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On Being a Doctor |


Robert L. Carolla, MD
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From CoxHealth, Springfield, Missouri.

Requests for Single Reprints: Robert L. Carolla, MD, CoxHealth, 2916 East Alpine Drive, Springfield, MO 65804; e-mail, robert.carolla@gmail.com.

Ann Intern Med. 2015;163(1):66. doi:10.7326/M14-2884
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After my mother's death and many years after I had been in practice, I was going through her papers and found a letter that a physician had written her 50 years earlier.





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Reflective Writing, Reflective Practice
Posted on July 10, 2015
Jennifer R. Hartmark-Hill, MD
University of Arizona College of Medicine-Phoenix
Conflict of Interest: None Declared
TO THE EDITOR: Dr. Carolla's essay (1) on the significant value of physician-written letters to patients' families touched my heart and inspired reflection. Narratives of clinicians taking the time to reflect upon and demonstrate value for the patient in the form of a letter are notable. One example of such is a letter written to the family of a woman with breast cancer that was picked up by CBS and other national syndicates after it was posted online by the woman’s son and went viral (2). The type of positive public reaction garnered, in addition to private reactions of families who receive similar letters, demonstrates the impact that a few moments of “above and beyond caring” can have. Patients’ responses are consistent with the desire to know they are seen as individual human beings, and that they are valued as such by their clinical teams, even (especially) in an era of an overwhelmed healthcare system and frequently burnt-out clinicians. Perhaps, like self-care, demonstrating thoughtful caring for others at a human-to-human level is needed most when there seems to be inadequate time and stress levels are high.
A growing body of evidence points to a “reflective practice” as one method to keep burnout at bay and promote reflective, resilient professionals (3,4). Dr. Carolla's article will be added to a portfolio of resources used with my medical students to deepen their understanding of the value of reflective writing. This value includes the ability to enhance the bond between physician/patient/family through caring written communication, as well as for the clinician's own well-being and resilience. I am certain Dr. Carolla's letters to his patients’ families support healing. His example will serve to inspire the next generation of physicians at the University of Arizona College of Medicine-Phoenix and beyond.

1. Carolla RL. Letters. Ann Int Med 2015; 163:66.
2. Letter from emergency room doctor goes viral. 2013 Feb 16. New York (NY). CBS News; [accessed 2015 Jul 9]. http://www.cbsnews.com/news/letter-from-emergency-room-doctor-goes-viral/
3. Epstein, RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Academic Medicine 2013; 88.3:301-303.
4. Bolton, GE. 2014. Reflective Practice: Writing and Professional Development. London (UK): Sage Publishing Ltd.
Author's Response
Posted on August 25, 2015
Robert L.Carolla, MD
Conflict of Interest: None Declared

I appreciate Dr. Hartmark-Hill’s kind comments about the article. I am touched that it may be a tool to inspire future physicians. Nearly 40 physicians have taken the time to communicate their comments to me--mostly by email but also with hand written notes/letters. I have heard from oncologists as well as a variety of subspecialists. All comments have been positive. I am truly stunned by the response. Clearly the article has struck a chord with many. In a sense, it went viral, Annals-style!
Of course, our patients desire state of the art care. This is what our training is all about, and this is what most of us are prepared to deliver. What the physician often overlooks is that patients also crave recognition that they are human beings with the right to be treated with kindness and respect. It is the physician’s duty to convey that he cares for his patient’s total well being. The technology, impersonality and endless delays of oncology treatment can be off-putting to even the most sophisticated, and terrifying for many. In the process of delivering the best technical care, the physician may lose sight of his patient’s humanity – and his own.
The letter is a simple, low-tech way to aid the family as they cope with the loss of a loved one, and that is its primary purpose. Writing it is an active way to provide closure for the physician, and to say goodbye to people with whom he may have become close. I applaud Dr. Hartmark-Hill’s observation that it can also be a time for the physician to privately reflect on the care he delivered and ask a few critical questions of himself: Did I give the best care possible? What could I have done differently? What have I learned from this patient and family? Did I provide for the emotional needs of the patient and family? At the end, did I help my patient cope with the fear of death?
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