Medicine and Mothering on the Front Lines of COVID-19

Two weeks ago I picked my kindergartener up from after-school basketball on a routine weekday afternoon. He bounded up to me, backpack in hand and asked, “Mom, do you know about coronavirus?” His teachers had discussed the viral outbreak and the need for good hand-washing skills. My budding epidemiologist went on to explain how the virus spread from bats to another animal to a human to another human to even more humans and so on. I tucked him into bed that night, marveling at his teacher’s skill in stressing hygiene and explaining the novel virus to a group of 6-year-olds.

Of course now coronavirus, or COVID-19, is all anyone is talking about, reading about. Coronavirus has uprooted my personal and professional life. As a family medicine physician working in Seattle, and as a mom to three young children, COVID-19 has consumed my day-to-day activities and workplace. As a primary care clinician and parent at a U.S. epicenter of the outbreak, there is no other word for home or work right now than upheaval.

I am also a writer, a creator of art. But I have struggled to find the time and emotional space to articulate and explore all the layered questions this crisis has presented to me—as a physician, as a mother to young children, as a creative being in this world. Fragments of essays, lines of poems, pour out of me as I wake with anxiety in the middle of the night, as I run around a deserted Seattle park, as my children beg to gather with their friends, as I discharge a clinic patient who pauses as she exits the exam room: “Thank you for being a doctor.”

As a participant of Harvard Medical School’s inaugural Media & Medicine program, I’ve recently been trained in writing Op-Eds for the public, in discerning misinformation and disinformation in the media about healthcare issues, in thinking creatively about how we can use podcasting or plays or poems to tell stories that make a difference to important public health topics. My classmates and I, healthcare professionals from all over the world whose projects focus on varied themes from mental health to vulnerable populations, from physician burnout to cancer awareness, suddenly find ourselves in the middle of a pandemic, sharing stories from our respective locations worldwide.

My work right now, though, is focused here, on my community: the people I hold most dear and the place I grew up in, I trained in, I live. My colleagues and community are at the forefront of this pandemic. I feel the rising sense of fear, the wave of overwhelm, the steady thrum of kindness.

For now, I offer this. Anyone who attended medical school with me knows I like to make lists. I approach a seemingly insurmountable task by compiling, organizing, and splitting it up into manageable components. Over the last two weeks, as local healthcare systems faced rapidly changing recommendations, confusion about suggested protocols, differing messages on testing capability, questions about adequate protection and supplies, as schools closed and family schedules were upended, I gathered information. Here is my contribution, my list of reliable resources and information for the worried, weary, and hopeful among you.

Despite my own swirling anxieties, I’m grateful for the work I’m trained to do, in medicine and in the humanities. I’m thankful for my colleagues—every aspect of the health care team—who are committed to serving our community’s most vulnerable, and each other, through an uncertain time. I’m bolstered by the parents sharing resources and tips about how best to support our children through unprecedented upheaval. This, I know: we are distilled in a crisis to the best, or the worst, that is in us. May we cling to the best, stand firm in sound science, look to compassion and art that sustains our souls, and encourage others to do the same.

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Narrative Medicine Monday: Medicine and Its Metaphors

In this excerpt in Guernica from Eula Biss’ book On Immunity, she wonders at the different metaphors in medicine. Though paternalism is clearly fraught with issues, if it “has fallen out of favor in medicine… how we should care for other people remains a question.” Biss explains Michael Merry’s distinction between paternalism that promotes good or prevents harm, such as “in traffic laws, gun control, and environmental regulations,” and the misuse of regulations that are “often used to justify a coercive use of power.”

Biss notes the alternative that is offered, autonomy, has caused “the paternalism of doctors [to be replaced] by the consumerism of patients.” Today’s physicians see the results of this shift in their daily work, responding to patients’ requests of “tests and treatments from a menu based on [their] consumer research.” In modern medicine, the consumerist culture is such that, as Biss notes, “doctors may be tempted to give patients what we want, even when it is not good for us.”

How do we address the problems for patients and for healthcare providers with both the paternalistic and the consumerist cultures? Biss turns to the idea that a more caring framework might be the answer. When her son requires a surgery her father advises, “‘If you’re going to get medical care you’re going to have to trust someone.’” Biss notes she usually consults her father first regarding medical issues—she trusts him. But the decision point regarding her son’s medical situation was not her father’s area of expertise. She realized she had to rely on another’s advice.

Biss tries every other treatment option for her son that was suggested by other specialists or friends. She does her research. But eventually her son’s symptoms worsened: “Then his breathing, already loud, became irregular at night. I crouched next to his bed, holding my own breath during the pauses in his breathing to gauge how long he was going without air. After particularly long pauses he woke, gasping and coughing. I scheduled the surgery.”

When the day of the surgery comes, Biss “was most hopeful not that the surgery would enact a miracle, but that it would simply do no harm.” Biss then requests to remain with her son as he undergoes anesthesia, which the doctor resists: “Studies had shown, he told me, that the body language and facial expressions of anxious mothers can cause children to fear surgery and resist anesthesia.” Biss persists, and she and the anesthesiologist come to a compromise: she will hold his hand but not be in view of her son as the medicine takes effect. When he wakes from anesthesia, Biss has not been summoned to the recovery room yet and her son calls out for her in panic. The experience is traumatic for both Biss and her son. All the anesthesiologist offers is that her son won’t remember “any of this,” though Biss replies, “I will.”

Biss’ father offers a new metaphor for modern medicine, that I believe both patients and physicians can envision: Dracula. Her father argues that “‘medicine sucks the blood out of people in a lot of ways.’” There are the financial aspects for the patient, and dire emotional consequences for patients, their families, and often for healthcare providers, who are suffering from an epidemic of burnout. Biss notes that her physician father himself is “fairly skeptical of medicine,” stating that “‘most problems will get better if left alone. Those problems that do not get better if left alone are likely to kill the patient no matter what you do.’” It is a grim declaration in many ways, but perhaps the vampire metaphor puts patients and physicians on a more appropriate plane: working together to resist the anemia of compassion and trust that threaten us all, and in so doing improve the care we give and receive.

Writing Prompt: What metaphor do you think is most accurate of medicine today? Can you think of another metaphor for the difficulties encountered by patients and healthcare professionals? Have you experienced, as a patient or as a physician, the issues with paternalism or consumerism in medicine? Alternatively, what role should skepticism or comfort play in medicine? Write for 10 minutes.

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Media & Medicine

I’m an introvert. I recently took an online Myers-Briggs test a work colleague sent me, and I scored a solid INTJ. This categorization has been stable for me since high school. Though I do enjoy social events and meeting new people, as a true introvert, I find conferences exhausting. Medical or otherwise, the constant introductions, social navigating, and personal storytelling involved can prove daunting.

Last April, I was in Boston at a medical conference and had lunch with a group of women physicians. I struck up a conversation with the woman sitting next to me, trading the standard questions: where we’re from, our medical specialty, our interests. I told her about my passion for writing and narrative medicine and storytelling and physician wellness and bioethics and the humanities and, in turn, heard all about her upcoming book and the wonderful work she was doing in Boston.

A month later she emailed me, saying she had just attended a narrative writing event at her hospital, run by Dr. Suzanne Koven, and that what Dr. Koven was doing seemed very much aligned with my interests and the work I hoped to do in Seattle. Would I like a virtual introduction?

And that, as they say, is history. At least for my work and life. I spent over an hour speaking with Suzanne, learning about her path in both medicine and writing, and how she formed the Literature & Medicine program that has been running for over a decade. I knew I’d like Suzanne immediately when her first words to me were, “Well, let’s discuss our mutual favorite topic: narrative medicine.”

Under Suzanne’s guidance, I went on to establish a Literature & Medicine program at my own institution in Seattle, and she has since become Massachusetts General Hospital’s first Writer-in-Residence.

So when I heard that she and Neal Baer were starting a Media & Medicine course at Harvard, looking at how we can use storytelling to address pressing public health issues, I knew I wanted to be involved.

This past week, the inaugural Media & Medicine class met together in Boston for five days of lectures and networking, community and conversation. With a cohort of 50 people from all over the world, there was rich discussion and consideration of how we can use journalism and podcasting, op-eds and plays to address issues in healthcare.

I was impressed with the many innovative ideas, including implementing design thinking to tackle complex healthcare problems, weaving public health education into television and plays, and using solutions journalism to show that “better is possible” to enact change. Keynote speaker Dr. Leana Wen urged us to start with our authentic selves and stick with the voice we know. We collectively wrote op-ed pitches, practiced playback theater techniques, critiqued podcasts, and turned partner stories into playdough and pipe cleaner art.

I met an impressive group of healthcare professionals from all over the world, eager to expand on work in public health, mental health, health disparities, physician wellness, and chronic disease. We learned from each other, advised each other, helped with networking solutions and built our own community of advocates for storytelling and listening, which we’ll continue to grow over the next six months as we work on specific public health projects.

I had so many rich conversations, and heard from experts in media and storytelling. I’m leaving Boston invigorated and exhausted. I can’t wait to work on my own project, focusing on mental illness, and support and champion the work of my fellow colleagues. Although taxing for introverts like me, I’m so glad I had that conversation, shared my story with the women physicians I met at that conference back in 2018. It speaks to the power of personal connection, of telling our stories with vulnerability and hope, and this, I think, is what the Media & Medicine program is all about.

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Paris

Bonjour! I’ve been remiss with posting lately due to travels. I went to Paris in early June for both work and pleasure. It had been a decade since I’d visited the City of Lights, and, despite several stressful setbacks (beware that Airbnb, even if reserved months in advance, can cancel within days of your scheduled arrival!), Paris did not disappoint.

I have a special affinity for the city, as it was the first place I traveled internationally. I took French in high school and went there as an exchange student, living with a host family for just a couple of weeks. It was the first time I’d been anywhere predominantly non-English speaking and my host family was attentive, warm and forgiving. My time in Paris was a gentle nudge out of my American suburban bubble. More drastic shifts in my world perspective would come later, but I always think of Paris fondly as my start to a love of travel. And, of course, it’s Paris! The richness of art, architecture, food, parks, history…. I’ve been back to Paris once each decade since and this, by far, was my favorite trip.

I had initially planned to attend a writing retreat right before my medical conference, but as the retreat was canceled, I instead had several days completely to myself in Paris before my husband arrived and my conference started. As a working mom with three little ones, solitary time in this magical city was bliss. I strolled the narrow streets, stepped into cafes and hidden parks. I hit my favorite Musée d’Orsay and Rodin and sat in quirky bookshops sipping espresso and writing in my notebook. I even had a chance to read a poem during a multilingual open mic night.

The summer institute I attended was also exceptional, an annual meeting of the minds hosted by the CHCI Health and Medical Humanities Network. This organization is a “hub for health and medical humanities research and collaboration” and this year’s theme, “Health Beyond Borders,” brought together experts in both narrative medicine and global health, each particular interests of mine.

Several talks I particularly enjoyed were:

A keynote by Ghada Hatem-Gantzer about her incredible work with women and girls who have suffered violence.

I connected with Shana Feibel on #somedocs prior to the summer institute when I stumbled across her post about presenting in Paris. Dr. Feibel spoke about a topic that resonates with me: “Bridging the borders between Psychiatry and other Medical Specialities: A Case for the Medical Humanities.” I hope to continue to learn from her work in this area.

Sneha Mantri from Duke is a neurologist with her Master’s in Narrative Medicine and gave a fascinating presentation about border crossing and modern medicine as it relates to Mohsin Hamid’s novel Exit West. I also learned Dr. Mantri was in the same narrative medicine class at Columbia as Stephanie Cooper, who I’ve gotten to know well through the Seattle chapter of the Northwest Narrative Medicine Collaborative. It’s a small, connected world!

Columbia’s Danielle Spencer presented innovative work on the idea of lived retrospective diagnosis, or metagnosis. I’m looking forward to her book on this topic, forthcoming in 2020.

Emergency Medicine physician Craig Spencer gave a moving keynote presentation about his work with Medecins Sans Frontieres and specifically the migrant crisis in the Mediterranean.

I returned from Paris rejuvenated and energized on many fronts. C’est magnifique.

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Narrative Medicine Monday: Perchance to Think

A couple of years ago I was driving to work when I pulled up behind a car that had a red bumper sticker with white block lettering: “THINKING IS WORK.” When I arrived at my desk that day I wrote this statement on a Post-it note in my barely legible handwriting and moved on with my busy primary care clinic day.

Since then, I’ve had little time to ponder this idea, but it’s always been there, in the back of my mind, the Post-it still pinned to my desk bulletin board. We live in an accelerated world, saturated with information at our disposal. Though I’ve noticed, in my life and in medicine, there is less and less time to access this information, to research, or just think.

Dr. Danielle Ofri’s latest piece in the New England Journal of Medicine highlights this issue. In “Perchance to Think” Ofri outlines a common problem among primary care (and I’m sure all speciality) practices – there isn’t time allotted to actually think about a case. Ofri gives the example of a patient with slightly abnormal lab tests ordered by another physician. As the primary provider, Ofri is then tasked with sorting out whether this patient has adrenal insufficiency or rheumatoid arthritis while also addressing his six known chronic conditions. Ofri notes that, for primary care physicians, “adrenal insufficiency resides in the wobbliest, farthest-flung cortical gurus I possess.” Ofri quickly realized, as her “patient stacked his 15 medications on my desk – all of which needed refills, and all of which could interfere with adrenal function” that what she really needed to give this patient the best care possible was “time to think.”

In medical school we have time to study, to think deeply as we learn the intricacies of the human body and how to treat illness when things go wrong.

Once out in practice, though, there isn’t the luxury of that time to ponder. More and more demands are put on the physician, be it “last week’s labs to review, student notes to correct, patient calls to return, meds to renew, forms and papers spilling out of my mailbox.” Ofri eventually gives up, gives in to the time constraints of the system, and refers the patient to endocrinology to sort out the adrenal insufficiency issue.

As a primary care physician myself, this is an all too familiar dilemma. Ofri recognizes that this situation is untenable to all involved: the patient, the primary care provider, and the specialist. “In the pressurized world of contemporary outpatient medicine, there is simply no time to think. With every patient, we race to cover the bare minimum, sprinting in subsistence-level intellectual mode because that’s all that’s sustainable.”

Ofri eventually takes the time to listen to a podcast on adrenal insufficiency, addend her note and contact the patient with a more cogent plan until he’s able to see endocrinology. But this was time that isn’t usually allotted or even available in a normal physician’s busy life: “many of our patients’ conditions require — time to think, consider, revisit, reanalyze.”

Ofri laments there’s no way to code for contemplation, but asserts that giving physicians the time to think could improve efficiency. “We would save money by reducing unnecessary tests and cop-out referrals. We’d make fewer diagnostic errors and avert harms from overtesting. And allowing doctors to practice medicine at the upper end of our professional standard would make a substantial dent in the demoralization of physicians today.”

Here’s to considering a more wholistic way of practicing medicine, one that includes the intellectual rigor that attracted most physicians to medicine in the first place. After all, thinking is work.

Writing Prompt: Do you think giving physicians time to think would make a difference in efficiency? Have you experienced a case similar to Ofri’s, where if you had a little more time to research, you could manage the case yourself? As a patient, do you notice the time pressures on your physician? Describe what it’s like to experience this as a patient, as a provider. Write for 10 minutes.

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Narrative Medicine Monday: A Tense Moment in the Emergency Room

Author and physician Danielle Ofri’s latest piece in The Lancet outlines “A Tense Moment in the Emergency Room.” Ofri describes the concern of an African-American medical student as a “young man stormed into the doctors’ station… and held up his toddler. ‘My baby’s choking and you guys aren’t doing anything.'” The medical student knows she is least senior of the gathered medical professionals, but she also is the “only African-American person among the white doctors” and is “acutely aware of the fraught dynamics,” given the child’s father is also African-American. She considers stepping forward to assist, even though per her estimation the child is not in imminent danger. Instead, she holds back. Ultimately, the “highest person in the medical hierarchy” asks the man to return to his room and the situation escalates.

Ofri notes what anyone who has visited or worked in a hospital is keenly aware of: the hospital is a stressful place. Given the already heightened tension, if you “[a]dd in issues of race, class, gender, power dynamics, economics, and long wait times … you have the ingredients for combustion just hankering for tinder.” The broader issue is that “racial and ethnic disparities in medical care are extensive” and “implicit or unconscious bias is still entrenched in the medical world.” How have you witnessed this issue in giving or receiving medical care yourself? Do you know if the organization you work at, or receive medical care from, is working to address implicit bias in medicine?

The medical student’s reaction to the father differed from her white colleagues: “When the father stormed into the doctors’ station, she saw fear and concern; her fellow physicians saw aggression.” These issues are complicated by the various power dynamics that exist in medicine. On one hand, the medical student wonders if she would be treated similar to the father if she were a patient there, given they are both African-American and therefore “look the same to the outside world.” However, in that situation she was both “part of the powerful group—the doctors—but as a medical student, she was singularly powerless… a medical student might just as well be part of the furniture.”

Ofri contends that in the medical field we often justify our behavior in tense encounters “because we surely know that we are not racist, or sexist, or homophobic. We are good people and we have chosen to work in a profession dedicated to helping others, right? How could our actions possibly reflect bias?” Ofri calls us to seek out stories, to listen to one another. Medicine, after all, “remains an intensely human field: illness is experienced in human terms and medical care is given in human terms. We humans bring along our biases and stereotypes—that is true—but we also bring along our ability to communicate and to listen.” I know this is a skill I need to continually cultivate in my own practice. How might you listen better today?

Writing Prompt: Have you experienced a similar situation as this medical student regarding power dynamics, wether related to race, class, gender, or level of training? Think about such an event, either during your medical training or when encountering a medical professional as a patient. How did the people around you react differently? How did you react? Did your perspective of the incident change over time? 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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Autumn YAWP

For the second year in a row, I’m attending Centrum’s Autumn YAWP (Your Alternative Writing Program). It’s quickly becoming a favorite retreat as it’s designed just for introverted writers like me. Late morning is an optional gathering for a communal free write, the rest of the day is for your own writing, revision, reading, and exploring.

The setting is serene and includes trails, beaches and modest comfortable accommodations at Fort Worden. Nearby Port Townsend provides plenty of cafes, restaurants and a wonderful bookstore and theater.

I have specific goals for the weekend, including developing a new syllabus for a Literature & Medicine program I’m leading for physicians, working on a book proposal for a new manuscript, and final edits on a poem I plan to submit soon. Grateful for the time and spaciousness of this place to read and write and rest.

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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: Preparation

Abigail Lin’s poem “Preparation” in the Journal of the American Medical Association begins with a heartbeat as the focus of a medical student’s studies. She notes “we studied valves as if they were pipes: / what makes them rust, or clog.” There’s a note of bravado as the student starts their journey in medicine: they “marveled… as if we had built it ourselves.”

The humility comes later, realizing the fallacy in believing that “we could learn the architecture of grief / simply by examining blueprints.”

I remember marveling at the intricacies of design in my college introductory biology courses. I had in mind that I wanted to be a physician, but one of my most surprising revelations was learning about botany. I was amazed by the specificity of design in plants, the complex workings of how they grow, receive nourishment from the sun, from the rain; how they give back to the earth.

Lin’s poem is a caution to new medical providers. Much of our learning is in the machinery of the patient, the inner workings of the body. So much more is involved in treating the patient, not merely the disease.

Writing Prompt: If you are a medical provider, recall when you first started studying medicine. Were you naive, as Lin’s poem asserts? Is there something you’ve studied that you’ve marveled at? Did you learn a more nuanced appreciation as you progressed in your career? Recall an instance that contributed to that maturity. Write for 10 minutes.

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