Narrative Medicine Monday: The Burnout Crisis in American Medicine

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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Free Write Friday: Fish

My dad is a fisherman. For decades he wakes predawn, slurps his miso soup under the lone pendant light hanging above the kitchen table. My mom sews mesh pockets into his fishing vest, fashioned for easy portability of his catch as he climbs the steep hill back to our Hawaii home. He says he likes the quiet, the peace, the solitary sunrise. To the fish he is a hunter, to the ocean he is miniscule. He is a witness to simplicity, to grandeur, to the significance, the impermanence of it all.

He regales with stories of almost being swept away: a riptide, an irritated eel, an aggressive ulua he fights to reel in, almost to his own demise. He says if he has to go, this is the way he prefers: swallowed up by vastness, not dust to dust but water to water.

Mom waits for him on the beach, latest novel in hand in the grey dawning light. They leave just as the tourists saunter onto the sand with their bright towels, their sweating coolers, their rented snorkel masks and fins.

We run to him when he arrives home, rinses off his fishing gear and his salt water soaked tabi boots, a type of Japanese shoe with a split toe and rubber sole. He proudly displays his catch as he transitions to the galley kitchen, deftly cleans and fillets the fish, readying it for that day’s dinner.

He settles in the turquoise armchair to prepare his fishing pole and reel for the following day. His clothes dry in the afternoon sun as his lids lower for a siesta.

Most nights Dad pulls out the deep fryer, lowers the breaded morsels into the sizzling oil. We three kids wait impatiently at the kitchen table for him to place a large plate of freshly fried fish next to our bowls of calrose rice, of pickled daikon radish. We complain about having the same meal every night for six summer weeks on end.

Now I crave fish, expect it, miss it when we make a pilgrimage to the Aloha State. I never learned the skill, had the temperment, the patience, the passion for catching fish. Nearly 80, my dad still wakes before the sun, ventures out to commune with, to capture the sea life. My dad, he is a fisherman.

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Narrative Medicine Monday: Mom at Bedside, Appears Calm

I recently attended Harvard’s Writing, Publishing and Social Media for Healthcare Professionals conference and wrote about how networking and finding “my tribe” was a meaningful part of the conference. Case in point: a friend I met there recalled my interest in narrative medicine when she went to a talk by Dr. Suzanne Koven, the Writer in Residence at Massachusetts General Hospital. Dr. Koven is an internist and writer and has spearheaded the innovative Literature & Medicine program at MGH. My friend initiated a virtual introduction and Dr. Koven kindly agreed to speak with me about her successful program at MGH.

I’m inspired by her work in bringing narrative medicine to front-line medical providers. Today I’m featuring a New England Journal of Medicine piece she wrote from a very personal experience titled “Mom at Bedside, Appears Calm.”

Koven opens the essay with the things she carries “everywhere we go… two plastic syringes, each preloaded with 5 mg of liquid Valium….” She describes how they treat her son at “the first sign of blinking or twitching,” and that “[w]hen he relaxes, so do we.”

Koven is a physician, with all of the benefits and pitfalls that entails, navigating the tumultuous waters of a loved one suffering an illness that is particularly unpredictable and unnerving, especially when it affects a child. Her son continues to seize, still without an identifiable cause, taking “40 pills a day, crushed, on spoons of Breyers cookies-and-cream ice cream. Still he blinks and shakes, shakes and drops.”

With subsequent admissions to the hospital, Koven finds that she grows “more at ease” with the other parents of ill children and that she “clings to the nurses, Jen and Sarah and Kristen and ‘the other Jen,’ as we call her.” She glances at her son’s chart one night and it reads: “Mom at bedside. Appears calm.”

Though her son is eventually diagnosed and treated effectively, grows into adulthood and no longer suffers seizures, this period of unpredictable anxiety still haunts her: “occasionally my terror will snap to life again…. A siren sounds…. I still stop to see which way the ambulance is heading.”

Writing Prompt: Nowadays much of the medical record, including a physician’s progress note, is available right away to the patient via an online portal. Have you read a phrase or comment in your medical record that gave you pause, caused reflection? Did the comment align with how you felt in that moment, how you were perceived by the physician or nurse? If you’re a doctor, how would you answer the question Koven received: “Is it easier or hard to have a sick child when [you’re a] doctor?” Write for 10 minutes.

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Free Write Friday: Sculpture

I settle at a table under a small tree. Leafy shadows dance on the tabletop, circular and marked with a giant “e.” Cyclists pass on the path before me, leisurely tourists on rented cruisers, road bike commuters eager to get to their destination.

A woman dressed in black lays out a large wool blanket on the grass. Eyes closed, palms up, she reclines onto her back, her face, her posture an offering to the sun that warms overhead. Everyone seems content on a day like today, gratitude easy for a city freed from months of grey with sun glinting off emerald waters, ferries crisscrossing and sailboats venturing to the horizon.

Pedestrians stop to consider the sculptures in the park. I hear a woman point to my table, the adjacent tree and benches. “It spells Love & Loss,” she explains to the elderly man hunched at her side. A glowing ampersand rotates above the installment on the other side of the tree. She goes on: “The tree is actually the ‘v.’ It spells ‘Love’ from this perspective on the path. If you climb the hill and view it from there, you see the word ‘Loss.'” He grunts in response, unimpressed.

I sit and write on the “e,” consider the love, the loss that marks a day, a season’s transition. The people pass, they soak it all in. Another person stops to consider the art: “I think it’s supposed to spell out ‘Love,’ but I’m not sure where the ‘e’ is.” She puzzles over this with her companion. My notebook, my novel, my bag, my water bottle are strewn over the ‘e’ as I work.

I gather all my things, make room for the hidden letter as a tanker ship enters the bay. I climb the grassy hill. Time for a new perspective.

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Free Write Friday: Flight

A toddler is whimpering a few rows in front of me, the cries familiar but blessedly not emitting from one of my own children. Crystals form at the edge of the triple-paned window, a patchwork of tan fields replacing snow-capped mountains below.

I relish the window seat as we cross the country, no one chatting at me, no requirement to interact. The three women traveling alone in my row are not interested in conversing. We pull out our novels, our iPads, our Bluetooth headphones to mutually ignore via podcast. It feels luxurious, this solitude in flight, this lack of responsibility.

I do wonder about the strangers that fill the narrow seats behind me, that line the rows in front. What are they doing? Where are they going? Where are they from? Are they heading home or on vacation or on business? Are the cramped quarters with scant sustenance and stale recycled air an annoyance or a reprieve from daily monotony, the chores of home life?

I’m most curious about my seat mate but I don’t make small talk until we’ve almost landed. I saw her credit card when she bought a Tom Douglas chicken curry bowl deceptively wrapped in aluminum foil, reminiscent of a TV dinner. Block letters eked out “Fred Hutch,” indicating the large cancer research institute famous in the Northwest. I wonder, is she a MD, a PhD? Is she a researcher or a clinician? Does she have children?

Throughout the flight she studied a sheet of paper with neat type and mumbled quietly to herself. She must be giving a talk. I bet she’s a mom, no time to practice her lecture until she’s suspended 10,000 feet in the sky, away from the demands of making dinner and wiping noses, of sticky fingers and work reports and piles of laundry and school paperwork. I want to know her all of a sudden, understand who she is and where she’s going. I venture a question as the landing gear deploys below.

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Narrative Medicine Monday: The Game of Catch

Noah Stetzer’s poem “The Game of Catch” is featured in the current issue of the Bellevue Literary Review as well on Poetry Daily. Stetzer begins by describing an “idyllic” game of catch, then expands his narrative, including idioms and phrases the word catch might conjure up.

As the poem progresses it becomes more intimate, more ominous, a recounting of Stetzer’s own story of “catching” from another: “in my voice, catch my breath, no-it’s when small blue flame/ignites kindling; the kind of catch that’s alone in itself the thing/one avoids…” Stetzer guides the reader through his own experience of catching an illness that, though “unexpected,” also seemed “inevitable” and ultimately leaves us with the idea that this is a game we all play.

Writing Prompt: Take another word commonly used in medicine: treat, contract, mass, inject. Think of all the other ways this word is used, in idioms or otherwise. What is surprising or illustrative about the words we use in illness and health? Alternatively, think of a time you “caught” a disease from another person. Maybe it was a stranger or someone you knew intimately. Did you feel, as Stetzer did, that it was “unexpected” but also “inevitable?” Write for 10 minutes.

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Free Write Friday: Loose Tooth

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.

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Narrative Medicine Monday: Brain on Fire

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

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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Free Write Friday: Breakfast

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.

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