“Please come to room 227. Right now. They're going to do the final salute.” My text to the resident ends with, “This is really unique.” As a hospitalist at the VA, this is only my second final salute. I want them to savor it too.

“OK, be right up,” the senior resident replies.

I line up with staff along the hallway of 3-West. The family at the far end of the hall is easily identified since they are not wearing scrubs. More noticeable, though, is how close they stand as they console each other. Since COVID-19, we have spent months policing this space: masks, eye protection, 6 feet of safe distance, solitary meals. Sometimes even our patients refuse to be examined. Hugs in the hospital are almost never an event, and yet here is a family attending to their own humanity.

Further down the hall I spot the team. Leading the pack is a haggard resident alongside a cheerful intern who is struggling to keep multiple pagers secured to his waistband. Two medical students trail behind, speed walking to catch up. Ill-fitting white coats blow behind them as they hurry. They resemble an album cover for a medical rock band. They wear apprehensive faces, unsure of what lies ahead, yet determined to be the doctors they are training to become.

“Stop running! You're going to scare people. This isn't a code. He's already dead!” I scold in my head.

Instead, I check myself. They don't need correction. Rather, I need to model a willingness to be present even when it's uncomfortable. My smile from behind a mask makes my eyes crinkle at the edges. I hope this is a visual cue to relax. As they make their way to where I stand, I watch as their faces instantly change. They know this veteran died; after all, they pronounced his death, started the death note, and dictated a discharge summary. Yet, I watch as the usual apprehension from being called to the bedside gives way to something far more sobering, a sadness in its finality.

The room still holds our patient, the man we've been rounding on all week. Except now there's a large American flag draped over his body. A senior nurse with curly hair and a freckled chest begins to push the gurney holding his body out of the room. Another nurse follows with an iPad playing taps. Some of us salute, while others place hands behind their backs or gently touch their hearts. I wonder why it takes a death for us to participate in rituals collectively.

Each week the learners become precious to me. Perhaps getting to know them is my own ritual. We spend hours together rounding, teaching, and on a slow weekend call day, spinning stories in shared laughter. A short huddle before we round in the morning helps us slow down, regrouping for the day ahead. I read to them snippets from an essay or some poetry. I lead them in 3 minutes of calisthenics, air squats and leg lunges, channeling Richard Simmons. Sometimes it's 4 minutes of meditation, or I ask a question and sit in my own discomfort with the silence as they formulate their responses.

“Your grade is not dependent upon your participation,” I preface.

“If you have an injury, a disability, or something doesn't feel right, please modify the activity. You just being part of the circle is enough. Listening is a gift,” I remind them.

I could chalk up these rituals to living alone during a pandemic, not having children, no pets to tie me to a schedule, or not enough hobbies, but that's not it. My teaching is intentional, and it is directly tied to my identity. Over the past few years my identity as a physician has changed. I have forfeited doctoring patients for doctoring learners. I smile when the patients defer to “their doctor,” the trainee. If the trainee is going to be seen as the patient's doctor, I cannot maintain the status quo where I'm the patient's “real” doctor. I must step aside for the learner to step into their identity as physician. I have to allow them the space to find their own practice style, to shine, and at times, under supervision, to fail.

We practice with short dress rehearsals in the hallway before going into the patient's room. I give them phrases from the work of Back et al1  if they get stuck, like, “Dr. Cowan, do you have anything to add?” Or I might ask, “Dr. X, may I add something?” I am certain to give them back the limelight after I clarify a question or correct something. They resume being the patient's doctor, while I go back into the circle as “supervisor” and “part of the team.” I'm a supporting actress on the team, no longer a leading character. They run through their lines and sometimes still tremble at the bedside. They give cancer diagnoses, navigate end-of-life conversations, call family, and pronounce the dead. We pause for teaching, having looked up our clinical questions from the day before. They smile back at me from behind masks. “I'm proud of you,” I tell them. As we walk between patient rooms on rounds, I ask a learner to pause and self-reflect or I coach them on one thing to improve upon. These are highly specific feedback sessions that take no more than a few minutes. This is where I see connections made, forever sealed with a patient encounter.

Lately, I wonder if I'm more of a priest than a doctor. Am I the attending who attends to the emotions of my team? Perhaps that's what doctoring truly is. We attend. We show up as a witness to another's experience, helping our patients make sense of their stories. Perhaps as the attending, I help the learner make sense of the stories they witness. After all, what they witness will shape their own story.

As we line up along the hallway, my own brittle irritation and exhaustion lessen. I'm melting into something softer as I savor these brief minutes with the team. I want to tell them how meaningful these moments are when we connect with ourselves and our patients, experiences that nourish even the most avoidant. I want to tell them the guidelines will change, so develop professional humility early.

Instead, I remain silent. After all, this is their practice. They decide how far out to wade into their own emotions, how much to give on any given day, who is worth opening up to, and most importantly, what they will do when love joins a family meeting or anger shows up when the cancer comes back. In a couple of days, our medical rock band will disperse as a team. They have other rotations to experience. I close my eyes, hand on heart, and wish them an easier time than I had, yet hope they will embrace suffering in an effort to become even better.

“Could I add something?”: teaching communication by intervening in real time during a clinical encounter
Acad Med