A recent book, co-authored by National Academy of Medicine members, offers insights on how health care providers can build trust with their patients and strengthen the intangible skills essential to patient-centered care.
By Jamie Durana
What does it mean to be a good clinician?
It’s a question that clinicians grapple with early on in their training and return to time and again during their careers. Beyond anatomy, physiology, pathology, treatment protocols, and myriad other areas of technical know-how is a more elusive set of skills that clinicians must develop, such as how to advocate for patients, how to navigate uncertainty, how to practice empathy, and how to recover from mistakes. These intangible qualities shape every encounter in medicine, but they aren’t easy to teach or to master.
The recent book, Masterclass in Medicine: Lessons from the Experts, gathers essays from clinicians reflecting on these intangible skills. Drawing on experiences of accomplished physicians across disciplines, the book offers personal reflections on the emotional, ethical, and relational skills that shape every meaningful interaction in medicine. Aimed at students, educators, and practicing clinicians alike, Masterclass in Medicine explores an invisible curriculum: the parts of medicine that are hard to teach but essential to practice. These skills take on even more importance at a time when rapid technological innovation is changing the medical field.
The idea for the book grew out of a shared passion for medical education among its three editors: rheumatologists Dr. Marcy Bolster, Dr. Jason Liebowitz, and Dr. Philip Seo. And from their recognition that some of the most important lessons health professionals can learn aren’t always easy to access. Bolster, Liebowitz, and Seo set out to capture the wisdom that clinicians build over time but rarely have the avenues to share. Liebowitz says the three envisioned the book as somewhere between a textbook and anthology of essays sharing insights on “professionalism, ethics, humanity: the intangibles in medicine that are important but hard to just glean from a rote textbook.”
An Invisible Curriculum
Much of what it takes to care well for patients isn’t taught in formal coursework. Learning the skills to navigate uncertainty, earn trust, or advocate for patients happens over the years and in informal ways like talking with colleagues. But these skills underpin how clinicians show up for their patients from the start.
Speaking about his own medical training, Liebowitz recalls that courses in clinical skills focused heavily on conducting patient interviews, physical exams, and simulated patient exercises. But reflection about topics like identity, values, or systemic barriers was too often an afterthought. “It was sort of like, ‘You’ll pick it up as you go’,” he says.
“I don’t remember having any collection of essays or reflections [in medical school] where we really talked about the experiences of clinicians,” Liebowitz recalls. Instead, he says there was an expectation that students and early clinicians would pick up lessons organically throughout their training and early years of practice. Liebowitz describes the book as an effort to make those lessons easier to access and to give students and colleagues a starting point for deep conversations about health care.
The chapters are written by clinicians from a wide range of specialties, backgrounds, and career stages. Several National Academy of Medicine members are among the authors: Dr. Katrina Armstrong, Dr. Michele Barry, Dr. Mark Cullen, Dr. Ralph Horwitz, and Dr. Jerome Kassirer. The authors share stories beyond the work of doing medicine, but about being a caring clinician. Liebowitz emphasizes the intent was to create something that would resonate not just with trainees, but also with seasoned clinicians and maybe even readers outside of medicine. Through the essays, the book brings together a “group of very thoughtful, experienced clinicians to talk about a wide range of topics that are really important from the level of medical school, really all the way deep into someone’s clinical practice and even someone who’s been practicing 30 years,” he says.
Reflections from Authors
‘The magic of medicine’
One area where traditional medical training is often at odds with learning these intangible skills of medicine is when it comes to navigating uncertainty, says Dr. Katrina Armstrong. Armstrong is chief executive officer of the Columbia University Irving Medical Center. She explains that she wrote the chapter “Dealing with Uncertainty” to capture a lesson that medical students and practicing clinicians alike may struggle with during their careers: how to make peace with the fact that it simply isn’t possible to know all the answers. There are inherent variabilities in medicine. And, in a field where having the answers and confidence are applauded, absorbing this lesson can be tricky.
Armstrong says that “the magic of medicine” lies in the human side and coaches medical students and trainees to focus on how they show up for patients. “You cannot solve the uncertainty of their outcomes, but you can walk the journey with them,” she says. A relationship based on trust is the most valuable thing a clinician can offer to a patient, not an ability to know all the answers.
“The key issue is for patients and physicians to essentially trust each other,” she says. Trust that the patient’s best interests are always at the center of any decision or recommendation, trust that communication will always be open and honest — those foundational elements are central to high-quality care. Armstrong emphasizes that patients are not a monolith, each person has different needs and experiences, which makes that relationship-building essential.
Armstrong says that health professionals experience a great deal of pressure to unravel uncertainties they encounter. She says clinicians may think that the answers are always “just one more test” away, but, even as the field evolves thanks to rapidly advancing technologies, these tools have limits and can sometimes raise even more questions.
“We have this belief, I think, that by becoming more and more certain about our knowledge that we’re actually going to be improving human existence,” explains Armstrong. “And I think the paradox that we recognize is that every new technology — every new step — just adds uncertainty.”
Armstrong says medical education often shies away from acknowledging uncertainty, but she believes it should be embraced as a learning tool. While working at Massachusetts General Hospital, Armstrong and her colleagues would often present to medical students about cases where the answer was unknown because it offered a more realistic view of what a physician encounters.
Through the reflections Armstrong shares in the chapter, she hopes health professionals will be able to find balance given that uncertainty is inherent to their profession — and in life — so they can focus on the human side of medicine. Even as the field advances and medical innovations grow, Armstrong says, “we’re never going to reach a point where it isn’t equally important to be walking that journey with a patient.”
‘A path to patient advocacy’
Medical diagnosis is only one part of caring for patients, says Dr. Michelle Barry. Barry is a professor and infectious disease and global health specialist at Stanford University. She says it felt important to write about patient advocacy because “listening to and advocating for our patients is any good physician’s duty.”
Advances in medicine bring new opportunities, but they can also sometimes challenge relationship-building. “The need for an electronic record and mandated time limits also push against quality one-on-one patient care,” says Barry. “At the same time, it’s never been more important to hear and understand their needs and their stories.”
Clinicians overwhelmingly come to the profession out of a desire to help people. Barry says there’s “a path to patient advocacy” for everyone and she hopes the examples shared in her chapter can inspire health professionals. “At the most fundamental level, any physician can bring a nonjudgmental mindset, and deep sense of humility and empathy to every patient encounter,” she explains.
Barry hopes the chapter will help readers reflect on the importance of building trust in the patient-clinician relationship, as well as the need to learn about a patient’s life and experiences beyond strict medical information. “By listening to patient stories and understanding their cultural contexts, doctors can use that knowledge to advocate for better, more comprehensive and compassionate care regardless of a patient’s wealth or background,” says Barry.
Throughout her experiences working with patients, Barry reflects that patient advocacy is a key element in her practice and her passion for medicine. “I’ve never felt more useful than I did during the times when I was finding creative ways of getting care to patients who needed it and may not have otherwise received it.”
Keeping the Conversation Going
Masterclass in Medicine can already be found in some medical school classrooms, but its potential reach can extend beyond formal education. Liebowitz says the editors would like to see the reflections in the book prompt conversations between colleagues, students and mentors, and even with patients. “I’m hoping one of the things that comes out of this is a desire for those who work in the medical world to share these stories with each other,” he says. “This could just be a starting point.”
It’s understandable that technical skills may come to mind first when imagining what it takes to be a good clinician. But Liebowitz suggests the book reveals something fundamental for those who work in health care. “There’s a huge power differential when a patient walks into a doctor’s office,” says Liebowitz. Patients may be in a hospital gown, ill, or in bed, or be expected to share deeply personal information with their medical team. He says the book “pulls back the curtain a bit” and humanizes clinicians in ways that may not always be evident.
In a field where practitioners are pulled in countless directions, the intangible aspects of medicine may be moved to the backburner. Yet these skills — understanding uncertainty, advocating for patients, mentoring the next generation — represent the essence of health care professions. Or, as Liebowitz puts it, sharing these stories “just gets to the heart of medicine.”
Related Podcast
Hear Bolster, Liebowitz, and Seo talk about the making of Masterclass in Medicine: Lessons From the Experts in Episode 61 of The Nocturnists: Conversations.
