Physicians bear witness to patients’ experiences in writers’ workshop
Resident physicians continued the legacy of narrative medicine at Yale at the 19th annual Yale Internal Medicine Residency Writers’ Workshop.
Courtesy of Anna Reisman
Eleven physician-writers reflected on the limits of medicine and the art of honoring patients through writing at the 19th annual Yale Internal Medicine Residency Writers’ Workshop.
The two-day intensive writing workshop returned fully in-person in November, with lively group discussions and writing exercises. Anna Reisman ’86, professor at the School of Medicine and director of the Program for Humanities in Medicine, and Lisa Sanders MED ’97, associate professor of medicine, co-directed the workshop.
Many pieces featured experiences that were traumatizing to the residents or that bore witness to a patient’s traumatic event, Reisman noted. To Sanders, this year’s pieces all address some kind of “moral injury,” capturing moments when the limits of medicine were reached.
“It’s like if you’ve ever seen a dog on a chain, run, run, run, and then they get to the end of the chain and they stop,” Sanders said. “Often that’s something that happens in medicine, as you’re going as far and as fast as you can, and then you reach the end of what we can do — either emotionally or physically for a patient. It’s a terrible shock so many times.”
The annual reading on Feb. 2, when residents share their pieces aloud, is Sanders’ favorite day of the year. These pieces are also collected in a booklet called “Capsules” to be distributed to the medical community. Four of the participating residents — Victoria Lewis, Anna Delamerced, Katherine Feder and Preetha Hebbar — organized the theme of the booklet and reading.
“We all found ourselves together stuck with the image of water, and particularly the idea of the ocean shore and the way that the shore can be a sight of reflection, of remembrance, of grief, longing and joy,” Lewis said at the event. “The order of the pieces you’ll hear today were intentional and intended to mimic the flow of a wave, starting with a crash and then pulling us back into the ocean’s eternal ebb and flow.”
The reading, and booklet, launched with the story of a car crash, then flowed through various water metaphors expressed in the pieces. It ended with a resident’s reflection on visiting a seafood restaurant recommended by a patient who had passed.
Nathan Maris, a pediatric resident, took the stage first with his short story of a car crash. In the piece, his words take two paths: first the literary style of a third person narrative, then the dry, technical jargon of a medical record. Maris said he hoped to articulate the “inherent gap” between the patient’s experience of illness and the physicians’ perception of that experience.
“The human mind is not meant to process catastrophe with such haste,” Maris wrote. “A vodka-sodden SUV clips her rear fender … Her world is a tangle of pavement and sagebrush and steel and snow and bone and blood.”
The structure of Maris’ story is circular, beginning with the patient’s plans to take her GRE and start an MBA, and ending with the patient’s final day of inpatient rehabilitation. After injury and recovery, she leaves with GRE prep books loaded onto an iPad and eventually an acceptance packet in the mail.
“Aside from treating patients directly, one of the most important parts of being a resident is bearing witness to our patients’ experiences and affirming their innate human dignity in spite of their suffering,” Maris told the News. “Every physician does this in different ways, but writing just happens to be one method that I employ.”
Natasha Freeman, an internal medicine resident, studied comparative literature in college and narrative medicine in graduate school. She was grateful to find medical colleagues who were interested in the humanistic side of medicine.
Freeman called it “a testament to the workshop’s popularity” that she only got into it during her third and final year of residency. Her story was about a patient care experience her mind kept revisiting.
“I took care of this man with advanced cancer and schizophrenia who was forsaken by the system and everyone in it,” Freeman told the News. “He lost his ability to advocate for himself in words that made sense, and therefore his needs were not attended to — the system did not allow for it.”
In her piece, Freeman details how the patient has not been outside for nearly 300 days. Scribbling zig-zags on colored construction paper, the patient asserts to her that he is writing medical research. He tells Freeman that he does not have metastatic cancer, that his own research cured cancer. When she tries to bring him to reality, the patient tells her that he wants to leave, that he has not been allowed to eat or drink in five years — currently hooked up to tubes — and all he wants is orange juice and a breakfast sandwich.
The ethics committee had recommended months ago to stop the chemotherapy, needles, restraints and prohibition on eating — all the treatment that extends his life while deteriorating his quality of life — but the patient’s conservator refuses to authorize the change in treatment plan. Without a court order to override the conservator, the patient is stuck.
“[The patient] knew exactly what he wanted, it was obvious if you read between the lines of his psychosis and saw his emotions,” Freeman said. “Knowing how he felt and being forced to contradict those feelings by the system was somewhat of a traumatic experience, and that compelled me, despite my exhausting schedule, to write about it.”
To Freeman, creative writing can and should be used as a tool for advocacy — to give a voice to herself, peers and patients. Delamerced, a pediatric resident, also writes to advocate for patients, and has published op-ed pieces in the past that shed light on health topics in the community.
Delamerced’s piece was a short memoir in which she found resilience reflecting on her mother’s strength. Her mother had immigrated from the Philippines to Connecticut as a teenager, and had also endured the trials of medical residency.
“I will tell her about my time in New Haven. The tearful nights, the 24 hour shifts, the unexpected heartaches,” Delamerced writes. “Hugs from children leaving the hospital. Sunrises and sunsets … If I should have a daughter, I wonder what she will think when she hears these stories.”
Delamerced reflected on the feelings of inadequacy and otherness that her mother must have felt but endured with grace.
Laila Knio, a psychiatry resident, valued sharing lived experiences with her fellow writers. It would be hard to feel true to herself, she said, if she disconnected from her creative side. There were periods of her medical education where Knio recounted losing herself to the learning of medicine — they were “the darkest.”
According to Reisman, people often write their narratives from a detached perspective at first. The workshop encourages them to reflect on what it felt like to be in the room where an experience happened — how all of the senses felt, how the body reacted to a particular emotion.
“We talked about the normal [writing] workshop stuff like opening in medias res and plot and what we wondered about,” Knio wrote to the News. “But we also talked about how to honor our patients in our writing, about what disclosure looks like as physicians, about how to tell the truth without doing harm. It felt like a rare and precious space.”
Hebbar delivered the reading’s final piece. To her, she said, writing can be a form of processing and escapism, whether exploring challenging emotions or patient cases. An internal medicine second year resident in the primary care program, Hebbar’s piece came from her first year of residency.
“Mr. R,” Hebbar’s patient, was an overnight admission. His prostate cancer had spread to his skull, “wreaking neurologic havoc,” Hebbar wrote. He could no longer walk. To her, Mr. R looked too young to be in his 50s and this sick.
“I stared at his shaved head and imagined cancer burrowing into bone underneath,” Hebbar wrote. “It felt improbable that something so catastrophic could hide under the smooth contours of his skin.”
Mr. R and his wife were thrilled to hear that Hebbar was new to Connecticut. One summer afternoon, staring out at the ocean, Mr. R marveled about the best fried fish in the area, insisting that Hebbar check out Stowe’s Seafood in West Haven.
Though Hebbar moved to a new rotation and was no longer his physician, she kept tabs on him. One day, when checking on his chart, Hebbar discovered that Mr. R had died. Nearly a year later, Hebbar and her fellow intern drove in 85 degree heat to West Haven Beach.
“There was a physical intensity to the moment which allowed for reflection upon the life we had lost and the doctors we were becoming,” Hebbar writes. “Then, as we had long promised, we crossed the street to Stowe’s and ate the best fish in the world.”
Reflecting on the workshop, Hebbar said she enjoyed seeing how people’s brains work outside the hospital. When people who previously had just been “somebody [she] worked with” unveiled their writing and stories, she formed a deeper appreciation for who they were as people.
Ann Soliman, chief resident in internal medicine, returned to the workshop as a facilitator after taking part in the 17th annual workshop. The workshop being her first taste of narrative medicine, Soliman welcomed the chance to step back, reflect on what affected her and enjoy “a fundamental human thing.”
Soliman noted the workshop’s value for doctors at the residency stage. Resident physicians embark on a new role, entering people’s lives in a way not previously welcomed or expected before.
“I think a lot of people really resonate with experiences at that time because it’s very much a transformation in responsibility,” Soliman said. “It’s the first time they are directly caring for a patient who died or pronouncing a patient who died.”
Each year, a doctor-writer is invited to speak at the School of Medicine’s “Writing and Medicine” Grand Rounds, which takes place the same day as the annual resident reading. Physician and writer Anna DeForest, an alumna of the workshop, delivered the talk “Language for an Infinite Distance: Art as Work in Medicine” as this year’s visiting speaker.
The Yale Department of Internal Medicine established the Writers’ Workshop in 2003.