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Points of Contact: Using First-Person Narratives to Help Foster Empathy in Psychiatric Residents



The authors aimed to determine if writing narratives in psychiatric training can foster empathy for severely and persistently mentally ill patients. One resident wrote first-person narrative pieces about three different patients at a community mental health clinic. She reviewed these pieces with a writing supervisor weekly. The supervisor and resident examined the style of writing, choice of words, and story line to help the resident learn about her feelings about the patient. In each narrative, different choices were made that provided clues about that particular resident-patient relationship. These writing exercises helped the resident become more connected to her patients, develop interviewing skills, and engage in more self-reflection. Narrative writing effectively fostered empathy in a PGY-1 psychiatric resident working with severely and persistently mentally ill patients. This exercise also fostered understanding of countertransference and improved psychiatric history-taking skills. Psychiatry training programs may want to consider incorporating narrative writing exercises into their curriculum.
Brief Report
Points of Contact:
Using First-Person Narratives to Help Foster
Empathy in Psychiatric Residents
Serina R. Deen, M.D., M.P.H.
Christina Mangurian, M.D.
Deborah L. Cabaniss, M.D.
Objective: The authors aimed to determine if writing narratives
in psychiatric training can foster empathy for severely and per-
sistently mentally ill patients.
Methods: One resident wrote first-person narrative pieces
about three different patients at a community mental health
clinic. She reviewed these pieces with a writing supervisor
weekly. The supervisor and resident examined the style of writ-
ing, choice of words, and story line to help the resident learn
about her feelings about the patient.
Results: In each narrative, different choices were made that
provided clues about that particular resident-patient relation-
ship. These writing exercises helped the resident become more
connected to her patients, develop interviewing skills, and en-
gage in more self-reflection.
Conclusion: Narrative writing effectively fostered empathy in a
PGY-1 psychiatric resident working with severely and persistently
mentally ill patients. This exercise also fostered understanding of
countertransference and improved psychiatric history-taking skills.
Psychiatry training programs may want to consider incorporating
narrative writing exercises into their curriculum.
Academic Psychiatry 2010; 34:438441
The ability to empathize with patients is vital to
becoming a good clinician (1–3). Although many
believe that the capacity for empathy is innate, medical
educators have tried to develop exercises and tech-
niques to foster empathy in clinicians (4, 5). Coulehan
et al. (6) define empathy as “the ability to understand
the patient’s situation, perspective, and feelings, and to
communicate that understanding to the patient.” While
empathy is important for all clinicians, it may be par-
ticularly critical for psychiatrists who must rely on their
understanding of the patient’s internal experience in
order to diagnose and treat their patients. Nevertheless,
trainees may have a more difficult time learning to
empathize with patients whose internal experiences are
very distant from their own—for example, patients with
hallucinations, delusions, or cognitive impairment (7).
These differences might represent significant barriers to
developing empathy with severely and persistently
mentally ill patients, especially early in psychiatric
Medical educators have found that writing narratives
can be a very powerful and effective method of fostering
empathy with patients early in training (4). As Charon (8)
writes, “Narrative competence permits caregivers to
fathom what their patients go through, to attain that illu-
minated grasp of another’s experience that provides them
with diagnostic accuracy and therapeutic direction.” Nar-
rative writing exercises have been used with preclinical
medical students, clinical medical students, and residents
to nurture all parts of the doctor-patient relationship, in-
cluding promoting self-reflection and developing empathy,
professionalism, and trust with patients (5, 9 –14). One
form of narrative writing exercise, which involves writing
autobiographical stories from the patient’s viewpoint, has
Received November 30, 2008; revised May 17, August 10, and Septem-
ber 15, 2009; accepted September 21, 2009. Dr. Deen and Dr. Cabaniss
are affiliated with the Department of Psychiatry at New York State
Psychiatric Institute and with the Department of Psychiatry at Columbia
University in New York City. At the time of submission, Dr. Mangurian
was affiliated with the Department of Psychiatry at New York State
Psychiatric Institute and with the Department of Psychiatry at Columbia
University. At this time, Dr. Mangurian is affiliated with the Department
of Psychiatry at the University of California, San Francisco. Address
correspondence to Serina Rayhan Deen, Columbia University Depart-
ment of Psychiatry, NY State Psychiatric Institute Box #99, 051 River-
side Dr., New York, NY 10032; (e-mail).
Copyright © 2010 Academic Psychiatry
438 Academic Psychiatry, 34:6, November-December 2010
been successfully used with junior and senior medical
students (4, 13, 15).
One PGY-I psychiatric resident (SD) undertook a
project in which she used a self-reflective exercise to help
her to understand the severely and persistently mentally ill
patients with whom she was working in a community
mental health clinic.
During her rotation at a community mental health clinic,
one PGY-1 resident at Columbia University elected to
write narrative pieces about three patients of her own
choice with whom she was working. She wrote the narra-
tives during a weekly, 3-hour writing block that she built
into her 3-month elective. She wrote these pieces in the
first person, imagining that she actually was the patient
during a normal day in that person’s life. She had a clinical
supervisor for each of these patients (CM), with whom
she discussed patient care for 2 hours per week as part of
the clinical rotation. She also met weekly with a writing
supervisor (DC), another psychiatry faculty member who
did not have any interaction with these patients, to discuss
her narrative writing. Each session with the writing super-
visor lasted 1 hour during which the resident read one
piece aloud and then the two discussed different aspects of
the resident’s style of writing, choice of words, and story
line to help the resident learn about her feelings about the
patient. The goal of these sessions was left open-ended,
but it was broadly conceived as a possible mechanism to
explore countertransference.
The PGY-1 wrote three narrative pieces ranging from
three to six double-spaced pages about three separate pa-
tients. Each narrative took roughly 3 hours to write.
After a few writing supervision sessions, it became clear
that the resident had chosen to write about patients with
whom she had had a difficult time developing a connec-
tion. The supervisor and the resident realized that in each
situation, these narrative choices were different and gave
clues about some aspect of that particular patient that
helped the resident to empathize with the patient’s subjec-
tive experience. They called these “points of contact.” In
each case, the resident felt that discovering these points of
contact through writing helped her to connect to her pa-
tients and to promote empathy. In addition, she felt that the
process improved her interviewing skills because she
imagined her patient’s lives more completely, thus in-
creasing her ability to ask them more meaningful ques-
Below are a few examples from the resident’s writing,
with some related supervisory process:
Patient #1: This patient was a young, morbidly obese, Latino man
with schizophrenia and a borderline low IQ who was depressed and
paranoid and said little about his feelings. The resident wrote:
My music protects me. Or maybe it just distracts me. I don’t know.
But if I can’t find my headphones, I can’t leave the house. There are
too many people out on the streets who want to jump me ...But
when I listen to my music, I can make it...Yeah, I’m nervous when
I walk out the door, but I listen to my songs, and I get caught up in
the beat, and I’m walking to the beat, and I don’t think about them
as much.
The resident had first written a third-person version
of this narrative, and had then switched to the first
person. When comparing the two versions, the supervi-
sor and resident noticed that the sentences of the first
person version were much shorter and choppier. They
thought that it might be like the rap music the resident
imagined that the patient was listening to. During this
discussion, the resident noted that in their first session,
the patient had offered her his headphones in order to
listen to music that he had composed. The resident had
liked the music and had imagined jogging to it. Thus,
the music was their point of contact. Once she found
this link, the resident was more able to empathize with
his perspective and to ask him relevant questions that
helped her to learn about him and to foster the thera-
peutic alliance.
Patient #2: This patient was a young African American woman with
schizophrenia who had marked poverty of speech and blunted
affect. Although during their interviews the resident felt that the
patient was not explicitly sharing many of her thoughts and feel-
ings, she did tell the resident that she was losing custody of her
3-year-old daughter, whom she visited once a week. The resident
I tuck my baby doll under her pink quilt, and I turn off the light.
She clings onto my hand, and it takes all I have to peel her tiny
fingers off of mine. I take a long last look at her—I want to be
able to notice how she’s changed next week. I tell her I’ll be
back real soon. That’s what I hope. That’s all I can pray for.
That I’ll be back real soon.
In discussing the piece, the resident revealed that she
had been moved by the story of the impending loss of
custody. Through her writing, she realized that this was
her point of contact with this remote patient. Allowing
herself to imagine her patient’s feelings enabled her to
439Academic Psychiatry, 34:6, November-December 2010
feel more empathy toward her in their subsequent in-
teractions. Interestingly, after reading the piece, the
clinical supervisor (CM) also noticed increased empa-
thy for the patient.
Writing imaginative narratives about her patients helped
one PGY-1 psychiatric resident to connect to several emo-
tionally distant patients. Beginning in the third person, she
discovered for herself the way in which writing in the first
person enabled her to “crawl into the patient’s skin” more
easily. She “found herself” writing about things that she
had not emphasized in her meeting with her patients. She
and her supervisor discussed these “points of contact,”
helping her to better understand both her feelings about
her patients and each patient’s subjective experience.
Thus, by allowing herself to imagine things about her
patients’ lives, the resident unearthed ways in which she
had connected to the patients without even realizing it.
As Marshall and O’Keefe (13) noted, writing in the first
person changes the signifiers of “him/her” to “I/me,”
reducing the distance between the clinician and the
patient and giving the writer of the patient’s story a
stronger investment in the patient’s future and the out-
come of the medical care. While most trainees under-
stand the idea of feeling sympathy toward their patients,
it is the concept of empathy, or as Zinn (16) writes,
“understanding an individual’s subjective experiences
by vicariously sharing that experience while maintain-
ing an observant stance,” that is fostered in this exer-
In addition to fostering empathy, this resident’s experi-
ence provides some evidence that narrative writing may
offer other benefits to psychiatric residents. It promotes
self-reflection and nascent exploration of countertransfer-
ence by giving residents permission to take time to think
about their patients’ lives. While the concept of counter-
transference is usually somewhat undeveloped in new
trainees, this exercise provides a forum in which to begin
to explore how similarities and differences between their
lives and their patient’s lives may affect their interaction.
Using writing to explore countertransference was under-
taken by Bhuvaneswar et al. (17), who incorporated the
process of journal writing into a psychiatry intern’s emer-
gency psychiatry rotation. Narrative writing in particular
may also help residents to think of their patients as whole
people, rather than just collections of symptoms (14). It
may also help them to become better interviewers by
allowing them to use their imaginations to think of the
next question to ask, develop hypotheses about our pa-
tients’ motivations, and try out formulations. Thus, en-
couraging students to imagine things about their patients
can have an important role in developing them into cre-
ative thinkers who are curious about themselves and their
Despite these potential benefits, there may be limita-
tions to the use of narrative writing for psychiatric resi-
dents. This resident elected to write narratives; this might
not be as readily embraced by all trainees, especially if it
were a required course rather than an elective. In addition,
this type of exercise inherently exposes the resident’s
countertransference, and thus supervisors would have to
be extremely sensitive to this, particularly if it were done
in a group. It is essential that the participating supervisors
emphasize the ways in which these narratives are, of
course, fictions, and are thus not to be confused with their
patients’ histories. Trainees should be able to recognize
that their own imaginings of a person’s life are colored by
their own feelings and experiences and that they can learn
about themselves through their imaginings. Careful super-
vision from experienced teachers is of the utmost impor-
tance in this type of project.
This exercise could be conducted individually or in a
group setting in which group members learn from each
other’s experiences. While this writing was done about
severely and persistently mentally ill patients, it could
easily be adapted for residents working with any type of
patient population. We believe that this exercise allows
trainees to imagine their patients as complete individuals,
promotes self-reflection, and helps develop more empathic
At the time of submission, Dr. Deen and Dr. Cabaniss reported
no competing interests. Dr. Mangurian is a mentor for an
APIRE/Janssen Research Scholar and will receive $500 in hon-
oraria for this role.
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... • Increased emphatic communication or attitudes with patients [6,42,43,53,62,98,103,119] • Improved patient satisfaction [38,39,85] • Barriers to empathy and administrative changes to curb them were identified by participants [66,70,142] • Participants identified lapses in patient care [63] • Improved patient rated empathy score [12] Enablers and barriers for successful curricula Table 7 provides a summary of the major enablers and barriers to implementing a successful curriculum. ...
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Narrative medicine (NM) is an educational tool that can be used to promote the professional competencies of medical students. This study aimed to investigate Iranian medical students’ perceptions of the first NM program offered in 2019. The study was conducted on 69 medical interns who participated in the weekly NM program that was part of the professional ethics course for two months. We used a questionnaire to determine medical interns' perceptions and personal attitudes toward NM. Three experts confirmed the validity of the questionnaire in Persian, and its reliability was verified by internal consistency (α = 0.879). The independent t-test was used to compare the differences in the total scores of students' perceptions. Data analysis was conducted using SPSS 23 software (P < 0.05). The response rate to the questionnaire was 95.65%. The results showed overall students' perceptions of the program were found to be positive. Furthermore, the scores showed a significant difference in terms of gender (P = 0.014), but none in terms of marital status (P = 0.936). According to the results, NM was effective in improving students’ reflections and their empathy with patients. Therefore, it is recommended to include NM in professional ethics education.
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PREFÁCIO Esta publicação registra um percurso único e peculiar, da Universidade de Passo Fundo, de um caminho que trilhamos juntos, instituições de ensino e SUS, em todo o Brasil, cada grupo da sua forma, mas movidos pelo mesmo ideal do direito à saúde para todos, da atenção à saúde integral e humanizada, da formação de profissionais capazes de abarcar esses ideais e retratá-los no seu fazer em saúde, na construção diária do SUS. A Secretaria de Gestão do Trabalho e da Educação na Saúde foi criada em 2003, no Ministério da Saúde, com a missão de desenvolver políticas e programas que buscassem assegurar o acesso universal e igualitário às ações e serviços de saúde, impondo à função da formação e da gestão do trabalho, a responsabilidade pela qualificação dos trabalhadores e pela organização do trabalho em saúde, constituindo novos perfis profissionais com condições de responder à realidade de saúde da população e às necessidades do SUS. A construção, política e técnica da educação na saúde aconteceu a partir da articulação interministerial entre o Ministério da Saúde e o Ministério da Educação e do estabelecimento e cumprimento de agendas comuns entre: gestores da saúde e da educação, representantes de instituições de saúde e de educação (Escolas Técnicas do SUS, Instituições de Ensino Superior e de Pesquisa); organizações profissionais da saúde e representantes dos movimentos organizados da sociedade. Buscou-se a integração do ensino com a rede de prestação de serviços do SUS instituída como ato pedagógico que aproxima profissionais da rede de serviços de saúde das práticas pedagógicas e os professores dos processos de atenção em saúde, possibilitando a inovação e a transformação dos processos de ensino e de prestação de serviços de saúde. As estratégicas foram múltiplas, gradualmente formuladas de forma integrada às já existentes, e de forma crescente em complexidade, conectadas às politicas de saúde e educação, e apoiadas na política nacional de educação permanente em saúde, como nos ensinaram Maria Alice Roschke e Cristina Davini. Foi assim que iniciamos em 2005 com o Pró Saúde I (por curso), dirigido às profissões que já estavam incluídas na Estratégia de Saúde da Família (Medicina, Enfermagem e Odontologia), evoluímos no edital seguinte para todas as profissões da saúde com o Pró Saúde II em que os projetos deveriam ser únicos para cada instituição, desta vez não mais separados por curso, mas integrando todos os cursos - primeira indução da formação para o trabalho interprofissional (EIP). A EIP foi também promovida pelo reconhecimento e institucionalização da Residência Multiprofissional e em Área Profissional da Saúde. Seguimos avançando e vieram o Programa de Educação pelo Trabalho em Saúde (PET Saúde), o PET Saúde da Família, o PET Vigilância em Saúde, o PET Saúde Mental e o PET Redes de Atenção à Saúde. Além da reorientação da formação na graduação, outras estratégias se somaram como o Pró Residências, o Programa Telessaude Brasil Redes, a Universidade Aberta do SUS e o REVALIDA (Exame Nacional de Revalidação de Diplomas Médicos). A avaliação do Pro Saúde e do PET Saúde nos permitiu identificar a necessidade de promover também iniciativas que pudessem fortalecer a formação docente e o desenvolvimento de pesquisas no campo da educação na saúde, Foi assim que nasceu também o Programa Nacional de Desenvolvimento Docente - Pró Ensino, numa parceria entre a SGTES e a CAPES/MEC. A Universidade de Passo Fundo (UPF), com 50 anos de trajetória na educação superior, 61 cursos de graduação, dos quais 13 na área da saúde, teve projetos contemplados em todos os editais do Pró Saúde e do PET Saúde. Nos seus avanços constantes, construiu-se a parceria com a rede de serviços do SUS de Passo Fundo, que é o terceiro principal polo de saúde a região sul, junto com Porto Alegre e Curitiba. O sucesso dessa parceria resultou em 2017 na formalização do Contrato Organizativo de Ação Pública Ensino-Saúde (COAPES). Nesta publicação encontramos um registro valioso dos caminhos e resultados de sucesso alcançados pela UPF em parceria com a rede de saúde de Passo Fundo. Os temas da reorientação profissional na graduação em saúde são abordados pelas perspectivas dos diversos atores envolvidos, e foram enriquecidos pela interdisciplinaridade, envolvendo temas como a comunicação, a sociologia e a antropologia nas profissões da saúde, a humanização e uma reflexão sobre o currículo. Não apenas o currículo que se estabelece institucionalmente, mas aquele que é construído na prática, no dia a dia das atividades acadêmicas, por meio das escolhas de cada estudante e pelos docentes na mediação do processo de ensino-aprendizagem baseada em metodologias ativas. Esta obra se soma a muitas outras já publicadas, mas é ao mesmo tempo, única e original, comprovando mais uma vez, que há sempre novas oportunidades nos aguardando, e que o caminho se faz ao caminhar. Boa leitura! Ana Estela Haddad Assessora do Ministro da Educação (2003-2005), Diretora de Gestão da Educação na Saúde da SGTES, Ministério da Saúde (2005-2012), Professora Livre Docente, Associada da FOUSP, Coordenadora da Estação FOUSP-ABENO da Rede de Observatórios de Recursos Humanos em saúde, Pesquisadora em Políticas Públicas do Instituto de Estudos Avançados da USP.
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O Capítulo 20 deste livro indica os referenciais teóricos que norteiam a proposta de estruturação de currículos por competências para área de Farmácia.
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The authors discuss journal writing in learning emergency psychiatry. The journal of a psychiatry intern rotating through an emergency department is used as sample material for analysis that could take place in supervision or a resident support group. A range of articles are reviewed that illuminate the relevance of journal writing for the learning process, including articles about resident resilience, "autognosis," the learning process in psychiatry, and "limbic music." Journal writing is a useful tool in consolidating knowledge, and can be used along with traditional exercises for learning psychiatry such as writing chart notes, process notes, and completing required studies for examinations. Psychiatry training should continue to explore the use of journals as residents continue to write them.
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Education in Psychiatry, like Treatment in Psychiatry, begins with a case vignette to illustrate an important problem in clinical psychiatry. However, the goal of Education in Psychiatry is to present and evaluate methods to teach students, trainees, and other psychiatrists how to treat patients with these problems.
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People with mental illness around the world continue to suffer from stigmatization and limited care. Previous studies utilizing self-report questionnaires indicate that many medical students regard clinical work with psychiatric patients as unappealing, while the professionalism literature has documented a general decline in students' capacity for empathy over the course of medical school. Through in-depth interviews, this study attempts to better understand the formation of medical students' perceptions of psychiatry and the implications of that process for a more general understanding of the impact of emotionally-laden experiences on medical students' capacity for empathy. Forty-seven fourth-year medical students who had expressed interest or performed well in psychiatry were asked a series of questions to elicit their perceptions of the field of psychiatry. Interview transcripts were systematically coded using content analysis and principles of grounded theory. Stigma, stereotypes, and stressfully intense emotional reactions seemed to adversely affect the students' expected satisfaction from and willingness to care for the mentally ill, despite enjoying psychiatry's intellectual content and the opportunity to develop in-depth relationships with patients. Teaching faculty need to directly address the stigma and stereotypes that surround mental illness and actively help medical students cope with the stress that they report experiencing during their psychiatry clerkship in order to improve the recognition and treatment of psychiatric illness by newly graduating physicians. More generally, the relationships that we identify among stress, stigmatization, and stereotyping along an empathic spectrum suggest that increased attention should be paid to the stress that empathy can entail. This perspective may allow for the creation of similarly targeted interventions throughout the medical school curriculum to counteract the decline in empathy, the so-called "hardening of the heart," associated with physician-training worldwide.
Narrative medicine has emerged in response to a commodified health care system that places corporate and bureaucratic concerns over the needs of the patient. Generated from a confluence of sources including humanities and medicine, primary care medicine, narratology, and the study of doctor-patient relationships, narrative medicine is medicine practiced with the competence to recognise, absorb, interpret and be moved by the stories of illness. By placing events in temporal order, with beginnings, middles and ends, and by establishing connections among things using metaphor and figural language, narrative medicine helps doctors to recognise patients and diseases, convey knowledge, accompany patients through the ordeals of illness – and according to Rita Charon, can ultimately lead to more humane, ethical and effective healthcare. Trained in medicine and in literary studies, Rita Charon is a pioneer of and authority on the emerging field of narrative medicine. In this important and long-awaited book she provides a comprehensive and systemic introduction to the conceptual principles underlying narrative medicine, as well as a practical guide for implementing narrative methods in health care. A true milestone in the field, it will interest general readers and experts in medicine, humanities and literary theory.
Medical schools have been slow to include meaningful end-of-life (EOL) educational experiences in their curricula. As an area of inquiry and focused clinical experience, death is “conspicuous” by its absence, reflecting a medical culture that defines death as failure. The author asked fourth-year medical students at one institution to describe their experiences with dying patients and their families, the skills and attitudes they brought to these encounters, the support they received from attendings and residents while caring for dying patients, and suggestions for the medical curriculum that would help prepare them for care of the dying. Using a qualitative method, she analyzed ten students' written narratives, which dealt with experiences during their third-year clerkships, and compared these reflections with the literature on EOL care in medical education. The themes that emerged provided four organizers for this essay: (1) students' worry and uncertainty about EOL care, (2) guidance and role modeling in EOL care, (3) preparation for EOL care, and (4) conclusions and recommendations for the medical curriculum. In general, students did not feel well prepared or supported as they cared for their first dying patients, including, for example, delivering a terminal prognosis or obtaining a DNR. However, while they did wish for more support and role modeling from residents and attendings, they generally believed that care of the dying can be learned only through direct clinical experience. These beliefs call into question curricular issues of placement of EOL inquiry—most often in the preclinical curriculum—and the teaching of its content, currently overwhelmingly by lectures. The author concludes with recommendations for thoughtful, integrative, interdisciplinary curriculum changes in EOL education.
Fourth year U.S. medical students' first-person narratives of a patient's experience of AIDS are analyzed using a conceptual framework that builds on the interactive model of narrative critique. Relational and affective convergence and, conversely, relational and affective dissonance, reveal imaginative reconstructions of emotional and interactional themes depicted in the patient's original story. Attention is focused on representations of isolation, contamination, shame and fear. Elements of indeterminacy and openness in the patient's description of his experience with AIDS provided students with opportunities to create an imagined response to HIV infection in their own narratives. The narratives describe social interaction that is tainted and constrained by the presence of infection and its associated stigma. The emotional content of the student narratives portrays an affective landscape that resonates. elaborates and, in some cases, distorts the feelings expressed in the patient's story. The narratives call attention to the way in which individual meanings are externalized, objectified and projected onto a socially and morally salient 'other'. Using the first-person narrative approach in the seminar on AIDS proved to be an effective method of sensitizing students to the experience of living with HIV infection. The challenge for medical educators lies in creating opportunities for students to develop increased empathy toward individuals with AIDS.
What a wonderful explication of the interpersonal phenomenon called empathy by Zinn.1 In my own study of this clinical skill, at once (for me) diagnostic, therapeutic, and personally/ professionally rewarding, I cannot recall a more thoughtful analysis or lucid presentation. Zinn has contributed importantly to my understanding of "doctoring," an interpersonal healing phenomenon shared, I believe, with our brothers and sisters in the major and minor healing and caring professions throughout history. Our equally wonderful biomedical technology has tended to marginalize "doctoring" and has distracted us from valuing and developing the skills of empathic understanding and responding. Not if, but when we demarginalize "doctoring," we will also realize restored social approval, fewer malpractice claims, better patient cooperation, fewer tests ordered, fewer medications prescribed, and greater personal satisfaction with our work. Grandiose? Maybe. Wouldn't it be wonderful? Stay tuned.I also propose two questions for reflection: To what extent does