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Using Stories To Mentally Survive As A COVID-19 Clinician

Kaiser Health News:States - June 11, 2020

Dr. Christopher Travis, an intern in obstetrics-gynecology, has cared for patients with COVID-19 and performed surgery on women suspected of having the coronavirus. But the patient who arrived for a routine prenatal visit in two masks and gloves had a problem that wasn’t physiological.

“She told me, ‘I’m terrified I’m going to get this virus that’s spreading all over the world,'” and worried it would hurt her baby, he said of the March encounter.

Travis, who practices at the Los Angeles County + University of Southern California Medical Center, told the woman he knew she was scared and tried to assure her she was safe and could trust him.

Asking many questions and carefully listening to the answers, Travis was exercising the craft of narrative medicine, a discipline in which clinicians use the principles of art and literature to better understand and incorporate patients’ stories into their practices.

“How do we do that really difficult work during the pandemic without it consuming us so we can come out ‘whole’ on the other end?” Travis said. Narrative medicine, which he studied at Columbia University, has helped him be aware of his own feelings, reflect more before reacting, and view challenging situations calmly, he said.

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The first graduate program in narrative medicine was created at Columbia University in 2009 by Dr. Rita Charon, and the practice has gained wide influence since, as evidenced by the dozens of narrative medicine essays published in the Journal of the American Medical Association and its sister journals.

Learning to be storytellers also helps clinicians communicate better with non-professionals, said writer and geriatrician Dr. Louise Aronson, who directs the medical humanities program at the University of California-San Francisco. It may be useful to reassure patients — or to motivate them to follow public health recommendations. “Tell them a story about having to intubate a previously healthy 22-year-old who’s going to die and leave behind his first child and new wife, and then you have their attention.”

“At the same time, telling that story can help the health professional process their own trauma and get the support they need to keep going,” she said.

Teaching Storytelling To Doctors

This fall, Keck School of Medicine of USC will offer the country’s second master’s program in narrative medicine, and the subject also will be part of the curriculum in the new Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, which opens its doors July 27 with its first class of 48 students. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Narrative medicine trains physicians to care about patients’ singular, lived experiences — how illness is really affecting them, said Dr. Deepthiman Gowda, assistant dean for medical education at the new Kaiser Permanente school. The training may entail a close group reading of creative works such as poetry or literature, or watching dance or a film, or listening to music.

He said there’s also “real, intrinsic value” for patients because a doctor isn’t only being trained to care about the body and medications.

“Literature in its nature is a dive into the experience of living — the triumphs, the joys, the suffering, the anxieties, the tragedies, the confusions, the guilt, the ecstasies of being human, of being alive,” Gowda said. “This is the training our students need if they wish to care for persons and not diseases.”

Dr. Andre Lijoi, a geriatrician at WellSpan York Hospital in Pennsylvania, recently led a virtual session for 20 front-line nurse practitioners who work in nursing homes. Two volunteers recited Mary Oliver’s 1986 poem “Wild Geese,” which reads, “Tell me about despair, yours, and I will tell you mine. Meanwhile the world goes on.”

Sharing the poet’s words helped the nurses relieve their pent-up tensions, enabling them to express their feelings about life and work under COVID-19, Lijoi said.

One participant wrote, “As the world goes on around me I mourn seeing my aging parents, planning my daughter’s wedding, and missing my great niece’s baptism. I wonder, when will life be ‘normal’ again?”

Processing Fear To Provide Better Care

Dr. Naomi Rosenberg, an emergency room physician at Temple University Hospital in Philadelphia, studied narrative medicine at Columbia and teaches it at Temple’s Lewis Katz School of Medicine. The discipline helps her “metabolize” what she takes in while caring for COVID-19 patients, including the fear that comes with having to enter patients’ rooms alone in protective gear, she said.

The training helped her counsel a worried woman who couldn’t visit her sister because the hospital, like others around the country, wasn’t allowing relatives to visit COVID-19-infected patients.

“I’d read stories of Baldwin, Hemingway and Steinbeck about what it feels like to be afraid for someone you love, and recalling those helped me communicate with her with more clarity and compassion,” Rosenberg said. (After a four-day crisis, the sister recovered.)

Dr. Pamela Schaff (right) discusses narrative medicine in the Hoyt Gallery at the Keck School of Medicine of the University of Southern California, as Chioma Moneme, a student in the class of 2020, looks on. (Credit: Chris Shinn)

Close readings can also help students understand the various ways metaphor is used in the medical profession, for good or ill, said Dr. Pamela Schaff, who directs the Keck School’s new master’s program in narrative medicine.

Recently, Schaff led third-year medical students through a critical examination of a journal article that described medicine as a battlefield. The analysis helped student Andrew Tran understand that describing physicians as “warriors” could “promote unrealistic expectations and even depersonalization of us as human beings,” he said.

Something similar happens in the militarized language used to describe cancer, he added: “We say, ‘You’ve got to fight,’ which implies that if you die, you’re somehow a failure.”

In the real world, doctors are often focused narrowly, devoting most of their attention to a patient’s chief complaint. They listen to patients on average for only 11 seconds before interrupting them, according to a 2018 study in the Journal of General Internal Medicine. Narrative medicine seeks to change that.

While listening more carefully may add one more item to a physician’s lengthy “to-do” list, it could also save time in the end, Schaff said.

“If we train physicians to listen well, for metaphor, subtext and more, they can absorb and act on their patients’ stories even if they have limited time,” she said. “Also, we physicians must harness our narrative competence to demand changes in the health care system. Health systems should not mandate 10-minute encounters.”

Telling The Patient’s Whole Story

In practice, narrative medicine has diverse applications. Modern electronic health records, with their templates and prefilled sections, can hamper a doctor’s ability to create meaningful notes, Gowda said. But doctors can counter that by writing notes in language that makes the patient’s struggles come alive, he said.

The school’s curriculum will incorporate a different patient story each week to frame students’ learning. “Instead of, ‘This week, you will learn about stomach cancer,’ we say, ‘This week, we want you to meet Mr. Cardenas,'” Gowda said. “We learn about who he is, his family, his situation, his symptoms, his concerns. We want students to connect medical knowledge with the complexity and sometimes messiness of people’s stories and contexts.”

In preparation for the school’s opening, Gowda and a colleague have been running Friday lunchtime mindfulness and narrative medicine sessions for faculty and staff.

The meetings might include a collective, silent examination of a piece of art, followed by a discussion and shared feelings, said Dr. Marla Law Abrolat, a Permanente Medicine pediatrician in San Bernardino, California, and a faculty director at the new school.

“Young people come to medicine with bright eyes and want to help, then a traditional medical education beats that out of them,” Abrolat said. “We want them to remember patients’ stories that will always be a part of who they are when they leave here.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Fighting COVID And Police Brutality, Medical Teams Take To Streets To Treat Protesters

DENVER — Amid clouds of choking tear gas, booming flash-bang grenades and other other “riot control agents,” volunteer medics plunged into street protests over the past weeks to help the injured — sometimes rushing to the front lines as soon as their hospital shifts ended.

Known as “street medics,” these unorthodox teams of nursing students, veterinarians, doctors, trauma surgeons, security guards, ski patrollers, nurses, wilderness EMTs and off-the-clock ambulance workers poured water — not milk — into the eyes of tear-gassed protesters. They stanched bleeding wounds and plucked disoriented teenagers from clouds of gas, entering dangerous corners where on-duty emergency health responders may fear to go.

Many are medical professionals who see parallels between the front lines of COVID-19, where they confront stark racial imbalances among those stricken by the coronavirus, and what they see as racialized police brutality.

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So donning cloth masks to protect against the virus — plus helmets, makeshift shields and other gear to guard against rubber bullets, projectiles and tear gas — the volunteer medics organized themselves into a web of first responders to care for people on the streets. They showed up early, set up first-aid stations, established transportation networks and covered their arms, helmets and backpacks with crosses made of red duct tape, to signify that they were medics. Some stayed late into the night past curfews until every protester had left.

Iris Butler, a 21-year-old certified nursing assistant who works in a nursing home, decided to offer her skills after seeing a man injured by a rubber bullet on her first night at the Denver protests. She showed up as a medic every night thereafter. She didn’t see it as a choice.

“I am working full time and basically being at the protest after getting straight off of work,” said Butler, who is black. That’s tiring, she added, but so is being a black woman in America.

Iris Butler (left), a certified nursing assistant, stands with two other street medics she worked with during a protest on June 1, in Denver. She says she met the two, who declined to give their names, a few days earlier while tending to injured protesters.(LJ Dawson for KHN)

After going out as a medic on her own, she soon met other volunteers. Together they used text-message chains to organize their efforts. One night, she responded to a man who had been shot with a rubber bullet in the chest; she said his torso had turned blue and purple from the impact. She also provided aid after a shooting near the protest left someone in critical condition.

“It’s hard, but bills need to be paid and justice needs to be served,” she said.

The street medic movement traces its roots, in part, to the 1960s protests, as well as the American Indian Movement and the Black Panther Party. Denver Action Medic Network offers a 20-hour training course that prepares them to treat patients in conflicts with police and large crowds; a four-hour session is offered to medical professionals as “bridge” training.

Since the coronavirus pandemic began, the Denver Action Medic Network has added new training guidelines: Don’t go to protests if sick or in contact with those who are infected; wear a mask; give people lots of space and use hand sanitizer. Jordan Garcia, a 39-year-old medic for over 20 years who works with the network of veteran street medics, said they also warn medics about the increased risk of transmission due to protesters coughing from tear gas, and urge them to get tested for the virus after the protests.

The number of volunteer medics swelled after George Floyd’s May 25 killing in Minneapolis. In Denver alone, at least 40 people reached out to the Denver Action Medic Network for training.

On June 3, Dr. Rupa Marya, an associate professor of medicine at the University of California-San Francisco and the co-founder of the Do No Harm Coalition, which runs street medic training in the Bay Area, hosted a national webinar attended by over 3,000 medical professionals to provide the bridge training to be a street medic. In her online bio, Marya describes the coalition as “an organization of over 450 health workers committed to structural change” in addressing health problems.

“When we see suffering, that’s where we go,” Marya said. “And right now that suffering is happening on the streets.”

A table is filled with supplies for injured protesters at an apartment complex that became the central command for Denver’s street medics on June 1.(LJ Dawson for KHN)

In the recent Denver protests, street medics responded to major head, face and eye injuries among protesters from what are sometimes described as “kinetic impact projectiles” or “less-than-lethal” bullets shot at protesters, along with tear-gas and flash-bang stun grenade canisters that either hit them or exploded in their faces.

Garcia, who by day works for an immigrant rights nonprofit, said that these weapons are not designed to be shot directly at people.

“We’re seeing police use these less-lethal weapons in lethal ways, and that is pretty upsetting,” Garcia said about the recent protests.

Denver police Chief Paul Pazen promised to make changes, including banning chokeholds and requiring SWAT teams to turn on their body cameras. Last week, a federal judge also issued a temporary injunction to stop Denver police from using tear gas and other less-than-lethal weapons in response to a class action lawsuit, in which a medic stated he was shot multiple times by police with pepper balls while treating patients. (Last week in North Carolina police were recorded destroying medic stations.)

Denver street medic Kevin Connell, a 30-year-old emergency room nurse, said he was hit with pepper balls in the back of his medic vest — which was clearly marked by red crosses — while treating a patient. He showed up to the Denver protests every night he did not have to work, he said, wearing a Kevlar medic vest, protective goggles and a homemade gas mask fashioned from a water bottle. As a member of the Denver Action Medic Network, Connell also served at the Standing Rock protests in North Dakota in a dispute over the building of the Dakota Access Pipeline.

Aj Mossman prepares to go out as a street medic at a protest in Denver on June 1. Mossman, a Denver EMT studying for nursing school, was shocked to be tear-gassed and struck in the back of the leg with a flash grenade while treating a protester on May 30.(LJ Dawson for KHN)

“I mean, as bad as it sounds, it was only tear gas, pepper balls and rubber bullets that were being fired on us,” Connell said of his recent experience in Denver. “When I was at Standing Rock, they were using high-powered water hoses even when it was, like, freezing cold. … So I think the police here had a little bit more restraint.”

Still, first-time street medic Aj Mossman, a 31-year-old Denver emergency medical technician studying for nursing school, was shocked to be tear-gassed and struck in the back of the leg with a flash grenade while treating a protester on May 30. Mossman still has a large leg bruise.

The following night, Mossman, who uses the pronoun they, brought more protective gear, but said they are still having difficulty processing what felt like a war zone.

“I thought I understood what my black friends went through. I thought I understood what the black community went through,” said Mossman, who is white. “But I had absolutely no idea how violent the police were and how little they cared about who they hurt.”

For Butler, serving as a medic with others from various walks of life was inspiring. “They’re also out there to protect black and brown bodies. And that’s amazing,” she said. “That’s just a beautiful sight.”