Stories in the Service of Making a Better Doctor (long)
- From: Nann Bell <hanbellGOGATORS@xxxxxxxxxxxxx>
- Date: Tue, 28 Oct 2008 22:14:46 -0500
interesting, from the NY Times
http://www.nytimes.com/2008/10/24/health/chen10-23.html?nl=8hlth&emc=hlth :
October 24, 2008
DOCTOR AND PATIENT
By PAULINE W. CHEN, M.D.
The white-coated crowd with stethoscopes slung casually around their necks
would have looked familiar to anyone who has attended morning hospital
rounds. Resident physicians and medical students milled about, chatting
animatedly, and at the appointed hour, the attending physician signaled to
begin.
But instead of filing toward a patient¹s room, the group at Saint Barnabas
Medical Center in Livingston, N.J., settled into a conference room at the end
of the hall, not to recite details of patient cases but to read ³Empty
Pockets,² a personal essay by Dr. Kevan Pickrel from The Annals of Internal
Medicine. In the piece, Dr. Pickrel describes being unable to save a
36-year-old woman, then going to the waiting room to inform the woman¹s
family of her death:
³The youngest daughter sat on Dad¹s lap looking at pictures in an outdoors
magazine. The older sat watching her hands rest in her lap. [The] husband¹s
eyes lifted to me and met mine. I didn¹t, couldn¹t, say a word.... He turned
back toward his daughters, a single father, and they lifted their eyes to
his. As he drew a breath to begin, his eldest daughter knew.²
After the reading, the attending physician, Dr. Sunil Sapra, looked up at the
group assembled. ³Do you identify with any of these situations?² he asked.
³Yes, it happens all the time,² a resident responded immediately. Others
nodded in agreement, and one resident flicked a tear away.
The next morning, in a similar room at New York-Presbyterian Hospital in
upper Manhattan, a group of obstetrics and gynecology residents gathered to
read E.B. White¹s short story ³The Second Tree From the Corner.² Told from
the perspective of an anxiety-ridden patient, the story ends with the main
character finding meaning in his life and suddenly feeling liberated:
³He felt content to be sick, unembarrassed at being afraid; and in the jungle
of his fear he glimpsed (as he had so often glimpsed them before) the flashy
tail feathers of the bird courage.²
As the reading ended, one of the young doctors commented on how personally
fulfilling it was to help her patients and how those feelings invigorated
her, even after many hours of work. Other doctors in the room nodded in
agreement.
While it has long been understood that clinical practice influenced the
youthful writing of doctor-authors like Chekhov and William Carlos Williams,
there is now emerging evidence that exposure to literature and writing during
residency training can influence how young doctors approach their clinical
work. By bringing short stories, poems and essays into hospital wards and
medical schools, educators hope to encourage fresh thinking and help break
down the wall between doctors and patients.
³We¹re teaching the humanities to our residents, and it¹s making them better
doctors,² said Dr. Richard Panush, a rheumatologist and chairman of the
department of medicine at Saint Barnabas.
The idea of combining literature and medicine ? or narrative medicine as it
is sometimes called ? has played a part in medical education for over 40
years. Studies have repeatedly shown that such literary training can
strengthen and support the compassionate instincts of doctors.
Dr. Rita Charon and her colleagues at the program in narrative medicine at
Columbia University¹s College of Physicians and Surgeons found, for example,
that narrative medicine training offered doctors opportunities to practice
skills in empathy. Doctors exposed to literary works were more willing to
adopt another person¹s perspective, even after as few as three or four
one-hour workshops.
³You want people to be able to leave their own individual place,² Dr. Charon
said, ³and ask what this might be like for the child dying of leukemia, the
mother of that child, the family, the hospital roommate.²
Over the last 15 years, an ever-increasing number of medical schools have
begun offering narrative medicine to medical students. These courses often
involve writing, reading and discussing works by authors as diverse as Leo
Tolstoy, Virginia Woolf, Lori Moore and various doctor-authors. Students then
explore the relevance of these texts, and their own writing, to their
clinical work.
But until recently, few educators have attempted to bring such literary
training into residency programs.
Residency is the most intense period of a young doctor¹s life. The years
spent squirreled away in hospitals and clinics are rich in clinical learning,
but the wealth of that experience comes at the cost of free time.
And with time at a premium, residency program directors and clinical
educators have been hesitant to add narrative medicine to their curricula,
particularly since it has never been clear that such an addition would have
any effect other than further overworking the trainees.
That could be changing.
For over a year now, Dr. Panush, a tall, bespectacled, soft-spoken man with
the lean physique of a runner, has been systematically incorporating
literature into the daily rounds of every one of the internal medicine
residents at Saint Barnabas Medical Center.
As part of the Accreditation Council for Graduate Medical Education¹s
Education Innovations Project, Dr. Panush and his faculty colleagues bring
poetry, short stories and essays to rounds each day and discuss them in the
context of the patients they see. These daily discussions, supplemented by
offsite weekly conferences, form the core of the residents¹ narrative
medicine experience.
One year into the program, Dr. Panush and his colleagues looked at the effect
of these daily discussions on the residents and their patients. What they
found were significant improvements in patient evaluations of residents and
patients¹ health and quality of life, from hospital admission to discharge.
A handful of other residency programs across the country have taken steps
toward establishing narrative medicine training for their residents,
including Vanderbilt University¹s Department of Surgery and New
York/Presbyterian Hospital-Columbia¹s Department of Obstetrics and
Gynecology. As with the program at Saint Barnabas, it has been the doctors
within these departments who have initiated the workshops, sessions and
lectures.
³As we improve the technology of medicine, we also need to remember the
patient¹s story,² said Dr. A. Scott Pearson, an associate professor of
surgery at Vanderbilt University Medical Center.
To that end, Dr. Pearson has completed a pilot study examining the
feasibility of incorporating narrative medicine into Vanderbilt¹s surgical
residency and has plans to make such training available eventually to all
surgical residents at his medical center. Dr. Pearson believes that narrative
medicine will not only help residents reflect on what they are doing and how
they might do better, but may also aid surgical educators in teaching
professionalism and communication skills.
³Narrative medicine changed my entire approach to medicine,² said Dr. Abigail
Ford, a senior resident in obstetrics and gynecology at New York-Presbyterian
Hospital/Columbia who studied under Dr. Charon as a medical student. ³As a
doctor you are really a co-author of patients¹ experiences and need to hear
their story and take it on.²
With her former professor¹s guidance, as well as the support of Dr. Rini
Ratan, the residency program director, Dr. Ford has initiated a narrative
medicine program for her fellow obstetrics and gynecology residents. While
the program is still in its first year, ³we¹ve always run over,² said Dr.
Ford. ³People have to be dragged away.²
³Our hope is to look at it in terms of physician empathy,² added Dr. Ratan,
³Does it add anything? Does it prevent natural jadedness over the course of
the busy training process? Does it prevent burnout?²
In the near future, Dr. Ratan and Dr. Ford also hope to begin doing the kind
of patient outcome evaluations that Dr. Panush and his colleagues have begun.
³To do what we¹re doing is pretty simple,² said Dr. Panush. ³But the
measurement stuff is harder. The program needs to be supported
institutionally and internally.²
Despite such challenges, the effects of these programs are striking. Dr.
Benjamin Kaplan, a second-year resident at Saint Barnabas, remarked on the
transformation he saw in fellow resident physicians during the first year of
the humanities program.
³Their management of patients changed,² Dr. Kaplan said. ³They remembered to
do things that I don¹t think they would have otherwise done, like always
talking to the family, gently touching patients, and continually explaining
the course of treatment and what the doctors are thinking so patients know.²
And the time commitment? ³It does get pretty busy,² Dr. Kaplan conceded. ³But
if you want to make time for it, you can. Spending a half hour a day to
remember that we are all human, not just doctors or pharmacists or nurses or
patients, is important enough that I think you should do it.²
Although it is still too early to determine the long-term effects of
narrative medicine on doctors in training, residents were quick to note that
certain essays, short stories and poems they have read on rounds continue to
influence their work.
Dr. Ramesh Guthikonda, a second-year resident at Saint Barnabas, spoke about
a poem called ³When You Come Into My Room,² by Stephen A. Schmidt. In the
poem, published in The Journal of the American Medical Association, a man
struggling with chronic illness lists all that he believes a doctor meeting
him should know:
³When you come into my hospital room, you need to know the facts of my life
that there is information not contained in my hospital chart
that I am 40 years married, with four children and four grandchildren....
that I love earthy sensuous life, beauty, travel, eating, drinking J&B
scotch, the theater, opera, the Chicago Symphony, movies, all kinds, water
skiing, tennis, running, walking, camping...
that I am chronically ill, and am seeking healing, not cure.²
The poem so affected Dr. Guthikonda that he began regularly asking his
patients about their hobbies and families, and he enrolled in a Spanish class
so he could learn to better pronounce their names. ³My rapport with patients,
especially with my Hispanic patients, was not up to the mark,² he said. ³I
never asked about the patients¹ lives, about who they are. I am much more
sensitive to those issues now.²
Reflecting on the changes in Dr. Guthikonda, Dr. Panush said, ³We changed the
way he thinks and does medicine. You can¹t put a p-value on that.²
---
Nann
remove the Gator cheer to email me
Change everything. Love & forgive.
.
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