“I know I’m supposed to be unemotional, professional, stoic. But when that four-year-old kid died on my rotation, I almost lost it. How can I deal with that?”
Tell me your story.
“How can I tell my family I don’t want to face chemo again? I want to be home. I want to live, but not at this price.”
Tell me your story.
“Is this your first time in detox? Have you ever been in withdrawal?”Those two questions wafted out into the hospital hall – two simple yes/no questions, with a lifetime of story behind them: What was this person’s situation? How had he landed in this hospital, in this condition, where he was being asked to share such an intimate, difficult confession with a doctor who was a complete stranger?
Tell me your story.
Beyond the necessities for survival, is there any more fundamental human need than to connect with others through stories? They let us feel kinship, experience emotion, and understand or challenge the people and world around us. Stories let us learn, share, get angry, become motivated, understand difference and appreciate community.
Stories are integral in medicine, too, say Gary Hoff, D.O., FACOI, FACC, and Norma Hirsch, M.D., associate and assistant professors of behavioral medicine, respectively. The two believe this so deeply that five years ago they pursued special training in order to bring to DMU an elective called The Healer’s Art. Now offered at approximately half of the nation’s medical schools, the course gives students a safe environment to discuss difficult topics without feeling unprofessional or unfit for the rigors of learning and practicing medicine.
In the past year, Hoff and Hirsch developed and taught a new elective, Literature and Narrative Medicine. DMU Magazine talked with the two faculty members on why storytelling is important in health care and in medical education.
DMU Magazine: The Healer’s Art elective was created by Rachel Naomi Remen, M.D., clinical professor of family and community medicine at the University of California-San Francisco School of Medicine, to give medical students opportunities to explore human dimensions of medicine rarely discussed in medical training. They include loss, grief, healing, encounters with awe and mystery, and self-care practices.
Hoff: The course helps us explore the power of being human in medicine. It’s intended to examine, promote and enhance skills of human contact. It’s a way for participants to strengthen and understand their own innate power to make a difference.
Hirsch: The course lets students know it’s okay for them to have a human moment. You don’t stop being a person when you become a doctor. Our patients respect us for our strength, but they love us for our vulnerability and humanity.
The course is facilitated by physicians from DMU or the community. That gives students a way to identify with clinicians as role models. Students know, for example, that I know how to hold a stethoscope correctly, but they also know I’ve taken care of dying patients.
Hoff: For the Literature and Narrative Medicine elective, the idea is that if you think about being human at a very basic level, most of what we do is tell stories. “How was your morning?” But what we don’t do in medicine is tell students this [importance of storytelling].
I teach a History of Medicine course. That didn’t appeal to students, so I changed the course’s name to The Story of Medicine. The students loved it. Why? Because we love stories.
Hirsch: Your patients can get a lot of information about health and their conditions on the Internet, but they come to you for your knowledge. In telling stories, there’s wisdom. William Osler, a Canadian physician [and one of the four founding faculty members of Johns Hopkins Hospital], once said, “It is as important to know the patient who has the disease as it is to know the disease that has the patient.”
Hoff: Stories are what really matter. As physicians, we’re taught to take objective histories. If a patient complains his ear hurts, we ask, “When did it start? When does it feel the worst?” I don’t want to minimize the value of that, but we also need to know how the problem is affecting the patient’s life.
In Literature and Narrative Medicine we teach “close reading,” a technique of literature analysis that’s not just reading; it’s thinking and reading and looking deeply into the text, thinking about who the narrator is, why the story was written, what is said and unsaid, and more. That should be our approach with patients. The idea is to foster more inquisitiveness, to go beyond mere curiosity.
Hirsch: You need the context, and the “why now?” Why is the patient coming to see you now? Physicians are admonished to listen carefully to the patient. If you listen carefully, the patient will tell you what is wrong with him. If you listen very carefully to the patient, he will also tell you what is wrong with you. Healing is bidirectional, not a one-way street. The physician gets something out of it, too, beyond a fee.
Hoff: We try to come at narrative medicine from all directions – from the patient who is ill, the caregiver, the patient’s family and the community.
Hirsch: Those different lenses are very hard for medical students to figure out. Some of our readings in the course are 50, 100 years old, so students also are incredulous on how far medicine has come in such a short time. Once, mastectomies were performed without anesthesia. Dr. Hoff and I were taught pediatrics by doctors who had no antibiotics. So part of the class is for students to read these stories and gain perspective.
Hoff: Unless students or their loved ones have experienced health care personally before medical school, they have a very narrow perspective. And when you read a story that was written in Great Britain in the 19th century, with a certain style and diction, you may be able to infer something from that. We talk about taking that interpretive skill into the patient encounter.
I’m convinced that teaching people to be mindful, to pay attention to detail and minutiae, is one of the most important things we can teach.
Hirsch: The stories we read in the class, the questions and discussions they bring about and the understanding they foster are not something students will get during residency.
Hoff: Some will gain that type of understanding through experience.
Hirsch: Some who look for that understanding may turn to the arts.
Hoff: Or they never gain that understanding.
Hirsch: Those are the “fixers.”
Hoff: For individuals like that, it wouldn’t matter if you soaked them in the humanities. There’s always been this dichotomy for me between medicine and the arts, but neither is exclusive of the other. Medicine is an art informed by science.
If Hippocrates were alive today, he wouldn’t know jack about today’s drugs and technology, but he would understand today’s profession of medicine. Galen [considered the greatest physician of the Roman Empire] would understand. He knew you can do much more for patients if they trust you. Who you are is more important than what you know, even though you have to know a lot.
Hirsch: And it’s important to know what you don’t know. Those who blunder on are more dangerous. To hear people’s stories is a huge diagnostic tool that’s as important as the CAT scan machine.
Hoff: No other profession will let you know such intimate things about people; no other allows you to touch certain parts of the body, for that matter. And you have to show patients you’re willing to have them tell you things they feel guilty about. You have to have a “way in” to understanding and interacting with them in such an elemental and personal way. We believe close reading – and close observation – can begin to equip our
students to do that.
Having “a way in”
In the fast-paced, high-pressure world that health care can be, it can be a challenge for providers to truly connect with patients. That can be especially difficult with patients you’re meeting for the first time and those who are scared or feel guilty and embarrassed about what ails them. To start the conversation and keep it going, DMU faculty Gary Hoff and Norma Hirsch offer these suggestions.
- Ask open-ended questions that can lead to an unfolding story, such as “Can you tell me what’s bothering you?”
- If you already have a few morsels of information, another useful prompt is “I understand that ________ is a problem at this time. Tell me what’s new.”
- “Tell me how your [condition/problem] impacts your quality of life. What is the hardest part of this for you?”
- “What can you no longer do that you wish you could still do?”
- “If I had a magic wand to change things, what would you most want the magic wand to change?”
Couple your questions with active listening – engagement with the patient in as many ways as possible while the story unfolds. That entails focused attention – eyes, body language and so on.
Truly crucial is not interrupting. Give the patient sufficient time to tell the story as he/she experienced it. One expert recommends letting the patient speak for at least five minutes before asking any questions at all after the opening one. Then it’s safer to ask probing and more detailed questions.
Tell us your story
Tell us your story Individuals with a story or art to share are invited to submit it to Abaton, Des Moines University’s student-produced literary journal.
First published in 2007, Abaton serves as a creative way for contributors and readers to explore aspects of health care that “often elude academic disciplines,” states its website, www.dmu.edu/abaton. Visit the website to view past issues or submit a work for consideration.
Powerful stories: recommended reading
Whether you want a tome to help you tune in to the human side of medicine or fun reads for the beach, DMU community members offer these suggestions.
Assistant Professor Norma Hirsch, M.D., and Associate Professor Gary Hoff, D.O., recommend Kitchen Table Wisdom: Stories That Heal by Rachel Naomi Remen, a physician, professor of medicine, therapist, creator of The Healer’s Art course and a long-term survivor of chronic illness. This commonsense collection of true stories reveals the power and mystery of life through the experiences and lessons of patients.
R. Tim Yoho, D.P.M., FACFAS, dean of the College of Podiatric Medicine and Surgery, suggests for inspiration Proof of Heaven by Eben Alexander, a neurosurgeon who once argued near-death experiences are impossible – until his own seven-day coma convinced him otherwise. For DMU students, Yoho recommends Samuel Shem’s The House of God, a poignant story of the education of American doctors as told through experiences in caring, pain, tragedy and humor of six medical interns.
For additional inspiration, DMU Provost Karen McLean, Ph.D., suggests Unbroken: A World War II Story of Survival, Resilience and Redemption by Laura Hillenbrand. Soon to be released as a movie directed by Angelina Jolie, it tells the gripping true story of Louis Zamperini, a teenage delinquent, Olympic runner and Army Air Corps lieutenant who, during World War II, survived a plane crash in the Pacific Ocean only to become a prisoner of war brutally treated by the Japanese.
For pages that will transport you to a different place and time, Jodi Cahalan, Ph.D., M.P.H.’01, M.S.’93, PA-C’89, DFAAPA, dean of the College of Health Sciences, recommends The Alienist by Caleb Carr. In this fast-paced read, based in 1896, then-New York City Police Commissioner Theodore Roosevelt enlists a New York Times reporter and a psychologist – an “alienist” – to help solve a murder.
For wisdom you can apply immediately, Richard Salas, Ph.D., multicultural affairs director, recommends Maura Cullen’s 35 Dumb Things Well-Intended People Say, a guide on how to avoid well-meaning but harmful comments that widen the diversity gap, and instead communicate more inclusively.
Looking for something on the lighter side? Yoho recommends Sh*t My Dad Says by Justin Halpern. In this touching, laugh-out-loud memoir, the author, dumped by his girlfriend at age 28, moves in with his crusty 73-year-old father who’s never one to mince words. Matthew Henry, Ph.D., chair of physiology and pharmacology and a two-wheeled enthusiast, suggests Bike Snob: Systematically and Mercilessly Realigning the World of Cycling by New York City blogger and writer BikeSnobNYC. Wickedly funny, it provides a unique look at the world of bicycles and their riders.