Narrative Medicine

Narrative Medicine Monday: A Tense Moment in the Emergency Room

No Comments

Author and physician Danielle Ofri’s latest piece in The Lancet outlines “A Tense Moment in the Emergency Room.” Ofri describes the concern of an African-American medical student as a “young man stormed into the doctors’ station… and held up his toddler. ‘My baby’s choking and you guys aren’t doing anything.'” The medical student knows she is least senior of the gathered medical professionals, but she also is the “only African-American person among the white doctors” and is “acutely aware of the fraught dynamics,” given the child’s father is also African-American. She considers stepping forward to assist, even though per her estimation the child is not in imminent danger. Instead, she holds back. Ultimately, the “highest person in the medical hierarchy” asks the man to return to his room and the situation escalates.

Ofri notes what anyone who has visited or worked in a hospital is keenly aware of: the hospital is a stressful place. Given the already heightened tension, if you “[a]dd in issues of race, class, gender, power dynamics, economics, and long wait times … you have the ingredients for combustion just hankering for tinder.” The broader issue is that “racial and ethnic disparities in medical care are extensive” and “implicit or unconscious bias is still entrenched in the medical world.” How have you witnessed this issue in giving or receiving medical care yourself? Do you know if the organization you work at, or receive medical care from, is working to address implicit bias in medicine?

The medical student’s reaction to the father differed from her white colleagues: “When the father stormed into the doctors’ station, she saw fear and concern; her fellow physicians saw aggression.” These issues are complicated by the various power dynamics that exist in medicine. On one hand, the medical student wonders if she would be treated similar to the father if she were a patient there, given they are both African-American and therefore “look the same to the outside world.” However, in that situation she was both “part of the powerful group—the doctors—but as a medical student, she was singularly powerless… a medical student might just as well be part of the furniture.”

Ofri contends that in the medical field we often justify our behavior in tense encounters “because we surely know that we are not racist, or sexist, or homophobic. We are good people and we have chosen to work in a profession dedicated to helping others, right? How could our actions possibly reflect bias?” Ofri calls us to seek out stories, to listen to one another. Medicine, after all, “remains an intensely human field: illness is experienced in human terms and medical care is given in human terms. We humans bring along our biases and stereotypes—that is true—but we also bring along our ability to communicate and to listen.” I know this is a skill I need to continually cultivate in my own practice. How might you listen better today?

Writing Prompt: Have you experienced a similar situation as this medical student regarding power dynamics, wether related to race, class, gender, or level of training? Think about such an event, either during your medical training or when encountering a medical professional as a patient. How did the people around you react differently? How did you react? Did your perspective of the incident change over time? Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Intern

No Comments

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.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: The Name of the Dog

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.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Preparation

No Comments

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.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Why Doctors Should Read Fiction

No Comments

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.

Continue Reading

Narrative Medicine

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

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.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Creating a Clearing

No Comments

In “Creating a Clearing,” storyteller Lance Weiler interviews the originator of Narrative Medicine, Columbia University’s Rita Charon. Charon describes how she ended up in medicine and primary care and the origins of the field of Narrative Medicine. She felt she was missing something as a physician from her formal medical training at Harvard. So instead she sought out the English Department: “I figured they were the ones on campus who knew something about listening to stories…” Her time there led to a PhD and, in her words, it taught her “how to be a doctor.”

Charon points out that we are all patients. What do you think of her idea that “we do not have to divide ourselves into mind on one side and body on the other or body on one side and self or personhood on the other, but instead we are all mortals inextricably bound to our bodies, our health, our frailties, our eventual mortality. This is how it is within that element that we don’t become ourselves, but [we] are ourselves”? Do you feel that the medical system tends to separate our bodies from our minds, from our personhood?

Charon explains how Narrative Medicine has grown over the years and now attracts all kinds of people in fields of health care, art, history and beyond. She states that the field of Narrative Medicine has “created a clearing,” a safe space for patients and clinicians and artists to “show people how to listen with great attention and respect.”

Charon describes how we’re traditionally trained as physicians to address a patient’s problem. Western Medicine is a disease model, focused on diagnosing, preventing or treating a problem. Charon takes a different approach. She first listens, focusing on what is important to the patient. I like how Charon begins: “I will be your doctor. I need to know a lot about your body, your health, your life. Tell me what you think I should know about your situation.”

She notes that both sides suffer from the typical patient-physician encounter: “[patients] come in armed with their list of questions that they’ve written down so as not to forget any in their precious twelve minutes, which is all they’re allotted. The clinician, on his or her side, is already looking at the wristwatch aware that there’s another three people in the waiting room waiting for what’s going to amount to the same brusk, impersonal, divided attention. So nobody’s getting what they want or need or desire or can benefit from.” Does this sound familiar to you? Are you hopeful, as is Charon, that if patients and clinicians lead on medical reform we can find a better way? What would that look like?

Writing Prompt: What skills do you find most helpful to listen to another person’s story? What would it be like as a patient to have a doctor ask you: “Tell me what you think I should know about your situation”? How would that question change the conversation? Think about what aspect of your training was most pivotal to teaching you how to be a doctor/nurse/physical therapist, etc. Are you surprised that for Charon it was her studies in English? Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: In Shock

No Comments

Although I’ve never met her, author and critical care physician Rana Awdish on some level feels familiar. Not only are we both part of a supportive online group of physician-writers, but I just finished reading her wrenching memoir, “In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope.” Awdish’s gripping account of her near-death experience, subsequent hospitalization in her own ICU and revelations about the shortcomings in both support for and education of medical providers in the realm of empathy are illuminating. Her book is infused with challenge and hope and a call to transform the way we train physicians and care for patients.

Awdish is thrust from the world of providing medicine into that of receiving it – a patient under her own colleagues’ care. The contrast of these positions of power and vulnerability are striking and Awdish describes the jarring experience and her own enlightenment as she pivots between these two roles. She shares with the reader her revelations regarding how we provide medical care to those in crisis and inspires us to find a better way.

I was particularly convicted by Awdish’s insight into how medical training encourages physicians to suppress many of our emotions. She traces this ideal back to the father of modern medicine, Sir William Osler, who encouraged “‘aequanimitas.’ Osler regarded this trait as the premier quality of a physician. It represented an imperturbability that was described as manifesting in ‘coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril.'”

Awdish asserts that as physicians “we aren’t trained to see our patients. We are trained to see pathology. We are taught to forage with scalpels and forceps for an elusive diagnosis buried within obfuscating tissues. We excavate alongside our mentors in delicate, deliberate layers, test by test, attempting to unearth disease. The true relationship is forged between the doctor and the disease.” Do you agree with Awdish’s assessment? Why or why not?

If you’re a physician, if you’re a patient: read this book. Discuss it with your colleagues, mull over it with your book club. The questions Awdish raises, the challenges she poses are vital to improving the way we care for each other in our most acute times of need.

Writing Prompt: If you’re a physician, did you learn to develop “aequanimitas” through your training? Did you feel this trait was a requirement, overtly stated or otherwise, to be a “good physician?” Have you yourself ever been a patient feeling, like Awdish, “powerless in a way that is impossible to imagine, from a privileged position of wholeness and well-being?” Awdish lists biting phrases that were directly said to her or that she overheard when she was a patient. Have you experienced similarly painful words from a medical provider? Have you said such words to a patient before? Try writing from both the patient and the medical provider’s perspectives. Write for 10 minutes.

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Baptism by Fire

1 Comment

Pediatric Intensivist Gwen Erkonen’s fast-paced essay “Baptism by Fire” was recently highlighted in one of my favorite online creative nonfiction journals, Hippocampus Magazine. The piece begins with Erkonen sitting in Grand Rounds, a newly minted attending physician. Erkonen deftly describes the apprehension and weight of responsibility all physicians experience when, after a decade of training, they are finally in charge: “Four years of medical school, three years of pediatric residency, and three more years as a pediatric critical care fellow. My time as a medical apprentice is done. I no longer have an attending physician to help me with my decision-making. I am solely responsible for my patients.”

Erkonen’s pager calls her to an excruciating emergency: a toddler with extensive life-threatening burns. The reader is thrust into the dire situation with her as she assumes care of the critical patient, running the resuscitation efforts of the medical team and communicating with the young girl’s mother in the waiting room.

Erkonen not only relays her own inner turmoil during this first challenge of her new career, she also conveys her keen observations of the other participants. The surgery resident she first meets in the trauma bay “looks cool and in control with his hands folded across his chest and a broad-based stance, but I can tell from his shaking voice he’s not sure what to do.” Erkonen’s details describing the patient’s devastated young mother gives us insight that the family’s narrative is multi-layered and tragic even before this catastrophic event: “She starts to sob, and buries her head in the older lady’s chest. Then I notice that she has a disposable Bic lighter in her hand. She keeps flicking it so that flames jump from the spark wheel…. I notice that her hands are dirty. Not from the fire but because she hasn’t showered in several days.”

Most any physician can empathize with Erkonen’s inner dialogue. Years of training doesn’t negate the adrenaline-infused uncertainty when you first encounter the incredible weight of trying to save another’s life: “Feeling like an idiot, I nonetheless plow forward.” Erkonen is unflinchingly honest in her description of the events and her vivid details leave the reader breathless, exhausted and empathetic, as if we were watching them unfold on a medical drama, yet responsible along with her.

Writing Prompt: Think of a time when you were in a new position that held intense responsibility. Maybe it was your first week as an attending physician or a new job managing a large part of your workplace. Maybe it was your first hours as a new parent. Describe your own inner dialogue and your perception of others you interacted with during that time. Alternatively, try re-writing Erkonen’s essay from the point of view of the surgical resident, the burn nurse, the patient’s mother, the priest, the trauma surgeon. Write for 10 minutes.

 

Continue Reading

Narrative Medicine

Narrative Medicine Monday: Bedside Rounds

No Comments

John L. Wright’s poem, “Bedside Rounds,” speaks to the apprentice-like training of physicians. It is a passing on of skills from the experienced to the inexperienced, from the knowledgeable to the clinically naive. Most medical students, unless they have a background in another medical field, have little to no real experience in the hands-on component of medicine. They take years of study – biology, anatomy, pathophysiology – and translate that book smarts into skills of diagnostic touch, suturing skin, prescribing treatment. 

One method of transforming head knowledge to a practical skill set is through bedside rounds: a gaggle of medical students and resident and fellow physicians (still in training) following after an experienced attending physician. Each morning this group travels from bedside to bedside, discussing the patient’s disease, the patient’s prognosis, the patient’s progress, the patient’s treatment plan. In recent years, medical schools have worked on making this process more inclusive of the patient who, after all, is the subject of the discussion. 

Wright’s poem touches on the experience of that patient, ill and incapacitated, being talked over in a cryptic language, determinations being made about the status and plan while the patient may still be steeped in a cloud of confusion. 

Wright finds himself in a comparable situation when his landscape architect brings her intern along with her one day. As this professional passes on her skills to her protégée, discussing his yard in detail, Wright begins to feel something he hadn’t expected: “I begin to resent them—the little games they play.”

Writing Prompt: Think of a time you’ve experienced bedside rounds as a physician, as a patient or while visiting someone in the hospital. If you were the patient, how did you feel when the medical team discussed your case in front of you? Did they include you in the discussion or explain what they talked about? If you’re a medical provider, choose a memorable bedside rounding experience: running rounds for the first time, being a brand new medical student, noticing something significant with the patient’s demeanor while their case was being discussed. Write for 10 minutes.

Continue Reading