Commentary PD. Paperwork versus patient care: A nationwide survey of residents’ perceptions of clinical documentation requirements and patient care. J Grad Med Educ. 2013;5:600–604. 4 Beckman H. Three degrees of separation. Ann Intern Med. 2009;151:890–891. 5 Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302:1284–1293. 6 Beckman HB, Wendland M, Mooney C, et al. The impact of a program in mindful communication on primary care physicians. Acad Med. 2012;87:815–819.

7 Drybye LN, West CP, Satele D, et al. Burnout among U.S, medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443–451.

References cited in List 1 only 8 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet. 2009;374:1714–1721. 9 Charon R. Narrative Stories: Honoring the Stories of Illness. Oxford, UK: Oxford University Press; 2006. 10 Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other

four? Resilience strategies of experienced physicians. Acad Med. 2013;88:382–389. 11 Epstein RM, Krasner MS. Physician resilience: What it means, why it matters, and how to promote it. Acad Med. 2013;88:301–303. 12 Hales J. Senior lecturer, Department of Medical and Social Care Education, University of Leicester, UK. Personal communication with H. Beckman, October 23, 2014. 13 Fernando AT, Moir FM, Davis PG, Kumar S, Dorehty I. CALM: Computer Assisted Learning for the Mind. Auckland, New Zealand: University of Auckland; 2010. https://researchspace.auckland.ac.nz/ handle/2292/17073. Accessed February 9, 2015.

Teaching and Learning Moments All the Small Things “She’s altered for some reason. It’s not entirely clear why,” my attending forewarned as she hurriedly moved on to the next admission. I pulled back the curtain to find Ms. Rodgers, an obese, elderly woman sitting upright and asleep on a gurney. She was arousable, but her thick Southern accent was difficult to follow. She appeared to be telling a story, but it didn’t answer any of my questions. I skipped to the physical exam, given my limited progress gathering her history. With each facial expression I silently made for her to mimic, Ms. Rodgers appropriately followed my nonverbal commands: smiling, frowning, and raising her eyebrows, testing each cranial nerve. She was even quick to scold me with “your hands are so cold.” I initially believed that she was presenting acutely altered. However, her exam was unlike those of the other acutely encephalopathic patients I had managed before.

and, more importantly, page the surgical team as her pancreatitis was worsening. While attending to these priorities, I also called her nursing home to ask about her glasses. Transfer after transfer on the phone, I was convinced the message would surely get lost. Ms. Rodgers’ condition worsened throughout the day, and by evening we had transferred her to the ICU. My resident encouraged me to visit her, and I will always be thankful for his gentle urging. I found Ms. Rodgers in her new ICU bed, again upright and asleep, but this time sporting her glasses.

Though note after note documented “baseline mentally challenged,” I later learned that Ms. Rodgers was actually legally deaf and neither a lip reader nor fluent in sign language. Yet, my attempts at writing notes and greetings for her proved useless as she strained to read them. Her presbyopic squint was reminiscent of my own mom’s when she needed her glasses. Unfortunately, Ms. Rodgers had come from her assisted living facility without her invaluable eyewear.

I gently woke her as I pulled out the notes I had written earlier in the day and, for the first time, I could assess her pain and ask how she was feeling. I shared the brief plan to help manage her pain. Now that she could see, she could be more informed and aware of her medical care. And although she was deaf to her surroundings, she was no longer blinded by her environment. The next day, Ms. Rodgers’ status further declined, and she required pressor support and mechanical ventilation. I continued to follow her care from afar though I was no longer a part of her primary medical team. During my subsequent visits, I noticed a pile of printer paper on her bedside tray. The ICU staff had started to write her notes in an attempt to comfort her and explain all the lines and tubes in place—it was validating.

The next morning, my to-do list for Ms. Rodgers was piling up. I needed to order blood cultures, urine cultures,

Securing Ms. Rodgers’ glasses didn’t cure her pancreatitis. But it made a difference. And it got me thinking about how

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difficult it can be as a medical student to feel as if you are really contributing or to find your niche or place on the team. As a student, the greatest care we provide may not be the medicine we prescribe nor the diseases we learn to manage. Some of my most prized accomplishments have been seemingly small feats—finding someone a primary care physician for the first time or printing a list of nearby Alcoholics Anonymous meetings for a struggling alcoholic. I’ve come to enjoy this role of unsung hero in my four years as a medical student. Eventually, we will make those big decisions, but for now, sometimes all we can do is make sure that the little decisions don’t get lost. What we can do at this point may actually be important for a patient’s care, just in a different way. Throughout my life, I’ve often been told that “no matter how small the effort is, if it’s done consistently, it will start compounding. Little things make big things happen.” So the devil may be in the details, but the angel’s there too. I’ll always try to care for the patient as a whole, while of course being mindful of all the small things. Author’s Note: The name in this essay has been changed to protect the identity of the patient. Acknowledgments: The author wishes to thank and acknowledge Hedy S. Wald, PhD, for her mentorship, guidance, and support in preparation of this piece. Lindsey Negrete L. Negrete is a fourth-year medical student, Warren Alpert Medical School of Brown University, Providence, Rhode Island; e-mail: lindsey_negrete@ brown.edu.

Academic Medicine, Vol. 90, No. 6 / June 2015

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.

All the small things.

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