A Medical Humanist's Note

Finding Our Strength

 “In times of crisis we summon our strength…
call on every resource…every forgotten image…
every memory that can make us know our power.”
– Muriel Rukeyser

How does one live with uncertainty when facing a life-threatening illness? Where does one find inner strength? Where does one look for supportive resources? Most patients will tell you that they frequently ask themselves these questions.

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Transforming Medical Crisis into Opportunities to Find Meaning in One’s Life

The Center for Communication in Medicine, which I am a founder, decided that our next SpeakSooner Community Education Program on October 26 in Bennington would focus on the theme of transforming a medical crisis into an opportunity to find meaning and joy in one’s life. Planning this event brought to mind a woman whom I had known from time passed.

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Who is This Doctor at My Bedside?

Recently, a friend went to the emergency room with complaints of severe GI pain and was admitted to the hospital. Naturally, she was worried about the cause of her symptoms, which she had been experiencing on and off for 6 months. Under the care of her family doctor she tried several medications but none seemed to alleviate her pain entirely. Now, the doctor who she had known for many years and trusted was no longer involved in her care. Instead, a hospitalist appeared at her bedside and would be in charge of the case.

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 “In times of crisis we summon our strength... call on every resource...every forgotten image... every memory that can make us know our power.” - Muriel Rukeyser How does one live with uncertainty when facing a life-threatening illness? Where does one find inner strength? Where does one look for supportive resources? Most patients will tell you that they frequently ask themselves these questions. During my tenure as a medical humanist at the cancer center in Bennington I created “Writing is Good Medicine” a program that offered patients an opportunity to express their experience through the written word, which is not a neat narrative. The method builds on the literature of stream of consciousness but differs in that patients are provided an opening line as a place to begin. The program was not designed to teach the elements of writing but, rather, to help voice their intimate thoughts and emotions, which are not found in medical textbooks or office notes. With this in mind, I often encouraged patients to share their unedited writing with the cancer care team. It struck me that Rukeyser’s inspirational quote could be a prompt for exploring sources of strength in facing a healthcare crisis. Here is what one of the patients wrote in 2005. After reading her words, you’ll understand why I saved the piece. My power is there...but not the whole picture...It lies deep inside...sometimes used without “over thinking” ...just used or there because it is the natural thing to do... I like it best that way... It was hard to start writing about “power.” It is a concept that invokes many confusing feelings. I don’t think I have ever wanted the responsibility of power...when I think about power...it also brings thoughts of feeling over powered by someone or something else...using my own power in a negative way is something I don’t want to do...So power I guess has a charged meaning for me... My illness has caused me to look deep inside myself for a way of doing my best to get well, and to enjoy my “well” time...I think I have thought first about being at peace within myself...and looked to my spiritual life for strength in this moment.    Interesting: strength is much more a part of my vision...it fits better than power... Many times in my life I have attacked and beaten things up with my brain...sometimes I have exhausted myself in the process...That will not work this time. My strength or power this time lies in my ability to be at peace with the fact that there are aspects of this situation that no amount of energy can control...only by accepting that, can I open a window to the light and focus on what I can do to help my body, mind, and spirit not only to heal...but to maintain, grow, change and evolve in spirit. The unpredictable parts of this experience test my strength...sometimes I am afraid that I can make myself sicker... sometimes I know I do not have that power...in many conversations my sister tells me so...I am happy to hear it...it is almost a relief to know when I am not in control of things...because then I am not to blame...Funny that “blame” marches in here... It is hard to talk about my spirit but I do believe in grace and soul, and spirit...I find comfort and strength in prayer. I know from childhood I find comfort and strength in prayer...I find childhood a comfort in my beliefs...and that inner vision is my place of peace and comfort...I know that God has loved who I am from the beginning...and it is with me as I take this journey...I remember in the Spring when I wasn’t troubled and worried about everything...I knew I didn’t want to keep on being afraid...I remember asking God to take away the fears so that I could live life to a better purpose...regardless of the circumstances. Strength then is an inside job...but not a lonely one. People, places and things come into my life to enrich my spirit and help me focus on worthy objectives...Staying open and aware and receptive is important ...sometimes I am too tired, and I just hang on...sometimes I am afraid and I am learning to talk about my fears with those who can listen...sometimes I waste my energy on things that are not my business. And, sometimes I am surprised by the peace and beauty I sense in simple moments. Many people love, care for, and pray for me...I feel circle wide about me...I know I am blessed by their caring and prayers. My mind can paint beautiful, comforting thoughts and pictures for me ...connecting me with love and grace in that place. A resource for strength and renewal! Perhaps some of my ambivalence about power—comes from AA principles where admitting powerlessness brings a kind of power to live a normal life...trying to beat alcohol was such a waste of energy and I got beat up in the process...So I have to find the parts of this new disease that are my business and work in the ways I can to help myself get well. Identify and accept my best efforts to those things I can do to enhance my treatment and help myself get well. In the dictionary there are many definitions of power. One is “the ability to do or act; capability of accomplishing something.” There were actually 22 definitions...some referred to energy and strength. I know that even within this illness I can maintain my identity and still live to good purpose: that is power! The part about responsibility with respect to power...has to do with outcomes...this is a bit daunting with respect to the disease itself... Today I am not so anxious about this aspect...maybe because I am regaining perspective... and things are again “right” sized.”                I’d suggest you take a moment and use Rukeyser’s words to write about what gives you strength. You may see for yourself why writing can be good medicine. I’m sure there are lessons here for all of us.
“When I completed medical school and residency in the Northeast, I rarely thought about the intersection of religion and medicine. But when I moved to the South for a combined fellowship in pediatric hematology-oncology and hospice and palliative medicine, I found myself enrolled in a crash course at the bedside,” explained Dr. Erica Kaye (Finding Faith, Journal of the American Medical Association, February 18, 2020). Dr. Kaye describes in intimate detail her initial awkwardness for requests to pray with patients and their loved ones and how she learned over time that faith can have a place in medical care. Reading the article catapulted back to the early 2000’s. While serving as a medical humanist at the cancer center in Bennington, I had been asked to administer a form that surveyed the role of a patient’s religious and spiritual beliefs in facing a cancer diagnosis. The medical staff was interested in understanding whether a patient’s faith helped sustain them in times of crisis. In addition, the survey could offer insight into how religious or spiritual beliefs might influence treatment decisions. This could be valuable information when discussing a plan of care with patients and loved ones. I respectfully approached each patient to explain the purpose of the survey. In one instance a patient stopped me part way through the first question and said, “Are you telling me that if I would have prayed more, I wouldn’t have gotten cancer.” Needless to say, I was stunned and a bit tongue tied. I finally said something along the lines of, “Some people find comfort in their faith while others might look to something else to ease distress during hard times. I don’t think you got cancer because you didn’t pray enough.” He seemed relieved as did I. The survey was discontinued after a short period of time. I didn’t get an official explanation but I think it was viewed as too intrusive, not an area of inquiry that belonged in the arena of science. Frankly, I didn’t see why asking about the role of one’s faith at times of crisis is not relevant.  Why dismiss what we may not fully understand but could offer comfort to those living with the uncertainties about the future. “Within the medical community,” Dr. Kaye notes, “I imagine that I am not alone in my struggle to understand the unknowable. I wonder if wrestling to reconcile medicine and faith, though, misses the point. For some, maybe finding faith simply means reconnecting with the feelings that led us into medicine. Perhaps one can think about faith, not in terms of what we know or in whom we trust, but rather as the inevitable product of shared wonder in the face of the indescribable. At the intersections of medicine, science, and spirituality, I find a community of questioners, sharing one another’s confusion and burdens, caring and connecting meaningfully with one another, and answering Yes in affirmation of the search for the sacred.” What has been your experience with doctors in discussing the role of faith in facing illness?
We expect doctors to provide state of the art care and help us get better from whatever ails us. By nature, patients are self-centered and believe that doctors should only be concerned about our problems. Of course, that’s their job but we often overlook what it’s like to practice medicine in today’s healthcare delivery climate. So, should we make an effort to openly acknowledge the increasing time pressures and demands facing those who have our health and well-being in their hands? With reports of significant physician burnout, do they need our support and understanding? The answer is yes and yes. In “Clarifying the Language of Clinician Distress” (Journal of the American Medical Association, January 31, 2020), authors Wendy Dean, MD, Simon Talbot, MD and Arthur Caplan, PhD explain issues that contribute to physician distress. The list includes making difficult clinical decisions, reduction of quality time with patients and the financial framework of medical care. Although there have been initiatives to help clinicians improve self-care and manage stress, there have been no successful remedies to address the systemic causes of burnout. In a related commentary on WBUR (Boston) Dr. Dean, one of the articles’ authors, delves deeper into this problem by identifying moral distress and moral injury as the underlying factors that result in burnout. She shares a personal experience regarding the disengaged care her husband (also a physician) received at their local hospital, which almost led to his death. She notes, “The system has bound the physicians so tightly with scheduling, data and metrics, policies and punishments, that they too could hardly breathe… They stopped fighting back because it was futile. They were beaten and stopped empathizing, became disengaged.” If we don’t stop to acknowledge that clinicians are confronting increasing time pressures and burdensome record keeping, we are ignoring the other half of the doctor-patient relationship. It is not a leap to conclude, as Dr. Dean points out, that burnout can also impact the care we receive. With this issue in mind, you probably wouldn’t be surprised to learn that we chose the topic of “Building Physician’s Trust with the Healthcare System” for a recent Doctors Conversation Hour, a program hosted by the Center for Communication in Medicine. From the discussion that evening it was quite apparent that doctors are very concerned about how increasing demands impact effective patient care, which is also a key source of their job satisfaction. It’s a complex problem with many competing stakeholders and finding a solution remains a challenge. This topic also takes me back 20 years. During my tenure as a medical humanist at the cancer center in Bennington I would often hear patients tell me --“doctors have a stressful job.” I would encourage them to tell their doctors what they said to me. Now, you can say that am I proposing that patients openly express empathy toward doctors about what is being imposed on them by the healthcare system. It may appear that it’s a lot to ask of seriously ill patients and their loved ones but we need to let one another know we’re in this together. Our lives may depend on it.
In my previous blog “Waiting for Test Results” I shared a conversation from the early 2000’s that I had with a receptionist at the cancer center about responding to inquiries for test results. In those days there were no patient portals so patients and loved ones often agonized over having to wait for a call or office visit to learn results of a biopsy or scan. Now, with access to results available electronically, you would think that technology has eased the anxiety associated with waiting. The good news about patient portals is getting results faster but the bad news is the challenge of reading a report that features unfamiliar medical terminology, a foreign language that most of us barely understand. Small towns increase the chances of bumping into patients I’d known during my time as a medical humanist at the cancer center in Bennington. Recently, I was shopping at the local supermarket when a patient recognized me. I stopped and asked how she was doing. While offering an update on her health, she suddenly blurted out, “I hate the patient portal.”  She went on to say that she knows how to use a computer and navigate websites but finds the online reports barely intelligible. Sounding exasperated she went on to say, “I don’t know what the medical jargon means. I guess I could look it up on the internet but I’d rather call the doctor’s office to speak with someone. I’ve been a cancer patient and I need to understand what the test results mean.” Supermarkets have narrow aisles and a woman nearby overheard our conversation. She interjected, “Sorry to interrupt but I happen to like the portal for things like making appointments and refilling medications but I need to talk with a nurse or doctor about stuff that’s more complicated.” We both looked at her with an acknowledging smile. I have come to appreciate that some of us are comfortable with a patient portal and don’t mind the extra work visiting other websites in order to clarify medical terminology. Others may not be computer savvy or just not like to rely on electronic tools for health information. No matter what method we prefer, it’s most important to ask questions and be sure that you understand the answers. I’d also suggest you tell healthcare providers your preferred method of receiving healthcare information. I think it’s fair to say that doctors, nurses and receptionists can still expect to be asked when test results will be ready. I can only hope that when the information is not yet available, the person taking the call remembers to say, “not soon enough.”
Those familiar with my work as a medical humanist would not be surprised to hear that I’m still having conversations with patients about the challenges of navigating the healthcare system. Often time these interactions occur at the local supermarket or while walking on Main Street in town. I continue to be asked what to do about waiting for test results, which is frustrating and anxiety producing. When I think about this common complaint, I am reminded of an incident back in the early 2000’s during my tenure at Southwestern Vermont Regional Cancer Center. It goes like this. I was within earshot when the receptionist cradled the telephone between her ear and shoulder as she jotted down the patient’s message. “I don’t know when the doctor will have the results of your biopsy,” she said “but I will let her know that you called.” I could hear exasperation in the receptionist’s voice having to repeat this response so often. I imagined what it would be like being on the other end of the receiver.  What would I want to hear in response to the question, “When can I expect the results of a biopsy or any diagnostic test?” Not soon enough were the words that came to mind. When the receptionist got out of her chair to place a note in the doctor’s incoming message box, she realized I had been listening. “Is there some way I could make waiting for results easier for patients? Is there something else I could say?” she asked. “How does this sound? I said. “I don’t know when the doctor will have the results of your biopsy, but what I do know—it’s not soon enough. We’ll let you know as soon as we know” “It would certainly help me if I were the patient,” the receptionist countered. In my role as medical humanist on the cancer care team I spent a lot of time listening and documenting what patients said about living with uncertainty and resulting worries. I also observed how often doctors had to wait to receive test results, especially if they were analyzed at another hospital’s lab. At times, I found myself reminding the clinical and support staff that the difference between feeling ignored and feeling cared for could be a matter of just a few words. The incident I just described takes into account how recognizing the patient’s perspective could have a positive impact on their state of mind and help humanize the relationship with healthcare providers. Because, in just a few words, a doctor, nurse or even a receptionist can demonstrate empathy and lessen anxiety, one of the most common side effects of living with uncertainty. I must note that since the time of my exchange with the receptionist, the patient portal system has become a mode of communication for accessing test results. Although this electronic method offers a convenience, it has its own issues with patients understanding the medical language used in the reports. This will be a subject for another blog. Now, I’d like to pose these questions to readers. For patients and loved ones-- what else could help you manage anxiety when waiting for test results? For healthcare providers-- do you have a preferred way of helping ease patients’ worries in situations such as this one?
It’s a new year but I find myself reflecting on times past. So much for the lyrics of Auld Lang Syne, “Should old acquaintance be forgot and never brought to mind.” What catapulted me back in time was a recent article in the Journal of The American Medical Association (JAMA) that highlighted the patient’s perspective of illness. I found myself back in 1999 thinking about when I was unexpectedly invited to join the staff of Southwestern Vermont Regional Cancer Center as a patient navigator. I had no experience in the world of medicine but, like writers do, I observed doctor-patient interactions, listened to patients’ stories and read the medical record. Over the next 2 years I observed how a communication gap between doctors and patients could have an effect on making informed decisions about care. These observations helped prepare me to create and implement the role of medical humanist, in which I documented the patients’ understanding of their diagnosis, prognosis, treatment plan and concerns that may not have discussed at the visit with their oncologist. My note was included in the medical record. When I asked one patient about what she would have liked to talk about with her doctor, she was quick to say, “I want my doctor to understand what my quality of life means to me.” In another instance, a doctor reviewed my note and claimed, “They never told me that.” The intention of my note was to help facilitate communication between doctor and patient about what may have been misunderstood or unspoken at the office visit. The JAMA article (January 2, 2020) has the cumbersome title of “Adding Patient-Reported Outcomes to Medicare’s Oncology Value-Based Model.” To my surprise, the authors confirmed what so many have said-- the medical humanist model I implemented 20 years ago was ahead of its time. The article refers to the Centers for Medicare & Medicaid Services Innovation Center (CMS) study for improving quality of care for cancer patients. Without getting too deep in the weeds of the findings, what stood out was the importance of firsthand patient-reported outcomes about the effects of chemotherapy, i.e. physical, psychological, quality of life. Communication issues with providers were also documented. It’s worth noting that when patient generated information is delivered to providers in a timely fashion, there is improved symptom detection and control, quality of life and communication as well as increased satisfaction with care. In addition, there were fewer emergency room and hospital visits, lowered healthcare costs and improved overall survival. The article notes that funding for these innovative programs can be an obstacle, as it was when my medical humanist position was terminated in 2005. So, it remains to be seen if patients, who are the real experts about their experience, will have a new communication platform. I must admit that it’s gratifying to see that core components of the model I created in Vermont are gaining traction at a national level. Whether or not the CMS’s patient-reported outcomes model is implemented in the near future, the Center for Communication in Medicine will continue to offer SpeakSoonerâ programs and tools to prepare patients to identify and articulate needs and concerns. Now, we have data from the CMS study that shows timely and clear communication can lead to reduced treatment side effects, improved quality of life and lower healthcare costs, which is what we observed long ago. You can say that I have been heeding the advice of Dr. Herb Maurer, an oncologist from my time at the cancer center, who told me, “Go give them some humanism.”  
Adrienne Barnes, a nurse diagnosed with pancreatic cancer, was featured in “Voices From The Lived World of Illness,” a video produced by the Center for Communication in Medicine. During the interview she shared her frustrations when her doctor tells her “there’s really nothing I can do for you.” She was then asked what would be the best way for doctors to understand the importance of timely and compassionate communication about patients’ concerns. Adrienne replied, “Get sick.” Dr. Marie Archambault Carlson, an internist at the Durham (NC) VA Medical Center, offers a personal account of living with debilitating side effects from cancer treatment in the Journal of the American Medical Association article “You Did Not Teach Me What You Thought You Did.” She shares how this experience has influenced her perspective about life and as a physician caring for patients. “Sometimes the battered, suffering patient with a poor prognosis can rise again, not fully cured, but enough to regain a life. It is letting my colleagues see my weakness, see my value, and hold me up. Perhaps my job is not teaching pathophysiology but how to think about the person inside of patients, to recognize their fears and questions, to link their humanity to ours.” There is something paradoxical about doctors and nurses being patients. Perhaps, that is why it is so compelling to hear their stories about what it’s like on the other side of the hospital bed. With this in mind, several SpeakSooner® Community Education Programs over the past 18 months featured panel discussions with healthcare providers who have faced serious illness. The panelists often talked about feeling scared and overwhelmed with difficulty navigating the healthcare system, even though they’re familiar with language and procedures inherent in the medical world. Like other patients, they were looking for a doctor to care for them with compassion. I certainly don’t believe that healthcare professionals being diagnosed with a life-threatening illness is the answer for prompting open and honest communication. However, I do believe that our responsibility as patients is to remind those who are imparting medical advice about the lived experience of illness. We need to ask questions and invite them into conversations about worrisome issues and concerns. As Dr. Carlson suggests, these personal accounts can help doctors understand and consider the “person inside the patient.” Adrienne also talked about what she was looking for from her doctors. She said, “I was looking for a medical companion that could say we can do this. This is a really bad disease but you’re young— link arms with me and my husband—and tell us ‘there’s lots of stuff out there we don’t know about and see what we can do.’” Is that asking too much?
The Center for Communication in Medicine, which I am a founder, decided that our next SpeakSooner Community Education Program on October 26 in Bennington would focus on the theme of transforming a medical crisis into an opportunity to find meaning and joy in one’s life. Planning this event brought to mind a woman whom I had known from time passed. She and I met in 1984 when my son and her daughter had attended the same nursery school. At the time she had been referred to as “the lawyer with a high degree of competence.” However, when she introduced herself to me she said, “I’ve been diagnosed with breast cancer.” For reasons I couldn’t explain I heard myself say, “Perhaps you can think of it as a gift.” Immediately, I wished I could have swallowed my words but it was too late. “What do you mean?” she asked. “For me,” I said, “we don’t always know the reason things happen to us but in time it can reveal itself.” I scribbled my name, phone number and address on a scrap of paper. I didn’t expect to hear from her. Pat called me the next morning and we took our first walk together. It was a long walk. I explained what I meant. She listened and asked questions. When she talked, I listened and asked questions. You could say we walked and talked for 19 years and became best friends. In many of our conversations Pat acknowledged that she’d rather not have been diagnosed with cancer but it became a gift of sorts, an opportunity to use the hand she was dealt to find a greater meaning to her life. In 1999, her breast cancer recurred. She was a patient again. But during the intervening years she transformed her personal experience into a drive to secure funds for breast cancer research. As a founding member of the National Breast Cancer Coalition (NBCC) and politically savvy attorney, she helped US Senator Patrick Leahy (VT) recognize that because women served in the military there might be research funding available through the Defense Department budget. It was and they were successful in securing funding, which continues to this day. Now she turned her attention to the role of patient advocate in cancer care, which she and others in the NBBC believed should be an essential service.  She understood that the healthcare system was challenging to navigate, even for someone with her past experience and educational background. In her inimitable style, she confronted the Director of Medical Oncology at the regional cancer center in Bennington, VT and told him he needed to hire a patient advocate. He also recognized the need and agreed to fund a 20/hour per week position but asked her to draft a job description and whether she had anyone in mind. This is where I once again came into the picture. Pat asked if I would write a job description and encouraged me to consider taking the position. She had the personal experience of having me as a friend who offered support and was someone who did not shy away from talking with her about emotional struggles. I recall telling her, “I don’t write job descriptions. I’m not that kind of writer and it's not something I’d feel comfortable doing. Besides, to advocate for another you must know the experience personally.” She replied, “Call it what you want but you’re empathetic and would be good at helping patients navigate the healthcare system.  Besides, you don’t get paid for your short stories and you would with this job.” I met with the Medical Director of the Cancer Center and he hired me. I refused to use the title patient advocate so I called myself a “Patient Resource Consultant.” For the most part I did what writers do—observed, listened and read (doctors’ notes). I also helped patients access supportive resources within the medical center and in the community. It was through this experience that I witnessed a communication gap between the language of medicine and the patients lived experience of illness, which often resulted in misunderstandings. In 2001 Pat stepped in again and called a meeting with the CEO of the hospital, which my husband Bernard and I also attended. By this time the three of us founded the Center for Communication in Medicine, a nonprofit with a mission of improving communication between patients, families and healthcare providers. We suggested that the cancer center offer a program to help bridge the communication gap. Through what I had discovered working as a Patient Resource Consultant, I envisioned a program where I would meet with patients after their visit with the doctors and ask a series of questions about what they understood about their diagnosis, prognosis, treatment plan and whether there was anything they would have liked to discuss with their doctor. I shared the note with the cancer care team, which helped to facilitate communication about misunderstandings. This is how the “Medical Humanist” model was born. You could say that Pat’s diagnosis was a gift to her and me. She transformed how breast cancer research was funded and I had an opportunity to create a program that improved communication in cancer care. But, like her, I wish she didn’t have cancer.
I recently stumbled upon an old email from a nurse with whom I worked with many years ago at the cancer center in Bennington, VT.  At the time she had asked me: “Do patients, really want their doctors/nurses to be human?  Or do they want them to do what they were trained to do and fix the problem? You know that it takes about 20 years for a person to realize that his parents are human beings who don't know it all?  It's enlightening and freeing, but also a bit disappointing.  I think patients might feel the same way about their doctors.” “So what if a person is a really good doctor or nurse, but not a great communicator?  There seems be a big gap between what I have learned in nursing school about "acting confident" so that the patient feels comfortable with your care and "giving up authority for humanity" as Anatole Broyard, suggests in Intoxicated By My Illness.” I understood that her words were a reflection of what she was questioning about her professional role but also reminded me of what I observed with nurses in the changing landscape of healthcare delivery. There was a time when nurses would not only tend to a patient’s medical problems but also listen to their stories, especially how illness was impacting their lives and those of loved ones. In observing that nurses were increasingly providing more specialized medical care to “fix” problems with less time for personal conversations, it became apparent that as a medical humanist I was entering the intimate space that nurses had occupied. I could sense they felt a loss and hoped that my medical humanist’s notes would prompt both doctors and nurses to follow up and address the patient’s concerns. We all want our doctors and nurses to know the science of medicine. Yet, from what I’ve learned from patients, they are looking for someone who can communicate openly and honestly and soften the harsh realities of facing a serious illness. So, I think the answer to the question posed by my nurse colleague about whether we would be better off with a healthcare provider who is good at fixing us or a human being sensitive to the our circumstances is a false choice. All of us deserve both.
Recently, a friend went to the emergency room with complaints of severe GI pain and was admitted to the hospital. Naturally, she was worried about the cause of her symptoms, which she had been experiencing on and off for 6 months. Under the care of her family doctor she tried several medications but none seemed to alleviate her pain entirely. Now, the doctor who she had known for many years and trusted was no longer involved in her care. Instead, a hospitalist appeared at her bedside and would be in charge of the case. For patients and their loved ones who encounter the hospitalist model, it can be quite unsettling. This is not to say anything negative about these doctors because they are well trained. Most challenging in these circumstances, however, is building a working doctor-patient relationship in a relatively short period of time. As much as patients can be uncomfortable asking questions or expressing concerns to any doctor, hospitalists may also find themselves in an awkward position. They do not know the person who is the patient but may be the first doctor to present a serious or terminal diagnosis. Receiving “bad news” is shocking to patients and not heard in complete sentences. And, delivering this news is extremely challenging for hospitalists. Fortunately, my friend did not have a life threatening illness. But, her experience jogged my memory of what a hospitalist at a Massachusetts medical center shared with me about delivering bad news to someone he met only a few days earlier. He said, “I hear a challenge from these patients for physicians to “walk” with the dying patient, to be present, to share the experience. Cure is no longer the issue so neither is failure, except the failure to be compassionate and present. In my experience, the patient who has accepted the terminal nature of the illness still wants to live, to be heard, to be acknowledged and to be loved. Every doctor and caregiver can offer these gifts and thereby help and heal.” It appears to me that communication barriers to a working relationship between doctor and patient, whether in or out of a hospital, can be bridged by open and honest conversations about the circumstances in which they both find themselves.