residency – MARY PAN

Narrative Medicine Monday: Jamaica Kincaid’s “Girl” and the Challenge of Growing Up in Medical Training

October 7, 2019 No Comments

I first read Jamaica Kincaid’s “Girl” as part of a generative writing workshop during a summer writing residency. Our small group gathered folding chairs around long tables set up in an old barn near the Stillaguamish River in rural Washington. I was taken with each of the readings poets Jane Wong and Claudia Castro Luna had us read, but “Girl” struck me most, with its unusual punctuation, jarring directness, and call to re-examine the lessons we receive.

Emergency physician and writer Dr. Naomi Rosenberg explains in a recent JAMA article how Jamaica Kincaid’s “Girl” resonates in a very different environment–with new physicians in a narrative medicine workshop.

Rosenberg comments on the unexpected “striking similarity” these physicians have to Kincaid’s young girl, joining “a system that demands they quickly learn the skills of their craft, the rules of survival, and the values they will fight for all while navigating their instinctive psychological responses to illness, injury, healing, injustice, and grief.”

Rosenberg and the “burgeoning narrative medicine department” at her urban hospital have used “Girl” in the residency didactic curriculum, medical school electives, and writing workshops for all health care system employees with a goal to “constantly explore ways to help physicians, nurses, staff, and students ‘develop attention.'”

She describes how when they ask the residents to read “Girl,” intially they are met with resistance. How could this lyrical prose about coming of age in an island culture relate to healthcare professionals who “treat gunshot and stab wounds, deliver babies, diagnose cancer, unclog dying hearts for a living?” And yet, the new physicians quickly make the connection: “‘It reminds me of residency,’ one obstetrics-gynecology resident tells us, ‘a million instructions and things to do. It’s all over the place, and rapid fire.'”

At the end of the session a simple writing prompt is given, “metabolizing their own experiences and taking a moment to string words together—something young physicians today rarely, if ever, get a chance to do.” The result is surprising: “an exploration of hierarchy, medical education, and the silent curriculum of growing up.”

I wrote about my own experience at Columbia’s Narrative Medicine workshop, where we did a similar exercise and I again encountered Kincaid’s “Girl.” I love Rosenberg’s use of this piece to help new physicians still finishing their training grapple with the accelerated nature of a medical residency, the growth and expectations that come with modern medicine. It also was interesting to learn that Rosenberg herself used “Girl” as inspiration for her own wrenching New York Times essay, “How to Tell a Mother Her Child Is Dead” which I wrote about here and is one of my own favorite pieces to use for reflection and discussion among healthcare professionals.

As Rosenberg recognizes, literature has a way of “again and again, deepen[ing] our inspection and understanding of the internal and external worlds.”

Writing Prompt: Take a cue from Rosenberg’s exercise and respond to “Girl” by writing instructions on how to be a healthcare professional (nurse, physician, pharmacist, etc.) Alternatively, write instructions on how to be a patient, or a patient’s parent or partner or child. Write for 10 minutes.

Narrative Medicine

Narrative Medicine Monday: Intern

December 24, 2018 No Comments

I’ve written about physician and author Dr. Sayantani DasGupta’s concept of na rrative h umility 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.

Narrative Medicine

Narrative Medicine Monday: How Storytelling Can Help Young Doctors Become More Resilient

November 25, 2018 No Comments

Physician and author Dr. Jessica Zitter shows “How Storytelling Can Help Young Doctors Become More Resilient” in her recent essay in the Harvard Business Review. We know that this issue is vital to increasingly stretched and stressed medical providers, the consequences of which are discussed in previous Narrative Medicine Monday posts here and here. I wrote a short piece in Pulse for their “Stress and Burnout” issue that outlines a typical day for a modern primary care physician and have also studied and taught narrative medicine as a tool to better care for our patients and ourselves. Zitter has a unique perspective on the particular challenges for physicians and patients in end of life care, given she is board certified in both critical care and palliative care medicine.

Zitter addresses this issue through a “new program which uses storytelling to help young doctors reflect on how they handle the emotional and psychological toll of caring for suffering patients.” She opens up to a group of new physicians about running the code of a young woman in the ICU, the resistance to letting a patient go, even when nothing remains other than suffering: “We are expected to be brave, confident, and above all, to never give up. And all the more so in particular cases, such as when a patient is young, previously healthy, or has a condition that appears reversible on admission. And in cases when our well-intended but risky interventions might have actually made things worse, it is almost impossible to let go.”

When the experienced Zitter suggests that they instead institute pain management and sedation rather than attempt resuscitation the next time her heart stops, the physicians-in-training bristle. She questions a culture that promotes doing everything, including “this technique, that intervention, a whole host of options that would never have saved this woman.” Zitter admits she gives in to the other physicians, decides to fight “to the end, the way real heroes do.” The result is tragic. “The patient died a terrible death.”

Zitter reflects on this experience and shares it in the hope that it will help other young physicians who will certainly encounter the same, given that our culture and medical training makes it so “we often feel unable to question or diverge from scripted approaches — ones which may actually cause more suffering than benefit.”

To combat this, Zitter looks to storytelling, asserting that “[d]ata show that the use of stories to process the challenging experience of being a doctor increases empathy, enhances wellness and resilience, and promotes a more humanistic health care culture.” After Zitter shares her story with the group, others begin opening up about their own experiences and a “genuine conversation proceeded, one which addressed the emotional pitfalls and psychological challenges of this work.”

Zitter is also part of a 2016 Netflix documentary called “Extremis.” This short film takes a hard look at the grueling decisions patients’ families, and the physicians who inform them, make near the end of life in the ICU. In it, you can appreciate the need to “provide safe spaces for healthcare professionals to reflect on and process their own suffering. Then we will be fully available to do the hard work of patient-centered decision making in the moments when it is really needed — at the bedside of a dying patient.”

Writing Prompt: Have you had to help make decisions for a patient who is critically ill in the ICU? What issues came up? How was your interaction with the medical team that cared for your loved one? Alternatively, consider watching the short documentary “Extremis” and write about a moment that struck you or perhaps changed your way of thinking about end of life care. If you’re a medical professional, think of a time you witnessed an end of life situation when the patient experienced more suffering than was necessary. Do you agree that our culture contributes to performing “risky interventions” that “might have actually made things worse,” because we insist on fighting “to the end, the way real heroes do?” How do you think sharing such stories might promote wellness? Consider writing about a challenging situation from the perspective of the attending doctor, the resident, the patient, the nurse, the family member. Write for 10 minutes.

Narrative Medicine

Narrative Medicine Monday: The Name of the Dog

October 22, 2018 No Comments

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.

Narrative Medicine

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

July 2, 2018 No Comments

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.

Ramblings

Free Write Friday: Breakfast

April 20, 2018 No Comments

Growing up, sugary cereals were only allowed for special occasions in my family. If we were on vacation my parents would succumb to the pleas of their three children and buy an eight pack brick of miniature cereal boxes: Sugar Pops, Apple Jacks, Frosted Flakes. We’d line them up on the dining room table, barter and trade and bicker as siblings do. My favorite was Honey Smacks, neon cartoon frog jubilant on the front, ready to leap. I liked the caramel flavor, the bean-like shape of the kernels in my small mouth.

***

My mom would always wake with us, sit at the breakfast table no matter how early, clad in her cotton nightgown and cushioned slippers. The lone overhead light shone like a spotlight in our eat-in kitchen. I remember her stirring a pot of Cream of Wheat on the stove, my much older brother off at college, my younger brother still slumbering in his bed. I don’t remember talking much; we were both slow to articulate upon waking. The warmth of her presence, the hot cereal sweetened with a dollop of brown sugar, was the best kind of start to brave a new day.

***

In residency we’d all gather for morning sign-out to discuss the overnight events on each patient under our care. Those of us on call would grab breakfast as soon as the hospital cafeteria opened; if one was tending to a patient, writing an order, responding to a page, the other would collect their food for them. We all knew the preferences of each other, constant companions for 36 hour shifts, 3 years of working 80 hour weeks together. You get to know how a person takes their coffee, how they like their oatmeal. There were cheesy eggs, regular eggs, strips of bacon, big vats in steel containers heated under red lamps. I liked getting a plate of scrambled eggs with a scoop of white rice, a couple of soy sauce packets tucked in my scrub shirt pocket. I’d mix them all together as I joined my colleagues for pre-dawn sign-out, a makeshift comfort food after an exhaustive night of work.

Writing

Till Chapbook

December 15, 2017 No Comments

I didn’t get a free write done this week but did attend the launch party for the 2017 Till Chapbook. This local organization supports writers, builds community and hosts a writing residency at Smoke Farm each summer. Last June I attended the residency and spent several days reading books on craft, floating down the Stillaguamish River, attending workshops by the likes of the Jane Wong and Claudia Castro Luna, ate homemade fare by our fabulous chef and wrote, among other things, my first published poem Instead, which you can find in the 2017 Till Chapbook. I’m grateful for the talented writers I met and enjoyed hearing several of them read their work at the release party this week. Here’s to Till and the writerly community they cultivate.

Narrative Medicine

Narrative Medicine Monday: County Hospital Residents

March 27, 2017 No Comments

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.

Narrative Medicine

Narrative Medicine Monday: Family Summons

January 9, 2017 No Comments

When rotating through the Intensive Care Unit in medical school or residency, one of the most significant skills learned, in addition to adjusting mechanical ventilation settings and how to run a code, is how to conduct a “family conference”. This is where loved ones, preferably including the patient’s designated medical decision proxy, gather to discuss the patient’s status, prognosis and treatment plan. As these patients are severely, sometimes suddenly, ill, these can be very challenging conversations.

In “Family Summons” Amy Cowan illustrates how she was surprised to have a patient’s family gather in the middle of the night, wanting to speak with her as their family patriarch’s physician. Her piece highlights how important it is to listen and extract the true identity of the patient, the life they lived beyond the ICU. Establishing this portrait can help inform the care team as well as free the family members to make decisions in line with what their loved one would want.

Writing Prompt: Have you ever attended or conducted an important medical family conference? How was it run? If not, can you imagine what questions you might ask to best get to know the patient? Think about if you were the patient in the ICU; who would you want to gather on your behalf and what might they say when asked about you and your life, what’s important to you? Write for ten minutes.

Narrative Medicine, Writing

Narrative Medicine Monday: Published!

January 2, 2017 1 Comment

Starting the year off sharing some great news! I recently received in the mail the Fall 2016 Edition of OUHSC’s Blood and Thunder Journal, which includes two of my essays. I’ve had several pieces published in online journals but there is a special kind of excitement that comes from seeing your name in print on a tangible page. I’m humbled that two of my favorite shorts “Expectant” and “Burst” found a home in this narrative medicine collection.

“Expectant” chronicles the very first delivery I witnessed. Obstetrics was a revelation to me as a young medical student, especially never having had children myself. I was in awe of the entire process and this short essay reveals my own insecurities as I was christened into the world of medicine.

“Burst” is about my first continuity delivery in residency training: a pregnancy meant to be followed throughout all nine months to completion. I was a new physician and had much to learn about the unpredictable nature of obstetrics.

One of my writing goals for 2017 is to make significant progress on a book-length collection of narrative medicine essays. I’m starting the year off taking Creative Nonfiction’s online course “Writing Your Nonfiction Book Proposal”. Finding time to edit and submit my work has been a continual challenge but writing classes provide encouragement and structure to make the time, harness the energy and muster the gumption to keep at it. I’m eager to let go of the draining and perfectionist tendencies of 2016 and write on in 2017. Holding a palpable culmination of my writing efforts is an encouraging way to embark on a new year and I’m grateful.

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