Ep18 - Narrative Medicine: The Power of Storytelling in Healthcare: Part 2

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 behind modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power. Oh my gosh. When I work with hospitals and institutions, learning how to manage conflict and learning how to do— this is one of the things that I teach. So often when people get in these situations, they're trying to defend a position. You have a position and you're trying to defend it. So like your friend, she was talking about the doctor on the radio show talking about mammography breast cancer screening. That's a position. This is my position. I am going to come on this radio and my position is you don't start mammography until X date. And then you have somebody who calls in and they have a position. I don't agree with your position because I have this story. And so as long as we're locked in positional diametrics, we're not going to get anywhere. But as soon as you start telling stories, you move from positions to interests. And once you move to interests, you start to build commonality. And this is the beauty of a shared narrative, that when you actually can tell a story that has parts, maybe not the whole story, but parts that start to resonate with the person that you are telling the story with, you start to create a trust. You start to create an environment where you're listening. I think that when you are teaching your residents and medical students to go into a room and look at everything, this power of observation that you're teaching them, teaching this on rounds, teaching this with music videos. Is you are showing them ways to find commonality. Because when they look at what's going on in that room, they will find something that will resonate. And whether they realize it or not, they will use that in that interaction. They will use that in the story that they are creating with the patient. That is a much more beautiful place to start a clinical relationship than, this is my position, and then having the patient push back, this is my position, because you're never going to get past that. I also love how you illustrate this so beautifully that so often when you were talking about that, they hadn't really been taught about this idea of creative listening or observation since they were in nursery school. And I would also add to that, I agree with you 100%, is that they have grown up and probably are in some part successful as medical students and residents because they know right and wrong. There's a right and there's a wrong. When you're asking people to do artistic interpretation of any kind, And there is no right or wrong. If you've never been asked to do that, that's terrifying. What's the right answer? There is no right answer. What do you think the story is? And all of a sudden they don't know how to do that. And that's why I think you found the next day they were all coming back to you. You planted that seed in them where they actually had to do creative listening and creative thinking. And that was a completely novel experience to them. And so I love that you use that as part of your teaching, that you are encouraging them To look at the world in a way that's not black and white and right or wrong. And that's only going to enhance what they become as clinicians. One of the things that I also love that you talk about, especially with your background in musical theater and being a producer, is that you feel like doing that deep work, actually creating art for the masses, made you a better doctor, that you were able to build those powers of reflection. So is that kind of part what you're— And giving to your students and residents by encouraging them to look at music videos and approach this process of narrative competence?

Yes, except I no longer attend. So I saw my first patient in 1976 and I saw my last. I still take care of friends and relatives who call me all the time for advice, and I still make referrals for people, but I don't attend on the clinical service. I haven't since 2023. So I don't do that with patients. I do still do morning report though. But again, I don't have relationships with those people. I don't see them sometimes. Some of them I will only see once. But in this class, that is a real chance to have an in-depth relationship, to teach them the powers of what you just said, which is the thing that I love about musical theater is there's no accounting for taste. Like today, my wife and a friend and I were sitting having a drink on patio, and we were talking about the different— and she takes people on tours to New York. And I said, do you take them to Broadway shows? She said, no, I give them a list of the shows that I like. And then we went through the various shows that we liked or didn't like, and we came upon one, a show called Stereophonic, which was a play that had music in it. It's the story of Fleetwood Mac, but it's fictionalized. And it's a 3.5-hour show, which normally I can't stand that long. And it's the story of being a record producer and the tensions between Stevie Nicks and the rest of the band. And I loved it. I just loved it because I have that— I've produced 2 record albums. I know what that looks like in the studio. I recognize those tensions. And there were lots of moments where nothing was being said. It was literally, you were just watching the engineer moving the things, and the musicians were just standing there. And I was like, this is what it's like. This is exactly what it's like. I just loved it.

Wow.

My wife hated it because it was too long and it was too boring. And the other woman didn't like it. I said, oh, everybody likes Terry Funk. I don't like it. But there can be no right or wrong in terms of taste. Even if I say to somebody, you're an idiot if you like that, but there is no accounting for taste. So there's a Latin phrase that one of my friends from graduate school, Bill Keaton, as an economist, taught me, de gustibus non disputandum est. And he used to say that all the time. And that means there is no accounting for taste. And so when things are subjective, which much of medicine is, Much of it is subjective, then you get people to be comfortable with the uncertainty of there isn't a right or wrong answer here. You can't be a doctor without understanding that many times there are dilemmas or there are clinical paths where there isn't a right or a wrong. There is only a preference. And a lot of the times the answer is 49% yes, 51% no, or the other way around. And one of my college roommates is a man named Larry Bacow, who was the president of Harvard for 5 years. And he said, people think, and thank God he's not the president of Harvard now. Alan Garber is, who's also A friend of mine. He, Alan has the same combination of degrees as me. And Alan's doing really an amazing job. And Larry was the president for 5 years. And he said, people think that it was very tough for me to make decisions. He said, the truth is, by the time a decision got to me, the president, everybody had done so much homework that there was not a clear answer. It was always 49-51. And so I said to myself, it doesn't really matter which one of these 2 I pick. Because the call is so close. And that's true in medicine a lot. Like not the randomized trials and the meta-analyses and the clear guidelines. They don't apply to most people. They apply to a lot of people, but medicine is inherently messy and there's more to consider. And that's where storytelling, you really need to be uncomfortable with uncertainty. And you need to be uncomfortable with the fact that there isn't a right or wrong answer here. The number of times that I had to teach my residents, I would often say to them, learning how to be a doctor requires that you have to learn how to have the nerve to make a decision and stick to it. And you're going to be afraid to make the decision. The first time you give pulse steroids to somebody with overwhelming inflammatory disease, the first time you take somebody to the OR for appendicitis and you're not sure they have appendicitis, Or the first time that you commit somebody to a medication with an irreversible side effect. Like, you have to have the nerve to do that. So I'm going to let you make decisions as long as they are not harming the patient, or as long as they're not clearly wrong, because sometimes they're going to make clearly wrong decisions, or as long as they're not going to occur a cost, or as long as they're not going to be painful to the patient. For example, EMGs are very painful. If somebody was ordering an EMG for a reason that was unnecessary, I wouldn't let them do that. And I've also been known to go down to the CAT scan room and pull people out of the CAT scan because they were getting unnecessarily radiated. But I said, as long as it doesn't fall in, even if it's something that I wouldn't do, there is often not a right or a wrong. I'm going to let you make this decision. And I'm going to tell you, I would've done this, but what you are doing is not wrong. Do it. And let's see how it works out. And the look on their faces when I tell them I wouldn't do that, but I'm letting you do it. But you cannot learn how to be a physician if you don't know how to make these decisions independently, because someday you're going to be on your own.

Yep. I have a thing that I do with our incoming interns. That when I first meet them, I tell 'em, I know you don't feel like a doctor yet, but sometime, and probably during this year, something will happen. You will make a decision, you will have an interaction, you will make some type of intervention. And after that intervention, you will see your patient get better, or you will find that you actually did help somebody because of a decision you made. And at that point, you're gonna actually say, oh my gosh, I think I might actually be a doctor. And I always tell them, I want you to come back to me and I want you to tell me the story. When that happens to you, because you'll know it. And it's really interesting because when you first have that conversation with them and they say, they almost feel like you're reading their mind because they definitely don't feel like a doctor and they're all in that imposter status. I'm not really sure why I have this degree, but here I am. And then they realize it's okay, but you will. And these are the things that will help you get there. So I think it's really great how you frame narrative as a way for making people comfortable with uncertainty.

Yeah.

Having that sort of vulnerability that goes with telling stories, but you're also encouraging them to walk out on that, own that story a little bit as you tell it. And that's going to help make them more confident as clinicians as well.

There's 2 flip sides to that. Sometimes they make mistakes. And so periodically I would be walking up the stairs to the hospital and seeing one of the residents saying, hi, how's it going? And they burst into tears. I know exactly why. I bragged them up to my office. I said, tell me your story. And then I would have to teach them that even— I use a baseball analogy— even the best hitter in the world ever only hit .400, like 40% of the time got a hit. How can you expect to be perfect? I know you were taught to be perfect to get into medical school. You're not going to be. You're going to make mistakes. That's why we have malpractice insurance, is because untoward things happen. And then I also teach them how to deal with that. The vast majority of the time they thought they killed somebody. And I would point out, I said, oh, you didn't kill anybody. What happened had nothing to do with you. So that was a lot of it, but sometimes they would make a mistake. And I said, this is what's going to happen. Emily Silverman is really big on that. She's actually writing a musical about malpractice and people making mistakes and shame in medicine.

Wow.

So that's one category. And then there's a flip side to this too. I would often tell my students that I'm going to teach you interactively, which means I'm going to ask you questions. Let me let you in on a little secret. I don't expect you to know the answers to these questions. You're just students. That's why you're a student. You're not a graduated doctor. You're not finished your residency. You're just a student. Don't worry about not knowing the answer. At the end of my career, One of the residents interpreted that statement as belittling them by telling them, oh, you are just a student. And that taught me, I was like, really? That taught me that maybe this is a generational thing. That taught me that somehow that person's expectation was that they knew everything.

Mm-hmm.

And I was like, I don't know everything. And I saw my first patient in 1976. You definitely don't know everything. There's, there are generational changes in their attitudes. There was one kid on Twitter, I think he was from a medical student in St. Louis, who complained that his attending had him shadow him when he went to see patients so that the student could see How he interviewed patients and how he elicited physical findings and how his brain worked in terms of making decisions. This student thought it was abusive. And he wrote, I've been seeing patients on my own for a whole year. I didn't need this guy to make me follow him around to observe him. And I thought, oh man, are you not getting the point?

Yeah. Yeah. There's a humility that goes with learning how to do this, learning how to see patients and tell stories. And that humility, like you're talking about, I've been in private practice since '97 and I, I am learning every single day and I'm actively involved in my process as a learner because there's so much stuff I don't know. This was, and this is so just again, random story, but when I was a senior in high school, they have the big banquet, the awards, whatever. And there was a guy who spoke. I don't remember who this guy was, but I remember this very clearly. A cowboy and an Indian were out outside and on the prairie, and the cowboy draws a tiny circle and tells the Indian, that's what— he draws a bigger circle and says, that's what I know. And the Indian steps back and draws a huge circle encompassing both of the first 2 circles that the cowboy has drawn. And he looks at the cowboy and says, And that is everything that you or I don't know. And it's a beautiful story because it illustrates so well this essence of humility that we carry around with us is really the essence of wisdom. And I think if you give that to people in story form, that if you do find yourself in conflict with a colleague or a patient, as you are telling this story from a humble standpoint, it's like, this is all the stuff I don't know. But I think together we can actually make this better. And the ability to teach humility is hard because you can't really teach humility, right? You can model it, but it's really hard to teach it. And I will say this pretty confidently, unfortunately, at some point that medical student that wrote that tweet's going to get humbled.

Yeah.

I don't think you can go through this educational process to becoming a physician without meeting humility at some point in your career. And I think especially if you have the idea that you've done it all and seen it all as a student. Which is terrifying that at some point that humility is going to come back to you without a doubt.

You should have seen the comments in the tweet. Some of them were like, you're an idiot, and some of them were, you should report that faculty member to the Office of Mistreatment. Like some people actually thought he was right. A lot of them.

That's even scarier. That's legitimately even scarier that people agreed with that. No, no, that's honestly, if someone took me around and wanted to Show me clinical behavior and clinical decision-making as a medical student. Oh my gosh. I was like, thank you so much. Thank you. Certainly would not have put that on a tweet anyway. Before we depart, if you were going to give somebody 2 or 3 things, a couple of suggestions to become a good storyteller, what would you encourage them to do?

That's a good question. So I'll think back to the things that I teach them. First of all, this is me not being humble. Of the 10 students, one of them got her story published in the New England Journal of Medicine. 2 of them got them published in JAMA Internal Medicine. One of them got them published in the Canadian Medical Association Journal, and the veterinarian got her story published in a veterinary journal. So 5 of the 10 so far had their stories published and the course just ended a few months ago. So I was very proud of the fact that they could.

Wow.

You're not supposed to be results-oriented, but like when Anu, it's the same woman who wrote The Leaves of the Canyon, when she got her story accepted by the New England Journal of Medicine, I was like, holy shit, that is amazing. So what did I mostly tell them? To tell a story that's meaningful to them and to use words that people can relate to. So don't use a $5 word when a $2 word will work. Don't use a $2 word when a 25-cent word will work. Tell the story in an engaging fashion that's easy for people to follow and use your own voice because your voice has validity. I once wrote a viewpoint For Kathy DeAngelis for JAMA on something with a medical student, something on medical education. And normally I rewrote all of them so that they were in my voice, but this particular one was written by a student. And even though it was not my style at all, I liked it. It was different and I liked it. And I was co-author. He was the first author. I was the senior author. And Kathy sent it back to me and said, I'm rejecting it. And I said, why? She said, you didn't write this. I can tell you didn't write this. And I said, you're right, but I like the way it's written. She said, all of these viewpoints that you write have to be in your voice. And I said, okay. So we sent that paper somewhere else. And so I tell them like this, I get to know them and sometimes they will read something and I will say, this just doesn't sound like something you would say. Tell it in your own voice. Make it sound like you.

I've, Helped.

I used to have a pre-med mentorship program and I can write the best essay to get into medical school because I've seen 400 of them. And I will sometimes read them and say, this is not what I would say, but this sounds like you. This sounds like what a 21-year-old graduate from the University of Western Ontario who grew up on a farm, this sounds like what that person would say. Or I would say, you copied this, not plagiarized, but you copied a style from someone else. It's just not you. No person like you would talk like that. And they would say, you're right, it isn't really me. And so use your own voice, make it engaging, And then there's some clear devices. I like the 2 stories slamming together as a device and practice it to tell your story. Here's something else that's really always fascinated me. I learned from my attending at MGH in 1976, Peter Yurtdach, who was really big on the oral presentation. That's telling a story. You're telling a story. Not eliciting facts. And he said, all stories can't be longer than 7 minutes. So I have a stopwatch here. Number 2, I'm going to use a dictaphone and record it, and you're going to listen to this after so that you can hear how you told it and how you might tell it better. And so I did that. And students, When I was a medical student, I don't remember whether we were intimidated by that or not, but we did it. And we did listen to it. It was very valuable because it's always embarrassing to hear your own voice, but you would say, oh, I said that. I should have said this. No star athlete ever doesn't look at videos of their own performance. That's what they do. No concert violinist wouldn't listen to their own recording. That's how you learn. Medical students do not want to do this. And so I would frequently say, we're going to tape your— I did this just with the medical students. I'm teaching you how to tell a story. I said, this is the time we're listening to you. This is where you get to shine. Nobody's listening to you when you're not talking. This is your time to show us your stuff. So be good, get good at it. And to do that, I'm going to record you. And they were always like, do you have a phone? Yes. Does your phone have recording? Yes. Turn it on. And they're like, no, I don't want to do that. And I said, turn it on. And I remember once a medical resident, it was a woman, put her arm around the student and said, you don't have to do this if you don't want. And I said, yes, she does. And I said, we are all listening to you now. The only person who's going to listen to this recording is you. You can't be afraid of the sound of your own voice. You will never be a doctor if you're afraid of the sound of your own voice, because you got to talk. And they are like, oh, really? And that is a key lesson in storytelling, which is listen to yourself. Like, you'll get better at it. I'm a way better writer now. than I was when I started. The worst thing I ever wrote was my PhD thesis because it was the first thing that I ever wrote. And I always tell people that. So use your own voice, tell a story that's engaging and meaningful to you, and don't be afraid to listen to yourself.

Love it. Dr. Detsky, this has been a pleasure. You are an amazing storyteller, and I so appreciate you being here on the podcast. If people want to reach out to you, if they have questions, what's the best way for them to find you? My email. Sounds good. We will put that in the show notes.

You have that and you can put it in the chat.

We sure will. So, Dr. Detzke, again, thank you so much for being here. All of you who've joined us today on Scalpel and Sword, thank you so much for your time. And as always, my peaceful warriors, be at peace.

And I second 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.