Narrative Medicine Monday: Close Encounter

Abraham Verghese writes about his experience treating victims of hurricane Katrina in his essay “Close Encounter“. The experience reminds him of working overseas in India and Ethiopia, where “the careful listening, the thorough exam, the laying of hands was the therapy.” Have you ever been in a situation providing medical care when this type of personal touch was the primary treatment? What does taking away many of the medical resources that we take for granted reveal about the other important aspects of medicine? 
Verghese goes on to describe a dignified man in his 70’s who has a chilling tale of survival. Verghese reflects on what it means to say and to hear “I’m so sorry.” What do you think it means to this man to hear those words? 

Writing Prompt: Verghese begins and ends his piece mentioning the “armor” providers strap on for challenging work shifts. Have you tried to wear such armor in your practice? What was the result? As a patient have you been cared for by medical professionals who seem to wear this armor? How did they come across? Have you ever been “wounded” by a patient interaction? Do you agree with Verghese  that the willingness to be wounded may be all we have to offer as providers? 

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Narrative Medicine Monday: You Will Feel A Pinch

With a title like “You Will Feel A Pinch“, I couldn’t help but read Marylyn Grigas’ poem in the Bellevue Literary Review. Whenever I’m doing an injection with a numbing medication for a procedure, I say exactly this: “You will feel a pinch, then a burn.” This is just how she begins.

There are so many phrases that I use automatically and repetitively with patients on a daily basis. Leaving the room for the patient to change for a physical exam, I inform: “The gown opens in the back, the paper drape unfolds over your legs.” Performing a Pap smear and gynecologic exam, I explain I’m going to “use my other hand to feel your uterus and ovaries and make sure I don’t feel any masses or anything abnormal.” I listen to the lungs on the back and ask the patient to “take deep breaths through your mouth”, then as I move to auscultate the lub-dub of the heart on the chest I ask them to “breathe normally.” I once had a patient laugh and reply, “What does that mean?” These phrases come out of our mouths, rote habit, without thought as to what a patient, who might be hearing those words for the first time, might perceive. 

After much trial and error you discover what tends to work to communicate with patients in a way they can understand. You begin to anticipate the questions they’ll ask, such as if the gown opens in the back or the front, and preempt with answers. But I think over time, over years, it becomes such second nature that the words fall out without pausing to think about the meaning.

Two years ago I had a skin lesion on my back that was bothering me and I asked my doctor to “burn” it off with liquid nitrogen. This type of so-called cryotherapy is a treatment I perform on others regularly. I always warn “this may sting” and have had incredibly varied responses, ranging from people barely flinching to  crying out in pain. When my own turn came I was acutely surprised at how painful it was, much more than just a “sting”, both during the application and for several days after. I developed a new empathy for the recipients of my cryotherapy treatment going forward. I shudder when I think of all the coaching phrases confidently uttered to my patients in labor a decade before I experienced labor pains myself. 

Why do you think Grigas opens her poem with this oft used warning? What does this phrase seem to make her think of? How does her poem evolve and what do you think it’s about?

Writing Prompt: Think about something you say regularly to patients, almost automatically. Unpack the phrase. Imagine yourself in the patient’s position hearing this for the first time and write from their perspective. What other things might come to mind when a patient hears this phrase? If you’re not a medical professional, can you think of sentences you’ve heard from doctors or nurses that were confusing or funny or easily misunderstood? Write about this for 10 minutes. 

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Narrative Medicine Monday: Jefferson’s Children

We get a glimpse into both the patient and the physician’s perspective of a manic presentation in Maureen Hirthler’s “Jefferson’s Children“. Her dramatic opening (“If you don’t do something right now, I’m going to hurt my children.”) inserts the reader into the mindset of the patient, desperately asking for help to make sense of her racing and disturbing thoughts. As the emergency physician enters the scene, the narrative shifts and the reader becomes the provider, trying to make a definitive diagnosis and determine an appropriate treatment plan. 

The physician feels the patient should be admitted for psychiatric evaluation and treatment but is unable to find a bed for her and meets resistance from both the patient and her superior. Can you feel her frustration? Have you ever been in a similar situation?

The lack of appropriate, affordable and available psychiatric treatment has been discussed and debated much in recent years. What are the barriers you’ve noted to getting yourself, your loved ones or your patients the mental health care they need? If you could create the ideal mental health system, what would that look like?
Writing Prompt: Try writing from the first person perspective of a manic patient first arriving at the hospital or clinic. What about a severely depressed patient? A very anxious patient? Now write the same scene from the perspective of the medical provider (physician or therapist). How does the scene change?

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Narrative Medicine Monday: E.R.: Port-au-Prince 

H. Lee Kagan reflects on one memorable night working in a Haitian Emergency Room in “E.R.: Port-au-Prince“. What is Kagan expecting of his experience? When I’ve worked overseas, often in a wholly different medical system and in a resource limited environment, I’ve had similar anxieties, drenched in insecurity. Usually I come to realize I was worrying about all the wrong things. Kagan finds himself unsure how to respond when a patient who was raped arrives in the E.R. He questions himself after this encounter. Do you think he should have done something differently? What did Kagan learn about himself?

Writing Prompt: Have you experienced working or living across cultures or in a different system than the one you’re used to? What was different? Did you learn something about yourself or about medicine? Consider re-writing this piece from the point of view of the patient, the nurse who steps in or the volunteer nurse who can’t sleep. Does this give you new insight? 

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Narrative Medicine Monday: How to Tell a Mother Her Child Is Dead

Naomi Rosenberg, an emergency room physician, writes a gripping essay in the New York Times entitled “How to Tell a Mother Her Child Is Dead”. She writes her detailed and heart-rending instruction in second person. Is her use of second person effective? Can you see yourself in this situation, having to deliver the most terrible news? Those of us in medicine have had to deliver bad news, often frequently: a cancer diagnosis, a chronic debilitating illness diagnosis, a loved ones imminent or unexpected death. Rosenberg brings the reader into her situation and hints at the lessons she’s learned on how and how not to approach such a grueling task.

Writing prompt: Have you ever had to deliver bad news? If you’ve had to do this many times what lessons have you learned? If you’ve received bad news, how was it delivered? How do people respond differently to difficult news?


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Narrative Medicine Monday: An Enlarged Heart

Cynthia Zarin writes a detailed account of a time her daughter fell ill in “An Enlarged Heart”. She explores her own realization that her daughter was significantly sick and also documents her encounters with the medical system on the path to diagnosis and treatment. 

Writing prompt: Write about a time when you were caring for a loved one with an unexpected illness. How did you respond? What were the challenges you encountered with the health care system? What, if anything, did you struggle with yourself?



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Narrative Medicine Monday: What the Nurse Likes

Cortney Davis’ poem “What the Nurse Likes” reveals what it’s like to care for patients. She notes in her commentary about her poem that she realized “it is necessary for caregivers to say shocking things occasionally about the type of work that they do”. This poem has helped me reflect on what I enjoy about my work and consider what may seem interesting or odd to those outside of the medical field.

Writing prompt: What do you like about caring for patients? What do you dislike? What do you like about receiving medical care? What do you dislike? Write for ten minutes. Think about if any of these things may be shocking to others. Did you surprise yourself?

*Cortney Davis’ website has some more excellent prompts to try.



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Narrative Medicine Monday: My Patient Doesn’t ‘Do’ Vaccines

The New York Times Well column features many excellent pieces about medicine from the patient, physician and public health perspectives. Danielle Ofri’s “My Patient Doesn’t ‘Do’ Vaccines” is a snapshot of an every day encounter for a physician: a patient disagrees with the recommended care plan. Although immunizations are one of the most common areas of disconnect these days, this can and does happen in many other situations as well: a patient requests antibiotics for a viral illness, a physician recommends a procedure that a patient doesn’t want, a patient requests labs or studies that aren’t indicated, a physician recommends a medication that a patient is hesitant to take. Instead of just letting the situation pass by during a busy clinic day, Dr. Ofri decides to become curious, to engage her patient and educate him on the medical science. He, in turn, is able to voice his concerns and viewpoint.

Writing Prompt: Write about a time there was a disconnect between you and your physician or your patient. Were you curious during the encounter to understand the other person’s fears, concerns or hesitation? Why or why not? As providers, how best can we address valid concerns while staying true to evidence based care? How do our backgrounds color our perspective and ability to engage others?

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Narrative Medicine Monday: The Grand Hotel Mackinac Island

Welcome to Narrative Medicine Monday. Each Monday I’ll post a narrative medicine piece, a short discussion, a few questions and a related prompt. I hope this will provide a place for thoughtful reflection and discussion about medicine and how narrative medicine can help tell patient and provider stories in a meaningful way.

Thomas Gibbs’ The Grand Hotel Mackinac Island is an intense braided essay by an obstetrician, published in Hippocampus Magazine. From the very beginning, we are thrust into Gibbs’ crisis: his obstetrical patient is hemorrhaging and her life is in danger. He intersperses these events with details about the vacation, long awaited, he was supposed to leave for that same day. Gibbs touches on what it means to be a physician invested in your patients, and the inherent sacrifices therein.

If you are a medical provider, have you ever been in a situation where you felt you just couldn’t leave a patient, even for a significant personal or family event? What are the privileges of being a medical provider? What are the sacrifices?

All of us have had to sacrifice an aspect of our personal life due to our work, be it inside or outside of the home. What have you let go of because of your work?

Writing Prompt: Think about a time your life was disrupted by an unexpected medical diagnosis or outcome, either as a patient or as a medical provider. Write for 10 minutes about this disruption. Did you have to let go of anything to be present?

*A note about prompts: When writing from a prompt, consider a “free write”, where you set a timer and write for the full 10 minutes and don’t edit while you write. There’s always time to return to editing later. Free writing is about getting your story down on paper; you may be surprised what your writing reveals.

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