Using Stories To Mentally Survive As A COVID-19 Clinician
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Dr. Christopher Travis, an intern in obstetrics-gynecology, has cared for patients with COVID-19 and performed surgery on women suspected of having the coronavirus. But the patient who arrived for a routine prenatal visit in two masks and gloves had a problem that wasn鈥檛 physiological.
鈥淪he told me, 鈥業鈥檓 terrified I鈥檓 going to get this virus that鈥檚 spreading all over the world,鈥欌�� and worried it would hurt her baby, he said of the March encounter.
Travis, who practices at the Los Angeles County + University of Southern California Medical Center, told the woman he knew she was scared and tried to assure her she was safe and could trust him.
Asking many questions and carefully listening to the answers, Travis was exercising the craft of narrative medicine, a discipline in which clinicians use the principles of art and literature to better understand and incorporate patients鈥� stories into their practices.
鈥淗ow do we do that really difficult work during the pandemic without it consuming us so we can come out 鈥榳hole鈥� on the other end?鈥� Travis said. Narrative medicine, which he studied at Columbia University, has helped him be aware of his own feelings, reflect more before reacting, and view challenging situations calmly, he said.
The first graduate program in narrative medicine was created at Columbia University in 2009 by Dr. Rita Charon, and the practice has gained wide influence since, as evidenced by published in the Journal of the American Medical Association and its sister journals.
Learning to be storytellers also helps clinicians communicate better with non-professionals, said writer and geriatrician Dr. Louise Aronson, who directs the medical humanities program at the University of California-San Francisco. It may be useful to reassure patients 鈥� or to motivate them to follow public health recommendations. 鈥淭ell them a story about having to intubate a previously healthy 22-year-old who鈥檚 going to die and leave behind his first child and new wife, and then you have their attention.鈥�
鈥淎t the same time, telling that story can help the health professional process their own trauma and get the support they need to keep going,鈥� she said.
Teaching Storytelling To Doctors
This fall, Keck School of Medicine of USC will offer the country鈥檚 second master鈥檚 program in narrative medicine, and the subject also will be part of the curriculum in the new Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, which opens its doors July 27 with its first class of 48 students. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)
Narrative medicine trains physicians to care about patients鈥� singular, lived experiences 鈥� how illness is really affecting them, said Dr. Deepthiman Gowda, assistant dean for medical education at the new Kaiser Permanente school. The training may entail a close group reading of creative works such as poetry or literature, or watching dance or a film, or listening to music.
He said there鈥檚 also 鈥渞eal, intrinsic value鈥� for patients because a doctor isn鈥檛 only being trained to care about the body and medications.
鈥淟iterature in its nature is a dive into the experience of living 鈥� the triumphs, the joys, the suffering, the anxieties, the tragedies, the confusions, the guilt, the ecstasies of being human, of being alive,鈥� Gowda said. 鈥淭his is the training our students need if they wish to care for persons and not diseases.鈥�
Dr. Andre Lijoi, a geriatrician at WellSpan York Hospital in Pennsylvania, recently led a virtual session for 20 front-line nurse practitioners who work in nursing homes. Two volunteers recited Mary Oliver鈥檚 1986 poem 鈥淲ild Geese,鈥� which reads, 鈥淭ell me about despair, yours, and I will tell you mine. Meanwhile the world goes on.鈥�
Sharing the poet鈥檚 words helped the nurses relieve their pent-up tensions, enabling them to express their feelings about life and work under COVID-19, Lijoi said.
One participant wrote, 鈥淎s the world goes on around me I mourn seeing my aging parents, planning my daughter鈥檚 wedding, and missing my great niece鈥檚 baptism. I wonder, when will life be 鈥榥ormal鈥� again?鈥�
Processing Fear To Provide Better Care
Dr. Naomi Rosenberg, an emergency room physician at Temple University Hospital in Philadelphia, studied narrative medicine at Columbia and teaches it at Temple鈥檚 Lewis Katz School of Medicine. The discipline helps her 鈥渕etabolize鈥� what she takes in while caring for COVID-19 patients, including the fear that comes with having to enter patients鈥� rooms alone in protective gear, she said.
The training helped her counsel a worried woman who couldn鈥檛 visit her sister because the hospital, like others around the country, wasn鈥檛 allowing relatives to visit COVID-19-infected patients.
鈥淚鈥檇 read stories of Baldwin, Hemingway and Steinbeck about what it feels like to be afraid for someone you love, and recalling those helped me communicate with her with more clarity and compassion,鈥� Rosenberg said. (After a four-day crisis, the sister recovered.)
Dr. Pamela Schaff (right) discusses narrative medicine in the Hoyt Gallery at the Keck School of Medicine of the University of Southern California, as Chioma Moneme, a student in the class of 2020, looks on. (Credit: Chris Shinn)
Close readings can also help students understand the various ways metaphor is used in the medical profession, for good or ill, said Dr. Pamela Schaff, who directs the Keck School鈥檚 new master鈥檚 program in narrative medicine.
Recently, Schaff led third-year medical students through a critical examination of a journal article that described medicine as a battlefield. The analysis helped student Andrew Tran understand that describing physicians as 鈥渨arriors鈥� could 鈥減romote unrealistic expectations and even depersonalization of us as human beings,鈥� he said.
Something similar happens in the militarized language used to describe cancer, he added: 鈥淲e say, 鈥榊ou鈥檝e got to fight,鈥� which implies that if you die, you鈥檙e somehow a failure.鈥�
In the real world, doctors are often focused narrowly, devoting most of their attention to a patient鈥檚 chief complaint. They listen to patients on average for only 11 seconds before interrupting them, according to a 2018 study in the . Narrative medicine seeks to change that.
While listening more carefully may add one more item to a physician鈥檚 lengthy 鈥渢o-do鈥� list, it could also save time in the end, Schaff said.
鈥淚f we train physicians to listen well, for metaphor, subtext and more, they can absorb and act on their patients鈥� stories even if they have limited time,鈥� she said. 鈥淎lso, we physicians must harness our narrative competence to demand changes in the health care system. Health systems should not mandate 10-minute encounters.鈥�
Telling The Patient鈥檚 Whole Story
In practice, narrative medicine has diverse applications. Modern electronic health records, with their templates and prefilled sections, can hamper a doctor鈥檚 ability to create meaningful notes, Gowda said. But doctors can counter that by writing notes in language that makes the patient鈥檚 struggles come alive, he said.
The school鈥檚 curriculum will incorporate a different patient story each week to frame students鈥� learning. 鈥淚nstead of, 鈥楾his week, you will learn about stomach cancer,鈥� we say, 鈥楾his week, we want you to meet Mr. Cardenas,鈥欌�� Gowda said. 鈥淲e learn about who he is, his family, his situation, his symptoms, his concerns. We want students to connect medical knowledge with the complexity and sometimes messiness of people鈥檚 stories and contexts.鈥�
In preparation for the school鈥檚 opening, Gowda and a colleague have been running Friday lunchtime mindfulness and narrative medicine sessions for faculty and staff.
The meetings might include a collective, silent examination of a piece of art, followed by a discussion and shared feelings, said Dr. Marla Law Abrolat, a Permanente Medicine pediatrician in San Bernardino, California, and a faculty director at the new school.
鈥淵oung people come to medicine with bright eyes and want to help, then a traditional medical education beats that out of them,鈥� Abrolat said. 鈥淲e want them to remember patients鈥� stories that will always be a part of who they are when they leave here.鈥�
This story was produced by聽, which publishes聽, an editorially independent service of the聽.