Writing

Narrative Medicine Monday: Poof

No Comments

This elegy by poet Amy Gerstler was selected by this month’s Poem-a-Day curator, Maggie Smith. I wrote about how Smith’s poem “Good Bones” hangs on a nondescript bulletin board in our clinic, though I never did figure out who posted it there. Each morning this month, I’ve been eager to see what poem Smith selects.

It’s no surprise that I think poetry provides much needed perspective to the world of medicine, and Gerstler’s “Poof” is no exception. Gerstler begins with a small bag of ashes on her lap, a gift from her late friend’s family. She recalls the service, the details of “staring at rows of docked boats” and the woman’s “impossibly handsome son.”

Gerstler speaks directly to her old friend, remembering that “You were the pretty one. / In middle school I lived on Diet Coke and / your sexual reconnaissance reports.” She imagines an alternative storyline where “your father never hits / you or calls you a whore.” Through Gerstler’s memories, both real and imagined, we get a glimpse of their bond, of the woman she, and this world, lost, even though we never learn her name, her vocation. (Why is it that these are the first things we ask? Always: What’s your name? What do you do?)

Gerstler gives us a remembrance that is more: a cinematic illumination of who this woman was: “You still / reveal the esoteric mysteries of tampons. You / still learn Farsi and French from boyfriends / as your life ignites.”

I like that Gerstler considers alternate storylines of their history together. Our formative years can be like this, wondering what different versions of us might transpire. I imagine (and, reaching middle age myself, have already succumbed to such reveries) our later years might also be prone to wondering what other tributaries of life paths might exist in the universe.

Ultimately, we learn that their lifelong relationship remains much as it is was in their adolescence: “I’m still lagging behind, barking up all / the wrong trees, whipping out my scimitar far / in advance of what the occasion demands.” Gerstler’s tender flashes of moments between the two is a tribute not only to her late friend, but also for all of us who are lucky enough to have kept company with cherished friends over the decades.

Writing Prompt: Think of a person (or patient, if you’re a medical provider) important to you who was suddenly gone. Write them an elegy in second person, or, alternatively, a letter. What are the memories, the moments, that stand out to you? Did this person vanish, as they did for Gerstler, with a “poof,” or would you use a different way of describing their absence from your life? Alternatively, consider writing an elegy or a letter to a long-time friend or patient who is still alive. Write for 10 minutes.

Continue Reading

Narrative Medicine, Writing

Narrative Medicine Monday: The Fall of Icarus & Musee des Beaux Arts

No Comments

I’m just finishing up a wonderful poetry course taught by Michelle Penaloza, and recently explored ekphrastic poetry. These are poems written in response to a piece of art. She had us read two different poems written about Brueghel’s “Landscape with the Fall of Icarus.”

I found the poem by W.H. Auden relates to medicine and illness in a way, a commentary on how suffering exists in the world while the rest of life goes on. Auden observes how well the “old Masters” understood suffering, “how it takes place / While someone else is eating or opening a window or just walking dully along.” For people who are struggling with illness, especially chronic illness, this normalcy and indifference of the rest of the world can seem almost as an affront. When dealing with a difficult diagnosis, it can be painful to see the world advance as it always has, even though it must. In Icarus’ case, Auden notes that “the expensive delicate ship that must have seen / Something amazing … / Had somewhere to get to and sailed calmly on.”

Writing Prompt: Consider writing your own ekphrastic poem or free write in response to Breughel’s “The Fall of Icarus.” What do you notice about the painting and how might you expand on its meaning? If you’re a medical provider, have you seen others suffering but, for whatever reason, had to move “calmly on?” Do you think medical training or the medical system contributes to this type of response? If so, how? As a patient, have you experienced an illness or suffering while the rest of the world goes on, unaware? How did that make you feel? Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Burnout in Healthcare

No Comments

I’ve wanted to attend Columbia’s Narrative Medicine workshops for years. Life finally aligned to make that possible this past weekend as I joined professionals from different disciplines gathered to address “Burnout in Health Care: The Need for Narrative.” As a wellness champion for my physician group, this year’s topic was particularly pertinent to my work and practice.

The conference consisted of lectures from leaders in the field of narrative medicine alternating with small group breakout sessions. I was fortunate enough to have Dr. Rita Charon, who inaugurated the field of narrative medicine, facilitate two of my group’s sessions, which consisted of close reading and reflective writing and sharing. This format allows for in depth discussion with medical and humanities professionals, as well as time for introspection about how best to expand on learned concepts and practices when we return home.

Several takeaways for me:

Narrative can be used to address many issues in healthcare, burnout among them. I’ve been facilitating a Literature & Medicine program for my own physician group, and have taught narrative medicine small group sessions to resident physicians, but am inspired to do more of this work to expand the reach to medical professionals and patients. Dr. Charon encouraged us to disseminate the skills deepened through the humanities, that these are what’s missing from a health care system that has become depersonalized. Skills learned through narrative medicine can improve team cohesion, address moral injury and bias.

Writer Nellie Herman offered Viktor Frankel’s words: the primary force of an individual is to find meaning in life. Herman showed us how writing can help us find that meaning, giving shape to our experiences, our memories. Harnessing creativity can be particularly important for those of us who experience moral injury because “when we write, we externalize what is inside us.” Through writing and sharing, we’re making a commitment to something, a raw, less mediated version of events. Through this vulnerability we connect to others; though difficult, that’s what makes it valuable.

Dr. Kelley Skeff approaches burnout and narrative from a physician educator’s perspective. It is not lost on anyone who has been a medical resident or trained them that “we have trained people to take care of patients, even if it kills them. We have trained people to keep quiet.” Skeff offers us this quote from Richard Gunderman: “Professional burnout is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice.” He implores us to combat the code of silence and ask ourselves and each other: What’s distressing you?

Maura Spiegel contends that “narrative language can proliferate meaning.” Spiegel used film clips to show how we can gain access to our own experience. In watching a film, we’re not called upon to respond, but we are often running our own parallel stories along with the movie. Spiegel showed clips from the movies “Moonlight,” “Ikiru,” and “Philadelphia,” and the documentary “The Waiting Room.” In that final clip we saw a young doctor run a code in the Emergency Room where a teenage boy dies. He then is tasked with telling the family the devastating news. He seeks out support from his colleagues on how to do this. Spiegel notes a quote from Jonathan Shay: “Recovery happens only in community.”

I was bolstered to hear about he the work of Craig Irvine and Dr. Deepu Gowda, who discussed how to create a culture for narrative work, both in academic institutions and in clinics. Dr. Gowda explored using narrative medicine sessions with the entire medical team (including nursing staff, administrators, physicians) and found improved teamwork, collaboration, and communication. Both suggested building a team of people interested in narrative work, be they art historians, philosophers, writers, physicians, or psychologists.

More than anything, this workshop churned up ideas and inspired methods that could be used at my own workplace to use narrative work to address burnout. I came away encouraged and connected to colleagues who are interested in the same questions and in addressing the daunting problem we face in our current health care system. Ultimately, we want to “allow voices to be heard, and address suffering, not only of patients but also of medical providers.” This work is challenging, but necessary. As Tavis Apramian noted in the final lecture of the conference, “the meaning that we draw from other people is the reason to keep going.” That it is. I hope to continue learning about this important work and am grateful for the faculty at Columbia who inspire tributaries (or rhizomes!) of narrative and creativity throughout the medical world.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Ikiru

No Comments

Today’s Narrative Medicine post highlights a first: a movie. As part of preparation for this week’s Columbia Narrative Medicine Workshop, I watched a 1952 Japanese film, Ikiru. This movie, directed by Akira Kurosawa, outlines the life and death of a man with end stage cancer.

I happen to also be facilitating a Literature & Medicine gathering this week, where the topic is “Confronting Mortality.” In it, we are reading Tolstoy’s novella “The Death of Ivan Ilyich,” which similarly shows a man facing a terminal illness and wrestling with the meaning of his life and the nature of his painful death.

In Ikiru the protagonist, Mr. Watanabe, has not missed a day of work in 30 years at the same tedious government job. The narrator notes that “he’s only killing time, he’s never actually lived.”

I’m certainly not a movie critic, but several things stood out to me, looking at this film through a narrative medicine lens. First, his physicians insist on withholding the terminal nature of Mr. Watanabe’s illness, stating it’s a “mild ulcer” only, even when Watanabe begs them for the truth. This scene reminded me of a panel on cultural issues in bioethics I attended many years ago. On the panel was a bioethicist from Japan, and he explained the cultural influence of withholding the true prognosis or even diagnosis of an illness from a loved one; that a physician might deliver a terminal diagnosis to a patient’s family member rather than to the patient themself.

We get flashbacks in the movie to understand the central character more. His wife died when his son was young and he never remarried. Although they live together still, Watanabe and his son have a difficult relationship; they struggle to really communicate and Watanabe in fact is never able, despite several efforts, to actually confide his diagnosis and angst to his son.

Mr. Watanabe comes across a stranger who he asks to show him “how to live” and they gamble and dance and drink, but ultimately he finds little lasting pleasure in these endeavors.

The central character then turns to an old colleague, a young woman, trying to decipher her vitality, her zest for living. Through this interaction, he resolves to get a park built for the community. In the end he succeeds, battling the bureaucracy he was a part of himself for decades. It seems the completion of the park gives the dying man some semblance of peace, a legacy solidified, which produces the meaning he was struggling to find.

Writing Prompt: At one point in the film, Watanabe tells a colleague “I can’t afford to hate people. I haven’t got that kind of time.” What are the different ways you’ve seen patients who are terminally ill react to facing their limited time? Did they give up hate? Or something else? In Mark Doty’s poem “Brilliance” the patient initially gives up investing in anything he can’t finish. Why do you think Watanabe decided that the playground would be his last project, his last investment in what little energy and time remained? Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: A Tense Moment in the Emergency Room

No Comments

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.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Trying to Help

No Comments

Poet and physician Dianne Silvestri outlines practicalities near the end of life in her Hospital Drive poem, “Trying to Help.” She begins with an entreaty: “Don’t forget when I die” and from there imparts instruction. She implores the reader “Remember the penciled page … that lists all important numbers.” She both instructs, but also attempts to absolve of any guilt: “It’s okay if no one peruses / my binders, journals, and files.” In the end, there is the sincerity of a small request, that “if you resume dance lessons, / please miss me … a little.”

Silvestri’s blend of instruction and request is both practical and wrenching. The narrator is preparing their loved one for that which cannot be prepared for. Her words are both freeing and binding. They offer solace in a hopeless situation.

Writing Prompt: Have you had a loved one or a patient who reacted to dying similarly to the narrator of this poem: putting things in order, advising their loved one about practicalities? How was this received? Who do you think the narrator is trying to help? Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: How Virginia Woolf Taught Me to Mourn

No Comments

Katharine Smyth explains “How Virginia Woolf Taught Me to Mourn” in her recent essay on Literary Hub. Smyth outlines how Woolf described the mourning period surrounding her mother’s death, and how that “spring of 1895 in London… may as well have been the winter of 2007 in Boston” when she was grieving her own father.

Smyth and her mother illustrate how people can react to grief differently. Her mother “saw the ringing doorbell as an interruption,” while Smyth “liked hearing from the outside world: grief is rapacious, and cards and flowers functioned as its fuel. As long as they continued to proliferate, the experience of loss was active, almost diverting. It was only when their numbers dwindled, then ceased altogether, that a kind of dullish hunger set in.” I think the same can be said of those who experience trauma. Often, others surround you during and immediately after the event, but as time progresses and active support dwindles, a loneliness takes its place.

One of Smyth’s friends “invited me to her parents’ apartment for a kind of mini sitting shiva. For several hours she and her mother listened as I talked about my father’s life; I loved that neither was cowed by death’s awkwardness.” This gift to Smyth seemed an unexpected balm. Do you think most of us succumb to death’s awkwardness? Why do you think this is a cultural norm?

Smyth notes that when the distractions end, “Above all, I disliked the passing of time, disliked the thought that every minute carried me further from my father.” She can relate to Woolf’s surreal experience in the wake of a parent’s death: “The tragedy of her mother’s death, she said, ‘was not that it made one, now and then and very intensely, unhappy. It was that it made her unreal; and us solemn, and self-conscious. We were made to act parts that we did not feel; to fumble for words that we did not know. . . . It made one hypocritical and immeshed in the conventions of sorrow.'”

Smyth identifies with Lily in Woolf’s To the Lighthouse: “her frustrations are those of the grown writer who must confront grief’s fogginess, its unreliability. ‘Why repeat this over and over again?’ she thinks angrily of her attempts to register the fact of Mrs. Ramsay’s passing.” Smyth, too, finds herself repeating, “My father is dead, I continued to say, my father is dead.”

In To the Lighthouse, Smyth discovers that Woolf conveys “her understanding that we all need some structure by which to contain and grapple with our dead.”

Writing Prompt: Although not religious, Smyth finds the act of sitting shiva cathartic, finds herself “longing for ritual, for structure, for some organizing principle by which to counter the awful shapelessness of loss.” Think of your own experience of grief or loss. Can you relate to the healing benefits of structure? Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Brain Biopsy

No Comments

Pathologist and poet Dr. Srinivas Mandavilli illuminates the microscopic, and the universal, in JAMA‘s “Brain Biopsy.”

Mandavilli lets us know that in “neuroradiology they have a gift for reading the mind.” In moving a glass slide, he learns to “bow in silence and see an underworld / —an otherworld where planets improvise like nuclei.” The narrator alternates between the microscopic and the broader cosmos. Through this, Mandavilli evokes a sense that we are all part of a grander whole, even the minuscule and aberrant parts of us.

His poem ends with the relational, with a hint at the journey we travel: “While we drive on a summer evening, she rests, / her long fingers intertwine, the heft / of her dark tresses strewn carelessly like the road ahead.”

Writing Prompt: Think of the smallest and largest components of life, of existence. How are they connected? Alternatively, pull out your old histology textbook or your child’s microscope. Examine a slide and write what you see, how this observation makes you feel. Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Hammond B3 Organ Cistern

No Comments

Poet Gabrielle Calvocoressi conveys what it feels like to experience a reprieve from wanting to kill herself in The New Yorker‘s “Hammond B3 Organ Cistern.” She begins with the wonder: “The days I don’t want to kill myself / are extraordinary. Deep bass.” Calvocoressi is nearly at a loss for words: “There should be a word for it. / The days you wake up and do not want / to slit your throat.” Clearly, though, she finds them, unflinching in her descriptions of suicidal thoughts. She wants the world to celebrate with her on the days she does not experience this urge: “Come on, Everybody. / Say it with me nice and slow / no pills no cliff no brains onthe floor“

What Calvocoressi portrays is the visceral reality that erupts for a person who knows the severity of of suicidal urges and wakes to find “I did not / want to die that day.” Calvocoressi wonders, “Why don’t we talk about it? How good it feels.” In this extraordinary poem, Calvocoressi does.

Writing Prompt: Have you suffered from a serious illness that may feel different from one day to the next, such as severe depression? What does it feel like on the “good” days, the days your illness is improved or in remission? Can you relate to Calvocoressi’s exuberance for this state, the “deep bass,” the “leaping?” Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: The Insulin Wars

No Comments

Dr. Danielle Ofri’s opinion piece in the New York Times last week outlines “The Insulin Wars.” As a primary care physician who cares for hundreds of patients with chronic diseases, including diabetes, I could relate to Ofri’s frustration and outrage on behalf of patients and providers.

Ofri describes how her patient’s insurance company keeps changing the insulin that is preferred and therefore covered. This can be challenging for both the patient and the prescriber to keep up with, and there can be serious health consequences if there is a gap in use of this critical medication.

Ofri notes that “[b]etween 2002 and 2013, prices tripled for some insulins.” She offers several reasons that this is the case, but highlights that insurers use “pharmacy benefit managers, called P.B.M.s, to negotiate prices with manufacturers. Insurance programs represent huge markets, so manufacturers compete to offer good deals. How to offer a good deal? Jack up the list price, and then offer the P.B.M.s a ‘discount.'”

The end result for patients who can’t cover the costs of this vital medication may mean self-rationing, fluctuating blood sugar levels, and rejected prescriptions. For physicians, “it’s an endless game of catch-up.” It’s also a “colossal time-waster, as patients, pharmacists and doctors log hours upon hours calling, faxing, texting and emailing to keep up with whichever insulin is trending. It’s also dangerous, as patients can end up without a critical medication for days, sometimes weeks, waiting for these bureaucratic kinks to get ironed out.” There can be dire consequences for a diabetic patient to have short or long term uncontrolled diabetes.

In trying to get her patient’s insulin switched to an acceptable alternative, Ofri discovers that the insurance company “now had no insulins on its top tier. Breaking the news to my patient was devastating.” Ofri realized that the insurance company had found a way to place the burden on physicians and patients: “Let the doctors be the ones to navigate the bureaucratic hoops and then deliver the disappointing news to our patients. Let patients be the ones to figure out how to ration their medications or do without.” This piece highlights a sobering fact too common in modern medicine: the system often gets in the way of the best interest of the patient. We can, we must, find a better way.

Writing Prompt: Have you encountered a similar issue with insulin, either as a patient or as a physician? Have you seen other vital medications involved? What frustrates you most about the situation? How does this issue affect the patient-physician relationship? Write for 10 minutes.

Continue Reading