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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Fam Med. Author manuscript; available in PMC 2009 June 18.
Published in final edited form as:
PMCID: PMC2698430

Number 406, “Standard”

It was an innovative study. Before seeing a patient with a cold, we were given a randomized card directing us to complete a “standard” or “enhanced” visit. We wanted to see if a connection between the clinician and patient makes a difference in the duration and severity of the common cold. I liked the “enhanced” visits because I was able to relate to the person, make eye contact and get to know the individual beyond the illness. The “standard” visit, however, did not allow a connection to take place. Just do the job and get out. Did the patient have a cold or not? There was no time for bonding; the study protocol would not allow it when you opened the “standard” card.

I was on the second of four patients who needed to be seen, and I was feeling good after spending close to ten minutes bonding during the previous “enhanced” visit. As I prepared for the second, I looked at the monitor showing the patient in the room via a computer screen that recorded each encounter. I saw a happy 12-year-old girl with her hands together as if she were saying a short prayer. I thought to myself, “Please don’t let this one be a “standard.” In the chart holder outside the room there was a stopwatch to time the encounter, various other materials and the familiar manila envelope determining my fate. There was always a moment of anticipation before breaking the seal. One part of me wanted a “standard” visit, so it would not take much time and I could get on with my other work. Another part of me wanted the “enhanced” because I always felt good afterwards, as if I was allowing new opportunities to unfold.

On the outside of the envelope was the number 406. I pulled out the card and there it was….. “standard.”

I entered the room and tried not to make eye contact. I felt her presence, an innocence and kindness. “What brings you in?” I asked as I fidgeted with my papers, trying not to connect. “I have a cold,” said number 406. I could sense she was disappointed that I was not returning her inviting non-verbal gestures. “Let’s have a look.” She climbed up on the table, and I asked only yes and no questions, sticking to the “standard” protocol. I avoided eye contact and successfully dodged the bonding that so eagerly wanted to happen. She was the type of person who allowed her inner beauty to be revealed, inviting others to share in it. But maybe this was just a result of her young age? Turning my back toward her, I washed my hands. Remaining quiet, I looked in her throat, ears, felt her neck and listened to her lungs. Fighting back the urge to look directly at her, I ended the visit with the common phrase, “Do you have any questions?” What she said next penetrated my external armor.

“Do you have a family?”

My heart sank. She was reaching out, trying to connect, but I did my duty and stuck to the protocol. Responding in a sterile voice, I announced, “I have a wife and three kids.” Without giving her a chance to respond, I asked, “Any more questions?” Dejected, she shook her head, “No.” At that moment I felt pain, a deep sense of guilt, as if I had just squashed the potential for a friendship. I wanted to spend more time getting to know her. I realized that through creating a relationship, we allow unknown mysteries to unfold, giving meaning and joy to this work. Mysteries that cannot be predicted but when discovered bring excitement. It is like finding an unexpected cave in the woods or developing an insight that creates a new perspective. Creating connections brings awareness to what is possible. Number 406 was trying to bond, to open the box to see what can be. Maybe she sensed I needed this more than she did.

I left the room and hit the button on the stopwatch. It read three minutes and eleven seconds. I started to feel my stomach turn and a sense of nausea creep into my abdomen. In just three minutes I ruined my day because I did not let myself receive an invitation of life being offered through a kind-hearted twelve-year-old girl. I was so concerned about the quality of the data I did not allow the real lesson to shine through. I wish I had broken the protocol.

I started to think about the consequences of my actions. Did this ruin her day as it did mine? Will it make her cold worse? How will this shape her attitude and beliefs toward physicians in the future? The statisticians will enjoy teasing this out as data get analyzed to find statistical significance for the “truth.” But what was most significant to me was how terrible I felt blocking a patient’s attempt to relate in a basic human way. Even if data show that a “standard” or “enhanced” visit makes no difference, I know that making connections is the most important aspect of my work, and it is what will help me facilitate healing and be healed. We will continue to collect data to show the importance of this non-specific variable; yet now the results will matter little to me. Number 406 reminded me that beauty is something I experience, not something I prove.

I went on to the next patient with a sense of discovery. The experience with number 406 gave me insight into what I love most in this profession. With new optimism I walked up to the next exam room door feeling a little better and opened the manila envelope for number 407.



Financial Support: The randomized controlled trial noted in this article is sponsored by the National Center for Complementary and Alternative Medicine at the National Institutes of Health (NIH NCCAM 1-R01-AT-1428-01). The University of Wisconsin School of Medicine and Public Health and the University of Wisconsin Department of Family Medicine have also invested substantially in this trial, particularly in the support of the author. Dr. Rakel has no conflicts of interest.