Narrative Medicine

Narrative Medicine Monday: Intern

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I’ve written about physician and author Dr. Sayantani DasGupta’s concept of narrative humility before. The first piece I read of DasGupta’s was in Lee Gutkind’s 2010 collection, Becoming a Doctor. Her essay, “Intern,” is a compelling snapshot of a brand new physician.

DasGupta writes the piece in third person and reveals the things that she “hoarded.” The essay is reminiscent of Tim O’Brien’s classic “The Things They Carried.” I relate to DasGupta immediately, the hoarding of “Xeroxed protocols and carefully transcribed antibiotic regimen[s].” DasGupta brilliantly captures the unsure medical intern, who “hoards” in order to feel prepared for anything in a very unpredictable new profession where lives are at stake.

In describing the things hoarded, DasGupta outlines the life of the intern. She notes the importance of keeping “bottles of chemical developer” to look for occult blood in stool. They were always “impossible to find when you needed them” and “there was nothing worse than standing in a patient’s room with a gloved finger full of excrement and nowhere to put it.”

As the essay progresses, DasGupta’s hoarding becomes more figurative. She “hoarded her patients—especially the usually healthy infants,” who, she admits, during a hard night’s call provide an escape “just to hold and rock a baby.”

DasGupta describes hoarding her senses, “taste, primarily, because she found herself so empty” and the hand cream she rubbed on as a ritual, because “[s]he missed the feeling of her own skin.” She hints at how a career in medicine becomes all consuming, that “no matter how much she bathed, or how expensive her soap, her nose seemed filled with the smells of the hospital, the sick, and her own stale and sticky body.”

She is sincere about the toll arduous medical training takes on her sense of self, her physicality, her sexuality: “despite all the pain, she often found herself yearning—aching—to be touched.” DasGupta reveals the challenges to her own marriage during this intense time of training and that, as an intern, there is little space to think of anything else but the work: “In that stillness, she allowed herself to consider—would he wait until the end of internship to leave her? For the rest of the day and night, there would be no more time for such thoughts….”

Of course, DasGupta speaks of sleep and time, the difficulties of each as an intern working all hours of day and night, the pressures unceasing: “She hoarded sleep when she could get it, in the darkened backs of lecture halls, on the cheap, scratchy couches in the residents’ lounge….”

Ultimately, DasGupta’s essay reveals the inner dialogue of a new physician’s arduous first year, gives a glimpse of the challenges to those outside of medicine, and evokes memories for those of us who lived through it.

Writing Prompt: If you’re a physician, think back to your intern year or your first year of medical school. What did you hoard? Make a list. If you’re not in the medical profession, think of when you first started a new job — what did you gather around you to make you more confident, better prepared? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: My Human Doctor

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Dr. Sara Manning Peskin writes in the New York Times about the fallibility of physicians and its emotional toll in “My Human Doctor.” Peskin introduces us to her patient, Shirley, who was given a diagnosis of multiple sclerosis. This patient finds that in assuming this chronic, often debilitating, disease, even the very word itself “crippled her. She’d stopped driving, stopped working, and adjusted to the stigma of having a chronic disease.” After a hospitalization due to a serious reaction to one of her medications, it was discovered that “Shirley might not have had multiple sclerosis at all.”

Peskin reflects that in medical training we do discuss errors but “[w]e don’t talk about the emotional trauma of hurting a patient. Instead, most physicians cope with guilt, self-doubt and fear of litigation in private. After our patients, we become ‘second victims’ of our mistakes.” Given the recent spotlight on depression and burnout in medicine, Peskin highlights an important point that we ignore to our peril. Some organizations are realizing this and offering more programs such as Balint, peer support groups, and expanded counseling services to explore and address this emotional trauma.

When Peskin suffers the consequences of a mistake made by her own physician, the response she receives is “‘I can’t turn back time.'” Peskin experiences first hand that “[a]pologies are difficult for doctors, not only because we have to cope with hurting someone, but also because we are scared of the legal implications of admitting culpability.” Peskin outlines how the U.S. system differs from many other countries, where the “‘no-fault’ system is based on injury from medical care and not on proof of physician negligence…” and “doctors and patients remain on the same side, and more patients get paid.”

Peskin does end up apologizing to her patient, Shirley, for the misdiagnosis of multiple sclerosis. They were then able to move forward in the doctor-patient relationship and discuss Shirley’s adjustment to the “possibility of not having a chronic disease.”

Writing Prompt: Think of a time your doctor made a mistake. How did they approach the error? Did they apologize? If you’re a physician, think of a mistake that you or a colleague made that is particularly memorable. What happened and how did you respond? How did the situation affect the patient-physician relationship? Consider writing about this experience from both the patient and the medical provider’s perspective. Write for 10 minutes.

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Narrative Medicine Monday: The Name of the Dog

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In The New England Journal of Medicine essay “The Name of the Dog,” physician Taimur Safder remembers a lesson learned early in residency. Safder is stumped when, “as a freshly minted doctor,” he presents “a patient who was admitted for chest pain after walking his dog” and his attending asks a curious question: “‘What was the name of his dog?'” Safder is initially perplexed as to why this question even matters, but when the attending physician takes the group to the patient’s bedside to inquire, he realizes that very question “led to a transformation I did not fully appreciate at the time: there was an actual person behind that hospital-issued gown.”

This lesson proves valuable to Safder’s medical training. Through it, he forms similar connections with patients that allow him to “have difficult discussions about [the patient’s] immigration status and what it meant for his treatment plan,” and sign a “treaty under which [Safder] would read the ‘studies’ [the patient] brought in about black cherry and milk thistle and she would start taking one new medication every 2 months.” In learning about a person beyond their identity simply as a patient, trust develops and the patient-physician relationship can grow.

While caring for a patient who eventually ends up in hospice, Safder comes to another realization: “the question that I’d been carrying around since my first day of residency could work another type of transformation: it helped my patients see the person behind the white coat.”

Writing Prompt: Has there been a question you’ve asked a patient that revealed essential information about them as a person? Have you, as a patient, been asked a question by a medical provider that may not have seemed directly medically relevant but was important to them understanding you as a person? What was the question? What did it reveal? Write for 10 minutes.

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Narrative Medicine Monday: Preparation

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Abigail Lin’s poem “Preparation” in the Journal of the American Medical Association begins with a heartbeat as the focus of a medical student’s studies. She notes “we studied valves as if they were pipes: / what makes them rust, or clog.” There’s a note of bravado as the student starts their journey in medicine: they “marveled… as if we had built it ourselves.”

The humility comes later, realizing the fallacy in believing that “we could learn the architecture of grief / simply by examining blueprints.”

I remember marveling at the intricacies of design in my college introductory biology courses. I had in mind that I wanted to be a physician, but one of my most surprising revelations was learning about botany. I was amazed by the specificity of design in plants, the complex workings of how they grow, receive nourishment from the sun, from the rain; how they give back to the earth.

Lin’s poem is a caution to new medical providers. Much of our learning is in the machinery of the patient, the inner workings of the body. So much more is involved in treating the patient, not merely the disease.

Writing Prompt: If you are a medical provider, recall when you first started studying medicine. Were you naive, as Lin’s poem asserts? Is there something you’ve studied that you’ve marveled at? Did you learn a more nuanced appreciation as you progressed in your career? Recall an instance that contributed to that maturity. 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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Narrative Medicine Monday: The Burnout Crisis in American Medicine

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A recent article in The Atlantic by writer and resident physician Rena Xu highlights the toll rigid regulations and decreasing autonomy takes on medical professionals.  In “The Burnout Crisis in American Medicine,” Xu illustrates the causes of burnout and the consequences of a system that makes it challenging for doctors to do what they were trained to do – care for patients.

In the article, Xu tells the story of a patient admitted to the hospital for cardiac issues. She is then found to have a kidney problem that is in need of a surgical procedure. Unfortunately, the anesthesiologist who tries to book the the surgery finds that the computer system won’t let him schedule it because the patient already had a cardiac study scheduled for the following morning. A computer system issue took hours of Xu’s time, all because “doctors weren’t allowed to change the schedule.”

Xu expresses understandable frustration that her “attention had been consumed by challenges of coordination rather than actual patient care.” I’m sure every medical professional can relate. In today’s healthcare environment, much of the work we do in medicine is clerical and administrative. Xu notes that “doctors become doctors because they want to take care of patients.” Instead, many of our “challenges relate to the operations of medicine–managing a growing number of patients, coordinating care across multiple providers, documenting it all.”

I liked Xu’s analogy of a chef attempting to serve several roles in a restaurant without compromising the quality of the meals. The restaurant owners then ask her to document everything she cooks. There are a bewildering array of options for each ingredient and “she ends up spending more time documenting her preparation than actually preparing the dish. And all the while, the owners are pressuring her to produce more and produce faster.” Any physician who has worked with the ICD-10 coding system can relate.

Xu notes the looming physician shortage in coming decades as the population ages and a large swath of physicians retire: a crisis in its own right. The only remedy is to improve “the workflow of medicine so that physicians are empowered to do their job well and derive satisfaction from it.”

Patients might not realize that “burned-out doctors are more likely to make medical errors, work less efficiently, and refer their patients to other providers, increasing the overall complexity (and with it, the cost) of care.” As patients, we should be fighting for our healthcare organizations to promote a culture and systems of wellness among medical providers. The care we receive depends on it.

Writing Prompt: If you’re a physician, what is greatest stressor in your daily practice? Have you had to make “creative” work-arounds, like the anesthesiologist in Xu’s article, just to do the right thing for your patient? If you’re a patient, have you considered how your physician’s well-being might affect their ability to care for you? What systemic barriers are in the way of addressing this crisis? Write for 10 minutes.

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Narrative Medicine Monday: Brain on Fire

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Susannah Cahalan’s gripping book Brain on Firerecounts her sudden descent into psychosis and her parents’ frantic search for the cause. (Fair warning that this post contains spoilers to this real-life medical mystery.) Cahalan, a successful young New York City journalist, notes small changes at first: mild numbness, forgetfulness, nagging insecurities.

After Cahalan suffers an overt seizure, she is further evaluated by a top neurologist. He is convinced, after her MRI, exam and blood work all come back normal, that her symptoms are due to alcohol withdrawal, despite no history of heavy alcohol or illicit drug use.

I was struck by the glaring assumptions made by her physician; the details of her narrative were lost on him and the opportunity for detecting her rare diagnosis was missed. Cahalan later in the book asserts the misdiagnosis was a “by-product of a defective system that forces neurologists to spend five minutes with X number of patients a day to maintain their bottom line. It’s a bad system. Dr. Bailey is not the exception to the rule. He is the rule.”

I couldn’t agree more with Cahalan. Our system as it currently stands requires physicians to see more patients in less time, respond to more emails, make more phone calls and review more lab results, often at the end of a nonstop 10 hour day. It’s no wonder details of a patient’s narrative are missed. There’s no space to think deeply about a case, delve into the specific details that may provide a vital clue.

As Cahalan’s mental fitness deteriorates and her paranoia heightens, her mother insists she be admitted to the hospital and her neurologist acquiesces, finding a bed with 24-hour EEG monitoring at New York University Langone Medical Center.

Cahalan doesn’t retain many memories of the month she was hospitalized but does piece them together for the reader, using video obtained while being monitored for seizure activity, hospital notes and the recollections of her family and friends. Through these she paints heartbreaking snapshots of a young vibrant woman’s loss of function and reality.

Cahalan eventually comes under the care of a physician who finds time to listen to her story, every detail from the beginning. His diligence connects her to the proper clinician and results in her correct diagnosis and treatment. Cahalan’s account made me think of Dr. Danielle Ofri’s book What Patients Say, What Doctors Hear. The details of her story were so imperative to discerning, even suspecting, the correct diagnosis. Hers is a cautionary tale that reiterates the need for system reform if we want our doctors to have the time to put their extensive training to use and get it right.

Writing Prompt: After Cahalan recovers, she notes that she has difficulty distinguishing “fact from fiction.” She muses on memories lost and formed and struggles with the fear that she could, at any time, relapse. The experience causes her to reframe the brain as vulnerable. Do you think of the brain as fragile? Why or why not? Do you agree with Cahalan that a primary defect in the medical system is one that forces providers to see so many patients to “maintain their bottom line”? Think of a time this affected you as a patient. If you’re a provider, think of a time a diagnosis was delayed or missed because of systemic pressures resulting in a missed piece of a patient’s narrative. Write for 10 minutes.

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Narrative Medicine Monday: Grace and Forgiveness

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Oncologist Dr. Catriona McNeil writes about a severe adverse outcome her patient suffers in The Journal of Clinical Oncology’s “Grace and Forgiveness.”

Dr. McNeil treats her patient, Liz, who also happens to work in the same hospital, with a standard chemotherapy for breast cancer. When Liz suffers a rare but known possible complication from her chemotherapy, McNeil finds herself grappling with feelings of guilt, of responsibility. She initially wonders if she made a mistake, if there could be some other cause to her patient’s catastrophic decline: “The chemotherapy order had been checked and rechecked. Had I made a mistake? … She’d had nowhere near a cardio-toxic dose of chemotherapy. No, it couldn’t be that. Until eventually it could no longer be anything else.”

McNeil considers the early clinical studies of the chemotherapy she used, how those oncologists also might have “sat with a distraught family in a tiny room and had the same awful conversation. And yet how bland and unthreatening those little rows of text in the medical journals had seemed. How they’d sat so neatly in a small font near the bottom of the toxicity tables—cardiac death, 0.1% or thereabouts; just a handful of patients. Rare. Unlikely.”

This essay illustrates the limitations of medicine and the bias of human nature. It’s difficult to acknowledge we or our patients could suffer a detrimental complication, especially when it’s statistically rare. McNeil conveys the weight prescribing providers carry when such an event occurs. Although we all know, as patients and physicians, that there are no guarantees in medicine, it is jolting to experience what McNeil calls “the trauma of an adverse patient outcome.” Even though there “had been no malice or intent, no mistake or neglect,” McNeil still harbors guilt as she alone “had signed the chemotherapy order.”

Any treatment advised, from ibuprofen to chemotherapy, can have dire side effects. Learning to grapple with those consequences and continue to move forward with empathy for both self and the patient poses a great challenge to the medical profession.

Writing Prompt: As a patient, think of a time you’ve suffered an adverse outcome from a treatment prescribed by your physician. Even if you were well informed about the risks, benefits and alternatives, how did the experience affect you? Did it alter your opinion of your doctor or of medicine in general? If you’re a medical provider, write about a time you prescribed the best treatment available but your patient had a detrimental outcome. How did that affect you and your practice? Write for 10 minutes.

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Narrative Medicine Monday: The Train

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I featured one of Dr. Thomas Gibbs’ other essays on my very first Narrative Medicine Monday post in 2016. Today’s piece, found in the excellent flash essay journal Brevity, highlights another experience altogether. Dr. Gibbs is an obstetrician and therefore encounters dramatic medical emergencies that can put two lives at risk simultaneously. This was the case in “The Train,” when Gibbs is paged in the early morning hours about a bleeding pregnant patient who works in his office. Gibbs tells her husband to drive the patient himself to the hospital as he knows the urgency of the situation and that the local EMTs would take longer to get her there. He treats the patient as she arrives and disaster is averted. When he goes to inform the patient’s husband in the waiting room, he finds the husband shaken. In just getting to the hospital, all of them were in danger.

This piece made me think of all the advice we give patients, all the instructions we get from well-meaning physicians. Sometimes this advice has unintended consequences, either because patients misinterpret what was said or the instructions weren’t communicated effectively or because of events entirely out of anyone’s control. When you read the final lines of this essay, what were your first thoughts about the situation?

Writing Prompt: Have you given or gotten advice from a physician that, when followed, caused unforeseen consequences? Consider what happened or imagine what could have happened. As a physician, how did this change your medical practice or, as a patient, your relationship with that physician? Write for 10 minutes.

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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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