Narrative Medicine

Narrative Medicine Monday: Wernicke-Korsakoff

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Poet and medical student Sarah Shirley describes an evolving interaction with a patient in “Wernicke-Korsakoff.” The patient initially finds complaint with everything: “the too soft too hard bed, the lunch that came with only one spoon though clearly two spoons were required.” Shirley struggles to connect with the disgruntled patient, who clearly wants nothing to do with her as an intrusive medical student.

Throughout my medical training and career I’ve encountered patients, like in “Wernicke-Korsakoff,” where “everything is thrown back.” They were angry at their disease, angry at the medical providers, angry at the system, angry at the world. At times, I’ve been one of those patients myself. There’s no doubt health and illness affect our mood. Many of those who are suffering build a shell to cocoon themselves off from the damaging world. Often they are rightfully skeptical of a medical system that has many failings. Shirley finally breaks through to her patient in the end, after searching for the right connecting point. 

Writing Prompt: Think about a time you were sick. How did being ill affect your mood and interactions with others? Were you inclined to cling to others for support or did you find yourself “raging against the world?” Perhaps you experienced both. What about a time when you were caring for someone who was sick? Did they allow you to connect with them right away or was it a struggle? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: An Expert in Fear

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Author Susan Gubar writes about cancer making her “An Expert in Fear” in her timely essay. She asserts that this anxiety has become more acute in the recent political climate, with debates about major changes to healthcare, Medicaid and insurance coverage in the forefront of our national discourse.

Gubar contends that cancer fears fuel other fears and that cancer patients become “experts in fear.” If you’ve dealt with cancer, has this been your experience? She also highlights the detrimental impact fear can have on our health, and that severe financial distress has been found to be a risk factor for mortality in cancer patients. Gubar feels there is no appropriate word for the dread she experiences today. It is a “fear of fear spiraling into vortexes of stunning trepidation” and has, in fact, become all-pervasive and metastatic. 

Writing Prompt: What fears do you harbor related to health and illness? Have you found that the political climate impacts that anxiety? Do you agree with Gubar that fear is pervasive in today’s world? Write for 10 minutes.

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Motherhood

Mothers in Medicine

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I’ve long been a fan of Mothers in Medicine, a collaborative blog of supportive mama docs. Many of the contributors are still in medical training and the community is made up of various different specialities. I’m delighted to come onboard as a regular contributor to MiM. You can find my posts under “MP.” I’m so grateful for this community of mama docs who get it. If you’re a mom or momma-to-be and at any point in your medical training or career, I recommend checking out Mothers in Medicine as the candid posts are honest and instructive about the challenges of holding these two important roles. 

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Narrative Medicine

Published: Timeline

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I’ve tried to write a piece like Timeline several times. It’s simply a chronicle of my typical work day, but, in the past, I never was able to get it just right. It didn’t flow sufficiently, wasn’t a clear reflection of the exhaustion I feel at the end of the day. 

When I discovered Pulse’s “More Voices” column theme this month was “Stress and Burnout,” I felt compelled to finish this piece for submission. It was initially much longer, but I think the confines of the short word count (less than 400) was helpful in honing it to only the necessities. Previous versions of this essay were written in first person or third person. Second person, I’ve discovered, suits the purpose of the piece. My goal is to place the reader in the shoes of the primary care physician, feel the weight of her day, the exhaustion inherent in the constant churn of a general practitioner’s practice. I hope this piece provides a snapshot of a day-in-the-life of a family physician, and evokes a thoughtful reflection on the state of our health care system and the very real crisis of physician burnout. 

I’m grateful to Pulse for publishing Timeline and for their regular promotion of issues relevant to patients and medical providers through narrative medicine poetry and prose.

Writing prompt: When do you feel most stressed at work? When do you feel energized? Have you witnessed signs of burnout in your colleagues or your own medical provider? List your own timeline of a typical workday. How do you feel when you read it back? Write for 10 minutes. 

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Narrative Medicine

Narrative Medicine Monday: How We Wrestle Is Who We Are

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Writer Brian Doyle’s son is unexpectedly born with a heart defect. Doyle reflects, a decade later,  about his memory of this diagnosis and subsequent surgeries in “How We Wrestle Is Who We Are.” He describes the heartbreaking clarity of that time, “thinking that his operations would either work or not and he would either live or die.” Faced with the potentially catastrophic outcomes of the situation, Doyle also asks himself some difficult, honest, heartrending questions. Do you agree with Doyle’s assertion that “what we want to be is never what we are?”

Writing Prompt: Consider a time when a loved one or patient was gravely ill. What thoughts and questions did you wrestle with? Consider writing a letter, as if to a friend or to yourself, about your struggle. Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: The Evidence-Based Metaphor

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Medical student Brit Trogen argues that metaphor is not only an important tool in doctor-patient communication but that physicians should be trained to use the most effective metaphors to deliver medical information. Her recent article “The Evidence-Based Metaphor,” uses the example of the medical student’s simulated patient encounter, where actors portray patients and then provide feedback to aspiring physicians about their communication skills. All medical students go through rigorous testing to ensure they can manage the science of medicine, but the more nuanced communication skills required to be an effective clinician can be more difficult to both train and test. Trogen wonders what if there were a way to help guide young physicians toward better communication with their patients, thereby improving the health and well-being of those they’re tasked to care for.

Trogen notes that time pressures are evident for physicians in today’s medical system: “With appointment times creeping ever shorter, a physician may have only moments to explain a complicated scientific concept to his or her patient in a way that is both clear and memorable.” I struggle with this every day in my own practice; many of these concepts take years of study to understand fully. How can they best be distilled down so patients can make a truly informed decision?

I appreciate Trogen’s idea to promote “evidence-based communication” just like we adhere to the values of evidence-based medicine. This is the idea that the treatments we prescribe, the screening modalities we suggest, the procedures we perform be based on research-driven facts, substantiated studies that show that this plan is the best course of action for most. Instead of basing medical care on a whim, it’s based on evidence. Research-based evidence could also have a role in how best to convey information to patients effectively in a time limited way. 

Do you agree with Trogen that physicians would be more effective if equipped with better communication tools, rather than just scientific knowledge? What do you think about her statement that “knowledge is important, but not always sufficient?” As a primary care physician, much of my day is spent helping patients brainstorm how they can remember to take their medications, what changes could be made in their lifestyle to add in some exercise or improve their diet, why they should consider a colonoscopy or cutting back on alcohol or get certain screening tests based on family history. I know I’ve honed some of my own communication skills over my years in practice, but I would welcome a way to reach each patient, if possible, in a more effective and proven way. 

Writing Prompt: Do you recall a physician using a metaphor to describe a treatment plan, disease process or other medical process? Was it helpful? Write about the experience. If you’re a medical provider, think of something you often counsel patients about. Try brainstorming metaphors or consider writing a complete fable on this topic. Alternatively, think about a doctor-patient interaction that hinged on very good (or very poor) communication. Describe the encounter and the benefit or consequences. Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: County Hospital Residents

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Abby Caplin’s “County Hospital Residents” profiles immigrant physicians, re-training in an American residency program. Caplin’s poem begins with the more general–where a physician is from–and contracts into the more intimate details, the sequence of events that brought this person into this profession far from home.

Writing Prompt: Have you encountered an immigrant physician as a patient or through your own medical training? What was their story? Imagine leaving your home country to practice medicine and live your life elsewhere. What would be the greatest challenge? What does the diversity and experience of immigrant physicians bring to our medical community? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Dinosaurs

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Ophthalmologist Maria Basile writes of the evolution of surgery in “Dinosaurs“, part of the Poetry and Medicine column in JAMA. Her poem reflects on innovations in how surgery is performed and is a commentary on the constant churn of medical reinvention. 

Have you or a loved one personally benefited from a recent medical innovation? Can you think of something important that might have been lost through adopting a medical advancement? Also consider the challenges posed by some new medical procedures and breakthroughs. When kidney dialysis first emerged as an option for treatment of kidney failure and there was very limited availability. Decisions needed to be made about who would receive this treatment. Sometimes a medical innovation raises unforeseen and difficult ethical challenges. 

Writing Prompt: Think back to when you first started medical training. How has medicine changed since that time? What were considered the greatest innovations or bioethics questions of that time? What are they now? Alternatively, think about what was considered a medical marvel when you were a child. How is that innovation viewed today? Write for 10 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: The Heroism of Incremental Care

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As a primary care physician myself, I found Atul Gawande’s new article “The Heroism of Incremental Care” encouraging and empowering. The New Yorker piece highlights the importance of longitudinal care between a patient and their primary care provider.

When Gawande visits a headache clinic in Massachusetts, the physician there tells him she starts by listening to the patient: “You ask them to tell the story of their headache and then you stay very quiet for a long time.” What have you found is the most important component of a physician-patient encounter? If you are a provider, do you feel you’re always able to listen to the patient’s full story? If you’re a patient, do you feel listened to when you see your doctor?

When Gawande visits the primary care clinic in Boston, he’s told the reason primary care is important to bettering patient health is due to the “relationship”. Do you agree? Have you had a relationship with a primary care provider that has invariably improved your health over the years? If you are a primary care provider, has this been your experience with patients?

Writing Prompt: Gawande writes of the clinic he visits: “At any given moment, someone there might be suturing a laceration, lancing an abscess, aspirating a gouty joint, biopsying a suspicious skin lesion, managing a bipolar-disorder crisis, assessing a geriatric patient who had taken a fall, placing an intrauterine contraceptive device, or stabilizing a patient who’d had an asthma attack.” Think about the last time you saw your primary care provider. Write about that visit in the present tense, then project a decade or two into the future. Imagine how that visit, and many others like it, might have made a difference to your health decades from now. Write for 10 minutes.

 

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