Narrative Medicine Monday: Jamaica Kincaid’s “Girl” and the Challenge of Growing Up in Medical Training

I first read Jamaica Kincaid’s “Girl” as part of a generative writing workshop during a summer writing residency. Our small group gathered folding chairs around long tables set up in an old barn near the Stillaguamish River in rural Washington. I was taken with each of the readings poets Jane Wong and Claudia Castro Luna had us read, but “Girl” struck me most, with its unusual punctuation, jarring directness, and call to re-examine the lessons we receive.

Emergency physician and writer Dr. Naomi Rosenberg explains in a recent JAMA article how Jamaica Kincaid’s “Girl” resonates in a very different environment–with new physicians in a narrative medicine workshop.

Rosenberg comments on the unexpected “striking similarity” these physicians have to Kincaid’s young girl, joining “a system that demands they quickly learn the skills of their craft, the rules of survival, and the values they will fight for all while navigating their instinctive psychological responses to illness, injury, healing, injustice, and grief.”

Rosenberg and the “burgeoning narrative medicine department” at her urban hospital have used “Girl” in the residency didactic curriculum, medical school electives, and writing workshops for all health care system employees with a goal to “constantly explore ways to help physicians, nurses, staff, and students ‘develop attention.'”

She describes how when they ask the residents to read “Girl,” intially they are met with resistance. How could this lyrical prose about coming of age in an island culture relate to healthcare professionals who “treat gunshot and stab wounds, deliver babies, diagnose cancer, unclog dying hearts for a living?” And yet, the new physicians quickly make the connection: “‘It reminds me of residency,’ one obstetrics-gynecology resident tells us, ‘a million instructions and things to do. It’s all over the place, and rapid fire.'”

At the end of the session a simple writing prompt is given, “metabolizing their own experiences and taking a moment to string words together—something young physicians today rarely, if ever, get a chance to do.” The result is surprising: “an exploration of hierarchy, medical education, and the silent curriculum of growing up.”

I wrote about my own experience at Columbia’s Narrative Medicine workshop, where we did a similar exercise and I again encountered Kincaid’s “Girl.” I love Rosenberg’s use of this piece to help new physicians still finishing their training grapple with the accelerated nature of a medical residency, the growth and expectations that come with modern medicine. It also was interesting to learn that Rosenberg herself used “Girl” as inspiration for her own wrenching New York Times essay, “How to Tell a Mother Her Child Is Dead” which I wrote about here and is one of my own favorite pieces to use for reflection and discussion among healthcare professionals.

As Rosenberg recognizes, literature has a way of “again and again, deepen[ing] our inspection and understanding of the internal and external worlds.”

Writing Prompt: Take a cue from Rosenberg’s exercise and respond to “Girl” by writing instructions on how to be a healthcare professional (nurse, physician, pharmacist, etc.) Alternatively, write instructions on how to be a patient, or a patient’s parent or partner or child. Write for 10 minutes.

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Narrative Medicine Monday: History Taking in the Anatomy Lab

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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Narrative Medicine Monday: Preparation

Abigail Lin’s poem “Preparation” in the Journal of the American Medical Association begins with a heartbeat as the focus of a medical student’s studies. She notes “we studied valves as if they were pipes: / what makes them rust, or clog.” There’s a note of bravado as the student starts their journey in medicine: they “marveled… as if we had built it ourselves.”

The humility comes later, realizing the fallacy in believing that “we could learn the architecture of grief / simply by examining blueprints.”

I remember marveling at the intricacies of design in my college introductory biology courses. I had in mind that I wanted to be a physician, but one of my most surprising revelations was learning about botany. I was amazed by the specificity of design in plants, the complex workings of how they grow, receive nourishment from the sun, from the rain; how they give back to the earth.

Lin’s poem is a caution to new medical providers. Much of our learning is in the machinery of the patient, the inner workings of the body. So much more is involved in treating the patient, not merely the disease.

Writing Prompt: If you are a medical provider, recall when you first started studying medicine. Were you naive, as Lin’s poem asserts? Is there something you’ve studied that you’ve marveled at? Did you learn a more nuanced appreciation as you progressed in your career? Recall an instance that contributed to that maturity. Write for 10 minutes.

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

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 Monday: When Patients Mentor Doctors

When Patients Mentor Doctors: The Story Of One Vital Bond” tells of physician Aroonsiri Sangarlangkarn’s longitudinal relationship with a patient she comes to call a friend. The bond between them affects her views on what can be gained through understanding patients on a more personal level.

Sangarlangkarn first meets Roger as part of a medical school program that matches up aspiring physicians with geriatric patients who provide mentorship on medicine from a patient perspective. She then encounters him again after she has finished her training and he is hospitalized under her care. She reflects on the value of her deep knowledge of his personality and history.

I liked reading about Sangarlangkarn’s own lengthy description, written years prior as a medical student, of the patient’s social history. It included intimate details such as Roger’s parents’ names, his boyhood aspirations and his favorite board game. When I was a medical student I remember taking a very detailed history of a woman who was in the hospital for treatment of her malignant tumors. I spent over an hour with her, just chatting with her about her history. No physical exam, no review of medications. The final typed up document I turned into my advisor was over two pages long. Now, as a busy primary care physician, I, like Sangarlangkarn, can see how the emphasis on efficiency causes time constraint that makes it difficult to have meaningful patient-physician conversation that could contribute to helpful personal knowledge. Sangarlangkarn laments that “our interactions with patients have become so regimented and one-dimensional that we no longer get to know the multifaceted person outside the hospital.”

What do you think about Sangarlangkarn’s suggestion regarding the value of patient home visits? This is often done for patients in hospice care or who are unable to physically get to a clinic. Home visits because of the time they require seem much more costly to the system but Sangarlangkarn argues that the value – the ability to get to know the patient on a different level – provides invaluable information. She writes: “To effectively provide care for someone, it’s important to learn who they are, what they eat, how they breathe.” She, in fact, due to her detailed knowledge of the patient, is the only one who eventually can get him the end of life care and support he needs.

Writing Prompt: Think about a time you visited an ill person at home, whether that be an apartment, house or adult family home. Describe what you saw, what you smelled, what you talked about, how you felt. What do you think can be gained by entering into a person’s living space? Alternatively, consider a patient you’ve known for years, maybe decades. What do you know about that patient because of a longitudinal relationship that might be of benefit to you if you had to deliver bad news or discuss different treatment options or medications? Write for 10 minutes.

 

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Narrative Medicine Monday: Published!


Starting the year off sharing some great news! I recently received in the mail the Fall 2016 Edition of OUHSC’s Blood and Thunder Journal, which includes two of my essays. I’ve had several pieces published in online journals but there is a special kind of excitement that comes from seeing your name in print on a tangible page. I’m humbled that two of my favorite shorts “Expectant” and “Burst” found a home in this narrative medicine collection.

“Expectant” chronicles the very first delivery I witnessed. Obstetrics was a revelation to me as a young medical student, especially never having had children myself. I was in awe of the entire process and this short essay reveals my own insecurities as I was christened into the world of medicine.

“Burst” is about my first continuity delivery in residency training: a pregnancy meant to be followed throughout all nine months to completion. I was a new physician and had much to learn about the unpredictable nature of obstetrics.

One of my writing goals for 2017 is to make significant progress on a book-length collection of narrative medicine essays.  I’m starting the year off taking Creative Nonfiction’s online course “Writing Your Nonfiction Book Proposal”. Finding time to edit and submit my work has been a continual challenge but writing classes provide encouragement and structure to make the time, harness the energy and muster the gumption to keep at it. I’m eager to let go of the draining and perfectionist tendencies of 2016 and write on in 2017. Holding a palpable culmination of my writing efforts is an encouraging way to embark on a new year and I’m grateful.

 

 

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Free Write Friday: Hospital

 

1997

She’s volunteering, decided what she wants to do. She catches the bus to the hospital from campus, heavy backpack weighing down her slight shoulders. She has a badge, a short powder blue jacket. She works in the playroom: coloring, washing toys, light streaming through the wall of windows as she stoops to read aloud a picture book or set up a seasonal craft on the low plastic tables. The children come in wheelchairs, heads bald or misshapen or shaved with intention. Tubes may be in their nares or arms. All of it is foreign and she doesn’t know how to act naturally so she smiles a lot, maybe too much. Sometimes she delivers a toy to a child confined to their own room: in isolation. Before entering she puts on a crinkly gown and a mask and latex free gloves, just as she was trained to do. She plays with the child, chats with the teen, tries to connect, but her own awkwardness and all the barriers for protection get in the way.

2003

She’s in medical school, deciding what she wants to do. She rotates through the hospital, a shadow of a doctor in a short white coat, tagging along after her resident. Her pockets are weighed down with too much: laminated cards on how to run a pediatric code, a clipboard with preprinted index cards to keep track of each patient’s labs and history, black ball point pens to record chart notes, gum. She learns she always needs to have gum on hand. She walks the halls, familiar but transformed now she’s armed with some knowledge. She gets to know the palpable quiet of the hospital in the middle of the night. The ceilings here are low; everything is miniaturized to make children feel more comfortable, in this place where discomfort distinctively reigns.

2007

She’s in residency, an MD after her name. She doesn’t wear a coat, but instead a black fleece vest with zippered pockets. Sometimes she’s mistaken for a nurse, but she still doesn’t wear the long white coat; it’s just not the way things are done. She monitors her patients and her medical students. She presents each case to the attending each morning at rounds. She knows what she wants to order in the cafeteria when it opens at 2 a.m. for all the providers who are there overnight on call. She’d rather sleep than eat, but that’s not the way things are done here. Residents review the progress of patients with the medical students, with each other, over the mid-night meal. The lights are turned down low and the children are in cribs and in isolation rooms and can’t breathe well or can’t eat well and most certainly won’t sleep well. The nurses page her and talk in quiet voices. Many patients get better and she discharges them. Some are known by all the staff and roam the halls with their IV poles like tiny emperors, because this place, this hospital, too, is their home.

2016

She brings her infant, the youngest of her three, in to see the specialist. She parks in the newish garage built in the same place she used to catch the bus up the hill. She wheels her baby in the stroller. She waits in line to check in, gets an adhesive visitor’s badge with her picture and her child’s name. There’s a Starbucks downstairs now, in this new wing, but she doesn’t have time to stop for a latte. Her child is crying and she’s late. She wears a red raincoat, her pockets filled with the random items of a mother: a used tissue, a miniature toy construction truck, a purple hair clip, a binky, her smartphone. She’s anxious about seeing the specialist, about the prognosis and treatment plan. She has already texted her friend, the pediatrician, who made helpful recommendations, gave expert advice. She now has the luxury of giving and getting medical opinions in an instant, a byproduct of years of training and now experience as a practicing physician. She waits in the waiting room with other families. Some children read, some run, some sit in laps, some in motorized wheelchairs. Her child’s name is called and her baby is weighed, measured. She sees the physician. Her baby is prescribed medication, which she gets from the pharmacy. A girl waiting in line behind her talks animatedly about a book she wants to read. When she turns to check on her baby she can see the girl’s shaved head, the scar from surgery. So many children here so ill, so resilient. As a mother, she always feels grateful, feels guilty, in this place.

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