The power of narrative medicine

The award-winning essay in the CMAJ, "Sometimes, often," beautifully showcases the power of narrative to forge a deep connection between physicians and patients. The article clearly resonated with our readers, as it was the most-read humanities piece this year. On this episode, the author, Dr. Simran Sandhu, delivers a powerful reading of her article. She then speaks with Drs. Blair Bigham and Mojola Omole about what inspired her to write the essay and how storytelling enables her to build deeper connections with her patients, and in turn, find meaning in her practice.

Next, Dr. Indu Voruganti joins the conversation. She is a radiation oncologist and instructor in the Narrative-Based Medicine Program at the University of Toronto.  Dr. Voruganti describes narrative medicine as a tool for combating burnout and promoting empathy in medical practice. She advocates for creating space for reflection and vulnerability, and argues that narrative medicine has the potential to enhance both patient care and physician well-being.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca

The CMAJ Podcast is produced by PodCraft Productions

Transcript

Dr. Mojola Omole: 

Hi, I am Mojola Omole.

Dr. Blair Bigham:

I'm Blair Bigham. This is the CMAJ podcast.

Dr. Mojola Omole: 

So today, Blair, we're trying something a little bit different.

Dr. Blair Bigham: 

We are, as we head into the second half of summer, we thought we would shift from a research and clinical focus to something a little bit different. And today, we're gonna talk about one of the humanities articles in CMAJ.

Dr. Mojola Omole: 

And it's not just a regular humanities article. This is our most-read humanities article of the year. It's called "Sometimes, often" and is written by Dr. Simran Sandhu, who's a first-year resident in internal medicine at UBC. 

Dr. Blair Bigham: 

It's a pretty amazing piece of writing and a wonderful example of turning the experience of medicine into a powerful piece of narrative. And so that sort of gave us an idea, Jola, that we were gonna try a new opportunity to explore the field of narrative medicine. I thought this would be a really cool idea. Narrative medicine is something that a lot of people talk about. They sort of think it's a secret sauce to medicine, both for physicians who are often burnt out, but also for patients who sometimes don't feel heard or have really complex stories that can get overlooked in the day-to-day hustle and bustle of a hospital.

Dr. Mojola Omole: 

And I'm still trying to sort out what exactly narrative medicine is, if it's, and how do we incorporate that into our day-to-day practice. So we're going to explore this field of narrative medicine with Dr. Indu Voruganti. She's a radiation oncologist, but also teaches at the University of Toronto's Narrative Medicine program, which I didn't know existed. But before we speak to her, here's Dr. Simran Sandhu reading her article in CMAJ entitled, "Sometimes, often"

Dr. Simran Sandhu: 

“Sometimes, often”.

Number one, setting up the interview:

Before I meet you, I already know of you. I'm the stranger assigned to prod your wounds and commit your secrets to memory. “You're also nosy. Have you ever thought about becoming detectives?” Before I meet you, I already know you are dying. In some ways, you know this too. There's no space for euphemisms in the small of your curtain-enclosed emergency room. You're not passing like a truck through an overpass or sand through your daughter's outstretched fingers. There are no losing battles here. I know of you through clinic notes and biochemistry; you're canceled chemotherapy. I read the words "mass" and "malignancy" until they metastasize, permeate through identity. You become your diagnosis. But you remind me you have always been more. The doctor parts the curtain as she enters, I follow, pull it closed behind me. "I'm sorry. Let's pretend fabric is privacy. That there is enough quiet here to hear our own heartbeats." Sometimes, often, this is the best we can do. There is the baby girl screaming in the room next to yours, a man coughing his lungs out through his body next to where you sleep. Your brow furrowed in pain. Your daughter is silently praying.

Number two, assessing perception:

What do you understand about the stage of your cancer? You laugh. I don't know anything anymore. What you do know is that a month ago you were preparing for spring, pulling the weeds out from the garden, earth embedded under your nails. A month ago you were dancing at your grandson's fourth birthday and telling your brother on the other side of the world that you missed him. We’re thinking about visiting soon. You understand that a month ago you felt like you were living, not just enduring, and now you are here. Bedbound, drowsy, blinking through fatigue and hospital fluorescence. “Forget the cancer,” your daughter says. “Mom's a fighter.” You turn your head on the pillow, close your eyes. We don't need new blood work to tell you are tired.

Number three, invitation:

Shall we get to the heart of the issue? Sometimes, often, the hospital is a place built for simultaneous suffering. There always exists the unimaginable. It eats and eats and eats and forever stays starving. I'm not sure why. How hungry is it today? Would you like to know?

Number four, knowledge sharing:

I carried your secret on the way here. Folded it as if it were something fragile into the pocket of my scrubs. It's heavier than you would think. More precious. Sometimes, like now, with your daughter holding her face in her hands, it catches in your throat. Reminds you how pain works and how it leaves you less naive. Sometimes, often, it humbles us. Reminds us we are more human than we would like to be. On the ward you tell me the coffee is terrible here. Nothing like your espresso machine back home. You used to toast the beans yourself. You joke, ”I'd rather have chemo again than another sip, honestly.” For someone who's dying, you are so full of life. Is there anything I can do for you today to help you feel more comfortable? “Oh no, not unless you can cure the cancer. Maybe rewind time back to when I didn't know there was something wrong with me.” I offer you quiet instead, then a tea. You are trying not to cry in front of me and I can tell. When you close your eyes, I try to be strong too. “Maybe something for the pain,” you say finally.

Number five, exploring emotions:

If you want, you can tell me about yours. This quiet grief collecting on your hospital windowsill. At your bedside, I will swallow my own to make more room for you. Tell me about your pain today. Are you still feeling nauseated? Tell me about your family, the way your brother taught you how to fish. Tell me about the bread your husband used to bake every Monday morning, the way you still sleep alone on your side of the bed. Remind me again, how to stay soft, tender-hearted despite, tender-hearted still.  Is it terrible of me to say I am tired? Holding secrets can be heavy. Let me share this one with you. Sometimes, often, medicine can hurt as much as it heals.

Number six, strategy and summary:

It is not easy watching you become quiet, your fire dimmed, you sleep more, find yourself confused more often. One day you reach for my hand. You call me by your daughter's name. It is my last day with you. I never get to see you afterward, but the team says, you went the way you wanted. I cry when I find out your brother made it just in time to brush the hair from your brow the way he used to when you were children.

I think about it often. The way medicine can offer a different kind of hope. Not one for cure maybe, but one for meaning, for choice, for closure and resolution. A quiet moment to say thank you. I love you. I miss you already. Goodbye. Sometimes, often, we carry the memories of patients in another emergency department on another rotation, I part the curtain as I enter, pull it closed behind me. I remember.

Dr. Mojola Omole: 

That was Dr. Simran Sandhu reading her essay in CMAJ, entitled 'Sometimes, often’. The most-read humanities article in CMAJ so far this year. And Simran is with us today to talk more about that beautiful essay that she wrote. So Simran, what inspired you in the first place to write this?

Dr. Simran Sandhu: 

Yeah, so this piece was actually inspired by several real patients. I was privileged enough to encounter during clerkship. And so I knew in this piece I wanted to take a more creative approach and actually subvert the SPIKES protocol medical students are often taught to use in kind of breaking bad news. For example, setting up the interview, assessing perception, and so on. Because I felt, especially as I transitioned from pre-clerkship to in-hospital learning, suddenly medicine and the way healthcare members operated within healthcare, it was anything but black and white. And so, for example, as medical students, we're taught to provide care in these idealistic situations: you set up the interview, you turn off the pager, you make the room as comfortable as possible for when you deliver life-altering news or diagnoses. And then yet, we're forced to provide this kind of care in the most unideal situations. Often late in emergency rooms with a million kinds of sounds going on in the background. And so I followed each step of this framework through my experience with this patient from presentation in the emergency room to their time on the ward, and finally their death. And I named it “Sometimes, often” to highlight that the standardized frameworks and protocols physicians sometimes hold very dear to their heart and to an ideal are not always possible in real life. But that doesn't mean we can't do our best in transcending some of the most difficult aspects of medicine and end of life in particular through human connection and compassion.

Dr. Mojola Omole: 

So this is, this sounds really profound and I can't imagine that you're in first-year residency only. What in your background and your history informs this level of thoughtfulness that you bring to the practice of medicine?

Dr. Simran Sandhu: 

Yeah, I think for me, I was lucky enough to grow very closely with my grandparents. And so often I was usually at home just with my grandparents listening to their stories. And I didn't think about end of life or palliative care until I experienced it as a family member with my grandpa. And so I think unfortunately, like having a family member die from a chronic disease or a cancer diagnosis, it unfortunately equips you with the introspection or the ability to think most about what is important at end of life. What is that thing as a family member or as a patient is most important when cure is not possible. And so I think it unfortunately primes you even prior to medical school and thinking about these situations and you know, if you had a loved one who was in the hospital, like how would you best want them to be treated? And what is most important for you, especially as a provider to help with that?

Dr. Mojola Omole:

 It is such a moving and beautiful piece. What were you trying to capture? What did you want at the end of reading it? What did you want the audience to be left with?

Dr. Simran Sandhu: 

I think for me, a lot of medicine, I'm very early in my training and I think because of that I am very idealistic in many ways and I completely acknowledge that. But at one point I write in the piece and it's me saying to the patient, "Remind me again how to stay soft, like tenderhearted despite, tenderhearted still." And I think for me, I was alluding to burnout here, which has been so prevalent within healthcare, especially with the pandemic. And I really believe it's been in moments where you're able to pause as a physician or provider. And it's really through patient stories and empathy that we're reminded in a way of the work we do and how regardless of how difficult, it's still so important and personal. And though, although this might be our hundredth time having a discussion, a goals of care discussion with a patient or making a diagnosis, acknowledging that this conversation for this patient is still something that's so individual and unique and is unfortunately their first time and so just remembering that.

Dr. Mojola Omole: 

Beautiful.

Dr. Blair Bigham: 

Simran, your peers in residency, do they seem to have a similar approach? Do you think this is like a new wave, an attitudinal shift that newer physicians are taking this narrative approach? Or do you feel sort of like you're on an island sometimes and you're the only one trying to hear some of the softer sides of this?

Dr. Simran Sandhu: 

Yeah, so it's a difficult question to answer, Blair, because I unfortunately have just been limited in terms of the people I've worked with. But I would say I've been lucky enough at Queens to have peers and mentors who really have been pushing towards this kind of thinking. But I think it also very much depends on the service you're on and how busy it is and the attending you have that week. But I remember early into my CTU training, I had a mentor at Queens who told me, "Your job is to know your patient in and out. And I don't just mean what diagnosis they have, I want to know their history and what actually brought them into the hospital." And so, I think that alongside having a very early and integrated palliative care education, which I think has been unique to Queens, has been really helpful in having us just be primed for those conversations and that kind of thinking. I will say, however, that it's difficult always to uphold these kinds, the, the way you operate in healthcare in this way all the time. And so I think despite our best intentions, there's still been on service where you're, you're just not able to do this. But I definitely see, especially in my younger colleagues and peers, it's been more prevalent for sure.

Dr. Mojola Omole: 

Simran, at the end of the article, you say, “medicine can offer a different kind of hope, not one for care maybe, but one for meaning, for choice, for closure and resolution.” Tell me more about what that means for you.

Dr. Simran Sandhu: 

Yeah, and so for me, I think unfortunately for a lot of patients and my experience dealing with my grandpa's death, there comes a point when you understand that nothing else can be done, and you make your peace with that and you think, well, what else do I have left? And I think that's when a lot of people realize is the, is more human connection part of it where I don't have much in terms of a cure, but I'm still able to live out these last few days the way I want to or with the family I have around me. Perhaps this is a goals of care discussion that someone has decided they just want to be comfortable with the time that they have left. And so that's a choice that they're able to make and live out the rest of their days or whatever, whether that's weeks to days to months, the way that they choose.

Dr. Blair Bigham: 

Let's bring Dr. Indu Vorugantii into the conversation now. She's a radiation oncologist in Toronto. She's also an instructor in the narrative medicine program at the University of Toronto. Indu, thank you so much for joining us. 

Dr. Indu Voruganti: 

Thank you so much for having me. It's a pleasure to be here.

Dr. Blair Bigham: 

The term narrative medicine gets thrown around quite a bit these days along with just the word narrative. Let's step back a little bit. Tell us what is narrative medicine, and what are we talking about when we use the word narrative?

Dr. Indu Voruganti: 

Yeah, that's a great question. And so I have a couple of kind of elevator pitches, if you will, but ones I think hopefully all of you may identify with in some way. And I think the first is that narrative medicine is a movement that takes a clinical and a scholarly approach but more so than that, even just a reflective approach to honour the central role that story plays in healthcare and caregiving. That's what I fundamentally believe it is, is that it's a movement that we bring ourselves back to the idea that the care of those who are ill or sick lies in stories fundamentally. Before we had all the technological advances of CT scans and blood tests and medications and immunotherapy, what did we have? What did the doctor or the caregiver have in their black bag? And that was the ability to sit and listen first and foremost and witness birth, growth, life, death, illness, suffering, joy, and all the emotions that that life brings and offers. And so, I believe fundamentally that narrative medicine is the ability to reflect and perhaps train ourselves to be more reflective in our practice of caregiving and medicine. And that really, I think for me personally, this has evolved over time, and I'm actually heading into a direction of treating brain tumors primarily as a focus. So in that, I experience a whole lot of suffering and witness that. And, and with that has come a lot of toying with burnout through my training and through where I'm headed. And so to me, narrative medicine has actually really served as a tool for negotiating and navigating the challenges of medical training.

Dr. Blair Bigham: 

That's, it seems a little bit counterintuitive, doesn't it? That by getting to know people better, we somehow can prevent burnout. It always seems, I guess my habit, put up your walls. I don't wanna know about your kids. I don't wanna know about your pets, I don't wanna know about your life. You're critically sick, you're gonna die on me. I'm just gonna say that you are the end stage COPD-er. How is it that by getting to know people better, by delving into and leaning into their narrative, it can actually protect us from burnout?

Dr. Indu Voruganti: 

Yeah, that, that's a great question. And I don't think any of us really have the exact answer, the exact science down, but we certainly strive to find meaning in what we're doing. And that's fundamentally what I think this is about. And we cannot spend an hour with every person and learn about every single detail and nor should we necessarily strive to because then that might actually do a disservice to the patients thereafter. We have to balance efficiency and the system, if you will, with the ability to provide effective medical care. But I would argue that training in narrative competence, which I believe is the ability to recognize details and extract the details that are pertinent, if you will, from a person's story in an effective way, can actually improve the efficiency by which you give care, while also creating a space to reflect. So I think it boils down to a narrative competence. As well as the ability to reflect thereafter.

Dr. Blair Bigham: 

We often hear that there's like clinical medicine and there's narrative medicine, right? It's like the hard science and the soft science or however you wanna split it. There's always a dichotomy. How do you teach narrative competence to medical students and to residents so that they're not just being transactional and mimicking, you know how you've all, we've all seen people do the SPIKES  algorithm and it's a disaster, right? Like they're, they don't get it. They're not in it, they're just reading off a script. How do you make it authentic when you are a learner? And maybe it's best to ask Simran this, like, Simran, have you had training in narrative medicine that allowed you to do this? Or did your heart just bring this out on its own?

Dr. Simran Sandhu: 

I think unfortunately, like you alluded to, a lot of medical training is done in a way that's very artificial and sterile. And so I think the best way to approach these conversations in real life is to be able to witness them or observe them. And so I've had the privilege of being able to sit in with the during these conversations with attendings and senior residents. And so it really is seeing how they approach these conversations in ways that are meaningful and authentic and sincere and building that approach for yourself based on them. And so you take little pieces that ring true for you and your style of providing care until you've built an approach that feels right for you and your patient.

Dr. Blair Bigham: 

Indu, do you have any tips for people either who are in practice or who are coaching those who are developing their practice on how to make space for this and really truly integrate it into their work with patients?

Dr. Indu Voruganti: 

Certainly, I have several thoughts on this because I think I'm one of the folks that feels very strongly about the importance of space for this kind of work within medical school curriculum or even residency curriculum, any stage of training. And I think what Simran just said really resonated with me because narrative medicine, yes, it's become a more formalized field and a scholarly institution with a capital "I," etc., but really, we are all storytellers. I think no matter who we are, we have stories to tell and we can listen to stories. And these are skills that are inherent to whoever we are as human beings. And so I think what the actual study or practice of narrative medicine tries to harness is that ability to reflect. And the reality is not everyone is going to automatically buy into that or feel comfortable with that because it takes vulnerability, it takes the ability to create a safe space. And depending on students' interests, they may not be interested or drawn into that. But I think within a group, there usually are folks who are interested in this aspect and can help to draw other people in. And, as Simran said, she's been quite fortunate to have role models who model really authentic and deep behaviors and habits that have inspired her, but also peers. And I think when I reflect on my own medical school experience, it was my peers who really made me believe in the value of sharing our stories and reflecting and being a safe space to talk about the tragedy we're witnessing. And those are peers, even though we've all gone off to different residency programs and specialties that are very diverse, we all come back to that and still share our experiences. And then as I went through oncology training, I found there was actually surprisingly a lot of resistance to this kind of reflective capacity. 

Dr. Blair Bigham:

Oh, wow. 

Dr. Indu Voruganti:

Which was very surprising to me.

Dr. Blair Bigham: Why do you think that is?

Dr. Indu Voruganti: I, you know, I'm still thinking about it. I don't know if it's because some of the traditional aspects of training have been really emphasized. Learning the diagnostic acumen, the volume that you're dealing with, unfortunately. And also, like you alluded to earlier, sometimes folks putting up those walls as a self-protection. And I found that some of my peers perhaps were less keen to pause and reflect. But I like to think that there were stories that stayed with them and perhaps a space was created that would've been a good opportunity to reflect on what they've witnessed.

Dr. Blair Bigham: 

Right. It really is a common point for all physicians regardless of specialty. We can all connect over stories. Simran, congratulations on, and thank you for writing this essay. It won the undergraduate narrative award for palliative medicine writing from the Canadian Society of Palliative Care Physicians. And it's just such a, not only a beautifully written piece but a beautifully crafted piece. It just really resonated with all of us here at the podcast. And I thank you for writing it and for joining us today. Simran Sandhu is an internal medicine resident at the University of British Columbia. And Indu, thank you so much for joining us. Indu Voruganti is a radiation oncologist and instructor in the narrative medicine program at the University of Toronto. 

Jola, I am so glad we took a risk and tried something new with this episode.

Dr. Mojola Omole: 

It was really great. And I think for me, as I go through it, it's interesting 'cause today I went to a talk for high school students who were interested in medicine. And one student asked me, he's like, "Well, what do you do when things are really sad?" And I was like, "Well, I just cry." I'm like, "I honestly, if it's a tough patient, and if their story moves me, then I cry." And I think that in medicine, because the structure of medicine was based on the military, it's that we're not supposed to have any weaknesses. But through this process of us trying to create no weaknesses, we actually create weakness and that's why we have burnout, because we don't…

 Dr. Blair Bigham: 

Oh, that's such a good way of putting it.

Dr. Mojola Omole:

We don't have space for ourselves to reflect about what's happening inside of us. Like, I think it's impossible not to feel sad or overwhelmed or sometimes joyous about what's happening with your patient. And we were taught that, well, that's not important. It's the diagnosis and it's treating them and getting them out the door. But really and truly, the connection is, at least for me, it's what drives me and makes me want to keep working. And I wonder if we spend more time on that and we give space and we kind of peel back the layer and we teach each other how to be reflective, we would be better physicians, but we would also be better people and maybe lower that divorce rate for surgeons.

Dr. Blair Bigham: 

I think we might be happier. It does sound like more work because we all love to fall back on sort of patterns and habits and algorithms. But even if the medicine is the same patient to patient for one disease, the circumstances are always different. And the interaction can be different and unique. And instead of just, you know, going to work and seeing 25 people in clinic one day, or just like moving, you know, we always talk about, "Oh, the STEMI in resus three," no, that's not a STEMI. It's a lot more than a STEMI. And if we lean into that, we can sort of have a more interesting day at work. It almost sounds selfish to sort of get something out of a patient interaction, but if we can stay engaged with people, then we'll see the good that we're doing, we'll make the connections with people who we’re potentially helping and, in return, can sort of refill the tank.

Dr. Mojola Omole: 

For sure.

Dr. Blair Bigham: 

That's it for this week's episode of the CMAJ podcast. I hope you liked the twist that we added today. We're gonna keep trying to innovate to make this podcast interesting and meaningful and helpful to you, our listeners. In return, we'd love you to do us a favor. Help us get the message out, share our podcast wherever your friends are, let your colleagues know about us. And please do remember to like us wherever you download your audio. I'm Blair Bigham.

Dr. Mojola Omole: 

And I'm Mojola Omole. Until next time, be well.