Free Write Friday: Pay Phone

We hardly see them anymore, the free standing booth a novelty. A friend’s son once asked, “Mom, why do they say ‘hang up’ the phone?” Well, this is why: the dangling silver cord like a techy serpent, tethered to a bulky handset.

Now we’re all cordless, no need to connect other than with head down, blue screen filtering. Everything is shiny, posed, captured. No hang ups, strings attached, call waiting. All is instant, polished, curated.

I remember anticipating a call at home, phone ringing in the kitchen, my dad answering hello soon after I picked it up in my basement bedroom. “I GOT IT!” reverberating through the house, high pitched preteen voice anxious for privacy.

I remember fumbling with silver coins at the pay phone, flipping through weathered white pages skimming for the right name, pen scratches and coffee stains marking the tissue-like paper.

I remember a friend’s dad’s car phone, brick handset centered between the front seats of their Chevy Suburban. The wonders of a phone call made from a moving vehicle, away from a stationary box without foundation, without directional bounds. It was fancy, magical, very nearly unheard of. I watched in awe as he answered, mid-errand and corresponded, communicated, then moved on about his day.

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Narrative Medicine Monday: And Still We Believed

Emergency physician Dr. Rebekah Mannix relays the story of her teenage goddaughter who developed vomiting and eventually a dire diagnosis of metastatic cancer in JAMA’s “And Still We Believed.”

Mannix finds herself researching experimental treatments, hoping for a “miracle,” but unable to find any in the medical world: “We did not comprehend that someone so healthy and vibrant…could succumb.” Even after the patient was transferred to comfort measures only, Mannix admits she “still wasn’t ‘there’ yet.” “Even as I knew she would die, I believed she wouldn’t.”

Mannix speaks to the idea that even as physicians, as scientists, we “know better” but still our humanity takes precedence over logic and understanding. There is a lesson here for medical providers. Patients may comprehend what we tell them, but they might not always believe it: “Even as they sit holding the hand of a loved one on a morphine drip–whose organs have shut down, whose words have ceased–they still may not believe death will come.”

Writing Prompt: Have you ever experienced a dire diagnosis for your yourself or a loved one and not believed it? If you’re a physician, how can we best navigate supporting a patient or their family when, despite clear evidence to the contrary, they “still believe.” Write for 10 minutes.

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Narrative Medicine Monday: Solving for X

Author Pam Durban tries “Solving for X” in her nonfiction piece in Brevity. Durban tells us that she’s “never been good at word problems,” the kind that involve trains and “variables of time, speed, and distance.” At seventy years old, she is now able to “manage the simpler calculations” such as knowing that she “doesn’t need a dental implant that lasts fifty years.” At her current age, though, she finds some of these “word problems of life” are riskier and “always end with an unsolvable X–the date of her death.”

Durban muses on how to manage these unsolvable Xs. She experiences a bout of amnesia in an E.R. and recalls an uneasiness with the concept of eternity, finds her “multiplying Xs” just as unnerving. Durban masterfully gives us a glimpse into the mind of a woman in the last part of her life, but highlights that even nearing the end, the question of time can be perplexing, unsettling and stretch out into the future.

Writing Prompt: Have you calculated, like Durban, your need for a thirty-year roof or if you’ll be around for the next solar eclipse? Can you relate to Durban’s unease with “multiplying Xs?” Why do you think she “sees a way” in the memory of returning to her father’s grave? If you are a medical provider who cares for elderly patients, what can you take from Durban’s essay that might be helpful in how you approach patients who are making decisions about medical care and treatment plans? Write for 10 minutes.

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Free Write Friday: Hula

She always wanted to learn hula, admired hips swinging, grass skirt swaying. Bare brown feet, toes kissing the earth, arms outstretched, calling out a narrative. As a spectator she pieced together a story told long ago, tethered to form and melody.

The girls wear magenta lipstick, long hair swept to the side with a plumeria, a hibiscus, an orchid for adornment. She longed to be made up too, tell a story with her movements, with her hands raised heavenward.

Ballet never appealed to her; such delicacies were not in her constitution. She did like tap dance, clipping the hard floor, reverberating sound. Tap, though, still possessed a harsh edge: a clank of form, of function. Not a gentle sway, like the hula, like this place: fluid, fragrant. Here she relaxes into her bones; the breeze, the rolling waves smooth and synchronous to her heartbeat, to her soul.

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Narrative Medicine Monday: Why Doctors Should Read Fiction

Sam Kean’s article in The Atlantic, Why Doctors Should Read Fiction,” highlights what many medical schools, residencies and medical groups are realizing: medical providers and patients alike benefit from physicians taking an interest in literature. Kean asks, “if studying medicine is good training for literature, could studying literature also be good training for medicine?”

Kean’s article outlines a study in Literature and Medicine, “Showing That Medical Ethics Cases Can Miss the Point.” The study found that “certain literary exercises…can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.”

Students rewrite and dissect short stories that expose an ethical case study, such as physician-writer Richard Seltzer’s “Fetishes.” The study’s author, Woods Nash, argues that “short stories are far more effective means of teaching students and health-care professionals to wrestle with the mess, to pay attention to narrative perspective and detail, and to become more comfortable with ambiguity.”

Writing Prompt: Have you read a piece of fiction that outlined a certain bioethical dilemma? Do you agree with Kean’s assertion that doctors should read fiction? How might the practice prove beneficial to a medical provider? Read Seltzer’s “Fetishes” and rewrite the story in short form, as a poem or case study. What new insight do you gain from this exercise? Write for 10 minutes.

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Free Write Friday: Swing Set

The swing set in their their backyard was evergreen, angled legs buried among the smooth stones of a playground’s gravel. Their mother would shoo them out the sliding glass doors, the house couldn’t contain two growing boys and their spirited sister.

She’d scamper down the grassy hill, passing the roses, transplants from their previous rambler in another affluent suburb. That house was too small for their growing family but she remembers the room she shared with her baby brother fondly. The tiny dresser with yellowed fabric, decorative flowers and overlapping plaid; just flashes, fragments of memories.

This new house was bigger, each child their own room, a greenbelt bordering their backyard. She liked to explore among the sticker bushes, pretend to make a meal from the salmon berries that lined the creek each spring.

Two swings hung from the top bar of the modest play set and she usually started here, choosing the one on the left if she beat her brother to it. Skinny legs pumped high, leaning back and letting go at the top of the arc; just the right timing to jump far, ever farther, trying to beat her previous sneakers’ impression in the gravel.

Then she’d move on to the face-to-face glider, tiny backed seats allowed swinging with a friend. They’d hold on to chained ropes on either side, leaning back, leaning forward, mirrored and synchronized.

Eventually they’d grow too big, knees touching. Other activities took precedence as outdoor play receded into childhood. Green paint peeled, rust emerged. Too many years neglected in the damp Northwest air.

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Narrative Medicine Monday : What Can Odd, Interesting Medical Case Studies Teach Us?

Physician author Siddhartha Mukherjee writes in the New York Times about coming across an unusual case study recorded by the late Oliver Sacks. Sacks describes the case of a woman who had a “lifelong history of seeing people’s faces change into dragonlike faces.” Though not a neurologist, like Sacks, Mukherjee is fascinated by the case. A thorough evaluation, including neurological examination, M.R.I. scan and experimental treatments revealed no answer or resolution.

Mukherjee is puzzled by the inclusion in a prominent medical journal. He ponders: “There was no revelatory flourish of diagnostic wizardry….. It was as if Sacks lobbed the puzzle into the future for someone else to solve: In some distant time, he seemed to imply, another neurologist would read this story and find resonances with another case involving another patient and complete the circle of explanation.”

Mukherjee notes that Hippocrates, the father of medicine, himself outlined case histories that remained a mystery without a clear diagnosis. Mukherjee recognizes that medicine has changed: “But over the years, as the discipline of medicine moved concertedly from descriptive to mechanistic, from observational to explanatory and from anecdotal to statistical, the case study fell out of favor. As doctors, we began to prioritize modes of learning that depended on experiments and objectivity.”

Mukherjee seems almost melancholy about the demise of the case study and what this omission means to medicine: “I miss the acuity of the observations, the scatter plots of symptoms that cannot be put into neat boxes, the vividness of description…. I worry that unknown unknowns will go unwritten — that buried within such cases, there might have been a cosmos of inexplicable observations that might, in turn, have inspired new ways of thinking about human pathology.” What role might narrative medicine play in honing the observational and descriptive skills of medical professionals that Mukherjee notes is lacking in today’s medical world?

Writing prompt: Do you agree with Mukherjee that something is lost in devaluing the case study? If so, what is lost? Think of a patient or family member whose illness was unique and perhaps undiagnosed. Write their case study, a detailed accounting of their history of illness. Write for 10 minutes.

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Free Write Friday: Campsite

I like waking up in the tent, shadows from evergreen trees looming, voices from the adjacent campsite echoing as if through a tunnel, muffled and yet amplified. I took a nap, youngest child restless the night before, waking up in her crib every couple of hours whimpering, unable to articulate what was the matter. I sang to her from just above, hanging over the opening of the the Eurovan pop top, coaxing her back to sleep. “Shhhhhh,” I pleaded, “it’s sleepy time.” She’d suck her tiny thumb dutifully, nestle her chilled toes back under the blanket and fall into a temporary slumber.

We spent the morning on the trail, a 1.2 mile hike to the falls; unambitious I thought, but the way there all uphill elicited whining and necessitated cajoling and stops for snacks of peanut butter sandwiches since I couldn’t find the jelly. We carried the toddler in the hiking backpack, secured by straps, covered by sunshade. The other two discovered perfect walking sticks, treasured for a bit, then tossed aside in search of more appealing finds.

In the evening we ride our bikes around the campground, sampling different loops with unexplored hills and towering trees. Then we settle at the amphitheater for the kids’ ranger program. Khaki-clad speakers with wide brimmed hats talk about native wildlife, the history of the park, admonish about safety and recycling. We dissect owl pellets, we search for huckleberries and signs of animals scampering in the nearby bushes.

After s’mores we sit by the fire crackling. Does it cackle? The flames burst up from the pit, leaping to their destiny, unable to reach their desired height. Instead they are confined, sequestered. I look up to see the black outline of the trees, pine needles fuzzy against the dusky sky, bluing to black. The shadows are spooky and comforting. A paradox of sensibilities.

A gaggle of preteen girls stroll by our campsite, gossiping loudly. My husband remarks, ”That will be M soon.” A troupe, a pod. That’s how she’ll survive, how she’ll thrive or shrink, the passageway to adulthood. For now, this stage, she sleeps silently in the tent as we watch the embers flicker and pop, sip drinks, read books by the rising firelight.

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Narrative Medicine Monday: Relapse

Poet and nurse practitioner Carolyn Welch captures a summer moment in Intima‘s “Relapse.” Welch’s daughter suffers from mental illness. She begins with an acknowledgment that is familiar to anyone who loves a person with a chronic condition that remits and relapses: “Of course we knew it could happen.”

Welch’s poem is a recognition that life moves forward despite the shadow of such a recurrence threatening to disrupt: “…summer plodded on with heat and harvest– / a steady supply of peppers and tomatoes;” The garden and growth are reliable, predictable, even as Welsh speaks to her daughter who has returned to an undesirable state of illness. Welch, with heartbreak evident, realizes “the meds are off.”

Writing Prompt: Consider a chronic illness that can relapse, often unpredictably: depression, multiple sclerosis, addiction, cancer. How does it feel to be the family member, the physician, the patient for each of these conditions? Write a triptych that includes each of these perspectives. Alternatively, near the end of her poem Welch acknowledges a “nagging failure of want.” Have you felt a similar sentiment as a family member is suffering? Write for 10 minutes.

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Narrative Medicine Monday: The Poetry in Primary Care

Returning from vacation as a primary care physician, as any physician, can be a daunting task. I wrote a flash essay for Pulse about the intense timeline of a typical family physician’s workday. You can imagine after being gone for a week the mountain of forms, test results, and emails that accumulate. Even when you have, as I do (many don’t), supportive partners who do their best to clean out as much of the inbox as possible, there’s a particular dread and pressure that occurs for the primary care physician returning to work. In medicine, everything is connected to a patient. A response delayed, an aberrancy missed, means damage—emotional or physical—to a very real person.

It was on such a day, back to work after a week of camping and s’mores and searching for sand dollars on a Washington coast beach with my family, that I stumbled upon a poem. Our clinic is set up with exam rooms jutting in from corridors that originate like tributaries from the hallways that line the perimeter of the building. Our offices dot the exterior hallway, windows overlooking the parking lot or other buildings in the business complex.

I was walking along this exterior hallway, brisk step between patients, stuffing my stethoscope back into my stiff white coat pocket, when I was struck by a nondescript sheet of paper tacked to the bulletin board just outside our nurses’ office. “Good Bones” caught my eye, made me pause mid-stride. There were patients to examine, lab results to respond to, phone calls to make, radiographs to interpret, but I stopped and turned and read the familiar lines.

I’ve followed poet Maggie Smith’s work for some time. I find poetry alluring and intimidating. I took Michelle Penaloza’s excellent poetry class at Hugo House last fall to overcome my perplexion, but found it would take much more investment to grasp all I wanted about the craft of poetry. Smith’s work is relatable; my contemporary, a mother, an artist, her words resonate and I instantly became a fan.

But to see her here, amidst my other vocation, my medical science workday of Pap smears and skin biopsies and asthma exacerbations, was foreign, a collision of worlds. Though I’ve written about and taught narrative medicine for several years now, though I’m aware of the benefits, to both the physician and patient, of integrating the humanities into the science of medicine, I’ve still found it challenging to be present with such art during the compressive restrictions of my primary care workday. So, Smith’s poem, tacked inconspicuously along a back hallway bulletin board, among graphs of clinic access and Medicare Five Star goals and HEDIS measures and Press Ganey patient satisfaction scores, was a welcome interruption, a surprising reminder, an appropriate intermission interjected into a hectic workday.

I asked around for several days after, attempting to determine who had posted the poem of maintaining hope amidst a broken world. Though I was told it had been up for weeks, maybe months, I never did find the culprit. That same week Glennon Doyle highlighted this very poem on her social media. For me a collision of two women I admire, I’ve never met, whose good works are far from medicine, far from my little corner of primary care amidst the jutting mountains, the emerald waters of the Pacific Northwest. But the lessons, the convictions, the challenge of poetry is relevant, maybe the most relevant to my interactions with patients, my titration of insulin regimens, my diagnoses of cancer, my prescribing of antidepressants, my listening to histories to evaluate an unintentional weight loss or a shortness of breath or an abdominal distention leaving a patient in excruciating pain.

Maybe an antidote to our broken healthcare system, the crux of narrative medicine, a balm for medical professionals suffering from compassion fatigue and secondary trauma and a system that increasingly squeezes the humanity out of of its providers, rests in the complex workings, the simple act of reading poetry. There’s instruction in the words, in the art of the line break, illumination of humanity in the universal themes presented. A reminder that at the heart of medicine we serve people, we are people, we are all in this together. Poetry infuses humanity back into this most human, most intimate of professions. Medicine is a science but it is also an art. For all of our sakes, maybe it’s time to embrace that pairing in an inspired, more hopeful way.

Writing Prompt: How do you talk with children about the difficult aspects of this world? Despite the brokenness observed and felt, do you try to sell your children on the world in the hopes that they would attempt to make it beautiful? Do you see poetry in medicine? Why or why not? Write for 10 minutes.

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