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Tales from the Ward

Tales from the ward

Research shows we all love a good story. A study in the journal Brain Connectivity, for example, suggests that brain changes in connectivity may remain for a few days after reading a novel.

In medicine, stories often hold the keys to making a diagnosis or improving patient care. But, central to storytelling is the ability to effectively communicate, not just with patients and their families, but also with colleagues and mentors. As the roles for telemedicine, robotics, and even augmented reality in medicine expand, some researchers are focusing on making sure conversation and storytelling - tools and skills that have been around since the beginning of time - still play a central role in health care.

According to
Julia E. Szymczak, PhD, an assistant professor of epidemiology, in-person conversations between physicians and patients should not be an afterthought, but should be thought of as the “lifeblood of medical practice.”

Szymczak is a sociologist and qualitative researcher whose work delves into the experiences of physicians and healthcare workers to see why policies intended to improve health care quality succeed or fail. By gathering stories from health care professionals, she works to bring tools used by sociologists, like narrative interviews and ethnography (in which researchers immerse themselves within a group to learn cultural insights), to health care.

As a researcher, Szymczack sees a concerning trend in medical training, as students are under increasing pressure to be more efficient with large workloads in a time-pressured environment.

“Trainees report pressure to use fewer words— to get through things quicker,” Szymczak says. “There is less time and space for trainees to tell stories.”

One of her mentees, Elle Saine, an MD-PhD student, has taken these lessons to heart, making time for informative conversations with her patients. Saine and Penn medical student Vidya Viswanathan have developed narrative medicine skills that they put into practice in May at a Story Slam hosted by the College of Physicians. The competition challenged medical students from schools across the region to share their best five-minute story. Audience members voted on their favorites (Viswanathan won second place out of the 14 participants, and both Saine and Viswanathan’s videos are available below).

Patient stories indeed translate into an entertaining story slam, and there are so many to choose from. After all, medicine often fulfills the characteristics of a great story: it gives us a character to root for (typically a patient), often one who is enduring a terrible struggle (say, a chronic condition or illness), and journey that often unwraps layers of who the person is. Depending on the severity of the patients’ health, they may be perfectly healthy when they leave the hospital, their story may end with their death, or somewhere in between with a re-defining of their identity in light of health challenges. The hopeful suspense that they make a complete recovery makes for a compelling story.

Gathering these stories and the pertinent facts of a patient’s health and background is a cornerstone of high-quality medical practice – each bit of detail may be an important clue for how to diagnose a patient, or even help them with a non-medical issue that’s a barrier to better health, like housing insecurity. The tools to build this skill set that are well embedded in the medical curriculum at the Perelman School of Medicine, where all students take a “doctoring” course in their first and second years. Patients share stories in the first year of the course, giving the students perspective and tools to discuss topics like sexism, racism, LGBT health, and other areas they may experience in their careers.  The second year prepares those in the class for their first year of clerkships where they interact with patients directly in clinical settings. Additionally, every student in the course shares a story about their experience with clerkship, talking about stressors and difficult situations they experienced.

Szymczak explains to students that the stories physicians tell each other are also a social activity by which trainees can learn about the norms of the discipline, establish a common professional identity, and draw support from each other to get through the difficult parts of training.

Progression on clinical units is partly based on the ability to take patient feedback and translate that into a framework that shapes a diagnosis or care plan, a skill that doesn’t always come quickly.

In her first clinical rotation, on a Family Medicine unit, Saine noted that early on she found it difficult to parse out what part of a patient’s history was relevant to their case.

“Many times, what matters most to patients is not that chief complaint that they’re coming to the doctor’s office for,” Saine says. “And, what physicians see as the most pressing issue actually isn’t the patients most important issue.”

As a medical student, Saine has a little more time to talk with patients than a physician sometimes has, and she uses that time wisely. Saine says establishing a sense of safety and trust at the onset is paramount. Much of that trust results from understanding what happened around the patient’s chief complaint and considering what her patients consider “quality of life.”

“If you don’t have that information, you’re forming judgments off of what a patient would ‘typically be,’ and you’re potentially missing who they are and why they can’t reach their health goals,” Saine said. “So, you’re missing a key point for intervention to help get them to a space between what you think is most important for their health and what they think is most important for their life.” 

Like many other working environments, information is constantly flowing in healthcare settings. Szymczak says both verbal and non-verbal sharing of information is not only important in arriving at a diagnosis but is also required to communicate urgency, and make sure things don’t fall through the cracks.

“A lot of the reason why medical errors happen is communication failure,” Szymczak says. “Things get missed when the chain of communication breaks and this can sometimes cause dire consequences.”

In addition to facilitating safe practice, informal communication between healthcare workers can help clinicians cope with the emotional challenges of providing care to sick patients. Szymczak says there is an overarching “solider through” mentality in the culture of medicine, which creates an opening for the value of storytelling.

“Physicians are not supposed to show weakness, not supposed to get sick, their emotional lives are not something people like to talk about or admit,” Szymczak says. “Storytelling gives them the space to talk about their humanness as a clinician to each other as a way to recognize the human element of providing care.”

These conversations allow clinicians to provide better comfort to her patients and their families, Saine says, including developing the skills to process the trauma associated with patients dying.

“For many students, that’s their first experience with death, and there is a surge of emotions that takes place,” Saine says. “It’s a hard thing to talk about.”

Saine says we’re seeing a dogma change away from the prevailing notion of the 19th and 20th centuries that patients are untrustworthy managers of their own bodies — a notion that the patient can’t understand what they’re experiencing and it’s the role of the physician to use their senses to figure it out rather than the patient having a voice in the decision-making.

“All patients’ insight is valuable,” Saine says.

Insights from patients also helps Viswanathan in her medical training, but also provides insights in operation of a website and podcast that she founded called Doctors Who Create, which is dedicated to promoting creativity in medicine. The platform tells stories of innovative people in medicine and how they are changing medical culture to promote creativity instead of conformity.

“In terms of clinical practice, my experience in journalism and in managing an organization of 30 people has allowed me to learn how to communicate effectively and tailor each patient interaction to the patient, rather than to the template of a note on a computer screen in the electronic medical record,” Viswanathan said, noting that her work on Doctors Who Create has kept her motivated and passionate about medicine through the most rote parts of medical training.

Viswanathan met many of her physician role models by interviewing them and hearing their stories
about how they navigated the challenges of preserving their creativity and empathy in a field where many struggle with burn out.

Whether starting a website, conducting research, or treating patients on medical wards, sometimes  critical insights appear when you least expect them.

“These conversations emerge organically,” Szymczak said. “They don’t need to be formulated in a story slam, or a narrative medicine grand rounds – it can be as simple as allowing people space to let off steam and talk about what’s going on.”

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