Narrative medicine can help process experiences ‘on a very deep level’

Key takeaways:

• Narrative medicine is a powerful tool that physicians can use to better understand their patients and themselves.
• Reflection is a major part of narrative medicine and helps writers consider a new perspective.

HONOLULU — Health care providers can gain a deeper understanding of both their own and their patients’ experiences through writing and participating in narrative medicine, according to a session at the CHEST Annual Meeting.

This session, chaired by Abhishek Bhardwaj, MD, assistant clinical professor at University of California, Riverside, also included Rana Lee Adawi Awdish, MD, MS, FCCP, pulmonary and critical care physician at Henry Ford Hospital, and Avraham Z. Cooper, MD, clinical assistant professor of internal medicine at The Ohio State University Wexner Medical Center, who each shared their writing journeys, why writing is important for both themselves and others and tips on how to ease into narrative medicine.

Journey to writing

For Awdish, writing started as a way to better understand herself.

Her book, In Shock, tells her story of how it felt to become critically ill at the end of her fellowship. Through this work and further writing, she has seen the power writing has on others and how it can expand to influence policy.

“In the process of writing, I could extend that out to understand the experience of my team and what it felt like to be a physician caring for another physician who was critically ill and the pressures that we all put on ourselves to perform perfectly in those situations and what those stresses do to us as clinicians,” Awdish said. “From there, I felt I could expand the circle out again and start thinking about patient stories differently, thinking about the ways that we could use something, for example, during the pandemic for advocacy or to influence the public that certain measures were necessary.”

Before going to medical school, Cooper majored in English literature with a focus on poetry. After experiencing many transformative situations during medical school, he thought back to what he learned while in college.

“I realized that the poetry that I had been practicing and learning about in college could be an outlet for me,” he said during the session.

Cooper also observed writing in his day-to-day life as a physician through progress notes, and all the different voices he saw portrayed in these notes added to his appreciation for writing.

When they first started writing, both Awdish and Cooper faced challenges; however, they each learned how to overcome them in their own ways. For Cooper, the challenge was determining if he had something to say, which he solved by thinking out his ideas/topic beforehand.

“What I started to do that definitely helped me was when I want to write a paper about an idea and communicate some concept or write a poem, was really understanding what it was going to be about before I did anything,” Cooper said. “Really understanding, zooming out, thinking about themes, thinking about what my message was going to be and really understanding that before I do really any writing ... was pretty transformative for me.”

Awdish emphasized the significance of writing and said that writing is not just “brain vomit” on a piece of paper, rather it allows physicians to reflect on themselves and their situations.

“[Writing] more often is a process of sensemaking where you are looking at your experience and then looking at it again, pressing on it and seeing what more it can tell you in this iterative way until you really get what's behind it,” she said. “To me, that is the reason to write, to know what you think on a very deep level that you might be afraid to even say that you think on first pass.”

Power of reflection

Throughout the session, Awdish emphasized the importance of reflection in narrative medicine because it allows you to consider and gain insight on aspects about a patient that you may have not thought about at first.

To demonstrate the power of reflective practice, Awdish shared an example from the COVID-19 pandemic, in which one of her patients criticized her for wearing a mask. Adopting this practice allowed her to ask the patient about their own experience in the pandemic, to which she heard back that they have been feeling lonely and isolated from their family.

Hearing this response, Awdish was able to share her own similar feelings and relate to the patient.

“[Reflective practice] opens up what's available to us in a way that we might not know about otherwise,” Awdish said.

Becoming accustomed to reflecting while writing also can help clinicians decipher what stories are theirs to share with the world and which are not.

“There are a lot of patient stories that I think make people vulnerable that I wouldn't put into the world but without writing about it, I don't really know enough about what I'm thinking,” Awdish said.

Concerns, risks

When asked about how to overcome the fear of being judged for their writing, Cooper highlighted the idea of enlisting people you trust to provide their opinions early in the writing process so that you gain awareness of the different ways it could be perceived.

For narrative medicine in particular, reading from the perspective of a patient or patient advocate is crucial and important to remember, he said.

Awdish added to this point by emphasizing that patients do not have a lot of power.

“One of the tools that was helpful for me in deciding how to disclose controversial things was recognizing that ultimately our patients are the most powerless in the power hierarchy,” Awdish said.

Taking this mindset on can be risky at times, she added, but it could provide something that is needed.

“Taking risks, although risky, can sometimes surprise you with what people are willing to support and to hear,” she said.

“My rule for myself in my writing is always that the patient's experience exists behind the door that I only have this much access to,” Awdish added. “I only know my lens on it, and I can write from that perspective, but if I find myself trying to write from the patient's experience of what happened, that is not my story to tell. I try to keep myself on my side of the door and talk about what I've learned.”

Writing on social platforms

When discussing the role of social media platforms in narrative medicine, Awdish said it is important to reflect on what you are sharing through your writing before going straight to social media.

“There are some things that you put out in the world because you're looking for a kind of response in real time, a pulse check,” she said. “How are other people thinking about this? I'm curious about this question. And then there are things that really require a lot of self-reflection, distance and perspective. That might be something like a longer-form essay or a book where you really do need some time to process what you're believing and letting it evolve over time; it wouldn't be appropriate for social media.

“Thinking about the why, what is my reason for using this medium in this moment can help direct you into where your story belongs now,” she added.

Although social media can be a helpful storytelling tool, having a platform is not a necessity when classifying yourself as a writer, Cooper said.

“[In] being a physician/health care worker who is documenting, you are writing,” Cooper said.

Those who write in health care can be considered writers without receiving attention from a social media post or being recognized by a publication, Cooper added.

Tips for getting started

Because writing involves processing many feelings and emotions, first drafts will likely just be seen by yourself, Cooper said. Refinement over several drafts is key to getting the best version of your story out into the world.

For those who want to better their writing and learn more about narrative medicine, Awdish mentioned the narrative medicine community from Columbia University that hosts virtual workshops.

“They'll pick a piece, you'll do a close reading of it, the group will reflect on what they noticed in it and then you write in the shadow of what you've just read together,” Awdish said. “Then people share, and there's no obligation to share.

“Close attention to word choices to symbolism and metaphor can really expand your notion of what's possible,” she added. “It definitely made me more aware as a writer.”

Another tip for aspiring writers is to build up a community of people with whom you feel comfortable sharing your writing and receiving feedback. During the session, Awdish said she has a friend who she is not ashamed to show her first drafts to, as well as professors of literature who evaluate her writing with a critical lens once it has been revised.

“Sometimes we need the courage to tell that deeper, truer story, and having someone reflect back to us can be very helpful,” Awdish said.

“Even though sometimes you see a piece that has one author's name on it. there are always many, many people who have contributed to that process,” she added. “That can be invisible, but it's real.”

Cooper said connecting with Awdish was helpful when he was trying to find his voice, emphasizing the importance of finding people who you can go to for valuable feedback.

Working as an editor for other writers can also give you more insight into your own writing, Cooper said.

“If you're given an opportunity to work as a reviewer or an editor, and to sort of think critically about other people's writing, you sort of get a sense of ‘OK, that's why that worked really well,’ or ‘no, this is how I think this could be improved,’” Cooper said during the session. “You have to create complete solutions for that writer for them, and that actually helps with your own development.”

Lastly, Cooper recommends reading and taking guidance from other authors.

“I think reading a lot is very important,” he said. “Reading with intent and really understanding different authors, why you like their writing and why it speaks to you [are important things to consider].”