Monday, March 27, 2017

irresistible communication


If you’re interested in storytelling as a diagnostic and therapeutic tool, you should get a copy of the book, “Irresistible Communication” by King, Novik and Citrenbaum. (It’s out of print but still available “used.”)
Image result for irresistible communication
In this book, the authors discuss subtle communication techniques that encourage and facilitate storytelling in the clinical setting, for example, when delving into a patient’s medical history. These techniques operate on a subconscious level to engage the patient/client in ways that relax him, and affirm the fact that he is being heard and understood. They enable the clinician to read the patient’s body language and to understand how the patient accesses and processes information—whether he is a visual, auditory or kinesthetic learner—and how this affects memory, receptivity and comprehension.
“Seek first to understand,
then to be understood.”
~Stephen Covey~
Some of this is accomplished by simply mirroring the patient’s posture, respiratory rate, eye movements and positional changes. If the patient is anxious and breathing rapidly, the clinician can begin by matching the patient’s respiratory rate and then gradually slowing and deepening his own breathing. When the patient is engaged, his breathing will begin to slow and deepen, enabling him to relax. His anxiety will then lessen.

Observing the patient’s eye movements can tell a lot about how the patient processes information. Whether his gaze is directed upward to the right, upward to the left, or to one side or the other suggests the predominate sensory pathway by which he accesses memory.
Let’s say the patient was involved in a car crash. You can get a good idea of how he remembers it by the direction of his gaze and the language he uses to describe the scene. For example, he may say, “I heard the tires squeal right before the truck slammed into my car,” while gazing sideways and to the right, where the impact occurred. He is processing the accident according to what he remembers hearing. If you ask him, then, “What color was the truck?” this will take him out of his story. His memory will blur and important information may be lost, whereas if you ask him, “What else did you hear?” he may recall the sound of crumpling metal, broken glass, the voices of people coming to help, the sirens…all in accurate detail. He may never remember the color of the truck if he doesn’t process memory visually.

A visual person might recall the way the blood splattered on the windshield or way the lights were flashing in the ambulance. His gaze may be directed up and to the left or right as he recalls the details.

A kinesthetic learner might describe the shards of glass striking his face, or the sharp pain in his neck at the moment of impact.
The same traumatic experience can be recalled differently according to the patient’s predominant sensory processing pathway.

“To effectively communicate,
we must realize that we are all different
in the way we perceive the world and
use this understanding as a guide
to our communication with others.”
~Tony Robbins~
Interestingly, the clinician can put this information to use when treating the patient. The visual learner may benefit from written instructions or diagrams. The auditory learner may do better with a CD or audiotape. The tactile learner may constantly want to touch the injured area. Ask the visual learner, “Do you see what I’m saying?” Ask the auditory learner, “How does that sound to you?” Ask the kinesthetic learner, “How do you feel about that?”

Repeating or rephrasing what the patient says is another way to improve effective communication. Asking the patient to repeat instructions is also useful. How many times has a patient gone home with written instructions when he can’t read…
This, of course, is an oversimplification of a complex and intriguing approach to communication techniques. Since “Irresistible Communication” was published almost 35 years ago, a vast amount of research into the neurophysiology of sensory processing pathways has been published.

It reminds us that a lot more goes into narrative than telling a story, and listening involves a lot more than just hearing.
"I know that you believe you understood
what you think I said,
but I am not sure you realize
that what you heard is not what I meant.”
~Robert McCloskey~

Thursday, March 23, 2017

memories are made of this


As a retired physician, I am bursting with memories. Some are biggies…like the five-hour ambulance ride it took to transport a fragile premie from a rural upstate hospital to the medical center where I was a resident. Lights and sirens the whole way. Or running a clinic out of a tent in the African bush without electricity or running water. Or prepping a patient who was sent to the OR by the emergency room doc for an appendectomy in the middle of the night…when my pre-op exam revealed a leaking aortic aneurysm instead. That got things moving!
On the other hand, some memories are brief, isolated moments that punctuate the middle of a busy day…a dousing with pee during a newborn exam, a spontaneous embrace or word of gratitude from an appreciative patient, a smile or a grimace or a groan.
“We don’t remember days.
We remember moments.”
~Cesare Pavese~

Monumental or trivial, happy or sad, memories stick with us. When you consider the number of patients we see every day over the course of our careers, all the details we tend to, all the information we process, it’s amazing we remember any of it.

Imagine, though, what it must be like for your patient. You may already have seen twenty patients that day. It’s all a blur. Each patient, on the other hand sees one physician or provider that day—you—and will be totally focused on this particular encounter. Years later, he may still recall the fear or dread that tempted him to cancel his appointment. The smell of cigarette smoke on your clothing. The impatient sigh that escaped when you glanced at your watch. How cold your hands were, or how warm. How hurried you were, or how kind…
“…You will never know the value 
Of a moment
Until it becomes a memory.”
~ Dr. Suess~

 …when you don’t remember the patient at all.
Whether you’re a provider or a patient, if you’re interested in narrative medicine, you have to tap into those memories. Relive those moments. Reflect on your experience. And share what you have learned.
“One day you will be just a memory
For some people.
Do your best to be a good one.”

Monday, March 13, 2017

it's not too late...yet

If you are interested in, or simply curious about the concept of narrative as an instrument of healing, you should run right out and pick-up a copy of “What Patients Say, What Doctors Hear” by Danielle Ofri, MD.
In this book, the author explores the doctor-patient relationship and tackles the issues of communication and miscommunication and how they affect medical outcomes. If you harbor any cynicism about the relevance of narrative medicine as a healing practice, you should read this book. If you want to learn more about it, you should read this book. Then lend it to a friend. Or two. Or three…
Among the issues she tackles are:
·       Obstacles to effective communication that suck the best of us dry—time constraints, over-booked schedules, exhaustion, and burdensome mandates and initiatives that have nothing to do with improving patient care

·       The importance of listening skills when obtaining the patient’s medical history, and how our body language, attention and response can intimidate or discourage the patient from sharing important parts of his story

·       The importance of our personal backstory, and how it affects our expectations and interactions with patients

·        How the use of jargon reflects our attitudes about patients, for example, referring to the disease rather than the person who has a disease (the diabetic, the epileptic, the asthmatic) or labelling the patient who “failed” treatment, the “poor historian”, or the “noncompliant” patient

·        The effect of gender, race, culture, socioeconomics, and religion on communication

·        How to break bad news to the patient and his family

·        The correlation between poor communication and malpractice claims, and the pros and cons of disclosing medical errors

·        How effective communication influences the perception of pain, and how this has been likened to a placebo effect

…none of which we learned about in medical school.
Thankfully, it’s not too late for us. Narrative medicine is all about communication as a healing practice. If it interests you, I recommend Ofri’s book. And…if you missed the debut conference on Narrative Medicine at Kripalu Center last summer, the good news is that they are running it again this year and registration is now open. You can find a link to this summer's conference here
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Among other leaders in the field, Rita Charon will be speaking.
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Rita Charon
Rita Charon, MD, PhD, is professor of medicine and executive director of the program in Narrative Medicine at the College of Physicians and Surgeons of Columbia University. She completed her MD at Harvard Medical School and her doctorate in English at Columbia. A general internist, Rita took her PhD when she realized how central the telling and listening to stories is in the work of doctors and patients. She teaches literary theory, narratology, and creative writing to students and faculty at the medical center and in the graduate Narrative Medicine program. Rita is author of Narrative Medicine: Honoring the Stories of Illness, coeditor of Psychoanalysis and Narrative Medicine and Stories Matter: The Role of Narrative in Medical Ethics, and coauthor of the forthcoming Principles and Practice of Narrative Medicine.
Also attending again this summer will be Nancy Slonim Aronie (my fav).

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Nancy Slonim Aronie

Nancy Slonim Aronie is the author of Writing from the Heart. She has been a commentator for National Public Radio’s All Things Considered, was a visiting writer at Trinity College in Hartford, Connecticut, wrote a monthly column in McCall’s magazine, and was the recipient of the Eye of The Beholder Artist in Residence award at the Isabella Stewart Gardner Museum in Boston. Nancy won teacher of the year award for all three years she taught at Harvard University for Robert Coles.

If you are interested…and you should be…check out I’d love to meet you there.





Monday, February 13, 2017

what good is a story without a teller

What good is a story without someone to tell it? A story without someone to hear it?
True story:
A few years back, a young man in our community was involved in a terrible automobile accident. Prior to that day, he had a reputation as the high school jock, athletic and good looking. He was described as cool and cocky. He was well-liked, if sometimes irresponsible.
The accident left him in a coma for weeks. His doctors gave his family no hope for recovery based on the appearance of his scans. Nevertheless, his parents insisted upon continuing life support. He went from the intensive care unit to acute care to rehab over a period of six weeks or so with no improvement.
Then one day he opened his eyes. He started responding to simple commands. He was able to recognize the people at his bedside. Long story short, he went on to make a full recovery with the exception of a few subtle cognitive deficits. He came out of the experience a humble, caring young man with no recollection of the weeks he spent unconscious.
During his entire hospitalization, the boy’s mother kept a daily journal. It helped her remember what the doctors told her from day to day so she could process it when she had a few moments to herself.

She kept track of who visited her son, how kind and concerned they were, how heartbroken they felt. She recorded everything the doctors and nurses who cared for him said and did, and she recorded her own thoughts and feelings about her son’s condition.
The point is that without his mother’s journals, this entire period in his life would have been lost to him. He had no memory of it. It helped him immensely to read his mother's journals in order to make sense of what had happened to him and what a miracle his recovery represented. They reconnected him with his friends when he read about their bedside visits. He came to understand how close to death he’d come.
His mother's journals weren't lovely flowered books filled with beautiful prose. They were honest and raw and desperate...but they recorded reality for her son and filled in the blanks for him.

She wrote them at a time when she never imagined her son would read them for himself. That chapter in his life might have remained, forever, a story without a reader…and, except for his mother's journals, it might have remained a story without a writer.

PS: It will remain a matter of faith vs speculation as to whether a bedside visit from the boy's beloved dog had any effect on his recovery…but he woke up three days later.


Monday, February 6, 2017

how will your story end?

photo thanks to Andrea Lauren

In my last post, I connected my decision to retire at an early age (if sixty is considered early…) with the evolution of a health care system that has become highly technical and increasingly impersonal. While this transformation may offer some advantages in terms of efficiency and productivity, it jeopardizes the patient/physician connection and ultimately, imperils the patient’s ability to heal.

I closed my practice after thirty years in Family Medicine because working within the system scared me. I told my patients and colleagues I was retiring…when I meant that I was quitting.


I didn’t put it quite that way, of course. It wasn’t as though I simply got fed up with things, turned in my stethoscope and tongue blades, and slammed the door on my way out of the office. I wasn’t impulsive about it at all. I agonized over the decision years.
I didn’t leave because of the long hours, or the fact that I’d been running hopelessly behind schedule all day, every day for three decades. I didn’t leave to take an easier position or to make more money. I didn’t ask to be excused because of fatigue or forgetfulness or ill health.
I didn’t retire because of the oppressive paperwork or its successor--an oppositional-defiant EMR system. I wasn’t defeated by our baffling coding and reimbursement system. The ever-present threat of litigation. A pharmaceutical industry that invests as heavily in marketing as it does in research. A health insurance industry whose number one priority is corporate profit.
That wasn’t what got to me. The problem was that, in an effort to see more patients faster, I was forced to send patients on their way knowing that I hadn’t heard the full story. I often sensed that something else was going on…some issue I didn’t have time to explore. For instance, why a patient’s breath reeked of alcohol when he had an appointment for a sore throat at nine-o’clock in the morning. It took me ten minutes to diagnose and treat his throat, while his alcoholism went untended. Who had time?
In an effort to squeeze more patients into the schedule, important parts of their stories were being missed, and that scared me. Failure to diagnosis is the #1 basis for malpractice claims in this country. Worse, I worried that a patient would suffer or die because I didn’t have time to hear the whole story.
What finally got to me was the erosion of my authority as a competent and caring physician by self-proclaimed intermediaries who had neither knowledge of nor concern for my patients’ wellbeing. By business managers who failed to understand the importance of the patient/physician relationship, and how it impacts the patient’s ability to heal. By corporate geniuses who dismissed the power of eye-to-eye contact, the importance of undivided attention, and the gift of understanding in favor of productivity quotients and RBRVS units.
In the end, the risk to my patients outweighed everything I held sacred in medicine. In the end, I had to leave.
End of story. End of rant.


Tuesday, January 31, 2017

what if?


When I got home after the debut conference on Narrative Medicine at Kripalu Center for Yoga and Health last summer, I couldn’t wait to share my enthusiasm with my husband. He is a dedicated family physician who also struggles to keep patient care a priority while coping with the initiatives and mandates imposed by an aggressive and mercenary hospital health system.

I cited the importance of taking time to hear the patient’s whole history and how it can lead to more accurate diagnosis, expeditious workup, and effective treatment. I emphasized the importance of trust, hope and faith in the doctor/patient relationship and how this promotes healing.

I suggested that our colleagues might be interested in learning about it.

His response?

“That will never happen.”

And, for a couple of reasons, I’m afraid he was right. It takes time to listen to the patient’s story (a.k.a. his medical history). It slows you down. At the end of the day, you won’t have seen as many patients, and therefore, you won’t have generated as much income. Short of anecdotal reports, there is insufficient proof (data) to suggest that exploring the patient’s narrative improves patient outcomes or conserves resources. The system is fueled by competition for power and control rather than compassion and connection.

My husband’s skepticism led me to ask again, “What would it take to change the system as it is evolving?”

This led me back to an important storytelling technique. If you have a story to tell but you’re not sure how to develop it, an excellent tool is to begin with the question: “What if…?” or, “What would happen if…?”.

For example, what if you could prove that the time spent listening to patients translated into the need for fewer follow-up appointments? What if it improved patient motivation and compliance? What would happen if policy makers and health system managers could be convinced to reconsider productivity quotients and to question the validity of the RBRVS scale in the interest of improving the doctor/patient relationship?

What would it take to convince a CEO, CFO or healthcare policy maker to understand that the present system is failing both patients and providers? Well…

·         …what if his father died of pneumonia three weeks following early discharge from the hospital based on a predetermined protocol that failed to take into consideration the fact his father didn’t have the strength to generate an effective cough?

·         …what if his son died of a heroin overdose when he’d denied drug or alcohol abuse at his sports physical just a week earlier?

·         …what if he had to see his own physician because of a laceration he sustained slicing his bagel for breakfast, and then missed a critical meeting with the architect regarding plans for an expansion because no one in the practice had time to fit him in?

Before they concede the need for change, perhaps the system would have to fail the very people who conceived it, promote it and continue to defend it despite its inherent shortcomings. Perhaps then, ambition would bow to compassion.
“It can be argued that the largest yet most neglected
health care resource, worldwide, is
the patient…”
~Dr. Danny Sands~

In my next post, I’ll explain what this has to do with my decision to retire prematurely…




Tuesday, January 24, 2017

who has time to listen?


The premise that storytelling plays an important role in patient care arises from our commitment to obtaining a complete and accurate medical history. The important components include:
·         the history of the present illness (HPI) including the onset, duration and severity of symptoms
·         the past medical history (PMH) including previous illnesses and hospitalizations for everything from trauma to surgery to depression
·         the family history (FH) of serious medical conditions that have a tendency to run in families (for example, certain cancers, hypertension, diabetes, heart disease, etc.), genetic tendencies, even mental health issues
·         the social history (SH) including smoking, alcohol and drug abuse, cultural and socioeconomic factors, employment, as well as diet and exercise

There was a time (Yes, I am old enough to remember it.) when physicians actually took the time to ask about these matters. They observed the patient tearing up as she recounted her mother’s battle with breast cancer and the panic she felt when her own breast started to ache. They noted the moment of hesitation just before the patient lied about his sexual activity or substance abuse. They connected the patient’s obesity with his shortness of breath because it was visible to them.
Nowadays, the patient records his history on a checklist along with his demographics and insurance information.

The physician barely has time to inquire about the time of day much less explore the full spectrum of the patient’s symptoms, much less his lifestyle, much less his emotional response to what is happening to him…all of which impact the provider’s ability to make an accurate diagnosis, develop an effective treatment plan and help the patient heal.
True Story:
The patient was a twenty-three-year old woman who presented as a “walk in” (meaning she arrived at the office without an appointment because she had an urgent problem) on a day when the schedule was already booked and I was running late, as usual. She had a black eye, but there was more to it than that.
She told me she had been jumping on the bed (Really? A twenty-three year old??) when she lost her balance, fell and struck the corner of the nightstand, but there was more to it than that. Her boyfriend was kind enough to bring her to the office, but that’s not all he did.

Image result for Xray of  a blowout fracture

The patient had a blow-out fracture of the right orbit (meaning a fracture in the bone that surrounds the eyeball). She needed immediate evaluation and treatment by a skilled specialist. As I was making preparations for her transfer to the ER, I asked her one question: “What really happened?”

It was no surprise to me when she confided that her injuries were caused by a blow from her boyfriend’s fist. She shook with fear as she told me this wasn’t the first time something like this had happened. She felt like she had nowhere to turn.

Besides emergency medical treatment, she desperately needed social services—a safe place to live, a PFA order, someone to stay with her during recuperation. Oh…and she was uninsured. She would definitely need help with the bills.

A single question uncovered a flood of life changing issues for the patient. It was a question you won’t find on any checklist anywhere.

The point is that the importance of storytelling in medicine cannot be overstated.

The question is: “Are you willing to listen?”