Dance and Medicine

The mid-point of medical residency is probably the bleakest point in medical training. The daily grind of death and disease wears young doctors down, and the end of residency seems impossibly far off. In the second year of my residency at Bellevue Hospital, I began taking dance class at the Martha Graham studio in Manhattan. It turned out to be an unexpectedly visceral lifesaver for me.

Here is an excerpt from the essay, “Pas de Deux,” which appears in the new anthology from “Becoming a Doctor,” edited by Lee Gutkind. (Norton, 2010.)

“One day, after a long night in the ICU, I rushed straight to dance class, leotards under my scrubs. I had spent the bulk of my last thirty hours with Nilsa, a young woman dying of HIV. Nilsa’s body was ravaged by bacterial, viral and fungal infections. The body cavities that weren’t drowning in their own fluids were hemorrhaging blood. Her temperature never dipped below 103°. The breathing machine provided oxygen in exchange for her tuberculosis-laden breaths. I injected sedatives when she convulsed, her water-logged lungs laboring to absorb more oxygen. The nurse and I arranged icepacks around her burning skin, but they melted rapidly. Her death was slow and brutal. Her mother, two brothers, and aunt sat with her, weeping into their protective respiratory masks.

I limped out of the hospital after signing Nilsa’s death certificate. There were so many infections that I couldn’t decide which one to write for “immediate cause of death.” My sleep-starved body longed for bed, but my aching soul dragged my protesting limbs to East 63^rd Street.

We were doing the plié-relevé series, a set of exercises that I have always found particularly beautiful. There is one point, in fifth position, in which the drama builds until the climax occurs with just one simple motion: a 90° twist of the body while lifting into a relevé, one arm scooping an arc into the sky. In one brief, but compelling, moment, the whole class rises into the air as a single being, sweeping its focus from the one corner of the room to the other. Physically subtle, yet emotionally dramatic, almost more so for the understatement of the movement.

…I look back now and realize that it was the continual infusion of the aesthetics of dance that helped keep me alive throughout those draining years. After each daily dose of agony and suffering, I needed not only to witness beauty, but to participate in beauty. I was well aware that I couldn’t possibly approach the feats of the advanced dancers, but that turned out not to matter at all. It was enough just to be a bit player in that world, to be a miniscule stitch in that weave of beauty.”

Reprinted from “Pas de Deux” by Danielle Ofri, from “Becoming a Doctor,” Gutkind, L., ed. ©Norton, 2010.

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Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients.

View the YouTube book trailer.

You can follow Danielle on Twitter and Facebook, or visit her homepage.

Her blog, Medicine in Translation, appears on Psychology Today’s website.

Poetry in Medicine

When I make rounds with my students and interns, I always try to sneak in a poem at the end. I think poetry is important because it helps convey the parts of the medical experience that don’t make it into textbooks. It’s important because it teaches creative thinking—something of immense value to doctors.

It’s important because interpreting metaphors is a critical clinical skill in diagnosis; patients’ symptoms often present in metaphorical manners and we doctors need to know how to interpret our patients’ metaphors. Last but not least, there is a therapeutic value to introducing beauty into a situation that is not commonly associated with aesthetics.

I’ve been giving poetry to my medical team for a few years now, but I’ve always wanted to give poetry to my patients. Unfortunately, English is not the first language for most of the patients in my hospital, so this has been challenging.

But there is one set of patients that seems to consistently speak English—the alcoholics. The Bowery-type alcoholics aren’t necessarily the favorite patients of the interns. These patients are frequent fliers, they are clinically “uninteresting,” they are often malodorous, and their illness is perceived as self-inflicted. But they do speak English.

So one morning on rounds, our team went to examine a new alcohol-withdrawal admission. His condition was standard: alcohol-on-breath, speech slurred, fingers trembling, hair and beard disheveled, body odor a mix of unwashed socks and cheap beer. He was cranky, and impatient with the detailed questions we asked.

As the team was finishing up, I whipped out some papers from my pocket—Jack Coulehan’s poem “I’m Gonna Slap Those Doctors. I gave a copy to the patient and distributed the rest to the resident, interns, and medical students. Asking their forbearance for this slight divergence from medical protocol, I plowed onward and read the poem aloud.

I’m Gonna Slap Those Doctors

Because the rosy condition

makes my nose bumpy and big,

and I give them the crap they deserve,

they write me off as a boozer

and snow me with drugs. Like I’m gonna

go wild and green bugs are gonna

crawl on me and I’m gonna tear out

their goddamn precious IV.

I haven’t had a drink in a year

but those slick bastards cross their arms

and talk about sodium. They come

with their noses crunched up like my room

is purgatory and they’re the

goddamn angels doing a bit

of social work. Listen, I might not

have much of a body left,

but I’ve got good arms -- the polio

left me that -- and the skin on my hands

is about an inch thick. And when I used

to drink I could hit with the best

in Braddock. Listen, one more shot

of the crap that makes my tongue stop

and they’ll have something on their hands

they didn’t know existed. They’ll have time

on their hands. They’ll be spinning around

drunk as skunks, heads screwed on backwards,

and then Doctor Big Nose is gonna smell

their breaths, wrinkle his forehead, and spin

down the hall in his wheelchair

on the way to the goddamn heavenly choir.

(from Medicine Stone, 2002. © Jack Coulehan, reprinted with permission)

As I read the poem, I could feel the atmosphere in the room changing, ever so slightly. The focus shifted from the patient to the poem, and everyone was an equal neophyte with this particular poem.

When I finished reading, some of the medical team looked uncomfortable, but the patient was smiling broadly. “This is great,” he said. “I love it!” With his pronouncements, everyone relaxed a bit.

“You know,” the patient continued, seemingly happy to have an audience, “ I used to read some books, back in the day.” He sat up in bed, more animated now. “I like history stuff—ancient Greeks, ancient Romans. Real characters, those guys.”

We ended up having a conversation about his childhood in small-town New Jersey, how he cut classes in high school to putter around on the beach.

We left the room feeling awkward but also somehow lighter. Suddenly our patient wasn’t just another alcoholic drying out on the ward. He was a real person, someone who stood out in our minds.

The poem certainly didn’t change the course of his devastating disease of alcoholism. It didn’t offer him the epiphany to suddenly quit drinking or to reconnect with his estranged family. His liver enzymes didn’t miraculously normalize. His platelets didn’t bound back to health. But it gave all of us a sense of human connection.

Throughout his four-day stay in the hospital, the patient was much more pleasant to the team. I noticed that the students and interns wandered in more frequently to say hello. We all felt just a bit more connected.

Rx: Take two sonnets and call me in the morning.

If you are interested in poetry and medicine, check out this unique conference at Duke University on May 21-23. Life Lines: Poetry for Our Patients, Our Communities, Ourselves. (I will be giving a presentation there.)

Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients. View the YouTube book trailer.

You can follow Danielle on Twitter and Facebook, or visit her homepage.

Her blog, Medicine in Translation, appears on Psychology Today’s website.

Burnout

Taking care of ill patients exerts an enormous physical and emotional toll. Caregivers of all types—doctors, nurses, therapists, family members—are susceptible to these strains. But reactions to these stresses are different. Some caregivers possess large emotional reserve and strong support systems. Others become cynical or callous. Still others find that these stresses exacerbate underlying depression or drug and alcohol issues. For most caregivers, it is a complex combination of individual coping mechanisms and an evolution of our personalities—for better or worse.

In this video “Intensive Care,” I tell the story of a remarkable and brilliant physician who had a profound effect on me during my medical training. It is a true story, but the names have been changed.

The essay is from the book “Singular Intimacies: Becoming a Doctor at Bellevue” (Beacon Press). The reading was filmed at Baruch College.

Watch video here.

Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients. View the YouTube book trailer.

You can follow Danielle on Twitter and Facebook, or visit her homepage.

Her blog, Medicine in Translation, appears on Psychology Today’s website.

Music in Medicine?

The holiday season is finally over. Not to be a complete Grinch, but I am more than happy to see all the tinsel and reindeer and artificial snow come down from the halls of our hospital. Whether all that holiday ornamentation actually belongs in a hospital is fodder for a difference essay, but the part that I’m most glad about is that the piped-in music has stopped.

Every morning, for two long months, when I slogged into the hospital to make rounds on my ill patients, I had to suffer the repeating loop of Christmas music on my way to the elevators. It’s not necessarily that I dislike holiday music—though these renditions were definitely not Grammy finalists—but that I didn’t want someone else’s music forced into my head.

Music is intensely personal. Unlike the art that adorns the hospital walls, which I am free to turn away from if I don’t like, the music was inescapable for the length of the hallway, which could feel interminable on the 57^th loop of “Jingle Bell Rock.”

Music has strong therapeutic qualities, as evinced by the growing number of music therapy programs in hospital settings. There’s even a scientific journal “Music and Medicine” devoted to scientific developments in musicology that affect patients.

But I wonder about the effects on the staff who are forced to listen to music that is not of their choice? I’m not sure about the rest of my colleagues, but I am horrifically susceptible to musical worms—the melodies that get stuck in your head and replay in perpetuity.

So, for the majority of the extended holiday season, I would round on my patients and review their medical conditions with “Deck the Halls with Boughs of Holly” as an underlying basso continuo. Some would say that this could be a good thing, but personally I felt hostage to these saccharine tunes.

When finally I turned in despair to my (Jewish) supervisor, he said confessed to me in a low voice: “Oh, this is my favorite time of year. The music in hall just makes me feel so happy.”

Maybe it is just personal taste, but to me music is too potent to squander with tinny Muzak forced on the unbidden masses. Here’s an essay I wrote on music and medicine that appeared in The Lancet, trying to reconcile my day-job as a physician and my after-hours gig as a struggling cello student. I’d appreciate your thoughts.

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Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients. View the YouTube book trailer.

You can follow Danielle on Twitter and Facebook, or visit her homepage.

Her blog, Medicine in Translation, appears on Psychology Today’s website.

Writing About Patients: Is it Ethical?

There is a veritable epidemic of doctor-writers out there. What is going on?

Are doctors suddenly in the kiss-and-tell mode? What about confidentiality? Professionalism? HIPAA?

As one of the aforementioned doctor-writers, I look upon this trend with both awe and trepidation. I suspect that that this flourishing literary phenomenon relates to the public’s fascination and fear about all things medical. It also relates to the falling away of previous, pedestal-like images of doctors and doctoring. Lastly, it may have occurred to the medical profession—and this has taken a few centuries, it seems—that doctors have profound emotional reactions to the work we do, and that exploring these reactions may offer benefit to both patient and doctor.

Whatever the reason, this literary genre appears to be here to stay, and it is worth considering the ethical implications. Legally, there doesn’t appear to be much beyond protecting identity and avoiding libel.

But physicians clearly need to work with a higher bar. For starters, patients speak to doctors with an expectation of confidentiality. This is vastly different from an ordinary citizen speaking to a journalist. This confidentiality needs to be preserved. Unless a patient indicates otherwise, a doctor-writer must change the name and identifying characteristics. My rule of thumb is that the description must be different enough that it would be tough for anyone other than that person or a close associate to recognize them.

This, of course, brings up an issue of reliability. We’re trafficking in nonfiction, not fiction. When I write, I try to ensure that the aspects I change are not the crucial ones in the story. When talking about the intricacies of an illness, it probably doesn’t matter whether the hair is blond or brown, or the country of origin is Trinidad rather than Jamaica. If these minor things mask the patient’s identity without altering the key aspects of the story, then I think it is a reasonable trade-off.

But most importantly, there is the consideration that patients come to us for our help. They are in a particularly vulnerable situation and doctors have an ethical obligation to put that first. If, at some later time, this seems like a story that might edify the current discourse, the doctor might think about writing it up. It is helpful to let some time pass, so that the situation is no longer “active.” If it’s possible to obtain consent, we should do so.

If I can’t obtain consent, then I need to ask myself whether I feel the patient might be hurt by the publication of the story. If there’s any thought that this person would be uncomfortable or embarrassed or pained, then the story stays in the drawer, no matter how amazing it is. (I have one powerful story—about a patient lied to me, and the implications of that lie—but I suspect that my patient would be unhappy if he ever saw the story, so I’ve never pursued publication.)

Ultimately, I want to give a respectful rendering of my patient’s story, one that I hope would honor them and what they’ve endured. Of course this is necessarily a subjective decision, but it is the only internal ethic that I can live with. My patients have entrusted me with their stories, and I need to respect that. If a particular story can edify future doctors, or educate the public, there might be value in publishing it.

I choose these stories very carefully. I obtain consent when possible—patients almost always have a positive reaction. I let time pass. I try my best to write a story that honors them, and show a draft to them if circumstances permit.

Ultimately, doctor-writers have to treat patients’ stories as we treat our patients, realizing that we are in a privilege position, and taking care not to abuse that.

(Read more about the ethics of doctors writing in Danielle Ofri’s essay in The Lancet.)

Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients. View the YouTube book trailer.

You can follow Danielle on Twitter and Facebook, or visit her homepage.

Her blog, Medicine in Translation, appears on Psychology Today’s website.