Narrative Medicine Monday: What You Don’t Know

Today’s Narrative Medicine Monday is a bit different in that I’m posting an excerpt from a radio show rather than a sample of poetry or prose. Stories of medicine, health and illness are found in all types of art, including written form, oral stories, music and visual mediums.

This American Life is a prolific radio show that covers widely varied topics in a heartfelt, honest and often humorous way. Each show has a theme and this past week’s episode was titled “In Defense of Ignorance.” In the first act, “What You Don’t Know,” writer and producer Lulu Wang tells her family story of deciding to keep test results of the most dire news from her grandmother. Her family’s Chinese heritage influences the stance they take in keeping her grandmother in the dark about her terminal diagnosis. Wang, raised mostly in America and very close to her grandmother, doesn’t agree with this position but, at her family’s request, complies. 

Wang’s family story brings up issues of bioethics, cultural norms and how bad news affects health and illness. How might cultural norms influence the very standards of bioethics in a particular case? Do you agree with the family decision to keep the grandmother in the dark about her terminal diagnosis? Why or why not? Do you think her grandmother actually knew all along? Spoiler alert: Do you think not telling Wang’s grandmother contributed to her surviving despite her dire diagnosis? Wang mentions the Chinese belief of the connection between the mind and body. What are your thoughts on this connection?

Writing Prompt: Think about your own family dynamics and cultural norms. How do you think this has shaped your own views on health and illness? Can you think of a time this construct specifically influenced your medical decision making? Alternatively, think about the connection between the mind and body. Do you think one influences the other? How? If you had a terminal diagnosis, would you want to know? Why or why not? Write for ten minutes. 

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Narrative Medicine Monday: Reprieve

In his poem “Reprieve,” Jeffrey Harrison writes about the several months following a cancerous brain tumor removal. Everyone is able to take a breath while the patient resumes his daily activities. Although it seemed “a miracle almost,” they “all still wondered how long it would last.” The narrator questions if this time period felt like an “afterlife” to the patient. I like how the narrator lists the simple daily tasks the patient was able to resume, giving us a glimpse into his life and what he had been missing because his illness. 

Have you or a loved one had a serious illness that, for a time, seemed resolved? How did you feel when the treatment worked? If the illness recurred, how did you look back on that time period?

Writing prompt: Think about a time when you, a patient or a loved one was well following a serious illness. Were you able to trust in that period of wellness? Were you always wondering if the illness might come back? If so, how did that undercurrent of worry limit you? How did it feel to grow strong again or resume your daily activities? Write for 10 minutes. 

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Narrative Medicine Monday: County Hospital Residents

Abby Caplin’s “County Hospital Residents” profiles immigrant physicians, re-training in an American residency program. Caplin’s poem begins with the more general–where a physician is from–and contracts into the more intimate details, the sequence of events that brought this person into this profession far from home.

Writing Prompt: Have you encountered an immigrant physician as a patient or through your own medical training? What was their story? Imagine leaving your home country to practice medicine and live your life elsewhere. What would be the greatest challenge? What does the diversity and experience of immigrant physicians bring to our medical community? Write for 10 minutes.

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Narrative Medicine Monday: Dinosaurs

Ophthalmologist Maria Basile writes of the evolution of surgery in “Dinosaurs“, part of the Poetry and Medicine column in JAMA. Her poem reflects on innovations in how surgery is performed and is a commentary on the constant churn of medical reinvention. 

Have you or a loved one personally benefited from a recent medical innovation? Can you think of something important that might have been lost through adopting a medical advancement? Also consider the challenges posed by some new medical procedures and breakthroughs. When kidney dialysis first emerged as an option for treatment of kidney failure and there was very limited availability. Decisions needed to be made about who would receive this treatment. Sometimes a medical innovation raises unforeseen and difficult ethical challenges. 

Writing Prompt: Think back to when you first started medical training. How has medicine changed since that time? What were considered the greatest innovations or bioethics questions of that time? What are they now? Alternatively, think about what was considered a medical marvel when you were a child. How is that innovation viewed today? Write for 10 minutes. 

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Narrative Medicine Monday: When Patients Mentor Doctors

When Patients Mentor Doctors: The Story Of One Vital Bond” tells of physician Aroonsiri Sangarlangkarn’s longitudinal relationship with a patient she comes to call a friend. The bond between them affects her views on what can be gained through understanding patients on a more personal level.

Sangarlangkarn first meets Roger as part of a medical school program that matches up aspiring physicians with geriatric patients who provide mentorship on medicine from a patient perspective. She then encounters him again after she has finished her training and he is hospitalized under her care. She reflects on the value of her deep knowledge of his personality and history.

I liked reading about Sangarlangkarn’s own lengthy description, written years prior as a medical student, of the patient’s social history. It included intimate details such as Roger’s parents’ names, his boyhood aspirations and his favorite board game. When I was a medical student I remember taking a very detailed history of a woman who was in the hospital for treatment of her malignant tumors. I spent over an hour with her, just chatting with her about her history. No physical exam, no review of medications. The final typed up document I turned into my advisor was over two pages long. Now, as a busy primary care physician, I, like Sangarlangkarn, can see how the emphasis on efficiency causes time constraint that makes it difficult to have meaningful patient-physician conversation that could contribute to helpful personal knowledge. Sangarlangkarn laments that “our interactions with patients have become so regimented and one-dimensional that we no longer get to know the multifaceted person outside the hospital.”

What do you think about Sangarlangkarn’s suggestion regarding the value of patient home visits? This is often done for patients in hospice care or who are unable to physically get to a clinic. Home visits because of the time they require seem much more costly to the system but Sangarlangkarn argues that the value – the ability to get to know the patient on a different level – provides invaluable information. She writes: “To effectively provide care for someone, it’s important to learn who they are, what they eat, how they breathe.” She, in fact, due to her detailed knowledge of the patient, is the only one who eventually can get him the end of life care and support he needs.

Writing Prompt: Think about a time you visited an ill person at home, whether that be an apartment, house or adult family home. Describe what you saw, what you smelled, what you talked about, how you felt. What do you think can be gained by entering into a person’s living space? Alternatively, consider a patient you’ve known for years, maybe decades. What do you know about that patient because of a longitudinal relationship that might be of benefit to you if you had to deliver bad news or discuss different treatment options or medications? Write for 10 minutes.

 

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Narrative Medicine Monday: Things My Daughter Lost In Hospitals

Toni L. Wilkes reveals her daughter’s illness journey through her poem “Things My Daugther Lost In Hospitals” in the journal The Healing Muse. I’m struck by how she alternates between the physical, tangible losses (“a pear-shaped gallbladder”) and the more unexpected costs (“her husband’s patience”). As a reader, I almost miss the surprising and heart wrenching losses, placed innocuously among the more conventional ones. I’m compelled to return to each line and deconstruct the poem, in search of these melancholy nuggets that reveal the true toll.

Writing Prompt: List all of the things you’ve lost or gained by being a medical provider. Alternatively, list all of the things you’ve lost or gained through an illness. Consider the concrete (i.e. money) and the more intangible (i.e. time). Write for 10 minutes. 

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Narrative Medicine Monday: Line of Beauty

Arlene Weiner writes of her post-surgical incision in “Line of Beauty,” a poem featured in the online narrative medicine journal Intima. The narrator’s physicians describe her incision site as “beautiful.” She notes the young surgeon admired her incision site “with feeling” but then left her undressed. The reader gets the impression he is appreciating his handiwork but forgetting about the patient it belongs to. Have you ever felt that way about an interaction with a medical provider?

I like how Weiner contrasts this surgery, an “insertion,” with her previous ones, including “a chunk of back punished for harboring promiscuous cells.”

Writing prompt: Think about the different words we use to describe medical procedures or ailments. How might a patient’s description differ from that of a medical provider? Does it matter what words are used? Have you ever had a doctor use a word that surprised you? Write for 10 minutes.

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Narrative Medicine Monday: Going Solo

Nurse and writer Amanda Anderson describes the final moments of caring for a patient in the ICU in “Going Solo“.

Anderson opens the piece noting that she decides to scrub the patient’s teeth clean. Why do you think she’s determined to complete this simple act?

The author comments that this passing feels different than others because she doesn’t also have the patient’s family to nurse through the process. Her actions are per protocol, “governed only by a set of instructions:
1.  Administer pain dose once, prior to extubation.
2.  Extubate patient.
3.  Administer pain dose every three minutes for respiratory rate greater than twenty,
or obvious signs of pain, as needed.
4.  Notify house staff at time of asystole.”

How do you feel when you read through the protocol that Anderson follows? How do you think she feels and how does she convey that through her writing?

I appreciate Anderson’s candidness in immersing us in her thought process. She plays jazz for him, then realizes, what if he hates jazz? As medical providers, we only get a snippet of a patient’s life. If you’re a medical provider, have you ever wondered about a specific patient’s life outside of the hospital? How could that information inform their care? As a patient, what do you wish your medical providers knew about who you are?

Writing prompt: As a medical provider, think about a protocol you follow, a procedure or list of instructions you adhere to in a certain situation to provide care. List the steps. Now consider an unwritten protocol, such as a nurse in caring for family members throughout their loved one’s death in an ICU. List the steps. How do they compare? Alternatively, think about an encounter you’ve had in the medical world: a ten minute doctor’s office visit, visiting a friend who is hospitalized, getting or giving an immunization. Imagine the broader life of the person who was giving or getting that medical care. Consider their life narrative. Write for 10 minutes.

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Narrative Medicine Monday: The Heroism of Incremental Care

As a primary care physician myself, I found Atul Gawande’s new article “The Heroism of Incremental Care” encouraging and empowering. The New Yorker piece highlights the importance of longitudinal care between a patient and their primary care provider.

When Gawande visits a headache clinic in Massachusetts, the physician there tells him she starts by listening to the patient: “You ask them to tell the story of their headache and then you stay very quiet for a long time.” What have you found is the most important component of a physician-patient encounter? If you are a provider, do you feel you’re always able to listen to the patient’s full story? If you’re a patient, do you feel listened to when you see your doctor?

When Gawande visits the primary care clinic in Boston, he’s told the reason primary care is important to bettering patient health is due to the “relationship”. Do you agree? Have you had a relationship with a primary care provider that has invariably improved your health over the years? If you are a primary care provider, has this been your experience with patients?

Writing Prompt: Gawande writes of the clinic he visits: “At any given moment, someone there might be suturing a laceration, lancing an abscess, aspirating a gouty joint, biopsying a suspicious skin lesion, managing a bipolar-disorder crisis, assessing a geriatric patient who had taken a fall, placing an intrauterine contraceptive device, or stabilizing a patient who’d had an asthma attack.” Think about the last time you saw your primary care provider. Write about that visit in the present tense, then project a decade or two into the future. Imagine how that visit, and many others like it, might have made a difference to your health decades from now. Write for 10 minutes.

 

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Narrative Medicine Monday: Monday Morning

Audrey Shafer, an anesthesiologist and mother, writes of medicine and motherhood in her mesmerizing poem “Monday Morning“. Highlighting two simple moments at home and at work, Shafer explores the contrast and commonalities between motherhood and her work in medicine. No wonder I love this piece!

What do you think of the juxtaposition of the narrator’s young son and the cool sterile environment of the operating room? The OR is a glaringly lit, predictably ordered, pristine place. As a mother, I could picture the incredible contrast of her preschooler son’s soft body clutching his favorite blanket in the dim early morning. A home with young children is often unpredictable, littered and intimate.

Shafer comments that the one who is exposed and vulnerable in this poem is the author herself. Would you agree? What do you learn about her as a person and as a working mother by reading this poem?

Writing Prompt: Think of a moment at work that reminded you of or seemed in direct contrast to a moment at home. How does your personal life inform your work and vice versa? Write for 10 minutes.

 

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