Tuesday, February 24, 2009

So many symbols, so little time...

I don't exactly have time to write this post -- but if I let any more time pass, I'll be kicking myself.

A good friend of mine likes to call me out on my flagrant inability to tell worthwhile stories with punchlines and/or climaxes. I apparently never mastered the "beginning --> middle --> end" storytelling construct -- and, as it turns out, I don't see the world like that either. I see the world in fragments, meaningful and inspiring in their own right, and find a way to weave them all together through occasionally overly complex "life policies" and themes. I detect themes and symbolism wherever I go, especially when they don't really exist to anyone but me. (See also: the red blood cell "practicing commitment" to its career path).

Some might call it psychosis. Others, as it turns out, call it "narrative competence" and cite it as an essential part of taking good care of patients.

Today I read another great article by Rita Charon, M.D., Ph.D., founder of the narrative medicine movement, in which verbal or written narrative devices are used to provide both self-constructed and shared insights between patients and physicians. I've referenced Dr. Charon and narrative medicine in a previous posting, appreciating the mechanism by which the act of blogging truly does foster my clarity and focus as I process and cope with my training experiences. In the Feb 26 2004 New England Journal of Medicine, Dr. Charon writes:

A 36-year-old Dominican man with a chief symptom of back pain comes to see me for the first time. As his new internist, I tell him, I have to learn as much as I can about his health. Could he tell me whatever he thinks I should know about his situation? And then I do my best not to say a word, not to write in his chart, but to absorb all that he emits about his life and his health. I listen not only for the content of his narrative, but for its form — its temporal course, its images, its associated subplots, its silences, where he chooses to begin in telling of himself, how he sequences symptoms with other life events. I pay attention to the narrative’s performance — the patient’s gestures, expressions, body positions, tones of voice. After a few minutes, he stops talking and begins to weep. I ask him why he cries. He says, “No one has ever let me do this before.”
In the effort to help doctors understand what they and their patients experience in the presence
of illness, medical educators have been paying increasing attention to narrative competence, defined as the set of skills required to recognize, absorb, interpret, and be moved by the stories one hears or reads. This competence requires a combination of textual skills (identifying a story’s structure, adopting its multiple perspectives, recognizing metaphors and allusions), creative skills (imagining many interpretations, building curiosity, inventing multiple endings), and affective skills (tolerating uncertainty as a story unfolds, entering the story’s mood). Together, these capacities endow a reader or listener with the wherewithal to get the news from stories and to begin to understand their meanings.

I spend a LOT of time thinking about this, as it were. It makes sense. It is completely consistent with how I see the world, and completely consistent with how I interact with people who depend upon me in a non-medical context (i.e., the cyclists I coach). "Theme abstraction" impresses the hell out of me when I see it -- both because it's exceptional and out of the ordinary for a stranger to do, and because simple social psychological theory indeed dictates that we are drawn to "like" qualities and traits that are most "like" ourselves. I'm a theme-abstracter. Lo and behold, I ranted and raved a few weeks ago about my advisor spontaneously abstracting themes about my learning style. And come to think of it, the one doctor who has ever cared for me whom I've really really liked -- what I liked about her most of all was that she really DID actively attempt to piece together the story of my life.

By and large, doctors do NOT do this -- don't see the value in it. Takes too long. Is "irrelevant." Is "crazy." In my professional experiences to date, I've seen this a gazillion times -- that self-awareness is perceived to reflect psychiatric illness, specifically a mood or anxiety disorder. I've always thought that was bullshit. When my research patients have had lists of medications and chronology of symptoms and procedures, I've been tremendously impressed! What discipline it takes to encode one's world on an 3x5 index card. What self-awareness it takes to find one's own mechanism of control in a world of medical chaos. Those under whom I've trained never seemed to agree -- and I've learned from observing those perceptions and misperceptions enough to influence how I behave as a patient myself. I have to go see a new gastroenterologist soon-ish (sooner than soon-ish?)-- and, in so doing, will remind myself, first-hand, of how much of a burden it is to tell one's story from the beginning -- to capture all of the details, and to put them in context. And to do so while maintaining good impression-management skills. My story's not complicated. It's dressed up and ready to go, with all its bows and ribbons and "life policies." It'd be super-efficient to write down all the relevant dates and symptoms and associations -- and yet, that appears "crazy" and will compromise the receptiveness of my new audience (i.e., this person to whom I am entrusting my health). Nobody knows my story better than me. I have an exceptional mastery of the details -- details that I know, professionally, are important. I have themes and lessons to make sense of all the medical "fragments" I've lived through. And I know how to tell them well. Yet, if I tell it to the best of my ability, I would be categorized as "crazy." So I'll have to give a mediocre history and play along with this pathetic set of expectations.

I'm lucky. I'm being trained in a way that is consistent with MY values. For my Medical Student Leadership Group course today, our theme was Narrative Medicine. The idea was to go over to the hospital and randomly chat with patients -- just giving them a safe space to tell their stories, knowing that we'd learn something from whatever they spontaneously shared. The two men with whom I visited really DID love to talk. They liked the idea of serving as a resource for a doctor-in-training. They talked about their families, and how tedious it was to be in the hospital. Nothing tremendously insightful... except for the fact that the whole experience, for which I'd been incredibly excited, was SO awkward. Why? Because there I was, in my new white coat, imposing myself into a human being's world and asking for their story. It felt weird because it was clearly perceived (by the patient) as weird -- because "people in white coats" by and large do not ask for stories. They don't want to hear about how you rode a motorcycle 40 years ago and think about it, now that you have two artificial hips. They don't want to hear about where you took your grandkids on their summer vacation the year prior. The fact that "someone in a white coat" asked about these things and was experienced as AWKWARD... how telling that is.

Wearing my white coat for the first time around real patients was SUCH a big deal to me. I felt self-conscious. I looked the part fo' sure -- but on one level, I worried about being misperceived as actually having legit knowledge to match the expectations of the "look" I was pulling off. I was wearing the right things to gain "access" to this special world -- but VERY mindful of how much I didn't belong. (My understanding is that EVERYONE feels like this for a very long time. I'm okay with it.)

On another level, I was able to appreciate that nobody thought I knew anything -- which was good, because I didn't. Not really, anyway. A lot of my colleagues rant frequently about how little we know. We actually know a whole lot, which is crazy in and of itself. The way I make sense of it to myself is that we're at the point where we know and recognize a lot of really useful, complicated things -- but don't actually know what to DO about any of it. I'm always shocked, though, when I see something and know what it is. Little things: the chapped corners of the mouth of the woman with whom I visited when I shadowed the hospital chaplain, the clubbed fingers of the man I saw when I rounded with the chairman of Medicine earlier in the Fall, a random reference in a lecture that I really SHOULDN'T "get" but somehow do, a complicated article in the New York Times today on the precise mechanisms of anti-flu drugs. I know a lot of stuff that I NEVER thought I'd know a few months ago. That's a big deal to me, too.

After our patient visits, my colleagues and I walked together in a pack through the long corridor back to the medical school. I caught a glimpse of our reflections in the glass. My eyes misted a bit. This was actually my life. Walking in a pack of white coats, "belonging" there... without fully belonging.

During my White Coat Ceremony on Friday, our keynote speaker spoke of how just putting on the coat wasn't going to necessarily be this life-altering moment -- not to expect that of it. That it's just a symbol to mark this next chapter of our lives, the responsibility we are coming to embrace -- and that it will forever be a part of our identities. That, even if we don't wear it while around patients, that we'll never take it off. I bought that. But when I returned to my seat after being cloaked on stage in front of over 700 people, I really did feel like an entirely different person.

The powerful sense of responsibility, of commitment to my goals -- to myself, to the people who believe in me, to my future patients. It enveloped me. Shook me. My core heated up fast. My eyes perceived the soft glow of a migraine aura. My eyes burned with tears. This was my life. I wanted to scream and cheer and... sob. But I didn't even dare whisper to my classmate beside me, "This really feels different." I was just so sure that I didn't see this response matched, externally at least, by anyone around me. I felt almost isolated in my joining my new community, even if just for a few minutes. Isolated by my consumption with this symbol, with my insistence on abstracting themes and "moments" and requirements that everything that happens means SOMETHING.

But it was that isolation that allowed me a moment of solitude in a room of 700+ people. Clarity amidst unchanneled energy.

By the time I stood with my colleagues to take our oath, I felt empowered. Invigorated. Inspired by a genuine belief that I was going to be awesome at "this." Where "this" was my life.

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