Narrative Medicine

Narrative Medicine Monday: Solving for X

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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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Narrative Medicine

Narrative Medicine Monday: The Bright Hour

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I first came across Nina Riggs’ book, The Bright Hour, because of its comparison to another popular memoir, physician author Paul Kalanithi’s When Breath Becomes Air.

Riggs was a poet, and her writing style reflects this; short chapters with descriptive elements and a musicality to the sentences that leaves us wanting more. She is honest and funny. Diagnosed with breast cancer in her thirties, a life just hitting its stride with two young boys in tow.

In describing Atul Gawande’s book Being Mortal, Riggs illuminates the heart of her own memoir “of living and dying.” She notes the attempt “to distill what matters most to each of us in life in order to navigate our way toward the edge of it in a meaningful and satisfying way.”

Riggs navigates the world of oncology and the process of dying with candor and a clear sense of self. When her oncologist discusses her case with colleagues she bristles at the standard name for the meeting of minds: “Tumor board: the term kills me every time I hear it. You’re just saying that to freak me out, I think. What is actually a group of doctors from different specialties discussing the specifics of your case together around a table sounds like a cancer court-martial or a torture tactic.”

She takes her young sons to her radiation oncology appointment in the hopes of getting them interested in the science behind the treatment. In the waiting room, she becomes acutely aware of how, taken as a group, her fellow cancer “militia” appear: “Suddenly I am aware of so many wheelchairs. So many unsteady steppers. So many pale faces and thin wisps of hair and ghostly bodies slumped in chairs. Angry, papery skin. Half-healed wounds. Growths and disfigurements straight out of the Brothers Grimm. So many heads held up by hands.” Have you ever been entrenched in a world of medicine or illness and then suddenly seen it from an outsider’s perspective?

Riggs ushers the reader into her new world as breast cancer patient. In a particularly striking scene following her mastectomy, she goes to pick out a breast form from the local expert, Alethia. “‘Welcome!’ She says. ‘Let’s find you a breast!’ She tells me that according to my insurance, I get to pick out six bras and a breast form…. The one she picks comes in a fancy square box with gold embossed writing: Nearly Me.” As Riggs’ contemporary, I could see the grave levity in the situation; Riggs is a master at sharing her experience, heartache and humor alike.

In the end, this is a memoir of a young woman who is dying. She acknowledges this and realizes that, near the end, there is a metamorphosis of light: “The term ‘bright spot’ takes on a whole new meaning, more like the opposite of silver lining: danger, bone pain, progression. More radiation. More pain medicine. More tests. Strange topsy-turvy cancer stuff: With scans, you long for a darkened screen…. Not one lit room to be found… not one single birthday candle awaiting its wish. No sign of life, no sign of anything about to begin.”

Writing Prompt: If you’ve read Kalanithi’s When Breath Becomes Air or Atul Gawande’s Being Mortal, how does their approach to writing about dying compare with The Bright Hour? Riggs comments on a kinship with the “Feeling Pretty Poorlies” she meets during her radiation treatment but because of HIPPA privacy regulations, never knows if they finished treatment or if it was “something else” that caused them to disappear. Did you ever participate in a treatment where you saw the same people regularly? Did you wonder about them after that time ended? Think about the privacy rules set in place to protect patients’ privacy. What are the benefits? Do you see any drawbacks? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Lessons in Medicine, Mortality, and Reflexive Verbs

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I “met” Dr. Robin Schoenthaler through an online group of physician writers. Schoenthaler has been universally encouraging to our growing community of novice and accomplished writers and offers practical and helpful advice. Her kind of wisdom and support is so needed in both the literary and medical worlds.

This article by Schoenthaler, published in the New England Journal of Medicine, describes her use of Spanish during her medical training in Southern California. Schoenthaler learned much of the language from her patients, notably a “young woman named Julia Gonzalez” who, admitted with acute myeloid leukemia, taught the young Schoenthaler “considerably more than Spanish nouns and verbs.” After several rounds of chemotherapy, Julia improves and is discharged. This, along with Schoenthaler’s progress in Spanish, bolsters the young doctor.

Schoenthaler recalls that in medical school she fell in love with, “of all things, reflexive verbs. I loved the concept of a verb that made the self the objects.” Schoenthaler found that reflexive verbs gave her what seemed to be a “kinder, gentler way of speaking to patients in those early, awkward days of training. It felt so much more graceful to say to a stranger, ‘You can redress yourself’ rather than ‘Put your clothes back on.'” I too remember the awkwardness, in words and in deeds, of being a new physician. So much is foreign; the medical jargon and culture, the intimacy of illness and body each patient entrusts us with.

Schoenthaler finds that trying to discuss a topic as challenging as cancer tests her Spanish language skills. Near the end of medical school she attends a language immersion school in Mexico and her Spanish improves dramatically. When she returns, her patient Julia is readmitted with a grave prognosis. Distraught, she calls her mentor and he advises: “‘Now, you concentrate solely on her comfort.'” The new doctor translates his words into Spanish, “with its reflexive verb: ‘Ahora nos concentramos en su comodidad’ (Now we concentrate ourselves on her comfort). We, ourselves, all of us.”

Schoenthaler makes it their mission, instead of a cure, to provide comfort for Julia in her last days: “I held her hand and rubbed her wrists and used my reflexive verbs. We were both speaking a foreign language.” After Julia dies, Schoenthaler calls Julia’s mother, using the Spanish words she’s learned to convey the worst of all news: “‘Se murio’ — ‘She herself has died.'” The mother’s response needs no translation.

Writing Prompt: When you were first starting to care for patients, what words or phrases seemed most awkward? As a patient, have you had medical providers use phrasing that seemed detached or confusing? If you speak multiple languages, think about the different ways sentences are formed. What gets lost or jumbled in translation? Alternatively, think about a time you had to tell a patient’s loved one they died. What words did you use? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: The Second Floor

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Poet Rachel Hadas describes how those near the end of life grow distant before they pass in “The Second Floor.” She begins with a dream, consisting of “a harried pilgrim to a shrine.” She states that “[a]s quickly on their short legs toddlers move, / tall parents lumbering in slow pursuit, / so they speed onwards, people whom we love.” I like the unexpected juxtaposition of the unsteady toddler at the beginning of life to the dying loved one at the end. She paints an image of Sam and his daughter cradled together in “[s]leep and love, the quick, the nearly dead.”

Writing Prompt: Do you agree with Hadas’ assertion that the terminally ill are “somehow out of reach well before the grave?” Why or why not? What role do dreams play in our processing of ill or dying loved ones? Have you experienced such a dream? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: The Last Heartbeat

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Cortney Davis’ “The Last Heartbeat” explores her competing identities as daughter and nurse at her dying mother’s bedside. Davis opens the poem as she holds her mother’s hand, counting her last heartbeats, witnessing her last breath. She ends with greater questions of life and soul as she walks with a friend through a cemetery.

Writing Prompt: If you’ve been at the bedside of a loved one as they died, what do you remember most? What have you forgotten? What about at the bedside of a terminal patient? Did this experience prompt greater questions about the soul? Write for 10 minutes.

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Narrative Medicine, Writing

Published: Nine Lives

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I’m thrilled to announce my essay “Fired” appears in a new book, Nine Lives: A Life in Ten Minutes Anthology, forthcoming from Chop Suey Books Books in June. Valley Haggard, of Life in 10 Minutes, is the mastermind and editor behind this exciting project. I can’t wait to get my hands on this compilation! You can purchase your own copy of Nine Lives, which is made up of short essays that follow the “ages and stages of life” online on June 14 from Chop Suey Books.

My piece that appears in this book highlights a moment I shared with my grandpa “Gar” during the last days of his life. In honor of Narrative Medicine Monday and this short personal piece, today’s writing prompt will focus on hospice.

Writing Prompt: Have you spent time with someone on hospice or near the end of their life? What do you remember the most? What have you forgotten? If you’re a medical provider, how does caring for someone as a medical professional compare with caring for a loved one at the end of life? If the experience was overwhelming, try focusing on the details: a glance, a thought, a smell, an item, a phrase. 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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Narrative Medicine

Narrative Medicine Monday: Going Solo

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Nurse and writer Amanda Anderson describes the final moments of caring for a patient in the ICU in “Going Solo“.

Anderson opens the piece noting that she decides to scrub the patient’s teeth clean. Why do you think she’s determined to complete this simple act?

The author comments that this passing feels different than others because she doesn’t also have the patient’s family to nurse through the process. Her actions are per protocol, “governed only by a set of instructions:
1.  Administer pain dose once, prior to extubation.
2.  Extubate patient.
3.  Administer pain dose every three minutes for respiratory rate greater than twenty,
or obvious signs of pain, as needed.
4.  Notify house staff at time of asystole.”

How do you feel when you read through the protocol that Anderson follows? How do you think she feels and how does she convey that through her writing?

I appreciate Anderson’s candidness in immersing us in her thought process. She plays jazz for him, then realizes, what if he hates jazz? As medical providers, we only get a snippet of a patient’s life. If you’re a medical provider, have you ever wondered about a specific patient’s life outside of the hospital? How could that information inform their care? As a patient, what do you wish your medical providers knew about who you are?

Writing prompt: As a medical provider, think about a protocol you follow, a procedure or list of instructions you adhere to in a certain situation to provide care. List the steps. Now consider an unwritten protocol, such as a nurse in caring for family members throughout their loved one’s death in an ICU. List the steps. How do they compare? Alternatively, think about an encounter you’ve had in the medical world: a ten minute doctor’s office visit, visiting a friend who is hospitalized, getting or giving an immunization. Imagine the broader life of the person who was giving or getting that medical care. Consider their life narrative. Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Family Summons

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When rotating through the Intensive Care Unit in medical school or residency, one of the most significant skills learned, in addition to adjusting mechanical ventilation settings and how to run a code, is how to conduct a “family conference”. This is where loved ones, preferably including the patient’s designated medical decision proxy, gather to discuss the patient’s status, prognosis and treatment plan. As these patients are severely, sometimes suddenly, ill, these can be very challenging conversations. 

In “Family Summons” Amy Cowan illustrates how she was surprised to have a patient’s family gather in the middle of the night, wanting to speak with her as their family patriarch’s physician. Her piece highlights how important it is to listen and extract the true identity of the patient, the life they lived beyond the ICU. Establishing this portrait can help inform the care team as well as free the family members to make decisions in line with what their loved one would want.

Writing Prompt: Have you ever attended or conducted an important medical family conference? How was it run? If not, can you imagine what questions you might ask to best get to know the patient? Think about if you were the patient in the ICU; who would you want to gather on your behalf and what might they say when asked about you and your life, what’s important to you? Write for ten minutes.

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