At the annual “Stories of Yale Internal Medicine” Medical Grand Rounds, memories shared create a space for reflection, where a person can leave thinking about the human experiences that have impacted them most in their career.
This year’s grand rounds celebration was no different. The theme was physicians sharing their perspectives, and putting themselves in someone else’s shoes. Some put themselves in the shoes of their own patients and of patients in general. Others, in the shoes of physician colleagues who are back home in a country where poverty reigns, whose lives could be in danger just for providing medical care.
Some shared their perspective on how they could have provided a patient with even better care, while another shared hers as an Iranian woman, mother, and doctor who, in her native country, could have lost her daughter as other Iranian mothers have to violence mostly from the Islamic Revolutionary Guard Corps (IRGC).
Hearing and telling stories are appealing to an audience because they are a human impulse, said Vincent Quagliarello, MD, vice chair for education and academic affairs in the Department of Internal Medicine at Yale School of Medicine (YSM). “Storytelling has been a human behavior for millennia.”
Telling narratives drives humans because it has helped them survive and has even become the basis of the evolution of the species, he added. “It’s the reason why we love books, we love movies, and dinner with friends,” said Quagliarello, who also is a professor of medicine (infectious diseases) at YSM and clinical chief of infectious diseases.
So, in his perspective, physicians share stories so that their work has value and meaning, builds empathy, and creates community.
“Woman, Life, Freedom”
Mahsa Jina Amini’s death was a pivotal moment for Iranians, leading to massive protests for basic human rights in the streets of Iran.
One day in early September, Susan Kashaf, MD, MPH, associate professor of internal medicine who lived in Iran for much of her childhood, saw a post of Amini in a hospital bed in Farsi on one of her social media feeds. Farsi now takes more effort and time for her to understand than English, so she continued with her day seeing patients at the West Haven VA Medical Center.
At the time, her daughter Leila was 17 years old and applying to college. Kashaf would contrast her daughter’s experience to those of her peers in Iran who were being oppressed, tortured, and even murdered for speaking their minds.
Amini was killed by Iranian government’s “morality police” while detained for wearing her hijab loosely. Her death resulted in worldwide outrage. Or, as Kashaf said, “Her life, her dreams of being a lawyer destroyed for showing some hair. She was beaten, and hospitalized, and died from her injuries.”
“My newsfeed transformed overnight to pictures of young girls who looked like my Leila, wore their black eyeliner like my Leila. Videos of them laughing, singing, cooking, and dancing like my Leila,” she said while her voice quivered.
Kashaf knows it wasn’t always like that. She remembers how life in Iran changed after the Islamic Revolution in 1979 when she was in the third grade. “Schools were made single-sex, and hijab became compulsory. First a scarf, and then a manteau: a loose knee-length raincoat type of cover-up; but only in brown, black, gray, or navy, with pants underneath.”
“And there were morality police prowling the streets for anyone breaking the rules. Beige Nissan Patrol SUVs looking for people wearing makeup, showing hair and immodest clothing, or walking with a member of the opposite sex.”
Her family escaped Iran in 1984 and since then she had kept the “Iran part” of her life “tightly sealed” until the events from last fall revived memories of her childhood experiences after the insurrection.
“My heart hurt for what I saw on my newsfeed and, for the silence around me, no one seemed to know or care. I went through my day mechanically, wondering how it was fair that I could take care of patients, while my Iranian colleagues who tended to wounded protesters were being threatened, imprisoned, and murdered. How was it that my Leila could apply to college and speak her mind?” said Kashaf.
Kashaf, who also is an academic advisor in the Office of Student Affairs at YSM, felt alone, in pain, and detached, so she created community and found connection with other Iranian Americans like geriatric psychiatrist Yauss Safavi, MD, at Yale, who helped her face their pain about Amini’s murder.
“We locked eyes and cried. We decided to start a weekly Zoom to support each other. A campus community blossomed, from a young woman who had moved to the United States to start her postdoctoral two weeks before Mahsa Jina’s murder to a venerated Yale professor,” she added.
Kashaf concluded that, whether they are Iranian or non-Iranian allies, having people show up even in small ways creates connection and community at Yale. That is because it helps lessen the pain and create a sense of belonging.
Kashaf cited a 13th-century poem called Bani Adam (Humankind) by Persian-Muslim polymath Sa’adi Shirazi, better known as Saadi: “Human beings are like parts of a body created from the same essence. When one part is hurt and in pain. The others cannot remain in peace and be quiet. If the misery of others leaves you indifferent, and with no feelings of sorrow you cannot be called a human being.”
“Belly of the whale”
“I heard the story of your demise before I met you. A failed heart transplant, a heart rejected,” said Grace Lesser, MBA, MPH, a nurse-midwifery student at Yale School of Nursing (YSN).
She was referring to one patient among many who have gotten a heart transplant at Yale New Haven Hospital. Now, 368 days later, she could not speak and only had the ability to give non-verbal consent.
“It is my job to care for you today,” Lesser said to herself when she was about learn about his case and shadow the assigned nurse.
Lesser, who also is a women’s health nurse practitioner student, added she couldn’t help but fill the silence with chatter, so she crooned out loud: “Such a beautiful family you have,” gesturing toward the patient’s photo in a tuxedo, standing proudly beside his daughter at her wedding.
She tried to get validation from her patient before continuing with delivering care. She began tube feeding and afterward went on to wash his body and pack his wound.
Meanwhile, she said to herself: “I was told that when your body had started fighting the foreign heart, when your breath had become shallow, and your balance weak, you had asked to die.”
Lesser added: “Perhaps you had pleaded to follow in the footsteps of the donor whose brain had gone dark, and who had offered their beating heart to you. Perhaps someone had told you then that there's always hope, that it's worth the fight. And so, you're held hostage in this place that preserves time.”
She thought he looked like a suburban dad because his middle was thick, yet his ankles were so thin she could wrap her hand around them. She, with the other nurse, prepared to bathe him and pull him up to care for his pressure ulcer.
She questioned in her mind: “Who were you before your heart failed? Before you were told that medicine would save you? Who were you when you could bathe yourself?”
The patient’s wife arrived to check on his care, as she did every afternoon.
“My final task is to give you antibiotic eyedrops prophylactic to prevent the next emergency,” thought Lesser as she continued with her duties. Her patient doesn’t want to receive them, yet she knows he won’t get his way as she administers them while she thinks of her two-year-old not wanting to take medication.
Then, there was an intimate yet bittersweet moment. “When I restored your glasses,” Lesser thought, “I noticed the lenses were covered with oil and flakes of skin. I asked if I could clean them begging for forgiveness, desperate for connection. Your eyes flickered with surprise at my offer while you nodded your chin, and my heart skipped a beat.”
She added: “Your body is washed, and your wound is packed. But cleaning your glasses feels like my one true act of service today. I'm proud that I noticed how dirty they were. It's the little things I think to comfort myself. How satisfying it will be to see again.”
“Being Patient”
Nancy R. Angoff, MD, retired this year after 30 years of service as a physician. She is now professor emerita of medicine (general medicine) and dedicates much of her time to acting.
She plays the roles of various patients at Quinnipiac University’s standardized patient program.
To this new pursuit, Angoff said she brings all the lessons her patients taught her over the years.
She referred to a patient she had treated early in her career at the West Haven VA Medical Center with congestive heart failure that produced chronic symptoms: swollen legs and fluid in the lungs. In her role as a standardized patient, she drew on her memory of when Community Health Care Nursing students were visiting the patient at home because she had gained three pounds.
Angoff then continued her grand rounds presentation in the voice of the patient: “What the students interviewing me do not know and will not know unless they asked me is that I stopped taking the second dose of Lasix because it made me get up at night to pee too many times. Also, last night for dinner, I ate pizza.”
For her second role, Angoff played the wife of a man who had a stomach tube placed because he had trouble swallowing after his stroke. Angoff said, “My character is tired, worried, and anxious.”
She played a woman in her sixties with an eighth-grade education, who was not sure she could take care of the tube. The nursing students demonstrated how to clean it, but used terms she didn’t understand. In their feedback sessions they learned that it’s important to speak to patients and their families in an understandable way, without using jargon.
Lastly, she became a hospital phlebotomist who had contracted AIDS after drawing blood from a patient with HIV. “I didn't take the prescribed post-exposure prophylaxis because of side effects, and [felt] a little cockiness from having survived many previous needle sticks,” she said, “but I am very worried about this test and have been waiting anxiously at employee health to get the results.”
For this part, Angoff transformed into a patient she treated in the 1990s who had developed AIDS and was mistreated by her previous doctor. Remembering the anger of her patient, Angoff decided not to make it easy for the medical student who was going to give her the results of her blood test. Angoff’s intent was to teach the rising physician how to name and support their patient’s emotions when receiving difficult news.
Angoff, speaking as herself, concluded by saying she now finds “meaning and purpose through the standardized patient program and my own memories and experiences.”
“The Third Light”
As a mantra for herself, Laya Jalilian-Khave, MD, postdoctoral associate in the Department of Psychiatry at YSM, repeats: “To sit with one’s pain.”
She first said her mantra when she was a newly graduated doctor doing a required service rotation in a hospital at the border between Iran and Afghanistan.
There, she interacted with children lost at the border. She saw fire and flying rockets at night, returned medical reports of dead and shot soldiers, and treated women who had lost their homes and children in the war as well as multitudes of injured refugees.
“Working as a doctor in poverty-ridden places is rough,” she said. “You keep trying to fix things, but they keep falling apart. You get impatient but people look you in your eyes and invite you to take a share of their patience. The light in their eyes is often tired and sometimes wet but it's always there.”
“In that remote hospital where I worked, I learned to look at life with a new light. A life, not because of—but despite—everything surrounding it,” she said.
When two eyes meet, they create a third light, Jalilian-Khave added.
In her story, and as a doctor, she emphasized on the opportunity of building a safe space with patients no matter how challenging that may be.
“Resident Clinic”
Sarah Householder, MD, an Internal Medicine-Pediatrics PGY1, walked the audience through an afternoon of charting after a day as a training physician intern at a primary care clinic.
One of her patients of the day was an 11-month-old but because of language barriers, she and the baby’s mom could not discuss various topics.
The video interpreter service kept cutting out, so conversations about lowering the infant’s crib and his first dentist appointment weren’t possible at the moment. A brief motivational interviewing intervention for the mother’s smoking habits didn’t happen then either.
A 15-year-old with cough, congestion, sneezing and a headache came in for treatment. Householder was not able to pre-chart for this visit since it was added to her schedule at the last minute, but she was convinced the patient had allergies or a viral infection. That was until the attending found an effusion in the patient’s right ear.
Afterward, she examined the chart of the patient, where three viral infections and two right-ear effusions had been documented, and thought of other potential problems she had not considered before.
Because of the nature of the clinic, “I typed in my exam findings and wrote a thorough assessment of logic that happened hours after the patient left, hoping that the next doctor who sees her will pick up what I missed,” she said.
“Try to avoid drinking fruit juices,” she recommended to her diabetes patient.
Her last chart was of a 75-year-old woman who was not at goal yet, and went in for a diabetes follow-up after missing the previous one because of transportation issues. Householder said she thought everything had gone well.
They talked about the patient’s nighttime insulin, seeing the eye doctor, and how she loves walking and orange juice, yet tries to avoid the juice.
Hours later she noticed her patient’s high blood pressure reading. Even though it was very unlikely for her to see the patient again, as a training physician, she later learned that she could have gotten a social worker involved with the patient to help with transportation issues and her next appointment.
“How did I miss that?” she said. “Part of me wonders if this is just [the nature of] primary care. Patients come in expecting to be seen quickly, leave quickly, and have their refill forms and questions satisfied on the same timescale. Things get missed. And I know that inefficiency and missteps are expected in the intern year and that this will, likely, hopefully, get better with time.”