A Place To Stop

 

Stop
Stop (Photo credit: Swamibu)

 

In our narrative medicine course we have moved into group presentations. On the first day of the quarter I had students sign up to be in one of eight groups to work on group projects and to do a group in-class presentation. I picked eight topics, using the list of topics (keywords) from NYU’s Literature, Arts, and Medicine
database
as a guide. The eight topics I chose this summer were: Aging, cancer, death/dying, disability, drug addiction, infectious disease, mental illness, and racism. The group assignment was to research and expand upon the topic resources listed in the NYU database—to approach this as if they were doing an in-service training on the topic at their work site. I asked them to produce a one-page (front and back) handout of their favorite resources, along with two to four possible in-class writing prompts and reflective questions. Each group was given 45 minutes to present on their topic and to lead the class in discussion and reflective writing. (Note: our class sessions are four hours long, although we don’t typically go quite that long).

This past week the first two groups did their presentations (on aging and cancer) and both did an excellent job. The groups used an interactive PPT presentation, weaving in poetry, prose, artwork, comic books, YouTube videos, and movie clips. I was impressed by the range and depth of their presentations and class discussions, as well as their application of the close read drill adapted from Dr. Rita Charon’s work. Group members also shared some of their personal stories related to their health topic and did this in a moving but professional way.

 

When I was planning this narrative medicine summer course, I was resistant to the idea of building in group projects. As a student I always preferred to have individual assignments since I could then control the time commitment and the outcome. I knew that the majority of my students in this course would be busy with their nursing jobs and families as well as with school. But a colleague convinced me to use group projects, saying the students were used to them and that what they came up with was typically of high quality. I have purposefully allowed time at the end of each class session for students to meet in their groups for planning purposes and I stay around to answer any questions that may arise. Some groups have also set up online discussion boards on our course website to facilitate their group planning. (In my mind, this is the only really useful function of online discussion boards.) That seems to have worked well for them so they don’t have to meet in person outside of class.

 

Two things particularly struck me from the in-class presentations and discussions. One was the number of students who had personal experience with either a close friend or family member or a patient who was given a diagnosis of a serious cancer over the phone or in a voicemail message. We talked about how insensitive that is and what nurses can do to influence physicians, nurse practitioners, and other healthcare providers to think through how to give bad news in a more supportive way. The other thing that stood out to me in the class discussion was a comment a student made that this narrative medicine class is “A place to stop and to process these things we don’t get to process.” Other students said they agreed with what she said and talked about how nurses are so much into the care giving role, not only at work but also in their personal lives, that having a time and space to stop and reflect on how it is affecting them is a powerful thing.

 

Ah yes. There were really three things that struck me during last week’s class session. The third was that this is all heavy stuff to process and write about and how much environmental context matters—as in the actual physical classroom setting. We have a nice smallish amphitheater classroom with excellent acoustics, state-of-the-art audiovisual equipment that is easy to use, reasonably comfortable chairs and tables, and a full bank of windows looking out over a grassy marsh full of birds. I’d forgotten what a pleasure it is to teach in a classroom with windows. It also helps that it is one of the loveliest summers in Seattle’s history. Teaching this narrative medicine course in a windowless classroom in the middle of a Seattle winter would have a much different feel.

 

 

Close Reading Drill Simplified

This past week in the Narrative Medicine course I am teaching, I introduced students to the approach to close reading (she refers to it as a drill) as taught by Dr. Rita Charon and her colleagues at Columbia  University’s Program in Narrative Medicine. I then had students apply this to do their own close reading of JD Salinger’s short story “To Esme, With Love and Squalor.”

As a way of introducing them to close reading I had them read Rita Charon’s chapter “Close Reading” in her book Narrative Medicine: Honoring the Stories of Illness (Oxford University Press, 2006). This is a weighty chapter in a weighty book and I have discovered that many of my students were simply overwhelmed by it. So here is my streamlined version of ‘doing’ a close reading drill as applied to narrative medicine. I present the elements of close reading in the order I like to do them myself because it is more the way I read and analyze what I read.

1.     Desire (Dr. Charon’s term). What appetite or emotion is satisfied by reading this? What bodily sensations do you have while reading this? What intellectual or emotional desires arise? Put more simply: what is the overall feeling you have when reading this? (A related and interesting question would be: And what does this reveal about you as the reader?)

2.     Frame. What’s included and what’s left out of this narrative? Where did this first appear—what was the intended audience of the work? For instance, Salinger’s short story first appeared in the New Yorker in 1950. What can we surmise about his intended audience?

3.     Temporal scaffolding. How is time handled in the narrative?

4.     Form. Structure, genre, narrator, use of metaphor, allusion (especially what other works are referred to either explicitly or implicitly?), and diction

5.     Plot. What happened.

Dr. Charon makes the case that learning the skills of close reading as applied to narratives, whether written or in plays, movies, etc, can help health care providers learn to be more attuned to the illness narratives of their patients. Careful reading, careful listening, it makes sense at some level and I am teaching that to my students. Salinger’s short story that I had them read and analyze through close reading is a complex but engaging piece of writing. It has enough content about the health effects of war—PTSD especially—that nurses and others in the health professions find it interesting. Salinger’s use of frame, time, diction, and metaphor are exquisite. So this short story makes for a good—but sufficiently challenging—narrative on which to practice close reading. I found that most students did well with this assignment and really dug in. Since class this past week fell on July 4th, this was an individual take-home assignment, so I have not yet had the opportunity to discuss it with them in class.

I always have these nagging questions in the back of my mind: Does close reading detract from the pleasure of reading? And by extension, does ‘close reading’ a patient’s illness narrative detract from the pleasure of the patient-provider interaction? Do we start thinking about patients less as people and more as stories to be analyzed, stories to be recorded in our heads and then later used as material for our own written stories? Does that start to distance us from our patients? Is it like walking up a familiar flight of stairs—pleasantly distracted—then thinking about walking up the stairs and by paying attention to it, tripping? If writers consciously try to pay attention to the craft of writing, does the art of their writing suffer?

I’ve been re-reading one of my favorite books, David Ulin’s The Lost Art of Reading: Why Books Matter in a Distracted Time (Sasquatch Books, 2010). He raises these questions as well—for writers and readers in general. He states, “(…) I recognize this as one of the fallacies of teaching literature in the classroom, the need to seek a reckoning with everything, to imagine a framework, a rubric, in which each little piece makes sense. (…) leaving us with scansion, annotation, all that sound and fury, a buzz of explication that obscures the elusive heartbeat of a book.”

If I used this class assignment again I would add the personal reflection writing prompt: Write about a time when you were so overwhelmed by emotions that you had difficulty communicating—or write about a time when you were caring for a patient experiencing this.

 

 

A Patient Named Noname

IMG_0787I once had a patient named Noname. She was a thin wisp of a young woman who came to the community health clinic where I worked as a nurse practitioner. This was back in the late 1990’s soon after I had moved to Seattle from the East Coast. I was still having a bit of culture shock, getting acclimated to Seattle’s rain, tree-huggers, and serial killers. When I first met Noname I was dating a man who was a tree-hugger but thankfully was not a serial killer. He was way into natural food and meditation, so I had Namaste continually playing in my head like an annoying Bee Gees song. So when I looked at the new patient name ‘Noname’ on the patient chart and entered the exam room, I greeted her as Noname, pronouncing it as if she were a cousin of Namaste. She laughed nervously and corrected me: her name was no name. As in she didn’t want to give her real name, so it was just a placeholder of sorts. It wasn’t as if she was in clinic that day for any sort of health complaint that would make her concerned for her privacy. I never did get the story of her name, of her no name.

I remembered Noname this past week as I began teaching an eight-week Narrative Medicine course at the University of Washington, Bothell. I have close to 45 wonderfully smart and creative nursing students, all in their BSN-completion program. That means they all have their RN either from diploma or community college programs and are back to take the courses necessary for their BSN. They are all working full or part-time as nurses so they have a lot of ‘real life’ experience to draw upon.For the first in-class writing prompt I used one of my favorites learned from Dr. Rita Charon and her colleagues at Columbia University’s Program in Narrative Medicine: Write the story of your name. Everyone has rich stories to tell about their names—including the patient named Noname. I find this writing prompt to be an excellent starter prompt, as well as a way of allowing people to introduce themselves in a unique way. Of course, with 45 people in class we didn’t have time for everyone to read their stories out loud, but I have had the privilege of reading all of them and it helps me to get to know the class. I pointed out that this writing prompt can even be used effectively with patients. For instance, I’ve found that it is so much better to ask a patient (with a strange to me name), “Can you tell me the story of your name?” versus the usual “What country are you from?”

After presenting them with some basics of Narrative Medicine—what it is, where it came from, Dr. Charon’s approach to close reading—we practiced close reading together using a variety of short pieces of poetry and prose and film clips. The poetry I used was from Cortney Davis (I Want to Work in a Hospital), Raymond Carver (What the Doctor Said), Rachel Haddad (Stereotactic Biopsy), and Suzanne Edison (Teeter Totter). For the film narrative/close reading I showed them clips from the movie Magnolia (1999)—specifically two clips that are available on YouTube. One clip is the regret deathbed soliloquy by Earl Partridge (played to perfection by Jason Robards), and the second clip is of the male hospice nurse (played also to perfection by Philip Seymour Hoffman) on the phone trying to track down Earl’s estranged son (played—OK—also to perfection—by Tom Cruise). I love these two clips because they portray hospice care and hospice nursing so truthfully. They lent themselves to some rich class discussion and close reading skill building.

For the last in-class close reading and writing exercise I turned to writing by one of my favorite local authors, Judith Kitchen (Distance and Direction/ Coffee House Press, 2001); Half in Shade: Family, Photography, and Fate/ Coffee House Press, 2013). I used her sample short essay F-Stop, which is surprisingly complex for such a short prose piece (available on her website). We first did a close reading of this essay. Then I showed them a photograph of a man reading to three small children around a campfire. I asked them to write the story of this photograph—to just make one up—thus pushing (or pulling?) them into the realm of fiction writing. I could tell that many of the students struggled more with this writing prompt. Some told me they had never been asked to write fiction before in nursing school. But they persevered and came up with some wonderfully rich stories.

I’ll be writing a series of posts over the next seven weeks of this Narrative
Medicine (for nursing) course. Since Narrative Medicine isn’t ‘done’ very much in nursing schools—and I think it should be—my hope is to share my experiences with others who may adapt it for their own teaching.

Cultural Humility Redux

English: Haystack
English: Haystack (Photo credit: Wikipedia)

It is past time to retire the term ‘cultural competency’ in favor of the more enlightened ‘cultural humility.’  The word ‘humility’ is a problematic one for people, especially for health care providers or academics used to doing everything possible to avoid being humble. We are groomed to be arrogant. (See earlier post “Cultural Competence, Meet Cultural Humility” Aug. 16, 2011.)

But I’m reminded of one of my favorite quotes from a favorite author, William Maxwell, from his book Time Will Darken It:

“People often ask themselves the right questions. Where they fail is in answering the questions they ask themselves, and even there they do not fail by much. (…)There is no haystack so large that the needle cannot be found. But it takes time, it takes humility, and it takes a serious reason for searching.”

I juxtapose this quote with one from Craig Irvine who teaches in the Columbia University Program in Narrative Medicine. Mr. Irvine is a former Benedictine monk whose area of expertise is narrative ethics. He talks about empathy (necessary for cultural humility) as being “my experience of the mystery of my relationship with another person” as opposed to the usual understanding of empathy (in healthcare settings at least) as knowing the other person or “stepping into their shoes.” Craig states, “empathy brings me to myself.” (Quotes are from my notes of a talk he gave at a narrative medicine conference I attended in October, 2010).

We really never can know someone else, and as William Maxwell points out, many times we fail to even know ourselves. But in the words of Lyle Lovett, “Who would you be if you didn’t even try?”

That brings me to my hearty recommendation of a relatively new video I happily stumbled across yesterday (thanks to Community-Campus Partnerships for Health.) The video was written/produced by Vivian Chavez and is titled, “Cultural Humility: People, Principles and Practices.” (Aug. 9, 2012 release date/ 30 minutes in length.) The video features interviews with various people, including physician Melanie Tervalon and nurse/educator Jann Murray-Garcia, co-authors of the journal article “Cultural humility vs. cultural competence.”(Journal of the Poor and Underserved, 9(2) 117-125.)

According to Tervalon and Murray-Garcia, the three principles of cultural humility include:

  1. Lifelong learning and critical self-reflection
  2. Recognizing and mitigating power imbalances
  3. Institutional accountability (they emphasize for the power imbalances, but I would add accountability for the structures/support/leadership necessary for lifelong learning and critical reflection… these are usually woefully lacking.)

While watching this video for the first time I was thinking—wait! Where are the white people in this? But at least I did recognize my own white privilege arrogance in the question. I continue searching in my haystack.