On This the Last Day of My Medical Education…

2 04 2014

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…I wanted to share a letter that I wrote to myself just less than two years ago, on the day before my third year of medical school began.  The day before I officially started working in the hospitals for the first time.

I was terrified.

Honestly, I did not think I was capable.  The two years in front of me felt daunting and impossible.  I did not think I have the strength of character to go down such a difficult road.  I seriously questioned whether this path was right for me.  I seriously questioned whether I was right for this path.

I am a person who invests in multiple interests in order to protect myself.  It seemed to me, however, that medicine demands that you invest in it wholeheartedly as a career, or you will not make it through the process.  I wasn’t sure I could do that.  I wasn’t sure I would make it.

I was telling all of this to a pretty incredible friend, and she inspired me to capture all of my fears and self-doubt in a letter to address to myself, to read two years later, on my 27th birthday.

Today, April 2nd, 2014 was my last day working in the hospitals as a medical student.  In a few months, I will be a first-year resident.

I have so many feelings and words I want to say that I don’t know where to begin right now.  But today, as it was my last day, all I could think about was this letter that I wrote to myself two years ago.  I really hadn’t read it since I wrote it.  But today, for some reason, I really wanted to read it.

So I read it, and now I share it with you here today, for anyone who may question whether medicine is for you, or for anyone who was/is ever terrified that a career might demand your undivided focus for a lengthy period of time.  I just hope you know that you are not alone in your fears, doubts, and hesitations.  And even though I ended up sticking with medicine, it doesn’t mean I would have been unhappy had I ended up figuring out that medicine was not for me.  For me, the important thing was to give myself a break, and let myself truly try medicine before I made a decision one way or another.

It really isn’t the destination.  It really is the journey.

And so today, as I’m nearing the end of this leg of my journey, I find myself reflecting back on my last few years here, and that is where my super cheesy letter to myself finds its start…

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Dear June,

Happy birthday!  Hope you are enjoying the Sunshine or rain or whatever weather it is today.  Remember to travel slow enough through life to appreciate what is around you.

When you read this, you may have decided that medicine is not for you.  And if that is the case, I hope you realize that this is more than ohkay.  I write this not as a prediction, but as emancipation.  I know that you are scared of giving 100% because you are scared to fall short.  You’ve always tried to do a million different things at the same time, and all of those eggs in all of those baskets gave you security to know that even if you fail, you have all of those other baskets to hold you.  It was the courage to not care about failure that allowed you to be successful in different domains.  It was spending 40 hours a week for 4 months working on a project because it made you happy, and not because it would look good on your CV.

Somewhere along the way you forgot how to enjoy whatever it is that you’re doing.  You became so afraid of what the next moment holds that you forgot to love the present one you inhabit.  You are about to enter core clerkship tomorrow, and looking back in 2014, I hope you look back realizing that you squeezed every moment for what it was worth.  You can worry about being wrong, looking stupid, acting a certain way to please patients or staff, but what did it do for you in 2011 and the first half of 2012?  Nothing, except create a mask of fear that you used to protect yourself, which only ended up consuming you.

When you look back from 2014, I hope you realized every day that each rotation is 4 weeks long.  That means that each rotation is 20 to 24 days long.  Each day you spend in the ward, in the clinic, or in the OR is one less day there.  You are going to end up choosing just one specialty, or maybe you will decide to drop out of medicine altogether.  Either way, it means that each day you spend in internal medicine, in trauma surgery, even in obstetrics and gynecology, is 5% of your entire time in that field.  You may never scrub into another surgery.  You may never deliver another baby.  You may never see or treat that illness again.  And for sure, there will be many patients who you will never see again.  And they deserve your full attention.  They deserve the you who laughs and loves with all your heart and all your soul.  They deserve a person who cares just as much about their comfort as their treatment.  They deserve a person who sees them.  And that requires you not burdening yourself with fears and worries and concerns about the future that you have absolutely no control over.  It requires you to be authentically you and present in the face of fear.

But if I know you like I know me, then by the time you read this letter, you will have made it through intact and complete.  You will have opened yourself to learning without self-judgment.  You will have made it through knowing yourself fiercely and having the determination to be yourself unapologetically.  You will have set yourself free from not only others’ expectations, but your own, which are infinitely harsher.  You will have treated each day in the rotations like it was your last one there, because it very well could have been.  You will always remember that what makes you you isn’t your technical prowess or limitless knowledge, but how you use all of that to listen to patients, colleagues, friends, family, people; and leave every person that you interact with a happier, healthier individual than before you met, whether you decide to do that using medicine, or not.

Congratulations, June =).  Happy 27th!

With love (and I write this because I think you often forget to love yourself),

June
July 29th, 2012 (the day before clerkship begins)

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Ten Things I Love About Australia

8 06 2013

Snorkel

1) Security at the airport takes 1 minute (especially for domestic flights and is quick even for international).  No taking off shoes, no cleaning out pockets, no taking off my jacket, and you are allowed to bring food, as many fluids as you want (shampoos and conditioners can be carried on!), and the officers are super nice.

2) Marsupials!  Everywhere!  Apparently locals find them nuisances because they sleep in backyards and front lawns.

From kangaroos…

Kangaroo

…to kangaroo rats…=P

Kangaroo Rat

3) There is a nickname for everything (and it’s the same nickname): Brisbane = Brissy, Gladstone = Gladdy, Rockhampton = Rocky, and football = footy.

4) People are relaxed here.  Nobody takes themselves too seriously.  Doctors are addressed by their first names, and the Australians make fun of everyone, especially themselves.  Australians I have met have been incredibly generous and hospitable.

5) Medical specialties do not seem as rigidly defined.  For example, ENT surgeons can remove molluscum contagiosum from toes, fingers, etc; and general surgeons can do C-scopes and remove potentially cancerous skin lesions without fuss or the need to refer to someone else.

6) There are fun, beautiful towns and cities all along the east coast, each of them incredibly unique, so a whole different world is just a roadtrip or a quick plane ride away!  The diversity of each of the places I have been to is breathtaking.

7) Tanned, athletic, beautiful people everywhere in warm weather clothing.  Full stop.

8) “Cold” is 10 degrees in the middle of Winter……..but it does flood up to 10 meters here in certain areas occasionally.

9) People here tell me I have an accent =P.  Actually, I love the accents and the slang here.  People actually sound like they do in tv shows and movies.  I enjoy being called mate.  Green peppers are actually capsicum.

10) Postcard-worthy pictures… everywhere.

Tannum Sands Beach

Tannum Sands Beach

Sydney Harbour Bridge

Sydney Harbour Bridge

Great Barrier Reef

Part of the Great Barrier Reef

1770

1770, Queensland

Manly Beach

Manly Beach

In Australia, what I learned the most is the importance of adjusting your schedule to achieve maximum Sun exposure on a daily basis.  I learned to be flexible and prioritize what is truly important, which is to enjoy life as much as possible.  That is the true reason for existence, and I cannot be more grateful for my great Australian lesson.

And finally…Bonus #11) All the beds are on wheels…what is up with that?!





The Confidence to Drive on the Other Side of the Road

28 05 2013

Time has flown by, and I am now at the end of my third year of medicine.  I am currently doing my rural family medicine rotation in a small town in Australia, and I have been loving my time here.

Because it is a small town, the only way to get around is to drive, and, of course, in Australia, they drive on the left side of the road, which is the opposite of what it is like in Canada.

Now if you had asked me whether I could drive on the other side of the road a year ago, I would have told you NO WAY, especially not in a big, crazy busy city like Sydney (which I did just last weekend), because I hadn’t driven at all for three years, much less on the other side of the road.

Now I’m sure there are readers who will be thinking that I am silly for thinking that driving on the other side of the road is a big deal, but you should know that I am so anxious and hesitant, getting myself so lost in the potential consequences of my actions that I can too often become paralyzed and fail to end up taking a step at all.

So then how was I able to be bold and brave (as a couple of my colleagues put it) and drive on the other side of the road in a new country in a busy, chaotic city with massive traffic and poorly designed roads (Sydney) when I haven’t driven in three years?

Well, it’s all thanks to trauma surgery.

The short answer is that when you learn how to deal with patients coming in with gunshot wounds, stabbings, massively broken bones, and injuries from being hit as a pedestrian by a car; you become less stressed about the littler things.

The long answer is that I absolutely loved my trauma surgery rotation, and found it an incredible privilege to be there.

Watching the surgery residents deal with incoming trauma, I noticed how calm they were.  The patient could be unconscious with massive wounds and completely fractured bones, but it was as if the more serious the situation, the calmer the residents were.  Patients would sometimes have massive hemorrhages, be deteriorating quickly, and require immediate intubation/chest tubes/etc; but unless you were experienced, you wouldn’t be able to tell how serious the situation is from watching the staff calmly at work.

Wanting to be effective, efficient, and optimally care for my patients; there were a couple of times when my voice started speeding up and increasing in pitch, my walking pace became more rapid, and my shoulders tensed themselves up reaching towards my ears.  I felt like I needed to quicken my pace to take care of the patient this second, but twice I remember two different residents telling me to chill out.  I remember then recognizing how stressed/anxious/frustrated/impatient I was at the time, and I deliberately took deeper breathes, relaxed my shoulders, and smiled gently.  It was as if I was doing a heavily simplified form of mindfulness therapy on myself.

But hey, it worked.

The biggest lesson I took away from trauma surgery was why I needed to be calm.  I will be always grateful to the residents who made me realize that when my shoulders tensed up, my brain also tensed up.  I would lose my ability to think coherently, I would become extremely absentminded, and I would lose (most importantly) my sense of humour.  Essentially, in times of stress I lose who I am, and that, beyond turning me into a mindless automaton, has the side effect of rendering me useless as a clinician, to the detriment of my patients.

Sometimes it feels like if I am too relaxed at work, I am not doing my job right.  I worry that if I am too calm, I am forgetting something important.  But actually the opposite is true.

I worry that making jokes and allowing too much of your personality to show through is arrogant or unprofessional or a hindrance to my performance as a future doctor.

Well, now, I think that it still is a very delicate line, but I know now that if I become so stressed that I lose my sense of humor or I worry so much about doing the right thing perfectly that I become paralyzed, not only do my patients suffer, but it is not sustainable for my career.  If I lose my ability to enjoy the work that I do, why am I going into work at all?

So thanks to the month with my incredible trauma surgery team, I learned how to be calm in the craziest of situations.  I try to remember that joking and laughing at the right moments is not unprofessional or arrogant, but necessary and important for patient care.  Whenever I feel my shoulders tense up and my voice quicken, I take a deep breath and I remind myself that if I can handle patients with gunshot wounds, perforated appendices, and ischemic bowel in a calm, logical manner; what’s a little bit of driving on the other side of the road on the other side of the world?





Hiatus

6 09 2011

I suppose this was inevitable, but as much as I love writing in this blog, I feel that it is no longer as rewarding for me as it used to be.  It currently feels more like an obligation than an opportunity, and as such, I am going on hiatus, in hopes of trying to preserve whatever quality this blog had, and in hopes of not writing until I feel inspired and motivated to do so.  I also haven’t quite figured out how I will navigate blogging about patient stories while maintaining respect and privacy, so perhaps it’s best to wait before I blog again.

Anyway, here’s to focusing on living life fully right now, and perhaps writing about it later.





The Power (& Responsibility) of Idea-Sharers

25 04 2011

The cartoon above is by David Horsey, from the Seattle Post-Intelligencer.

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“An idea is like a virus: resilient, highly contagious.  The smallest seed of an idea can grow. It can grow to define, or destroy you.”
Inception (2010)

It is worth mentioning, again, that vaccines have been scientifically proven over and over to not be a cause of autism.  I mention this here today because even though the original scientific paper that suggested MMR vaccinations as a potential cause of autism has been retracted, and the author completely discredited, this idea is still alive and well today.

An article by Generation Rescue (the anti-vaccine organization supported by Jenny McCarthy) published a month ago (March 30, 2011) protested a new vaccination requirement against pertussis, diphtheria, and tetanus in California, with one argument being that there was no diphtheria outbreak last year in the US.  Yes, there was no outbreak, but that’s because widespread vaccinations largely eradicated this illness in many industrialized nations.  If herd immunity (i.e., the vaccination of a significant portion of a population provides a measure of protection for individuals who have not developed immunity) did not exist to protect the entire community, illnesses like diphtheria would be allowed to return to our communities.

But my post today is not about the ridiculous arguments against vaccinations, or how these incorrect notions are extremely detrimental to public health and our society, though I’m always happy to be part of those conversations.

No, my post today is about the infectiousness of an idea, just like they described in the movie Inception.  An individual’s ideas can determine the course of one’s life – his or her ambitions, decisions, careers, and passions.  A society’s ideas shape a community’s laws, morals, dreams, and beliefs.

Barack Obama arguably became the President of United States because of a campaign of ideas: “For Obama is a man who recognizes the power of ideas, and in particular the idea of hope.”

China bans Facebook, Twitter, YouTube, and censors Hong Kong news when it mentions certain instances of rebellion against the government, because they are afraid of the spread of ideas.  Every city in China has a mayor in charge of maintaining and solving the problems of the city, but every city also has an appointed governmental official more powerful than the mayor, in charge of maintaining the minds and political beliefs of the citizenry so they are in line with what the Chinese government wants.

I mention the above as examples of how powerful ideas are, and how they shape our world.

Ideas can obviously be used for both good and evil (yes, and shades in between), and I believe it is this notion that TED talks were predicated on.  TED is all about “ideas worth spreading”: free talks available online given by great thinkers and doers, challenged to give the best talks of their lives.  I value TED for its inspiration and their belief that good ideas belong free to the community so that they can be built upon by others, but most importantly, I see TED as an organization that promotes ideas that are well-founded and truly novel over ideas that are fear-mongering and false.

It is because of my shared passion of discovering and spreading good ideas that I decided to get involved with the 2011 TEDxMcGill, an independently-organized local event in the Montreal and McGill communities that is licensed by TED.  My hope is that we will find some undiscovered, phenomenal idea-sharers in our community and help propel their thoughts to the world.

If you are similarly passionate about the power of ideas and you’re interested in volunteering with TEDxMcGill this year, please check out www.tedxmcgill.com and apply before the end of this month (April)!

This was a well-disguised promo piece, don’t you think?

I leave you today with two TED talks.  The first is about the dangers of denying science (where the anti-vaccine movement is featured).  The second is about how science can answer questions of morality.

Good ideas, in my opinion, are not necessarily ones that everyone will agree upon or even believe in 100%, but they are thought-provoking and relevant conversation starters that change an individual or community’s perspective on matters of daily importance, based upon sound evidence and building upon previous ideas of the world.

Thus, I present the two TED talks below because they certainly are fascinating thoughts…

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Reminder: Have Fun! @ Now

17 04 2011

For my recent audition for another McGill musical, I chose to do a comedic monologue for the first time in my life.  And I performed it with a Southern accent, which I had never tried doing before.  Since I have little experience with either accents or comedy, I would normally stay away from trying something so novel, especially when the goal is to try to get a part in a show with this monologue, so why did I do it?  Why didn’t I do something that was safe and that I knew I could do?

Well, the first part of the answer comes from my vocal coach, who has been helping me to sing all of these different styles of rock music for the med school rock band that I’m in (in preparation for the med talent show at the end of May), and she forced me to realize that the essence of rock music is freedom and authenticity and not having a right answer or following the rules all the time.  I am, for the most part, a classically-trained singer, so it has always been about technical precision and perfect control of my voice.  My mentor, however, got me to understand that if I am to be any good at rock music (and this includes Zeppelin, AC/DC, the Beatles, etc.), I need to be able to let go of trying to be perfect and focus on having fun and enjoying the beat and the rhythm and just being the music.

My job was to have fun, and it really was freeing to take risks with my voice.  I surprised myself multiple times at what I could do.  I sounded like a completely different vocalist than my usual musical theatre routine, and it sounded authentic.  I realized that I never bothered trying to sing rock because I didn’t think I could do it, and I had no idea how much fun I was missing out on.

Through the process, there are times when I kind of relate to Natalie Portman in the Black Swan, because to be “perfect”, she had to let go of the notion that there is perfection.  She had to learn to let herself be and feel the art.  But the comparison here is pretty stretched, because I am not that talented of an artist, and I am nowhere near perfect.

In any case, the second incident that pushed me to try a comedic monologue with an accent for the first time in my life was also in preparation for the talent show.  We have been filming some skits to be played at the talent show, and it has been one of the best experiences of my life, because essentially we spent a sunny day running around outside, acting in and filming ridiculous scenarios and looking marvelously silly.  It was a bunch of friends joking around, giving each other new ideas on how to make something funnier or better in another way, and making films for no other reason than because it’ll be an awesome addition to the talent show, and we want to put on an amazing show because all the money we raise will go to the Starlight Foundation.  Because all the deadlines and expectations were self-imposed, we were free to enjoy the process of creativity, and basically just laughed a lot and produced some great scenes.  It made me realize that comedy is just about taking risks and going big and being silly and not being afraid of making a complete fool of yourself, and most importantly, having the time of your life doing it.

The combination of these recent events allowed me to realize that I don’t know whether I will get into the musical that I’m auditioning for, but I do have a chance to perform and try something completely new and different with the audition monologue.  It’s the only opportunity that’s guaranteed right now, so why not leverage it to challenge myself?

More importantly, this past week has shown me the incredible potential rewards of taking risks and letting myself enjoy being in the moment of the art rather than constantly pondering what I want the art to achieve.  The art will speak for itself and it is an untameable beast that others will take what they want from it.  All I have control over is just being present when I’m in the moment, which, funnily enough, usually contributes to good art.

I learned the joys of letting myself look silly and act silly, and I know now that I have amazing friends who will do it with me, and who will support me every step of the way.  So why the heck not?

And how do I get good at something, anyway, if I’m not actually willing to get my hands dirty and just do it?

But most importantly, if I’m not having fun singing rock music or auditioning for a show, then what’s the point?  I do performing art because it’s my escape from medicine.  If I’m so worried about getting the part in a musical that I’m not even having fun in the process, what is the freaking point?





Is empathy teachable?

29 03 2011

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The following is an essay I wrote for Physicianship class, on the subject of whether empathy is a teachable quality.  In a lot of ways, the essay is a continuation of my exploration of a subject I have been thinking about for a while

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Corpus Sanus in Mente Sana: “A Healthy Body in a Healthy Mind”

Empathy is distinct from sympathy.  Whereas the latter focuses on understanding and supporting the feelings or interests of another person, the former encompasses being able to experience the feelings, thoughts, and emotions of another person. (1)  Sympathizing often refers to feeling sorry for someone, whereas empathizing allows one to understand the perspective and concerns of another person, and by extension, their decision-making process, without necessarily agreeing with their actions personally.  The question of whether empathy is teachable requires the exploration of several factors, including whether this is a skill versus a virtue, how this quality produces better physicians, what tangible methods might exist to teach empathy, and most importantly, whether the medical education should strive to teach empathy at all.

Smajdor et al. (1) argue that “‘empathy’ as it is commonly understood, is neither necessary nor sufficient to guarantee good medical or ethical practice.”  First, they believe that empathy is often described as a virtue, a quality that makes a good person and thus a good doctor, but this reasoning is flawed, in part because possessing empathy does not a good person make, and being a good person does not equate to a good doctor.  Empathy is the ability to understand another person’s intentions and actions, but this power can be used for evil as well as good, as in “a gunfighter may use his empathetic powers to predict an opponent’s next move without losing the urge to kill him”. (2)  There may be an unwarranted association between possessing empathy and using it to take care of patients.

Smajdor et al. (1) goes on to point out that a good person may not make a good doctor, especially as more time spent on soft skills means that time needs to be taken out of another part of the medical curriculum.  Furthermore, medical doctors require clinical objectivity to function effectively, the professional distance with patients that allows surgeons to operate without cringing at the sound of the bone saw.  Arguably, a physician overly concerned with feeling their patient’s pain may be unnecessarily distracted from practicing effective medicine, to the detriment of both the doctor and the patient.

And yet, there is much evidence for the power of empathy in medicine.  Even Samjdor et al. (1) admit to the value of subjectivity and empathy in specialties where longer-term relationships are established with patients, such as general practice or psychiatry.  Physicians with greater empathy scores were correlated with significantly better diabetes control in their patients. (3)  This may be due in part to the physicians’ abilities to better understand their patients’ individual circumstances, allowing for recommendations and treatment options that better catered to unique lifestyles and thus allowed for better adherence.  Empathy may also have created a better therapeutic alliance and greater trust between doctor and patient, again leading to increased adherence.  This empathic relationship has been shown to lead to “better immune function, shorter post-surgery hospital stays, fewer asthma attacks, stronger placebo response, and shorter duration of colds”. (4)

It is the author’s belief that one’s capacity for empathy is, like intelligence, genetically determined.  One piece of supportive evidence is the finding that administration of testosterone significantly impaired the ability of women to cognitively empathize, and the effect can be predicted by fetal testosterone effects on the right-hand second digit-to-fourth-digit ratio, suggesting that empathetic powers may be at least partially determined prenatally. (5)  However, in the way that one’s potential IQ is a range whose exact number is determined by the interplay between genetics and environment, so, too, can one’s empathetic powers be developed.  Thus, although empathy may not be teachable, certainly one can strive to ensure that students enter medical school somewhat equipped with this ability and with the desire to use it to help others.  This has been accomplished using such screening tools as the multiple mini-interviews, with evidence of valid assessment of non-cognitive attributes, including empathy. (6)  After admission, courses should be aimed at offering skills to refine empathetic powers, such as the ability to recognize paralanguage and better understanding of different religions, but ultimately, these should not be sold as lessons on empathy.  Experience with patients in different settings is perhaps the best way for students to discover their own empathetic abilities, because the empathy we should strive for is one where doctors understand unique patient life circumstances (1), which requires exposure to these varied scenarios.  Yuen et al. (7), for example, found that even a half-day exposure to chronically ill older patients improved medical students’ appreciation for chronic illness care, as well as empathy and sensitivity towards individualized care of chronically ill patients, even after graduation.

Empathy commonly decreases in the third year of the medical curriculum, likely due to a combination of reasons, including a shift in focus to professional distance and clinical neutrality, increased time pressures, an adoption of technological advances that minimize human contact, a paucity of proper role models, and inappropriate treatment of the students. (4)  Again, it suggests that the problem with empathy is not necessarily that it needs to be taught, but that individual powers can wax and wane depending on the type of education that students receive.  Both empathy and professionalism have been demonstrated to decrease with increasing medical student burnout (8), so it is vital for a medical education to cultivate empathy, if only to help maintain mental health and prevent burnout, which is estimated to be experienced by 60% of practicing physicians. (4)  Decreased empathy leads to a poorer physician-patient relationship, which is associated with decreased trust in physicians and more patient complaints and malpractice claims, as well as decreased job satisfaction, quitting the profession, substance abuse issues, and suicide. (4)

The question is thus not how to teach empathy, but how to develop this existing attribute in students, and prevent its loss during the medical curriculum.  Smajdor et al. (1) make a distinction between etiquette and empathy; whereas the latter is perhaps an innate, unteachable ability to understand individual experiences, the former are more generalizable skills in clear and courteous communication, which is much more teachable, such as with classes on how to listen to paralanguage, make eye contact, and conduct patient-centred, holistic medical interviews.  Perhaps through practicing these etiquette skills and appreciating their emphasis in school, students will reflect on the importance of empathy and nurture their own abilities.

As to how to prevent loss of empathy, research at McGill (9) suggests that there simply needs to be a concerted effort to remove barriers to the medical students’ natural desires to care for their patients.  These barriers include the sometimes seemingly incompatible teachings of empathy and efficiency, the common practice of prioritizing medical education over patient care, the objectification of patients, and the institutionalized practice of wounding patients (e.g., performing unnecessary IVs on anaesthetized patients without their consent) for the sake of learning.

All of the evidence above suggests three key methods of cultivating empathy in students: reflective writing, for students to record their own experiences and process their own reasons and ways to empathize (10); practice in communication and interaction with patients to hone these skills and better understand what caring is on an individual basis; and, most importantly, better role models in senior physicians who must practice what they preach and work to change the systemic inefficiencies in empathic education.

Clinical objectivity is arguably well integrated into the medical curriculum.  As to empathy, although it may not be teachable, one’s medical education should certainly cultivate this quality in future physicians.  It is the balance between objectivity and subjectivity, professional distance and empathic relationships, which allows for proper maintenance of mental health in both physicians and patients, and a healthy mind is the key to a healthy body for everyone involved.

Corpus sanus in mente sana.

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Empathy Essay References