Narrative Medicine Monday: The X-ray Waiting Room in the Hospital

“The X-Ray Waiting Room in the Hospital” by author Randall Jarrell thrusts us into his “big shoes and wrinkled socks,” and one of those “much-laundered smocks” that all the patients wear. Jarrell laments “[t]hese new, plain, mean / Days of pain and care…” and that “routine / Misery has made us into cases.” He describes the “machine” that each smocked patient suffers in, and the reader gets the sense that Jarrell is referring to more than just the mechanics of the x-ray, but also the greater “machine” that is medicine.

Jarrell was an American poet and critic who lived in the mid 20th century but his commentary on the patient’s experience of modern medicine still rings true. Jarrell wants each “nurse and doctor who goes by” to acknowledge him and each patient as an individual, but instead finds that “we are indistinguishable.”

Jarrell concludes that instead of trying to “make friends” with the medical professionals and get them to recognize his individuality, “It is better to lie upon a table, / A dye in my spine.”

Writing Prompt: As a patient, have you ever felt “indistinguishable” from other patients to your medical provider? If you’re a medical professional, do you agree with Jarrell’s assertion that “this routine / Misery has made [patients] into cases?” Can you think of a time when a patient has become merely a case, to you or a colleague? What are the consequences of this, to both the patient and they physician? How can we help doctors and nurses to see patients as individuals again? Write for 10 minutes.

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Narrative Medicine Monday: Brilliance

Poet Mark Doty’s “Brilliance” shows a dying man changing his perspective near the end of life. In Doty’s poem, the man has “attended to everything, / said goodbye to his parents, / paid off his credit card.” He gives away his pets, finds the risk of owning too great, realizes that he “can’t have anything.” When someone suggests he get a bowl of goldfish, he replies “he doesn’t want to start / with anything….” For just a moment, the man allows himself to imagine the goldfish he might like: “hot jewel tones, / gold lacquer.” The fantasy, though, is fleeting because “I can’t love / anything I can’t finish.” Eventually he recants that decision, saying “Yes to the bowl of goldfish. / Meaning: let me go, if I have to, / in brilliance.”

Writing Prompt: Have you ever been at a place in your life when you didn’t want to start with anything new? What prompted that feeling? If you’re a medical provider, think of a time you’ve seen a shifting perspective in patients near the end of life. Write for 10 minutes.

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Narrative Medicine Monday: Reasons for Admission

I opened up a nondescript brown package last week to discover Bellevue Literary Review‘s latest issue, showcasing a beautiful new redesign.

In this 35th issue, Gaetan Sgro’s poem “Reasons for Admission” reveals the complexities surrounding modern day hospitalizations. Sgro notes that often the reasons are contradictory: “Having just gotten insurance. Never having had insurance…. Because you are terrified of dying alone. Because you are terrified of living alone.” Sgro is clearly attune to the many and varied kinds of hospital admissions, including the seemingly non-medical. I like Sgro’s play on words that shows two hospitalization realities: “Because of a broken system. A positive review of systems.”

Writing Prompt: This poem is part of Bellevue Literary Review‘s “Dis/Placement” issue. Why do you think this poem fits this theme? If you work in a hospital, list the reasons, obvious or more subtle, each of your current patients was admitted. Alternatively, think of a patient who has been admitted for one of the reasons Sgro lists in his poem. What was their story? Write for 10 minutes.

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Narrative Medicine Monday: How Storytelling Can Help Young Doctors Become More Resilient

Physician and author Dr. Jessica Zitter shows “How Storytelling Can Help Young Doctors Become More Resilient” in her recent essay in the Harvard Business Review. We know that this issue is vital to increasingly stretched and stressed medical providers, the consequences of which are discussed in previous Narrative Medicine Monday posts here and here. I wrote a short piece in Pulse for their “Stress and Burnout” issue that outlines a typical day for a modern primary care physician and have also studied and taught narrative medicine as a tool to better care for our patients and ourselves. Zitter has a unique perspective on the particular challenges for physicians and patients in end of life care, given she is board certified in both critical care and palliative care medicine.

Zitter addresses this issue through a “new program which uses storytelling to help young doctors reflect on how they handle the emotional and psychological toll of caring for suffering patients.” She opens up to a group of new physicians about running the code of a young woman in the ICU, the resistance to letting a patient go, even when nothing remains other than suffering: “We are expected to be brave, confident, and above all, to never give up.  And all the more so in particular cases, such as when a patient is young, previously healthy, or has a condition that appears reversible on admission. And in cases when our well-intended but risky interventions might have actually made things worse, it is almost impossible to let go.”

When the experienced Zitter suggests that they instead institute pain management and sedation rather than attempt resuscitation the next time her heart stops, the physicians-in-training bristle. She questions a culture that promotes doing everything, including “this technique, that intervention, a whole host of options that would never have saved this woman.” Zitter admits she gives in to the other physicians, decides to fight “to the end, the way real heroes do.” The result is tragic. “The patient died a terrible death.”

Zitter reflects on this experience and shares it in the hope that it will help other young physicians who will certainly encounter the same, given that our culture and medical training makes it so “we often feel unable to question or diverge from scripted approaches — ones which may actually cause more suffering than benefit.”

To combat this, Zitter looks to storytelling, asserting that “[d]ata show that the use of stories to process the challenging experience of being a doctor increases empathy, enhances wellness and resilience, and promotes a more humanistic health care culture.” After Zitter shares her story with the group, others begin opening up about their own experiences and a “genuine conversation proceeded, one which addressed the emotional pitfalls and psychological challenges of this work.”

Zitter is also part of a 2016 Netflix documentary called “Extremis.” This short film takes a hard look at the grueling decisions patients’ families, and the physicians who inform them, make near the end of life in the ICU. In it, you can appreciate the need to “provide safe spaces for healthcare professionals to reflect on and process their own suffering. Then we will be fully available to do the hard work of patient-centered decision making in the moments when it is really needed — at the bedside of a dying patient.”

Writing Prompt:  Have you had to help make decisions for a patient who is critically ill in the ICU? What issues came up? How was your interaction with the medical team that cared for your loved one? Alternatively, consider watching the short documentary “Extremis” and write about a moment that struck you or perhaps changed your way of thinking about end of life care. If you’re a medical professional, think of a time you witnessed an end of life situation when the patient experienced more suffering than was necessary. Do you agree that our culture contributes to performing “risky interventions” that “might have actually made things worse,” because we insist on fighting “to the end, the way real heroes do?” How do you think sharing such stories might promote wellness? Consider writing about a challenging situation from the perspective of the attending doctor, the resident, the patient, the nurse, the family member. Write for 10 minutes.

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Narrative Medicine Monday: Caring for Ms. L

Dr. Audrey Provenzano explores the difficulties in treating opioid use disorder in The New England Journal of Medicine‘s “Caring for Ms. L.” Provenzano has already developed rapport with Ms. L when one day the patient admits to her doctor that she had “taken a few of the oxycodone pills prescribed for her husband… [a]nd like a swimmer pulled into the undertow, she was dragged back into the cold, dark brine of addiction.” Ms. L is eager to try a treatment called buprenorphine but Provenzano doesn’t have the special license or training to prescribe the medication. Ms. L expresses disappointment at needing to establish care with a different provider. She trusts her doctor and doesn’t want to tell anyone else about her addiction.

Provenzano confesses that “the reason I didn’t have a waiver to prescribe buprenorphine was that I didn’t want one…. Every Friday I left the office utterly depleted, devoid of the energy or motivation it would take to spend a weekend clicking through the required online training.” She admits that more than anything, she avoids the training because she “did not want to deal with patients who needed it.” Provenzano had witnessed the toll addiction can take on a patient’s relationships and life and “[a]lready overwhelmed, I did not want to take on patients with needs that I did not know how to meet.”

Most primary care physicians can relate to Provenzano. There is already an alarming amount of burnout that exists among today’s physicians; the thought of adding another degree of complexity seems untenable to most, especially if it seems the therapeutic need is insurmountable.

Provenzano notes, though, that when Ms. L returns to her for diabetes treatment after seeing a colleague for the buprenorphine “a space had opened between us.” Ms. L doesn’t return for follow up and it is a year later that Provenzano learns that Ms. L died of an overdose. Provenzano experiences a “profound sadness” for Ms. L’s family, though “it was the shame that kept me awake.” She can’t help thinking that, given the strong patient-physician relationship they had previously developed, if Provenzano had treated Ms. L herself things might have turned out differently.

Provenzano goes on to get buprenorphine training and experiences both the therapeutic and complex social aspects of managing patients with opioid use disorder. She advocates for moving beyond just the training needed to prescribe medications for this chronic disease, but also urges us to “recognize, name, and talk about the social issues that must be addressed” and establish “team-based behavioral health and social work resources.”

Provenzano eventually finds treating patients with opioid use disorder “the most meaningful part of my practice.” She ultimately experiences great satisfaction in providing some normalcy to patients who are “roiled by overdose and estrangement.” Have you experienced the same?

Writing Prompt: As a patient, can you understand or appreciate Dr. Provenzano’s hesitation at first? If you’re a physician, have you experienced a similar hesitation? If you’ve suffered from addiction, what has been the most therapeutic intervention you’ve received? Think about an experience with addiction, either on a personal level or with a patient, that was particularly difficult. Then consider an interaction or moment that was a breakthrough. Write for 10 minutes.

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Narrative Medicine Monday: My Human Doctor

Dr. Sara Manning Peskin writes in the New York Times about the fallibility of physicians and its emotional toll in “My Human Doctor.” Peskin introduces us to her patient, Shirley, who was given a diagnosis of multiple sclerosis. This patient finds that in assuming this chronic, often debilitating, disease, even the very word itself “crippled her. She’d stopped driving, stopped working, and adjusted to the stigma of having a chronic disease.” After a hospitalization due to a serious reaction to one of her medications, it was discovered that “Shirley might not have had multiple sclerosis at all.”

Peskin reflects that in medical training we do discuss errors but “[w]e don’t talk about the emotional trauma of hurting a patient. Instead, most physicians cope with guilt, self-doubt and fear of litigation in private. After our patients, we become ‘second victims’ of our mistakes.” Given the recent spotlight on depression and burnout in medicine, Peskin highlights an important point that we ignore to our peril. Some organizations are realizing this and offering more programs such as Balint, peer support groups, and expanded counseling services to explore and address this emotional trauma.

When Peskin suffers the consequences of a mistake made by her own physician, the response she receives is “‘I can’t turn back time.'” Peskin experiences first hand that “[a]pologies are difficult for doctors, not only because we have to cope with hurting someone, but also because we are scared of the legal implications of admitting culpability.” Peskin outlines how the U.S. system differs from many other countries, where the “‘no-fault’ system is based on injury from medical care and not on proof of physician negligence…” and “doctors and patients remain on the same side, and more patients get paid.”

Peskin does end up apologizing to her patient, Shirley, for the misdiagnosis of multiple sclerosis. They were then able to move forward in the doctor-patient relationship and discuss Shirley’s adjustment to the “possibility of not having a chronic disease.”

Writing Prompt: Think of a time your doctor made a mistake. How did they approach the error? Did they apologize? If you’re a physician, think of a mistake that you or a colleague made that is particularly memorable. What happened and how did you respond? How did the situation affect the patient-physician relationship? Consider writing about this experience from both the patient and the medical provider’s perspective. Write for 10 minutes.

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Narrative Medicine Monday: May Cause

Writer Elspeth Jensen highlights the many instructions we are confronted with when taking medications in her Bellevue Literary Review prose poem “May Cause.” Jensen’s poem accelerates throughout and hints at the absurdity of all we are told to do, not to do, of all we are advised to avoid, to look out for: “Use care when operating a vehicle, vessel, boat, until you become familiar with blurred vision, symptoms worsening, fear, or sadness.” Jensen repeats “do not” six times in this short poem. The reader, as the patient, feels the anxiety evoked by the many stipulations of being medicated.

Writing Prompt: Think of the last time you read the instructions given to you with your medication. Perhaps you still have one in your medicine cabinet. Take it out and read it in full. How many times are you told “do not?” Is anything confusing? Humorous? Did you adhere to the instructions? Why or why not? Write for ten minutes.

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Narrative Medicine Monday: On the Eve of My Mother’s Dying

Writer Peggy Duffy’s flash nonfiction piece in the latest issue of Brevity, “On the Eve of My Mother’s Dying,” is a snapshot of her mother’s last days on hospice.

Duffy opens with the assertion that those who work in hospice “coordinate.” In my experience, both as a physician and as a family member, caring for those at the end of life, this verb rings true. The hospice people coordinate all the details of transport and durable medical equipment and adjustment of medications for comfort and, ultimately, Duffy realizes, “my mother is actively dying, and they strive to coordinate that too.”

Duffy’s father is upset they are not coaxing his wife into eating, despite her being unresponsive. The social worker explains to him “that unless my mother opens her eyes and asks for food, unless she can swallow, she cannot eat.” Duffy understandably struggles with her father’s resistance to accepting why they can’t give her mother water to drink: “Not long after I leave, he calls. Why won’t they give her water? She can’t swallow. What about on a teaspoon? You have to swallow even the tiniest amount of water. How can she survive without water? (Pause) She isn’t going to survive. I remind him she signed an advanced directive years ago when she was still lucid and knew what she was signing.”

Duffy is surprised at the stretching of time in the final days of her mother’s life: “I can’t work, can’t think, can’t sleep. I never knew dying could take so long.” If you’ve cared for a loved one on hospice, did you experience the same distortion of time as Duffy?

The piece ends with a touching, and surprising, kiss from Duffy’s mother: “Something long dormant stirs beneath my chest where my heart lies. I lay my head on her chest where her heart still beats.”

Writing Prompt: Have you had difficulty explaining any aspect of end of life care to a spouse, child or parent of a dying patient? Often loved ones have discussed clear wishes of what they would like done, and not done, when nearing the end of life. When it comes time to actually carry out actions according to these wishes though, this still can remain a painful process. Have you experienced this first hand? Write for 10 minutes.

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Narrative Medicine Monday: The Name of the Dog

In The New England Journal of Medicine essay “The Name of the Dog,” physician Taimur Safder remembers a lesson learned early in residency. Safder is stumped when, “as a freshly minted doctor,” he presents “a patient who was admitted for chest pain after walking his dog” and his attending asks a curious question: “‘What was the name of his dog?'” Safder is initially perplexed as to why this question even matters, but when the attending physician takes the group to the patient’s bedside to inquire, he realizes that very question “led to a transformation I did not fully appreciate at the time: there was an actual person behind that hospital-issued gown.”

This lesson proves valuable to Safder’s medical training. Through it, he forms similar connections with patients that allow him to “have difficult discussions about [the patient’s] immigration status and what it meant for his treatment plan,” and sign a “treaty under which [Safder] would read the ‘studies’ [the patient] brought in about black cherry and milk thistle and she would start taking one new medication every 2 months.” In learning about a person beyond their identity simply as a patient, trust develops and the patient-physician relationship can grow.

While caring for a patient who eventually ends up in hospice, Safder comes to another realization: “the question that I’d been carrying around since my first day of residency could work another type of transformation: it helped my patients see the person behind the white coat.”

Writing Prompt: Has there been a question you’ve asked a patient that revealed essential information about them as a person? Have you, as a patient, been asked a question by a medical provider that may not have seemed directly medically relevant but was important to them understanding you as a person? What was the question? What did it reveal? Write for 10 minutes.

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Narrative Medicine Monday: What Insomniacs Do in Bed

Donna Steiner lets us know “What Insomniacs Do in Bed” in her poem in The Healing Muse. Steiner touches on those heightened moments in the middle of the night, when the rest of the world seems muted. She admires much, including “the under-valued texture of flannel sheets” and “the capacity of our aging lungs.” She notices the absence of all sorts of things, including “of rain, of drizzle, of shower…” Steiner wonders about “germs and mites and viruses, and whether they multiply right now,” a vivid recognition of what those of us up at ungodly hours imagine.

Over the past two decades I’ve often been awake in the middle of the night, occasionally due to insomnia but more frequently because of medical work or motherhood, nursing my own babe or delivering a new life into the world in the pale hours of almost-morning. Steiner issues a call to accept the gift of repetition, that it is a “form of education.” Perhaps the most significant to the insomniac is the “merciful repetition of daybreak.”

Writing Prompt: Have you suffered from insomnia? Does Steiner’s poem resonate with you? What do you do when you’re up at night and no one else is? If you’ve been up in the middle of the night for another reason (residency, parenting), what did you notice about being awake when the rest of the world is sleeping? Write for 10 minutes.

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