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

Playing “Out of Book”


Unexpected statements from patients can force clinicians to improvise. As in chess, it helps to view these as challenges with potential rewards.   

When Ms. R came in for her visit, it happened to be on a day when a pre-med student was shadowing me. I introduced the student, and then Ms. R and I started our conversation. We discussed her chronic conditions, new happenings in her life, and finished with a recommendation that she get the COVID-19 vaccine. What Ms. R said next surprised me. 


“Doctor, if this vaccine turns out to be harmful someday in the future, how will you feel about recommending it to me?” 


I took a moment before I replied. “Ms. R, I would feel awful if that happened. But I would feel just as awful if you got COVID and became very ill or died. The vaccine is the safest way to protect you from a serious danger that’s around us right now.” 


When we debriefed after the visit, I told my student that the patient’s response to my advice about the COVID-19 vaccine caught me by surprise. 


“Dr. M, you played out of book,” he said, referring to a strategy from chess, a burgeoning passion of his. Not much of a player myself, I became the learner and he the teacher. Much of serious chess play involves documented “openings” and “moves,” reminiscent of the template and sequence of a medical interview. Also like medicine, chess requires that you try to understand how someone else is thinking, and it may be entirely different than the way you do. Unlike a chess player, the clinician’s goal is not to emerge victorious, but to “win” a path forward and a better relational connection. 


Sometimes someone does an unexpected move, and leaves you in a new position that you haven’t experienced before, without a predetermined “move” or response. This is when players have to go “out of book.” While this requires a player to pivot and improvise, it can be a learning experience, and make for a much more exciting game. 


Ms. R did eventually get vaccinated. Initially I felt pressured by her question, but realized it was her way of looking for reassurance. As the chess players say, I had to improvise, but the experience built rapport and improved my “game.” 





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