Narrative Medicine

Narrative Medicine Monday: The Evidence-Based Metaphor

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Medical student Brit Trogen argues that metaphor is not only an important tool in doctor-patient communication but that physicians should be trained to use the most effective metaphors to deliver medical information. Her recent article “The Evidence-Based Metaphor,” uses the example of the medical student’s simulated patient encounter, where actors portray patients and then provide feedback to aspiring physicians about their communication skills. All medical students go through rigorous testing to ensure they can manage the science of medicine, but the more nuanced communication skills required to be an effective clinician can be more difficult to both train and test. Trogen wonders what if there were a way to help guide young physicians toward better communication with their patients, thereby improving the health and well-being of those they’re tasked to care for.

Trogen notes that time pressures are evident for physicians in today’s medical system: “With appointment times creeping ever shorter, a physician may have only moments to explain a complicated scientific concept to his or her patient in a way that is both clear and memorable.” I struggle with this every day in my own practice; many of these concepts take years of study to understand fully. How can they best be distilled down so patients can make a truly informed decision?

I appreciate Trogen’s idea to promote “evidence-based communication” just like we adhere to the values of evidence-based medicine. This is the idea that the treatments we prescribe, the screening modalities we suggest, the procedures we perform be based on research-driven facts, substantiated studies that show that this plan is the best course of action for most. Instead of basing medical care on a whim, it’s based on evidence. Research-based evidence could also have a role in how best to convey information to patients effectively in a time limited way. 

Do you agree with Trogen that physicians would be more effective if equipped with better communication tools, rather than just scientific knowledge? What do you think about her statement that “knowledge is important, but not always sufficient?” As a primary care physician, much of my day is spent helping patients brainstorm how they can remember to take their medications, what changes could be made in their lifestyle to add in some exercise or improve their diet, why they should consider a colonoscopy or cutting back on alcohol or get certain screening tests based on family history. I know I’ve honed some of my own communication skills over my years in practice, but I would welcome a way to reach each patient, if possible, in a more effective and proven way. 

Writing Prompt: Do you recall a physician using a metaphor to describe a treatment plan, disease process or other medical process? Was it helpful? Write about the experience. If you’re a medical provider, think of something you often counsel patients about. Try brainstorming metaphors or consider writing a complete fable on this topic. Alternatively, think about a doctor-patient interaction that hinged on very good (or very poor) communication. Describe the encounter and the benefit or consequences. Write for 10 minutes.

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Ramblings

Free Write Friday: Cabin

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They like to take the ferry, run to the front or the back deck as soon as we embark, salty wind whipping their tiny faces. Their small bodies lean up against the kelly green railing, white foam erupting as the boxy boat rips through the murky waters of Puget Sound. We’ll have some Ivar’s clam chowder for lunch, too many saltines or oyster crackers dumped in the compostable bowl. Their dad will douse the fish ‘n’ chips in sour vinegar and the middle child will follow suit. 

Once we arrive to the island we’ll stop for groceries. Just the basics, just the staples of milk and bananas and eggs and coffee, then wind across the narrow strip of land. Leaving pavement, curving down a gravel-lined lane, slender sticks of evergreen trees reach to the pale sky. They look as if they could topple, bend at the whim of a strong gust, but they’re deceptively sturdy, roots diving deep to anchor. Like toothpicks they taper at the top, their branches fanned out, curved upward. Sometimes an eagle will rest on an upturned branch, as we all rush to observe the regal creature before it stretches its wings to take flight.

We unpack, get reacquainted with the comfortable surroundings. Giant windows and a spanning deck overlook the water below. Down a sharply steep path, dozens of stairs treacherously slick in mid-winter mossy dampness lead to the rocky beach. I like to sit above it all, the steely water below is calming; a constant motion that, strangely, evokes stillness. I wonder if the eagle feels the same; looking down from afar details are missed but the larger picture, the grandness of a distant perspective is captured.

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Narrative Medicine

Narrative Medicine Monday: What You Don’t Know

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Today’s Narrative Medicine Monday is a bit different in that I’m posting an excerpt from a radio show rather than a sample of poetry or prose. Stories of medicine, health and illness are found in all types of art, including written form, oral stories, music and visual mediums.

This American Life is a prolific radio show that covers widely varied topics in a heartfelt, honest and often humorous way. Each show has a theme and this past week’s episode was titled “In Defense of Ignorance.” In the first act, “What You Don’t Know,” writer and producer Lulu Wang tells her family story of deciding to keep test results of the most dire news from her grandmother. Her family’s Chinese heritage influences the stance they take in keeping her grandmother in the dark about her terminal diagnosis. Wang, raised mostly in America and very close to her grandmother, doesn’t agree with this position but, at her family’s request, complies. 

Wang’s family story brings up issues of bioethics, cultural norms and how bad news affects health and illness. How might cultural norms influence the very standards of bioethics in a particular case? Do you agree with the family decision to keep the grandmother in the dark about her terminal diagnosis? Why or why not? Do you think her grandmother actually knew all along? Spoiler alert: Do you think not telling Wang’s grandmother contributed to her surviving despite her dire diagnosis? Wang mentions the Chinese belief of the connection between the mind and body. What are your thoughts on this connection?

Writing Prompt: Think about your own family dynamics and cultural norms. How do you think this has shaped your own views on health and illness? Can you think of a time this construct specifically influenced your medical decision making? Alternatively, think about the connection between the mind and body. Do you think one influences the other? How? If you had a terminal diagnosis, would you want to know? Why or why not? Write for ten minutes. 

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Motherhood, Ramblings

Free Write Friday: Treadmill

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Someone just wanted it out of their house, a bargain at $100, less than a month’s membership at the local gym. Her husband had been wary; another contraption in the basement? But she was pregnant with her third baby, knew there would be no escaping once this little one came, no time to leave for exercise or much of anything. With three under five, it would be difficult to even make it around the lake with the jogging stroller anymore. So she took up the space, hoping it would run, it would work, it would fit into her new morning routine. 

It’s old, dusty when she first folds it down. The belt is loud, too loud to hear the TV over the grating whir. She winces, hoping it won’t wake up the children, but down in the basement the sound that rises to the second floor must just be a pleasant buzz, converging with the white noise machines in their bedrooms. 

Nothing fancy, no bells, no whistles, but it runs. She starts slow, a brisk walk, but quickly accelerates to jogging pace; no time to dilly dally. Heavy legs pumping, headphones jammed into her ears. She can just barely make out the words from the morning news, the NPR co-host waxing poetic about immigration, about divisive politics, about the latest breaking headline. It’s turned up too loud, probably not good for her ears, she thinks, but the cardiovascular exercise makes up for the auditory damage, right? 

The baby monitor is perched precariously where the magazine should be set. She never understood this: how could someone read while running? It always seemed foolhardy to turn a magazine page while jogging on a moving floor, always seemed impossible to lean in to decipher the miniscule type while working up an active sweat. 

Sometimes she’ll see the baby stirring on the monitor, she’ll hear a whimper from the floor above, children starting to argue over their morning cereal. So she runs faster, picking up the pace: 6.5 mph, 7.0. Must. Finish. Run. She starts sprinting. Sometimes she makes it, finishes the 3 miles before the children take over the morning. Sometimes her preschooler comes down to watch, cozy blankie and pull-up in hand, eager to get his day going. He might play with his cars for a bit, watch her quizzically, examining the contraption that lets her move so much without going anywhere. “Mama, a pulley!” She smiles, nods. Lately he’s been obsessed with finding pulleys everywhere. 

She misses running outside, rain on her face, dodging puddles, watching the seasons change around the nearby lake’s circumferential path. Fellow runners are motivating and she seems to run so much faster when she’s exercising outside. But this, it gets the job done; it gets the endorphins rising before 6 a.m. She gets her daily exercise, the muscles worked, the healthy fatigue. And, a year later, she thinks: this may be the best $100 I’ve ever spent. 

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Narrative Medicine

Narrative Medicine Monday: Reprieve

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In his poem “Reprieve,” Jeffrey Harrison writes about the several months following a cancerous brain tumor removal. Everyone is able to take a breath while the patient resumes his daily activities. Although it seemed “a miracle almost,” they “all still wondered how long it would last.” The narrator questions if this time period felt like an “afterlife” to the patient. I like how the narrator lists the simple daily tasks the patient was able to resume, giving us a glimpse into his life and what he had been missing because his illness. 

Have you or a loved one had a serious illness that, for a time, seemed resolved? How did you feel when the treatment worked? If the illness recurred, how did you look back on that time period?

Writing prompt: Think about a time when you, a patient or a loved one was well following a serious illness. Were you able to trust in that period of wellness? Were you always wondering if the illness might come back? If so, how did that undercurrent of worry limit you? How did it feel to grow strong again or resume your daily activities? Write for 10 minutes. 

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Ramblings

Free Write Friday: Current

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I was a cautious child, hesitating to do anything that might jeopardize a fragile status quo. But I grew up spending my summers on the beaches of the north shore of Kauai and grew comfortable with the fickle ocean, the swells of the sea, the ebb and flow of the tide.  

In the afternoon sun I could float on my body board for hours, waiting to catch a wave. I got to know the patterns of the ocean; a swell would come and I could predict if and when it would crest, white foam spilling over onto itself. I could anticipate if the swell would falter, just a tease of a wave really, petering out before it reached the sandy shore. 

Sometimes I’d get lost in my own reverie, daydreaming with the hypnotic rise and fall of the waves. I’d look up to realize I was far from my mom on the shore who was pretending to read a book. A worrier, like me, I suspect she was always half watching us rather than lounging, making sure we weren’t caught in a current or by a wave we couldn’t withstand. 

Sometimes her arms would flail back and forth over her head, like windshield wipers, her miniature form signaling from a distance. Maybe it was time to go, head back to the condo to wash off the sand that stuck in nooks and crevices of sunburned skin or was trapped beneath the mesh lining of my Lycra swimsuit. Or maybe she had noticed all the swimmers veering off to her left or to her right, a strong current carrying away her babies in tow. She’d put down her unread novel and signal us to the safety of the shore. 

A momentary flash of panic, my mother’s voice echoed in my head that it was better to swim parallel to the shore, not directly perpendicular, if caught in a riptide or strong current. Not the most direct route, it seems counter intuitive, but it’s the key to safely reaching solid ground. I’d heed her advice, tanned arms pumping overhead, one after the other, slowly carrying me back to white sands. 

When I reached the shore, my feet on solid ground, and looked back at the water it all looked so innocuous, so unassuming. But the metal warning signs posted on sturdy rods stuck deep in the sand and my mother’s furrowed brow admonished: don’t underestimate its power, be careful. If you’re not, it might just carry you away.

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Narrative Medicine

Narrative Medicine Monday: County Hospital Residents

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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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Ramblings

Free Write Friday: Spoon

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He carries the spoon everywhere, has for the last few weeks. It’s a wooden spoon, sturdy and stick-like, good for digging and rapping along a concrete wall on the way to preschool. His constant companion, the spoon is good for a lot of things.

He has an affection for the spoon, like he does his cozy blankets or baby sister. The spoon can’t be left at home without an uproar. It accompanies him to bed for naps and nighttime, it rests on his lap for episodes of Octonauts, it’s enclosed in his hand when he’s having his diaper changed or in his car seat, it lays in front of him when he’s brushing his teeth or eating his yogurt.

He knows never to use it to hit others but he brandishes it enthusiastically, swinging this way and that as he gestures emphatically telling animated stories. It’s become an extension of his upper appendage. I have to remind him to not accidentally knock his baby sister on the head. It’s been a magic wand, a shovel at the beach, a fishing pole, a drumstick, a golf club. 

He’s had obsessions before: rope, treasure maps, kites. But the spoon in its simplicity, its practicality, has staying power. It stirs, it points, it protects. It’s a tool, it’s a weapon, it’s a musical instrument.

The spoon is a steady, sturdy companion to rely on; I can see why he keeps it by his side. I know at some point he’ll move on to his next obsession, the next important thing in his singularly focused world. But I suspect he’ll always remember this ratty spoon fondly, and treasure it as so much more than it seems to be. 

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Narrative Medicine

Narrative Medicine Monday: Dinosaurs

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Ophthalmologist Maria Basile writes of the evolution of surgery in “Dinosaurs“, part of the Poetry and Medicine column in JAMA. Her poem reflects on innovations in how surgery is performed and is a commentary on the constant churn of medical reinvention. 

Have you or a loved one personally benefited from a recent medical innovation? Can you think of something important that might have been lost through adopting a medical advancement? Also consider the challenges posed by some new medical procedures and breakthroughs. When kidney dialysis first emerged as an option for treatment of kidney failure and there was very limited availability. Decisions needed to be made about who would receive this treatment. Sometimes a medical innovation raises unforeseen and difficult ethical challenges. 

Writing Prompt: Think back to when you first started medical training. How has medicine changed since that time? What were considered the greatest innovations or bioethics questions of that time? What are they now? Alternatively, think about what was considered a medical marvel when you were a child. How is that innovation viewed today? Write for 10 minutes. 

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Ramblings

Free Write Friday: Band

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We played musical chairs in the high school band, every few weeks had the opportunity to challenge the seat in front for a better position in the concert band hierarchy. The director limited the frequency of a challenge so it wasn’t an incessant churn. It was a matter of pride, a source of anxiety. On the designated day we’d draw slips of paper to tell us who would perform first. The challenged and the challenger would retreat to the hallway behind the band room for the sake of fairness, ensuring anonymity, playing the chosen piece, notes echoing across the linoleum floor. 

I played the clarinet because my older brother played the clarinet and I suspect my parents didn’t want to buy another instrument. So I was convinced that the clarinet was the only instrument I wanted to play. A practical choice, a safe choice, a non-choice. Easy to lug home as a fifth grader, enough compatriots to sink into a sea of black woodwinds. Disappearing was the thing you wanted as a preteen anyway. Some brave souls chose the French horn or the tuba, the cello or the oboe. The coolest kids played the drums or saxophone.

I did practice, was decent enough. No real musical talent but I could play with feeling. It got me far enough to be one of the first few chairs. I was challenged or challenging all the time. Sweaty palms, I’d retreat behind the heavy classroom door with my opponent, often a friend. Fingers slipping off the silver rings, compressing and popping in cadence. I liked to go first because I got it over with. I liked to go second because I could tailor my performance to the weaknesses of my opposition. I liked to win first chair; felt full of myself, a boost to my fragile teen self esteem. I liked to be second chair so I didn’t suffer the angst of playing solos in the heavily attended concerts. 

Now, decades later, I have nightmares that I’m supposed to play in a band concert and haven’t practiced at all, can’t read the music, don’t remember how to play a single note. I’m embarrassed, mortified I arrived so unprepared. I try to disappear into the sea of instruments, remain undetected. Instead I realize that not contributing to the wave of melody is just as problematic as inserting an errant note. 

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