Narrative Medicine Monday: In Shock

Although I’ve never met her, author and critical care physician Rana Awdish on some level feels familiar. Not only are we both part of a supportive online group of physician-writers, but I just finished reading her wrenching memoir, “In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope.” Awdish’s gripping account of her near-death experience, subsequent hospitalization in her own ICU and revelations about the shortcomings in both support for and education of medical providers in the realm of empathy are illuminating. Her book is infused with challenge and hope and a call to transform the way we train physicians and care for patients.

Awdish is thrust from the world of providing medicine into that of receiving it – a patient under her own colleagues’ care. The contrast of these positions of power and vulnerability are striking and Awdish describes the jarring experience and her own enlightenment as she pivots between these two roles. She shares with the reader her revelations regarding how we provide medical care to those in crisis and inspires us to find a better way.

I was particularly convicted by Awdish’s insight into how medical training encourages physicians to suppress many of our emotions. She traces this ideal back to the father of modern medicine, Sir William Osler, who encouraged “‘aequanimitas.’ Osler regarded this trait as the premier quality of a physician. It represented an imperturbability that was described as manifesting in ‘coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril.'”

Awdish asserts that as physicians “we aren’t trained to see our patients. We are trained to see pathology. We are taught to forage with scalpels and forceps for an elusive diagnosis buried within obfuscating tissues. We excavate alongside our mentors in delicate, deliberate layers, test by test, attempting to unearth disease. The true relationship is forged between the doctor and the disease.” Do you agree with Awdish’s assessment? Why or why not?

If you’re a physician, if you’re a patient: read this book. Discuss it with your colleagues, mull over it with your book club. The questions Awdish raises, the challenges she poses are vital to improving the way we care for each other in our most acute times of need.

Writing Prompt: If you’re a physician, did you learn to develop “aequanimitas” through your training? Did you feel this trait was a requirement, overtly stated or otherwise, to be a “good physician?” Have you yourself ever been a patient feeling, like Awdish, “powerless in a way that is impossible to imagine, from a privileged position of wholeness and well-being?” Awdish lists biting phrases that were directly said to her or that she overheard when she was a patient. Have you experienced similarly painful words from a medical provider? Have you said such words to a patient before? Try writing from both the patient and the medical provider’s perspectives. Write for 10 minutes.

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Narrative Medicine Monday: Baptism by Fire

Pediatric Intensivist Gwen Erkonen’s fast-paced essay “Baptism by Fire” was recently highlighted in one of my favorite online creative nonfiction journals, Hippocampus Magazine. The piece begins with Erkonen sitting in Grand Rounds, a newly minted attending physician. Erkonen deftly describes the apprehension and weight of responsibility all physicians experience when, after a decade of training, they are finally in charge: “Four years of medical school, three years of pediatric residency, and three more years as a pediatric critical care fellow. My time as a medical apprentice is done. I no longer have an attending physician to help me with my decision-making. I am solely responsible for my patients.”

Erkonen’s pager calls her to an excruciating emergency: a toddler with extensive life-threatening burns. The reader is thrust into the dire situation with her as she assumes care of the critical patient, running the resuscitation efforts of the medical team and communicating with the young girl’s mother in the waiting room.

Erkonen not only relays her own inner turmoil during this first challenge of her new career, she also conveys her keen observations of the other participants. The surgery resident she first meets in the trauma bay “looks cool and in control with his hands folded across his chest and a broad-based stance, but I can tell from his shaking voice he’s not sure what to do.” Erkonen’s details describing the patient’s devastated young mother gives us insight that the family’s narrative is multi-layered and tragic even before this catastrophic event: “She starts to sob, and buries her head in the older lady’s chest. Then I notice that she has a disposable Bic lighter in her hand. She keeps flicking it so that flames jump from the spark wheel…. I notice that her hands are dirty. Not from the fire but because she hasn’t showered in several days.”

Most any physician can empathize with Erkonen’s inner dialogue. Years of training doesn’t negate the adrenaline-infused uncertainty when you first encounter the incredible weight of trying to save another’s life: “Feeling like an idiot, I nonetheless plow forward.” Erkonen is unflinchingly honest in her description of the events and her vivid details leave the reader breathless, exhausted and empathetic, as if we were watching them unfold on a medical drama, yet responsible along with her.

Writing Prompt: Think of a time when you were in a new position that held intense responsibility. Maybe it was your first week as an attending physician or a new job managing a large part of your workplace. Maybe it was your first hours as a new parent. Describe your own inner dialogue and your perception of others you interacted with during that time. Alternatively, try re-writing Erkonen’s essay from the point of view of the surgical resident, the burn nurse, the patient’s mother, the priest, the trauma surgeon. Write for 10 minutes.

 

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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: County Hospital Residents

Abby Caplin’s “County Hospital Residents” profiles immigrant physicians, re-training in an American residency program. Caplin’s poem begins with the more general–where a physician is from–and contracts into the more intimate details, the sequence of events that brought this person into this profession far from home.

Writing Prompt: Have you encountered an immigrant physician as a patient or through your own medical training? What was their story? Imagine leaving your home country to practice medicine and live your life elsewhere. What would be the greatest challenge? What does the diversity and experience of immigrant physicians bring to our medical community? Write for 10 minutes.

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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.

 

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