Narrative Medicine

Narrative Medicine Monday: History Taking in the Anatomy Lab

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Bethany Kette writes about “History Taking in the Anatomy Lab” in the latest issue of JAMA. Kette describes how in medicine we almost always start with the history of the patient, then move on to the physical exam. Kette notes though that “there is one time in our medical careers when we are instructed to perform the most thorough physical examination possible without learning so much as the patient’s name:” that of dissecting a cadaver in anatomy lab.

Now, fifteen years removed from that anatomy lab and ten years into my primary care medical practice, I can attest to the value of history-taking in a relationship developed over time: “It is a closeness and privilege that can provide purpose and meaning to routine acts of medical care.” Yet as medical students learning anatomy through the very intimate process of dissection, we receive very little information about our donors, only their age and cause of death.

In order to better understand the life of the woman who donated her body, Kette created the Obituary Writing Program at Georgetown. Kette developed the program with input from the Literature and Medicine Track director (how great that this is a track in a medical school!) and an obituary writer for the Washington Post. The result allows interested medical students to craft a real narrative about their donors, discover stories “that reveal a life.”

Kette interviews her donor’s son and learns that the woman was a “small-town farm girl” who graduated from Georgetown University School of Medicine: “She had literally stood in my footsteps in the same formaldehyde-scented labs in which I had spent the past year with her as my teacher.” The woman eventually retired from medicine to become a painter and was a “devout Catholic;” her faith informed her drive to help others. The medical students who participated in Kette’s program read the obituaries they had written during a ceremony at the end of the year, part of expressing gratitude to the donors themselves and to their loved ones for the gift of the donor’s bodies.

Kette’s program puts “history in its rightful place before the physical— students now interview the families of their donors before making the first cut in anatomy lab.” It also serves as a reminder to those of us well into medical practice that a person’s rich history, their life lived outside the hospital bed or exam room, is what we’re striving in medicine to help them return to, and what matters regarding their health, in the end.

Writing Prompt: If you are a physician, what do you recall about your initial interactions with your cadaver in anatomy lab? What did you know about the person’s history? What did you wonder or invent? Consider writing the obituary or life story of a well-known relative, friend or patient. How does outlining this narrative affect your relationship to this person? Write for 10 minutes.
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Writing

Narrative Medicine Monday: Poof

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This elegy by poet Amy Gerstler was selected by this month’s Poem-a-Day curator, Maggie Smith. I wrote about how Smith’s poem “Good Bones” hangs on a nondescript bulletin board in our clinic, though I never did figure out who posted it there. Each morning this month, I’ve been eager to see what poem Smith selects.

It’s no surprise that I think poetry provides much needed perspective to the world of medicine, and Gerstler’s “Poof” is no exception. Gerstler begins with a small bag of ashes on her lap, a gift from her late friend’s family. She recalls the service, the details of “staring at rows of docked boats” and the woman’s “impossibly handsome son.”

Gerstler speaks directly to her old friend, remembering that “You were the pretty one. / In middle school I lived on Diet Coke and / your sexual reconnaissance reports.” She imagines an alternative storyline where “your father never hits / you or calls you a whore.” Through Gerstler’s memories, both real and imagined, we get a glimpse of their bond, of the woman she, and this world, lost, even though we never learn her name, her vocation. (Why is it that these are the first things we ask? Always: What’s your name? What do you do?)

Gerstler gives us a remembrance that is more: a cinematic illumination of who this woman was: “You still / reveal the esoteric mysteries of tampons. You / still learn Farsi and French from boyfriends / as your life ignites.”

I like that Gerstler considers alternate storylines of their history together. Our formative years can be like this, wondering what different versions of us might transpire. I imagine (and, reaching middle age myself, have already succumbed to such reveries) our later years might also be prone to wondering what other tributaries of life paths might exist in the universe.

Ultimately, we learn that their lifelong relationship remains much as it is was in their adolescence: “I’m still lagging behind, barking up all / the wrong trees, whipping out my scimitar far / in advance of what the occasion demands.” Gerstler’s tender flashes of moments between the two is a tribute not only to her late friend, but also for all of us who are lucky enough to have kept company with cherished friends over the decades.

Writing Prompt: Think of a person (or patient, if you’re a medical provider) important to you who was suddenly gone. Write them an elegy in second person, or, alternatively, a letter. What are the memories, the moments, that stand out to you? Did this person vanish, as they did for Gerstler, with a “poof,” or would you use a different way of describing their absence from your life? Alternatively, consider writing an elegy or a letter to a long-time friend or patient who is still alive. Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Brain Biopsy

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Pathologist and poet Dr. Srinivas Mandavilli illuminates the microscopic, and the universal, in JAMA‘s “Brain Biopsy.”

Mandavilli lets us know that in “neuroradiology they have a gift for reading the mind.” In moving a glass slide, he learns to “bow in silence and see an underworld / —an otherworld where planets improvise like nuclei.” The narrator alternates between the microscopic and the broader cosmos. Through this, Mandavilli evokes a sense that we are all part of a grander whole, even the minuscule and aberrant parts of us.

His poem ends with the relational, with a hint at the journey we travel: “While we drive on a summer evening, she rests, / her long fingers intertwine, the heft / of her dark tresses strewn carelessly like the road ahead.”

Writing Prompt: Think of the smallest and largest components of life, of existence. How are they connected? Alternatively, pull out your old histology textbook or your child’s microscope. Examine a slide and write what you see, how this observation makes you feel. Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: In Life’s Last Moments, Open a Window

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British physician and author Rachel Clarke advises in The New York Times that to care best for our terminally ill patients we should, “In Life’s Last Moments, Open a Window.” Dr. Clarke relays the story of a patient dying of cancer who was nonverbal but clearly in anguish. “We tried talking, listening, morphine. His agitation only grew.”

Clarke initially questions if the “sheer vitality of nature might be an affront to patients so close to the end of life — a kind of impudent abundance.” Instead she finds, as in the case of her patient with tongue cancer who merely wanted his door opened wide to the adjacent garden, many patients develop an “intense solace… in the natural world.”

It is the song of a blackbird outside her window that gives one of Clarke’s breast cancer patients perspective that even “[c]ancer is part of nature too, and that is something I have to accept, and learn to live and die with.”

Clarke shuns the idea that end of life care needs to equate to a “dark and dismal place.” Instead, she contends that what should dominate hospice “is not proximity to death but the best bits of living.”

Writing Prompt: Clarke’s patient Diane notes that cancer is a part of nature. What are the implications of this statement for you as a medical provider, as a patient, as a loved one? When you’ve been ill, have you found solace in nature? Write for 10 minutes.

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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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Ramblings

Deadlines

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I have several deadlines looming this week, so my regular posts have gone by the wayside. In addition to a final rewrite of this essay for an upcoming anthology, I also had a big assignment due for my Hugo House Finish Your Book class this week, as well as putting the final touches on my AWP Writer to Writer application. Not to mention a new narrative medicine program I’m getting off the ground this fall, modeled after Dr. Suzanne Koven’s Literature & Medicine program at Massachusetts General Hospital in Boston.

I wrote about grace with the blogging schedule and the importance of fluidity here, but I also want to stay true to my regular writing practice. Sometimes though, deadlines take precedence. Come back Monday, with deadlines in check and blissfully on vacation, for a new Narrative Medicine post!

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Ramblings

Rhythm

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I’ve been out of step, out of commission the past few weeks. I was incredibly ill over Easter weekend, had to cancel family events and it took my body a week to recover. I also was preoccupied with taking the medical board exam this week, a once in a decade test to maintain my license. My usual pattern of writing and blogging fell out of rhythm for the first time in two years.

I’m hoping to refocus, regain some footing now that I have other distractions behind me. Writing is essential to my life, my own self-care and purpose. I’ve been thinking a lot about rhythms of life, what is nourishing and essential, how different stages can be taxing in familiar ways.

Each month this year I’ve focused on a different area of personal growth. April is dedicated to the Sabbath, that sacred space of rest. I’ve always struggled with the concept of Sabbath and today’s nonstop rush of a world feeds into my tendency of devotion to productivity, to my To Do List, to my ambitions. I’m reading Wayne Muller’s “Sabbath“, which is a call to incorporating a rhythm of rest.

This may seem contrary to what I just wrote, about needing to re-establish my focus on writing, on my rigid rhythms. But I don’t think they’re actually incongruous, this need for structure, this necessity of rest. I want to avoid being legalistic about my schedule, but I also find comfort in boundaries, in a steady rhythm. Life brings so much unexpected upheaval. I don’t think it’s disingenuous to find peace in a plan that provides structure, that carves out time for that which is nourishing, which is restful.

What are your thoughts on rest? What rhythms of life do you find helpful or limiting? I will continue to explore this idea of Sabbath, but also return to my rhythms of writing in the hope that I’ll find peace both in learning to rest and in work that brings me fulfillment.

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Writing

The Artist’s Way

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At the beginning of the year, I stumbled into a group working through Julia Cameron’s prolific The Artist’s Way. The premise is that we’re all created to be creative, that along the way our artistic self becomes “blocked” and, through a process of exercises and exploration, we can unleash our underlying creativity, transforming our own life in the process. It’s an involved undertaking, which I tackled in characteristic too-fast-out-of-the-blocks fashion.

I had heard of Cameron’s book but didn’t know much of what it was about when I agreed to commit myself to the group and the process. I’ve found the “Morning Pages” Cameron endorses a cathartic free-form journaling that does serve to unearth our core stumbling blocks and greatest desires in life. I’m recalling previous passions and brainstorming ways I could incorporate these childhood joys into my adult life: writing and playing music, performing elaborate plays, detailed needlework, making bracelets, dancing.

I have to admit I was skeptical at first. Despite being a life-long journaler with a history of a strong spiritual faith, I initially found some of her observations and suggestions new-agey and impractical. What modern professional parent has time to write three pages every morning and take their inner artist on a weekly date? I’ve since come around, appreciating the thematic chapters and exercises, the encouragement and confidence instilled that we are all creative beings, most content and most ourselves when we find ways to weave artistry into our lives.

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