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Medical Education, Medicine and Literature, Patient Care

Prescribing a story? Medicine meets literature in "narrative medicine"

Prescribing a story? Medicine meets literature in "narrative medicine"

woman reading bookIn the November issue of The Lancet, Chris Adrian, MD, postulates about what might be called “narrative medicine.” How do stories and poems alter our experience of caregiving, illness, and suffering? Does literature “help”?

Adrian, who is trained in both creative writing and medicine, thinks that artistic expressions of experience do bring something to clinical care, whether care is experienced on the giving or the receiving end. He also finds these benefits ineffable, impossible to quantify, study, or prove, and all the more powerful for it. He writes:

Lately I feel a strong, anxious conviction that writing and reading fiction and poetry might in fact execute some kind of alleviating change upon our suffering, even in the world of the hospital, upon that portion of our suffering related to illness and death. I can’t begin to argue logically or systematically how it actually does this. Accidentally or miraculously is about as far as I get when I try.

The reason literature, or perhaps art more generally, complements clinical practice is because it communicates in an entirely different language that speaks to different aspects of the human experience. Adrian ponders a line from W.H. Auden’s  “In Memory of W.B. Yeats,” which reads, “For poetry makes nothing happen…” and speculates:

…which is not by any means actually nothing, but instead a domain of activity so estranged from our degraded understanding of what human beings can do in the world that [Auden] had to call it Nothing to say what he meant.

Adrian, who is on faculty at the Columbia University Medical Center and an accomplished author, feels that medicine doesn’t train doctors how to interact with the less-scientific aspects of humans experiencing illness, injury, and suffering. There’s a gap or an absence in most medical care, and that’s where storytelling can step in. Columbia’s Program in Narrative Medicine, which originated in 2000, is dedicated to this idea. It draws participants from a vast array of fields, and inspired the International Network of Narrative Medicine. As its website states, “The care of the sick unfolds in stories. The effective practice of healthcare requires the ability to recognize, absorb, interpret, and act on the stories and plights of others. Medicine practiced with narrative competence is a model for humane and effective medical practice.”

Storytelling in medicine isn’t just for medical practitioners to engage in. Adrian’s musing was inspired by a new book by Carol Levine, Living in the Land of Limbo: Fiction and Poetry about Family Caregiving, which collects the stories of family members who dedicate uncountable resources to caring for sick loved ones. Consider also the longstanding role of the hospital chaplain, and the recent proliferation of doulas, both of whom are specialized professionals who work “next-to” medicine, absorbing emotions, anxieties, and fears, and providing nurturance. And then, of course, there are the patients themselves, who in Adrian’s words might benefit from “art as a considered clinical intervention… very nearly like prescribing a story.”

Previously: Intersection of arts and medicine a benefit to both, report finds, Literature and medicine at life’s end, Thoughts on the arts and humanities in shaping a medical career and Physicians turn to books to better understand patients, selves
Photo by Alex

Aging, History, Medicine and Literature, Medicine and Society, Stanford News

Stanford humanities scholar examines "the youngest society on Earth"

Stanford humanities scholar examines "the youngest society on Earth"

Young and old faces Over the past decades, our society has undergone a process of “juvenescence” that, according to Stanford professor Robert Harrison, PhD, makes it the “youngest on Earth.” For the first time in human history, he says, “the young have become a model of emulation for the older population, rather than the other way around” (as quoted in Stanford Report). The post-war period “has unleashed extraordinary youthful energies in our species and represents one of the momentous revolutions in human cultural history.”

Harrison is a professor of Italian literature whose new book Juvenescence: A Cultural History of Our Age examines the cultural forces that have brought about this development. The term “juvenescence” draws on the biological concept of neoteny, or the retention of juvenile characteristics through adulthood. Harrison’s research spans literature, philosophy, and evolutionary science.

His basic argument is that “juvenescence” can refer to either a positive or a negative change, and it isn’t clear which more accurately describes our current situation. The positive sense is one of cultural rejuvenation, while the negative one denotes juvenilization. Harrison explains, citing examples from his book:

Rejuvenation is about recognizing heritage and legacy, and incorporating and re-appropriating historical perspective in the present – like the Founding Fathers did when they created a new nation by drawing on ancient models of republicanism and creatively retrieving many legacies of the past… Unlike rejuvenation, juvenilization is characterized by the loss of cultural memory and a shallowing of our historical age.

…I feel ambivalent about where we are culturally in this age of ours.  It is hard to say whether we are on the cusp of a wholesale rejuvenation of human culture or whether we are tumbling into a dangerous and irresponsible juvenility.

Several aspects of our society suggest juvenilization. Most citizens of the developed world today enjoy the luxury of remaining childishly innocent about what they operate, consume, and depend on in daily life, while “in terms of dress codes, mentality, lifestyles and marketing, the world that we live in is astonishingly youthful and in many respects infantile.” Our culture’s emphasis on innovation and change honors the youthful drive that brings renewal and progress, but, without firm roots in the stability and wisdom of older generations and longstanding institutions, this risks being a meaningless chase after novelty. Youth’s genius is a luxury that requires solid foundations.

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Events, Medicine and Literature, Stanford News

"Deconstructed Pain:" Medicine meets fine arts

"Deconstructed Pain:" Medicine meets fine arts

Gernod_Weis_Oel_auf_Leinwand_150x200_1995Stanford’s medical school is just steps away from Stanford’s arts corridor, home to the Cantor Art Museum and the newly opened Anderson Collection at Stanford. This proximity results in a cathartic intersection between the arts and medicine, a connection captured by two recent events sponsored by Stanford’s Medicine & the Muse Program in Medical Humanities and the Arts.

The first event featured doctors and medical students reading poems they had written that were inspired by the paintings in the Anderson Collection at Stanford. The poetry reading included a performance by Stanford’s Musicians in Residence, the St. Lawrence String Quartet.

The second event, a gallery talk titled Honoring the Ghosts, celebrated Veteran’s Day by exploring the relationship between war trauma and art, through the paintings of the late Frank Lobdell, a World War II veteran and Stanford emeritus professor. The gallery talk, the first to take place in the Anderson Collection at Stanford, was an interdisciplinary event sponsored by Medicine & the Muse, the Stanford Arts Institute and the Anderson Collection. The event drew an overflow crowd, including World War II Veteran Genero Felice, Stanford student veteran Steven Barg and his wife, Shannon, also a veteran and Stanford physican John Scandling, MD, who majored in art history as an undergraduate.

The talk was introduced by Alexandar Nemerov of Stanford’s Art & Art History Department. Nemerov’s father, Howard Nemerov, was a World War II veteran who wrote about his war experiences, eventually winning a Pulitzer Prize for poetry. The audience listened intently as Sarah Naftalis, a doctoral student in Art & Art History, described Lobdell’s horrific World War II experiences: Part of a liberating party for the concentration camps in Germany, Lobdell’s unit came upon a burned barn full of concentration camp victims the Nazis did not want to be freed.

That experience influenced Lobdell’s work, and indeed, he stated that he worked out his war trauma “on the canvas.”

War trauma was also explored in the art, poetry and music event, when Hans Steiner, MD, used Jackson Pollack’s Lucifer as inspiration for his poem dedicated to his relatives killed in World War II.

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Medical Education, Medicine and Literature

The book that made me go to medical school – and other good reads

The book that made me go to medical school - and other good reads

books - 560

Editor’s note: Over the last several months, numerous young Scope readers have inquired about which books they should be reading to prepare for a potential future in medicine. We asked medical student (and SMS-Unplugged contributor) Natalia Birgisson to offer some suggestions.

“In my business, you can lose big, but sometimes you win big, too.” So begins page 87 of the book that made me go to medical school. It was the summer after my freshman year of college and I was volunteering in an outpatient pediatric ward. In the span of a week, I had seen two babies die. A newborn died of complications from seizures right in front of me, and a two week old baby died of malnutrition as we watched him wither away in an incubator.

I couldn’t stand the feeling of being a part of a system that was cumbersome and ineffective, I couldn’t stand my heart breaking, and I wanted to want to be anything other than a doctor. I lay in bed the next day and looked around my rented tropical room for distraction. On the night table was a book left by the last guest, The Soul of Medicine: Tales from the Bedside by Sherwin Nuland, MD, and what I found in his collection of stories was solace, companionship, and hope. It is a compilation of stories, each chapter written by a doctor in a different specialty discussing his or her most memorable patient. If you’re interested in medicine, the reality of it, then I suggest taking Nuland up on his offer to glimpse the mark that medicine leaves on a doctor’s soul. I keep it next to my couch in case a lost friend ever happens upon it the way I did.

Mountains Beyond Mountains by Tracy Kidder was the next book that strongly influenced me. A detailed glimpse into the life story and accomplishments of Paul Farmer, MD, PhD, who not only serves as a role model for anyone interested in global health, but who has changed the world for the better in a tangible way. What I remember from this book is a short scene in which we learn that, at least during the time the journalist was shadowing him, Farmer saw his daughter only once a month. They say that part of a teenager’s angst is realizing that her parents are not perfect and being angry at them for their flaws. Well, Dr. Farmer, I’m still angry with you for missing out on your daughter’s childhood the way my dad did. And for the rest of my life, when I think about changing the world by saving peoples lives, it will be with the caveat of improving on the model that he lived by. Because to me, there’s no point in helping strangers if I’m hurting the ones I love.

Blue Collar, Blue Scrubs and Hot Lights, Cold Steel by Michael J. Collins, MD, were two medical memoirs that resonated strongly with me. I read these the summer that I was writing my medical school applications. Somehow, the application process has a way of making everyone feel incompetent or mediocre at best. And here was a guy who decided to take post-bachelor classes as a construction worker, carpool to medical school, and marry the love of his life before starting residency at the Mayo Clinic. Almost every page of his books had me laughing or crying as I rooted for him.

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Events, Medicine and Literature, Stanford News

For group of Stanford doctors, writing helps them "make sense" of their experiences

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At a Stanford Pegasus Physician Writers Forum last week, psychiatrist Shaili Jain, MD, told the 40-or-so attendees that writing and practicing medicine are synergistic. Medicine and motherhood: not so much.

“As one of my mentors once said, it’s called ‘juggling the joy,'” Jain said. “People who don’t think it’s a challenge are either in denial – or someone else is doing all the hard work.”

Jain was one of five authors who shared their work. She read an essay, called “The Trimesters,” that she had written ten years earlier about her initial struggles coping with her duel roles as doctor and to-be mother. During her pregnancy, Jain suffered from intense all-day sickness. “Panic set in; was this what life was going to be from now on? I feared I had entered a no-man’s land of perpetual dissatisfaction,” Jain wrote. She had to tell her patients, some who suffered from severe mental disorders, she would be off work — a situation that left her uncomfortable with the blurring of roles. Pregnancy was personal, yet it impinged on her professional life.

Yet patients have no choice but to share their inner secrets, fears, goals, what medical school alum Ward Trueblood, MD, called their “heart songs” in the poem, “Cancer Doctor.”

It started when he slowed
to ask about a grandson’s picture
or fetched a cup of ice
for the bed-bound, listened to
talk of a fishing hole, heard about a dog
that licked a woman’s morning eyes…

They were sharing heart
songs rarely whispered.
He grew softer, invited
in this open window
of each one’s brave longing.

Medicine is a privilege, Trueblood went on to say. “As a cancer doctor, one shares soul with their patients… so here I am, 76, and I’m still going into the hospital,” he said.

And for Jain, writing is an essential part of her job as a physician. “I have a compulsion to make sense of what I’m experiencing,” she said.

The Pegasus Physicians Writers group meets regularly.

Becky Bach is a former park ranger who now spends her time writing about science or practicing yoga. She is an intern at the Office of Communications and Public Affairs. 

Previously: On death and dying: A discussion of “giving news that no family members want to hearWhen death comes rapping at the chamber door: Writers inspired by crises and medical emergencies and “How cancer becomes us”: A conversation with author and anthropologist Lochlann Jain
Photo by annazuc

Events, Medicine and Literature, Medicine and Society, Patient Care, Stanford News

Abraham Verghese discusses stealing metaphors and the language of medicine at TEDMED

Abraham Verghese discusses stealing metaphors and the language of medicine at TEDMED

Abraham Verghese TEMED

Few of us pay close attention to metaphors used in the language of medicine. Instead, our focus is typically on words relating to symptoms, test results and diagnoses. But as Stanford physician and author Abraham Verghese, MD, explained last week at TEDMED in San Francisco (which was co-sponsored by Stanford Medicine), metaphors, particularly as they relate to medicine, are significant because “they explain our past… [and] share our present and, perhaps most importantly, the metaphors we pick predicate our future.”

Verghese took conference attendees through a “grand romp through medicine and metaphor” during a session titled “Stealing Smart,” which featured seven speakers and their stories on how stealing something from another field, such as the principles of video game design, could improve medicine. As a child with “no head for math,” Verghese was drawn to the written word and developed a love for metaphors. His physical and metaphorical journey into medicine originated with his childhood reading and, as he sheepishly admitted, his reading list “had a certain prurient bias.” In fact, he selected the novel that set the course of his life, Of Human Bondage by W. Somerset Maugham, because the title “had great promise.” Despite it’s lack of salacious content, the book made a lasting impression on Verghese.

He recalled reading about how the protagonist, a boy named Philip who was born with a clubfoot, overcame great adversity to become a physician. The character was intrigued at the variety of patients he meets in the wards of the hospital and marvels at their willingness to open up about their personal lives at a time of distress. In describing the doctor-patient relationship, the author writes, “There was humanity there in the rough.” Those words spoke deeply to young Verghese and “implied to [him] that not everyone could be a brilliant engineer, could be a brilliant artist, but anybody with a curiosity about the human condition, with a willingness to work hard, with an empathy for their fellow human being could become a great physician.” He added, “I came into [the profession] with the sense that medicine was a romantic passionate pursuit. I haven’t stopped feeling that way, and for someone who loved words anatomy was such fun.”

Verghese reveled in the abundance of medical metaphors throughout his training. The prevailing metaphor in anatomy was that of a house, while the overarching metaphor of physiology was that of a machine. When it came to describing symptoms, there was no shortage of metaphors: the “strawberry tongue” associated with scarlet fever, the “peau d’orange” appearance of the breast in breast cancer and the “apple-core” lesion of colon cancer. “That’s just the fruits – don’t get me started on the non-vegetarian stuff,” he joked.

But all of the metaphors noted in his talk are 60-100 years old, and when it came to naming one from more recent times Verghese was at a loss. He said:

In my lifetime, and I suspect in yours, we’ve seen so many new diseases – AIDS, SARS, Ebola, Lyme… We have so many new ways at looking inside the body and scanning the body, such as PET and MRI, and yet, strangely, not one new metaphor, that I can think of… It’s a strange paucity because we are so imaginative. The amount of science that has been done in the last 10 years eclipses anything that was done in the last 100 years. We’re not lacking in imagination, but we may be lacking in metaphorical imagination.

This dearth of metaphor has two consequences, he said. The first is that Congress isn’t funding biomedical research to the level that is necessary to advance new discoveries and treatments. The second is that patients are “not as enamored with our medicine and our science as we might think they should be,” he said. Verghese implored the audience to “create metaphors befitting our wonderful era discovery.” He encouraged those in the crowd and watching the livestream online to accept this challenge, saying, “I want to invite you to name things after yourself. Go ahead! Why not?”

As he closed the talk, Verghese shared the metaphor that has guided his life by saying:

It’s the metaphor of a calling. It’s the metaphor of a ministry of healing. It’s the metaphor of the great privilege we’re allowed, all of us with anything to do with health care, the privilege of being allowed into people’s lives when they are at their most vulnerable. It’s very much about the art of medicine. And we have to bring all the great science, all the big data, all the wonderful things that we’re going to be talking about [at this conference] to bear one human being to another… We have to love the sick. Each and everyone of them as if they were our own. And you know what? They are our own, because we are all humanity there in the rough.

Previously: Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine, Inside Abraham Verghese’s bag, a collection of stories and Stanford’s Abraham Verghese honored as both author and healer

Medicine and Literature, Orthopedics, Patient Care, Pediatrics, Stanford News

From post-WWII Russia To 7-year-old Giana Brown, a limb-lengthening method evolves

From post-WWII Russia To 7-year-old Giana Brown, a limb-lengthening method evolves

young patientGiana Brown is one tough little girl. When she was 7 years old, an orthopedic surgeon, Jeffrey Young, MD, from Lucile Packard Children’s Hospital Stanford, placed a brace called a Taylor Spatial Frame on her lower left leg that would help lengthen it about three inches to match her right leg. To accomplish this, the brace would require adjustments of about one millimeter a day for more than six months.

Her parents could have made those adjustments, but Giana insisted on doing it herself. She used a little wrench to turn the knobs that would lengthen the struts on the brace according to a computer-generated, color-coded prescription sheet.

Sculpting Bones,” the story of Giana’s rare bone disorder, her surgery and her recovery, is featured in this summer’s edition of Stanford Medicine magazine. An animated graphic illustrates in detail how the brace and bone biology work together to lengthen limbs. The story focuses not only the remarkable method of cutting a bone and slowly lengthening the gap to allow it to grow — called “distraction osteogensis” — but also on the unusual history of the “external fixator” device that makes this growth possible.

The device originated in a remote region of Siberia, Russia, nearly 70 years ago, where a young doctor, Gavriil Ilizarov, MD, cared for a patient population that included soldiers returning from the front lines of World War II with a vast array of bone injuries. Ilizarov discovered his method of distraction osteogenesis by accident, and a revolutionary method of bone lengthening was born.

Several decades later, orthopedic surgeon Charles Taylor, MD, and his brother, engineer Harold Taylor, modernized the device, changing the angle of the struts for more flexibility, and creating a computer program that generated prescriptions, “accurate to within a millionth of an inch and a ten-thousandth of a degree,” for adjusting the struts daily.

Although Giana’s dad, Greg, accurately describes the device as “draconian-looking,” her surgeon, Young, hails it as an ideal tool for healing his pediatric patients. “I really like how the technology allows me to basically sculpt the bone,” he says. “It’s the perfect blend of engineering and art.”

For Giana Brown, the accuracy, simplicity, and artistry of the device has paid off: She’s back to running and playing with her friends the way a healthy, happy kid should. Read her story – and her tips for making life a little easier in the frame –  here.

Previously: Stanford Medicine magazine opens up the world of surgery
Photo of Giana Brown by Max Aguilera-Hellweg

Medicine and Literature, Stanford News, Surgery

A surgeon battles her own unexpected complications

A surgeon battles her own unexpected complications

I first interviewed Stanford surgeon Sherry Wren, MD, a year and a half ago for an article about a course she taught to other surgeons on global health care. Based on her personal experience from medical missions to Chad, Congo and Ivory Coast, it was obvious the course was a labor of love. Here was a surgeon who was passionate about her work, and whose goal it was to overcome any and all obstacles to save patients – from using papaya paste for wound dressing to hand drills for relieving brain bleeds. She made use of a combination of her surgical skills, her physical strength and her love for her work to accomplish her goals. “You have no idea how physically hard it is to crank a six-millimeter pin into someone’s femur with a hand drill,” she told me then. “And I’m strong.”

When Wren mentioned off-hand that she was still recovering from post-surgical paralysis after her own neck surgery, I knew there was another story waiting to be told. Almost two years later, that story about Wren’s struggle to return to surgery following the partial paralysis of one of her most important tools, her left hand, has been published in Stanford Medicine magazine. My colleague Paul Costello referenced it here earlier this month.

This is a story about a surgeon experiencing what it’s like to be on the other side of the scalpel when something goes horribly wrong. In the piece, she describes what she felt upon waking up following neck surgery:

My left hand was like a claw. I couldn’t lift my left knee. Then my surgeon came to see me, and I recognized that ‘Oh shit!’ look on his face, because I’ve had that ‘Oh shit!’ look many times.”

Wren, who injured her spine following a deep-sea diving shipwreck, also talks of her struggle to return to the demanding, 10-14 hours surgeries that she excels at despite lingering damage to her left hand and the accompanying depression that blindsided her. I wrote:

It was the correct diagnosis. The correct treatment. There was no surgical error. And yet somehow, the veteran surgeon who makes a living with her hands woke up partially paralyzed. The unexpected complications included paralysis of her left hand and her left leg, and a weakened right hand. Already she thinks, Will I still be able to operate? Already she thinks, What am I if I’m not a surgeon?

This is Wren’s very personal story, one that she tells open and honestly. The experience of being the patient has made her a better physician, she said. And it’s a story that she hopes by telling, others can learn from.

“I thought a lot about whether I wanted to share this story,” Wren said. I, for one, am appreciative that she did.

Previously: Sherry Wren, MD – a surgeon’s road home, Surgery: Up close and personal, Stanford Medicine magazine opens up the world of surgery Surgery: Up close and personal and Stanford general surgeon discusses the importance of surgery in global health care

From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.

Medicine and Literature, Stanford News, Surgery

The operating room: long a woman’s domain

The operating room: long a woman’s domain

In my recent story for Stanford Medicine magazine on the transformational changes in surgery, I reported that “women were once personae non gratae in the operating room.” An alumna of the medical school, Judith Murphy, MD, took me to task for my choice of words, for as she points out, women have long been the backbone of the OR.

“In fact, for decades, women outnumbered men in the OR – circulating nurse, scrub nurse, overseeing nurse, etc.,” she wrote to me. “So it is not that there were no women in the OR, but there were no women surgeons. No Women Who Count, although everyone knows these nurses are essential to successful surgery.”

When she was a medical student at Stanford in the early 1970s, she says female students and faculty had to use bathrooms and lockers that were labeled “Nurses,” whereas the men’s room was labeled, “Doctors.”

“We all laughed about it, but it did reflect the unconscious assumptions that your language still perpetuates, all these years later and after so much progress,” she shared with me. “The women who came after us were a bit more empowered and did not think it was funny; they complained, and the doors were changed to Men and Women.”

Murphy, a practicing pediatrician in Palo Alto for decades, says she might not have made note of the issue were it not for a recent encounter with a male acquaintance who, on learning she was connected to Stanford Hospital, said, “I never knew you were a nurse.”

“When he said that, I thought, ‘Darn, I can’t believe this is still happening.’ I gave him my usual response: ‘I have great respect for nurses and could never have done as good a job without them, but in fact, I’m a doctor,’” said Murphy, who is now retired.

“The power of the cultural unconscious assumption remains strong, even here where we have come so far,” she wrote. “This has been happening to me occasionally for 40 years, less so lately. I had hoped it would become archaic.”

Murphy says her response may have been a bit testier than in the past. But she can be excused, for it is always good to be reminded of our unconscious biases about the role of women in health care, reflected both in our language and behavior.

Previously: Surgery: Up close and personal and Stanford Medicine magazine opens up the world of surgery

From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.

Medicine and Literature, Stanford News

Stanford Medicine magazine in images

Stanford Medicine magazine in images

There were lots of oohs and aahs among my colleagues when we first got our hands on the latest issue of Stanford Medicine. The award-winning magazine always contains good stuff (kudos to editor Rosanne Spector), but we all agreed that the artwork in this issue was particularly strong. Above are some of the more striking images.

Previously: Stanford Medicine magazine opens up the world of surgery
First two images in first row by Max Aguilera-Hellweg; illustration by Gérard Dubois
Illustrations in second row by, from left to right, Jon Han, Tina Berning and Harry Campbell
Images in third row by, from left to right, Jon Han, Max Aguilera-Hellweg and Gérard Dubois

Stanford Medicine Resources: