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A Reflective Moment

Wald, Hedy S. PhD

doi: 10.1097/ACM.0b013e31819fb9ab
Other Features: Teaching and Learning Moments

Dr. Wald is clinical assistant professor of family medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; (

First-year medical students in a Doctoring course at the Warren Alpert Medical School of Brown University (which includes writing reflective “field notes” and small-group medical interviewing/clinical skills instruction) were asked to write an e-mail field note describing a surprise or discovery within a clinical learning experience. As a clinical psychologist preceptor, I provided individualized feedback to these narratives, as did my teaching partner, a cardiologist. Through this interactive process, a poignant narrative emerged for him:

“Dear Students: I enjoy being a student myself and continuing to learn. Sometimes we have a discovery that counts as a “threshold moment” and we are not the same person afterward. Let me share one of my threshold moments, not necessarily a pleasant memory, but incredibly moving and indelibly etched into my brain. Mr. White was the first person I ever saw die. I don’t think I had seen a dead person before, had not even been to a wake. There were probably cadavers in anatomy class by this point, I don’t recall. But they didn’t really count. It was the second year of medical school, and I was on the hospital wards. He was a pleasant elderly gentleman, with the whitest hair. I don’t remember his illness, or why the decision had been made for “supportive measures only.” The intern I was shadowing had been called by Mr. White’s nurse—she thought the end was near, and the intern had sent me to check things out (and let him know when the patient actually died). I sat at his bedside and watched his every breath. He was not on a ventilator; I don’t remember much equipment at all. He was being allowed to die without heroic measures. The hallways and room were dark and quiet, but there was a bright lamp at the head of the bed, side-lighting his face. He was peaceful, and appeared to be sleeping. His breaths became more and more shallow, and less frequent, then stopped. I sat for some time looking at him before going to report his death to the intern. I was no longer someone who had never experienced death. Looking back on that experience some 35 years later, I realize that it has virtually never been repeated. I have seen patients have a cardiac arrest from which we were not able to pull them back, or seen people die on the operating room table. But very rarely have I sat and watched someone peacefully take their last breath. A threshold moment. A transition. There are still many ahead of us.” —J

I paused and reflected. My colleague had joined the students on their educational journey, creating meaning and sanctifying his experience through the telling. His words touched me, evoking feedback aimed at promoting reflective capacity and highlighting interdisciplinary collaboration. I addressed my comments to him, sharing them with the “collective we,” our students, as he had done:

“Dear J—Your evocative words brought me there. With sanctity in the stillness, the hush, the slowed passage of time, you join Mr. White on his final journey. Perhaps you were his only comfort in those moments … no family present, no rescue team, no greater power to pluck him from the inevitable. And his last gift on earth is to offer you a threshold moment, and you will never be the same. Have you stepped back to reflect how you forever changed? Does the experience of death differ as an accomplished professional 35 years later or is it forever at his bedside—quiet, contemplative, mysterious, intangible, larger than life because it is the end of life? Did you start perceiving yourself differently, laugh a little louder, dance a little longer? Did you form inner “calluses” so the end of life would not affect you so deeply? Did you look in the mirror and not recognize the face staring back at you? Can you now explain the meaning of life? I am searching for the answer. Let’s leave the bedside and go teach our eight students about our threshold moments and they will teach us about theirs.” —HSW

Reflective writing exercises for students, it is posited, can help cultivate qualities of empathy and professionalism. In parallel process, for educators, sharing relevant reflections on our own personal or clinical experiences as we craft feedback to student’s narratives may enhance their reflective capacity, leading to a threshold teaching moment in the making of a doctor.

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The faculty narrative was edited for length. The author would like to thank the faculty member for granting permission to use the narrative.

Hedy S. Wald, PhD

© 2009 Association of American Medical Colleges