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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Narrative Medicine

Narrative Medicine Monday: Why Doctors Should Read Fiction

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Sam Kean’s article in The Atlantic, “Why Doctors Should Read Fiction,” highlights what many medical schools, residencies and medical groups are realizing: medical providers and patients alike benefit from physicians taking an interest in literature. Kean asks, “if studying medicine is good training for literature, could studying literature also be good training for medicine?”

Kean’s article outlines a study in Literature and Medicine, “Showing That Medical Ethics Cases Can Miss the Point.” The study found that “certain literary exercises…can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.”

Students rewrite and dissect short stories that expose an ethical case study, such as physician-writer Richard Seltzer’s “Fetishes.” The study’s author, Woods Nash, argues that “short stories are far more effective means of teaching students and health-care professionals to wrestle with the mess, to pay attention to narrative perspective and detail, and to become more comfortable with ambiguity.”

Writing Prompt: Have you read a piece of fiction that outlined a certain bioethical dilemma? Do you agree with Kean’s assertion that doctors should read fiction? How might the practice prove beneficial to a medical provider? Read Seltzer’s “Fetishes” and rewrite the story in short form, as a poem or case study. What new insight do you gain from this exercise? Write for 10 minutes.

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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: Relapse

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Poet and nurse practitioner Carolyn Welch captures a summer moment in Intima‘s “Relapse.” Welch’s daughter suffers from mental illness. She begins with an acknowledgment that is familiar to anyone who loves a person with a chronic condition that remits and relapses: “Of course we knew it could happen.”

Welch’s poem is a recognition that life moves forward despite the shadow of such a recurrence threatening to disrupt: “…summer plodded on with heat and harvest– / a steady supply of peppers and tomatoes;” The garden and growth are reliable, predictable, even as Welsh speaks to her daughter who has returned to an undesirable state of illness. Welch, with heartbreak evident, realizes “the meds are off.”

Writing Prompt: Consider a chronic illness that can relapse, often unpredictably: depression, multiple sclerosis, addiction, cancer. How does it feel to be the family member, the physician, the patient for each of these conditions? Write a triptych that includes each of these perspectives. Alternatively, near the end of her poem Welch acknowledges a “nagging failure of want.” Have you felt a similar sentiment as a family member is suffering? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: The Poetry in Primary Care

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Returning from vacation as a primary care physician, as any physician, can be a daunting task. I wrote a flash essay for Pulse about the intense timeline of a typical family physician’s workday. You can imagine after being gone for a week the mountain of forms, test results, and emails that accumulate. Even when you have, as I do (many don’t), supportive partners who do their best to clean out as much of the inbox as possible, there’s a particular dread and pressure that occurs for the primary care physician returning to work. In medicine, everything is connected to a patient. A response delayed, an aberrancy missed, means damage—emotional or physical—to a very real person.

It was on such a day, back to work after a week of camping and s’mores and searching for sand dollars on a Washington coast beach with my family, that I stumbled upon a poem. Our clinic is set up with exam rooms jutting in from corridors that originate like tributaries from the hallways that line the perimeter of the building. Our offices dot the exterior hallway, windows overlooking the parking lot or other buildings in the business complex.

I was walking along this exterior hallway, brisk step between patients, stuffing my stethoscope back into my stiff white coat pocket, when I was struck by a nondescript sheet of paper tacked to the bulletin board just outside our nurses’ office. “Good Bones” caught my eye, made me pause mid-stride. There were patients to examine, lab results to respond to, phone calls to make, radiographs to interpret, but I stopped and turned and read the familiar lines.

I’ve followed poet Maggie Smith’s work for some time. I find poetry alluring and intimidating. I took Michelle Penaloza’s excellent poetry class at Hugo House last fall to overcome my perplexion, but found it would take much more investment to grasp all I wanted about the craft of poetry. Smith’s work is relatable; my contemporary, a mother, an artist, her words resonate and I instantly became a fan.

But to see her here, amidst my other vocation, my medical science workday of Pap smears and skin biopsies and asthma exacerbations, was foreign, a collision of worlds. Though I’ve written about and taught narrative medicine for several years now, though I’m aware of the benefits, to both the physician and patient, of integrating the humanities into the science of medicine, I’ve still found it challenging to be present with such art during the compressive restrictions of my primary care workday. So, Smith’s poem, tacked inconspicuously along a back hallway bulletin board, among graphs of clinic access and Medicare Five Star goals and HEDIS measures and Press Ganey patient satisfaction scores, was a welcome interruption, a surprising reminder, an appropriate intermission interjected into a hectic workday.

I asked around for several days after, attempting to determine who had posted the poem of maintaining hope amidst a broken world. Though I was told it had been up for weeks, maybe months, I never did find the culprit. That same week Glennon Doyle highlighted this very poem on her social media. For me a collision of two women I admire, I’ve never met, whose good works are far from medicine, far from my little corner of primary care amidst the jutting mountains, the emerald waters of the Pacific Northwest. But the lessons, the convictions, the challenge of poetry is relevant, maybe the most relevant to my interactions with patients, my titration of insulin regimens, my diagnoses of cancer, my prescribing of antidepressants, my listening to histories to evaluate an unintentional weight loss or a shortness of breath or an abdominal distention leaving a patient in excruciating pain.

Maybe an antidote to our broken healthcare system, the crux of narrative medicine, a balm for medical professionals suffering from compassion fatigue and secondary trauma and a system that increasingly squeezes the humanity out of of its providers, rests in the complex workings, the simple act of reading poetry. There’s instruction in the words, in the art of the line break, illumination of humanity in the universal themes presented. A reminder that at the heart of medicine we serve people, we are people, we are all in this together. Poetry infuses humanity back into this most human, most intimate of professions. Medicine is a science but it is also an art. For all of our sakes, maybe it’s time to embrace that pairing in an inspired, more hopeful way.

Writing Prompt: How do you talk with children about the difficult aspects of this world? Despite the brokenness observed and felt, do you try to sell your children on the world in the hopes that they would attempt to make it beautiful? Do you see poetry in medicine? Why or why not? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: The Bright Hour

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I first came across Nina Riggs’ book, The Bright Hour, because of its comparison to another popular memoir, physician author Paul Kalanithi’s When Breath Becomes Air.

Riggs was a poet, and her writing style reflects this; short chapters with descriptive elements and a musicality to the sentences that leaves us wanting more. She is honest and funny. Diagnosed with breast cancer in her thirties, a life just hitting its stride with two young boys in tow.

In describing Atul Gawande’s book Being Mortal, Riggs illuminates the heart of her own memoir “of living and dying.” She notes the attempt “to distill what matters most to each of us in life in order to navigate our way toward the edge of it in a meaningful and satisfying way.”

Riggs navigates the world of oncology and the process of dying with candor and a clear sense of self. When her oncologist discusses her case with colleagues she bristles at the standard name for the meeting of minds: “Tumor board: the term kills me every time I hear it. You’re just saying that to freak me out, I think. What is actually a group of doctors from different specialties discussing the specifics of your case together around a table sounds like a cancer court-martial or a torture tactic.”

She takes her young sons to her radiation oncology appointment in the hopes of getting them interested in the science behind the treatment. In the waiting room, she becomes acutely aware of how, taken as a group, her fellow cancer “militia” appear: “Suddenly I am aware of so many wheelchairs. So many unsteady steppers. So many pale faces and thin wisps of hair and ghostly bodies slumped in chairs. Angry, papery skin. Half-healed wounds. Growths and disfigurements straight out of the Brothers Grimm. So many heads held up by hands.” Have you ever been entrenched in a world of medicine or illness and then suddenly seen it from an outsider’s perspective?

Riggs ushers the reader into her new world as breast cancer patient. In a particularly striking scene following her mastectomy, she goes to pick out a breast form from the local expert, Alethia. “‘Welcome!’ She says. ‘Let’s find you a breast!’ She tells me that according to my insurance, I get to pick out six bras and a breast form…. The one she picks comes in a fancy square box with gold embossed writing: Nearly Me.” As Riggs’ contemporary, I could see the grave levity in the situation; Riggs is a master at sharing her experience, heartache and humor alike.

In the end, this is a memoir of a young woman who is dying. She acknowledges this and realizes that, near the end, there is a metamorphosis of light: “The term ‘bright spot’ takes on a whole new meaning, more like the opposite of silver lining: danger, bone pain, progression. More radiation. More pain medicine. More tests. Strange topsy-turvy cancer stuff: With scans, you long for a darkened screen…. Not one lit room to be found… not one single birthday candle awaiting its wish. No sign of life, no sign of anything about to begin.”

Writing Prompt: If you’ve read Kalanithi’s When Breath Becomes Air or Atul Gawande’s Being Mortal, how does their approach to writing about dying compare with The Bright Hour? Riggs comments on a kinship with the “Feeling Pretty Poorlies” she meets during her radiation treatment but because of HIPPA privacy regulations, never knows if they finished treatment or if it was “something else” that caused them to disappear. Did you ever participate in a treatment where you saw the same people regularly? Did you wonder about them after that time ended? Think about the privacy rules set in place to protect patients’ privacy. What are the benefits? Do you see any drawbacks? Write for 10 minutes.

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

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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

Narrative Medicine Monday: Titanium Seed

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Poet Judith Skillman’s “Titanium Seed,” published recently in the Journal of the American Medical Association, describes the new “part of flesh inside” that is hers “to carry through / airports, not setting off / any alarms, they assure me, / not anything other than / a placeholder for cancer.”

She depicts the experience of getting a breast ultrasound, “the technician rubbing her wand / over and up hills of black / and white.” Skillman’s poem illustrates the anxiety associated with waiting for a diagnosis, the uncertainty of the pause that occurs after an aberrancy is found but before a definitive answer is revealed.

The seed represents an alteration of Skillman’s body, this reality of the possibility of cancer she harbors in her flesh unseen. She outlines how the patient is at the mercy of the medical diagnostician, describing how she lies “between two triangle pillows – / placed like an offering / to this Demi god who may / or may not find what appeared / on his screens.”

Writing Prompt: Think of a time you had a biopsy or lab test or imaging done and had to wait for the results. Sit in that space of uncertainty. Describe the experience. Did colors return, as they did for Skillman, when she receives a benign diagnosis? How did knowing contrast with the period of waiting? Try writing about this space of waiting from both the patient and medical provider’s viewpoint. Write for 10 minutes.

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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 Monday: Narrative Humility

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“Telling and listening become an antidote to isolation, a call for community.” – Sayantani DasGupta

Dr. Sayantani DasGupta is a leader in Narrative Medicine and faculty at Columbia University. What is narrative medicine? DasGupta explains it this way:

“Narrative Medicine is the clinical and scholarly movement to honor the central role of story in healthcare. Long before doctors had anything of use in our black bags—before diagnostic CAT scans, treatments for blood loss, or cures for tuberculosis—what we had was the ability to show up and to listen; to stand witness to birth, death, illness, suffering, joy, and everything else that life has to offer.”

In this TEDx talk at Sarah Lawrence College and in an essay in Creative Nonfiction on the same topic, she expands on the concept by describing narrative humility:

“Narrative humility means understanding that stories are not merely receptacles of facts, but that every story holds some element of the unknowable.”

DasGupta asserts that “listening to another person is an act of profound humanity; it is an act of profound humility. This is particularly true at those charged moments of illness or trauma, change or suffering.” Have you found this to be true, either as a patient or as a medical provider?

In a healthcare system plagued with burnout, DasGupta argues that narrative humility, learning to listen well to patients, can “deepen medical practice, bringing satisfaction and joy back to an ancient profession that is so much more than a business.”

Writing Prompt: Do you agree with DasGupta that we need to “once again train clinicians to elicit, interpret, and act upon the stories of others, that we hold in equal stead multiple ways of knowing—the scientific and the storied, the informational and the relational?” Why or why not? How can we do this? If you’re a medical provider, were you taught how to listen in your training? Have you considered the concept of narrative humility? Do you think it’s possible to practice this way in today’s healthcare system? Write for 10 minutes.

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