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Storytelling For Doctors / Medical schools try teaching compassion by having students write about patients

There may be something about the wearing of the white coat

that gets in the way of listening.

Maybe today's doctors are just too busy. Or maybe they haven't been taught

to actually stop and hear what the patient isn't saying.

Scientists at New York-Presbyterian Hospital in Manhattan and Stony Brook

University Hospital are leading the effort to teach doctors how to listen to

patients' stories so they can become compassionate partners in care. The art -

as opposed to the science - of medicine is being taught under the rubric

"narrative medicine," a new discipline that stresses listening and writing

skills intended to help health care workers better understand the patient's

condition.

At a recent program, hundreds of doctors, nurses and ethicists discussed

how important it is to find the time to listen, especially in a rushed

managed-care environment. The premiere event - a two-day meeting at New

York-Presbyterian Hospital's Columbia Medical Center and a daylong workshop

sponsored by Stony Brook University Medical School and the State University of

New York's "Conversations in the Disciplines" program - was deemed successful,

and plans are under way for another.

Doctors typically emerge from medical school having constructed armor to

withstand the daily reality of disease and death.

Compassion and sympathy - traits not always in evidence - can make

doctoring a more enriching experience, says Dr. Rita Charon, an associate

professor of clinical medicine at Columbia who started the narrative medicine

program there.

In the new seminars at Columbia, students are asked "to imagine a

perspective other than their own, to behold the full predicaments of patients,"

she said, and " ... to reflect on their own personal journeys through medicine

and through life."

But the making of such a doctor is not always easy or even welcome, Charon

added. Many who enter medicine do so for the science and may not have the

personality for the bedside manner that many patients complain is lacking

today. Charon says there is growing evidence that writing narratives about

patients is "powerful and effective" in helping foster relationships. And

patients who feel connected to their doctors seem to get better faster, she

added. She and colleagues are trying to devise ways to test why that's so.

Even when a patient's story is fully heard, it can get lost in today's

system, where diagnosis and billing information have been merged onto one form,

said Dr. Jack Coulehan, a staff internist at Stony Brook who also has

published books of poetry. The way the system is set up can "completely

eliminate the person's story, the medical knowledge gleaned from understanding

this history," Coulehan said. "Unfortunately, medicine sees anecdote as the

lowest form of science."

Just what is so important about a patient's story?

Coulehan says there is growing evidence that patients benefit from writing

stories about their illnesses. Patients who write about their experiences have

fewer symptoms and report a better quality of life, studies have shown. And now

that health care professionals are also learning to write patients' stories,

Charon and her colleagues believe, the care providers have a deeper connection

to the process of healing.

"When doctors and patients relate, there is a feeling of empowerment,"

Charon said. "There's a relationship that is important to healing."

Doctors have tried other means to gain understanding of patients. At

Loughborough University in Leicestershire, England, hospital patients were

given cameras and asked to chronicle their experiences.

When patients returned to their homes, researchers made house calls and

asked about the pictures. "That's when they began to share some of the things

that happened that upset them," David Morris of the University of Virginia said

at the Stony Brook workshop. One woman had been stuck in the bathroom; her

dressing came off, and she couldn't get out. The snapshot of an empty bathroom

captured her loneliness.

"People are often standing in front of us with life-threatening illnesses,

and we have to respond in a way that will help them," said Dr. Jay Baruch, who

took a year off during medical school at Stony Brook to pursue creative

writing. He is now an emergency room physician at Memorial Hospital in Rhode

Island and is on the faculty at the Center for Biomedical Ethics at Brown

University Medical School.

Coulehan says the very first book on medical ethics, written in 1803, said

that unless doctors consciously attend to tenderness, the heart will grow cold

- and "that is what we are trying to avoid."

That can be difficult in medical school, where, he said, "the holy grail is

technological comprehension. How can we help students understand that they are

dealing with their own stories and the stories of their patients?"

"Being a good doctor is listening," added Dr. Barry Bub, a family doctor

who now practices Gestalt psychotherapy in Manhattan.

But listening is not a popular tool among physicians, Coulehan said. In

research known as the "interruption study," patients were videotaped 20 years

ago during their initial examination. Most doctors interrupted the patient

after 21 seconds. Two years ago, the study was repeated and found that things

hadn't changed much - doctors interrupted, on average, at 23 seconds, Coulehan

said.

Many doctors say they'd like to listen more but that managed care puts

constraints on their time. "But the first interruption study was done way

before managed care," Coulehan noted.

Students are being taught listening skills, how to enter the examination

room in a respectful way and how to determine why the patient is there. "Pause

before you cross the threshold of the office," Coulehan said. "Listen to

yourself. Then, find out why the patient is there."

Patients have long complained of bad medical care, doctor insensitivity and

aloofness. Doctors, similarly, complain about patients' lack of understanding

about the many constraints placed on doctors and endless demands to make

everyone well.

"Today, medicine is impersonal, rushed and conflicted," said Charon, who is

trying to change the way doctors approach their chosen career.

She teaches several narrative medicine courses aimed at getting doctors to

"see what patients understand in the throes of being sick, and what [doctors]

undergo as they take care of patients."

At Stony Brook, Catherine Belling, associate director of the Institute for

Medicine in Contemporary Society is a Shakespeare scholar who gave up

literature to work in ethics and narrative medicine. "The practice of medicine

depends so completely on the narrative form," she says. Belling organized the

workshop, held on the last day of the three-day meeting.

Those attending the program refused to call this new work psychotherapy.

"But we are bound to honor their journeys, to help them develop their

empathetic skills and clinical courage," Charon says of this next generation of

physicians. "The patients we care for get into our bones, shape us into who we

become as doctors."

The physician still keeps stacks of patient index cards from when she was

an intern, in 1978. Among the tattered cards is one for a Mrs. Jenkins, who was

so sick and frail "she taught me how to hate life," Charon recalls.

Today, she tries to teach medical students and interns to metabolize the

pain of death and dying through writing. "We live our lives around sick and

dying people," she said.

She reads the story of a medical student who saw her first patient die. A

team of doctors and nurses were working on the patient and when emergency

efforts failed, the room grew quiet. The time of death was called out, and

everyone cleared the room. The woman lay naked on a board, her head bent back

and tubes taped onto her nose.

The student stood frozen in grief.

"This is what we put our students through," said Charon. She came up with

the idea of using a different form of patient chart: Half the chart is filled

with standard data: vital signs, recommendations, treatment plan. But in the

second part, students can write about the patient and their feelings regarding

his or her care.

Recently, 100 medical students were recruited into a study to test the

effectiveness of this parallel chart writing. They were assigned to either keep

a parallel chart or not. At the end of the study, the students who wrote

parallel chart entries received higher faculty ratings and also had closer

relationships with their patients, Charon said. Both their interviewing skills

and technical skills were better, she added.

At New York-Presbyterian Hospital, some of the oncology staff now meet once

a week to write, read and talk, and they are seeking a federal grant to study

whether the approach helps lower the burnout rate among staff.

At Stony Brook, first-year medical students are asked to write about the

human cadavers assigned to them - about the bodies themselves, the lives that

were lived, the losses that were felt when those lives ended.

"There is something about entering the life of another person that brings

insight and empathy," Stony Brook's Belling said. By the time the writing

assignment begins, the students are dissecting the person's brain. The course

is mandatory.

"It is a much healthier way for people to become doctors," Belling added.

�When doctors and patients relate, there is a feeling of empowerment. There�s a

relationship that is important to healing.� - Dr. Rita Charon, who started the

narrative medicine program at Columbia Medical Center

�There is something about entering the life of another person that brings

insight and empathy.� - Catherine Belling, associate director of Stony Brook�s

Institute for Medicine in Contemporary Society

'The way the system is set up can �completely eliminate the person�s story, the

medical knowledge gleaned from understanding this history. Unfortunately,

medicine sees anecdote as the lowest form of science.� - Dr. Jack Coulehan, a

staff internist at Stony Brook University Hospital

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