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Case Illustration 1

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Jeffrey Borzak, a patient I knew well, seemed to be recovering from coronary artery bypass surgery. On rounds, I sensed that there was something that was wrong, but I could not put my finger on it. In retrospect, his color was not quite right—he was grayish-pale, his blood pressure was too easily controlled, he was even hypotensive on one occasion, and he seemed more depressed than usual. He reported no chest pain or shortness of breath, and had no pedal edema, elevated jugular venous pressure, or other abnormalities on his physical examination. But still I did not feel comfortable, and although there were no "red flags," I ordered an echocardiogram which showed a new area of ischemia. An angiogram showed that one of the grafts had occluded. After angioplasty, Mr. Borzak looked and felt better, and he again required his usual antihypertensive medications.

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Case Illustration 2

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Elizabeth Grady recently came to be a patient in our practice. The practice, despite having long waits for appointments, was recently reopened to new patients to boost productivity. Mrs. Grady left her previous physician's practice because of a disagreement over seeking care in the emergency room rather than in the office for her out-of-control diabetes. Her blood sugar has never been below 400, and often was in excess of 600 mg/dL. Despite claiming to be on a diet, her weight kept increasing, and now she weighed nearly 500 lb. At the first visit, an irate sister accompanied her demanding that the patient be hospitalized immediately. On the second visit, Mrs. Grady was so anxious that she could not sit in the examination room; she was pacing in the waiting room until her appointment, and then indicated that she was in a rush to leave even though the appointment was on time. She no-showed for the subsequent appointment, and is now returning for her third appointment.

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Excellent patient care requires not only the knowledge and skills to diagnose and treat disease, but also the ability to form therapeutic relationships with patients and their families, recognize and respond to emotionally demanding situations, make decisions under uncertainty, and deal with technical failures and errors. These capabilities require that clinicians have self-awareness to distinguish their values and feelings from those of their patients, recognize faulty reasoning early in the diagnostic thinking process, be attentive to when a technical procedure is not going as it should, recognize the need to gather more data, and be able to incorporate disconfirming data into an evolving assessment of the patient. Often, there is no tool or "instrument" that can help physicians with these situations on a moment-to-moment basis other than their own cognitive and emotional resources and their capacity for reflection and self-awareness. Yet we spend little time during medical training "calibrating" this instrument. For psychotherapists, athletes, and musicians, self-calibration and self-awareness are often important aspects of training. In my view, the ...

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