Sunday, March 1, 2009

Narrative Medicine

Ms. Smith is a Caucasian 68-year-old morbidly obese (400+ pounds) woman being treated for congestive heart failure. She takes short, labored breaths, and has symmetrical pitting edema in her legs.

Ms. Smith cannot get up to move herself to sit on the bedside commode, so the petite Chinese nurse leaves to request additional help. As the nurse exits the room, Ms. Smith turns to me and says, "She can't do this by herself? What are they paying her for?"

Ms. Smith's father was an abusive alcohol addict. Ms. Smith divorced her husband about 30 years ago, after she discovered that he had cheated on her, the first clue being the gyn's diagnosis of chlamydia and gonorrhea. She had had a hysterectomy at age 28, due to a prolapsed uterus, following birth of twins. When she announced her intentions to divorce her husband, he said, "I wasn't going to stay with you, anyway. I wanted more kids, and you can't have any." Ms. Smith's ex-husband recently died of a stroke, following surgery for prostate cancer. Ms. Smith says "I am glad that G-d let me see him in such pain in my lifetime, the bastard deserved it."

Ms. Smith never leaves her house, but a kind neighbor drops off some groceries about twice a month. She has no relationship with her children or grandchildren, for reasons she did not specify. She has no plans to improve her life (her one pleasure is "spraying her sheets with perfume," which reminds her of the way her mom smelled, and provides an "aromatherapy" feeling). However, she does faithfully take her 13 medications every day.

I asked Ms. Smith what she had to lose by sending her grandkids Christmas or birthday cards. If she didn't have a relationship with them, the worst thing that can happen is that the situation remains the same. Ms. Smith, bitter during most of the conversation,lightened up during my blunt challenge. "Yes. That is true. What do I have to lose?" Then her smile faded. "I just don't think I'd be able to deal with the rejection."

In many ways, I'm privileged to work in a hospital; For better or worse, I get to witness and learn from other people's life mistakes. This is a woman who spends the overwhelming majority of her day watching TV in her bed. It would seem to an objective observer that a genuine attempt to live in any different way ought to be wholeheartedly embraced. Ms. B is not afraid of death ("I'm just waiting for God to take me, when he wants to take me"), but is utterly panicked about sending a Christmas card.

When I see situations like this, I realize just how irrational it is to be nervous about contacting an old friend or putting up an inarticulate blog post or do anything else, for which I might be judged. I see the ultimate futility of caring too much about what other people think.

I suggested an alternative for Ms. Smith- perhaps she can keep journals, which her granchildren could one day read. Ms. Smith started to ramble excitedly, "Yes. It could by my legacy to them. Something for them to know me by...It won't get my voice inflections...but I could still give them advice..make sure they don't make the same mistakes. I can tell them to always stay celibate. That is the only way to stay safe."
I've recently read about "Narrative Medicine," a movement pioneered by Rita Charon, in which patients, even (especially?) those in palliative care, write and reflect about their illnesses. To me, the narrative medicine is particularly seductive, as it provides opportunities for doctors to inculcate values in which they're often criticized for being remiss- empathy, consideration of the "whole" patient, and integration of other fields- all without sacrificing a commitment to evidence-based medicine.

The evidents suggests that narrative medicine may help mitigate pain, or even increase survivorship and longevity. Promoting science-based medicine is not in conflict with recognizing the bio-social-psychological model of medicine, nor realizing that the effects of, say, loneliness can discernible physiological consequences.

I had no major suggestions that were acceptable for Ms. Smith, on how she could perhaps improve her life (Therapy? No Nutrition Counseling? No). She will likely remain alone for the rest of her life. However, she might punctuate her TV-viewing with journal keeping. So, maybe I've my part to ensure Ms. Smith's lasting legacy.
I wonder when I'll start recommending to all the lonely seniors that they ought to start blogs.

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