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

The Things You Don’t Say


Writing poetry, like other forms of creative self-expression, can be a way to process distressing events in clinical care.   

You have 

Cancer I think your baby will 

Die I wish I could prove that you beat your 

Son I am tired 




Afraid for you 

So sleepy tired my feet 

Hurt you should not use  

Heroin If you had come here sooner you would have 

Lived I wish you would let yourself die 

Cleaner this treatment is 

Unnecessary your pain is a 

Lie you should say goodbye to your 

Father you look just like my child  





Brother and I am 

Afraid I love 

You I wish I could  





In the hospital, I was often reminded of this quotation by the writer Will Durant: “One of the lessons of history is that nothing is often a good thing to do and always a clever thing to say.” 


Evidence shows that like many other scientists (and human beings!), clinicians are intuitive decision-makers. But we’re also trained to couple our fast-thinking with slow-thinking, minimize our implicit bias, and shape our assessments carefully when talking to patients.  


We could argue endlessly about whether we’re successful at this or not. But most doctors I know do their best. Which is all that a primate species on a crowded planet in the 21st century can do. But sometimes all those words we don’t speak pile up inside of us. While we can learn to hold back our snap judgements, fears, discomforts, and frustrations, we still feel them deeply.   


Physicians have the highest suicide rate of any profession, higher than post-combat troops in the military (28-40 per 100,000 versus post-combat troops at 27.5). Researchers posit this is due to moral injury not simple burnout. PTSD research describes moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” 


So how do we find a balance between what we should say to patients and our own internal need to bear witness and speak our subjective truth?   


The poem above came from my own deeply withheld words. The things it was not appropriate for me to say to my patients. To remain effective as healers it is often important to say nothing, stand back, and let events speak for themselves. But I also believe that each doctor needs to find ways to vent the things they cannot say so that those words don’t spill over into anger at our patients, families, colleagues, trainees, and selves. I have found narrative medicine deeply healing and the therapy I needed for exactly that purpose. 


We must find ways to witness events we see in clinical care, in safe, non-harmful ways. Learning when to stay silent with patients is part of clinical training.  Learning how to metabolize and release our unsaid words so they are also healing is part of clinical mastery. 


For more on moral injury: “A New Paradigm For Growth,” by Dr. David Kopacz.

“Beyond Resilience: Fighting The Cause of The Burnout Pandemic,” by Dr. David Kopacz. 







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