EP17 - Narrative Medicine: The Power of Storytelling in Healthcare

In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, Explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power. Hello, my peaceful warriors. Welcome to the Scalpel and Sword podcast. I am your host, Dr. Lee Sharma, physician and conflict analyst. And I am so excited to have on the podcast today, Dr. Alan Detzky. Dr. Detzky is a physician and also an expert in health policy. His initial training was in economics. He graduated from Harvard Medical School, and he got a PhD at the Harvard-MIT Program in Health Sciences and Technology. He has been the physician-in-chief at the Mount Sinai Hospital in Toronto, and he is currently professor and clinical investigator at the University of Toronto Department of Health Policy, Management, and Evaluation. In addition to this, he also teaches a class in narrative medicine at the University of Toronto. And in addition to all of these amazing accomplishments, he has also been nominated twice as a producer for a Tony Award of 2 musicals, Jesus Christ Superstar and Come From Away. Dr. Detsky, it is an honor and a pleasure to have you on the podcast today.

Thanks for having me.

So we were talking before we jumped on the recording that the reason I had reached out to you Was because there was an op-ed piece in the Journal of the American Medical Association a couple of weeks ago that was written by one of your students that had taken the narrative medicine class that you teach at the University of Toronto. And she had written so beautifully about how this class had positively impacted her. And narrative is one of those things that I think we all assume we know how to do. We think we all know how to tell stories. But I think in the context, especially of the practice of medicine, but also in terms of conflict resolution, It's a vital skill. What got you into being interested in narrative medicine?

I started out in my career as a clinician scientist. I have a PhD in economics and I'm a general internist. And so I was hired into 2 departments at the University of Toronto. One was originally called Health Administration and then went on to become Health Policy Management and Evaluation. And that's where I have my tenured track position. And that's where I do a lot of my research through my course and the courses that I teach. But then I also was a general internist and very much viewed myself as a doctor. So I was cross-appointed to the Division of General Internal Medicine, first at Toronto General Hospital. And for 7 years, I was a clinician scientist. I did what scientists do. They write grants, they get grants, they don't get grants, they do the projects, they finish them, they write papers, they get the papers published, they don't get the papers published. I was on the traditional track of doing that. And the amount of medicine that I did was 3 months a year on the medical consult service, taking care of some medical problems and surgical patients. And then about 7 years into that, the chair of the department at U of T decided to make me the division chief. And he wanted me to develop the division. This was 1987. General internal medicine in Canada was Really almost dormant in that period. Most people were subspecialists. There were very few general internists. It was a thriving specialty in the United States dealing with primary care and war medicine, but in Canada, it was mostly subspecialty medicine. There were some excellent general internists, but there was no real training program in that. So when I started to take on the job as the division head, both for the university and the hospital, In Canada, you have no credibility as an administrator in a department of medicine if you don't have clinical credibility. You have to be a good clinician. And 3 months on the med consult service didn't cut it. So I expanded my clinical to include 3 months of med consults and 3 months of team medicine while I was the division head. So I did 6 months of attending. While I was the division head, both at the university and the hospital. And then in addition, because of my role in economics, I was like the managing partner of the group. We had a group of about 150 physicians. We had an economics plan and the chief of medicine seconded me to help run that financially. Well, at the end of that 9 years, a job came open as the physician in chief at Mount Sinai Hospital. And I applied for and got that job and we merged our groups together. So we became one department of medicine on 4 sites, 4 hospital sites.

Mm-hmm.

And I continued to do 5 months of team medicine attending while I was chief of medicine, which is a lot. And so when you get to do that much medicine and that much administration and that much research, you see a lot of humanity. You see a lot of stories, you see a lot of things happen. I was always surprised that at any given moment, especially when I was chief of medicine, my door was always open. Somebody could walk in at 5:30 in the afternoon on a Friday and lay something on me that would take 10 minutes for me to solve or 3 years for me to solve. I was always like, Didn't see that coming. So most of my writing was research, but in 2007, JAMA hired a group of 11 mid to senior career researchers to write op-ed pieces as something called contributing writers. So we were on the masthead, we were appointed to JAMA, we got paid, it was not very much. And our task was to write somewhere between 4 and 8 op-ed pieces a year. Kathy DeAngelis started this and here were the rules, which as a researcher, I just loved. They said, first of all, you pick the topic. Second, it's an opinion piece, so it doesn't have to be balanced. Third, we don't want any new data. So we don't want to be adjudicating veracity or accuracy of data. And it has to be in your voice. So those are the rules. I was like, no new data and doesn't have to be balanced and I get to write it. Like, shoot me. Like, good. Perfect.

All day long.

Yeah.

Yep.

And so along with that, I started to write in. I had written commentaries before. So because I have a broad range, topics were economics, they were clinical epidemiology, they were about patient care, they were about hospital care. There were a lot of different stories that came out, and JAMA has a section called A Piece of My Mind, published narratives. And so I started to write stories because some of these pieces didn't quite fit the viewpoint or commentary view. One of the first stories I wrote was a story called My Father's Voice, which was a story about contrasting what happens to young people and old people when they get really sick. And my father had an expression. He used to always say, young people might die, but old people have to. And that was the punchline of a story of 2 extremely sick people. One was young and one was old. The younger one was much sicker than the older one, but the older one died and the younger one didn't. Or I wrote a piece on my own PSA test and how That led to the value of reassurance, even though PSA was controversial at the time and it didn't change my life at all. And then I started to write other pieces with other authors. I wrote a story using Kafka's Metamorphosis as a metaphor for what it's like when physicians get sick, how you get trapped in your own cockroach and you become your own cipher. Which is the term that he used. And then I started to write stories about Miró's triptych, about dots and lines. Like, when you see dots and lines, is there a story here or isn't there? The same thing in medicine. When you see 5 different clinical findings, your tendency is to link them all together in a unifying diagnosis. But sometimes different findings have nothing to do with each other. COVID added a lot to that. Wrote a story called Le Petit Prince, which was a takeoff on that book, the metaphor for COVID. My absolute favorite is a story called The Hockey Stick, which is a young patient of mine who had sarcoma, terminal sarcoma, was dying. And I took over his care and he didn't want anything to do with anybody because he was sick of getting care. And so I had to find a way to connect with him. And I knew he had played minor league hockey for the Kitchener team about an hour away from Toronto, a minor league team. And so instead of medicine, I started to talk about hockey. And I said to him, what's your favorite team? Are you a Toronto Maple Leafs fan? He said, no, I'm a Tampa Bay Lightning fan. I said, you're from Kitchener. Why are you Tampa Bay? Oh, my favorite player is Steve Stamkos, who at the time was the captain. And then out of my mouth came words that I didn't expect, and he certainly didn't expect them. I said to him, would you like to meet Steven Stamkos?

Wow.

Like, yes, I would. And so I got him tickets to when the Lightning came next and the staff at the stadium treated him like royalty with his family. It turned out that Stamkos was injured and didn't make the trip up to Toronto. So he didn't get to meet him. He did get to meet him later. on a Zoom call, but his agent sent up a hockey stick and it was a story about how when you can't cure somebody's sarcoma, sometimes you can still do something that's fulfilling to them and you. And so that's, of all the stories I've ever written, that one is my favorite. And then about a year ago, my chair said, would you like to teach another course? I teach a course in health economics. I teach a course on how to write a paper that'll get published research. She said, we'd like you to teach something else. Would you like to teach? And she gave me some, some stuff. And I said, what I really would like to do is teach a course in narrative medicine, which is how to tell stories. Because you can tell from listening to me, I am a very good storyteller, even if I say so myself. I love to tell stories. And she said, oh, that'd be great. And we launched a course. I had 3 junior faculty who said they would help me, but really only one of them was able to because the others got too busy. So there was me and a woman who was a urologist who had taken Rita Charon's narrative medicine program at Columbia. Rita was a classmate of mine in medical school. So I knew, and we launched a course in last October that was going to last, it was a one semester course, but it lasted over the whole year. So we met about once a month. And 10 women signed up and me and was the teacher and Sarah. So there I was, me and 11 women. We talked about what narrative medicine is. How do you tell stories? We read stories. We gave examples of ones that I thought worked really well. I gave them some of the structures that I loved. One of my favorites is to take 2 separate stories and weave them together and have them come together at the end. That's a dramatic trip. I like to have something where you start at the beginning and then it's the last words. Basic tricks that I use in my writing. And Sarah had her own experiences as well. And we involved Emily Silverman, who runs The Nocturnist, and she did a session for us over Zoom. And the students really got into it. It was like It was, they didn't know each other to begin with. Like it said in that article that the 3 women wrote, Priya, Fiona, and Anu didn't know each other. And they were very nervous. And some of them thought, this is gonna be easy because there's no facts that I have to know. And some of them thought, this is gonna be hard because I'm gonna have to talk about my feelings. And also Canada's a bilingual country. So some, there was the French Canadians who sat in one corner and talked to each other in French.

Mm-hmm.

And one was a veterinarian. They They were all different fields in medicine. One was a nutritionist, and we just started to read the stories, talk about what they evoked. And the other technique that I use is something that I developed during COVID called the music video. And I take it for my clinical team, I would take 3 to 5 minutes a day to play a music video. Usually something from musical theater because I have a background and a side gig in musical theater, as you pointed out before. So I will pick a Tony presentation that's particularly good or a vocalist who's very good or an actor who's very good and show a video, or I'll take a pop song or I'll take an indie song and show them videos. And I use those as teaching them the powers of observation. In my clinical teaching, one of my sessions always was, let's look at the patient and tell me what you can discern about this patient from looking at them and everything that's around them. What does their hair look like? What's in the IV bag? Are there shoes next to the bed? Do they have a G-tube in? Is there oxygen next to them? Is there a bar above them for mobility? Does the chair look like it's ever been sat in before? Are there cards and flowers from family members? Like you can tell a lot about people from observing them. So I use that technique in the music video and I would ask them questions like, how do we know that the young girl in this video and the old girl are the same person, just at 2 different points in time? The answer is they were wearing the same red dress. What's the theme? And I have some favorites. For example, my favorite rock song is Hotel California.

Yep.

And I think people usually say it's the 6th best rock song. For me, it's the best. And like, the lyrics are just so interesting to try. What does this mean? It's not a hotel. And when at some point after 2 or 3 times when it became clear that being the only man in the room was making the dynamic interesting, I said, I often give people a nickname and maybe it was the 2nd or 3rd session I said, You women are the ladies of the canyon. And they of course had no idea what that meant. One of the next music videos we used was Joni Mitchell. My favorite albums, vocalists from— I was born in 1951, so I started college in 1969. And my favorite musical artists were, and I'm Canadian, were Joni Mitchell, Gordon Lightfoot.

Yep.

James Taylor and Simon and Garfunkel. I'm a folk rock kind of guy, and Joni and Gordon are at the top of that list. They had never even heard of Joni Mitchell, which was also funny, but they got really into it. And as I pointed out in that article, they started to learn a lot about each other. They talked to each other a lot in between the sessions. And one of the most important things that I teach all of my residents is Call people by their names. When they answer, this is cardiology, say, what is your name? And the reason you want to call people by their name is, first of all, it personalizes it. Secondly, if you want to find that person after, you need to know who they are. Like just today, I had a medical student that I arranged a consult for with a surgeon. He told me what happened. And I said, who was the surgeon? He said, I don't, I don't remember his name. I was like, how could you not know his name? Like, how are you gonna come back to him? So calling people by their name and they really picked that up. At least one of the students in the class had been my resident before. Anyway, that's how I got into narrative medicine.

Wow. There is so much that just in what you've talked about in terms of your journey into developing this class and what led you to develop your wonderful storytelling ability. There's so much I want to, even just what you just said, I want to talk about. But one of the things I kind of want to start with in terms of the story of the hockey stick that you had a patient with whom you were having difficulty communicating and clinically reaching. And rather than just pounding or even creating a power dynamic or saying, I'm the physician, I know what to do, whatever, you found a way to use a story, to use narrative. And in using that narrative. You created an atmosphere where that patient felt comfortable and was able to work with you and be your partner in their care. One of the things that you talk about in terms of this class, and also I think in your writings with narrative medicine, is the concept of narrative competence. And I think that's one of the things that's so beautiful about this class that you taught is, like you said, you are a storyteller. You love telling stories. But I think there's so many parts to the way that you tell stories. That really do help people understand that it's a skill that even if you're good at telling stories, that we can get better. One of the things you also mentioned when you talked about the story with your PSA that you wrote for JAMA is the concept of transparency. There is a vulnerability that goes with being a storyteller. And I think part of what we do as physicians and also using narrative to reach and develop And I think that's one of the things in the JAMA article that really came through to me is that you were able to communicate that to them. And there's even a part in that JAMA article where the veterinarian, I think, is writing a story and she's talking about having to deal with family members and the other people in the room were tearing up, even though she's talking about cats and dogs. There's a resonance that occurs there. As you've taught your residents and medical students about narrative and narrative medicine, do you see them becoming more transparent and vulnerable? As clinicians?

Yes. The music video experiment was really one that taught me a lot about how they handle this. Because first of all, I always like to work. I was never a 1 or 2 weeker until the very last retreat I attended.

Oh, wow.

Last retreat I attended was 2023, in which I agreed to do 3 weeks instead of 4. But I always wanted to do 4 weeks so that you could develop relationships. The idea that you can work with somebody for 1 week and actually get to know them is ridiculous. I said, I have standards. I don't care if you like me. I want you to like me, but I want you to learn something. And you know what? If you're not buying what I'm selling, that's okay. I would teach them, this is how you do an oral presentation. And because these are the key pieces of information that you want to communicate to the other listener. And things like, who takes care of this patient when they're not in the hospital? Who's their ongoing primary care doctor or their ongoing specialist? Residents had no idea why that was important. And I would have to explain to them. Why is that? Because I'm going to talk to them and tell them that their patient's here. To find out information. And after they leave, they're going back to that person and I want to know who that is. That kind of discontinuity of care that our trainees were exposed to really bugged me. So I always like to work with them for a month. And during COVID when there was a lot of crazy shit going on, I said, why don't we just try and break the tension? I'm now only learning about meditation and mindfulness. But this was my version of mindfulness, as if I invented it myself, which I didn't. And I said, we're going to just watch something. It's going to not be about anything about medicine. I want you to put your phone down. I want you to take your to-do list and put it on the table. I'm going to turn the lights out and all we're going to do is watch the screen and you have to let go. Do you know how hard that is to do? To a team in the middle of the day, at the beginning of the day or the end of the day. Sometimes I would do it in the morning and sometimes I would do it in the afternoon. And when I first started to do this, the tension in the room was palpable. It was like, what do you mean? We've got stuff to do. We're busy. We have to be out by 10. We have stuff to do. And I'm like, I don't care. Let it go. And then I would watch them. And over time, like the first day it was like, what is this crazy shit going on here? And then over time, I would say 80% of them, I could see them, their eyes were going to the screen and their hands were down by their side and their phone and everything was, they weren't touching it and they were just looking at it. And then There would be 20% of them who just couldn't do that. They just couldn't let go. They would be clutching and they would be, sometimes it was the fly-in person who was just there for the night. But after 4 weeks, really after 10 days, a whole group of them would go, what's the music video going to be today? Like, how are we going to let go?

Yeah.

Oh, this is enjoyable. Especially We in Canada have, we have internal medicine residents and we have what are called off-service residents who are from other specialties who aren't really, they're just there for a whole lot of reasons. A lot of it is work, just getting the work done. And a lot of them were like, this is the best part of the day because it's not medicine and it's something letting go. And I had one experience that really taught me how sometimes you just Don't know what's going on in the room. I had what was called a junior attending who was the attending between me and them, and then I rounded with him. But I had several sections where I would teach with them alone, because if I was always in the room with the junior attending, then they would defer to me. And I, and I wanted him to have that experience, or him or her.

Right.

So I did one, it was with a man, and I said, what do they want me to teach? And they said, why don't we try the music video? So I brought in Hotel California. I played it for them. I played them with the lyrics and I said, there's a story here. What is this story? What does this mean? And of course, people have been debating what Hotel California means for years. And even the people who wrote it, Don Henley, they've never told us what it means. Which is like the Talmud. And the room, we stopped and I said, what does it mean? The room was completely silent and no one was willing to volunteer what it meant because they had never been asked a question like this since nursery school. These are all medical student types. They were so uptight.

Finally.

One of the women, she was a family medicine resident. She started to translate it line by line. She said, this line means this and this line means that. She wasn't getting at the whole story, but at least she was at a try. And I was like, okay. I was trying to encourage. The other thing that I did, which my wife said is impossible, is I didn't say anything. I just said, what does this mean? And I sat there and the room was silent. For quite a while before this woman spoke up. I didn't try to prod them. And at the end she did that. And then none of the others had anything to say. And the 45 minutes were up and I said, and then I told them what I thought the song meant. And I walked outta the room and I said, that didn't work. That was a plus. And I was trying to figure out what didn't work about it. And I thought the reason was that I didn't really know this group. The junior attending knew them. I only knew them peripherally because I had only done some sessions with them. They had met me, but I wasn't really their preceptor. The junior attending was. I'm going to have to do that with a group that I know well. And then the next day, the junior attending comes to my office and sits down, plunks himself down and says, my wife and I played Hotel California on our phone last night. And we spent about 35 minutes trying to figure out what it meant. And I was like, oh, okay. At least you were provoked into doing that. And then he said, and the senior resident said to me this morning that the residents and students that missed the session because they were post-call or in some other session heard about it and said to her, can you get him to do it again? So I called her up and I said, Really? They want me to do it again? And she said, oh yes, I was all night long. I was thinking about it. What did it mean? And this morning when we came in, we weren't talking about the patients. We were talking about what does Ocala, California mean? I said, wow, you never can tell what's really working. And so you can get people, everybody has stories.

Yeah.

You just have to bring them out of them. The person who taught me the value of storytelling in her writing was Louise Aronson, who is geriatrician at UCSF and writes for— she was temporarily an associate editor at JAMA Internal Medicine in charge of a section called The Inside Story. And she once wrote a story in JAMA called The Power of Storytelling. And it was an anecdote about radio show where there was a very smart clinician talking about women and breast cancer screening and how screening too early leads to lots of false positives and mutilating surgery and how the science shows that you shouldn't start until some age. Everything was going really well until some woman phoned in and said, you killed my sister. Had breast cancer and it was found by mammography at the age of 38 and it saved her life. You're a monster for telling people not to do it until whatever age she said. And from then on, every caller who called in attacked the scientist and didn't let her talk. And Louise said what she should have done was told her own story about a 38-year-old woman who had mutilating surgery for her breasts because she had a false positive as the counter-narrative. How stories, it was a very powerful story, which I've used a lot. And I also want to give credit for the idea that I got for the hockey stick. I didn't make that up. There was an article written in New England Journal of Medicine called The Psychocatalytic Effect of Shocking People. And it was about how when you can't get through to your patients talking about what you want to talk about, say something that's completely outrageous that they're not expecting.

Hmm.

And it will shock them and they'll suddenly talk. So I knew this, this kid had his, like the sheet was over his head. He wouldn't even show me his face. And I knew if I said, would you like to meet Stephen Stamkos? That was the psychocatalytic. So I've used that technique many times. When you can't get through to somebody on what your agenda is, just find out what their agenda is and go for that.

Every episode is an invitation. To speak, to negotiate, to choose. I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional. Thank you.