time is up sooner, then I will still be grateful for all that I’ve been blessed with in this life – my husband, my beautiful children, and a lifetime of teaching little kids not only math but that they have the potential to do whatever they set their mind to.” The team wrapped up the conversation appropriately and left, but I lingered to talk more with her. I was astounded by the grace with which this woman just accepted a terminal diagnosis and the fact that she only had weeks to live. The longer I spoke with her, the more I realized that her acceptance came not from denial or shock but from the knowledge that she had lived life to the fullest, loved and been loved deeply, and made a positive impact in the world around her. As her husband crumpled with the weight of this news and I listened to her bolster his spirits, I realized that she poured from a very full cup of gratitude. It wasn’t that she had an easy life by any means; it’s just that she chose to be grateful for the positive people, events, and opportunities that she had along the way. As I walked home after that conversation, deliberately taking a roundabout route to process what had just happened, I realized a few things: What a sacred privilege we have been afforded to glimpse into the most intimate corners of our patient’s lives. How fortunate are we that through our chosen profession, we have the opportunity to help when we can medically, comfort them when we reach the end of our rope, and through it all be humbled by the strength and wisdom that many show in the face of something insurmountable. And finally, that while grades and test scores matter to some extent, ultimately, we are all on a path to be healers and caretakers in our society with all the position and ability to be the positive change we want to see in this world. I think Mrs. Smith answers that quintessential question for us. We give and give to others without burning out by first filling our own cup, to the brim with gratitude for all the opportunities, support, friendship, and love we have been fortunate to receive. It is this mindset that then allows us to pour freely – pour time, attention, and kindness into patient care and our community, simply because we have already acknowledged what a rich store we have in our personal vault. The beautiful thing about such an attitude is that this personal store is eternally refilled by family and friends who love us, at times by strangers who are kind to us, and by the knowledge that “yes, we are doing something meaningful.” So, I just want to end by expressing gratitude. Gratitude to Mrs. Smith and all the patients like her who imparted such wisdom in our interactions. Gratitude to family that loves unconditionally even when we are not the best versions of ourselves; to mentors who believe in us and help us find our way, even when we stumble and don’t believe in ourselves. Gratitude to the classmates who share the super-efficient pre-rounding data sheet they spent hours creating and friends who bring you a home-cooked meal when coming up to Jacksonville because they know you’ve been there for three weeks and there is only so much dining hall food anyone can handle. And finally, gratitude to this crazy, challenging, rewarding, hilarious, and unique journey that is medical school, for equipping us to be people who can spend our lives serving others. As one of my other patients remarked to me this week: “There are a lot of smart doctors out there who just treat the disease in the body, and then there are those who treat not just our disease but are also are like ministers who heal our soul. It’s these ones who truly care and have compassion for us that end up meaning the most.” Here is to always striving to be the latter.

Answer 1

Both the essays are reflecting on different lessons learnt by a med student during their student period. They render us the knowledge gained during the development of a patient - physician relationship. During the student period as well as the practicing period, a physician will be learning to handle different types of patients with different issues.

The first essay talks about learning of handling different patients in different way. Whereas, the second essay shows the qualities a physician learn from their patient.

When we look at the first essay, the physician is ready to change the outlook he/she had on the patient. He/she is tries to connect the patient's mentality with an artist painting. At first she wasn't able to make a bond with the patient. Neither was she able to explain or make the patient understand her condition. But, when she gave more importance to the patient's way of learning than her own way of learning, she was able to create a bond with the patient.

When she was ready to accept that the patient was a visual learner, and started explaining the patient condition with drawings, she was able to convey the informations in a more effective and efficient manner. If she had continued to explain the things the same way, she would have never been able to create any such bond with the patient. And the patient would have been left overwhelmed and confused. As she was ready to view the things from the patient's point of view, she became more diplomatic and could find success as well.

As a professional, we should be a little lenient rather than staying rigid and unmovable all the time. In the first essay we could see that the physician was able to accept that her way of explanation wasn't much of use to the patient. But, rather than complaining the patient, she accepted the fact that her method of explanation was not right for that particular patient. And she adopted a different method with no reluctance and could find success in it.

During the end of the essay, it was clearly shown that the physician - patient relationship was highly successful.

According to me, both the essays were successful in conveying the messages they tried to pass. The second essay focuses on developing gratitude towards everything we get during our lives. It also praises the medical profession of the unconditional opportunities it offers us to learn about different aspects of life. While the second essay taught us the importance of gratitude in life, the first essay taught us about adopting different teaching methods based on the patient's ability of learning.

As a health professional on process, these kind of messages will definitely hold an influence on changing my outlook over patient care and ongoing life. They have helped me to focus on gaining maximum knowledge and improving my skills from each patient rather than just focusing on the academic requirements. And I will always be responsible and hard working to become a health professional who is able to treat the disease as well as to heal the soul.