getting the whole story

 

 

A path through the woods at Kripalu.

 

This summer I'll be attending the third annual conference on Narrative Medicine at Kripalu Center for Yoga and Health. For the past two years, this is where I have found my inspiration as a physician and a writer.

 

All week long we will listen to leaders in the field describe the healing power of storytelling and how to practice it. Physicians from Harvard, Yale, Columbia and Stanford, published authors, health care providers, and holistic and native American healers will share their amazing stories with us.

 

So, why hasn’t narrative medicine taken off? Why aren’t physicians and patients everywhere engaged in storytelling as part of the therapeutic process?

 

“I’m not telling you it’s going to be easy.

I’m telling you it’s going to be worth it.”

~Art Williams~

 

To put it bluntly, if it doesn’t make money the CEOs and CFOs who head up competing hospital health systems aren’t interested. Administrators who drive health care systems forward are less concerned with, and less knowledgeable about, hands-on patient care than they are about productivity, profit, and power.

 

It’s no wonder patient satisfaction is at an all-time low, and physician burnout is at an all-time high.

 

“Burnout occurs when passionate, committed people

Become deeply disillusioned with a job or career from which

They previously derived much of their identity and meaning.

It comes as the things that inspire passion and enthusiasm

are stripped away and tedious or unpleasant

things crowd in.”

~mathewgates.co~

 

What would it take to reverse this trend?

 

Numbers.

 

Storytellers would have to prove that the practice of narrative medicine improves profits, shortens hospital stays, reduces the number of readmissions, or otherwise generates income and saves money. Forget patient satisfaction and physician empowerment.

 

“Stories are not material to be analyzed;

they are relationships to be entered.”

~AW Frank~

 

Or, maybe something like this will have to happen:

 

Let’s say the CEO of your hospital (let's call him Tom) experiences an episode of severe chest pain. He is impressed by the speed, efficiency and expertise with which he is evaluated in the ER, rushed to the cath. lab, stented, and admitted to the CCU. Two days later he is discharged.

 

He congratulates himself how well the system works. This is what drives him--efficiency, accuracy, and speed.

 

However, a couple of days following discharge, he experiences a syncopal episode during a board meeting. Again, he is rushed to the ER where his physical examination is unrevealing. His EKG is unchanged, and his chest X-ray and a stat CT of his brain are normal. He is admitted for observation. In the middle of the night, though, he suffers a cardiac arrest and dies.

 

~corticare.com~

 

 

Why? Because no one thought to ask him about heroin addiction…and he wasn’t about to bring it up. It wasn’t one of the bullets on the EMR for patients admitted with chest pain. Smoking? Yes. Exercise? Yes. Heroin? No.

 

If the possibility of heroin abuse crossed his cardiologist’s mind, he didn’t ask about it. Had he, however, asked about stress and how Tom coped with it, he might have uncovered the real story.

 

“Writing and humanities studies

produce better physicians…

because doctors learn to coax hidden

information from the patients’ complaints.”

~Rita Charon~

 

Maybe one of his investments bottomed out. Maybe he found out his wife was having an affair. It was all too much for him even though he managed to project a veneer of confidence, authority and success. His addiction was the hidden demon that ultimately took his life.

 

We may be skilled at zeroing in on the diagnosis and treating the patient. We know how to increase productivity and reduce costs. We pride ourselves on modern medical technology. But until we get the whole story, we can’t treat the whole person. Unless we know the whole truth, the patient won’t get well.

jan



 







the not-so-perfect day for a walk

 

 

 

 

Yesterday was a great day for a walk…as Winnie the Pooh would have put it, a perfect day to be quiet by a little stream and listen.

 

“Everybody should be quiet

by a little stream and listen.”

~Winnie the Pooh~

 

So, that’s what I did. My route took me back and forth across a lovely brook four times. The sky was clear blue, the sun was warm, and the air was still. The silence and solitude gave me time to think. It was a perfect day for me…but not for everyone.

 

In contrast to the comfort, peace, and gratitude I felt for my own good fortune…my thoughts were drawn to the news. Not just to the underlying current of poverty, violence, and sorrow that stalks mankind in general…but specifically to the young boy who suffocated in his car last week despite his pleas for help after calling 911…after texting his mother to say that, if he died there, he wanted her to know he loved her. My thoughts turned the eight-year old girl found dead after a brutal rape. And to their families’ shattered hearts.

 

I couldn’t help but think about the victims of the week’s senseless shootings. About the plight of animals who were neglected and abused. About the latest damage to the only environment we know. And, as a physician, about the people I know who are sick or dying.

 

“I am constantly amazed

by man’s inhumanity to man.”

~Primo Levi~

 

Arrrgh! It is all so insanely painful to contemplate. What are we to do?

 

A couple of hours after my walk, I went to my yoga/meditation class, and you know what? I felt better after it…stronger and calmer. It reminded me that as health care providers, we come to accept the fact that we can help some of our patients, but not all of them. We can save lives some of the time, but not all the time. We have to take the bad news with the good. We have no choice.

 

Nevertheless, because we have the skill and sensitivity to offer words and to perform acts of comfort, encouragement, and solace, we have the power to bring balance to the world. Without the good we do, without the gratitude we feel, without the kindness we offer, how would we survive?

 

Caring, giving, embracing hope…and perhaps even prayer…are necessary survival skills in a world that might otherwise go down in defeat. The good that we do, where we are, with what we have strengthens us for the journey.

 

“Do what you can,

with what you have,

where you are.”

~Theodore Roosevelt~

 

jan

 



 

 

 

 

 

a fork along the healing path

 

 

 

There is a fork in the road along the healing path in narrative medicine. One pathway invites patients to tell the stories of their illnesses. The other beckons health care providers to share their experiences as healers. The journey for both patients and providers is similar. It embraces memory, invites reflection, provides perspective, and engages support.

 

The patient’s narrative recalls his symptoms. He lists the diagnostic tests that were performed, names the medications that were prescribed, and traces his journey back to health…or not. All of which has to do with his care. But equally important is the fact that he can tell you how the diagnosis affected him emotionally and psychologically. He may have despaired to learn he had cancer. His entire world may have spun out of orbit because of a stroke or disabling injury. How will he manage if he can’t work? How will he support his family? Who will pay the bills and mow the lawn? He dreads burdening his wife and children with his care. He wishes he could die…not a healing thought at all.

 

If, on the other hand, the news is good, let’s say the lump turns out to be benign or the doctors are able to slip the stent in before the infarction occurs…the patient’s story may end on a happy note. Besides relief and gratitude, there may be some spiritual introspection. A surge in compassion and empathy. New found joy and peace. An entirely different story.

 

“Piglet noticed that even though

he had a very small heart,

it could hold a rather large amount

of gratitude.”

~AA Milne~

 

When the health care provider sets out on his narrative path, it takes him to the bedside of patients he has cared for over the years. He recalls patients with interesting and unusual presentations, baffling symptoms, and resistant conditions. He re-experiences his triumphs and his defeats. He may finally admit to the uncertainty, oversights, and errors in judgement that have haunted him over the years. He can name the patients who recovered against all odds.

 

“If you want a happy ending,

that depends, of course,

on where you stop your story.”

~Orson Welles~

 

But, just as important, he may finally acknowledge how hard it was to sustain his marriage and to be present for his children. He may have missed his son’s winning soccer goal at the state championship because he was tied up in the operating room, or he may have forgotten his wife’s birthday because of some committee meeting or other. A huge part of his story takes place outside of the hospital and office.

 

Our stories take into account more than what happened to us, when it occurred, or how it ended. They embrace how we react to life’s vagaries, how we interpret and process them, how we survive them physically, emotionally, and mentally, and who we become because of them.

 

“Telling our story does not merely

document who we are.

It helps make us who we are.”

~Rita Charon~

jan

 

 

 





the time it takes...the trouble it saves

 

 

 Training in the practice of narrative medicine focuses on motivating and enabling health care providers to uncover the real story behind the patient’s illness…not just his symptoms, but his attitudes toward health and healing, how his illness affects his life and the lives of people around him, and his fears and hopes for the future.

 

“It can be argued that the largest

yet most neglected health care resource

worldwide is the patient.”

~Dr. Warner Slack~

 

Let’s say a woman presents with a complaint of palpitations…the sensation that her heart has been beating rapidly and/or irregularly, off and on, for a couple of weeks. It scares her because her father died suddenly following a heart attack at the age of 54. She limits her caffeine intake, exercises regularly, and is otherwise healthy. When you see her in the office, her cardiac exam is normal…her pulse is 80 and regular. Her blood pressure is normal. So, you schedule her for a stress test and a cardiac event recorder. The only thing that shows up is an occasional episode of sinus tachycardia. You have now run up several thousand dollars in bills and you still have no diagnosis.

 

Had you taken time to ask about recent stresses in her life, she might have told you about the cigarette burn she recently found on her twelve-year old’s shirt sleeve. And how poorly he’s doing in school. And how worried she is about him because if he’s smoking already, what’s next? And how hard it is as a single mother because she has to work two jobs and she can’t keep her eye on him the way she should.

 

“We know that stress is perhaps

the most underrated of all  

our heart disease risk factors.”

~Michael Miller~

 

It’s no wonder her heart is acting up. But her cardiac condition is not the problem. Stress is. And stress can be a whole lot harder to treat than a cardiac arrhythmia. You could run every test known to mankind in an effort to convince your patient that her heart is fine…but until you identify and address the real issue, she will continue to have symptoms. Her problems will only get worse.

 

Narrative medicine encourages us to take time to elicit the patient’s whole story, and to consider the context of his illness. To touch the sensitive spot. To probe the wound. Not only to make an accurate diagnosis but to explore the patient’s fears, expectations, and beliefs about his condition…anything that might delay healing.

 

Or promote it.

 

“The good physician treats the disease;

the great physician treats the patient

who has the disease.”

~William Osler~

 

jan

 

 

 

 

 

 

 

 

 

 

 





i smell smoke

 

 

 

 

Another random rant:

 

It’s no wonder we have been hearing more and more about the problem of “burn out” among health care professionals as we witness the premature exodus of capable, dedicated physicians and nurses from a system that defies excellence in patient care by virtue of its unspoken battle cry: Bigger. Faster. Greedier.

Burn out is defined as:

 

“…a state of physical, emotional, or mental

exhaustion accompanied by

doubts about one’s competence

and the value of one’s work.”

~https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642~

 

But it doesn’t have as much to do with fatigue as it does with frustration. The problem isn’t about keeping up with technology or advances in diagnostic and treatment modalities. We can do that. The problem is that we are forced to compromise thoroughness in favor of efficiency. Connection in exchange for productivity. Compassion in lieu of profit.

Dedication, fulfillment, and integrity are no longer part of the equation.

When I gave up after thirty years in Family Medicine I told my patients and colleagues I was retiring…when I meant 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 for 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.

No. What finally got to me was the erosion of my authority as a physician by self-proclaimed intermediaries who had neither knowledge of nor concern for my patients’ wellbeing. When I started out in medicine the problem was oppressive paperwork; now-a-days it’s an oppositional defiant electronic medical record system. A 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…which translates into seeing more patients faster regardless of the complexity of the presenting problem. I worried I would miss something, and I feared for my patients because of it. It scared me. I had to leave.

 

“The very concept,

I would say ministerial function of being a physician,

is to be attentive, is to be present,

is to listen to that story,

is to locate the symptoms on the person

of that patient,

not on some screen,

not on some lab result,

but on them."
~Rosmarie Voegth~

 

It's no wonder we worry about competence given the constraints imposed on our ability to deliver excellent care to our patients. It's no surprise we question the value of our work when we measure it in terms of quality and compassion while the system is busy tallying the receipts. 

Physicians are encouraged to manage their stress…when they are helpless against it. To get outdoors more. To meditate. To eat better and to get more sleep…when, some days, we don’t have time to eat at all. When we can’t break away long enough to poop on the pot. When we don’t have the strength to blink at the end of the day…not because the work has gotten any harder, but because the hoops we have to jump through have multiplied…and somebody in a fancy office is holding them higher.

 

“America’s healthcare system is neither

healthy, caring, nor a system.”

~Walter Kronkite~

 

 Looking back on thirty years of practice in the American medical system, I can only say, "It weren't broke." But it sure needs fixin' now.

For more on professional burnout, check out  https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072470/

jan





 



this week's challenge

 

 

 

I just registered for the third annual conference on narrative medicine to be held at Kripalu Center for Yoga and Health in July. The title of this conference is "Narrative Medicine--A Cutting-Edge Approach to Healthcare."

*

Narrative Medicine A Cutting-Edge Approach to Healthcare

·                     July 8–13, 2018

·                     Sunday–Friday: 5 nights

·                     Presenter: Natalie Goldberg

·                     Presenter: Nancy Slonim Aronie

·                     moderator: Lisa Weinert

·                     and more…

For caregivers, doctors, nurses, yoga teachers, writers, and anyone interested in personal narrative as a healing path to recovery.

*

Now, I don’t know about you, but when I think of cutting edge approaches to health care I think of things like new and more effective antibiotics, high tech scans and digital something-or-others, and robotic microsurgical techniques. But storytelling?? Not so much.

Advances in medicine, whether having to do with the development of new drugs, tests, or methodologies, have to pass rigorous tests of their efficacy and safety before they are introduced into mainstream practice. This requires large scale randomized, double-blind, placebo-controlled studies…which are notoriously difficult to design. Once you have demonstrated the safety and efficacy of, let’s say, a new drug, you still have to consider its cost effectiveness, applicability and acceptance rate. It’s surprising anything makes it through the process. But storytelling??

 

“I love storytelling.

It’s endlessly healing.”

~Ben Vereen~

 

For the sake of this discussion, let’s assume that the techniques taught in narrative medicine programs represent an advance in the practice of clinical medicine…that this method improves patient satisfaction, shortens hospital stays, decreases the number of readmissions, and in the long run, saves time and money. The numbers that prove these claims may be hard to get at. How can we measure the effect of patient satisfaction on healing? How would we code and bill for the time it takes to listen to the patient’s real (aka “whole”) story? Won’t it wreak havoc on our schedules to engage with our patients on their terms?

 

There is one way to find out:

 

Try it.

 

See if it works for you. Other people have. Other healthcare providers have reported not only improved patient satisfaction, but an improved sense of personal and professional fulfillment, a greater sense of dedication to and connection with their patients, better insight into the cause and clinical course of the patient’s illness and recovery. More accurate diagnosis. Fewer unnecessary tests. More effective interventions. All of which add up to better health care.

 

“Each time I told my story,

I lost a bit,

the smallest drop of pain.”

~Alice Sebold~

 

This is my challenge: look over your patient schedule for the week. Find a day when you have a little built in leeway. Pick a patient who is coming in for the first time. Or for a new problem. Ask this question:

 

“What do you think I should know

about your situation?”

 

Then just listen. Try not to interrupt, or redirect, or clarify what the patient says. There will be time for that later. He will tell you everything you need to know…what has happened, how it affects him, how he feels about it, and what he thinks about it. Bam!

 

This is the technique employed by Rita Charon, director of the Program in Narrative Medicine at Columbia University and chief contributor to the landmark text, The Principles and Practice of Narrative Medicine.

 

If the concept behind narrative medicine interests you, you might consider ordering a copy. Or…attending this year’s conference!

jan