Looking Back to Move Forward: First-Year Medical Students’ Meta-Reflections on their Narrative Portfolio Writings

Abstract

The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. Furthermore, the current focus on competencies, coupled with concerning rates of trainee burnout and a decline in empathy, have fueled the search for pedagogic tools to foster students’ reflective capacity. In response, many scholars have looked to the tradition of narrative medicine to foster “reflective spaces” wherein holistic professional identity construction can be supported. This article focuses on the rationale, content, and early analysis of the reflective space created by the narrative medicine-centered portfolio at the Columbia University College of Physicians and Surgeons. In January 2015, the authors investigated learning outcomes derived from students’ “Signature Reflections,” end-of-semester meta-reflections of their previous portfolio work. The authors analyzed the Signature Reflections of 97 (of 132) first-year medical students using a constant comparative process. This iterative approach allowed researchers to identify themes within students’ writings and interpret the data. The authors identified two overarching interpretive themes—recognition and grappling—and six subthemes. Recognition included comments about self-awareness and empathy. Grappling encompassed the subthemes of internal change, dichotomies, wonder and questioning, and anxiety. Based on the authors’ analyses, the Signature Reflection seemed to provide a structured framework that encouraged students’ reflective capacity and the construction of holistic professional identity. Other medical educators may adopt meta-reflection, within the reflective space of a writing portfolio, to encourage students’ acquisition of a longitudinal perspective on who they are becoming and how they are constructing their professional identity.

Medical educators frequently cite reflective writing as a valuable tool to foster reflective capacity and to promote construction of a professional identity in competent and compassionate doctors.^1–6 The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. The need to aid students in fostering reflective capacity is particularly salient given the significant risks of burnout and a decrease in empathy during training.^7–9 Furthermore, the current focus on standardization and documenting competency may challenge or even counteract the construction of a holistic professional identity by devaluing individuation of personal talents, values, and goals—which, in turn, renders intentional efforts to support reflection all the more necessary.^10–13

Although medical schools around the globe have embraced reflective writing as a means of addressing many of these issues,¹⁴ some educators have voiced concerns that efforts to foster reflective capacity may be counterproductive when writing curricula are structured to document competencies or when student efforts are evaluated with a reductionist lens.^14,15 Indeed, Ng eloquently described potential pitfalls of using reflective writing to serve a utilitarian outcome consistent with the “dominant epistemological lens” of traditional medical institutions.¹⁵ To protect against these risks, some medical educators have looked to reflective tools anchored in the narrative medicine tradition as ideally suited to foster “open educational spaces,” sometimes called “reflective spaces,” wherein students may effectively develop their reflective capacity and construct a holistic professional identity.^16,17

Narrative Medicine

Within a narrative medicine framework, reflective space is created through a rigorous sequence of pedagogical actions.¹⁸ Participants start with a shared close reading of textual works that promote creativity and attention to detail. The shared reading and interpreting enhance trust within the group. Next, writing in response to open-ended prompts that echo the reading encourages medical students to shift from a reductionist to a more expansive way of thinking, from providing definitive, evidence-based answers to pondering existential and ambiguous questions. Then, reading aloud and listening to what participants have just written, along with responding to one another’s writing, inspires deep respect for the discovery potential of creative writing within a climate of safety and mutual respect.¹⁸

Development of a Narrative Portfolio

Educators at the Columbia University College of Physicians and Surgeons (P&S) have developed a longitudinal reflective writing portfolio (described below), incorporating many of these narrative medicine concepts, to provide a safe, purposeful, exploratory reflective space in which students may grow and share.¹⁶ To enhance the longitudinal scope and to augment the benefits of reflective writing within this portfolio, we designed an end-of-semester meta-reflection assignment called the Signature Reflection. Each semester, the Signature Reflection assignment prompts students to review their archive of portfolio entries, to write about what they notice about themselves in their previous writing, and through this exercise, to connect with their former and future selves.

This article focuses on the rationale, curriculum content, and early analysis of the “reflective space” created by our school’s longitudinal writing portfolio. Our analysis of Signature Reflections written by students after their first semester of medical school offered a unique window into the students’ perspectives on their own medical school journeys as expressed in their portfolios. We wanted to learn what students themselves would see when given the opportunity to look back on their own writings. We also wanted to learn whether their words might shed light on the learning outcomes of the portfolio, and if so, how. Finally, we wanted to understand if students used the portfolio to explore professional identity construction, and if so, how.

Context

For more than twenty years, through the narrative medicine program, medical students at P&S have been required to select and participate in creative and exploratory seminars within the humanities. Whether responding to visual or written works, students have written about these experiences, in part so that they might strengthen their skills of close observation and accurate and detailed representation, which can, in turn, deepen their capacity to attend to and even connect with patients and peers. Qualitative analysis of the P&S Narrative Medicine selectives have indicated that students recognize and appreciate the role of narrative medicine in their training and growth as future physicians.^4,19,20

In the context of a National Institutes of Health-supported project to enhance the social, behavioral, humanities, and arts curricula in the medical school, a task force of faculty and students convened in 2011 to look for ways to increase reflective writing throughout the curriculum using methods from the narrative medicine tradition. The aim was to provide students with a nuanced view, over time, of the professionals they are becoming. The task force met monthly for a year to review the literature on reflective writing and to examine peer institutions’ experiences. The task force considered the selection of appropriate texts and prompts, the maintenance of student engagement and trust (especially given privacy concerns), faculty training, and a mechanism for evaluation. As a result, in 2013, after learning from a one-year voluntary pilot, P&S launched a required reflective writing portfolio requirement for all incoming medical students. The task force hoped the portfolio would capitalize on the institution’s prior success with narrative medicine, allow students to benefit from a longitudinal writing curriculum, and offer students an individualized view, over time, of who they are becoming.

The P&S portfolio

Rooted within Foundations of Clinical Medicine (FCM), a P&S course focused on pre-clinical social and behavioral sciences and on core clinical skills, the portfolio goals are to reinforce students’ reflective capacity and to foster the construction of a holistic professional identity through a longitudinal program that offers multiple occasions for students to engage in guided reflections with input from peers and faculty mentors. We describe key features of the portfolio in Table 1.

Table 1.

Description of Key Features of the Columbia University College of Physicians and Surgeons’ Portfolio Curriculum, Initiated in 2013

Key features	Description
Non-evaluative	There have been calls to increase non-evaluative spaces in medical school to foster students’ self-motivation and to honor individualized learner identities, personalities, and learning approaches.16,17 Although our portfolio writing entries are mandatory, emphasizing the curricular centrality of reflection, they are explicitly non-evaluative.
Supportive feedback from trained faculty	To maximize educational dividends of reflective writing, it is important that students receive formative feedback from a supportive faculty mentor trained in close reading.3 When crafting written responses to portfolio entries, mentors use our institution’s Reading Guide for Reflective Practice,3 which directs faculty members’ focus to elements of literary form, such as perspective, observation, and mood. The result is appreciative mirroring and deepening of students’ recognition of what they have written.
Longitudinal	The longitudinal nature of the portfolio encourages students to recognize their changes over time, honoring their struggles as well as their successes.
Narrative medicine exercises	Examples of literary texts and writing prompts used to promote reflection: Reading: “The Artist,” poem by William Carlos Williams22 Prompt: Write about a moment of unexpected beauty. Reading: Short excerpt from The English Patient by Michael Ondaatje32 Prompt: Write about a room of care. Reading: Short excerpt from My Own Country: A Doctor’s Story, by Abraham Verghese33 Prompt: Write about being an outsider.

Because the purpose of the portfolio is to learn reflection through writing, as opposed to the goal of demonstrating reflection in writing, entries are mostly in-class, unedited, narrative medicine exercises. Additional writing prompts are diverse, ranging from reflections written after the students first meet their cadavers to considerations of their early clinical experiences. Students upload their portfolio writing entries to a university portfolio website. Students submit at least six writing entries and one end-of-semester meta-reflection during each of three pre-clinical semesters; entries continue during subsequent clinical clerkships. Faculty encourage students to submit additional voluntary entries throughout their undergraduate medical education at P&S.

The narrative medicine method used during in-class exercises has been well described elsewhere.^18,21 Briefly, small groups of 12 to 14 students, led by FCM faculty-mentors who are trained in the narrative medicine tradition, engage together in close reading and discussion of complex literary texts.³ Faculty select the narrative texts, which parallel the arc of students’ medical school experiences, for their implicit congruence with the on-going course themes (e.g., awareness of multiple perspectives in a clinical encounter). However, faculty do not explicate the curricular and thematic connections for students; rather students are encouraged to make their own observations and interpretations of the text, and to practice articulating and interpreting what they notice. To heighten students’ observational and descriptive capacities, small-group discussions focus on such devices as form, time, metaphor, and mood. Following this discussion, students write individual responses to open-ended prompts designed to encourage their own creative, unique reflections. Finally, after writing, students have the opportunity to share their work with one another. For example, during a session focused on “The Artist,”²² a short poem by William Carlos Williams (see Appendix 1), students ponder and discuss questions about the relationships of the characters and the setting. Who are the people in the poem? Who are they to one another? Who is the narrator? What is going on? What is the mood? Next, they respond to the prompt, “Write about a moment of unexpected beauty.” After writing for no more than ten minutes, students are invited to read what they wrote, either in pairs or with the larger group, and small-group members respond to the shared writing. See Appendix 1 for an exemplar student portfolio response. Students must submit 1 to 2 narrative medicine entries and their Signature Reflection to their faculty-mentor each semester; however, most entries remain private unless a student invites the FCM faculty-mentor to provide commentary. Mentor feedback is not evaluative but instead relies on similar close reading methods of observation and description that models what the students are learning. (These methods are described in detail elsewhere.³) FCM faculty-mentors accompany their first-year students through their remaining years of medical school, and their written feedback provides the basis for individual mentoring meetings each semester.

Signature Reflections

One important and innovative component of the P&S portfolio is the Signature Reflection. At the end of each semester, students have twenty minutes of classroom time to read their entire collection of portfolio entries. Then, they spend 10 to 15 minutes writing a Signature Reflection in response to a prompt that encourages them to apply the same narrative medicine tools of close observation and description to their own previous writings. In this way, the Signature Reflection provides an opportunity for students to plumb their own writing for evidence of their efforts at self-recognition, to frame hypotheses about what they have experienced in medical school, and to draw conclusions about what they notice about themselves. This exercise offers a mechanism by which students may gain a greater understanding of themselves by looking back at what they have written.

Analysis of Student Writing

In January 2015, we analyzed Signature Reflections to understand the effect of the P&S portfolio on students’ reflective capacity and on their construction of a holistic professional identity.

Sample

The writing prompt used for these first-semester Signature Reflections was, “Write about the doctor you imagine yourself becoming; what did you notice about yourself in your writing?” Of the class of 160 first-year students, 4 students opted not to participate in this research and 24 Signature Reflections were not accessible through the portfolio website due to technical issues. Of the remaining 132 students, 97 (73%) specifically responded to the second clause of the prompt, “What did you notice about yourself in your writing?” To capture students’ impressions of, specifically, how they perceived, through reading their own writing, whether their own identities had changed over time (and if so, how), we limited our review to these 97 Signature Reflections. All students whose Signature Reflection was analyzed previously agreed to let faculty read their de-identified writings. The institutional review board of Columbia University deemed this project was exempt research.

Process of analysis

To initiate the analysis, 17 FCM mentors reviewed a sample of 60 de-identified Signature Reflections and, as a group, identified common words and concepts. A smaller group of six researchers placed these concepts within the context of the narrative medicine, reflective writing, and professional identity formation literatures. These common words and concepts formed the basis of our early code book and allowed us to construct an emergent conceptual representation of how the portfolio in general, and Signature Reflections in particular, contributed to students’ reflective capacity and professional identity construction. We then continued to apply and review codes from the code book for the remaining 37 Signature Reflections, iteratively revising the codes and code book employing the constant comparison method.²³ When the team reached agreement on a final code book, two of us (BK, LF) applied revised versions of the codes to all 97 Signature Reflections documents using Dedoose software (SocioCultural Research Consultants, University of California, Los Angeles with the William T. Grant Foundation). The larger team met weekly to continue to discuss the final coding and to address any questions that arose. Once we had applied codes to all 97 Signature Reflections, we examined the coded data to identify emergent patterns and salient themes, and then we revised our initial conceptual representation based on our emergent understanding of the contributions of the portfolio.

Signature Reflection Themes

Through our iterative analysis of the P&S portfolio, as described by students in their Signature Reflections, we detected two overarching themes: Recognition and Grappling. We describe these main themes and their six sub-themes—and illustrate each with exemplary quotations from students’ Signature Reflections—below.

Recognition

Narrative medicine techniques are designed to foster close attention to the stories of the self and of others,¹⁸ and indeed this was evident in our student writings. We chose “recognition” to describe students’ descriptions of their heightened awareness of their own attributes and of patients’ perspectives. Two sub-themes of recognition—self-awareness and empathy—appeared frequently in students’ Signature Reflections.

Self-awareness

Given the writing prompt, “What did you notice about yourself in your writing?” it was not surprising that students often wrote about how their own attributes would influence their professional identity construction. Whereas some students named specific personality traits and observed how their personality was represented in their writing, others commented on how the portfolio enhanced their awareness of self. To illustrate, one student wrote,

Throughout the semester, as I saw through my previous writings, I really tried to get in touch with my own feelings and motives for wanting to become a doctor and reflected on all the life experiences and people that have led me to this point in my life.

Empathy

Students frequently recognized their empathic, early-medical school selves and reported this awareness to be a valuable dividend of the Signature Reflection. To illustrate, one student wrote,

However, reading my portfolio entries from this past semester has given me some hope that I won’t lose the ability to empathize with patients and give them proper attention. During both of my [first semester] clerkships I learned that going out of my way to perform small acts of generosity for patients can be very meaningful.

Student Signature Reflections expressed empathy by showing an awareness of multiple perspectives and by relaying patient stories. Another student commented,

In the course of medical training, it can be very easy to forget these things—but looking back on my writing… I am reassured by the fact that I still view ‘patients’ first as people, as individuals with unique, important and worthwhile stories, perspectives, and life experiences, rather than as medical ‘problems.’

This student’s comment highlighted the importance and value of the longitudinal perspective supported by the Signature Reflections; in participating in this exercise, the student realized “it can be very easy to forget.”

Grappling

Another intriguing, but not surprising, theme pertained to students commenting on change and uncertainty over time. We chose “grappling” as the most fitting term to capture students’ descriptions of their wrestling with changes or surprises they encountered in the content of their earlier portfolio entries. Grappling was evident (1) when students discussed the changes within themselves, (2) in their worries about balancing emotional distance with compassion, (3) when they asked questions or exhibited wonder, or (4) when they expressed anxiety. These comments appeared to elucidate a mechanism by which the activity of writing a Signature Reflection both fostered—and was fostered by—reflective capacity.

Internal change

Many students wrote about the changes in their perspectives that they observed through their first-semester portfolio writings. Whereas many students, such as the three whose quotes appear above, noted changes that they considered positive lessons learned, others confronted changes they perceived as negative. Students noted changes in their confidence, empathy, and skills. One commented,

Looking back over what I wrote this past semester, a theme emerges. It’s one of being okay with feeling uncomfortable, different, confused, or uncertain. It’s one of striving to move from that discomfort, otherness, confusion, or uncertainty towards an understanding.

Another wrote,

I’m rather intrigued about the darkness of my writing because I see myself as a fairly positive person, and I still feel immensely grateful to be at an institution like Columbia for medical school. I was surprised that the excitement and positive outlook contained in that first piece has worn off to such a large extent. I guess school and integrating yourself into a new place is a lot of hard work and it’s easy to get a little down.

Indeed, the students above not only identified an “emerging theme,” but also expressed surprise and discomfort in doing so. This surprise, and the evident discomfort that ensued, may be uniquely facilitated by this meta-reflection exercise.

Dichotomies: Balancing emotional distance and compassion

Students expressed how the act of writing the Signature Reflection allowed them to perceive conflicts or “dichotomies”—between acculturating or becoming a professional and maintaining self; between maintaining a healthy emotional distance and showing compassion. One student described this awareness as seeing past “the barrier”:

Yet, there were moments in my writings where I brought down the barrier and [what] came out was a dichotomy, dissonant in nature. Excitement about the things I would potentially learn, but fear for the things I could no longer relate to (due to the things I will learn)...

Another student described her initial idealism in contrast to her focus on knowledge acquisition:

Our very first writing assignment where we had to describe the days that brought us her[e] made me think about how I would often forget about the end goal of being in medical school—to help people. I wrote it after the hyper of the white coat ceremony was coursing through my veins. As the semester progressed onwards I noticed that sometimes I would forget that sentiment to the pages of biochemistry textbooks that seemed to have little connection to actually helping patients.

Students described both fear and excitement as they recognized how they were changing or how they predicted change would be inevitable. Furthermore, as suggested by the latter quote, we propose that the act of reviewing their portfolio entries may have supported students’ recognition of conflicts and competing demands that were so deeply woven into their daily lives as to be undetectable day-to-day.

Wonder and questioning

Students often used the Signature Reflection exercise to examine thorny questions, to wonder about their past selves, and to project themselves into the future. These Signature Reflections relayed curiosity, imagination, and the repositioning of self back and forth in time. For example, one student pondered,

It’s really interesting to look back on my old writing and see it with the distance of time…I like the person who did the writing, even if I’m no longer exactly that person. I am not sure what kind of doctor that woman is going to become, I guess because I already feel a level of dissociation from her. I think she would have been a great doctor: a little naive, but incredibly optimistic. Concerned. Considerate. Hopeful.

Another considered,

I’ve come to recognize in reading my writing from the past semester that I’ve been particularly attentive to communication barriers and other issues that prevent patients from disclosing as much information as clinicians might hope: language and cultural differences, time constraints, and physical and emotional discomfort, among many others. And yet, as I write this, I wonder about my fixation on the ‘imperfect’ communication I have witnessed while shadowing other doctors or conducting my own interviews. I wonder, too, why I seem to think that ‘perfect’ communication always involves full disclosure and complete comfort with revealing information, whether intimate or not.

Some used the Signature Reflection as a touchstone to note and document valued characteristics that they were able to see “with the distance of time.” For other students, such as the author of the quotation immediately above, the act of observing themselves and recognizing trends led to questioning the assumptions they held about themselves, their values, their professional goals, and even the practice of medicine.

Anxiety

Students frequently observed anxiety in their own writing, often commenting on the “uncertainty,” “faking,” and “frustration” caused by the myriad demands of medical education. To illustrate, one student wrote,

A recurring theme in my writing this semester has been anxiety. I entered medical school like a kid running through the gates of Disneyland. Five months later, that excitement has been overwhelmed by a flood of uncertainty, insecurity, and second-guessing.

Another commented,

When I read my piece on “Being an outsider,” it strikes me how very much I still feel like I’m faking every time I put my white coat on. That I am pretending that I know so much more than I do. I know that in many instances in day-to-day living, one can “fake it till you make it.” But in my training to be a doctor, it seems like the stakes are higher.

Yet one more student observed,

What I notice however, is a disconnect. I write about connecting and feeling and caring, but my daily activities are unrelated. I spend most of each day studying the facts that allow one to practice medicine. It is necessary of course, but I still wonder: Do we really further our goals by ignoring them during the lengthy pursuit? I get frustrated easily when I don’t use my time well. Even five minutes of sitting on a train has to be productive—reading, studying, communicating. Yet how will I be a patient doctor when I can’t be a patient student?

In reviewing their reflections, students noted the extent to which they were grappling within their everyday lives, as they commented on balancing multiple factors such as professional goals, family, friends, and personal well-being with increased educational demands. For these students, the Signature Reflection may have surfaced a recognition of a disquiet or angst within themselves that lay previously unnoticed or unexamined either by themselves or their mentors.

Discussion

A required, longitudinal narrative portfolio, augmented by periodic meta-reflection (such as our Signature Reflection), offers students the practice and space to give form to recognition and grappling. With the distance of time, students are able to reflect on their past reflections; they have the opportunity to monitor and consider their growth and change. This reflective process, though potentially uncomfortable for some, may ultimately foster the construction of a holistic professional identity. One student captures the idea well: “Looking back over what I wrote…, a theme emerges. …It’s one of striving to move from that discomfort, otherness, confusion, or uncertainty towards an understanding.”

The recognition and grappling expressed in these Signature Reflections are not surprising. Indeed, others have elegantly described how creative writing supports the development of self-awareness and empathy.^6,24–26 Furthermore, themes related to medical student professional identity, such as uncertainty and conflict, were noted by Renée Fox as early as the 1950s.²⁷ Since that time, educators have continued to identify such themes as important modulators of medical students’ integration of their identities, values, and beliefs.^10,15,28 Our findings complement and extend these important themes by suggesting that our narrative portfolio and Signature Reflection allow students to discover, grapple with, and recognize for themselves the themes of changing identity, conflict, and uncertainty that other researchers have previously reported. Whereas others have used audiotaped dictations and interviews to capture students’ experience of professional identity construction,^29–31 we have relied instead on interpretations created by students themselves. Moreover, we believe our meta-reflective exercise promotes this process in a particularly powerful way: The students’ writing of their Signature Reflection allows their perceptions of who they are and who they are becoming to surface and be captured in permanent form. This physical representation can be examined by their present and future selves, their peers and faculty-mentors, and the broader medical education community. Thus, the Signature Reflections themselves contribute to the scholarly literature on reflective writing.

The P&S portfolio created a reflective space wherein recognition and grappling could occur through the following narrative medicine processes: close reading of narrative texts that encourage curiosity; open-ended writing using prompts that honor individual processes; and meta-reflection that helps student notice, give form to, and engage in the construction of their professional identity. Throughout this process FCM faculty provide supportive, non-judgmental mentoring by asking questions and attending to form. The open-ended, personalized questions foster responses from students and provide a forum for expressing and discussing conflicts, questions, and uncertainties. We believe the capstone assignment of our narrative medicine portfolio curriculum, the Signature Reflection, serves as a model to encourage students to grapple with uncertainty as it unfolds over the course of medical school.

Although our data source was actual student writings, asking students via interviews or focus groups to corroborate our findings would enhance trustworthiness. Also, only 73% of students responded comprehensively to the Signature Reflection prompt; as a result, we have made writing prompts and instructions more explicit (while still maintaining the openness of a reflective space).

Although our aim is to foster lifelong reflective skills in our students, this cross-sectional analysis of students’ first-semester Signature Reflections does not enable us to assess the long-term consequences of students’ participation in the portfolio. Encouraged by what we learned from these early Signature Reflections, we expect students’ benefits from this reflective process to increase over time. We are currently extending our analysis forward to include writing entries from the first three years of medical school, and we plan for our next analysis to focus more closely on longitudinal identity construction. Going forward, we hope to study the effect of the P&S Portfolio on the mentoring process and on medical students’ sense of community.

We believe that the “mirror” exercise embodied by the Signature Reflection has utility well beyond our institution. When situated within a reflective space such as the non-evaluative reflective writing portfolio presented here, other medical educators can adopt a similar meta-reflection process to encourage students’ construction of a holistic professional identity and to provide them with a longitudinal perspective on who they are becoming.

Appendix 1 Example of Narrative Medicine Text, Writing Prompt, and an Exemplar Student Response from the Portfolio Curriculum of the Columbia University College of Physicians and Surgeons, 2014

Example of narrative medicine text

“The Artist” by William Carlos Williams²²

Mr T.
bareheaded
in a soiled undershirt
his hair standing out
on all sides
stood on his toes
heels together
arms gracefully
for the moment
curled above his head.
Then he whirled about
bounded
into the air
and with an entrechat
perfectly achieved
completed the figure.
My mother
taken by surprise
where she sat
in her invalid’s chair
was left speechless.
Bravo! she cried at last
and clapped her hands.
The man’s wife
came from the kitchen:
What goes on here? she said.
But the show was over.

Writing prompt

Write about a moment of unexpected beauty

Exemplar student response

One week ago, I was shadowing a physical therapist in Milstein as a part of my [Foundations of Clinical Medicine] clerkship. Usually, I will spend an afternoon following [name] (the PT) as she walks with patients recovering from major cardiac or hip surgery. Usually, the patients are looking a little haggard—their hair is in complete disarray, their hospital gowns are stained with unidentifiable substances, and various tubes are carrying suspiciously-colored fluids in/out of their bodies. One of these patients, Mr. M, was particularly haggard—he had dementia, was very confused, and was inadvertently defecating on himself throughout his stay at the hospital. He was also only Spanish-speaking and suspicious of his care-takers and never wanted to work with [name] when we came by. But last Monday, his wife was able to make it to the PT session for the first time—and when we saw Mr. M, he was clean, had a fresh gown, and he didn’t smell of urine or feces. And for the first time, he was willing to go for a walk. Seeing the 180-degree reversal in Mr. M’s attitude and general well-being (maybe because he was comforted and looked after by his wife) was a beautiful and unexpected moment. It was also a sobering moment for me because I was made aware by how much the appearance of a patient altered my perception of and attitudes towards him/her. There is a lot about medicine that isn’t graceful or clean or simple—I realize that I need to get myself comfortable and prepared for that fact.