Narrative Medicine Monday: Hammond B3 Organ Cistern

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.

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Narrative Medicine Monday: The Insulin Wars

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.

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Narrative Medicine Monday: Narrative Gatherings

The first Medical Humanities Twitter Chat, or #medhumchat, happened January 2nd and was curated by Dr. Colleen Farrell, an internal medicine resident. Although I wasn’t able to fully participate (bath time for my three kids, as often is the case, was not a well-controlled event that offered much down time for a Twitter chat), I was able to go back and read the lively conversation.

Farrell notes in this follow up post the role the humanities play in helping “make sense of the seemingly senseless suffering and heartbreak I witness daily as a doctor.” This seems a common sentiment among medical providers today, as varied opportunities in narrative medicine expand.

Farrell’s blog post lists the Medical Humanities Chat readings and questions, along with a few responses from participants. It’s an interesting format to interact with medical professionals and patients from all over the world.

The next Medical Humanities Chat will be this Wednesday, January 16th at 9pm EST, on the topic of Racism & Medicine. I’m hoping, bath time willing, to be able to participate in this important discussion.

Locally, I recently attended the Northwest Narrative Medicine Collaborative‘s inaugural Seattle event, a medical moth with the theme of “My First Time.” The event sold out in just a few weeks and the stories told were varied, often humorous, and resonant with the crowd of both medical providers and the general public.

The next Seattle NW Narrative Medicine Collaborative event is yet to be announced, but I know is already in the works.

The popularity of these opportunities to share our stories, consider a narrative, process the intimate and at times wrenching role we as medical providers play in health and illness, highlights the thirst for such contemplation and conversation among increasingly burnt out physicians and frustrated patients. I find myself, ten years into my own career in primary care, seeking out such community, eager to help cultivate ways to gather and share.

I hope, wherever you are, you can find or foster similar opportunities to share your story, consider your patients’ narratives, and use the humanities as a tool for further introspection and connection.

Writing Prompt: Consider reading the pieces Dr. Farrell selected for the first #medhumchat and answer the questions posed in written form. Were your answers similar to the ones posted during the live chat? Did you gain a different perspective after reading through the conversation? Did any of your answers or reactions to the readings surprise you? Write for 10 minutes.

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Narrative Medicine Monday: Leaving the Body

Author Lisa Knopp shows how we can be drawn to the presence of a body even following death in Hospital Drive‘s “Leaving the Body.” After her mother dies, Knopp lingers in her hospice room, asking to stay as a woman enters to wash her mother’s body and ready her “for the people who are coming to pick her up soon.”

Knopp initially wonders about “the point of bathing my mother, since her body will soon be ash.” The nurse’s aide speaks to Knopp’s mother as she wipes her face and arms. Knopp finds this “comforting, this informing my mother of what’s about to be done to her, since I can feel that something of her is still here.”

When the aides remove the woman’s gown, Knopp is filled with wonder at her mother’s naked body. “Even though she would feel shamed by my scrutiny, I want to savor and memorize the details.” This body holds memories for Knopp, the substance of a mother-child relationship, connection: “I know their shape so well: large knee bones, slightly bowing calves, like those of her mother, and thick ankles. Just below her right knee on her inner calf is a blue vein, an inch or two long that has been there as long as I can remember.”

In these moments right after her mother’s death, Knopp finds herself “starving for her physicality” and tells the aide she’d like to touch her mother. She kisses her forehead and strokes the top of her head and wonders, “What is it that I’ll be missing now that my mother’s heart has stopped beating, and she’ll soon be turned to ash?” Her mother has died, but Knopp is still drawn to her physical body, the familiarity of her mother’s form that will cease to exist. Knopp shares that her greatest regret will be that “we didn’t spend more time in each other’s physical presence” and that this final sponge bath is her “last chance to see and touch and smell my mother, flesh of my flesh, my first home.”

Knopp recalls all of the beautifully mundane things she and her mother chatted about on the phone, though they rarely discussed her cancer or the grander questions Knopp yearned to ask her dying mother. The loss Knopp highlights in her essay isn’t so much about the flesh itself, but more about her experience of her mother that was contained in that body: her “voice, words, thoughts, laughter, and silences.”

Knopp reflects on the waning importance of physicality in our modern world, how the dean of her college encourages faculty to have more screen time and less face time with students, how so many interactions with friends are via social media and not in person.

At the end of the essay, Knopp combs out her mother’s hair, braids it with care and cuts a lock of hair as a token. Knopp is unsure what she will do with the lock of hair, but the gesture seems satisfying in the moment, keeping “more than just memories of her body” before they wheel her away.

Writing Prompt: If you’ve been present with a dead body, either a loved one or a patient, what did you experience while in that space? Was it difficult? Healing? Both? Did you feel drawn to touch the body, as Knopp did? What are your thoughts about Knopp’s observation that we spend significantly less time face-to-face? How do you think spending less time in the physical presence of others might affect us? Write for 10 minutes.

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