I am an internist, so I love developing a good assessment. It always starts with a complete problem list, listing out abnormalities, defining and refining problems, and re-ordering based on acuity. This is what we often teach in clinical reasoning. But, when was the last time you thought about what was going well for your patient? Identifying strengths in health can be helpful for several reasons. A particular strength may be able to be leveraged to help a patient navigate a difficulty. Celebrating a strength may provide the patient with the encouragement they need to move forward. It can also ensure that plans minimize disruptions to strengths. And, importantly, it helps us see the entirety of our patients.

• What is going well? Why?

  • This can be very basic. In the hospital we must always be thinking about nutrition, hydration, basic bowel and bladder function and mobility. What is going well in those areas. How can you celebrate the small success?

• How can you relay this to the patient or incorporate it into a plan of care?

There are moments when you may find that you are feeling disconnected from a patient or encounter. When it seems like whatever someone is going through is too distant to relate with. These are good times to remind yourself of similarities on a very fundamental human level.

• The patient who is having a difficult time, they want to feel safe, "Just like me."

• The patient who has a lot of really good questions, they want to know all the answers, "Just like me."

• The patient who has a serious condition, who may be quiet, they may want time to process, "Just like me."

• Think about the patient, imagine the context, and remind yourself that you probably share a lot of the same needs.

Having a rule or mantra can be helpful to return to again and again in moments that are difficult. They can help remind you of the much bigger role we play in the world. If you'd like motivation, here are my five rules for inpatient medicine:

• We treat patients, not numbers or diseases. This means we must always interpret data and conditions in the context of the patient, and who they are.

• Rounds are done by noon.

• At the end of rounds, we all say one good thing about the morning. Anything that brought you a smile or a little joy or a sense of satisfaction.

• Assume everyone in the hospital is trying their best. This means patients, nurses, aides, consultants, and VERY IMPORTANTLY make the same assumption for yourself.

• If you want something done, make sure you talk to the person who is going to do it.

We spend the greater portion of our days as physicians, identifying and describing problems. We make problem lists, and then we tackle them with resources and knowledge. That side of our brain is very well developed. One way to balance this out and practice humility is to identify good things that happen throughout the day.

• Identify a natural break point in your day. End of clinic or rounds for example.

• Identify who you've worked with in the morning, and consider asking them to join you in this exercise.

• Share something good from the day so far. It can be clinically related, it could also be something that you found enjoyable or pleasantly surprising.

• Incorporating this practice daily will strengthen your ability to recognize goodness, and balance out the problem-oriented approach to medicine we are commonly taught.

Practicing medicine comes with a lot of difficult moments. Difficulties can come in all shapes and forms. It can be a case where there are many conflicting pieces of information, the case with unanticipated complications, the case with an outcome that was beyond our control. Reflecting on these moments with self compassion can help us find opportunities for growth.

Self Compassion for Navigating the Difficult Case Time (Adapted from Kristen Neff, PhD)

• Recall a recent time when you were involved in the care of a patient where things could have gone better.

• Write out the details that were difficult - thoughts, feelings, the barriers you were up against, etc. Don't hold back, this is only for you!

• Now, recognize the struggle and difficulty you faced

• Recognize this is part of the experience of life and practicing medicine.

• After you've reflected you can ask yourself, what do I need to hear right now to express kindness to myself? Imagine what you may tell a friend.

  • Some example statements:

    • May I give myself the compassion that I need

    • May I learn to accept the outcomes beyond my control

    • May I forgive myself

    • May I be strong

• Feel free to tell yourself what you need to hear! Be kind, be constructive. Remember that great growth can come from nurturing.