Narrative Medicine Monday: Primum Non Nocere:

Emma Barnard is a visual artist and researcher focusing on fine art and medicine. Her latest installment, “Primum Non Nocere,” reflects the patient experience. Barnard’s work is influenced by her own interactions with the medical world as a patient and her research into this arena, including Michel Foucault’s term ‘medical gaze,’ used to “denote the dehumanizing medical separation of the patient’s body from the patient’s person or identity.”

I’m interested in Barnard’s method of creating art, where she follows a patient into the exam room and questions them right after, producing a drawing based on their response. She notes that many of the physicians are surprised at the resulting artwork: “During the consultation process patients show little emotion; it’s quite difficult to read how they really feel about the impact of the words spoken during the clinical encounter.”

Barnard also incorporates the physician and surgeon perspectives. Could you relate to her images of a physician’s experience in a busy clinic practice?  I could certainly identify with the depiction of others superseding the “self” and various demands of work and home life feeling compartmentalized. Do you agree with the neurosurgeons’ statement that as physicians we view a division between us and patients and that we have to understand this alienation “if we are to find ways to soothe it and become connected to our patients and to the essence of medicine?”

Writing Prompt: As a patient, have you ever experienced Foucault’s ‘medical gaze,’ where you perceived a provider as seeing you only as a body, rather than recognizing your personhood? What did that feel like? As a medical provider, have you ever caught yourself interacting this way with a patient? How can we work to overcome this tendency? Write for 10 minutes.

Continue Reading

Narrative Medicine Monday: Disaster Relief

Today’s Narrative Medicine Monday is a bit different. In light of recent catastrophic hurricanes in the U.S., there have been many stories about disaster relief and people stepping up to help in ways they’re not used to. One such person is Dr. Jennifer McQuade. This NPR story describes how McQuade, a melanoma oncologist, dropped off basic supplies to a shelter following hurricane Harvey and discovered the medical aid there severely lacking. She then found herself in charge of a medical shelter, enlisting the help of other physicians and medical providers via a physician moms social media group. Often in such situations we’re called upon to help each other in ways we might not imagine possible. As Texan Claudia Solis notes in the story, “There’s a kindness…. They’re your neighbor, and you have to help, and it’s beautiful.”

Writing Prompt: Have you ever found yourself in a situation where you had to provide medical care beyond your normal area of expertise? Have you ever been the recipient of such care? Describe the situation and how you felt. How did it bring you closer to the people around you? Write for 10 minutes. 

Continue Reading

Narrative Medicine Monday: A View from the Edge

Dr. Rana Awdish is a critical care physician turned advocate for training in compassionate care following her incredible near death experience in her own hospital. Her essay “A View from the Edge” in the New England Journal of Medicine provides an overview of her 2008 experience as a critically ill patient cared for by her colleagues.

In her book “In Shock,” out this October by St. Martin’s Press, she outlines her harrowing near-death illness and recovery. I’m eager to read Awdish’s book and hear more about how her experience led to advocacy for “compassionate, coordinated care.” In her NEJM essay she describes how “small things would gut me. Receiving a bill for the attempted resuscitation of the baby, for example…. A trivial oversight, by a department ostensibly not involved in patient care, had the potential to bring me to my knees.” After recovering, Awdish channels her grueling patient experience into a drive to transform the way we receive and provide medical care. She contends “we need to reflect on times when our care has deviated from what we intended — when we haven’t been who we hoped to be. We have to be transparent and allow the failure to reshape us, to help us reset our intention and mold our future selves.”

Writing Prompt: Have you noted an erosion of empathy among medical providers? If so, think of a specific example and write about how you felt as the patient. If you’re a medical provider, have you ever been cared for by colleagues at your own hospital? What was it like to be on the “other side,” as a patient? Did you come away from the experience with new knowledge and empathy that you then incorporated into your own practice? Write for 10 minutes. 

Continue Reading

Narrative Medicine Monday: Wernicke-Korsakoff

Poet and medical student Sarah Shirley describes an evolving interaction with a patient in “Wernicke-Korsakoff.” The patient initially finds complaint with everything: “the too soft too hard bed, the lunch that came with only one spoon though clearly two spoons were required.” Shirley struggles to connect with the disgruntled patient, who clearly wants nothing to do with her as an intrusive medical student.

Throughout my medical training and career I’ve encountered patients, like in “Wernicke-Korsakoff,” where “everything is thrown back.” They were angry at their disease, angry at the medical providers, angry at the system, angry at the world. At times, I’ve been one of those patients myself. There’s no doubt health and illness affect our mood. Many of those who are suffering build a shell to cocoon themselves off from the damaging world. Often they are rightfully skeptical of a medical system that has many failings. Shirley finally breaks through to her patient in the end, after searching for the right connecting point. 

Writing Prompt: Think about a time you were sick. How did being ill affect your mood and interactions with others? Were you inclined to cling to others for support or did you find yourself “raging against the world?” Perhaps you experienced both. What about a time when you were caring for someone who was sick? Did they allow you to connect with them right away or was it a struggle? Write for 10 minutes.

Continue Reading

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.

Continue Reading

Narrative Medicine Monday: New York Lungs

In her poem, “New York Lungs,” medical student Slavena Salve Nissan writes of the intimacy of knowing a patient “underneath her skin fascia fat.”  Nissan notes how her beloved city left a mark on her patient’s lungs. She thinks about the people who loved her patient and how even they didn’t know that the patient looks “like a frida kahlo painting on the inside.”

Place is a central theme in this poem. I like the subtle imagery of the medical student and her patient breathing the same air, from the same city, in and out of their lungs. This commonality, too, connects them.  

As a medical provider, we experience intimacies with patients that are both strange and surreal. It is a great privilege that our patients allow us, for the purpose of diagnosis or treatment, to perform these intrusions: cutting into the skin, sampling cells from the cervix, looking into the ears, listening to personal stories, palpating the lymph nodes. Over time this can become routine to the medical practitioner, but I do still wonder, and hope I never lose keen curiosity, about the lives of my patients beyond the exam room. 

Writing Prompt: Reflect on the vulnerability between a patient and physician. Is it surprising that we can be so open and trusting with a near stranger? Think about such a time, perhaps a surgical procedure or mental illness or embarassing symptom, when you put your complete trust in your medical provider. What was that like? Write for 10 minutes. 

Continue Reading

Published: Timeline

I’ve tried to write a piece like Timeline several times. It’s simply a chronicle of my typical work day, but, in the past, I never was able to get it just right. It didn’t flow sufficiently, wasn’t a clear reflection of the exhaustion I feel at the end of the day. 

When I discovered Pulse’s “More Voices” column theme this month was “Stress and Burnout,” I felt compelled to finish this piece for submission. It was initially much longer, but I think the confines of the short word count (less than 400) was helpful in honing it to only the necessities. Previous versions of this essay were written in first person or third person. Second person, I’ve discovered, suits the purpose of the piece. My goal is to place the reader in the shoes of the primary care physician, feel the weight of her day, the exhaustion inherent in the constant churn of a general practitioner’s practice. I hope this piece provides a snapshot of a day-in-the-life of a family physician, and evokes a thoughtful reflection on the state of our health care system and the very real crisis of physician burnout. 

I’m grateful to Pulse for publishing Timeline and for their regular promotion of issues relevant to patients and medical providers through narrative medicine poetry and prose.

Writing prompt: When do you feel most stressed at work? When do you feel energized? Have you witnessed signs of burnout in your colleagues or your own medical provider? List your own timeline of a typical workday. How do you feel when you read it back? Write for 10 minutes. 

Continue Reading

Narrative Medicine Monday: Found in translation?

Prolific writer, physician and narrative medicine pioneer Danielle Ofri writes about the assumptions we make and the significance of a shared common language in “Found in translation?,” an excerpt from her book Medicine in Translation.

Using interpreters for a medical interview is a skill learned in medical school and honed in residency. Medical providers are advised not to use family members as interpreters, as this could cause the patient to censor themselves or omit important details.   Sometimes though, given my monolinguilism, there isn’t much of a choice. I’ve needed many interpreters over the years, both on the phone and in person. There have been times, even with trained interpreters, that I’ve had the sinking suspicion that something significant was lost in translation. It may be because I ask a question, the patient and translator chat back and forth for a few minutes and in the end the interpreter relays a one sentence reply. Or simply because I realize, as Ofri points out in this piece, that the nuances and casual aspect of communication is lost when a third person enters the equation. Ofri notes her conversation with the patient through an interpreter was “polite and business-like. I asked the questions, he supplied the answers.”

Ofri makes certain assumptions about what language skills her Congolese patient might have or lack. The patient, in turn, also is surprised to learn that Ofri, a white American, speaks a language other than English. She notes how the dynamic of the visit changes after they discover they both speak Spanish. Suddenly, without an interpreter between them, they’re able to communicate on a more casual level. They each learn specific details about each other’s personal history; they “chatted happily.” 

Writing Prompt: Think of a time you’ve had to interact, either in medicine or travel, with another person who didn’t speak the same language. Did you feel like you were really communicating, getting to know the other person? What were your assumptions? If you’ve worked with a medical interpreter before, either in person or through the phone, how did this affect the interaction with the patient or physician? Were you worried something important was lost in translation? Write for 10 minutes. 

Continue Reading

Narrative Medicine Monday: When Patients Mentor Doctors

When Patients Mentor Doctors: The Story Of One Vital Bond” tells of physician Aroonsiri Sangarlangkarn’s longitudinal relationship with a patient she comes to call a friend. The bond between them affects her views on what can be gained through understanding patients on a more personal level.

Sangarlangkarn first meets Roger as part of a medical school program that matches up aspiring physicians with geriatric patients who provide mentorship on medicine from a patient perspective. She then encounters him again after she has finished her training and he is hospitalized under her care. She reflects on the value of her deep knowledge of his personality and history.

I liked reading about Sangarlangkarn’s own lengthy description, written years prior as a medical student, of the patient’s social history. It included intimate details such as Roger’s parents’ names, his boyhood aspirations and his favorite board game. When I was a medical student I remember taking a very detailed history of a woman who was in the hospital for treatment of her malignant tumors. I spent over an hour with her, just chatting with her about her history. No physical exam, no review of medications. The final typed up document I turned into my advisor was over two pages long. Now, as a busy primary care physician, I, like Sangarlangkarn, can see how the emphasis on efficiency causes time constraint that makes it difficult to have meaningful patient-physician conversation that could contribute to helpful personal knowledge. Sangarlangkarn laments that “our interactions with patients have become so regimented and one-dimensional that we no longer get to know the multifaceted person outside the hospital.”

What do you think about Sangarlangkarn’s suggestion regarding the value of patient home visits? This is often done for patients in hospice care or who are unable to physically get to a clinic. Home visits because of the time they require seem much more costly to the system but Sangarlangkarn argues that the value – the ability to get to know the patient on a different level – provides invaluable information. She writes: “To effectively provide care for someone, it’s important to learn who they are, what they eat, how they breathe.” She, in fact, due to her detailed knowledge of the patient, is the only one who eventually can get him the end of life care and support he needs.

Writing Prompt: Think about a time you visited an ill person at home, whether that be an apartment, house or adult family home. Describe what you saw, what you smelled, what you talked about, how you felt. What do you think can be gained by entering into a person’s living space? Alternatively, consider a patient you’ve known for years, maybe decades. What do you know about that patient because of a longitudinal relationship that might be of benefit to you if you had to deliver bad news or discuss different treatment options or medications? Write for 10 minutes.

 

Continue Reading

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? 

Continue Reading