Instituting “Affective Time Outs” at Oregon Health & Science University

By Larissa Guran

This year, Oregon Health & Science University rolled out a new medical school curriculum for incoming first year students. “Your MD” is an innovative program, with a completely new schedule and focus; it is replacing the current curriculum, which is retiring after it serves my classmates and me. This is an exciting time to be a student at OHSU, but one of the drawbacks of this transition year is the disconnect between first- and second-year students. Our school has a strong tradition of previous classes supporting and guiding new medical students through the overwhelming experience of the first year. From our Big/Little Sib program to the Sage Books of wisdom and advice passed down to the next class, we’ve worked hard as a class to stay connected to and supportive of the new students. One way we have done it is through an elective called “Leadership, Education, and Structural Competency.”

Through this class, a group of MS2s including myself are learning about structural competency and how to lead discussions, write lesson plans, and build collaborative learning experiences. After months of training and practice, we are leading several small-group sessions to discuss structural competency. This emerging concept in medical education builds medical student skills in dealing with patients’ social determinants of health. Social determinants (like socioeconomic status, built environment, education, and social support) are often considered a “can of worms” by many medical students. In this class, we learned that contextualizing care relative to these social determinants can significantly improve patient outcomes. Structural competency is a necessary skill for all medical students to develop so that we can effectively contextualize our future patients’ care.

In order to contextualize care, it is important to examine our own biases and presumptions. One of our initial lessons with the MS1s introduced the concept of unconscious bias. This self-examination is necessary for recognizing presumptions, opinions, and emotions we carry over into our relationships with patients, biases that influence every member of society.

Each session planned by the MS2s includes a clinical pearl that ties the abstract discussion of structural competency to the patient encounter. For our session on unconscious bias, we developed a unique clinical pearl that takes only a few seconds and has the potential to smooth potentially difficult interactions before they begin. We call it the “Affective Time Out.” In its entirety, our clinical pearl stated:

Before you enter an exam room, take a moment to reflect on the details of the case and any emotional reaction you might be having to it, previous interactions with the patient, or any threads to your own life that may connect to this case.

Awareness of emotional reactions helps maintain professional composure and ensures that you are offering the best care possible.

Modeled after surgical time outs, the Affective Time Out is a personal evaluation of our own emotional state prior to beginning a patient visit. It gives us a chance to acknowledge our emotional state or feelings about the encounter we are about to enter.

So much of human interaction is non-verbal. Impatience, frustration, or disappointment need not be spoken to be expressed; patients can read these non-verbal cues. Our emotional state may not even be related to the encounter before us, but it can derail the encounter and prevent us from forming connections with our patients. Because we are only human, we will surely at times fall prey to the impulse to judge or second-guess our patients’ choices or behavior. Patients will feel that judgment. Even worse, our emotional reaction to patients may keep us from providing the best care. If we are anxious to finish an encounter because of our own discomfort, we might miss something. If we make assumptions about what patients will or won’t do, we run the risk of limiting their therapeutic options before they have a chance to consider them.

The Affective Time Out is a brief check-in that enables a clinician to bring her awareness to her mental state. With awareness, she brings power and control. We won’t be able to stop reacting to our patients on an emotional level — and we shouldn’t try to stop. Our emotions allow connection, empathy, humor, and kindness to fill our therapeutic relationships. These bright sides of humanity are as important to our role as healers as our diagnostic reasoning. Awareness that sometimes we will have negative emotional reactions to our jobs, even our patients, can help us gain control over these moments and minimize their influence in our clinical relationships. Awareness of the negative makes space for positive connection, and it only takes a moment.

LGuranLarissa Guran, MPH, is an MD Candidate in the Class of 2017 at Oregon Health & Science University. She can be reached at