Editor's Corner: Narrative Medicine, Reflection, and Patient Care

From the 12/30/2020 newsletter

Editor’s Corner

 

 

Narrative Medicine, Reflection, and Patient Care

 

 

Bruce H. Campbell, MD FACS – Editor-in-Chief of the Transformational Times

 

 

Dr. Campbell, who has a background in Narrative Medicine, shares how the basics of Close Reading (Attention, Representation, and Affiliation) serve us well, both in medicine and in life ...

Jamaica Kincaid’s short story, Girl, is a list of forty-eight instructions and life lessons that the narrator, a Caribbean mother, is passing along to her daughter. 

 

…when buying cotton to make yourself a nice blouse, be sure that it doesn’t have gum in it, because that way it won’t hold up well after a wash; soak salt fish overnight before you cook it; … always eat your food in such a way that it won’t turn someone else’s stomach; on Sundays try to walk like a lady …; this is how you sweep a yard; this is how you smile to someone you don’t like too much; this is how you smile to someone you don’t like at all; …

 

The list allows the reader glimpses into the spoken and unspoken cultural traditions from a place far away. 

 

 

Exploring fiction and the arts with students and residents 

 

During a December Zoom-based narrative workshop, I read “Girl” aloud with the entire third-year medical school class. The students had just completed their first six months of clinical rotations, and I knew that the short story would seem to be set a million miles away from their recent lives: 

 

…this is how you grow okra—far from the house, because okra tree harbors red ants; don’t sing benna in Sunday school; you mustn’t speak to wharf-rat boys, not even to give directions …

 

The students broke into small groups to talk about the story, its structure, the narrator, and outside allusions. I asked them to think about how they themselves might fit into the story, and if they felt any obligations having read the text. 

 

Now, it was time to make it relevant. “Having experienced this story,” I said, “we will write for five minutes in its shadow. Here is your prompt: Create instructions on how to be a medical student.” What they discovered from their writing was remarkable. They made their own lists. They wrote about experiences. They went back and spoke to their pre-medical school selves. The responses were varied and heartfelt. 

  

Earlier this fall, I taught a Narrative Medicine elective course for fourth-year medical students. We watched videos, looked at visual arts, listened to music, shared poetry, and read fiction by writers including Albert Camus, Rafael Campo, Flannery O’Connor, and Richard Selzer. On the surface, many of the pieces seemed entirely divorced from medicine yet, in every case, we found ways to respond to prompts in the shadow of the works, either in writing or other forms of creativity. 

 

 

This week, I watched Gabriel Osorio Vargas’ Oscar-winning video short, Bear Story, with our otolaryngology residents. The animated film, which is neither medical nor political, is a wordless story-within-a-story about things that are left unspoken. After a conversation about the history of the piece and our initial reactions, I asked the residents to write in its shadow about a time when things might have had more than one ending. As physicians, we could all relate. 

 

The relevance of Narrative Medicine

 

In each of experience, the students and the residents gamely read fiction or experienced other forms of creative expression. Although some likely viewed it merely as a pleasant distraction from lives that are constantly focused on science, clinical knowledge, and patient care, my goal was to get them to practice “close reading,” a narrative technique centered around the precepts of paying close attention, creating a representation of each story so it can be told to someone else, and being committed to an affiliation with the artist or storyteller. Narrative Medicine (as developed at Columbia University) teaches that enhancing the skills needed to “close read” a piece of literary fiction, a painting, or any other form of creativity, encourages clinicians to build the exact same skills that we exercise when we deeply engage with the stories our patients entrust to us. The more we practice, the better we get.  

 

When I work with students, I routinely ask them whether they value writing, reflective, and narrative exercises in their medical education. The majority believe that these activities are important, yet many believe that their peers view reflective exercises as a waste of time. In other words, “I think this is really great, but I doubt my classmates do.” Our data, as we found here and here, say they significantly overestimate their peers’ negative views. In reality, most can benefit from and appreciate this type of activity. 

 

 

As we work toward designing medical education for the future, we should find innovative, measurable ways to include narrative opportunities into the curriculum that build skills and encourage wellness. As one of the M3 participants wrote: 

 

At first, I was unsure how I would feel about spending my morning writing and reflecting with students, but I found this extremely useful … I wish we had more of this placed in our curriculum.

 

When given the opportunity, the students had no difficulty seeing the parallels between the girl in Jamaica Kincaid’s story and their own experiences running into medicine’s “hidden curriculum.” But, until the opportunity to reflect and write arose, the changes remained hidden. 

 

Next steps

At MCW, we have several narrative- and humanities-literate colleagues whose gifts remain hidden. There are unexplored community-based humanities partnerships and opportunities. It is time to explore how best to employ the medical humanities to foster character, enhance caring, expand patient care skills, and deeply enrich the lives of our students, trainees, staff, and faculty. 

 

 

Bruce H. Campbell, MD FACS is a Professor in the Department of Otolaryngology & Communication Sciences and in the Institute for Health and Equity (Bioethics & Medical Humanities). He is a member of the faculty pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

 

 

On Joy and Sorrow in Our Long Winter

 From the 12/30/2020 newsletter

Perspective

 

 

On Joy and Sorrow in Our Long Winter

 

Ana Istrate, MD MS – Internal Medicine PGY-1 Resident

 

 

Dr. Istrate reflects on how her rotation through the COVID ICU as an intern is inextricably tied to the rest of her year …

 

 

 

Then a woman said, Speak to us of Joy and Sorrow.

  And he answered:

  Your joy is your sorrow unmasked.

-Kahlil Gibran, “On Joy and Sorrow”

 

 

At the beginning of this strange year, I took a solo trip to Washington DC, a city I had never seen before. Sunlight hit the Reflecting Pool like a knife, the air was uncommonly warm, and the National Mall was full of maskless strangers. It was impossible to find a quiet moment at the Lincoln Memorial. I met a family friend at the National Gallery of Art, where we made our way through currents of people, half in conversation with each other and half in conversation with the paintings and sculptures around us. I remember the contents of that conversation much less than I do the feeling of being in it, like floating on a raft through a luminous city, watching the threads of our childhood ripple in its wake.

 

It is curiously difficult to disentangle that more recent memory from all the memories of our lives that resurfaced then. Lately I find myself running through the locales of my past as if turning the pages of a photo album, aware that I am looking for a particular photo without knowing exactly which one. There is no living memory that seems best poised to clarify our present trial.

 

 

Rotating through the COVID ICU

 

Fragments of time in the COVID ICU remain more salient than what took place there: squinting through the glass doors of negative pressure rooms to see if oxygen requirements had shifted or ventilator settings had been recalibrated, noticing the unforgiving brown-red of facial pressure ulcers as we prepared to place another line, and catching a glimpse of our medical student’s eyes full of tears after our youngest patient had died. Equally vivid is the sensation of walking in each morning to be greeted by my co-residents’ familiar faces. It went unstated, as many important things in our lives somehow do, but they fueled my optimism.

 

I remember placing the phone back in its cradle at the end of one of my night shifts, having told a wife, whose halting, soft voice I don’t think I will ever forget, that her husband was not long for this world, to find one of my co-residents sitting next to me, prepared with morning eyes to receive the story of that night. It’s curious that we call these transitions of care “hand-offs.” At times, it seems we redistribute emotional loads too. (There is a certain generosity, I’ve also found, in the springing to action so specific to ICU care.)

 

Those of us who are interns have barely any point of reference for what being a physician was like before this pandemic, and we still spend much of our time taking care of non-COVID patients. We take it on good faith that the medical ICU was busier and more strained this winter than the last. For better or for worse, this profession and its members stand firm in their resolve to soldier on. And so, the mental and emotional burden on all those involved in patient care is nothing new under the sun, but perhaps more profound. I know I am not alone in the constant oscillation between hopefulness and seemingly impermeable disillusionment that this long season has brought us. There is a particular sting in the signs of indifference we encounter these days. It is present in the nonchalance of maskless strangers and the well-rehearsed backtracking of policymakers. Mercifully, we have little time to ruminate. That is the blessing of apprenticeship and its demands.

 

 

The thread unraveling behind us

 

And yet, that rushing in fragmented haste from one patient or idea to the next bewilders us into forgetting that there is a thread unraveling behind us. Grief, rather than being reserved for clearly demarcated losses, is less a discrete emotion and more a slow change of climate. At its most acute, it leaves us in tears. But mostly it is the inseverable string that links one loss to the next one in our lives. It becomes impossible to separate experiences, sleep deprivation notwithstanding. The death of my last patient in the ICU—a middle-aged, cadaverous man whose pancreatic disease marched him coldly into heart failure and whose death wish in his final hours left me heartbroken despite his ever hostile (wounded) demeanor—had nothing to do with COVID, and yet I cannot extricate his story from the pandemic playing out in the background.

 

So many of us take comfort in relegating this year to the corner of exception. We are keen to label this pandemic an anomaly. It is with a perverse kind of thrill, too, that the media delights in labeling this moment (and the next) as a historical turning point. And there is no doubt that, given everything that has happened, it will be. But how many of us can feel such cosmic shifts in our own inner worlds? It is frequently beyond the intimacy of human experience. Many of us have never confronted loss in so swift and raw a form, though we have been cognizant of it (I don’t only mean the loss of life but also the loss of dignity and patience and faith). I wonder if we can forgive ourselves when it all seems so muddled and even collides with the small joys we still discover in our lives.

The view from here

 

And lately, there is more cause to hope than there has been in the past year, though I follow the news from California and other overwhelmed regions of the world with a heavy heart. A collective joy surrounds these early vaccination efforts, which stems from a deep sense of relief. I couldn’t help but grin like a fool behind my mask as I felt the needle sink into my deltoid. (My vaccination card will be passed down through generations, I semi-jokingly tell my family and friends.) The winter solstice is behind us, and a new year is about to begin. In six months of residency, I have encountered more kindness than I ever expected. The waters of the Reflecting Pool greet me every time my cell phone wakens, and the Lincoln Memorial sits in the corner of that photograph like an afterthought. Life has not yet given me cause to change the backdrop, though the thread has unraveled so fast and far from there. Somehow, there’s no separating that afternoon from all the ones that followed.

 

 

 

Ana Istrate, MD MS received her MD from Case Western Reserve University. She is a PGY-1 in the Internal Medicine Residency Program at MCW.

 

The Patient Told Me “You cannot take care of me. You’re black and I don’t like black people.” How Do You Respond?

 From the 12/18/2020 newsletter

 

Perspective                       

 

 

The Patient Told Me “You cannot take care of me.  You’re black and I don’t like black people.” How Do You Respond?

 

 

Victor Redmon, MD

 

 

Dr. Redmon, a resident in the Med/Peds Program, shares what he has learned about speaking up when experiencing or witnessing moments of injustice …

 

 

My name is Victor Redmon.  I am a fourth-year internal medicine and pediatrics resident here at the Medical College of Wisconsin Affiliate Hospitals (MCWAH).  I have served on the MCWAH Diversity and Inclusion (D/I) Committee since my intern year.  Given the current political landscape and the ever-present pandemic, we felt it necessary to put out a narrative centered around “accountability,” both for yourself and your colleagues around you. 

 

The year of 2020 has been one for the ages. I have been more cognizant of reading articles addressing intolerance, injustice, and micro-aggressions this year, more so than in years past.  A student of mine recently asked me particularly good questions about accountability and when to speak up for yourself and others, when either your colleagues or patients make insensitive remarks.  I do not know if I gave him the best answer at the time, partly because I do not know if there is one right answer give.  

 

 

A patient care story

 

In medical school, I was taking care of a woman during my third-year internal medicine clerkship.  She was Caucasian and in her 60s.  We were treating her for a pneumonia, UTI and encephalopathy.  She was admitted overnight and the next morning I decided to follow her as one of my primary patients.  I walked in the room alone and introduced myself along with my role on the team.  She took one look at me and said, “You cannot take care of me.  You’re black and I don’t like black people.” I paused and then she went ahead to ramble on about other things that didn’t make much sense.  I asked permission to examine her and she stopped talking and let me perform my examination.  Once I was done, I thanked her and told her I would see her later in the day.  She said “Okay, but I don’t like black people.”  As we continued to treat her infections, she became more coherent and "with it.”  

 

The next day when I went to see her, she greeted me with a “Good morning,” 

 

I replied back, “Good morning. It looks like you are feeling better today.” 

 

She said, “Yes, I am. Who are you?”  

 

I realized that she did not remember our first encounter, so I re-introduced myself.  She thanked me and the team for our treatments.  The rest of the encounter with her was very pleasant and we discharged her home eventually.   

 

I keep thinking about how and why I handled this encounter the way I did.  I knew the patient was delirious from her active infections and hospitalization.  Does that give her a pass for what she said to me?  How much truth was in her words?  I never told anyone on my team about what she said to me.  Not my fellow third-year student colleague, not my intern, not my senior resident and not my attending.  Why did I choose not to?   

 

 

Another patient care story

 

During my second year of residency, I was senior resident of one the medical ward teams at the VA.  We had a patient who was notorious for his abuse of the health system, bigotry, and sexism.   He was homeless, and every time he was admitted to the hospital, it was a saga to get him discharged.  If you worked at the VA long enough, you knew this guy by name alone.  You were either on his good side or his bad side.  I had taken care of him several times in the past, starting when I was still a medical student.  The patient and I had a good doctor-patient relationship, and he was never disrespectful to me.  I wish I could say that for others.   

 

My third day on the team, my intern following this particular patient came back to the room laughing.  I chuckled and asked him what was so funny.  “Oh Mr. So-and-So being Mr. So-and-So,” he replied, “he’s not so bad if you’re on his good side.”  The patient had been medically ready for discharge for weeks and we had been working with social work and case management to find him a place to stay since he required home oxygen therapy.   After rounds, my attending went to speak with the patient alone to basically tell him that he will be discharged the following day, and he could not stay in the hospital any longer.  My intern, who was of East Asian descent, was now very nervous about how this will affect his relationship with the patient.  I told him that the patient would be more likely to be mad at the attending, but I offered to be there for him if he needed me.  My intern declined and said, “I’ll just see how it goes.”  

 

The next day, my intern came in laughing again: “Mr. So-and-So being Mr. So-and-So.”  I took it as a positive sign and moved on.   During rounds, my attending asked how Mr. So-and-So was doing today.  My intern said “He’s fine, nothing has changed medically.  But he hates you,” referring to my attending.   My intern then said, “He says he never wants to see ‘that brown, Jihad *********** again’.”  

 

This statement is wrong on so many levels.  My intern then laughed it off.  My attending, of Indian descent, was silent for a moment, but then said, “Well unfortunately, he doesn’t have a choice.”  I looked around and the rest of the team (the other intern and two medical students) was dead silent.  As a team we moved on and finished rounds.   The patient was discharged without much drama.  

 

Internally, I was an emotional wreck.  I felt anger, remorse, shock and regret all at once.  I didn’t know how to respond in that moment.  I was with people I had not grown comfortable with yet, so I froze and didn’t respond at all.  

 

The following day was switch day for both the interns and the attending, so I had a whole new team.   Approaching the patient about what he said would have not been a battle worth fighting.  However, I never approached anyone else on the team about what was said, how they felt and how we could have done things differently.  I missed an opportunity to point out intolerance and injustice and to take a stance on a perpetuated culture that needs to end.  I feel like I failed my team.  I feel like I failed as a leader.  

 

 

What I have realized

 

I could continue to write about countless stories that are similar and worse than which I discussed above.  

 

Whatever personal accounts or stories that my friends and colleagues have experienced, these types of encounters happen every single day.  Often, we are silent and decide not to say anything so we can keep the peace.  I no longer regret being timid in those moments. I felt I was doing what was necessary to “survive” and progress to where I want to be in life.  I imagine that others have taken similar stances for similar reasons.  

 

I do not think there one “right or wrong” way to handle these situations, but I do think it is a reflection on how little improvement we have made as a society in addressing these issues. 

 

I realize now that it is not about me or one person at a given time.  It’s about all of us as a society.  As a medical society, we have a significant impact on our communities, especially the marginalized communities.  It does not matter if you are a medical student, a physician, nurse practitioner, physician assistant, a nurse, a medical assistant, a physical therapist, or a speech therapist.  You have a voice.  You have a platform to use to speak out against injustice, intolerance, and micro-aggressions that we too often meet in our work environment.  

 

I am far from perfect and I do not pretend to be free of my own implicit biases.  I hope to further an inclusive culture.  I want to be called out if I am being insensitive or have a moment of intolerance -- because that’s how we grow as humans.  I hope that I can learn from my failures and successes.  At the same time, I hope others can learn from my experiences and their own experiences as well.  

 

 

A challenge to all of us

 

We can no longer stay silent about these issues.  There is a lot of work to be done, but small simple steps eventually lead to larger ones.  I intend to start speaking up for my colleagues; especially for my trainees and students, who are in a particularly vulnerable period in their life.  I hope I am not alone.  For MCWAH D/I, we hope that we are not alone. 

 

 

 

Victor Redmon, MD is a fourth-year resident in the MCW combined medicine and pediatrics (Med/Peds) residency program. 

 

 

Winter Equinox - Poem

From the 12/18/2020 newsletter


Winter Equinox

Tamera Amadei-Bourne 

The darkest day of the year
announces itself in a fortnight
heralding for us to 
pause – 
reflect – 
heal.

Winter slowly knocks
on the door,
grasping its icy, bone fingers
to the frame,

inching it open,
expanding the dark, crisp night.
failing to eliminate the pin prick of 
light.

Tress adorn with candles,
illuminating the familiar faces – 
Parents, child, spouse
as gifts are passed around.
Laughter defrosts the chill
enveloping us into an embrace,
eroding the darkness into a fine dust – 
freeing the light.

 This week’s poem is by Tamera Amadei-Bourne, a Research Program Assistant, whose passion is writing. She began writing when she was seven, and that love led to a degree in Mass Communications/English with an emphasis in Public Relations and Creative Writing. Poetry helped her heal through a personal tragedy, and she had the pleasure of seeing three of her poems published. This poem is inspired by the approaching Equinox and the turbulent times we are currently experiencing.