Peirce Johnston, MD, UC Professor, Clinical Psychiatry and Behavioral Neuroscience
Learning objectives
- Define narrative medicine
- Engage with writing or other forms of creativity that stimulate reflective practice, empathy, humility and self-expression
Assignment: The 55-word story
DUE April 15th
Working with patients and communities, especially vulnerable ones, requires self-care and a reflective practice is one method. As you saw in the readings, one way to reflect is to write a 55-word (exactly, only) story. See the article above.
Your assignment is to write a 55-word story related to a significant experience for you – regarding service, advocacy, your next steps or your past four years… you can choose the story.
How to Write a 55-word Story (From Fogarty article)
1. Think of a compelling story based on your experience (as clinician, patient, other?).
2. Write down everything you can think of.
3. Don’t edit, just write (phrases, words, key chunks of memory).
4. Put it away (optional and can be done at any time between # 2 and finishing).
5. Read over your writing and begin to clarify the idea or storyline that you want to convey.
6. Begin editing, sometimes ruthlessly.
7. Share your work with others for reactions and feedback.
8. Keep editing until you get to 55 words. Use your word counter, and also double check manually.
a. Title doesn’t contribute to word count but shouldn’t be more than seven words.
b. Contractions count as single words.
c. Eliminating articles (the, a, an) can help with word count.
9. If you cannot cut enough words, you probably have material that either would lend itself to
a longer essay or become multiple 55-word stories.
10. Given the brevity, formatting can make a big difference.
Please submit your 55-word story; AND:
(1) Why this story and (2) How you felt writing this story
The 55-word story:
Title: Three Questions
Story:
“¿Por qué vino aquí?” I asked.
“Problemas,” she replied.
I didn’t need more information. Writing asylum cases had taught me what “problems” meant (violence, loss, survival). Before, I only knew where patients came from. Now, I understand why. That day, I felt grateful, both for their resilience and for my growing understanding of the world.
(1) Why this story
I chose this story because I began writing narrative cases for immigrants seeking asylum back in January and it has been one of the most meaningful things I’ve done recently. It also ties into my work at BES, where I’ve spent time translating for patients (in addition to everything I’m doing as a part of my Service & Advocacy Project), which is where this conversation with a BES patient occurred on March 1st. These experiences have deepened my understanding of the people I serve and the resilience they carry. When I first began speaking to patients in Spanish, I always asked the same three questions: Where are you from? Why did you come here? When did you come here? At first, these questions helped me connect with patients, learning about their backgrounds and sometimes finding shared experiences. But after writing asylum cases, I’ve gained a whole new appreciation for their significance. I now recognize how much weight the answers carry, especially to the second question.
(2) How you felt writing this story
Writing this story felt fulfilling. I had already reflected on this moment and shared it with a friend, but putting it into words solidified just how much it meant to me. The woman’s simple answer—”problemas”—held years of suffering, sacrifice, and survival, and for the first time, I fully grasped its weight. I’m grateful for the opportunity to write these narrative cases and to form stronger connections with my patients as a result of this experience. I look forward to sharing this reflection with my boss, who I know will appreciate how meaningful writing narrative cases has been for me.
Thanks, Alec. So much said with so few words. There is resilience, fear, uncertainty, and ignorance on our part of how much someone else has gone through just to be sitting in front of us today. Being there to listen and document is the first part. Continuing to listen is often the second part.
On the phone, she said “If you really tried, maybe he could be himself again.”
We looked at him. Eyes open, mouth open. Not seeing. Not speaking.
“We think you should come visit.”
“Try everything. I’m not ready.”
The nurses watch from the doorway, shaking their heads.
Hospice sounded nice, until death came this close.
I have gone over and over my experience with this patient – it was probably the hardest situation I encountered in my clinical years. I have talked about it, written about it, and just the other day, I googled his obituary. And it still doesn’t feel like I have fully processed it. So that’s why I chose to try it here.
While writing it, I remembered many pieces of conversations that I had with the patient’s POA. But mostly I remember his face. And every time I go back to those memories, they become a little less striking and a little less visceral. I think that’s why I keep going over this patient’s story – because I want to wear it down a bit. It’s working.
Ugh, that is such a difficult situation. As a patient’s family member, there are definitely times where I haven’t felt ready for my loved one to die. But as a medical professional, it’s frustrating to know the outcome and not have people understand. Trying to fight these futile situations only makes working in healthcare more mentally difficult and increases burnout. I think ultimately we have to numb ourselves to these situations somewhat so we can continue on, but becoming too overly numb is also not productive or helpful to our patients. There is a really fine line we have to walk.
Hi Taylor-
The story I wrote about was a somewhat similar situation, with a patient I had who was at the end of their life. My patient however had a relatively quick course, for better or worse. I think it can be so hard for families to understand and face the realities of what hospice means, and I can see how this situation sticks with you.
Wow. Very powerful Taylor. I think it’s amazing the medical field has people like yourself that are so empathetic and feel so deeply for their patients. At the same time, I’m glad you have found some peace in wearing the emotions down a bit, as we can’t let these experiences take too much of a toll on our wellbeing. Well written! I hope you are doing ok with this.
Another trauma? Seriously?
30-year-old pregnant female with a GSW to the chest.
Running with a cooler, following the trail of blood down the hall.
Scalpel?
A life gained, but one lost.
As I sewed the wound we created to try to save her,
I promised myself I would never forget.
I think about her often.
I stayed for 13 hours on this trauma shift, much longer than I had to, especially on a weekend. But it was the first time I felt like I was actually having an impact on patients’ lives as a medical student, and I felt I couldn’t step away from my team when they needed me. I was making things happen. But boy, was that a double-edged sword, because I also felt the responsibility of it all. We had already been dealing with 2 other traumas when this patient was brought in with no call from EMS. I was exasperated, annoyed that more traumas were coming in when we couldn’t even keep up with what was already going on. As soon as I saw her though, the annoyance left, she needed to be here. That day we could only save her baby, but I promised myself that being annoyed or angry cannot be a feeling I have in the moment of taking care of patients. It was a privilege to take care of her in her last moments. I felt so ashamed that I let myself feel that way about someone in their dying moments, and I told myself I would never forget her or what I learned from that experience. This was such a pivotal moment in my medical school journey. I think my attending called me back into that room after time of death was called to show me that sometimes, patients just don’t make it. Even with all the people and supplies and effort, some people die. It was a hard lesson to learn, but it helped give me some closure and helped me move on to take care of the next patient.
Hi Jenna, thank you for sharing your story. You really highlight what it can feel like to have patients coming in when you already feel overwhelmed, but like you explain in your reflection, that feeling can quickly go away when you realize the patient in front of you is a real person and not just a bunch of notes and tasks that need to be done. Having this perspective is so important, but I know I am guilty of losing the perspective sometimes when things get busy. I also appreciate your reflection on the loss of life; my story as well centered around this, and I know it is a very complicated topic to grapple with. I think it will be easier overtime to deal with the loss of life we see in the hospital, but at the same time, I think it is important to still feel the loss – otherwise, it can be easy to lose the humanity in medicine.
“Are you giving up on him?”
Her husband was dying, imminently. A code would only made him suffer.
“Are you giving up on him?”
Did transitioning to hospice mean giving up? Was I advocating to just let her husband die?
“Are you giving up on him?”
The words haunted me as she signed the DNR.
The weight of caring for everyone else almost got you
Thankfully, you are alive and healing
I was able to educate you on stroke risk factors
And remind you how much your community needs you
Even amid your storms, you encouraged me
You told me I was meant for this work
You trusted me
Why this story?
I remember this being the second stroke patient I was carrying during my internal medicine clerkship. I felt deeply connected to both patients I cared for because I saw my father in them: they were African American males in their 50s experiencing their first stroke. Despite it being a frightening experience, both patients were able to return to baseline. My father has an extensive CVA history that has largely impacted his quality of life and our family. In a way, I felt a sense of duty to educate these patients about key CVA risk factors and lifestyle modifications and equip them with the insight they need to prevent future strokes. I deeply wanted them to have a better quality of life than I’ve witnessed my father have after multiple strokes due to poor blood pressure and cholesterol management.
How did I feel writing this story?
Somewhat nostalgic? This rotation was almost a year ago and I truly believe it to be a privilege to sit with patients in these life-changing moments they experience. Third year can certainly come with momentary feelings of inadequacy.. so to have the patient see something within me based on our interactions was very empowering and affirming that medicine was the right path for me!
“You should make the call.”
“What?”
“You’re taking care of her, you’re going to be a doctor, you should make the call.”
—–
“Hello, I am taking care of your mother. Things have worsened over the last hour; and you should probably come.”
“How soon?”
“I can’t say, but you should probably start driving now”
1) Why this story?
I chose this story, because it is the first time I have ever had to be in charge of a “difficult” conversation. I had taken part of plenty during my time as a 3rd year, but as a fourth year AI, I hadn’t realized it would be up to me to call family members, update them on the precarious status of their loved ones, and lead end of life care decisions. I hadn’t ever before told someone their loved one had, at best, hours left. I think this particular situation will always stay with me, because it was my first time being “in charge” of a case like this.
2) How you felt writing this story
I felt almost bittersweet writing this story. It was an incredibly incredibly difficult conversation, and not one I looked forward to at all. However as difficult as it was, I think we were able to give the patient the ending they would have wanted and the family was able to get to the hospital in time to say their goodbyes.
Grace – thank you for sharing such a powerful memory. I think that every time we are faced with our “first” anything, it holds even more weight and that we carry it with us for a long time. I like that you mention that, despite how difficult and unenjoyable these kinds of conversations are, they mean the world to the patient and the family in enabling the best ending we are able to offer. These are some of the most important moments and memories that a family will have, and how we handle them is so important.
Rice, meat, Mirinda
Rice, meat, Mirinda
Rice, meat, Mirinda
And then another.
“She just took an extra drink. What if we don’t have enough?”
I stepped forward to confront her. Eric held me back.
“It’s not a big deal. We can always get more.”
For Ugandan grandmothers who had nothing, one more drink was everything.
AND:
(1) Why this story
This was en encounter I had when I was studying abroad in Uganda. We were working at a rural clinic helping impoverished grandmothers learn how to sack garden as an alternative income. At each sack garden workshop, we catered full meals for the grandmothers or jajjas. This included mixed vegetable rice, meat, matooke, and Soda. One particular instant I remember feeling irritated that the grandmothers were acting “selfish.” However, taking an extra drink in the grand scheme of things was so inconsequential, especially when the grandmothers rarely get big meals and were most likely malnourished. Not everyone had grabbed a drink yet. How could she get 2? However these grandmothers didnt have anything, they were struggling to raise their grandkids whose parents had passed with AIDS. They saw a lot of food for the first time and only took 2 drinks. I should have been shocked more people did not.
(2) How you felt writing this story
I think it felt refreshing to reflect and admit to these feelings. I held on to a lot guilt. However, that was not productive. Coming from a place of privilege the way I and my group of college students viewed food way differently than the jajjas. We had ready access to food and were using our funding to provide meals. However, the Jajjas were just struggling to get by so it made sense to take more food when they could. Also our coordinator had originally told us we could get by with just serving a chapati for food rather than a whole meal because that is what the jajjas were used to. rather than save money on food, our group decided to pay for meals. Perhaps that was poor oversight on our part. We could have used money to pay for more teaching sessions and gotten more seeds and supplies for farming. Overall, it was a valuable lesson on how difference in wealth and values can manifest in our actions. Next time, rather than be judgmental, I hope to approach from a place of wanting to understand.
Pooja – I think you and Jenna touched on the interesting aspect of our own human responses to situations and the guilt that can come with that. You are right to reflect on it and use it as a lesson. Our immediate responses can reveal biases that we did not know we had and I think the best way to combat a bias is to simply see it, acknowledge it, and question its validity. We are always going to have reactions to patients and those reactions will be colored by our own lives, patients we’ve seen before, and the level of burnout or fatigue we’re feeling. Being open and curious about our gut reactions will get us far.
“I can’t live like this”
Bacterial pneumonia superimposed on flu A in the setting of end stage COPD, with persistent hypercapnia despite BiPAP
“I feel fine, the mask is uncomfortable, I don’t want to wear it anymore”
pCO2>100
“I wouldn’t want a tube down my throat”
“Why is this happening”
“What else can you do”
1) Why this story?
For me, I struggle with situations where I feel like our ability to fix the problem is limited, which is part of why I’m drawn to surgery. This story is embodies the numerous times where I have felt helpless as patient’s confronted the reality of progressive medical conditions that cannot be easily reversed or improved. It is so hard to feel like I cannot help, when there aren’t satisfactory options, that end stage COPD does mean end stage. I spent a lot of time with this patient and her family, helping them to understand the disease and what exactly was happening. A lot of snippets of those conversations have stayed vivid in my memory. I think that this story in particular, during my medicine AI, was one that really drove home why adult hospital medicine can be so emotionally challenging. Since I spent so much time with this patient over the course of two weeks, I think that I experienced her and families process of grief much more deeply.
2) How you felt writing this story?
Sad, conflicted. Her face, her family, the conversation felt very clear. I feel grateful that I was able to be in a position to take the time to spend with the patient and her family to really talk through and answer all their questions, to help them understand the disease and what was going on, but sad for the situation. Writing the story was cathartic in putting down the words that have intermittently floated around in my head since. I like that the 55-word story condenses a significant memory into just a few, key defining moments.
Hi Mary,
Great narrative, and I think it’s so relatable. Progressive medical conditions are so hard, because even with the perfect “guideline directed treatment”, the condition will continue to progress, which is certainly frustrating. I think the beauty of it is in what you talked about though, the complex discussions you can have with patients to help them understand their conditions and help them process their thoughts and feelings. Despite not being able to medically cure them, you can certainly help alleviate their mental burden or distress by taking the time to talk to them, which I’m sure your patient appreciated of you.
Cold hands, a face etched with fear, a frail body tired from months of pain
Surrounded by conflicted specialists and a worried family.
“You will take care of me, right?” she asked each time I left
Her memory stays with me, and the grief I experience when medicine can’t heal pushes me to work harder
I chose this story because it’s a story describing one of the most patient painful losses I have experienced. After building close with relationship with a patient and strong rapport with her family, medicine ultimately could not save her from her condition. She will always remind me of the importance of providing emotional support and human connection to a patient in addition to medical management. Additionally, her story reminds me of the importance, and that advocacy can change at different times–whether it is deciding a treatment plan, uncovering new details of a patient’s health, asking questions to specialists, figuring out how a patient will afford a medication, or simply listening.
This story sparks grief and sadness, but I don’t shy away from those feelings. As a physician, I never want to become desensitized to negative patient outcomes but instead remember them and use them to inform my approach with the next patient. I think it is important to constantly participate in self reflection and to always be willing to improve.
Krysten,
Your story was very moving. Grief can sometimes be so all consuming during moments like this, but I am so glad you are able to use it to remind you about the importance of connection and advocacy as you go forth in your career.
I agree that I also do don’t want to become desensitized to negative patient outcomes. I find that doing activities like this works to deconstruct some of the desensitization that has been slowly growing in the background for years. Self-reflection is a beautiful, powerful thing.
Walking into the room, I hear subtle sobs in the background.
“I can’t go on like this. I’m doing the best I can. I just want my baby to be healthy again.”
The desperation is piercing in her gaze.
At a loss for words, I sit beside her and listen as she unburdens her soul.
(1) Why this story
I chose this story because it is one of the moments that I swore I would never forget and was so moving to be apart of. It was so powerful to provide emotional support of someone who was going through one of the toughest moments in her life.
In medicine, I think we often look to ‘fix’ things. We can refer to psychiatry or start a new medicine if a patient is struggling with their mental health, but this instance showed me that there is often just as much power to being with and listening to people.
(2) How you felt writing this story
It was very moving to be able to write this story. While I always try to remember this moment, I’ve never attempted to relive it in such a manner. It was powerful to readdress the moment, the emotions, and the lessons I learned from that time in my life.
Amanda, I appreciate your story. I think you shared a common experience by physicians–wanting to comfort your patient but not knowing how. Listening is crucial and even therapeutic in these moments because it helps patients feel supported and cared for even though you are unable to solve their problems.
New admit, we’re giving this one to you.
“Sounds good”
Hep B positive. Enzymes in the 1000s. Continue to rise. Treatment started, mild improvement.
On day 3:
“He’s not responding well to my questions”
Not a good sign.
“Will he get a transplant?”
Not a candidate
“He’s so young”
But there’s nothing we can do.
Why this story:
I chose this story because it was my first patient death as a medical student. Beyond that, it was also the first time I saw the ethics behind deciding who can or cannot be a transplant candidate. This was a very young patient that I got the know over the course of a few days. At first he was doing fine, but a few days into his admission his mental status began worsening acutely. Due to some aspects of his social history, he was disqualified from liver transplantation candidacy despite the cause of his liver failure being acute hepatitis B rather than substance use. It was the first time I truly felt helpless when it came to the care of a patient. We were treating him according to the guidelines, but we all knew the outcome was likely death without a new liver, however there was nothing we could do. It’s a patient encounter I’ll never forget.
How I felt writing this story:
I think about this patient encounter from time to time. Writing the story brought back some of the feelings I felt back then such as sadness and frustration. I initially felt that it was an extremely unfair process for us to just sit there and watch the patient die. I think after a lot more experience, and time to digest the case, I understand why transplantation candidacy can be such a difficult decision to make for the committee. After all, there just are not enough organs for everyone on the list. I don’t think that feeling of frustration or sadness will necessarily go away when I think about this case, but I’ve come to understand why the outcome ultimately occurred.