Narrative Medicine with Syl jones -- 6 march 2016
On Sunday, March 6th, 2016, Syl Jones, a resident fellow in narrative health at Hennepin County Medical Center, visited Minnesota Medical Leaders to host a discussion-based meeting on narrative medicine. The crucial lesson I got out of the discussion was a realization that a narrative medicine approach in health care could be the much-needed solution for helping marginalized people achieve stability and independence.
“Most of medicine is actually narrative to start with.”
Mr. Jones believes that medicine is as much about science as it is art - the art of considering the perspective of another and appreciating the depth that goes into each unique narrative which comprises us. He explained that specialization, technological advancements, and an overwhelming amount of computerized documentation can cause physicians to be too narrow-minded in their considerations of a patient’s well-being or diagnosis. Mr. Jones spoke about what has been termed the ‘American Health Care Paradox’ - the fact that the U.S. spends more money on health care than any other country, yet in many avenues sees results lower than what we’d expect. One of the major explanations for this posed by Mr. Jones is that there’s not enough investment in social services. Mr. Jones said health care professionals need to better recognize that all the aspects and responsibilities of people’s lives are potential significant influences on their health and well-being. He also placed an importance on the broader context of patients’ lives that reminded me how I had been reaching this same idea through my own terms - within the same hospital that Mr. Jones conducts his current work.
As a volunteer in the Hennepin County Medical Center Emergency Department, I have come to know two types of patients. The first kind has no name or face; their visit is unexpected, and they are randomly seasoned throughout the day and night, enduring unfortunate but usually manageable medical emergencies. But the other patients have a different tone. These patients are not unfamiliar. They are the ones living without a home, addicted to drugs, trying to survive alcoholism, and often the ones living with multiple complex medical conditions that are poorly managed. All the nurses, doctors, PAs, etc. get a certain look on their face when they see one of these regular customers. It is a look of despair, and it is mirrored by the patient. “Oh no, Mr. ___, we just saw you here a few days ago! I hoped we wouldn’t see you back here.” These are the patients that the current social and health care system has failed.
All too often I witness marginalized people getting more accustomed to emergency departments than any civilian deserves to be. Although the kindness and effort I see as they are cared for at HCMC never fails to inspire me, I know that their emergencies trace back to something much larger that should have been addressed long before they had to be picked up by an ambulance. These marginalized people face structural oppression and are much more likely than other people to become caught in a vicious cycle of unemployment, lack of affordable housing, and no health insurance. This is an extremely vulnerable position, and any injury, suffering moment of drug use, or risky sexual encounter can send them into a downward spiral. Without transportation they may be unable to make it to the hospital for checkups, and without money they may be unable to afford medications to control diseases that require very assertive management of medications. And this is when the patients finally come to safety net hospital emergency departments like HCMC. HCMC beautifully manages the immediate life threats faced by such patients, but the emergency department is not equipped to provide the social support that these patients need to achieve a sustainable way of living, and this is why we often see them back the following week.
This is what Syl Jones means when he says that the American health care system is failing, and on this end, I couldn’t agree more. This is where I think narrative medicine - not only through the practice of physicians, but through the entire way healthcare is organized - could provide enormous benefits to at-risk patients and marginalized populations. While current resources, levels of training, and technology in in-hospital health care settings are generally excellent, there is a chronic problem with ED patients relying on emergency interventions and subsequently returning to situations where they have no support or means of escaping inhumane circumstances. In order for us to prevent so many people from being stuck in what are truly awful situations both inside and outside the emergency departments, we need a large, interwoven network of social services that support people well beyond hospitals. When a healthcare system not only emphasizes the physiological and technical aspects of a patient’s health but also the set of living conditions, relationships, and challenges that person is surrounded by, then I think there will be a vast improvement in the way we perceive and utilize the health services.
Narrative medicine could be one of the major components in providing this restructuring of healthcare, and one thing about Syl Jones’ talk that inspired me was the fact that so many students in my generation are educating themselves about topics relevant to this. As I come across more and more health-career-oriented peers, I see students making an effort to learn about the social determinants of health, the role of narrative medicine, and the settings in the world that badly need access to better health care and other resources. I see brilliant, driven members of my generation preparing to address the injustices occurring involving health care, and I see them having in-depth, emotional discussions with one another about how we’re going to do this. This gives me hope for the role we may some day have as physicians seeking to create positive changes.
Amidst helping me see the importance of social services in medicine, Syl Jones helped me realize what an important role doctors could play in narrative medicine, even though they certainly aren’t center stage. In addition to being intelligent, critical thinkers who can understand the physiological aspects of medicine in great depth, good doctors must also be able to connect with their patients in a way that can help ease the suffering and stress that occurs outside of the hospital. This means doctors must be equipped to bring up what can often be difficult topics to discuss face-to-face with patients, yet are absolutely critical to their health: “How have you been feeling mentally lately…. How are your relationships with family and friends….Are you practicing safe sex….Tell me how you’re doing.” For a patient to have the ability to completely open up to a physician who is both professional and empathetic is, in my opinion, one of the most powerful processes in health care. I think it is then the duty of the physician - as well as other health practitioners - to assist patients in making a smooth transition from clinical-care settings to out-of-hospital social service settings that can be as subtle or as involved as the patient wants.
This past week I read an essay for my humanistic healthcare and communication course called The Practice by William Carlos Williams which strongly related to Syl Jones’ discussion of narrative medicine. While at first this was one of the more difficult-to-understand pieces of writing about medicine I’ve encountered, it ended up being one of the most beautiful. In it, Williams describes moments in medicine when the seriousness of an illness causes a patient to perceive their existence and mortality in a deeper way, allowing profound thoughts and ideas to come forth.
Much like Syl Jones built the idea that everyone is a story, Williams builds up to the idea that a person’s experience of life is, in itself, a poem. These poems are unique for everyone, yet the transcendent, mysterious nature of them provides Williams with a sense of awe and beauty each time they come out:
“It will not use the same appearance for any new materialization. And it is our very life. It is we ourselves, at our rarest moments, but inarticulate for the most part except when in the poem one man, every five or six hundred years, escapes to formulate a few gifted sentences.”
And I will end my blog post with the end of Williams’ essay, describing the role of a physician in listening to the poems of others. This is how I envision Syl Jones’ goal for how physicians see their role in the future, and I think it might be my favorite quote I’ve ever encountered thus far about medicine. Thank you all for reading.
“The poem springs from the half-spoken words of such patients as the physician sees from day to day. He observes it in the peculiar, actual conformations in which its life is hid. Humbly he presents himself before it and by long practice he strives as best he can to interpret the manner of its speech. In that the secret lies. This, in the end, comes perhaps to be the occupation of the physician after a lifetime of careful listening.”
Leadership and Values with Dr. Rahul Koranne -- 11 October 2015
By Michael Sobin
We all aspire to do great things in life: to go to the moon, save someone’s life, be a leader. But getting to that point of matching our life’s aspirations is difficult, and there are necessary steps we must consider to give ourselves the best opportunity of reaching these dreams. So as an aspiring medical leader, what can I do to give myself the best opportunity of being that leader. A few weeks ago, Dr. Rahul Koranne, Senior Vice President of Clinical Affairs and Chief Medical Officer of the Minnesota Hospital Association, spoke to MML about being a good physician and becoming a medical leader. Dr. Koranne presented ten steps: practice your values, promote your brand, embrace change, other people matter, technology and measurement, continuously learn, work hard, serve the community, contemplate legacy, and just be. What I want to reflect on are the first and last points Dr. Koranne brought up. For the “practice your values”, we wrote down what we thought were the values we lived by and then asked the other members of the group if they saw those values in us. What I found through this exercise is not only that the values I live my life by are apparent to others, but there are a series of other values and strengths that I put on which I am not even aware of. Practicing your values means understanding who you are and being able to promote your strengths through them. For example, I will need to focus on my initiative and drive if I am to provide myself the opportunities to become a medical leader. It is the intent which matters and I plan to continue practicing my values with this in mind. The final point Dr. Koranne made was to “just be.” To be a leader means to be yourself, enjoying the moment for what it is, and taking your own strengths to your advantage. I was awed seeing what Dr. Koranne was able to do with his own strengths, and it motivates me to put forward my all and utilize my skills to become a physician and medical leader.
Discussions on Race and Medicine with Professor Jack DeWaard -- 27 September 2015
By Ben Lueck
Race is a topic that traditionally falls firmly in the category of social taboo. Talking about race has become something that most people are taught from a young age not to discuss, and at best people are taught to be “colorblind,” or not see race. However, the practice of colorblindness does not acknowledge that race is a real social construct that has serious implications in our everyday lives. This is why Minnesota Medical Leaders has taken the initiative to start these important discussions about race, especially how it pertains to medicine - to move beyond “colorblindness.” In doing so we invited Jack DeWaard, Professor of Sociology, to lead a discussion with our group on Race and Medicine.
Professor DeWaard began this discussion by talking about race as most people see it. Most people have a natural propensity to organize everything around them to simplify an inherently complex world. In doing so, we see race as a “bin” into which we can group people based on similarities. How any one person would choose to place people into bins may vary, but the most common ways to group people use the basis of skin color, culture, or religion. If this traditional system of racial classification functions well you would expect people in the same bin to be very similar to each other, while you would expect individual bins to be very different from each other. However, this is not the case, as you see as much variation inside of bins as you do between bins using any of the aforementioned criteria.
The next question Professor DeWaard posed was: if our current system of racial classification doesn’t work, how should we classify race? Before we can answer this question it is important to recognize that we as individuals are often not the ones who choose the bins into which we can place people. These bins are often pre-determined by governmental or economic processes that create this idea that bins are distinct from each other. However, in reality these traits which we use to classify people exist on a spectrum, and the way we divide this spectrum has serious, often disregarded, implications. In medicine, people are classified constantly, including on the basis of race. Therefore, how we as future physicians and researchers choose to divide this spectrum can have serious implications on research and how we report health statistics. Yet, it is also true that some diseases are more likely to affect a specific population, creating a difficult realism that race cannot be completely ignored. It will be up to as, as future physicians, to find the balance between providing personalized and effective medicine while not biasing ourselves in the work we do.
The final question Professor DeWaard left us with was: what is a better way to classify people? This is certainly not a simple question, but one that all of us will face at some point in our lives. This discussion provided a great platform to start a conversation surrounding the impact of race on society and medicine, while leaving each of us with food for thought. On behalf of myself and the Minnesota Medical Leaders, I would like to thank Professor DeWaard for taking the time to lead this discussion.
MML Membership Retreat: September 13, 2015
By Andrew Savitz
To kick off the new school year and to begin the journey that it will comprise, the Minnesota Medical Leaders held its first meeting amid the mud, trees, and rushing waters of Minnehaha Falls Regional Park. The agenda of our retreat was itself a journey and was designed with the following intention. As we moved deeper into the park, a new layer of social, personal, and professional development was explored and in so doing, mimicked the experience that is MML membership: an experience that fosters the strengthening of social bonds as well as professional and personal development.
After a formal welcome and before proceeding to the trailhead, MML members formed a circle and were led by our VP of Inter-Relational Development, Michael Sobin, in a teambuilding exercise. This activity was meant to encourage strong communication skills, trust, and cooperation.
Following this experience, the group was led next by our VP of Member Development, Melissa Hallenbeck. New mentor/mentee relationships for the year were announced and our continuously ongoing mentorship program was kicked-off with reflective questions, that mentors and mentees discussed one-on-one, as the group moved deeper into the park along the waterfall-fed river that lines the park’s main hiking trail.
Halfway along the trail we stopped at a wide-open area that is encircled by benches and includes a fire-pit at its center. New member (and now Alumni Relations Chair) Matt Freeman handed out a peer-reviewed journal article about physician communication and facilitated a discussion about what can be learned from the article’s findings. Together we discussed in small groups and as a large group, the importance of good communication within the doctor-patient relationship, how good communication can be developed, and the specific lessons that can be learned from the article being discussed.
For our final walk to our last location of the retreat, into the furthest depths of the park, we split off into pairs and shared with one another the question that unites us all: “Why do you want to be a physician?”
There are as many answers to that question as there are a diversity of experiences along the way toward medical school. We hope this retreat was just one of many experiences along the journey to this aspiration that binds us together and that it, like all other MML experiences, was one that served to foster personal and interpersonal growth.
Wangensteen Library Tour -- 4 December 2014
Thanks to Tom Strand, MML got the opportunity to take a tour of the Wangensteen Library and explore the vast contents found within.
As pre-medical students, we often find ourselves spending an inordinate amount of time contemplating, and stressing about, our future: When am I taking the MCAT? What classes will I take one, two, or three semesters from now? How will this experience help my medical school application? Last fall, a group of MML members took a brief respite from looking ahead to appreciate the past at the Owen H. Wangensteen Historical Library of Biology and Medicine.
Guided by Lois Hendrickson, the Wangensteen Library’s Interim Curator, MML members explored the history of the medical profession through a selection of the library’s over 80,000 texts and extensive artifact collection. Members had the opportunity to enter the world of the man considered by many to be the father of modern anatomy, Andreas Vesalius; as 2014 marks the 450th anniversary of Vesalius’ death (and 500th anniversary of his birth), the Wangensteen Library has constructed an exhibit commemorating the Flemish anatomist and the study of anatomy.
What is the value of studying the history of medicine? This is a common and understandable question: Why, when there is a seemingly infinite amount of scientific and clinical knowledge that is required for those in, and aspiring to, the medical profession should pre-medical students, medical students, and physicians bother with history? The English physiologist Sir Michael Foster provided an allegorical response to this challenge:
“What we know and what we think is not a new fountain gushing fresh from the barren rock of the unknown at the stroke of the rod of our own intellect, it is a stream which flows by us and through us, fed by the far-off rivulets of long ago.”
The history of medicine, or any scientific discipline for that matter, serves not only as a cache of ideas, as Foster acknowledges, but also provides countless archetypes to teach and guide contemporary students and medical professionals. Who better to study than Andreas Vesalius or William Harvey when attempting to understand the value of observation and experimentation? What better to study than the Black Death when attempting to appreciate the power disease can hold over society? What better to study than humoral theory and the practice of bloodletting to understand the potential for error in even the most popular theories and practices? Who better to study than William Halsted to acknowledge the possible fallibility of the most revered and genius of physicians?
The Hippocratic oath, recited by the vast majority of medical students upon graduation, is itself a historical vestige of ancient medicine preserved due to its perpetual relevance to the practice of medicine. Perhaps Dr. Eugene Cordell’s reflection on the value of history of medicine can explain the oath’s longevity:
“[The study of the history of medicine] furnishes the stimulus of high ideals which we poor, weak mortals need to have ever before us; it teaches our students, to venerate what is good, to cherish our best traditions, and strengthens the common bond of the profession.”
At its best, the history of medicine augments one’s appreciation for the medical profession, providing its students with a contextual understanding of medical practice, instilling intellectual and professional humility, and setting professional ideals to aspire to. MML’s visit to the Wangensteen Library was a rewarding experience, opening a doorway for members to explore an oft-overlooked facet of medicine.