In attempting to explain how physicians in my field of geriatric medicine think through clinical cases, I have come to realize over the course of my training that, although the prevailing schemas of clinical reasoning are often presented as algorithmic, the interval between observation and a formal diagnosis feels less like a straightforward thought process and more like a pause in interpretation in which meaning accumulates. Though this suspension in thought is alluded to by physicians as they form clinical impressions, it seems largely absent from medical education discourse. By describing this pause explicitly, as part of how a patient’s story and symptoms align, I have become better able to grapple with the uncertainty inherent in medicine. Naming this has helped me accept the interval the way a novelist might accept a story in progress, guided as much by instinct as by the rules of grammar.
As someone who pursued a fellowship caring for older adults, I most often encounter uncertainty, and this diagnostic pause, when I am on the geriatric medicine consult service. Here, I help support hospitalized patients by evaluating for a range of geriatric syndromes. A common question clinicians often ask geriatricians is whether a patient admitted to their inpatient service might have undiagnosed cognitive impairment. Each time a primary team reaches out, my task is to construct my own understanding of the admission, merging information from prior imaging, laboratory results, past hospitalizations and specialist visits with my interviews of patients and, often, their caregivers. In shifting from my computer screen to my scribbled notes, I again find myself returning to this pause, the moment when the dots begin to connect. Soon, what was a constellation of disparate concerns starts to take on a clear narrative. These momentary hesitations pull my assessments forward, rendering a patient’s answers into a format I can understand, digest, and retell.
I now tend to frame that movement from clinical data to newly constructed meaning as a translation from one language to another. In a 2024 interview from The Paris Review, the poet Anne Carson articulated a similar idea, using the term “hesitation” as a step in the practice of translation when teaching ancient Greek. She remarked, “Looking up things in a lexicon is a process that takes time. And it has an interval in it of something like reverie, something like suspended thought […] It’s very valuable, because things happen in your thinking and in your feeling about the words in that interval.” Later in the interview, she laments that with the rise of dictionaries embedded in word processing software, this period of hesitation was lost, and with that, new insights as well (Dwyer). Reflecting on my own assessments within the ever-shortening time constraints of contemporary medicine, I, too, can sense when there is a loss of Carson’s interval. Whether faced with a lengthy list of hospitalized patients or attempting to give each clinic visit its due attention, the pressure to simply “get through” clinical evaluations has become a defining feature of patient care. Pausing, even briefly, allows connections to build rather than relying solely on heuristics in a rush from admission to discharge.
To guide students and trainees within this hectic setting, medical education has designed numerous methods for synthesizing clinical information in an effort to give shape to that interval Carson describes. In geriatric medicine, for example, the 5Ms Framework breaks down the evaluation of a complex older adult into a cognitive map with five domains: Mind (cognition, mood, and behavioral changes), Mobility (gait, balance, and fall history), Medications (with a focus on adverse side effects), Multicomplexity (the presence of multiple, overlapping chronic conditions), and What “Matters Most” (a patient’s own goals, values, and preferences for their care). Though helpful for orienting oneself to a complex patient, even a well-taught framework like this one rarely accounts for the phenomenology of the process: what happens internally as one organizes those data points into something that feels more like a lifelike portrait than a checklist of observed features.
Particularly in the hospital setting, medical training also teaches one to parse abnormalities into “problem lists,” each bullet point linked to the reason for a patient’s hospital admission. In a given medical or surgical team’s daily progress notes, the list of tasks under a problem list is largely predictable, such as monitoring potassium and magnesium levels; following up with consultants from cardiology, psychiatry, and nephrology; deciding whether to continue antibiotics; and waiting for imaging reports to return. These are necessary. But the transition from routinized task to thoughtful inquiry requires a break in momentum. It is in that brief stillness where questions about what matters most to each patient surface, a site where the realities of illness meet the goals of care.
In doing so, this pause affords the time for mapping a patient’s values. While such questions often acquire a valence related to end-of-life planning and decision-making, primarily because they are introduced in moments of clinical decline, understanding a patient’s value system is broader than prognostic discussions. To explore what matters most is to unearth and even co-create how healthcare fits into a patient’s idea of a life well lived and a life worth living. These values-directed questions may include, “What are you hoping for?”, “What are you most worried about?”, “What makes your life meaningful?”, and “At what point would remaining alive be unacceptable?”(Nakagawa et al.; Childers et al.) Although the conversations that follow may seem like obvious ones that one would hope would be explored proactively, the structural demands of the workday limit the time needed for them to unfold.
Only by appreciating that interval in thought am I able to give myself the space for translation, the space to step back and see how a patient’s goals and values come into focus. As Carson elaborates, to hesitate is to wait and to remain open to new meaning made legible. Even when patients and I speak the same language, reading facial expressions, interpreting tone, and layering quantitative data onto a clinical history all remain components of the translation process. To translate is to accept that there is no seamless conversion from one phoneme to the next, and thus, to pause is to allow meaning to gather as it moves from one form into another, partially transformed, partially maintained. As evidenced by clinical interviews, this can occur between languages, within a single language, from text to image, or from image to sound.
And sometimes, rather than moving from language to language, I have found that the translational interval more closely resembles the act of analyzing a photograph or painting in a museum. On a previous tour at The Metropolitan Museum of Art, I noticed how the habits of attention I bring to art mirror those I rely on in clinical assessment, particularly as I stood before Salvador Dalí’s Madonna (1958). At first glance, the painting appeared to be an enlarged ear set within a frame, with repeating gray stipples of paint creating a near-pointillist effect. However, on closer inspection, the shape of the ear remained, but a female figure materialized at its center. Swirls of green and pink surrounded her until, eventually, a child became visible as well. The painting figures itself as a surrealist representation of the Virgin Mary and Child, a refracted version of Christian iconography. To perceive its layered meaning, I had to repeatedly shift focus between foreground and background.
Next to the painting itself, the museum label describes the work when viewed up close as “an abstract work composed of countless particle-like gray and pink dots.” Each problematized symptom or laboratory abnormality, like each painted dot, demands attention, yet it is the gap in thought as one shifts vantage points that allows deeper, values-oriented questions to emerge. In my medical training, these answers only came into being once I resisted the well-worn patterns of thinking that shape how clinicians are taught to assess a patient’s presentation. These ingrained roadmaps direct attention towards the immediate: the reason for a hospital admission, the reason why a certain set of symptoms worsened on a specific day, the reason today why a patient may need support from a geriatrician. Yet, as with Dalí’s painting, focusing solely on the paint splotches risks missing the sacred image diffused throughout.
The museum gallery encouraged a reflective posture I wished I could access as easily in the hospital setting. Standing before the work while trying to fix the moment in memory, pausing with an almost photographic gaze, reminded me of how the photographer Sally Mann describes her own creative process, in a register that extends the insights of Anne Carson. While Carson centers on what is revealed, or lost, in that interval of thought, Mann’s photography captures how pausing alters perception by disrupting linear thinking. In her memoir, she describes how her focus sharpens, her awareness nearly palpable, when she prepares to photograph a landscape, writing that “time slows down, becomes ecstatic” (212). Later, drawing on Poetics of Music by Igor Stravinsky, she remarks how her mind detects “that transcendent dimension of revelation and elation that gleefully eludes Stravinsky’s quantifiable time” as she waits for the right image to come into view (226). She returns to this state near the end of her documentary, What Remains: The Life and Work of Sally Mann (2005), as she reflects on the experience of taking a self-portrait, noting, “Your mind goes and brings bits and pieces of your past [and] your present and snatches a conversation back to you and they all weave together like some kind of peculiar tapestry that’s faded in different places” (What Remains 01:16:40-01:17:20).
Taken together, Mann’s observations show how this sense of ecstatic time textures a moment, her memories braiding themselves into a sensate encounter. While Carson’s “hesitation” captures the heightened awareness that occurs before meaning is assigned to a signifier, Mann’s account of her creative process articulates what follows that interval: the intuitive feeling of arrival, the culmination of her artistic vision. The delay that precedes actualization is often described as mysterious, even to artists, and that mystery has a clinical parallel. Beyond the cognitive work of deductive reasoning, to arrive at a diagnosis can feel as though it comes out of a stillness rather than a direct line of reasoning. Mann’s reflections echo this kind of moment my colleagues and I encounter when discussing a challenging clinical question. In geriatric medicine, diagnosis is not solely the identification of disease, but a wider impression of a patient situated within their values, physical abilities, and degree of illness. Like Mann waiting within that interval until her ideal photograph reaches her lens, or art historians grasping the larger form in Dalí’s Madonna, geriatricians often arrive at understanding only after lingering in that pause.
As I care for older adults, I continue to recognize these moments in my own practice. Time slows, warps even, when my initial impression contained in a consult note gains form and depth, eventually becoming a diagnosis that meets established clinical criteria. In that lull, I watch as brushstrokes appear on a canvas, and what began as scattered details settles into a distinct profile. As Dalí’s Madonna illustrates, seemingly disconnected details can deepen one’s clinical impression with each repetition of gazing and stepping back. Though the desire for meaning propels the narrative line, it is this pause, Carson’s hesitation, that reveals what might have been lost in translation.
Works Cited
Childers, Julie W., et al. “REMAP: A Framework for Goals of Care Conversations.” Journal of Oncology Practice, vol. 13, no. 10, 2017, pp. e844–e850. https://doi.org/10.1200/JOP.2016.018796.
Dalí, Salvador. Madonna. 1958, The Metropolitan Museum of Art, https://www.metmuseum.org/art/collection/search/484894.
Dwyer, Kate. “Throwing Yourself Into the Dark: A Conversation with Anne Carson.” The Paris Review, 17 Apr. 2024, https://www.theparisreview.org/blog/2024/04/17/throwing-yourself-into-the-dark-a-conversation-with-anne-carson.
Mann, Sally. Hold Still: A Memoir with Photographs. Little, Brown and Company, 2015.
Nakagawa, Shunichi, et al. “Patient Values: Three Important Questions—Tell Me More? Why? What Else?” BMJ Supportive & Palliative Care, 2023, https://doi.org/10.1136/spcare-2023-004302.
What Remains: The Life and Work of Sally Mann. Directed by Steven Cantor, HBO Documentary Films, 2006.
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Illustration by Julien Tromeur. Unsplash.