Get Out of Your Own Head

StockSnap_SWRREC0K3A copyBy: Carlos Chan (c2020)

At McMaster University, we prize the ability to engage in self-reflection and learn from our experiences so that we can become better physicians. We dedicate an entire morning to it every week in pre-clerkship (professional competencies), we have required writing assignments centered around the idea (our reflective physician portfolio), and it’s been touted as a tool to guard against burnout in medical practice. As someone who tends to live in his own head a lot of the time, I personally think that self-reflection is a great practice as well. But I got some very interesting and unorthodox advice from my preceptor during my first week of clerkship, which sort of turns that idea on its head.

This surgeon mentioned that he often sees that clerks get into their own heads too much and become neurotic about things that ultimately don’t really matter. In the grand scheme of things, it really shouldn’t matter if we slipped up on terminology in front of a patient, unintentionally slighted a colleague, or made any other mistakes that are easily repairable. But it often is difficult to keep our eyes on the big picture when we’re all tunneling towards the goal of matching to our preferred residency. Indeed, it is almost impossible not to go insane as predominantly type A personalities obsessing over every little detail and then retreating into our own heads when doing so. Despite all of that my preceptor’s point was that it does a disservice to the team you are a part of to retreat in this fashion. You have to remember that while you are there, you are present to care for your patients, to learn from the team and to assist them in the goal of creating the best possible outcome for the patient.

I found myself slipping into my own head one night on call when the surgical team had to tell a patient in the emergency room that he had metastatic colon cancer and that there was not much they could do for him from a curative point of view. In that moment, I found myself thinking how horrible I was feeling about the entire situation and how it felt rotten just to be there in that room, even though I wasn’t even the one breaking the news. I was only a spectator.  The patient didn’t even seem to see the rest of the team in the room, his eyes remained fixed on the senior resident talking him through the news.

However, beyond that I cannot remember all of the details. Maybe I was too tired or perhaps it was because I avoided looking at him due to my own discomfort about the entire situation. But my feelings regarding that event still linger, like formalin that stays in your nose long after you’ve left the anatomy lab. And I do remember one other thing, the only thing he said in response to the resident’s monologue detailing the news which he must have been dreading.

“Shit.” Repeatedly.

Truthfully, I don’t remember much else about that consult. The night was still young and there were other surgeries to participate in and many other consults to attend to. But as I reflected on that experience, I felt badly about the fact that I had made that entire experience about me in that room. I was predominantly centered on how bad I felt about the situation, and how much I wanted to leave. My preceptor’s advice about getting out of my own head lazily wandered back into my mind, and I realized that I had disengaged from that moment, and I was not centered on the needs of the patient. I realized in that moment I had done exactly the opposite of what he had said that I should do. As I thought more on that situation though I realize now that perhaps it would have been unreasonable for me to not focus on myself and what I was thinking in that moment since it was my first time witnessing such a situation and I’m not sure I would have been capable of attending to the needs of both the patient and myself . But now that I’ve had this patient encounter and worked through my feelings on the matter, I know that I will be better equipped to engage with this type of situation in the future.

I’m sharing this because it has been useful for me at the start of clerkship. I’ve since told myself to get out of my own head repeatedly whenever I encounter something new and scary or when I make a minor mistake that really does not deserve a second thought. Although this advice has been useful, I still think that there is a role for reflective practice. However, as with most things in life, balance is the key. It does not pay to stay in your head forever burning a circular track in your own mind. Stay in your head to figure it out but don’t stay too long. Your team and your patients need you. Get out of your own head and engage.

MINDFUL(L)

Mindful(I)-Jodi

By: Jodie (c2020), Photo By: Jodie (c2020)

 

The sign on the door reads,

“Mindfulness Course.”

My preceptor waves goodbye.

I walk inside.

 

One, two, three, four – four participants and a bearded therapist.

I know their backstories, these four strangers.

I begin to try matching files to faces.

Before I can complete my task, the request comes-

“Close your eyes. Focus on the breath.”

 

In… Out…

In… Out…

Cool… Warm…

Nostril… Tongue…

Chest Falling,

Abdomen Filling,

Noise Humming- Noise humming?

What is that noise I hear?

I cannot turn my ears off; they betray my mindful intent.

My thoughts are drawn out into the room,

In search of the noisy culprit.

Huummmm – Whoosh. Huummmm – Whoosh.

“What makes this jaunting sound?” I wonder,

Soft purring, punctuated with satisfying bursts of air-

 

Woops, I notice my distraction.

“Come on mind,” I tug it back to being.

Moments pass, Solitude, Solitude…

 

We wake up.

Back to solving my mystery.

Scanning the faces of my companions,

Seeking the source of the humming,

I find it.

I find her.

Black box, whirring, spurting,

Sitting beside her feet.

Long tube, clear plastic,

Slinking up across her lap,

Wrapping gently behind her ears,

And coming to rest just beneath her nose.

It sends oxygen whooshing into her nares.

Huummmm – Whoosh.

 

Now, who is the woman behind the machine?

One, two, three, four – She must be Stage 4.

I remember the file now.

Her pale skin and hollow cheeks tell the story.

Her bright eyes and astute words tell another:

 

“In some ways I’m ready to die,” she offers,

“And in some ways I’m not.

Because I know that things will carry on without me.”

“Like this course,” her friend chimes in.

“We’ll be here every Monday.”

“Yes,” she laughs, “Even after I’m dead.”

“Actually,” she interjects, “I’ll be here either way.”

 

A hand reaches out to wrap around,

Her long and boney fingers.

The hand belongs to a young woman,

Rosy face shaded beneath a ball cap.

As she turns her head towards mine,

My breath and eyes both catch-

As the pink ribbon tacked on to her white hat,

Comes starkly into view.

Could this be, number two?

The second stage 4 participant?

My mind wrestles to reconcile the record with her youth.

 

“I am ready too, but he is not,” she points across the table.

Stoic man, downcast eyes, participant #3.

A backstage figure begrudgingly yanked into the spotlight.

Father-daughter,

Wounded-wounding,

A duo desperate to heal each other,

Neither knowing how.

Fears fall on cowering ears,

Until the weight becomes too much,

And we turn again to practice.

 

And so it goes for the remainder of the meeting.

Breathing, calmness, stillness, quiet,

Then we join together,

Voices layer, slowly, faster,

Adding burden to the bars on which our weariness rests.

Comfort is tossed across the table,

Hearts unloaded, piling up within the space between us.

Cancer, pain, depression, shame,

It’s all laid out for viewing,

To which the therapist calms the swells,

With words of meditation.

 

 

“Focus on the breath,” he says,

“As it moves between your lips.”

But I focus instead on the single tear,

Slipping down my cheek.

 

“So much suffering,” number four,

Whispers between our reprises,

The therapist points out simple math,

“Suffering = Pain x Resistance”

None of us had learned this equation,

In all of our education.

He instructs, “Be with the pain,

Accept it in its fullness.”

He’s giving us the tools we need,

To complete the calculation.

 

Breathe in, Breathe out,

Four strangers sit around me.

In the stillness of my practice,

Joanie’s tank seems louder,

Making salient the bodily function that,

Occupies our attention.

 

Mind full, Mindful,

Mind full, Mindful,

The session’s hour passes.

 

The therapist makes a closing remark,

As we gather our belongings,

“This course has morphed into something different,

Than I originally imagined.

It seems that I forgot about,

The lives that drove you here in the first place.”

 

Group, palliative, family therapy,

The chameleon of Mindfulness courses.

We will gather again a week from now,

In all our states of being.

Reverence

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Photo and piece by Sarah Peters (c2020). 

The first delivery I ever saw was on YouTube. I was reclined on my bed—cup of tea in hand, and the familiar ‘ding’ of Facebook chats ringing from another Internet tab. I didn’t pay too much attention to the video, because I only meant to prime myself for the next day’s horizontal elective in Obstetrics & Gynecology. Many of my friends had already embarked on Labor & Delivery shifts, claiming the “magic” of delivery, explaining it was something that you simply must see to understand. I clicked back and forth to the YouTube tab throughout the video, making sure to catch the important parts—appearance of the head, clamping of the cord, delivery of the placenta. A few quick minutes later, I shut my laptop and went to bed, feeling a bit apprehensive about how I may react physically to the real thing in hospital (…maybe I should bring a paper bag).

Fresh in my scrubs the next morning, I eagerly awaited what the day had in store. My preceptor had one impending delivery: Nicole, a healthy woman pregnant with baby number 4, accompanied by her husband, and anticipating a quick and uncomplicated delivery. I was tasked with keeping tabs on mom and baby—I quickly learned how to read the printout of the fetal heart/uterine contraction monitor, and my preceptor patiently taught me about the basics of labor. To my delight, he took extra time to introduce me to “Fiona,” a plastic pelvic model used to demonstrate childbirth maneuvers, and “unnamed creepy black suitcase,” a large case full of rubber vaginas (yes, seriously) used to learn manual cervical examination.

After spending some time with my preceptor, Fiona, and the suitcase, I was surprised and excited to be given the opportunity to manually palpate Nicole’s cervix. It was a quick exam, and afterwards, I felt grateful to have earned the trust of both my preceptor and our patient—after all, it was a very invasive and sensitive exam. The afternoon continued with more teaching, observation, and exposure to new and interesting obstetrical cases. Eventually, during a brief break between patients, I found myself shooting the breeze with my preceptor and the team of nurses. It was casual conversation that ended with what felt like a bombshell: “Okay, Sarah, let’s go check in on Nicole. She’s almost ready, and you’ll be delivering the baby.”

I kept my cool, trying my best to exude professionalism, gratitude, and excitement. Internally, I looked and felt quite the opposite: my stomach churned anxiously as I mentally cycled through the delivery procedure that I had learned merely an hour before. Internal rotation, flexion, external rotation… was I missing something? Was flexion first? I didn’t have much time to think, because before I knew it, I was standing at the foot of Nicole’s bed, hands outstretched, eyes locked on the tiny human being who was making his first appearance into the world. My preceptor guided my hands as he talked through the birth, and in just a few minutes, Nicole’s son was calm, swaddled, and resting on her chest.

I could spend hundreds of words describing those few minutes: my sense of gratitude, the sharp awareness that I was the first human to touch Nicole’s son, the unexplainable reverence of witnessing the first moments of a new life. I felt an overwhelming and awe-inspiring sense of connection—I’m still not exactly sure to what, but I was completely present and aware of the moment’s intensity. Having the privilege of participating in this profound experience sparked a reflection on the intense trust that physicians receive from their patients. I realized that yesterday’s assessment of the ‘important parts’ of labor failed to take into account the patient’s whole story: the YouTube video didn’t capture dad’s teary smile and sense of relief, or Nicole’s admirable fortitude, or even the more ‘real’ components—smells, fluids, blood.

I want to be a physician who doesn’t forget about the whole story: the patient’s narrative. I’m coming to realize that these profound moments—a delivery, a death, a diagnosis—do not and cannot exist in a vacuum outside of real emotions and experiences. Physicians are somewhat akin to mechanics in that a job must be done, and they are under pressure to do it well: fix something, stitch something, put together pieces of a puzzle. Excellence in these skills contributes to the excellence of a physician, but I think that part of the ‘magic’ of medicine comes from the ability to remain mindful of what I’m doing, respect the immensely personal and intimate nature of the patient-physician relationship, and constantly reflect on my gratitude for the privilege of becoming part of this profession.

 

Fossils

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By Rebecca Lauwers (c2019). Photo credit to the author.

“Rebecca Lauwers shares a reflection written during her first year as a medical student.”

My first patient encounter of medical school occurred two days before the winter holidays.  I spent the day in child and adolescent psychiatry. The parents have lingered in my mind the most.  Sometimes they seem more haunted than the patients.

I keep thinking of one mother in particular.  She was looking for answers to questions she couldn’t bring herself to ask outright.  She would sidle up next to them, like she feared the answers, but not more than she depended on knowing.  The unspoken questions like, Is my child Good?  Is there something Wrong with her that goes beyond the sadness and the suicidality, beyond the rage? 

With her face she said, Alright, we can call all these things some sort of normal, we can find a way to bear them, just as long as she is not Bad, in those unspeakable ways…

With her words she said, “She never really seemed to care for her siblings…”

Scared mother.  Gentle mother.  I let her become vivid to me.  She looked far away, sifting memories the way she did on many drives home, through countless sleepless nights, stowed away for a meeting when she would get to talk to The Doctor, the one she hoped would Know.  Trying to make sense of why everything is the way it is now.  I felt deep respect for her, imagining this woman bent over her entire life looking for answers.  Back-breaking work brushing dust away from fossils.

When we spoke with her daughter later that day she begged to go home.  She started the meeting composed, almost poised, presenting what could be mistaken for a reasonable plan.  But her rational defence devolved quickly into angry demands and tears.  I wondered how you can make decisions about peoples’ safety when you don’t know them at all.  What do you do while you are still building the relationship?  How do you know what they need.

It snowed hard the whole day, so hard that a few outpatients cancelled.  I drove home slowly, wondering what exactly I had done to end up in this position: the witness; the learner; the one with a refuge, but also access.  It means nothing is asked of me.  Does it mean there is nothing I can offer?

I know this is the process, the very way I will learn how to make these calls.

But I must pause to acknowledge that these aren’t just stories to be passively consumed, even though I am the observer.  These are lives that continue on when my placement is finished and new experiences layer themselves atop my memories.  They continue on while I am standing in the anatomy lab on a Wednesday morning, pushing the buttons on the coffee machine, sitting under a Christmas tree listening to my own lungs.

They don’t want to live so they take too many pills.  They don’t want to die, so they call the ambulance themselves.  They say “Don’t turn on the sirens, I will meet you outside.  My brother will be scared.”

They want to know how to help their child.

They want to know how to help themselves.

I want to know how to help them.

We all have much to learn.

 

Palliative Care: The old and the new

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By Carlos Chan (c2020). Photo credit: Cicely Saunders Archive.  The second window from the right has an inscription underneath it which reads:
I will be a window in your Home,” the promise of David Tasma of Warsaw who died 25 February 1948 and who made the first gift to St. Christopher’s.

During my time in England, I spent a day at St. Christopher’s Hospice in London. They have a day program for healthcare professionals to come visit and learn about the history of palliative care, to tour the hospice itself and see the wards, and to talk about the future of palliative care and some possible challenges. I found myself in an odd group of visitors – two individuals who fundraise for the hospices across the UK, a director for another hospice, and a clinical psychologist from Japan on leave to study English. I was the only medical ‘professional’ in the visiting group that day.

St. Christopher’s Hospice was the birth of modern-day palliative care, started and built by Dame Cicely Saunders (a nurse, physician, and researcher) in London and her efforts were assisted by Dr. Mary Baines, who went to medical school with Dame Saunders herself. I was privileged enough to hear about the history of St. Christopher’s Hospice from Dr. Baines as she told stories of Dame Saunders and how the hospice movement came to be. In fact, I learned that the term ‘palliative care’ was coined by Dr. Balfour Mount, a urologic-cancer surgeon from Montreal (I am not very proud to admit that I had to have a British physician teach me Canadian medical history, but there it is). In fact, it seemed that the term ‘palliative’ was coined because hospice meant something else in French (I think it could be translated into ‘mouroir’, which would literally mean deathtrap, a pretty negative word. Now do note that this is hearsay, as I have not been able to independently verify online this as the reason for the invention of the term ‘palliative’, as suggested by Dr. Baines).

At the beginning of the presentation, as the only medical professional visitor that day, Dr. Baines singled me out for a question to begin her history lecture: What did physicians do for patients before the era of cures? As I was working my way through The Emperor of All Maladies and learning about the morbid history of radical surgery in the attempted cure of cancer, I somewhat facetiously told her that before cures were a part of the physician’s arsenal, surgeons merely cut out more and more in attempts to cure. Her response to my cheekiness was memorable – I can hardly imagine what she was like as an active and practicing physician. She shut that down very quickly and prompted me again and again for a real and more intelligent answer. Unfortunately, I was unable to provide her with the right answer (as you can see, I am not only killing it in my medical studies in Canada, but across the pond as well). It turns out that the answer was simple: before physicians could provide cures, they treated symptoms and provided comfort to patients and families. Simple. Which sounds suspiciously like… modern palliative care.

Dr. Baines’ point was that palliative care is not a new thing – it has been around as long as the physician’s profession has existed. Before cures were part of the arsenal of a physician’s black bag, symptom management and providing comfort were the only things that a physician was able to provide. It was a bit of a personal shock when I heard her answer – how could I have missed such an obvious thing? However, as the presentation went on, it seems like this was a struggle for most modern-day physicians to understand – Dr. Baines herself mentioned that she had to personally wrestle with the idea prior to joining Dame Cicely Saunders in founding the palliative care movement. It seems that this is a difficult concept for many new physicians to accept, given that most of us were born in an era where curative treatment is the expectation and anything less was a failure of the physician and modern medicine. After all, why did we choose to become doctors if not to cure our patients? However, the more I think about it, the more it makes sense that providing symptom management and comfort to patients remain at the core of what we do. My MF-4 tutorial had a ‘funny’ saying: “If you can treat it, then treat it.” However, what happens when we can’t treat it? That doesn’t mean we stop doctoring our patients. It just means that we reach into our black bag for other tools. I like to think back on Dr. Baines’ question as a good reminder that palliative care is not a new notion – and that it is for every single physician, regardless of their specialty or training, as it remains the core of what we are as a profession – both historically and as we continue onwards into the future.

 

The Encounter: An Essay

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By Nova Zhao (c2020). Photo credit Jonathan Kho @halfbakedphotos.

Every day on my walk to and from school, I pass through a lovely park. Usually, I walk at a fairly quick pace so as not to waste time or be late for class, ignoring those around me and avoiding eye contact. One afternoon on my walk through the park, a dishevelled-looking man on a bench asked me for money. This was not unusual – the park is frequented by the city’s sizeable homeless population. On most days, I would pretend I didn’t hear him or make an excuse like “I don’t carry change”. But on this particular day, I decided to chat with the man and listen to his story. He told me his name was J* and that he was a missionary from Vancouver. When I asked J what brought him to Kitchener, he revealed that he initially travelled here to see his mother, who had recently suffered a stroke and was very sick. Nonetheless, upon arriving, with no income, he found himself begging for money and sleeping in shelters.

We then chatted about astronomy, medical specialties (by this point I had already told J that I was a medical student), and nutrition. During our conversation, I glanced down at his legs and noticed what seemed like severe cellulitis. Upon questioning, he admitted that he had contracted MRSA due to his poor living conditions and was unable to pay for the medications he was prescribed. That’s when I understood the plight that this individual, and many others like him, have to endure every single day. Prior to this encounter, I seldom stopped to consider the health of people I saw on the street. But now I realize there is a large population in our Canadian cities that is constantly neglected when it comes to health. For example, homeless men in Toronto have a mortality rate 3 times higher than the mean.[i] Also, homeless adults often develop certain conditions earliery on that, which do not appear in non-homeless populations until old age.[ii] They suffer from preventable illness and death because of factors often out of their control, such as extreme poverty, cognitive impairment, and difficulties accessing health care. The problem is worse in some cities. In the Waterloo Region alone, there were almost three thousand people who experienced homelessness in 2017[iii]. Three thousand people at risk of diseases and illnesses last year that most of us can easily avoid by virtue of our clean homes and running water. This made me think: what am I doing to help?

I gave J some change so he could buy himself a meal, and a few cough drops to relieve his sore throat. However, this issue is much more complex than just food and illness. In order to make change, we need to address everything includingfrom basic necessities like food and housing, to community-level programs, government and healthcare policy, and societal beliefs. Unfortunately, I don’t possess the knowledge or power to effect change in all of these domains, but what I can do as a medical student and future physician is advocate. I can advocate for J and others like him who are disadvantaged in our health care system. That’s why I wrote this piece – to expose the difficulties that homeless individuals experience in health care and to advocate for change amongst my peers and fellow health professionals.

Change can be as simple or as involved as you want it to be. I invite my peers to start by questioning their own beliefs and behaviours towards homeless people. I know that from now on, whenever I encounter a homeless individual I will make an effort to challenge my own attitudes and stop to chat with them – because you can’t fully understand what someone else might be going through unless you hear their story.

*Name changed for privacy

[i] Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA 2000:283:2152-7.

[ii] Gelberg L, Linn LS, Mayer-Oakes SA. Differences in health status between older and younger homeless adults. J Am Geriatr Soc 1990;38:1220-9.

[iii] Waterloo Region. (2017). Retrieved July 30, 2018, from http://homelesshub.ca/community-profiles/ontario/waterloo-region

 

Somebody’s Baby

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By Alex Pearce (c2019). Photo credit @ilumire.

*Names have been changed for confidentiality purposes.

Jack* did not come into the shelter quietly. He blew in angry, yelling, slamming doors, and pointing fingers. His ongoing monologue was heard by everyone within 10 feet — sometimes it formed logical sentences, and sometimes it did not. From what I could gather, he was annoyed with a man named Ernest* – it wasn’t his fault, he would like everyone to shut the **** up, and he didn’t need any of this ****ing ****. To describe him medically, he seemed to be responding to internal stimuli, and his drooping red eyes, lack of coordinated movement and slurred speech pointed to some level of intoxication.

When asked by the staff if he wanted to come in to chat, he responded with an emphatic “no” and stormed off into the main lobby. Something was atypical about Jack’s presentation. Off to the left of the room, standing with her arms folded around herself, was his mother. Her eyes were heavy with the look of someone who had been through this with her son several times before. Yet, her eyebrows were knitted together with genuine concern over her son’s current condition. In order to try and de-escalate the situation, we took Jack’s distraught mother into the clinic room while a social worker went to talk to Jack one-on-one, and we let them know Jack was welcome to come and join the conversation at any time.

In the room, the staff I was with introduced us to Jack’s mother, and let her know that Jack was a client that was familiar to her, as he was a frequent visitor to the clinic building. The staff let her know that while we weren’t at particular liberty to disclose any information we had about Jack, she was welcome to share with us whatever she was comfortable with sharing, even if only for the therapeutic effect of talking about it. Jack’s mom proceeded to give us a full picture of how Jack’s life had played out up until the point where we had seen him today, yelling and angry in the shelter. She described a lifetime of mental health struggles, learning difficulties and neurocognitive concerns about Jack — a myriad of ways Jack’s brain had struggled throughout the years to help him take care of himself. On top of this, Jack had experienced several traumatic events throughout his lifetime that his mother said had caused him to spiral further away from a place where she felt she could help him. He had been abused by a family member at a very young age, and had started purposely hitting his head off of any surface he could find from the age of 18 months. From then on, his mother had watched as he struggled through school, struggled to cope with self harm, depression and social interactions, and then eventually struggle to cope with substance abuse.

All of these things had led him to where he was, in the shelter today, describing vivid hallucinations and bizarre thoughts, confused, and running out of options. He had been kicked out of his previous shelter for this behaviour. Jack’s mother  had seen him in plenty different states before, but never like this, she said. She was becoming increasingly worried about him, and didn’t know how to help him. If you were merely walking past Jack in his current state, you might have cast him as a classic young man living on the streets — seemingly intoxicated, aggressive, accusatory and destructive.

It is a rare opportunity to hear such a thorough life history, from birth to present moment, to give you a complete picture of how someone has ended up experiencing homelessness. It is a good reminder that everyone you meet is somebody’s baby.

The next thing we knew, Jack came knocking on the door of the clinic room. When we opened the door, a totally different Jack was standing there, social worker behind him. Jack looked meek and walked in quietly and then sat down next to his mom and held her hand. He apologized quietly and sat there on the examination table, head down, feet dangling off the edge of the table. Suddenly, it felt as if he had shrunk five sizes. After calming down with the social worker, he agreed to come chat. He admitted that the reason why he was so distraught today was that what he thought was weed last night had turned out to be peyote — something he only found out after consumption. He had been seeing and hearing all kinds of things ever since and seemed genuinely scared, ashamed, and unsure what to do. His eyes locked in on his mom like she was the only thing in his life not spinning wildly out of his control.

As a student observer in this situation, I became acutely aware that to anyone without the privileged view that I had at that moment, Jack was still that intoxicated, accusatory and destructive street youth — no evidence of anything otherwise.

He eventually agreed to stay at the shelter that night, and to come to the clinic the next morning to check in on how he was feeling. Agreeing to do that did not untangle Jack’s complicated situation, nor did it resolve any of the larger issues contributing to where he was that day. But for Jack — his mother held his hands and said, “Remember what we talked about about making one good decision a day? You just did that. And I’m so proud of you”.

In medicine, we are privileged to see people in significantly more detail than the rest of the world does. At the same time, we don’t always get the whole picture, and we often get to see people at their worst. My time on this elective, and this appointment in particular, taught me a lot about compassion, and the importance of always remembering that patients come into the office with a whole story behind them. We are just seeing today’s page.