Narrative Medicine

Narrative Medicine Monday: Hospital

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Poet and essayist Marianne Boruch illuminates a scene from a “Hospital.” Her poem provides a contrast of what an outsider might experience and the reality of those who work in such a place. She notes that “It seems / as if the end of the world / has never happened in here.” For patients and their loved ones, their worst day, their worst moment, often occurs in the confines of the hospital.

The narrator expects more, a kind of signal, of “smoke” or “dizzy flaring” but instead she waits, watching people go by as if on a conveyor. She sees “them pass, the surgical folk– / nurses, doctors, the guy who hangs up / the blood drop–ready for lunch…” They are going about their day, their work. She catches them at “the end of a joke,” but misses the punch line. Instead, it is lost in “their brief laughter.”

Boruch’s reflection reminds me of Mary Oliver’s lines in Wild Geese: “Tell me about despair, yours, and I will tell you mine. / Meanwhile the world goes on.” Boruch’s poem reveals the dichotomy of a hospital: while some can be devastated, others go about their day, wearing their designated uniform of “a cheerful green or pale blue.”

When I have been a patient, or the loved one waiting for word, the usually familiar hospital is completely transformed from how it exists for me as a physician. Boruch captures these parallel worlds in her poem, and gives the reader space for reflection on their disconnect.

Writing Prompt: Think of the last time you were in a hospital as a patient, as a visitor, as a medical professional. What did you observe? How did your experience differ based on the reason why you were there? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: A Tense Moment in the Emergency Room

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Author and physician Danielle Ofri’s latest piece in The Lancet outlines “A Tense Moment in the Emergency Room.” Ofri describes the concern of an African-American medical student as a “young man stormed into the doctors’ station… and held up his toddler. ‘My baby’s choking and you guys aren’t doing anything.'” The medical student knows she is least senior of the gathered medical professionals, but she also is the “only African-American person among the white doctors” and is “acutely aware of the fraught dynamics,” given the child’s father is also African-American. She considers stepping forward to assist, even though per her estimation the child is not in imminent danger. Instead, she holds back. Ultimately, the “highest person in the medical hierarchy” asks the man to return to his room and the situation escalates.

Ofri notes what anyone who has visited or worked in a hospital is keenly aware of: the hospital is a stressful place. Given the already heightened tension, if you “[a]dd in issues of race, class, gender, power dynamics, economics, and long wait times … you have the ingredients for combustion just hankering for tinder.” The broader issue is that “racial and ethnic disparities in medical care are extensive” and “implicit or unconscious bias is still entrenched in the medical world.” How have you witnessed this issue in giving or receiving medical care yourself? Do you know if the organization you work at, or receive medical care from, is working to address implicit bias in medicine?

The medical student’s reaction to the father differed from her white colleagues: “When the father stormed into the doctors’ station, she saw fear and concern; her fellow physicians saw aggression.” These issues are complicated by the various power dynamics that exist in medicine. On one hand, the medical student wonders if she would be treated similar to the father if she were a patient there, given they are both African-American and therefore “look the same to the outside world.” However, in that situation she was both “part of the powerful group—the doctors—but as a medical student, she was singularly powerless… a medical student might just as well be part of the furniture.”

Ofri contends that in the medical field we often justify our behavior in tense encounters “because we surely know that we are not racist, or sexist, or homophobic. We are good people and we have chosen to work in a profession dedicated to helping others, right? How could our actions possibly reflect bias?” Ofri calls us to seek out stories, to listen to one another. Medicine, after all, “remains an intensely human field: illness is experienced in human terms and medical care is given in human terms. We humans bring along our biases and stereotypes—that is true—but we also bring along our ability to communicate and to listen.” I know this is a skill I need to continually cultivate in my own practice. How might you listen better today?

Writing Prompt: Have you experienced a similar situation as this medical student regarding power dynamics, wether related to race, class, gender, or level of training? Think about such an event, either during your medical training or when encountering a medical professional as a patient. How did the people around you react differently? How did you react? Did your perspective of the incident change over time? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: The X-ray Waiting Room in the Hospital

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“The X-Ray Waiting Room in the Hospital” by author Randall Jarrell thrusts us into his “big shoes and wrinkled socks,” and one of those “much-laundered smocks” that all the patients wear. Jarrell laments “[t]hese new, plain, mean / Days of pain and care…” and that “routine / Misery has made us into cases.” He describes the “machine” that each smocked patient suffers in, and the reader gets the sense that Jarrell is referring to more than just the mechanics of the x-ray, but also the greater “machine” that is medicine.

Jarrell was an American poet and critic who lived in the mid 20th century but his commentary on the patient’s experience of modern medicine still rings true. Jarrell wants each “nurse and doctor who goes by” to acknowledge him and each patient as an individual, but instead finds that “we are indistinguishable.”

Jarrell concludes that instead of trying to “make friends” with the medical professionals and get them to recognize his individuality, “It is better to lie upon a table, / A dye in my spine.”

Writing Prompt: As a patient, have you ever felt “indistinguishable” from other patients to your medical provider? If you’re a medical professional, do you agree with Jarrell’s assertion that “this routine / Misery has made [patients] into cases?” Can you think of a time when a patient has become merely a case, to you or a colleague? What are the consequences of this, to both the patient and they physician? How can we help doctors and nurses to see patients as individuals again? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Reasons for Admission

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I opened up a nondescript brown package last week to discover Bellevue Literary Review‘s latest issue, showcasing a beautiful new redesign.

In this 35th issue, Gaetan Sgro’s poem “Reasons for Admission” reveals the complexities surrounding modern day hospitalizations. Sgro notes that often the reasons are contradictory: “Having just gotten insurance. Never having had insurance…. Because you are terrified of dying alone. Because you are terrified of living alone.” Sgro is clearly attune to the many and varied kinds of hospital admissions, including the seemingly non-medical. I like Sgro’s play on words that shows two hospitalization realities: “Because of a broken system. A positive review of systems.”

Writing Prompt: This poem is part of Bellevue Literary Review‘s “Dis/Placement” issue. Why do you think this poem fits this theme? If you work in a hospital, list the reasons, obvious or more subtle, each of your current patients was admitted. Alternatively, think of a patient who has been admitted for one of the reasons Sgro lists in his poem. What was their story? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: What Patients Say, What Doctors Hear

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Dr. Danielle Ofri’s latest book, What Patients Say, What Doctors Hear is a call to re-examine the way doctors and patients communicate with each other. Through fascinating patient examples and directed research, Ofri illuminates the pitfalls in the current medical system that lead to miscommunication and, ultimately, worse heath outcomes.

I was particularly struck by Ofri’s call for physicians to become better listeners, and thus “co-narrators” of a patient’s story. This term was coined by researcher Janet Bavelas, whose study shows that how physicians listen to a patient’s story in fact contributes to the shaping of that narrative. Ofri asserts that “medicine is still fundamentally a human endeavor,” that one of the most significant ways we can advance health care is by improving one of our most basic tools: communication.

I’m thrilled Dr. Ofri will be speaking to my medical group this week and I’ll be able to meet her in person. Dr. Ofri has written many books and essays important to the world of narrative medicine and is the Editor-in-Chief of the Bellevue Literary Review.

Writing Prompt: One chapter in Ofri’s book outlines a “Chief Listening Officer” who was hired by a hospital to listen to patients and translate their needs back to the hospital so they could improve care. Ofri notes the value of this, that “being listened to so attentively is a remarkably energizing experience. It makes you eager to continue engaging.” Have you ever had an interaction with a medical provider who listened to you and your story in this way? How did it make you feel? Did that experience benefit your health in any way? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Air Hunger

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The narrator visits her mother in the hospital in “Air Hunger,” a striking short essay found in University of Virginia’s narrative medicine journal Hospital Drive. 

Two months have passed since she last saw her mother, but in the interim the narrator notes her mother has “become a patient.” The details the writer shares give us a glimpse into how her mother’s illness has changed her over time. Her mother barely touches the lunch tray beside her hospital bed: “She picks at her food, but it’s air that she’s hungry for.” The narrator wants to ask her mom how she feels, but already knows the answer: “I can see what I see, I can hear what I hear.”

Writing Prompt: Have you witnessed a loved one’s deterioration of health over time? What was it like to see them in one light and weeks or months later note a dramatic change? Do you remember a moment when they became, either to themselves, to you or to others, “a patient?” Write for 10 minutes. 

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Narrative Medicine

Narrative Medicine Monday: Feeding Tube

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In “Feeding Tube” author Susan Kelly-DeWitt relays a memory of paper birds that a patient’s family hung over the hospital bed “—wild tropical birds, macaws and toucans, parrots and cockatoo.” The visual that Kelly-DeWitt provides is vivid. The reader comes away feeling that humanity reigns over the mechanical devices that tend to dominate the hospital landscape.

I remember very little about the physical details of the critical care hospital room where I participated in my first code as a medical student. I do remember sitting by the resident physician as he wrote his note in the patient’s chart at the nurses’ station just after the man had died. I looked across the desk into the patient’s glass-walled room, my eyes fixed on an elaborate dream catcher hung carefully, just over his bed.

Writing Prompt: The hospital can sometimes feel a like a sterile, mechanical place. Think of a moment or an item, like Kelly-DeWitt’s paper birds, that struck you as out of place or particularly telling about a certain patient, their family and their life. Write for 10 minutes.

 

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Narrative Medicine Monday: Bedside Rounds

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John L. Wright’s poem, “Bedside Rounds,” speaks to the apprentice-like training of physicians. It is a passing on of skills from the experienced to the inexperienced, from the knowledgeable to the clinically naive. Most medical students, unless they have a background in another medical field, have little to no real experience in the hands-on component of medicine. They take years of study – biology, anatomy, pathophysiology – and translate that book smarts into skills of diagnostic touch, suturing skin, prescribing treatment. 

One method of transforming head knowledge to a practical skill set is through bedside rounds: a gaggle of medical students and resident and fellow physicians (still in training) following after an experienced attending physician. Each morning this group travels from bedside to bedside, discussing the patient’s disease, the patient’s prognosis, the patient’s progress, the patient’s treatment plan. In recent years, medical schools have worked on making this process more inclusive of the patient who, after all, is the subject of the discussion. 

Wright’s poem touches on the experience of that patient, ill and incapacitated, being talked over in a cryptic language, determinations being made about the status and plan while the patient may still be steeped in a cloud of confusion. 

Wright finds himself in a comparable situation when his landscape architect brings her intern along with her one day. As this professional passes on her skills to her protégée, discussing his yard in detail, Wright begins to feel something he hadn’t expected: “I begin to resent them—the little games they play.”

Writing Prompt: Think of a time you’ve experienced bedside rounds as a physician, as a patient or while visiting someone in the hospital. If you were the patient, how did you feel when the medical team discussed your case in front of you? Did they include you in the discussion or explain what they talked about? If you’re a medical provider, choose a memorable bedside rounding experience: running rounds for the first time, being a brand new medical student, noticing something significant with the patient’s demeanor while their case was being discussed. Write for 10 minutes.

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Narrative Medicine Monday: Architecture of Mental Illness

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This fascinating National Public Radio story by Susan Stamberg reviews an exhibition at the National Building Museum exploring the links between architecture and mental health. It outlines the history of Washington, D.C.’s St. Elizabeths Hospital, first opened in 1855 and championed by Dorothea Dix, a pioneering advocate for more humane treatment of mental health patients.

The article states that Dix “‘believed that architecture and landscape architecture would really have a role in curing people.'” Do you agree? Have you witnessed physical surroundings play a significant role, either positively or negatively, for a patient or loved one with mental illness?

Some of the photos included in Stamberg’s story conjure up a dignified 19th century hotel. Dix was a proponent of having beautifully manicured grounds and St. Elizabeths was designed specifically to have “natural light and views of the outdoors” and “heat, tall arched windows and screened sleeping porches where patients could catch summer breezes.”

Writing Prompt: Use one of the photos from Stamberg’s story as a writing prompt for a free write. Imagine you are one of the patients (or nurses) in the St. Elizabeths Hospital of the 19th century. How does the space make you feel? Alternatively, if you’ve visited or worked in a contemporary inpatient mental health facility think about the design of the place. How could it be improved on? How do you think the features affect the inpatients? Write for 10 minutes. 

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Narrative Medicine Monday: Things My Daughter Lost In Hospitals

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Toni L. Wilkes reveals her daughter’s illness journey through her poem “Things My Daugther Lost In Hospitals” in the journal The Healing Muse. I’m struck by how she alternates between the physical, tangible losses (“a pear-shaped gallbladder”) and the more unexpected costs (“her husband’s patience”). As a reader, I almost miss the surprising and heart wrenching losses, placed innocuously among the more conventional ones. I’m compelled to return to each line and deconstruct the poem, in search of these melancholy nuggets that reveal the true toll.

Writing Prompt: List all of the things you’ve lost or gained by being a medical provider. Alternatively, list all of the things you’ve lost or gained through an illness. Consider the concrete (i.e. money) and the more intangible (i.e. time). Write for 10 minutes. 

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