Dr Christopher Travis, an intern (houseman) in obstetrics-gynaecology, 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’t physiological.
“She told me, ‘I’m terrified I’m going to get this virus that’s spreading all over the world’,” and worried it would hurt her baby, he says of the March (2020) encounter.
Dr Travis, who practises at the Los Angeles County + University of Southern California (USC) Medical Center in the United States, told the woman that he knew she was scared and tried to assure her that she was safe and could trust him.
By asking many questions and carefully listening to the answers, he 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’ stories into their practices.
“How do we do that really difficult work during the pandemic without it consuming us so we can come out ‘whole’ on the other end?” he asks.
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 says.
The first graduate programme in narrative medicine was created at Columbia University in 2009 by Dr Rita Charon.
The practice has gained wide influence since as evidenced by the dozens of narrative medicine essays 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, says writer and geriatrician Dr Louise Aronson, who directs the medical humanities programme at the University of California, San Francisco.
It may be useful to reassure patients or to motivate them to follow public health recommendations.
“Tell them a story about having to intubate a previously healthy 22-year-old who’s going to die and leave behind his first child and new wife, then you have their attention.
“At the same time, telling that story can help the health professional process their own trauma and get the support they need to keep going,” she says.
This fall (2020), USC’s Keck School of Medicine of USC will offer the country’s second master’s programme in narrative medicine.
The subject will also be part of the curriculum in the new Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, California, which opens its doors July 27 (2020) with its first class of 48 students.
Learning about living
Narrative medicine trains physicians to care about patients’ singular, lived experiences – how illness is really affecting them, says 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 says there’s also “real, intrinsic value” for patients because a doctor isn’t only being trained to care about the body and medications.
“Literature in its nature is a dive into the experience of living – the triumphs, the joys, the suffering, the anxieties, the tragedies, the confusions, the guilt, the ecstasies of being human, of being alive,” he says.
“This is the training our students need if they wish to care for persons and not diseases.”
Dr Andre Lijoi, a geriatrician at WellSpan York Hospital in Pennsylvania, recently led a virtual session for 20 frontline nurse practitioners who work in nursing homes.
Two volunteers recited Mary Oliver’s 1986 poem Wild Geese, which reads “Tell me about despair, yours, and I will tell you mine. Meanwhile the world goes on.”
Sharing the poet’s words helped the nurses relieve their pent-up tensions, enabling them to express their feelings about life and work under Covid-19, he says.
One participant wrote, “As the world goes on around me, I mourn seeing my ageing parents, planning my daughter’s wedding and missing my great niece’s baptism.
“I wonder, when will life be ‘normal’ again?”
Dr Naomi Rosenberg, an emergency room physician at Temple University Hospital in Philadelphia, studied narrative medicine at Columbia and teaches it at Temple’s Lewis Katz School of Medicine.
The discipline helps her “metabolise” what she takes in while caring for Covid-19 patients, including the fear that comes with having to enter patients’ rooms alone in protective gear, she says.
The training helped her counsel a worried woman who couldn’t visit her sister because the hospital, like others around the country, wasn’t allowing relatives to visit Covid-19 patients.
“I’d 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,” she says. (After a four-day crisis, the sister recovered.)
Close readings can also help students understand the various ways metaphor is used in the medical profession, for good or ill, says Dr Pamela Schaff, who directs the Keck School’s new master’s programme in narrative medicine.
Recently, she 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 “warriors” could “promote unrealistic expectations and even depersonalisation of us as human beings,” he says.
Something similar happens in the militarised language used to describe cancer, he adds: “We say, ‘You’ve got to fight’, which implies that if you die, you’re somehow a failure.”
In the real world, doctors are often focused narrowly, devoting most of their attention to a patient’s chief complaint.
They listen to patients on average for only 11 seconds before interrupting them, according to a 2018 study in the Journal of General Internal Medicine.
Narrative medicine seeks to change that.
While listening more carefully may add one more item to a physician’s lengthy “to-do” list, it could also save time in the end, Dr Schaff says.
“If we train physicians to listen well, for metaphor, subtext and more, they can absorb and act on their patients’ stories even if they have limited time,” she says.
“Also, we physicians must harness our narrative competence to demand changes in the healthcare system.
“Health systems should not mandate 10-minute encounters.”
In practice, narrative medicine has diverse applications.
Modern electronic health records, with their templates and prefilled sections, can hamper a doctor’s ability to create meaningful notes, Dr Gowda says.
But doctors can counter that by writing notes in language that makes the patient’s struggles come alive, he says.
The school’s curriculum will incorporate a different patient story each week to frame students’ learning.
“Instead of, ‘This week, you will learn about stomach cancer’, we say, ‘This week, we want you to meet Mr Cardenas’,” he says.
“We 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’s stories and contexts.”
In preparation for the school’s opening, Dr 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, says Dr Marla Law Abrolat, a Permanente Medicine paediatrician in San Bernardino, California, and a faculty director at the new school.
“Young people come to medicine with bright eyes and want to help, then a traditional medical education beats that out of them,” she says.
“We want them to remember patients’ stories that will always be a part of who they are when they leave here.” – Stephanie Stephens/Kaiser Health News/Tribune News Service