I was the first person in my family to attend college, and so when I went to medical school, I had no one to tell me what to expect. What I did know, however, was the way some doctors treated people like my mother, a Vietnamese refugee. As a teenager, I often translated for her when she went to the doctor. So, for the first 6 months of medical school, I prayed every night before I went to bed. Not to pass my classes, although in retrospect I should have, because it took me five years to get through medical school. No, I prayed that I would not lose myself while undergoing the training process.

One of the goals of medical training is to create clinical detachment. Through that process, the hope is that the trained physician knows how to separate the facts from everything else with the purpose of making the correct diagnosis and choosing the right treatment. Or, to put it another way, physicians need to separate the subjective from the objective. One way that we are trained to do this is to write SOAP progress notes. As a medical student, I heard the phrase SOAP notes a few times before I knew what it stood for. Perhaps because English was not my first language, I thought that I was missing something important. Why were they telling me about soap? Was I supposed to wash my hands before I wrote my notes? Later, I found out that SOAP stands for Subjective, Objective, Assessment, and Plan. The subjective information, that came from the patientswhat they told us. The objective consisted of the physical exam and the laboratory data. And even though I now know that the physical exam is fairly subjective, nonetheless, the objective information is the object of desire. I am not kidding. Read a typical physician note now, and it usually consists of a few sentences from the patients perspective and pages upon pages of lab results.

About 15 years ago, I met Mrs. S. I was in my mid 30s, married, and had a 3-year old at home. Mrs. S. was in her mid 70s. Tall, thin, gray hair, with lots of wrinkles. A Latina, she spoke English well, but with an accent that I found charming. At first, I did the usual things. Worked with her on her blood pressure. Got her to do the cancer screenings. As a primary care physicians, the work gets easier and more rewarding once I know the patients chronic conditions and how they approached their health and healthcare. This usually occur after about three or four visits over several years. I suspect this timing is one of the reasons why primary care specialties have trouble attracting medical students and residents. The hardest part of the relationship comes early, when one has to meet the patients, learn their history, figure out their knowledge, beliefs, and preferences, and understand what best motivates them to take care of their health. By the time our trainees get close to the good part, they have to leave their patients.

Mrs. S was easy. She did what we discussed. She came every 3 to 4 months regularly without any major surprises. For a primary care physician, the best visit begins with no chief complaint! There was one catch though. Every visit, she talked about her son. She had two, but only talked about one. He had died of pancreatic cancer in his late 40s. Mrs. S thought that he was misdiagnosed and blamed his doctor for not listening, for not picking up on the signs, for not doing the tests. It was hard for me to hear this without thinking that she was criticizing medicine in general, and me in particular. At first, I wanted to defend the doctor. Pancreatic cancer is hard to detect early, and often it did not matter anyway. Perhaps I also wanted to defend myself, because a similar case happened to me, and the patients wife never forgave me.

But then I would think about my own son. So, I said nothing except that I was sorry. Mrs. S would go on for about 5 minutes, and then we would say good-bye until the next time. The first few times, I did not write down in the note what she said about her son. Eventually, in my objective assessment, I wrote that perhaps her grieving had gone on too long, that perhaps I should think about her mood and the possibility of depression. At the following visit, I asked her about her mood. Whether she ever thought about anything else besides her son. That I was worried, that she was staying at home alone and not going out. She looked at me as if I were stupid. What do I need to go out for? I am happy, she said. I said, you dont seem like you are. Oh, I am, she said. Especially when I sit in my living room and play my operas on the stereo.

I was taken aback. Opera? It was not something I associated with her. I did not know much about operas. Unlike in America, where opera seemed to be a taste of the upper class, only hicks listened to old-style Vietnamese operas where I came from. And in America, the only operas I ever saw were soap operas on TV. The Young and the Restless. General Hospital.

Over the course of several years, Mrs. S told me about opera plots, or particular arias that she really liked. By then, I had 3 kids all under 8. I barely had time to think, much less listen to music. I wish that I had written these conversations in my notes, and it does not matter if they were in the subjective or objective sections. Because I would like to go back and listen to the arias that she liked.

This story ends more or less like all medical stories end. I received a call from the admitting resident one winter. Mrs. S was admitted for pneumonia. During the evaluation, he found she had widespread lung cancer. I thought, what did I miss? She had no symptoms for me to evaluate her lungs. No reason to screen for lung cancer. Still filled with doubts and regrets, I went to see her in the ICU. She was intubated. Definitely not what she ever wanted. She had said to me that death was nothing to her. She said Im not afraid of it. I will get to see my son.

I set up a meeting with her remaining son. I knew it was going to be hard, it always was when it was someones mother. I explained to him the clinical situation. And told him that Mrs. S said she never wanted to be on machines. And he agreed, that was what she told him too.

I thought, this is going rather well. He asked me, what should we do? And I wanted to say, based on what I know about your mother, she would want us to turn off the machine. And as I was saying that, I had a vision. Of Mrs. S. sitting on a sofa. An aria was playing, I couldnt tell which one. Everything was dark, except for her wrinkled face. And what came out of my mouth were the words that I wanted to say, but I also heard crying. It came from me. Then I had an out of body experience. I was standing there watching myself and thinking, this is rather unprofessional. What must the son think, when his mothers doctor is bawling? How does he have any confidence in you? Does this crying mean that your prayers not to lose yourself were fulfilled or a sign that you have failed to be a good doctor?

I think about Mrs. S. Sometimes when I chart, I listen to an aria. Even though I dont understand the words, the music makes me kinder when I write my assessment. And whenever I write or read SOAP notes or go to San Francisco General Hospital, a part of my brain thinks General Hospital is a SOAP opera. I no longer think that the objective is the objective. For me, the subjective is the objective. The goal is to get the patients story. Oh, and one more thing I am thankful for that Mrs. S gave me. That it is o.k. to cry, even if you are a doctor. After all, tears are often a part of operas, soap and otherwise.