Narrative Medicine

Narrative Medicine Monday: What is the Language of Pain?

No Comments

Anne Boyer asks “What is the Language of Pain?” in this excerpt from her book The Undying. Her analysis of pain is a commentary on modern society: “To be a minor person in great pain at this point in history is to be a person who feels inside their body when most people just want to look.” To be sure, ours is a society of superficialities. Boyer goes on to outline the different kinds of pain, including the “epic pain of a cure.”

She argues that “pain doesn’t destroy language: it changes it.” She describes Hannah Arendt’s claim that pain’s “subjectivity is so intense that pain has no appearance.” Have you experienced this type of intense pain? Were you able to find the words, the language to describe it? Boyer argues that pain is, in fact, excessively communicative, that “if pain were silent and hidden, there would be no incentive for its infliction. Pain, indeed, is a condition that creates excessive appearance. Pain is a fluorescent feeling.”

Boyer concludes the the question is not whether pain can communicate, but actually “whether those people who insist that it does not are interested in what pain has to say, and whose bodies are doing the talking.”

Writing Prompt: Would you argue that “the spectacle of pain is what keeps us from understanding it, that what we see of pain is inadequate to what we can know?” Why or why not? Think of a time you’ve been in pain or witnessed a loved one or a patient in significant pain. Try writing (or drawing or painting) the experience with all of your senses. Alternatively, consider what pain has to say to you or those around you. Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Who Heals the Healer?

No Comments

Dr. Huma Farid asks “Who Heals the Healer?” in her recent essay in JAMA, and her answer might surprise you. Farid describes weeping alongside her patient early in her obstetric training when she delivers a stillborn baby. The gravity of this experience affects Farid deeply as she reflects on human suffering, recognizing “that my work would encompass taking care of women at some of the worst times in their lives.”

As Farid progresses in her career, though, she realizes that she no longer has the same reaction, the same connection to the suffering of her patients: “My eyes dry, I wondered, when was the last time I had truly connected with a patient, empathized with her sorrow, and allowed myself to feel a sliver of her pain?”

Farid acknowledges that at that time she was also going through her own personal difficulties, and that despite this, she did her best to “remain empathetic and kind” to her patients: “I tried to give as much of myself as I could, but I felt like I had a finite, limited reserve of empathy.” Do you view empathy as a finite resource, or have you experienced a similar limited reserve to connect with your patients?

Farid’s commentary really resonated with me. It seems a simple statement to say doctors are human too, but it’s a reality we often forget. Most doctors are incredibly resilient and, even so, it only takes one personal life stressor to topple the precarious balance of mental and emotional rigors that come with being a physician in today’s healthcare environment. As Farid notes, the decline in empathy “may be driven by the demands of modern medicine and exacerbated by personal experiences.”

When I experienced my own significant personal life upheaval a few years ago, I, like Farid, “was still able to perform my clinical duties and to provide good patient care despite struggling to be empathic. However, studies have demonstrated that physician empathy improves both patient outcomes and patient satisfaction….” Ideally, for both the patient and physician’s sake, we would find ways to combat the decline in empathy that is an inherent byproduct of the current healthcare environment.

Ultimately, Farid determines that empathy “enables us to understand and connect with a patient’s perspective, an invaluable resource in an environment that has become increasingly polarized and rife with divisions.” Farid describes an interaction with a patient where she “mostly listened” and, in return, receives heartfelt thanks and hugs. Through that emotional and physical connection, Farid regains a piece of her “profoundly and imperfectly human” self. May we all find a way to move in that direction.

Writing Prompt: Farid wonders “what it meant for me that I had lost some ability to feel a patient’s pain.” If you’re a healthcare professional, have you lost some of that ability throughout your medical training or career? Think about a time you failed to have empathy for a patient’s suffering or, as a patient, that you felt your healthcare provider had little empathy for your pain. Alternatively, describe a time that your empathy has been “rekindled.” Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Vicious

No Comments

Tim Cunningham gives us a glimpse of Abdul, a teenage Rohingya refugee he encounters in a Bangladesh camp, in Intima‘s “Vicious.” Cunningham notes that his “belly was swollen like the rice fields” and “[t]hough described by many as non-literate because he had no official access to school, he could read the Quran with ease. His recitation of its Surahs was exquisite.”

When Cunningham meets Abdul in clinic, his pain is “everywhere,” as if “[h]is genocide had shifted internally, an annihilation of his once-healthy cells.” Abdul had lost his appetite entirely, did not “miss dahl and rice, mangos and bananas, though he knew that he should. ”

Cunningham imagines where he might transfer Abdul, had he the resources: “They would have diagnostics for his hepatomegaly and cachexia. They would have 24-hour staff, teams of nurses and physicians to treat and listen his life-story. The providers would all speak Rohingya. These thoughts were but daydreams. For extraordinary diseases, with extraordinary measures and extraordinary means, there are ways to treat illness.  If you are Rohingya, there is nothing.”

Cunningham’s prose elicits a visceral response to his patient’s physical and emotional trials, but it is Abdul’s word of response to a difficult intravenous stick that give both Cunningham and the reader pause: “Vicious.”

Writing Prompt: If you’re a medical provider, are there certain assumptions you make about a group of patients you see? How did you feel when Abdul repeatedly says “vicious?” What do you think that word might mean to him? What does it mean to you? Have you worked in a resource-poor setting or with a marginalized group of patients before? Recall an encounter with a patient. Write for 10 minutes.

Continue Reading

Ramblings

Free Write Friday: Loose Tooth

No Comments

She avoids brushing her teeth, the bottom central incisor hanging on by tender roots, too delicate for her seven-year-old sensibilities. She eats oatmeal and yogurt, asks for Tylenol to dull the constant ache and budding anxiety. “I don’t think I can go to school today,” she announces, brow stern, eyes pained. “My tooth, it just hurts too much.” We convince her, mouth still full of baby teeth yet to be discarded, in order to finish elementary school before adulthood she’ll have to learn to endure.

The first tooth was lost in dramatic fashion on a cross country trail in the middle of Washington’s Methow Valley. Our family paused for a snack of dried mango, parents and three children irritable from a wrong turn, traveling on rented skis much farther than anyone intended. Gnawing on the leathery fruit, our eldest suddenly exclaimed. Her mouth ajar just an inch, thumb and forefinger gripped a tiny nubbin, crimson blood dripping onto the late winter snow. We celebrated and paid her the going rate. Some friends said a dollar, others said two.

Now at home, her second loose tooth dangles and each day is a struggle. She can’t eat this, can’t brush that. I venture a suggestion: maybe Mama could help wiggle it out?

I remember my own dad reaching into my barely open mouth, gripping onto my jiggly tooth; the anticipation, the rush with extraction. My own daughter is crying now, she craves resolution but is loathe to let me complete a task that could cause even momentary agony.

“Use a tissue!” she cries. I defer to her wishes and lay a tissue over her dangling incisor as she backs away from me, eyes wild as if I am a monster from a nightmare that once haunted her slumber. I speak gently, grip firmly, twist slightly and then it’s out.

Her eyes brighten instantly, her mouth widens with an authentic grin. She forgets about the blood, the raw nerves, grabs the tooth from me and rushes downstairs to write a note to the fairy, requesting an exchange for funds. She’s saving up for a unicycle, likes to hand cash to the homeless people holding cardboard signs on the city streets. She bounds down the stairs with her treasure in hand, carefully scribes her request, tucking it under her pillow in anticipation.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Someone Else’s Pain

No Comments

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.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Heroin/e

No Comments

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.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: The Dilemma Doctors Face

No Comments

The spotlight has recently been on the opioid epidemic ravaging our country. As a primary care physician, I’m acutely aware of this issue and the challenges it poses to individuals, medical providers and the public health system as a whole. NPR’s The Takeaway recently did a program on understanding this crisis and approached it from many angles. Dr. Danielle Ofri wrote short a piece in Glamour magazine that gives a primary care physician’s perspective. In “The Dilemma Doctors Face,” Ofri notes that chronic pain is very real but differs from other chronic disease in that there is no definitive test or measurement for pain, it is subjective. “Chronic pain is real. It can ruin people’s lives. But the anvil of addiction and death can’t be ignored.” Ofri asserts that one challenge is that a system that doesn’t often pay for other ways of treating pain, such as physical therapy, acupuncture and massage, makes it easier for the medical provider to “just write a prescription.” Can you relate?

Writing Prompt: Have you or a loved one struggled with chronic pain? What were the challenges you faced when trying to find appropriate treatment? Have you or a loved one struggled with opioid addiction? What was the first sign that this had become an issue? If you prescribe opioid pain medications, how do you approach counseling patients about the risks and benefits of taking these medications? What are some of the challenges you’ve faced in having this discussion? Write for 10 minutes.

Continue Reading

Ramblings

Free Write Friday: Pain

No Comments


I notice it gradually, while exercising one morning. It’s a familiar routine, but that day bending over to touch the floor, leg lifted behind, I can’t hold the pose and my back gives way. The pain is insidious, then persistent. I go to work, hobbling throughout my day. Coworkers ask: What happened? Do you need something? Then they suggest: Try my chiropractor. Try downward dog. Here’s a hot pack. This is the only thing that helped my sciatica years ago. They’re all trying to be helpful but I can only wince. I can hardly walk. The pain is shocking, debilitating.

As a physician, I see people in pain every day. Pain from overexertion, pain from chronic illness, pain from medication side effects, pain from heartache. But to experience it myself, the slowing of body, the unexpected twitch of muscle with a movement, the limitations imposed by a body that isn’t working as it should, by a body that is a conduit for pain rather than a vessel for function: it’s humbling.

I don’t exercise for a week, then two. It’s hard to explain to others who only see me as able-bodied. They don’t realize. I shuffle as I cross the street; my husband and children walk casually ahead, so far ahead, on the crosswalk. I feel slow, I feel invalid. I get massage therapy, apply heat therapy, ingest ibuprofen religiously. The pain, initially searing in my back, flares unpredictably, shooting through my hip as I rise from sitting, as I twist to respond to a question, as I bend to pick up my baby from her crib.

A week into the flare, I just want to lie in bed, not get up, not go out. Though I am loathe to just lie there. I resent the creeping sluggishness. I want to defeat the lethargy and, simultaneously, be enveloped in it. I can suddenly see how people succumb: to numbing medications, to despair. Pain steals all functionality until the pain is all that’s left. And then it becomes your only companion. It is a cruel tease. One day or moment might feel a bit better, hope rises. Then, cruelly, it dissipates as the pain roars back.

One day I wake and can sit up without wincing, can walk with only a slightly antalgic gait. Everyone asks: How are you feeling? I feel tentative. I feel better. I feel anxious that it might come back, might return to level me again. I’ve learned now, it’s taught me. Pain is a presence, but also a thief.

Continue Reading