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 Monday: Out of the Straightjacket

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In recent years the importance of physician burnout, depression and the high suicide rate among physicians has become more visible. The New York Times article “Taking Care of the Physician” notes that physicians are “approximately twice the relative risk of suicide compared to people in other professions” and aren’t adequately trained to deal with many of the stressors that being a medical provider entail: “how to deal with conflict, how to deal with negotiation, how to deal with the distress of patients”. We learn the science of medicine but don’t receive enough instruction on the skills that can lead to resiliency in an emotionally grueling profession.

Dr. Michael Weinstein bravely shares his own story of severe depression, subsequent treatment and the struggle he experienced as a surgeon who desperately needed help regarding his mental illness. Weinstein’s essay “Out of the Straitjacket” in the New England Journal of Medicine reveals how he became “profoundly depressed, delirious, and hopeless. He’d lost faith in treatment and in reasons to live.” He describes the brutal hours and culture of residency training and how he went on to become a trauma surgeon, shouldering the emotional toll that intense work can take: “We often make decisions in the face of uncertainty that deeply affect our patients’ lives. When things went wrong, I frequently blamed myself.” Weinstein illustrates the failure in the medical culture to address the frequency of burnout and depression in our profession: “I didn’t know how to talk to my coresidents or faculty about medical mistakes and the accompanying self-flagellation.” He “felt trapped in [his] work and worried that [he] would expose [his] shortcomings if [he] sought a leave or disclosed [his] feelings.” How can we change the stigma associated with such a prevalent scourge on our profession, on so many who suffer from mental illness in this world?

Recent studies on physician wellness point to the fact that “it’s more effective to make changes at the level of the institution, rather than just telling the doctors to shape up in the wellness department.” So many physicians “enter medical school deeply committed to the field, they come with the desire to be empathic and compassionate, if we just create a system that nurtures what they come with then we will have less burnout and higher quality care.” How can we best change our institutions, our culture, to promote wellness in those who care for our health?

Writing Prompt: Do you or a colleague suffer from burnout or depression? How has your institution helped address this issue? How has it failed in addressing this issue? As a patient, what are your thoughts about Dr. McClafferty’s statement in the New York Times article: “If you’re my physician, I want you to be in good shape mentally, physically and emotionally, so you can be really successful at helping me”? If you’ve personally suffered from depression, what stigma did you experience? What was most helpful, from individuals or from your workplace, for recovery? Write for 10 minutes.

If you are suffering from depression or burnout, there is help:

For Physicians: AMA’s Steps Forward

For Patients and Physicians: National Suicide Prevention Lifeline

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Narrative Medicine

Narrative Medicine Monday: Standardized Patient

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Artist Kerry Tribe’s latest installment at the San Francisco Museum of Modern Art, Standardized Patient, brought back memories for me of medical school. The article on Tribe’s work by Hyperallergenic describes her as “interested in memory, language and awkward connections.” The relationship between patients and doctors-in-training certainly consists of awkward connections. I remember the standardized patients we worked with to learn how to take a basic medical history, how to perform a physical exam, even how to do pelvic and rectal exams without as much fumbling and hesitation inherent in such a personal exam. All the standardized patients I encountered were professional and helpful, giving valuable feedback and helping us prepare for a new component of the medical licensing exam: that of a standardized patient interaction. For this portion of the exam we flew down to California (the closest location for those of us training in the Pacific Northwest) and stood outside nondescript doors in our short white coats, much like the medical students in the last photo of this piece. I remember feeling terrified at what this patient, this actor, might judge me on. Was I too friendly? Not personable enough? Did I make enough eye contact? Ask the right questions? Perform the right physical exam? Give the correct reassurance and explanation?

Tribe’s installment “captures the atmosphere of a hospital: that draggy kind of feeling, as though everything is tired and washed out, as if you are waiting for something.” She shows the uncertainty of physicians-in-training: “We can see the tentativeness of the prospective doctor, as they question one SP about how her boyfriend has treated her and see how the doctor tries to comfort her.” I like that Tribe captures the nuances of medical training, that “[w]atching this display of effort creates empathy for the doctors as well as the actors. Seeing the feelings of both — impatience, kindness, concern — flash across their faces, you almost forget they’re acting….”

Writing Prompt: If you’re a physician, recall a particular interaction with a standardized patient during your training. What did it feel like? What did you learn? As a patient, were you aware that your physician trained with actors as patients? Does this seem strange or is it encouraging to you? What kind of focused training on communication or empathy might be helpful for your doctor today? Write for 10 minutes.

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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 Monday: What Patients Say, What Doctors Hear

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Dr. Danielle Ofri’s latest book, What Patients Say, What Doctors Hear is a call to re-examine the way doctors and patients communicate with each other. Through fascinating patient examples and directed research, Ofri illuminates the pitfalls in the current medical system that lead to miscommunication and, ultimately, worse heath outcomes.

I was particularly struck by Ofri’s call for physicians to become better listeners, and thus “co-narrators” of a patient’s story. This term was coined by researcher Janet Bavelas, whose study shows that how physicians listen to a patient’s story in fact contributes to the shaping of that narrative. Ofri asserts that “medicine is still fundamentally a human endeavor,” that one of the most significant ways we can advance health care is by improving one of our most basic tools: communication.

I’m thrilled Dr. Ofri will be speaking to my medical group this week and I’ll be able to meet her in person. Dr. Ofri has written many books and essays important to the world of narrative medicine and is the Editor-in-Chief of the Bellevue Literary Review.

Writing Prompt: One chapter in Ofri’s book outlines a “Chief Listening Officer” who was hired by a hospital to listen to patients and translate their needs back to the hospital so they could improve care. Ofri notes the value of this, that “being listened to so attentively is a remarkably energizing experience. It makes you eager to continue engaging.” Have you ever had an interaction with a medical provider who listened to you and your story in this way? How did it make you feel? Did that experience benefit your health in any way? Write for 10 minutes.

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Narrative Medicine Monday: Today, Magda

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Writer Catherine Harnett presents us with Magda in her opening paragraphs, a woman who wears “scarlet velvet shoes with bows, so ladylike” and “sends thank you notes to hostesses the next day.” Magda takes a cab to visit her husband, Conrad, who “cannot place her, though she seems familiar.” Magda notes that with this persona “she can talk with ease about The War, how hard it is to live without silk and chocolate.” Magda and Conrad have tea together and as she leaves she recalls the other roles she’s played. There is a melancholy sweetness to Magda’s character play. She has found a way to have satisfying interactions with her husband despite his progressive and painful memory loss. Her husband has, in fact, disappeared and Magda fills the void with her elaborate personas.

Writing Prompt: What do you think of Magda’s approach to meeting with her husband, who no longer remembers her? Is she taking on the different personas more for his benefit or for hers? Have you had a loved one who has forgotten who you were? How did it feel? If not, imagine someone close to you suddenly didn’t remember your life together. Write for 10 minutes.

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Narrative Medicine Monday: Still Not Convinced You Need a Flu Shot?

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Aaron E. Carroll provides a straightforward explanation as to why getting the flu shot is imperative to a healthy community. In his New York Times article “Still Not Convinced You Need a Flu Shot?” he notes we may be passing on the virus without realizing it, to people much more vulnerable than ourselves: “You can infect others a day before you show any symptoms, and up to a week after becoming sick. Children can pass along the virus for even longer than that.”

Carroll points out our lack of concern about the flu virus, so familiar every winter, is illogical: “Because the flu is so common, we tend to minimize its importance. Consider the contrast with how the United States responded to Ebola a few years ago. We had a handful of infections, almost none of them contracted here. One person died. Yet some states considered travel bans, and others started quarantining people.” He argues that we should be much more concerned about the flu, noting that influenza is the “only cause of death in the top 10 that could be significantly reduced by a vaccine. Lowering risks of heart disease, cancer or Alzheimer’s are much, much harder to do.” We have a way to decrease the morbidity and mortality from a common illness yet we choose not to harness that opportunity.

By looking at the history of the varicella vaccination, Carroll illustrates the benefit we gain through herd immunity and the ethical consideration of getting immunized even if you yourself are not at high risk. He notes that babies were dying from chicken pox prior to implementation of the vaccine, but “as rates of vaccination rose, the rates of death from varicella were low…. But more significant, from 2004 through 2007, not one child younger than 1 year old died in the United States from chickenpox. What was amazing about this finding was that we don’t vaccinate children that young for chickenpox — therefore, those babies’ deaths were not prevented because they were vaccinated. Their deaths were prevented because we vaccinated their older siblings.”

In a previous Narrative Medicine Monday post, I highlighted a New York Times article written by Dr. Danielle Ofri that I’ve used when teaching narrative medicine courses to medical professionals. It illustrates the challenge of communication between physicians and patients and why there often is a disconnect. How can we improve the dialogue to better inform the public and, ultimately, save lives?

Writing Prompt: Do you get your flu shot every year? Why or why not? Do you feel that you understand the reasoning for immunizations? What information might help you better understand? If you’re a medical provider, have you struggled to convey such information to patients? Think of such a time and write for 10 minutes.

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Narrative Medicine Monday: The Art of Translating Science

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Lise Saffran emphasizes the importance of meaning in public health communication in “The Art of Translating Science.” This conversation is imperative amidst a culture where many important topics become highly polarized and politicized. Saffran argues that it is important for scientists to not just speak more plainly, but emphasize understanding of a concept. She notes that this is more challenging today because “when it comes to politicized topics, our ability to understand is often overwhelmed by our inability to hear.”

As a primary care physician, much of what I do in my daily practice is translational work: explaining a diagnosis, a lab test result, the need for a certain medication, the risks and benefits involved in preventive screening. The goal is to ensure the patient understands the meaning of the medicine, not just the facts. As Saffran notes, “a single word may change the meaning of the whole story.” A physician is also interpreting the patient’s story, taking the narrative they provide about their illness and using this information to determine best next steps toward diagnosis and improving their health. A scientist communicating about public health issues needs to convey concepts on a much broader scale. Our ability to translate effectively will dictate our health as individuals and as a society going forward.

Writing Prompt: Think of a time when you didn’t fully understand what a physician was saying to you. Perhaps it involved a specific diagnosis or importance of a new medication prescribed or test ordered. Did you get the facts but miss the meaning? If you’re a medical provider, think about a time that you missed a significant part of a patient’s narrative. Did that lack of understanding affect their diagnosis or treatment plan? Alternatively, consider a time you read an article on a public health topic such as climate change or vaccinations. Did you understand the underlying purpose of the piece? Have you had a conversation with someone who disagrees with your viewpoint on such topics? What might have increased your ability to understand each other? Write for 10 minutes.

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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 Monday: Heroin/e

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In Cheryl Strayed’s essay “Heroin/e” she writes about our ways of facing death, dying, grief and the will to live. Strayed loses her mother to cancer and suffers her own descent into addiction. Strayed’s love for her mother is evident and the loss she feels is acute. When her mother first learns of her diagnosis, Strayed recounts them silently entering the restroom, “Each of us locked in separate stalls, weeping. We didn’t say a word.” Strayed describes the numbing of pain and the warping of time for each of them: “The days of my mother’s death, the morphine days, and those that followed, the heroin days, lasted only weeks, months–but each day was an eternity, one stacked up on the other, a cold clarity inside of a deep haze.”

Writing Prompt: What does it feel like, in a physical sense, to suffer from addiction? From grief? Do you think addiction and grief are linked? Why or why not? Think of your own experience or a time you’ve witnessed this in a patient. Write for 10 minutes.

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