Category Archives: doctor-patient

Psychology Today and recent headlines

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I am thrilled to have the opportunity to blog at Psychology Today. My first post at my new blog, In the Kingdom of the Sick, is up today. I would love it if you’d click on over, leave a comment, and subscribe to it. I will be posting lots of new content and articles over there, and will not replicate the material that appears here on my personal blog.

I also have a new piece up over at Cognoscenti, WBUR’s Ideas and Opinions page, where I am a regular contributor. It’s all about collaboration between patient and provider, and why participatory medicine is so important. I wrote a lot about this in my new book, and am happy to see it getting mainstream media attention.

Up next here: a book review of My Foreign Cities, a memoir about a woman’s experiences living with her husband’s cystic fibrosis.

On Becoming a New Patient

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As the first post here at my my new home, I thought it fitting to return to that seminal moment in the experience of being a patient: finding out you have an illness.

I recently spoke with someone who is newly diagnosed, someone who has otherwise been pretty healthy. Our conversation reminded me of how overwhelming this whole process of being a patient and navigating the health care system can be. As a lifelong patient, I don’t always pay as much attention to this stage in the patient experience as I should, and I started to make a list of all the things that popped into my head as we spoke, ideas both big and small.

What tips or suggestions would you add to this list? What do you know now you wish you’d known when you first received a diagnosis, or, for those who might still be in the process of receiving one, when you first started experiencing symptoms and going to doctors? I’d love to hear your thoughts in the comment section!

  • Don’t feel awkward or guilty about asking for a second opinion.
  • Ask lots of questions—it’s important you understand what’s going on with your health. If you don’t feel comfortable asking your doctor questions, consider meeting with a new doctor or provider to see if there is a better rapport.
  • Some days will be really good. Some days will be awful.  That is okay. Your feelings as you process this are all okay.
  • When it comes to waiting—waiting for appointments, waiting in hospitals, waiting for results, etc., expect the worst and hope for the best. Time works differently in the medical world.  It’s frustrating, it’s not always fair, but it is a reality of the patient experience.
  • A lot of things might seem scary and out of control, but don’t forget—this is your body.  If something doesn’t seem right—a provide doesn’t wash his or her hands; a lab tech sticks you too many times; the test someone is scheduling for you doesn’t sound like the test you know you need—speak up! It might be awkward, but social graces are not worth your health or your sense of comfort.
  • Spend some time getting to know the online patient community. Sometimes, the anecdotal experiences and wisdom there, as well as commiseration and validation, can be enormously helpful.
  • Remember that everyone’s experiences are different, and everyone is at a different point in the process of treatment, acceptance, etc. Not everything you read online will resonate with your experiences, or with what your doctor tells you. Again, ask lots of questions, and don’t be afraid to bring what you find online to your doctor.
  • Drink lots of water and wear layers when you have blood drawn—being dehydrated or cold makes it even harder to draw blood.
  • You won’t get a lot of rest as an inpatient, but there are lots of things you can do to create a better environment and a sense of calm: familiar books, music, and DVDs make a difference, certainly, but you can also inquire about the necessity of overnight vitals to see if you can get uninterrupted sleep, for example.
  • Sometimes you will really want people with you at appointments, or will want to talk about it. Sometimes, you will want to be alone, or want to talk about anything other than illness. These are your boundaries to draw, and it is okay to ask people to respect them.

Also, if you have a moment, definitely let me know if you encounter any issues with the comment system, the subscription service, or anything else that comes up as I fully switch over to this new space.

(And, I am really happy you followed me over here!)

On Technology and the Patient with Chronic Illness

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While saving a podcast I created for my students the other day, I inadvertently clicked on another item in my iTunes folder: my daughter’s first cry, recorded with my husband’s iPhone the moment she was born.

Momentarily overwhelmed with emotion, I scrolled through until I found another amazing entry: the sound of her hiccupping in utero, recorded with my iPhone during one of the many non-stress tests I had during my pregnancy. You hear the whoosh and thump of her heartbeat, and then every few seconds, you hear this unmistakable blip that is a hiccup.

An entry from a few months later makes my body clench: the horrifying sound of her struggling to breathe, rasping and gasping and choking and wheezing, when she was quite sick as a young infant. I played it for her new specialist so he could see what I meant when I talked about how much she struggled at night and while eating.

He nodded, playing it over several times, and sharing it with the fellow on his rotation. “I am so glad you recorded this,” he said to me, relaying any private fears of mine I’d look like some overly paranoid first-time mother. It was the first step in accurately identifying some of her health problems and getting her the right treatment.

My smart phone is just one of many ways technology has changed my experience of being a patient, being a pregnant patient, and being the mother of a patient. I get text messages from my pharmacy when it’s time to refill my prescription, and can accomplish more over brief e-mail exchanges with my own specialist than I do in some office visits. The patient health management platform my hospital uses has all lab results, imaging, results letters, and medical history available with a few clicks on a password-protected site.

I’ve written here before how social media is an important—and often, the only—source for connecting with other rare disease patients, people who can provide the anecdotal information on treatments and best practices that can make such a difference, information that we can use to have conversations with our physicians. It’s another form of data, and in the digital world of health information, data matters more and more.

I’ve been writing and researching in a lot more depth the way technology and social media have influenced patient-hood, and I know this post is just a snapshot glimpse of the many, many types of application. But as someone immersed in the research and the statistics, what I would really love to hear more about are the everyday experiences people have.

So tell me, how do you use technology to manage illness? How have technology and social media influenced your experiences as a patient? How you advocate for yourself or find information?

So I Dumped My Daughter’s Doctor

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Ah, the doctor-patient relationship.

I explored it a lot in Life Disrupted, but it is frequent fodder for this blog, too: seeing doctors as our advocates, knowing the importance of speaking up, and realizing I can just say no, for example. I’ve compared finding the right doctor to dating, and will tell anyone who cares enough to listen how wonderful my lung doctor is.

All of this is to say, by now I know what to look for, and I know what I will and will not tolerate. And then I had a baby, and I became the mother of a patient, and became her voice when it comes to health problems and doctor appointments.

Before she arrived, I did my due diligence. I researched pediatricians, ran some interview questions by my best friend, who is a pediatric nurse practitioner. I liked this pediatrician’s experience, and when I met with him before my daughter’s birth, I liked his approach. Our talk went well, and I left feeling reassured she would be in good hands.

Since she had jaundice and had trouble feeding because of it, we saw him a lot her first couple of weeks. I appreciate his close monitoring of her bilirubin levels and getting us to a lactation consultant, but even in those first early days we began to see signs Things Weren’t Quite Right with this relationship. And as her first days turned into first few weeks and more health problems emerged for my little girl, the evidence mounted:

No appointment, from a jaundice check to her 2-month check up (shots included), lasted more than five minutes. Five minutes. I am not exaggerating. Just enough time to weigh her, give a cursory listen to her lungs, and answer the one question I managed to spit out in time with “yes” or “no.”

I would mention discomfiting symptoms to him and he would brush them aside (real, legitimate symptoms—I won’t get too specific here to respect my daughter’s privacy, but trust me, legit) or, dash off a prescription.

When I would call to discuss her lack of improvement and ask for advice, we didn’t get anywhere. No investigation into what else could be causing the problems, no wanting to examine her when her symptoms got even worse, nothing.

Never once did he engage with my daughter aside from the perfunctory weight check; never once did he ask me how she was doing (or sleeping, or eating, or interacting, etc). Never once did he ask me how I was doing as a first-time parent, or if I had any concerns, etc. Developmental milestones? What, are those something you’re supposed to discuss with your doctor, ever?

Lastly, he said family medical history wouldn’t matter for a long time and would not discuss it, (like, walked away when my husband tried to discuss it). Um, hello? My family’s medical history is as complicated and lengthy as my own, and given some of her symptoms, very relevant.

One day, as I was about to call his office because she had gotten much worse, I stopped mid-dial. I was sick of hitting the same brick wall, and fighting to get him to pay attention to my daughter’s symptoms. She deserved a lot more than that.

I’d wanted this to work out because I’d invested time and energy into selecting him, had really liked him during our interview, and I kept hoping the doctor I thought he was would show up. I gave him the benefit of the doubt at first because I was the new parent and he was the seasoned doctor, but I know my kid. And I know when Things Aren’t Quite Right with her.

She is the most precious thing in the world to me, and I entrusted him to do right by her. Enough.

So that same day, I called a different practice. They worked us in that afternoon. In fact, their words were, “An infant with XXX? Bring her in right away!” With those words, I officially dumped her former pediatrician.

Her new practice took down her medical history, her family’s history, spent a long time discussing various possibilities and plans of actions with me, and got her in for necessary testing the very next day. From day one they were proactive in getting her the help she needed, and have been wonderful about answering my questions, following up on her specialist consults, etc. Together, we’re getting to the bottom of a few different issues.

I have been angry with doctors many times before, but never as angry as I was with her former pediatrician when her new team figured out some of what’s wrong with her, things he would have and should have found if he’d cared enough to listen and act…you know, do his job.

Rest assured she is a thriving, happy, smiley little baby but we are very, very lucky we did not have a much bigger crisis on our hands due to his apathy.

I am so grateful she has such amazing doctors working with us now, and that’s what is important. But I forgot how crummy it feels to be so disappointed in a doctor.

I have long said that communication is central to a good working relationship. Since I’m her advocate in the exam room, if I don’t feel I can speak with my daughter’s doctor about her health, then that is obviously not a tenable situation. I don’t need my hand held, I don’t need excessively long conversations, and I don’t call unless there is something significant going on, but I do need someone who listens, who asks appropriate questions, and who cares enough to look for answers.

In the Moment

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Various medical issues—some my own, most of them other people’s—have kept me away from here longer than I’d anticipated. Everything is okay, but recent events reminded me that health situations can change so quickly, that you can’t plan for some things, and that you have to be willing to adapt, switch gears, and sometimes, do what doctors tell you even if it wasn’t on your radar.

Living in the moment is not easy for me. I am a type A, detail-oriented, list-making person. My natural proclivity for being a control freak is certainly exacerbated by the fact that life with chronic illness very often throws all semblance of control out the window, but the natural proclivity is there nonetheless. For better and for worse, it’s who I am.

But right now, the best thing I can do is abandon my need for a tenacious grip on the future, to have a plan for every outcome and count on the details to soothe me.

When people find out you are pregnant, they naturally start asking a lot of well-intentioned questions: When are you due? Do you know what you’re having? How are you feeling? These are the easy ones to answer.

But then we get to harder ones: Will you have a c-section? Will you bottle feed or nurse? Are you going to have a second?

The short answer: Um, I don’t know.

Would you believe that in all of my many high-risk appointments and ultrasounds we have not discussed the actual birth? Partially it’s because I am only 23 weeks and we have time to discuss the rest, but it’s also because my entire team very much takes things day by day with me. Any change in labs, pulmonary status, infection status, etc and they want to know immediately. Right now, their focus is on keeping me as healthy as possible, because a healthier me means a healthier baby girl.

I realized a long time ago that having a medically intensive, high-risk pregnancy meant surrendering a lot of control to my expert doctors. Of course I have preferences—I’d prefer not to have major abdominal surgery—but I also know at the end of the day, we will decide what is best for the baby. I am not someone who can parse out a detailed birth plan, because my health will dictate what we do.

(I covered some of the risks of a PCD pregnancy in Life Disrupted but here’s a brief recap, for context: “normal” PCD infections last longer and are more serious in pregnant women, especially as lung volume changes, meaning I can reasonably expect to be in the hospital more often and for longer periods. The biggest concern is pre-term delivery, either since infections can trigger early labor or because we reach a tipping point where the risks of lower oxygenation outweigh the risks of premature birth. Whether I am induced earlier, need a c-section, or go close to full term and have a more traditional delivery depends on a huge number of variables, and again, I will do whatever my doctors say gives my baby the healthiest start possible. These are the major concerns; we’re juggling a lot of other competing issues too.)

I should also emphasize that though we have had some rocky patches so far, the baby is fabulous—healthy and thriving.

We haven’t discussed formula versus breastfeeding yet. If I can, I’d like to try; it depends on whether my medications after delivery are safe. I will defer to my team and what they say is prudent for the baby. Again, I have my own personal preferences but realize I may have to adjust my expectations for the best outcome.

Of all the well-intentioned and common questions pregnant women get, for several reasons the one about having more children is the one that drives me crazy. First and foremost, this pregnancy took so long to achieve and we continue to fight incredibly hard to keep her safe. I don’t want to fast-forward through this precious period of time, to think about hypothetical children. I want to focus on the child who is growing here in the present, the one we waited four years for. I do not take her safe entry into the world for granted.

But also? It’s a really personal, loaded question. I love having siblings and would love to be able to give our daughter siblings but it is complicated and for lots of reasons that I don’t need to detail here, it may not be in cards. Who knows what will happen, but I do know that I don’t need to be reminded of what I might not be able to give her, especially right now.

We’ve had some long, rough months and a lot of the journey remains ahead of us. Right now, in this moment, we are in a good, stable place. I want to enjoy this moment, and live fully in this moment. I am so grateful we are here, and that she is okay, and that is all that matters. As much as it goes against my instincts, I am relieved (happy) to just take things day by day. I can’t plan for everything. I can just do my best, listen to my wonderful doctors, nurses, and nurse practitioners, and hope that all our combined hard work pays off.

I realize this is a pregnancy-centered post, but I think the same applies to living with illness in general: health status can change in an instant, no matter what we do. We can’t spend every second worrying about what might happen or what else we could do to prevent things or we miss out on the present.

Doctors as Advocates?

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Yikes. It’s been awhile.

How are you?

Usually when I have gaps it means a few things: I don’t have too much I want to say and don’t want to post minutiae (I still want to be useful); I am acutely sick; or I have too many ideas and can’t get out of my own way.

In this case, a combination of a flooded house (hello, epic rain and no electricity!), an infection, and a lot of thoughts that needed time to marinate lest they come out as an unproductive rant equaled silence.

It’s been awhile since I’ve written about the doctor-patient relationship, an important subject in Life Disrupted.

For the most part, that’s because I’ve had such good experiences the past couple years with doctors who don’t just manage my diseases with me but work towards helping me meet my specific life goals. When things don’t work, we change them up. When we’re up against a wall, we find a new way to try to improve my quality of life. When the conversations are difficult and the risks overwhelming, we talk things through. A lot.

This is what has me stewing. A loved one underwent major surgery recently, the third major surgery in two years. It was a complicated, grueling surgery that necessitated significant nerve, disc, and hardware involvement in the spine. The doctor, whom we’ll call Dr. Brilliant Surgeon (or, Dr. BS, which is supremely fitting) is just that- a brilliant surgeon. But in my opinion, he’s not a very good doctor.

For example, it took three weeks to follow up with the results of a CT scan that showed tremendous problems, even though his office knew the patient was in incapacitating, wheel chair-inducing pain and needed some answers on what to do. The excuse? The office was undergoing new training and couldn’t respond to phone calls.

My response? When you have a patient who cannot walk and whose life has grounded to a halt until you report back, you find the time to make a phone call. You make the time, as it were.

For example, literally minutes before the patient was wheeled into the OR, the doctor announced that the surgery he was about to perform would be much more complicated and its success would be much more limited than the patient had been told would be the case for weeks. I understand he was doing what he felt he had to do while he was in there and I agree it needed to be done. However, three minutes is not a fair amount of time to process a huge change and a completely different set of expectations, especially when the test results that dictated the change had been available for a long time. Having a scared, anxious patient who now feels everything has changed and there is no control over the situation is not the optimal way to start a surgery, and since this was not an emergency, there was no need for things to unfold that way.

For example, after the almost six-hour surgery the patient spent several days in the hospital before going to a rehab. Not once did Dr. Brilliant Surgeon check in on the patient to see how she was doing physically (never mind emotionally.) Apparently, it is “not his policy” to follow up, and those quotes are direct.

Does that rub anyone else the wrong way? The way I see it, a patient is still a doctor’s patient before and after the OR.

Or perhaps my expectations for Dr. BS are out of whack?

I am not one to indiscriminately doctor-bash. That is not helpful for productive. But watching this person suffer, and knowing even a tiny portion of that suffering would have been less if this doctor had taken the time to communicate or care, leaves me feeling angry and frustrated.

Contrast these examples to a conversation I had with a new doctor of mine the other day. I was discussing my lung doctor with him, since I knew they would be communicating with each other at some point in the near future.

“He’s the best. He’s such an advocate for me,” I said, without even realizing how much I was summing up in those few words.

For as much as I’ve written about the need for communication, for good rapport, for someone willing to think outside the box, this quality is just as important in a doctor. An advocate is someone who invests his or her time in your particular battles and helps you fight them, who invests in your success and recognizes the importance of your goals and priorities.

An advocate is someone who is willing to make an extra phone call, or write an extra letter, or set aside time to consult if it means that ultimately, you will receive the care you need.

An advocate is someone who realizes there is a lot more to a successful outcome (surgical or otherwise) than simply what data reveals.

We all deserve advocates.

Doctors, Patients and Health Care Reform

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There’s been a lot of talk about the economic stimulus plan, comparative effectiveness and health care reform lately. And with good reason—health care reform is integral for our physical as well as our fiscal health.

But in today’s Well column, Tara Parker-Pope raises an important point: in all this talk of methods and outcomes, where is the doctor-patient relationship?

The column touches on a core critique of our medical system, one that right now is better equipped for acute care then prevention and wellness. Specifically, it explores our propensity to want prescriptions that might be unnecessary, or to favor newer or more expensive treatments or procedures when older or less expensive ones might suffice:

“Whether it’s invasive back surgery, medical scans or expensive drugs, patients and doctors alike often refuse to believe that costly treatments aren’t worth it.”

What I find interesting about this column is that it doesn’t posit the blame on just the patients who ask for drugs or the doctors who write the scripts—rather, it points towards the need for both parties to work together to achieve the best outcome.

I’ve written a lot about the doctor-patient relationship, and while I have much more to say about this particular manifestation, I can’t help but feel so much remains true—in the end, mutual trust and respect is fundamental to a healthy relationship and thus a healthier outcome.

The medical education our providers have and the experiential wisdom we have about our own bodies are not at odds with each other. If we combine them and ask the right questions of each other, hopefully we can filter out the unnecessary treatments and tests.

* * *
Another great edition of Grand Rounds is up at Health Business Blog. Check it out!

Nurses and Patients

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I’ve written about the doctor-patient relationship often. Whether it’s the need for communication and mutual respect or why primary care is important for patients with chronic illness, there’s much to say about this incredibly important relationship.

But when I read “Can Nurses Care Too Much?” in yesterday’s NYT, it occurred to me that I haven’t written as much about this other incredibly important relationship: nurse-patient.

In my personal life, I know a lot of nurses, and know how invested they are in their jobs and their patients. In my professional life, I often have nursing students in class and am always impressed with how engaged they are in what they do and how animated they become when patient care is discussed.

But it is in my patient life where I really see these qualities firsthand. For long stretches in my life I’ve spent several weeks a year as an inpatient, and from all those trips I can say this:

Nurses are the ones who can make (or break) a hospital stay. They are the ones who make sure my nebulizer medicines arrive on time, who jump in to give me chest physiotherapy if the physical therapist on the floor is tied up with someone else.

They are the ones whose conversations keep me distracted or encouraged, depending on what I need, and the ones who know that sometimes, visiting hours just don’t apply. In college, they calmed down my worried parents when I was an inpatient several states away, and they know that for someone who types all day long, getting an IV on the top of my hand is less than ideal.

Sure, I’ve had some negative experiences, just like I’ve had some doctor’s appointments I’d rather not repeat again. But the vivid memories, the faces and names and actions that stay fresh in mind, belong to the many nurses who have made serious medical situations a lot more tolerable.

Can nurses care too much?

That’s a pretty difficult question to answer because giving care can be such an emotional experience. (Be sure to read the NYT article, because the nurse-writer covers this poignantly.)

But what I do know is that when I’m wheeled onto a floor and my nurse comes in to greet me, or when I’m visiting a loved one and I see how compassionately and confidently their nurses speak with them, I am really glad that they do care.

***
In unrelated news, I just found out this week that Library Journal named Life Disrupted one of 2008’s Best Consumer Health Books. Check out the full list for some great titles.

Nurses and Patients

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I’ve written about the doctor-patient relationship often. Whether it’s the need for communication and mutual respect or why primary care is important for patients with chronic illness, there’s much to say about this incredibly important relationship.

But when I read “Can Nurses Care Too Much?” in yesterday’s NYT, it occurred to me that I haven’t written as much about this other incredibly important relationship: nurse-patient.

In my personal life, I know a lot of nurses, and know how invested they are in their jobs and their patients. In my professional life, I often have nursing students in class and am always impressed with how engaged they are in what they do and how animated they become when patient care is discussed.

But it is in my patient life where I really see these qualities firsthand. For long stretches in my life I’ve spent several weeks a year as an inpatient, and from all those trips I can say this:

Nurses are the ones who can make (or break) a hospital stay. They are the ones who make sure my nebulizer medicines arrive on time, who jump in to give me chest physiotherapy if the physical therapist on the floor is tied up with someone else.

They are the ones whose conversations keep me distracted or encouraged, depending on what I need, and the ones who know that sometimes, visiting hours just don’t apply. In college, they calmed down my worried parents when I was an inpatient several states away, and they know that for someone who types all day long, getting an IV on the top of my hand is less than ideal.

Sure, I’ve had some negative experiences, just like I’ve had some doctor’s appointments I’d rather not repeat again. But the vivid memories, the faces and names and actions that stay fresh in mind, belong to the many nurses who have made serious medical situations a lot more tolerable.

Can nurses care too much?

That’s a pretty difficult question to answer because giving care can be such an emotional experience. (Be sure to read the NYT article, because the nurse-writer covers this poignantly.)

But what I do know is that when I’m wheeled onto a floor and my nurse comes in to greet me, or when I’m visiting a loved one and I see how compassionately and confidently their nurses speak with them, I am really glad that they do care.

***
In unrelated news, I just found out this week that Library Journal named Life Disrupted one of 2008’s Best Consumer Health Books. Check out the full list for some great titles.

Practicing Professionalism

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It’s been a good week. The election is finally over, the results were met with grace and dignity by the losers and optimism by the winners, and hopefully we can all move forward.

(Plus, it’s Friday, and it’s officially been November for a full work week. Normally this would be a non-issue, but I realized last night I haven’t been acutely ill yet this month. I honestly can’t remember a 7-day stretch in November where I have been able to say that. I’m going to ignore the tiny little voice that says “don’t jinx this!” and hope instead this points to a better “plague season” for me.)

But the other reason this has been such a good week is this weird confluence of personal and professional interests that has taken place over the past few days. In my classes we’ve been reading a review article published a couple of years ago in the New England Journal of Medicine about developing professionalism in physicians. Initially, I chose the article because it is a good model for the type of evaluative research writing they are doing right now and while it is certainly useful for that, the content of the article itself has been even more beneficial.

We spent a good portion of class discussing the three concepts deemed necessary for developing professionalism: setting expectations, providing experiences, and evaluating outcomes. I was surprised by how readily they responded to these ideas, commenting on preceptors and colleagues in clinical settings who have been role models for them and instances where they really learned from someone else. And of course, they commented on the moments when the opposite happened, when they received little instruction or explanation from the people charged with assessing and training them.

They are thoughtful and passionate about what they do. They recognize that the best way to learn is by doing, and that sometimes the “doing” doesn’t go smoothly and certain doesn’t come easily. But they also realize that “doing” must be accompanied by knowledge, observation, and input from people with more experience…and that people who have authority also have accountability. Discussions like this remind of the privilege it is to see medicine from the other side. My personal experience as a patient is not something that comes into the classroom, but of course it is something that shapes my perspective.

With a week’s worth of discussions swirling around in my brain I sat down this morning to catch up on the latest doctor-patient column in the NYT’s Well blog. This week’s post, A Positive Approach to Doctors in Training, discusses the rigors of the intern experience and the “culture of fear and negative feedback” that permeates medical education. Could I ask for a more relevant topic to read?

Dr. Chen explores the negative reinforcement so common in the training doctors, and the tendency towards focusing on surviving, rather than improving, as a result. (And of course, the backdrop of last night’s Grey’s Anatomy, where the competition over surgical skills and opportunities took a somewhat macabre twist, added to my interest in this article).

But as noted in the article, research suggests positive reinforcement, long a staple in other professions, may have an important role in developing professionalism in doctors. (Obvious, right? But practice and theory can be far apart…). Of course we need to hear what we’re doing incorrectly so we can avoid making a (potentially serious) mistake again, but as published research, common sense, and several classrooms’ worth of future health care professionals seem to agree, knowing what we’re doing right is incredibly important, too.

All of this got me thinking about the practice of teaching in general. Setting expectations (syllabus, grading criteria, classroom policies, etc) and providing experiences (drafting, workshops, model writing, in-class prompts, etc) are easier to handle than evaluating outcomes (at least for me). I relate to my students’ concerns and experiences and I realize my responsibility in this. It can be an awfully difficult line to draw between giving comments that will help a writer improve (constructive criticism) and giving comments that ultimately deter or de-motivate a writer. I’m always conscious of highlighting moments in the text that work well, but at the same time I don’t want to gloss over moments that aren’t working but have potential.

And I am conscious of their consciousness—just as much as they don’t want pages full of red marks, they don’t want to only hear what they’re doing well, either.

One thing that has really emerged from the week of confluence is the reminder that in any kind of teaching environment, accountability works both ways. I want respect and hard work from my students, but they deserve all that from me too, whether it’s the way I choose to comment on a weak paper or the way I respond to their questions in class. This makes sense in the classroom and of course it makes sense in the hospital, too.