Narrative Medicine

Narrative Medicine Monday: Ikiru

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Today’s Narrative Medicine post highlights a first: a movie. As part of preparation for this week’s Columbia Narrative Medicine Workshop, I watched a 1952 Japanese film, Ikiru. This movie, directed by Akira Kurosawa, outlines the life and death of a man with end stage cancer.

I happen to also be facilitating a Literature & Medicine gathering this week, where the topic is “Confronting Mortality.” In it, we are reading Tolstoy’s novella “The Death of Ivan Ilyich,” which similarly shows a man facing a terminal illness and wrestling with the meaning of his life and the nature of his painful death.

In Ikiru the protagonist, Mr. Watanabe, has not missed a day of work in 30 years at the same tedious government job. The narrator notes that “he’s only killing time, he’s never actually lived.”

I’m certainly not a movie critic, but several things stood out to me, looking at this film through a narrative medicine lens. First, his physicians insist on withholding the terminal nature of Mr. Watanabe’s illness, stating it’s a “mild ulcer” only, even when Watanabe begs them for the truth. This scene reminded me of a panel on cultural issues in bioethics I attended many years ago. On the panel was a bioethicist from Japan, and he explained the cultural influence of withholding the true prognosis or even diagnosis of an illness from a loved one; that a physician might deliver a terminal diagnosis to a patient’s family member rather than to the patient themself.

We get flashbacks in the movie to understand the central character more. His wife died when his son was young and he never remarried. Although they live together still, Watanabe and his son have a difficult relationship; they struggle to really communicate and Watanabe in fact is never able, despite several efforts, to actually confide his diagnosis and angst to his son.

Mr. Watanabe comes across a stranger who he asks to show him “how to live” and they gamble and dance and drink, but ultimately he finds little lasting pleasure in these endeavors.

The central character then turns to an old colleague, a young woman, trying to decipher her vitality, her zest for living. Through this interaction, he resolves to get a park built for the community. In the end he succeeds, battling the bureaucracy he was a part of himself for decades. It seems the completion of the park gives the dying man some semblance of peace, a legacy solidified, which produces the meaning he was struggling to find.

Writing Prompt: At one point in the film, Watanabe tells a colleague “I can’t afford to hate people. I haven’t got that kind of time.” What are the different ways you’ve seen patients who are terminally ill react to facing their limited time? Did they give up hate? Or something else? In Mark Doty’s poem “Brilliance” the patient initially gives up investing in anything he can’t finish. Why do you think Watanabe decided that the playground would be his last project, his last investment in what little energy and time remained? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Why Doctors Should Read Fiction

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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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Narrative Medicine

Narrative Medicine Monday: Still Not Convinced You Need a Flu Shot?

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Aaron E. Carroll provides a straightforward explanation as to why getting the flu shot is imperative to a healthy community. In his New York Times article “Still Not Convinced You Need a Flu Shot?” he notes we may be passing on the virus without realizing it, to people much more vulnerable than ourselves: “You can infect others a day before you show any symptoms, and up to a week after becoming sick. Children can pass along the virus for even longer than that.”

Carroll points out our lack of concern about the flu virus, so familiar every winter, is illogical: “Because the flu is so common, we tend to minimize its importance. Consider the contrast with how the United States responded to Ebola a few years ago. We had a handful of infections, almost none of them contracted here. One person died. Yet some states considered travel bans, and others started quarantining people.” He argues that we should be much more concerned about the flu, noting that influenza is the “only cause of death in the top 10 that could be significantly reduced by a vaccine. Lowering risks of heart disease, cancer or Alzheimer’s are much, much harder to do.” We have a way to decrease the morbidity and mortality from a common illness yet we choose not to harness that opportunity.

By looking at the history of the varicella vaccination, Carroll illustrates the benefit we gain through herd immunity and the ethical consideration of getting immunized even if you yourself are not at high risk. He notes that babies were dying from chicken pox prior to implementation of the vaccine, but “as rates of vaccination rose, the rates of death from varicella were low…. But more significant, from 2004 through 2007, not one child younger than 1 year old died in the United States from chickenpox. What was amazing about this finding was that we don’t vaccinate children that young for chickenpox — therefore, those babies’ deaths were not prevented because they were vaccinated. Their deaths were prevented because we vaccinated their older siblings.”

In a previous Narrative Medicine Monday post, I highlighted a New York Times article written by Dr. Danielle Ofri that I’ve used when teaching narrative medicine courses to medical professionals. It illustrates the challenge of communication between physicians and patients and why there often is a disconnect. How can we improve the dialogue to better inform the public and, ultimately, save lives?

Writing Prompt: Do you get your flu shot every year? Why or why not? Do you feel that you understand the reasoning for immunizations? What information might help you better understand? If you’re a medical provider, have you struggled to convey such information to patients? Think of such a time and write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Locked-in Syndrome

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Pakistani bioethicist Anika Khan reviews Jean-Dominique Bauby’s remarkable story in her essay “Locked-in syndrome: inside the cocoon.” In it, she describes how Bauby, an editor of a prominent magazine who suffered a debilitating stroke, lived out his days entirely paralyzed but with mental clarity completely intact. Bauby’s only method of communication, and how he eventually wrote his 1997 book The Diving Bell and the Butterfly was by blinking with his left eyelid. He used a French alphabet provided by his speech therapist to painstakingly blink his way to communication with the outer world.

Khan relays some of Bauby’s remarkable insights into living in such a state and she also reflects on how medical providers need to take a “more empathetic look at the incapacity and helplessness experienced not only by patients with locked-in syndrome, but by analogy, other patients who have no way of giving voice to their experience of sickness. Often, patients become diseases, numbers and syndromes to healthcare professionals who have repeatedly seen illness and have lost the capacity to relate to the experiences of patients.”

Writing Prompt: Have you as a patient ever felt misunderstood by your medical provider? What were you trying to relay and what was the response that revealed to you the miscommunication? Think about your visceral reaction to this encounter. As providers, what specifically have you done to combat the risk of patients becoming “diseases, numbers and syndromes?” How do you maintain this empathy while still preserving some emotional boundaries? Write for 10 minutes.

 

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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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