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School of Medicine
From Kafka to Kendrick Lamar
They are an unlikely partnership in the academic medicine sphere. Benjamin Oldfield is a resident in internal medicine and pediatrics with a strong interest in literature and social justice. Lauren Small is a writer and adjunct professor of English at the University of Maryland University College who grew up in a family of doctors. But a common reverence for the power of storytelling brought them together to ask the question: Could narrative analysis and critical reflection benefit those who work in the Johns Hopkins Children’s Center?
Illustration Adrià FruItos
Lauren Small and Benjamin Oldfield believe that the act of storytelling and listening to stories lies at the heart of medicine. They created AfterWards as a monthly space for Johns Hopkins clinicians to build “narrative competence.”
Photography Chris Myers
Dreams of reality’s peace
Blow steam in the face of the beast
Sky could fall down, wind could cry now
The strong in me, I still smile.
The late-afternoon sun slants into a seminar room high in the Johns Hopkins Children’s Center, where a diverse group—nurses, residents, physicians, child life specialists, writers—have gathered together to watch a music video by hip-hop artist Kendrick Lamar. Far below, East Baltimore rowhouses line up in parallel. Kids call in the streets to one another, sharing the story of their school days, but their voices are unintelligible from our vantage. Only a few days ago, Baltimore was riven with unrest, cars burning, impassioned voices shouting. The video montage accompanying Lamar’s song “i” offers an eerie echo to recent events, as he runs through city streets while singing to an insistent beat, dancing past people who have gathered around a trash can fire, by two police who haul a man away in handcuffs.
“I don’t get it,” a nurse says. “But then this isn’t the kind of music I usually listen to.”
“Me neither,” a child psychiatrist says. “But I have a lot of patients who listen to Kendrick Lamar. To them he’s a hero. If I can’t understand him, can I really understand them?”
This is AfterWards, a program in narrative medicine we began in the Johns Hopkins Children’s Center in the winter of 2014. The needs, we felt, are great. Clinicians working at busy, academic, urban hospitals like Johns Hopkins experience hectic, emotionally charged days. Yet the pace of modern medicine leaves little time to process those experiences, to slow down, to reflect. It’s not surprising that burnout has become an increasingly recognized problem among caregivers at all levels. While the causes are complex, the isolation experienced during medical training and practice certainly contributes. So do professional expectations. William Osler named the ideal quality in a practitioner aequanimitas, or imperturbability in the face of great challenge. If Osler is correct, where is the release valve for practitioners who must project an image of courage and levelheadedness, ignoring their own vulnerabilities? Could literature and art, we wondered, provide a fulcrum on which to weigh the challenges and celebrate the victories of our practices?
So we created AfterWards as a space that exists within—and yet outside of—the usual clinical realm. We meet monthly in the Children’s Center on a drop-in basis; no advance preparation is required. Caregivers of all kinds—from nurses and child life specialists to attending physicians—are invited to attend. Each session centers on a literary text or artwork linked to a specific theme. In conjunction with Bertolt Brecht’s poem “Worker’s Speech to a Doctor,” we talked about the challenges of coping with the social contexts of illness. The music video for Suzanne Vega’s “Blood Makes Noise” initiated a discussion on how hard it is at times for patients to hear us when we present difficult diagnoses or disappointing news. Jan Steen’s painting The Doctor’s Visit led us to compare the intimacy of an old-fashioned patient exam with modern-day diagnostic tools.
After a formal discussion of the text or artwork, participants write privately in a free style about their own experiences. The close of the session focuses on shared reflection. All of this in one hour, in the late afternoon, when caregivers are most laden with the emotions and experiences of their busy days.
From the beginning, we felt it was important that AfterWards be broadly democratic. In a hospital where roles and hierarchies are often rigidly stratified, we decided to invite anyone who delivers care to patients. Attending physicians sit side by side with nurses and child life specialists. Psychiatrists gather with cardiologists; residents who are training in palliative medicine rub elbows with social workers from the NICU. The conversations that result are varied, intense, focused—and often surprising. Participants begin by talking about patients they have treated or experiences they have had on the wards (always protecting patient privacy). Often they end by talking about themselves.
One evening, we read W.H. Auden’s poem “Surgical Ward” in conjunction with the theme of bearing witness to suffering. Auden writes about patients who lie silent and motionless in their hospital beds:
A bandage hides the place where each is living,
His knowledge of the world restricted to
The treatment that the instruments are giving.
The language of the poem, we noted, depersonalizes the interaction between clinician and patient. Medical instruments operate independently with their own autonomy, rendering the caregivers invisible.
A physician in the room identified with Auden’s description, referencing moments when side effects of therapies cause morbid—and at times fatal—problems for his patients. For better or worse, he admitted, when things go wrong, he could distance himself. “You can blame the drugs instead of blaming yourself.” But a nurse on his floor felt she had no such defense mechanism. “Our care is so hands-on, so immediate, we can’t help but feel the suffering of our patients personally.” These two practitioners cross paths daily, but given the structure of the hospital day, they rarely have the opportunity to engage in this kind of exchange.
It’s counterintuitive. In the stressful, demanding atmosphere of a major urban hospital like Johns Hopkins, you might think that the caregivers who develop the thickest skin—the strongest defenses—are the ones who offer the best care. In actuality, the work of Carol Chou, an internist at the University of Pennsylvania, has shown that the opposite is the case, as have other researchers who focus on humanism in medicine. Physicians who identify themselves as “humanistic,” who find meaning in their work, feel that these qualities improve the care they give. When asked what makes their work meaningful, they identify strong connections to their patients. How do they maintain these connections? By listening—and tuning in—to their patients’ stories. The very act of storytelling and listening to stories, we believe, is at the heart of medicine. Honing those skills has import for the daily practice of any clinician. Being a good storyteller and a good listener, it follows, makes one a better doctor, or nurse, or therapist.
Rita Charon, who directs Columbia University’s Program in Narrative Medicine and is both an internist and a literary scholar, has called all individuals in medical encounters—patients, providers, policymakers and health activists—“obligate storytellers.” The way that patients convey their illness experience to providers, how physicians formulate treatment plans in culturally appropriate manners, and how clinicians and activists advocate for policy change all depend on the telling and metabolizing of stories.
Narrative medicine teaches that there is clinical significance to having skills in listening to and telling stories—that is, to having narrative competence. Pulmonologist Richard Schwartzstein, for example, has shown how the very metaphors that patients use to describe their respiratory distress are linked to distinct categories of disease with validated precision. When a patient describes shortness of breath as “air hunger,” for instance, this suggests chronic obstructive pulmonary disease, not other causes of respiratory distress, like heart failure or coronary artery disease. The specific words a patient may use contribute to a clinician’s diagnostic certainty. It follows that if we pay attention to the stories, and even the individual words, of our patients, we just may be better clinicians.
So we exercise our narrative muscles in AfterWards. A recent session on Franz Kafka’s dreamlike and fantastical short story “The Country Doctor” left our group wondering why a physician ends up naked in bed with the patient he has come to assist on a snowy night. Together we dissected the plot bit by bit to make sense of the end. Usually it is the patient, not the doctor, who bares all in the clinical setting. The doctor wears his uniform—stethoscope, white coat, hospital ID badge—like a suit of armor. When in a quintessentially Kafkaesque move, the doctor in Kafka’s story is unclothed, his self-doubts and vulnerabilities are revealed. We share in the chaos of his feelings as we navigate through Kafka’s frantic storyline. Our difficulties in reading mimic the all-too-frequent challenges we face as providers, trying to glean a clinical history from a patient in pain, or a family in distress. Often the manner in which a story is told reveals as much about the storyteller as the story itself.
Another session examined the Oscar-winning short film Helium by Danish filmmaker Anders Walter. The protagonist is a boy who is terminally ill, living in isolation on a hospital ward. As he suffers, he befriends a hospital custodian, who tells him stories about “Helium,” the place, he says, the boy will go to when his fight with illness ends. The clinicians, the film suggests, have failed in their effort to find a cure for this child, and all that is left is the delivery of hope. “What is our obligation to tell the truth to our patients?” asked a medicine-pediatrics resident. “Is it ever proper to engage their fantasies?” Not surprisingly, the child life specialists in the room had insights to offer the physicians. Their days, after all, revolve around using play to educate, calm and comfort young patients. “The imagination is a powerful tool,” one specialist reflected, “especially for children faced with treatments or illnesses they’re too young to understand. It helps us communicate with our patients, and that aids in healing too.”
The very act of writing, we’ve found, can be transformative. “Write about a time you had to deliver bad news to a patient or a patient’s family,” we suggested after reading Raymond Carver’s poem “What the Doctor Said,” which details Carver’s own experience when he learned he had lung cancer. “What happened? How did the conversation go? How did it make you feel?” We don’t collect the writings, and we don’t ask participants to read out loud—unless they choose to. What matters most is the private encounter between the writer and the blank page. Often the results are surprising. One senior faculty member in the Department of Pediatrics commented on her experience of writing about a patient who was suffering. “I found myself writing about a patient I cared for once in medical school, years and years ago. It was astounding. I hadn’t thought of that person in ages.”
Where does AfterWards go from here? We plan to continue our monthly drop-in sessions. We’ve also begun working in a directed way with smaller hospital groups, such as interns and fellows. In typical Johns Hopkins fashion, we’ve found ourselves growing curious about the effects of our program. The prospect of studying AfterWards in a formal way exposes an important tension. AfterWards is, after all, just that: a space outside of our ward time, where we can let down our guards, feel a little less scrutinized, a little less hierarchical, and, as one social worker commented, “communicate on common ground.” We maintain an intimate, voluntary and private atmosphere to promote freedom of expression. We haven’t surveyed our participants or done assessments of their responses.
But we do want to know more about how our program is working, if for no other reason than to hone and improve it. So we are about to embark on a series of semistructured interviews with participants, encouraging them to talk about their experiences. We have chosen a skills-based approach rather than an outcomes-focused one. As a benchmark, we will focus on qualities such as “professionalism” and “interpersonal skills and communication” as outlined by the American College of Graduate Medical Education. These are listed as core competencies for medical trainees, and analogous accrediting bodies for the nursing profession and others use similar language. Our hypothesis is that through the analysis of a diverse array of stories, songs, paintings and other works of art, AfterWards fosters these skills. The result is greater reverence for patients’ autonomy and their explanatory models, a respect for others in the workplace, and sensitivity to a diverse patient population.
Medicine is about treatment, about drugs prescribed and procedures conducted. It’s also about connecting. With modern-day scans, we can literally see inside our patients. Laboratory methods allow us to analyze the molecular makeup of their organs, their blood. But sometimes seeing into their minds is the hardest task of all.
I lost my head
I must’ve misread what the good book said
Oh woes keep me, it’s a jungle inside
Give myself again ’til the well runs dry
Kendrick Lamar’s song “i” doesn’t mention medicine, doctors or patients. But it tells the story of urban pathologies—mental illness, the war on drugs and the resulting disenfranchisement of many Americans—and one young man’s struggle to find meaning in that context. The day we tackled “i” in AfterWards was difficult. We were still reeling from the uprising in our city. The music video itself was graphic, with vivid images of suicide, drug use and violence. But that was the point: to take a hard look at the pathologies we encounter on a daily basis in our emergency rooms, wards and intensive care units. To ask: What can Kendrick Lamar teach us about our patients? About ourselves?
We may have been too high up in the Children’s Center to hear the children on Baltimore’s streets calling to one another below, but we got a bit closer to them that day.