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This month... Turning Over a New Leaf

Sanyu Janardan

I was a first-year medical student, starting my first afternoon at an outpatient clinic as part of an introductory course in clinical medicine. My white coat was freshly washed; I had a rainbow of pens in one coat pocket, and my shiny name tag dangled from the other. I only hoped that I was as prepared as I looked.

I entered Mrs. Carr’s room. A fifty-five-year-old woman, she sat gingerly at the edge of her chair, looking ready to get up at any moment, as if the appointment were already over. She gave me a cursory glance, then went back to folding and refolding the bus-ticket stub in her hands.

I asked a well-rehearsed question: “What brings you to our clinic?”

“Chocolate cake,” she answered.

I froze a little. My classmates and I had learned many things in medical school--anatomy, biochemistry, and countless mnemonics to help us remember key bits of knowledge. But the correct response to “chocolate cake” was not among them.

“For my grandbaby’s birthday,” she said. “I don’t have Internet, so I can’t find a recipe.”

Now I really froze. Having reviewed her chart with Dr. Jeffries, the supervising physician, I knew that Mrs. Carr was here to talk about her depression medication. I knew what to ask in order to gauge her mood; I knew her medication and its side effects. I just didn’t know how chocolate cake fit into the picture.

“How has your mood been lately, Mrs. Carr?”


“Can you elaborate on that for me? Bad in what way?”

“Bad as in bad.”

“How about your sleep? Energy level?”

“Bad, too.”

“Have you been taking your medication as prescribed?”

“Yes. You think I’m trying to make myself feel bad?”

“No, ma’am. Just trying to see what we can do to help you.”

“You can help me by finding that recipe.”

I continued to try to steer our conversation into the templates I'd learned in class. Cranking methodically through the screening questions with Mrs. Carr, I sensed her growing frustration.

Dr. Jeffries appeared at the doorway--a reprieve.

I filled him in on the history that I'd gathered, deftly omitting any mention of chocolate cake. He asked Mrs. Carr some questions, and then we headed to the computer station to check her lab results before determining whether to increase her dose of antidepressant medication.

But as I sat there Googling dosages on the computer, my mind kept drifting back to Mrs. Carr’s request.

Suddenly, the search term “Celexa dosing” gave way to “chocolate cake.”

I found a recipe that looked so good, I got hungry just reading it. I copied it down on a piece of paper and walked back to Mrs. Carr’s room.

She eyed me suspiciously, no doubt expecting more questions. When I handed her the recipe, her look turned to one of surprise.

She began to talk, and I began to listen.

I listened as she told me how she didn’t get along with her son-in-law, how her daughter wouldn’t stand up to him, and how this meant that she could only see her granddaughter once a year. I listened as she told me how she had stopped her Internet subscription in an attempt to make ends meet.

"My granddaughter is turning five, and I crocheted her some headbands, but I want to bake her a cake, too," she said. "No child’s birthday party is complete without a good cake."

As she talked, I realized that the problem wasn't her medication dosage; it was that her real-life circumstances would make anyone feel depressed. It dawned on me that no number of practice encounters with actor "patients" in medical school could prepare me for the conversations I would have with my patients in the real world, and that it wouldn't help me much to know the intricacies of a patient’s disease if I didn't also take the time to hear about his or her life.

If I'd asked Mrs. Carr why she wanted the recipe, instead of trying to fit her history into the checkboxes in my head, our visit would have been more productive, I thought. We could have talked sooner about the stresses in her life, rather than assuming that we simply needed to increase her antidepressant dosage.

Now, knowing more about her situation, I felt that raising her dosage would merely be slapping on a Band-Aid--a quick fix, not an enduring one. Luckily, there was still time to change course.

Mrs. Carr left the clinic that day carrying a recipe for chocolate cake, not a new prescription. She also had an appointment to visit a mental-health professional at the clinic in order to assess her situation more thoroughly and, I hoped, to get her the support and resources she needed and deserved.

Now, going through my first year of clinical rotations, I think of Mrs. Carr often. With modern health care's unrelenting focus on electronic medical systems and efficiency, I'm frequently tempted to use a boilerplate interview script before the patient has said a single word.

Every time I start down this path, though, I remember Mrs. Carr, who taught me not to jump to conclusions--and that, sometimes, the very best medicine is a listening ear.

Or maybe even a recipe for chocolate cake.

About the author:

Sanyu Janardan is a third-year medical student at the University of Minnesota. She loves all things related to sunshine, science, writing and the holidays. "Writing became a big part of my life when I began journaling while being diagnosed and treated for an illness in high school. Journaling helped me reflect upon my illness in a meaningful way, and this has compelled me to integrate writing into my life as a way to help me better process the experiences I have, both inside and outside of medical school."

Story editor:

Diane Guernsey



# Justin Sanders 2015-03-20 07:12
What a lovely and powerful story about really listening to patients. Well done!
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# Carolyn Eaton, MD 2015-03-19 17:33
I work with medical students from Year 1-3. You have encapsulated one of the tenets I always want to teach them: There are no lessons like those learned from your patients. Some of their stories will capture and captivate you. Share with them their joys and sorrows, for every bit of human connection will keep you more human and help prevent burn-out and isolation, a common problem among physicians. It's too bad you will not know how her grand daughter's 5th Birthday went.
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# Natalie 2015-03-19 12:42
As someone who takes antidepressants I have found a good piece of chocolate cake, milkshake, fine glass of wine is as effective as a dosage increase.
Just my experience. Thanks
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# LTCO Caroline 2015-03-19 11:41
Thank you. You're right on track. As a Long-Term Care Ombudsman, we often have to use our "listening" ears. Thanks for reminding us all.
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# Steve 2015-03-19 11:12
I agree that we should spend more time talking with patients. However, I hope that Ms. Janardan doesn't come away with the impression that depression is so easily managed in all patients and that she ends up treating some who suffer from it whose energy level is so low that they can't talk about anything.
And in any way denigrating antidepressants is as foolish as denigrating antihypertensiv es or medications for diabetes, problems that patients often have far more control over than they do mental illnesses.
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# Fadhilu Adejare 2015-03-10 01:54
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# Joyce Fish 2015-03-08 08:46
An important story,and delightful
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# Joyce Fish 2015-03-08 08:45
An important story, and delightful.
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# Karen Ruth 2015-03-08 06:19
Thank you for telling the most important story of medicine. Listening. As an RN in neuroscience and epilepsy 20 years, I was able to assess pertinent details for diagnosis and treatment with this skill. People are not just their symptoms but their situations, families, stressors and how they are meeting Maslow's hierarchy of needs. You have illustrated this beautifully in your well written story. The cake wove everything together! I can endorse you already as a fine MD!
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# pc 2015-03-07 14:40
I enjoyed this so much, my favorite kind of patient encounter, an unexpected lesson in life.
Thank you for sharing!
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# pc 2015-03-07 13:35
I enjoyed this so much, my favorite kind of patient encounter, an unexpected and pleasant lesson in life.
Thank you for sharing!
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# Pris Campbell 2015-03-07 05:24
I love this story!
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# Dorothy Blake 2015-03-07 02:01
Very impressive that so early in your career, you discovered another take on this woman's problems. . Your patients must be lucky to have you as an MD.

And can you share the recipe?

Dorothy Blake FNP
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# Abby Caplin, MD 2015-03-06 22:17
What an excellent story. Thank you for this--- your deep wisdom, your insightfulness and obvious respect for your patients.
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# Anna Schmidt 2015-03-06 21:18
" It dawned on me that no number of practice encounters with actor "patients" in medical school could prepare me for the conversations I would have with my patients in the real world, and that it wouldn't help me much to know the intricacies of a patient’s disease if I didn't also take the time to hear about his or her life."

I have had a lot of encounters with a lot of medical professionals in my 50+ years. The ones who made the biggest difference were the ones who understood this fundamental truth.
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# Slou 2015-03-06 19:44
Sweet story. Think you are going be a good doc too.
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# Rita C. 2015-03-06 19:19
Thank you for sharing this simple, but meaningful story with us. And now. . . am I the only reader hungering for a piece of that cake?
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# Lee Blue 2015-03-06 19:10
wonderful story! it illustrates the importance of listening -- to a patient, or to anyone. once the author really heard the request for chocolate cake recipe, it all came together.
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# Steve Schoenbaum 2015-03-06 19:01
Sanyu, this is a wonderful story, beautifully told and a great lesson fortunately learned early in your education and career. I'm troubled, however, by your saying, "It dawned on me that no number of practice encounters with actor "patients" in medical school could prepare me for the conversations I would have with my patients in the real world, and that it wouldn't help me much to know the intricacies of a patient's disease if I didn't also take the time to hear about his or her life." Even simulated settings should be teaching you to listen to and observe the patient. I do not believe it is a matter of actors vs. real patients but whether your preceptors are focusing on one of the most important issues in being a physician.
Good luck in your future career! I'm sure there is lots more to learn, and now you also have things to teach and are doing so through this story. Thanks!!
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# Betty Reiser 2015-03-08 15:16
This story, so well written is a beautiful example of the importance of humanizing the doctor/patient relationship through recognizing how the whole individual is crucial in medical diagnosis and treatment. This physician's sensitivity and awareness of the possibilities of different levels of care is so well exemplified here. It bodes well for her future as a doctor and caregiver.
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