Narrative Medicine Monday: Bedside Rounds

John L. Wright’s poem, “Bedside Rounds,” speaks to the apprentice-like training of physicians. It is a passing on of skills from the experienced to the inexperienced, from the knowledgeable to the clinically naive. Most medical students, unless they have a background in another medical field, have little to no real experience in the hands-on component of medicine. They take years of study – biology, anatomy, pathophysiology – and translate that book smarts into skills of diagnostic touch, suturing skin, prescribing treatment. 

One method of transforming head knowledge to a practical skill set is through bedside rounds: a gaggle of medical students and resident and fellow physicians (still in training) following after an experienced attending physician. Each morning this group travels from bedside to bedside, discussing the patient’s disease, the patient’s prognosis, the patient’s progress, the patient’s treatment plan. In recent years, medical schools have worked on making this process more inclusive of the patient who, after all, is the subject of the discussion. 

Wright’s poem touches on the experience of that patient, ill and incapacitated, being talked over in a cryptic language, determinations being made about the status and plan while the patient may still be steeped in a cloud of confusion. 

Wright finds himself in a comparable situation when his landscape architect brings her intern along with her one day. As this professional passes on her skills to her protégée, discussing his yard in detail, Wright begins to feel something he hadn’t expected: “I begin to resent them—the little games they play.”

Writing Prompt: Think of a time you’ve experienced bedside rounds as a physician, as a patient or while visiting someone in the hospital. If you were the patient, how did you feel when the medical team discussed your case in front of you? Did they include you in the discussion or explain what they talked about? If you’re a medical provider, choose a memorable bedside rounding experience: running rounds for the first time, being a brand new medical student, noticing something significant with the patient’s demeanor while their case was being discussed. Write for 10 minutes.

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Narrative Medicine Monday: Architecture of Mental Illness

This fascinating National Public Radio story by Susan Stamberg reviews an exhibition at the National Building Museum exploring the links between architecture and mental health. It outlines the history of Washington, D.C.’s St. Elizabeths Hospital, first opened in 1855 and championed by Dorothea Dix, a pioneering advocate for more humane treatment of mental health patients.

The article states that Dix “‘believed that architecture and landscape architecture would really have a role in curing people.'” Do you agree? Have you witnessed physical surroundings play a significant role, either positively or negatively, for a patient or loved one with mental illness?

Some of the photos included in Stamberg’s story conjure up a dignified 19th century hotel. Dix was a proponent of having beautifully manicured grounds and St. Elizabeths was designed specifically to have “natural light and views of the outdoors” and “heat, tall arched windows and screened sleeping porches where patients could catch summer breezes.”

Writing Prompt: Use one of the photos from Stamberg’s story as a writing prompt for a free write. Imagine you are one of the patients (or nurses) in the St. Elizabeths Hospital of the 19th century. How does the space make you feel? Alternatively, if you’ve visited or worked in a contemporary inpatient mental health facility think about the design of the place. How could it be improved on? How do you think the features affect the inpatients? 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: 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: Family Summons

When rotating through the Intensive Care Unit in medical school or residency, one of the most significant skills learned, in addition to adjusting mechanical ventilation settings and how to run a code, is how to conduct a “family conference”. This is where loved ones, preferably including the patient’s designated medical decision proxy, gather to discuss the patient’s status, prognosis and treatment plan. As these patients are severely, sometimes suddenly, ill, these can be very challenging conversations. 

In “Family Summons” Amy Cowan illustrates how she was surprised to have a patient’s family gather in the middle of the night, wanting to speak with her as their family patriarch’s physician. Her piece highlights how important it is to listen and extract the true identity of the patient, the life they lived beyond the ICU. Establishing this portrait can help inform the care team as well as free the family members to make decisions in line with what their loved one would want.

Writing Prompt: Have you ever attended or conducted an important medical family conference? How was it run? If not, can you imagine what questions you might ask to best get to know the patient? Think about if you were the patient in the ICU; who would you want to gather on your behalf and what might they say when asked about you and your life, what’s important to you? Write for ten minutes.

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Free Write Friday: Hospital

 

1997

She’s volunteering, decided what she wants to do. She catches the bus to the hospital from campus, heavy backpack weighing down her slight shoulders. She has a badge, a short powder blue jacket. She works in the playroom: coloring, washing toys, light streaming through the wall of windows as she stoops to read aloud a picture book or set up a seasonal craft on the low plastic tables. The children come in wheelchairs, heads bald or misshapen or shaved with intention. Tubes may be in their nares or arms. All of it is foreign and she doesn’t know how to act naturally so she smiles a lot, maybe too much. Sometimes she delivers a toy to a child confined to their own room: in isolation. Before entering she puts on a crinkly gown and a mask and latex free gloves, just as she was trained to do. She plays with the child, chats with the teen, tries to connect, but her own awkwardness and all the barriers for protection get in the way.

2003

She’s in medical school, deciding what she wants to do. She rotates through the hospital, a shadow of a doctor in a short white coat, tagging along after her resident. Her pockets are weighed down with too much: laminated cards on how to run a pediatric code, a clipboard with preprinted index cards to keep track of each patient’s labs and history, black ball point pens to record chart notes, gum. She learns she always needs to have gum on hand. She walks the halls, familiar but transformed now she’s armed with some knowledge. She gets to know the palpable quiet of the hospital in the middle of the night. The ceilings here are low; everything is miniaturized to make children feel more comfortable, in this place where discomfort distinctively reigns.

2007

She’s in residency, an MD after her name. She doesn’t wear a coat, but instead a black fleece vest with zippered pockets. Sometimes she’s mistaken for a nurse, but she still doesn’t wear the long white coat; it’s just not the way things are done. She monitors her patients and her medical students. She presents each case to the attending each morning at rounds. She knows what she wants to order in the cafeteria when it opens at 2 a.m. for all the providers who are there overnight on call. She’d rather sleep than eat, but that’s not the way things are done here. Residents review the progress of patients with the medical students, with each other, over the mid-night meal. The lights are turned down low and the children are in cribs and in isolation rooms and can’t breathe well or can’t eat well and most certainly won’t sleep well. The nurses page her and talk in quiet voices. Many patients get better and she discharges them. Some are known by all the staff and roam the halls with their IV poles like tiny emperors, because this place, this hospital, too, is their home.

2016

She brings her infant, the youngest of her three, in to see the specialist. She parks in the newish garage built in the same place she used to catch the bus up the hill. She wheels her baby in the stroller. She waits in line to check in, gets an adhesive visitor’s badge with her picture and her child’s name. There’s a Starbucks downstairs now, in this new wing, but she doesn’t have time to stop for a latte. Her child is crying and she’s late. She wears a red raincoat, her pockets filled with the random items of a mother: a used tissue, a miniature toy construction truck, a purple hair clip, a binky, her smartphone. She’s anxious about seeing the specialist, about the prognosis and treatment plan. She has already texted her friend, the pediatrician, who made helpful recommendations, gave expert advice. She now has the luxury of giving and getting medical opinions in an instant, a byproduct of years of training and now experience as a practicing physician. She waits in the waiting room with other families. Some children read, some run, some sit in laps, some in motorized wheelchairs. Her child’s name is called and her baby is weighed, measured. She sees the physician. Her baby is prescribed medication, which she gets from the pharmacy. A girl waiting in line behind her talks animatedly about a book she wants to read. When she turns to check on her baby she can see the girl’s shaved head, the scar from surgery. So many children here so ill, so resilient. As a mother, she always feels grateful, feels guilty, in this place.

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