In response to Dr. De Marco, I certainly agree that understanding achieved through self-reflection underlies the physician who is virtuous, caring, and beneficent. It is my belief that successfully educating physicians in the human side of medicine requires a combination of activities, including self-reflection, alongside acquiring knowledge and skills, particularly in patient–physician communication. This was the purpose of the reflective component of the "Patient-Doctor" course at Harvard Medical School. However, the question arises of how much of one's personal beliefs, religious faith, and preferences can be included officially in a medical school curriculum. It seemed to those of us who designed the "Patient-Doctor" course at Harvard that the reflective component in the curriculum ought to focus on professional interactions. There should be room for electives and voluntary endeavors outside the required curriculum for students who wish to go further in their process of self-reflection. I think that this would be all to the good and hope that it will occur if more attention is paid to the moral and humanistic aspects of medical care.

I agree with the sentiment of Dr. Paulsen's letter but am saddened by the specter of loneliness he raises. Yes, another aspect of self-reflection is sharing some of the burdens of becoming a physician with trusted colleagues, all of whom have similar burdens. The transition from student to fully mature physician has been lonely for many and should not be so.