Storytelling is at the core of humanity, and medicine is no exception. Carrying on the tradition, the Yale community gathered for the sixth annual special medical grand rounds, “Stories of Internal Medicine.”
“Historians have taught us that we’re hardwired as human beings to tell stories and to listen to stories and to appreciate stories,” said Vincent Quagliarello, MD, professor of medicine (infectious diseases) and vice chair for education and academic affairs for the Department of Internal Medicine, who introduced the event.
Since its inception, the event has extended its reach. “Stories of Internal Medicine” has been adopted outside of Yale, resulting in several of Yale’s stories being published in high impact journals including New England Journal of Medicine, JAMA, and Annals of Internal Medicine.
“I think it’s an especially valuable tool in medicine as so much of what we do as clinicians revolves around storytelling, including generating histories of physicals from our patients, grant writing, manuscript writing, mentoring colleagues,” said Quagliarello.
Seven storytellers took the stage–some in Fitkin Amphitheater and some virtually. They told vivid tales from methadone clinics, patients’ bedsides, and beyond.
Zoe Adams, who received her MD and MA in May and is now a first-year internal medicine resident at Massachusetts General Hospital, told the story of a man we’ll call Alex.
Alex had recently overdosed. Adams discussed treatment options with him, including methadone. He was vehemently against it. He didn’t want to be associated with that system, often casually referred to as “liquid handcuffs.” Rather than rehash the clinical benefits of methadone, Adams decided to tell Alex about methadone’s “troubled history.”
“I wanted to use history to illuminate the systems and people that have produced this landscape of inequality,” said Adams in her story. “Alex knew from his own experience that people with addiction were treated as lesser, like criminals, not patients, but I don't think he had fully grasped how big and how intentional it all was.”
She continued, “I knew I didn't have the power to save Alex or even prevent him from dying. I just wanted to create space for rage for context for questions. Perhaps if I could help him identify where his internalized stigma came from and why medications like methadone reinforced it, he may be able to reframe how he felt about himself. He could direct his anger toward systems and structures rather than turn inward.”
“A Prayer for These Hands”
Anita Vasudevan, MD, hospital resident, began her story with a Hindu prayer taught to her by her grandmother. “With the focus on my hand, I set an intention to myself and the universe at large: May these hands do something good today,” she said.
That day, Vasudevan had led a code–responsible for orchestrating a team of healthcare professionals in the resuscitation of a woman. While the team was on the scene, the response changed from full code to DNR (Do Not Resuscitate) and then back to full code and back to DNR. A last-minute request from relatives clashed with prior instructions from the patient.
“‘Revive’ is a word formed of good intention, to give back life so full of hope,” Vasudevan said. “Intentions, however, cannot predict outcomes. And sometimes the process cuts deeper than the product. In this case, the process took away our patient's well-documented agency and thrust a slippery decision into the hands of an overwhelmed family member and the orchestration of this code into my own.”
Nate Wood, MD, instructor of medicine (general medicine), took the audience back to April 2020. Recalling the early days of the COVID-19 pandemic when treatment options were nearly nonexistent, he said, “As a doctor, my go-to tools had been suddenly stripped from me.” From the hallway, he gazed at an elderly patient reminiscent of his grandmother dying from COVID. At the request of the patient’s family, he prayed over her after medical interventions were discontinued. Wood softly sang “Swing Low, Sweet Chariot” to the audience, just as he did for this patient and just as his grandmother once did for him.
“A Dubious Discharge”
Paul Bernstein, MD introduced “Chuck,” a patient experiencing homelessness who was admitted after an alcohol binge. After he was stabilized, it was time for his discharge–into 11-degree weather. Chuck’s family connections were weak at best, and he wanted nothing to do with homeless shelters.
“For two extra days on work rounds we found excuses to avoid the present eventuality,” said Bernstein. “No one on the team wanted to discharge a homeless patient back to the woods after he recovered from an illness that had nearly killed him. The social worker told us she was out of options, and we knew we should send him out.”
“'Out’ did not mean home,” continued Bernstein. Chuck had to be thrust back into the elements with no guarantee his tent would still be in the woods where he left it. An intern was delegated to deliver the news “in the name of education,” a decision that Bernstein ruminated on.
“His gaze told me all at once that he was as emotionally unprepared to deliver this news as he was to evict a homeless man into the cold,” said Bernstein at the end of his story.
“Love Letters from a Mobile Clinic Van”
Koeun Choi, MD, hospital resident, transported the audience to a mobile clinic in South Africa, where a group of men had eyed their van with suspicion while playing poker. Choi’s team’s mission was to encourage HIV testing. Many South Africans are reluctant to get tested because of the fear that comes with knowing–what if I passed it on to my family? In that way, Choi compared HIV to COVID-19. The “love letters” she referred to are not darling notes; they’re letters drawn from the terms for these highly transmissible, deadly viruses.
“We know how it feels to hold our breath around others wondering if it's safe. We know how it feels to wait for lab results to safeguard our interactions–the hope for the single line on the rapid antigen test to give us permission to connect with people,” said Choi. “Those moments of waiting for our own version of love letters brings into sharp focus the universal truth of how much we relish and fear losing our connections with those we love.”
“Night Shift Commander”
Andi Shahu, MD, MHS, clinical fellow, felt like a contestant on his own version of “The Amazing Race,” darting around the hospital answering pages, seeing patients, and writing. He was the on-call cardiology fellow for the night shift. It was his 10th night in a row, and he had two more before a day off.
“I never sit in one place for more than 15 minutes at a time,” said Shahu. “There’s no time to pee, eat, or drink. … Over the proceeding 12 hours, I spoke with many people, many whose names I no longer remember. And yet, the only thing I feel is loneliness.”
Shahu continued, “I've always viewed this as my calling. But I can't keep hurtling like this at full speed for the rest of my life at the expense of my own physical and mental health. The culture of medicine has taught us that we should put our patients first, above all else because to do anything else would be selfish. What's the right balance? When can I be more selfish?”
Abby Jones, MEd, adult geriatric acute care nurse practitioner, hates carwashes.
“Here I am bringing my car and most treasured possession to an establishment that promises shiny and better than new results in three minutes,” she said. “When I'm finally home, I admire my car from a distance, but upon closer inspection, there remains a residue of film left by the hasty rinse.”
The hospital, however, is the complete opposite of a car wash–decisions are nuanced, and treatment is deliberate. When she was a nursing student of the aging and dying, Jones was called in to perform postmortem care. “Just don’t look at the face and it’ll be fine,” she was told. But while they were hurriedly scrubbing the body, she locked eyes with him. That’s when she realized the hospital was more like a carwash than she had thought.
“From a distance our job is complete, but up close, we have done a great disservice,” she said. “... Personhood cannot be lost within the walls of a hospital under the care of a nurse. Nurses must lead the charge and caring for patients passed away with the utmost gratitude and respect. End of life care cannot be cheap, three-minute care. The patient who has just passed must be bathed with tenderness, moved with honor, and spoken about with dignity.”