a coveted haven. In a society where communication becomes reduced to keystrokes and memes, the doctor–patient rela­tionship can be taught, nourished, and promoted among our trainees.

Not until the twentieth century did the biopsychosocial concept of medical care become imaginable. As physicians gained a greater appreciation for patient individuality and the inuence of illness on the patient’s psyche, more emphasis was placed on learning about the patient’s narrative and developing trust [17]. The trusting relationship between phy­sician and patient transpires over time as the patient is reas­sured of the physician’s competence, if the physician is transparent about the process of treatment, and if the physi­cian appears motivated to attend to the patient’s best interests [22]. As a result, mutual participation became the third model of the doctor–patient relationship, in which the physician and patient shared power and responsibility for the patient’s health, granting patients greater control over their health. This model is particularly prevalent in chronic disease man­agement, in which shared decision-making and patient autonomy are important for successful outcomes [9, 17]. This patient-centered approach to the doctor–patient rela­tionship is more commonly seen in Western cultures [17].

Laughey etal. [21] provide an excellent outline for evalu­ating the resident’s performance during a patient simulation. In addition to critiquing the clinical aspects of the simulation encounter, the faculty should evaluate the learner on their ability to demonstrate empathy. Did the resident manifest good listening skills by maintaining eye contact and using body language that indicated interest? Did the resident allow the patient time to answer questions without interruption? Did the learner treat the patient as an individual and show interest in them as a human being? Perhaps the resident effectively responded to social cues or engaged in small talk to make the patient feel at ease. Did the resident acknowl­edge or overlook cues for empathy? Did they use words or phrases to indicate appreciation for the patient’s predica­ment? Was the resident effective in using nonverbal signals to encourage the patient [21]?

Not only are simulated patients useful for evaluating clin­ical and communication skills as well as measuring demon­stration of empathy, but the scenarios can be built to reect social issues or common challenges that physicians face daily and which affect the doctor–patient relationship. For example, scenarios might call for consideration of cultural diversity or they may require the learner to develop plans that work for the patient within the framework of a vulnerable population. One approach used in the Department of Medicine at SUNY Upstate Medical University employs a scenario that examines the effects of dehumanizing terms (in this case, “a non-compliant patient” scenario) and any bias that the learner may absorb during the simulation, inuenc­ing the doctor–patient relationship [37]. This provides a good lesson in avoiding terminology that may objectify or dehumanize a patient in their medical record or during a phy­sician’s sign-out to a colleague, as the terminology may cause bias that results in compromised medical care. This is particularly true for marginalized communities with impos­ing healthcare barriers [37].

Each genre can be highly effective, depending on its pur­pose. For example, utilizing visual arts in medical training can improve attention to detail and enhance the accuracy of observation [19], while triggering reection that reminds the learner of their original passion for medicine. The use of visual arts has been adopted in the curricula of several medi­cal schools. Most of these programs involve visits to art museums, during which students have opportunities to study a work of art, make observations about it, and discuss their observations with the curator, an art instructor, or a clinical faculty member. Some of these programs have the learners also create works of art based on a reection and write about the inspiration [8]. Residency programs have been less inclined to develop similar programs, although a small num­ber have also used visual arts experiences and found them effective. Learners have shown enhanced observational skills, a better ability to interpret facial expressions, as well as demonstrating improved empathy, tolerance of ambiguity, greater mindfulness, and emotional awareness [8]. While most of these efforts have involved educators with experi­ence in the ne arts, Kim describes a unique technological tool developed and used at Johns Hopkins that can be imple­mented even by those who have little or no training in art appreciation. This free tool, known as “Bedside Education in the Art of Medicine” (BEAM), is a web-based collection of images and poems linked thematically to patient situations. These images or poems can be accessed at the bedside or during rounds, and a discussion can be triggered by pub­lished prompts that may create greater understanding for the patient [19].

One of the most established methods for strengthening the doctor–patient relationship in medical training is the use of creative writing. The discipline of “narrative medicine” has become more prominent in undergraduate medical edu­cation, but its acceptance in residency training may be more limited even though its utility has been demonstrated. Like all arts-based curricula, narrative medicine is intended to promote greater understanding of the patient while improv­ing self-awareness and empathy, and strengthening the empathic bond between clinician and patient [7]. In a 2001 seminal manuscript exploring the virtues of narrative medi­cine, Rita Charon denes the movement as “medicine prac­ticed with the narrative competence to recognize, interpret, and be moved to action by the predicament of others” [6].

A comparable approach was used by an internal medicine training program, in which the residents completed social medicine consultations on patients with complex medical or social histories [4]. In this program, residents selected patients who were at high risk for hospitalization because of health or social issues. They would then interview the patients, taking in-depth life stories and social histories before writing third-person narratives retelling the patients’ stories. The residents would share these stories with the patients, make corrections if requested, and obtain consent to include these stories in the patients’ records. Residents would also create specic treatment plans for the patients based on their life stories. Participating residents expressed enthusiasm for these improved doctor–patient relationships [4].

Incorporating the Balint group into a residency program has value not only in allowing learners to share their stories and emotions, but it encourages their peers to pull from their own experiences and collaborate on solutions to enhance the doctor–patient relationship. At the same time, the partici­pants are also contributing to their own wellness. While the sessions are simplistic and easily integrated into didactic time, the discussions are structured, and the discussion leader must refrain from interjecting too frequently; it is therefore recommended (although not required) that the discussion leader have training in conducting the Balint group, which can be achieved through the American Balint Society [2].