Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Big “S” And Not Much “OAP” 


I could offer no medicine, but I was able to give my patient the best treatment possible just by listening and validating.  

In the second semester of my outpatient infectious disease clerkship, we were expected to move past shadowing and work toward independently performing an H&P. I went to see a new patient to the clinic, who was self-referred for care.  


I started with open-ended questions: “How have you been? What has been going on lately?” 


The patient began with her somatic symptoms, noting the full range of fever, chills, and GI upset. As I gave space, she took it up. She moved past her physical symptoms and began to share that she’d seen a few doctors before, all dismissing her continuing symptoms and questions, and recommending a therapy that she didn’t want.  


I struggle with redirecting patients who take detours and tangents. I want each person to feel heard and validated and to share as much as they want, because I believe there’s no such thing as too much information. But as I progress in my training, I’m learning that sometimes we must redirect patients. In the ever-decreasing time that’s allowed for an encounter, we aren’t offered the luxury of time to explore all parts of a patient’s thoughts, feelings, symptoms, as well as do a comprehensive physical exam.  


Nonetheless, I followed my patient down her path of being dismissed, turned away, and silenced. After 20 minutes with my patient, I hadn’t done a physical, gone over her home medications, or a full ROS. I thanked her for her time and openness and went to present her to my preceptor.  


I was unable to give a proper oral presentation in a SOAP format because I had a lot of S, not much O, and I couldn’t really think of an A and P. 


I recounted her constitutional and GI symptoms and then took a detour of my own. I told my preceptor, “She’s gone through a rough time; I think she just wants someone to listen.”  


My preceptor looked at me, and said, “Ok, so that’s our assessment and plan, let’s go do it.” 


In the room together, nervous that I’d wasted both my patient and preceptor’s time, my preceptor opened the floor asking what was going on. She, too, gave the patient space, and was able to elicit more of the symptoms and exposures that our patient was experiencing. 


Although we ended the visit suggesting that the patient continue with the therapy recommended by her other doctor, our patient was moved to tears because she finally felt like a member of the team and had been heard. 


Medicine is much more than a procedure or pharmaceutical regimen. As physicians, we have the power to bring about healing simply by listening, partnering, and affirming our patients. And sometimes, that is the best treatment possible. 








This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.