Narrative Medicine

Narrative Medicine Monday : What Can Odd, Interesting Medical Case Studies Teach Us?

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Physician author Siddhartha Mukherjee writes in the New York Times about coming across an unusual case study recorded by the late Oliver Sacks. Sacks describes the case of a woman who had a “lifelong history of seeing people’s faces change into dragonlike faces.” Though not a neurologist, like Sacks, Mukherjee is fascinated by the case. A thorough evaluation, including neurological examination, M.R.I. scan and experimental treatments revealed no answer or resolution.

Mukherjee is puzzled by the inclusion in a prominent medical journal. He ponders: “There was no revelatory flourish of diagnostic wizardry….. It was as if Sacks lobbed the puzzle into the future for someone else to solve: In some distant time, he seemed to imply, another neurologist would read this story and find resonances with another case involving another patient and complete the circle of explanation.”

Mukherjee notes that Hippocrates, the father of medicine, himself outlined case histories that remained a mystery without a clear diagnosis. Mukherjee recognizes that medicine has changed: “But over the years, as the discipline of medicine moved concertedly from descriptive to mechanistic, from observational to explanatory and from anecdotal to statistical, the case study fell out of favor. As doctors, we began to prioritize modes of learning that depended on experiments and objectivity.”

Mukherjee seems almost melancholy about the demise of the case study and what this omission means to medicine: “I miss the acuity of the observations, the scatter plots of symptoms that cannot be put into neat boxes, the vividness of description…. I worry that unknown unknowns will go unwritten — that buried within such cases, there might have been a cosmos of inexplicable observations that might, in turn, have inspired new ways of thinking about human pathology.” What role might narrative medicine play in honing the observational and descriptive skills of medical professionals that Mukherjee notes is lacking in today’s medical world?

Writing prompt: Do you agree with Mukherjee that something is lost in devaluing the case study? If so, what is lost? Think of a patient or family member whose illness was unique and perhaps undiagnosed. Write their case study, a detailed accounting of their history of illness. Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Curiosity and What Equality Really Means

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Atul Gawande’s recent commencement speech at U.C.L.A. Medical School, published in The New Yorker, begins with a story. He describes an Emergency Room encounter with a prisoner who had slit his own wrist and swallowed a razor blade. Gawande found himself caring for this person who had alienated himself from many others, who experienced many preconceived expectations, given his status, as well.

Gawande warns the graduates that “wherever you go from here, and whatever you do, you will be tested. And the test will be about your ability to hold onto your principles. The foundational principle of medicine, going back centuries, is that all lives are of equal worth.”

He asserts that there is a gap in the care that people receive, whether that disconnect be due to “lack of money, lack of connections, background, darker skin pigment, or additional X chromosome.” Have you noticed this in your own medical practice, in your own life? How did this injustice make you feel?

Do you agree with Gawande that, as medical professionals, we have a “broad vantage” of this issue? Do you also agree that “[w]e all occupy our own bubbles?” How have you seen this manifested in individuals and society as a whole?

Gawande argues that we should regard all people as having “a common core of humanity.” In order to put ourselves in others’ shoes, we need to have a certain curiosity, as Gawande does about his prisoner patient. Despite the way the patient threatens his chief resident, Gawande engages with the patient. He learns that “[i]n medicine, you see people who are troublesome in every way: the complainer, the person with the unfriendly tone, the unwitting bigot, the guy who, as they say, makes ‘poor life choices.’ People can be untrustworthy, even scary… But you will also see lots of people whom you might have written off prove generous, caring, resourceful, brilliant. You don’t have to like or trust everyone to believe their lives are worth preserving.”

In my ten years in practice, I have certainly found this to be true. I agree that, above all, remaining curious about others is the key to understanding, the “beginning of empathy.” As medical professionals, we are “given trust to see human beings at their most vulnerable and serve them.” That trust is sacred, should never be forgotten and should inform our every attempt to serve “all as equals” and cultivate “openness to people’s humanity.”

Writing Prompt: We all train, and many of us work, in hospitals. Gawande notes that hospitals “are one of the very few places left where you encounter the whole span of society.” Think of two encounters you’ve had in a hospital with people of backgrounds from different ends of a spectrum. Write about your interactions with each of them. Alternatively, think about what gives you status, or lack thereof, in society. How have you been treated by medical professionals? Do you think your experience would be different if you were a C.E.O. or a cabbie? Why or why not? Write for 10 minutes.

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Narrative Medicine, Writing

My Kind of People

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I’m currently in Boston at Harvard’s Writing, Publishing, and Social Media for Healthcare Professionals conference. I’ve learned so much from the speakers, agents and editors here but one of the biggest benefits has been the networking opportunities. I’m part of an online group for physician writer mothers (totally my people, I know!) and though I’ve interacted with many of them virtually, it’s been a true pleasure to get to know them in person. What an amazing group of creative women doing incredible work in medicine and writing.

As with so many conferences I’ve attended, I’m inspired to write more, submit more, fine tune my book proposal and my pitch. Most of all, I’m encouraged to finish my books-in-progress. Writing and publishing a book is a marathon endeavor. I am not a creature of patience or a natural extrovert, but this process is teaching me endurance, humility and boldness. If you’re in healthcare and a writer I highly recommend this annual conference for tips, tools and inspiration.

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Narrative Medicine

Narrative Medicine Monday: What I Would Give

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Physician and poet Rafael Campo has published several collections of poetry and prose. In his poem “What I Would Give,” Campo outlines the “usual prescription” given by physician to patient: “reassurance that their lungs sound fine” or “that the mole they’ve noticed change is not a melanoma…” He instead would like to offer them “my astonishment at sudden rainfall like the whole world weeping” and “the joy I felt while staring in your eyes as you learned epidemiology.”

Campo’s poem makes me think about all that we give to patients with each interaction, each hospitalization, over decades of caring for a patient and their family. Should we reorient the standard prescription for cure? As a patient, do you get reassurance from your medical provider? Comfort? What would be the best prescription?

Writing Prompt: If you could give anything to your patients, what would you give? As a patient, what do you expect to receive from your physician? What gives you comfort? Write for 10 minutes.

You can read more about Rafael Campo and his thoughts on the intersection of poetry and medicine in this interview with Cortney Davis, whose work I’ve featured on a previous Narrative Medicine Monday.

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Narrative Medicine

Narrative Medicine Monday: Of Mothers and Monkeys

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Caitlin Kuehn’s essay “Of Mothers and Monkeys” draws parallels between her research work with macaque monkeys and her mother receiving treatment for breast cancer in the same hospital. As her mother starts chemotherapy, Kuehn “rotate[s] between the animal ward and the human ward.”

Kuehn wrestles with the ethical ambiguity faced in animal research. Thinking of her own mother’s reaction to chemotherapy, she darts off to her work in the research lab, wondering “what animal first shared with my mother that sudden fear of a throat closing in… I realize that I—as a student, with very little power but a whole lot of responsibility—am complicit in a moral choice I have still not taken the time to make. Some days it is hard to remind myself that medical research has a purpose. Some days it is as clear as cancer. Some days I just do not know.”

When Kuehn’s mother needs injections to help boost her immune system after suffering from a serious sepsis infection, though Kuehn “could do a subcutaneous injection in the dark,” she becomes “shatteringly nervous” whenever she has to give her mother injections; the familiar activity takes on a different tone.

Kuehn’s mother begins to rely on her to answer medical questions, but Kuehn’s scientific expertise is limited to “what I have learned in my undergraduate science classes, or here at the lab. All of it applicable only to non-human mammals, or else too theoretical to be of any use for as intimate a need as this. I have no good answers.” I was struck by the fact that often, even for those of us who have extensive medical knowledge and training, we still lack “good answers” to those questions posed by suffering loved ones.

Kuehn has a strong reaction when her mother declares that she’s fighting her cancer for Kuehn and her sister: “She’s pushed her will to persevere off onto my sister and me. It’s too much pressure to be somebody else’s reason.” Have you ever been somebody else’s reason for fighting for survival? Did you have the same reaction as Kuehn to that kind of pressure?

Writing Prompt: At one point Kuehn responds to Domingo’s convulsions in the same comforting way she does when her own mother’s throat begins to swell during her chemotherapy: You’re going to be okay.  When a patient or loved one has been faced with a particularly challenging moment of illness, is there a mantra you’ve repeated to them? To yourself? Did it help? Write about the situation. Alternatively, reflect on Kuehn’s statement that “death is a condition of life.” Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Anatomy Lesson

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Poet Nellie Hill illuminates the process of learning anatomy in her Bellevue Literary Review poem, “Anatomy Lesson.” She notes that to “understand the heart you’ve got to memorize…” I remember searching for ways to memorize, as one professor put it, the “firehose” of information required as a new medical student. Anatomy is especially daunting, with all the blood vessels, nerves, muscle origins and insertions. Dissecting cadavers in anatomy lab is a rite of passage for every medical student, but we also drew pictures, color-coded organ systems, made up songs and stories to help us remember the essential information that is the human body. Hill starts with memorization, but takes the reader on a journey down the “snake path” of the body “to where thoughts become memories or dreams.” I like the imagery of “anatomy stacked like a ladder from your toes” and how Hill hints that the functional organ itself may also hold an intangible purpose.

Writing Prompt: Think about when you first learned anatomy. Even if you’re not in the healthcare field and never took a more intensive course in the subject, we all learn about basic bones and organs as children. Did learning about anatomy help you to see the body, and your own body, differently? When was the last time you thought about anatomy? What are your thoughts on how the physical body or certain organs might be connected to a greater or hidden purpose (acupressure points, the mind-body connection)? Write for ten minutes.

 

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Narrative Medicine

Narrative Medicine Monday: Someone Else’s Pain

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Brenna Working Lemieux’s poem “Someone Else’s Pain” illustrates the struggle to understand what others are feeling, how challenging it can be to fully grasp another’s suffering. The patient experiences “some driven-screw anguish that flares” that they attempt to explain. Lemieux can only “nod or shake [her] head.”

I can relate to Lemieux; medical providers regularly face the challenge to decipher a patient’s explanation of illness or pain. I delivered babies for many years before I had my own children. After I experienced labor for the first time myself, I cringed recalling many of the comments, modeled after other medical providers, I had made to laboring patients prior to experiencing that pain myself. I had been sympathetic to their pain but could not embody empathy in the same way I could after I had gone through a similar experience. I had no reference point to the crushing agony of contractions that I would later understand. Of course, we can’t fully experience everything our patients go through. However, we can become better at listening and responding to the story they are trying to tell.

Lemieux likens listening to the patient describe their pain to the focus she had in art class, “trying in vain to capture” an image of her hand. Her poem illustrates the nuances and importance of narrative to medicine, the need to hone our listening and storytelling skills to improve the relationship between patient and physician and, ultimately, medical care as a whole.

Writing Prompt: What is the biggest challenge in understanding another person’s pain or illness? Have you ever tried to describe such an experience to a friend or healthcare provider? Think of a time you were on the explaining or the listening end of such a conversation. Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: To Seize, To Grasp

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Writer Heather Kirn Lanier describes her daughter’s seizures in “To Seize, To Grasp.” Lanier begins the flash essay outlining her infant daughter’s first seizure: “not the worst one, although it brought the biggest shock.” Lanier relays what it’s like to be thrust into the medical world and terminology of a new diagnosis: “New traumas gift new glossaries. Words become boxes into which you can pack the pain.” She achingly describes the pain of watching her child seize, unable to do anything but wait: “But of course he could only do what I could do, which was inject medicine and wait.” Lanier closes the piece with her daughter’s worst seizure, which was not the longest. What was it that made this last one so frightening for Lanier? Can you relate to grasping onto that which can be lost at any second?

Writing Prompt: Have you been suddenly thrust into the medical world because of your own illness or a loved one’s diagnosis? What was it like to learn a new vocabulary and way of interacting with the medical system? What did you find most challenging or surprising? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: In Shock

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Although I’ve never met her, author and critical care physician Rana Awdish on some level feels familiar. Not only are we both part of a supportive online group of physician-writers, but I just finished reading her wrenching memoir, “In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope.” Awdish’s gripping account of her near-death experience, subsequent hospitalization in her own ICU and revelations about the shortcomings in both support for and education of medical providers in the realm of empathy are illuminating. Her book is infused with challenge and hope and a call to transform the way we train physicians and care for patients.

Awdish is thrust from the world of providing medicine into that of receiving it – a patient under her own colleagues’ care. The contrast of these positions of power and vulnerability are striking and Awdish describes the jarring experience and her own enlightenment as she pivots between these two roles. She shares with the reader her revelations regarding how we provide medical care to those in crisis and inspires us to find a better way.

I was particularly convicted by Awdish’s insight into how medical training encourages physicians to suppress many of our emotions. She traces this ideal back to the father of modern medicine, Sir William Osler, who encouraged “‘aequanimitas.’ Osler regarded this trait as the premier quality of a physician. It represented an imperturbability that was described as manifesting in ‘coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril.'”

Awdish asserts that as physicians “we aren’t trained to see our patients. We are trained to see pathology. We are taught to forage with scalpels and forceps for an elusive diagnosis buried within obfuscating tissues. We excavate alongside our mentors in delicate, deliberate layers, test by test, attempting to unearth disease. The true relationship is forged between the doctor and the disease.” Do you agree with Awdish’s assessment? Why or why not?

If you’re a physician, if you’re a patient: read this book. Discuss it with your colleagues, mull over it with your book club. The questions Awdish raises, the challenges she poses are vital to improving the way we care for each other in our most acute times of need.

Writing Prompt: If you’re a physician, did you learn to develop “aequanimitas” through your training? Did you feel this trait was a requirement, overtly stated or otherwise, to be a “good physician?” Have you yourself ever been a patient feeling, like Awdish, “powerless in a way that is impossible to imagine, from a privileged position of wholeness and well-being?” Awdish lists biting phrases that were directly said to her or that she overheard when she was a patient. Have you experienced similarly painful words from a medical provider? Have you said such words to a patient before? Try writing from both the patient and the medical provider’s perspectives. 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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