CHMP

Angilee Shah’s Career GPS blog for ReportingonHealth.org  interviewed Senior Fellow James Stubenrauch, who co-taught the first narrative writing course to students in the Hunter-Bellevue School of Nursing along with CHMP Senior Fellow and Poet-in-Residence Joy Jacobson. Her post, Why Health Care Professionals Should Write, addresses the reasons and benefits of writing for health professionals. Jim’s quote “”It’s part of a self-care strategy as well as making a better provider out of whoever does this kind of work,” he told Career GPS. “What I’m trying to do in this course is give people permission to get their own voices in the room and down on paper.”  Archived posts on Narrative Writing can be found here.

Reporting on Health is a project of USC Annenberg’s California Endowment Health Journalism Fellowships.

Credit: created by Mark A. Hicks, illustrator.

Manuscript of "The New Colossus" by Emma Lazarus; photo credit / The Center for Jewish History, NYC

In July, I wrote a post on the first-ever narrative writing course for nursing students at the Hunter-Bellevue School of Nursing. CHMP poet-in-residence Joy Jacobson and I taught the five-week course, which met twice each week for three hours per class. I’m happy to report that it was a great experience for us as instructors and, by the end of the course, the consensus among students was that they didn’t want the class to end.

Eleven nursing students were enrolled and one Hunter staff member audited the course; seven of the 12 participants were not native English speakers (their first languages were Mandarin, Korean, Russian, and Yoruba). Most had done little writing for themselves and all needed to improve compositional and grammatical skills. Nevertheless, all of the students produced creative and moving original writing in a variety of formats, including in-class exercises, blog posts, and personal essays.

Several readers of my previous post asked for more particulars about our teaching methods. Here I’ll focus on the in-class writing exercises.

We spent about the first half hour of each class on one or more “quick writes”—guided writing exercises designed to get everyone writing quickly and spontaneously, without concern for the rules of grammar, spelling, and punctuation. The ideas for the quick writes came from several sources, and we adapted freely from books such as Natalie Goldberg’s Writing Down the Bones: Freeing the Writer Within, and The Essential Don Murray, edited by Thomas Newkirk and Lisa C. Miller. We encouraged students to keep their hands moving and to trust their impulses, in the hope that they would get in touch imaginatively with emotions, memories, and sensory impressions, and write about experiences they wouldn’t usually commit to paper. Joy and I did the writing exercises along with the students.

We then spent the next hour of the class reading and discussing what we had just written. While sharing was optional—no one was forced to read aloud—most students were eager to read most of the time. It was remarkable how quickly this sharing helped establish a sense of trust and an atmosphere of mutual support and respect. The feeling that we were coming together as a community of writers proved to be essential as the course progressed and some of the writing prompts led class members into deep and sometimes turbulent emotional waters.

The idea for what may have been the most powerful of the quick writes came from Between the Heartbeats: Poetry and Prose by Nurses, an anthology edited by Cortney Davis and Judy Schaefer. A short piece by Ruth E. Brooks, “Dear Alma Mater,” is in the form of a letter addressed to the Harlem Hospital School of Nursing, which was closed in 1977. The author writes to her alma mater as if it was a person, saying how news of the school’s closing gave her a profound sense of loss. “Let me tell you what part of me was sealed behind those doors,” she writes, and then enumerates not only some of the nursing skills but also the philosophical perspectives she learned there. In concluding, she expresses her sense of indebtedness to the school for helping her transform her life in the process of becoming a nurse.

I found the piece very moving, so I began one class by reading this letter aloud and then asked the students to write a heart-felt letter to a place or a person—living or deceased—that is important in their lives; and I asked them not to hold back, and to write all the things they wish they could say or could have said. When given the chance to express their feelings about what matters most to them, even those students who had the most difficulty with written English wrote clear, straightforward sentences that carried tremendous emotional weight. The stories that came out, the courage the students showed in sharing them, and the way they supported each other’s telling were cathartic and inspiring.

Students also were required to keep a daily journal, and there were assigned readings and writing projects. The final project was a personal essay. One student, Jamie Torres, wrote about her experience of the course itself, and how the close reading and discussion of some of the poems in the Heartbeats anthology had given her a new appreciation of poetry and her own abilities as a writer. She kindly gave me permission to quote from her essay, in which she wrote:

I would encourage all nurses to step out of their comfort zone and start reading poetry, write in a journal, and begin to share their stories. We can call it Narrative Nursing. Louise DeSalvo, author of Writing As a Way of Healing, says, “Through writing we see ourselves as able to solve problems rather than as beset by problems. We enjoy a heightened sense of self. We become more optimistic.” This is what nursing desperately needs. Narrative nursing will give us an opportunity to practice hearing our voice, in a new and fresh way. Maybe through writing we will recognize our own worth.

We’re looking forward to a guest blog post from Jamie sometime soon.

Jim Stubenrauch

Notebook collection, a photo by Dvortygirl on Flickr.

A new writing course for Hunter–Bellevue School of Nursing graduate students got off to a great start this past Thursday evening. CHMP poet-in-residence Joy Jacobson and I will teach the class for the next four and half weeks of Summer Session II. Our immediate goal is to help the students sharpen their skills in writing—scholarly writing, blogging, and narrative writing—and in on-the-job communication. But we also hope to motivate students to invest more energy in their writing by developing a daily writing practice focused on their clinical and personal experience. We’ll supplement this work by close reading of literary and scholarly texts that deal with the experiences of illness and caregiving.

The combination of reflective writing and close reading is an adaptation of the pedagogical approach used in the emerging field of narrative medicine. The mission statement of Columbia University’s Program in Narrative Medicine provides a good introduction to the aims of this discipline:

Narrative Medicine fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness. Through narrative training, the Program in Narrative Medicine helps doctors, nurses, social workers, and therapists to improve the effectiveness of care by developing the capacity for attention, reflection, representation, and affiliation with patients and colleagues. . . .

(I wrote a previous blog post about a presentation given by the founder of the Columbia program and one of the pioneers in this field, Rita Charon, MD, PhD. An extensive bibliography with links to several publications by Charon and others can be found here.)

We adapted our guidelines for developing a daily writing practice from Writing as a Way of Healing: How Telling Our Stories Transforms Our Lives, a fascinating book by Louise DeSalvo, professor of English at Hunter and leader of a memoir workshop in the MFA Writing Program. (She also blogs at Writingalife’s Blog.) Anyone interested in writing as a means of exploring the self will find sound advice and much food for thought in this book. DeSalvo writes

This book is an invitation to engage with your writing process over time in a way that allows you to discover strength, power, wisdom, depth, energy, creativity, soulfulness, and wholeness. . . . to use the simple act of writing as a way of reimagining who you are or remembering who you were. To use writing to discover and fulfill your deepest desire. To accept pain, fear, uncertainty, strife. But to find, too, a place of safety, security, serenity, and joyfulness. To claim your voice, to tell your story. And to share the gift of your work with others and, so, enrich and deepen our understanding of the human condition.

These are not mere self-help bromides. DeSalvo draws on a growing body of evidence from research conducted by James W. Pennebaker and others that demonstrates the beneficial psychological and physiological effects of a specific kind of writing about disturbing or powerfully emotional events. According to DeSalvo, Pennebaker discovered that “to improve health, we must write detailed accounts, linking feelings with events [the emphasis is DeSalvo’s]. The more writing succeeds as narrative—by being detailed, organized, compelling, vivid, lucid—the more health and emotional benefits are derived from writing.” (Pennebaker’s Web page at the University of Texas, Austin, has an extensive bibliography of his research, with links to free downloadable files. Click on Publications. He is also the author of Opening Up: The Healing Power of Expressing Emotions.)

DeSalvo and others, such as Sara Baker, who facilitates what she calls Woven Dialog creative writing workshops with patients at the Loran Smith Center for Cancer Support in Atlanta, Georgia, and elsewhere, also note an important caveat: this kind of writing practice, especially at the beginning of the process, can stir up strong negative feelings, particularly among those who have experienced real trauma (for example, those who have survived cancer or violent abuse). It’s important not to push oneself too far; or, as Baker writes: “We must not use our work to retraumatize ourselves or put ourselves in danger.”

Baker encourages imaginative writing—using the tools of fiction and poetry to offer what she has called “an oblique route” that may give a survivor of trauma “more freedom to connect with emotional and often buried truths” than the more direct route of memoir would provide. (Sara Baker blogs at Word Medicine.)

At the first class meeting last week, students dove right into a guided writing exercise called “My Least-Favorite Patient or Colleague.” First, each of us made up a list of nouns or adjectives beginning with the letter ‘B’ that described the person we had in mind; then another list of words beginning with the letter ‘S’ that described how that person made us feel; and a third list, of verbs or verb phrases beginning with the letter ‘T,’ that described what we would like to do to or with that person. Then, based on this material, each of us wrote a simple “list poem”—that is, a poem in which each line begins with the same word or phrase (such as “I remember…”). The last line has to have a strong twist or surprise, something like the punch line of a joke. And to cap it off, the title of the poem is written last (and is often humorous or ironic in retrospect). You can imagine how this little exercise got the juices flowing.

Stay tuned. We may be publishing some of our students’ writing on the CHMP blog in August.

Civil War House, Circa 1863, Mathew Brady

Jim Stubenrauch is a CHMP senior fellow.

Tomorrow, Saturday, April 9, will be the 146th anniversary of General Robert E. Lee’s surrender to Lt. General Ulysses S. Grant at Appomattox Court House, Virginia. I happen to know this because I spent several hours this past week watching The Civil War, the 1990 documentary by Ken Burns. Like many millions of other viewers, I’ve seen bits and pieces of it over the years. PBS stations tend to haul it out during pledge drives, but even without the fundraising breaks, I find it’s hard enough to stay with a multipart television show spread over several nights. In any case, by now it’s been aired so many times and so many of the images it contains are so familiar that, I suspect, many people have the impression they’ve seen it all even if they really haven’t.

I found out this week that I hadn’t really seen much of this documentary. Read the rest of this entry »

Jim Stubenrauch is a writer and editor with 15 years’ experience in medical publishing, health care, and education.

Phot credit: Healthmax LLC

A couple of weeks ago I attended a lecture by Rita Charon, MD, PhD, professor of clinical medicine at the College of Physicians and Surgeons of Columbia University and the founder and current director of Columbia’s Program in Narrative Medicine.

Entitled “The Clearings of Narrative Medicine, or How the Sick and Those Who Care for Them Can Unite,” the lecture was presented by the Center for the Study of Science and Religion, part of Columbia’s Earth Institute.

Charon began her lecture by noting both the difficulty and the necessity of bridging the divide between the seemingly opposing worldviews of science and religion. “It’s a very grand and risky gesture,” Charon said, “to put an ‘and’ between opposites like science and religion.”

Explaining the metaphor in the title of her talk, Charon said she has taken to calling narrative medicine a “clearing” to connote that the field, young as it is, is like a clearing in the forest, a place where sunlight shines and the undergrowth blossoms, and birds and animals pass through.

“There’s a beauty and there’s an enclosure and there’s a safety,” she continued, speaking in a soothing rhythm and saying that this kind of safe clearing is what the narrative practice of medicine seeks to create, a place where the stories of patients and providers alike can be told and heard, given and received. “So within these spaces or clearings that we make with our work, when we hold classes or workshops or conferences”—or when she solicits stories from her patients as in the anecdote, below —“what happens is this kind of clearing . . . where patients and families and doctors and nurses and social workers and chaplains—I’m going to go on—and poets and novelists and intellectuals and artists gather; and we gather in these clearings to know together what it means to have a body, to be mortal, to age, to become ill, to become better, and to be alive.”

Charon, a general internist in practice with the Associates of Internal Medicine at Presbyterian Hospital, then spoke movingly of a devout woman, a Jehovah’s Witness, who had been her patient for many years. Long ago, the woman had refused a blood transfusion after a cardiac procedure and came close to dying. Her husband and son stood vigil while she lay near death, and the hematologist had done everything possible to avoid the need for a transfusion, and she had lived. “She would have chosen death,” Charon said, “but she lived.”

Now, years later, her patient was a widow, living alone, seeming depressed and lonely. Trying to think of something to discuss that would give the woman pleasure, Charon asked her about her church work, going door to door. “Tell me a story about a visit when someone was grateful,” Charon said to her patient. And the woman told her about a man who was grateful for the news that God had not forgotten him.

“These are the things that I learn in my ordinary practice of medicine,” Charon continued. “The news that God has not forgotten us.” And then, Charon said, when they moved on to the business of treating her patient’s diabetes, hypertension, and osteoarthritis, they were in “a very different clearing than had I not heard that God has not forgotten.”

Charon said narrative medicine is “medicine fortified with the skills of knowing what to do with stories, of recognizing them when they’re told by our patients, and knowing how to tell our own experience.” She spoke of working with young medical students, interns, nurses, and social work trainees who are “floored” by their first encounters with intractable suffering and death.

“They say, ‘Is this what I chose, to live a life around sick and dying people?’ And what we find gives them the buoyancy to continue as generous helpers, is for them to tell their stories to us. So we teach them how to write. The better they are at representing what they see about the world of illness, the better they’re able to perceive it. So we help the students—and our colleagues—write their way through practice. And it’s only when they write that they understand and can discover what it is that they’ve been through.”

There’s more I’d like to say about Rita Charon’s lecture and her ideas about the narrative practice of medicine, and I hope to do so in a future blog post. In the meantime, please explore some of the links embedded in the text above. Also, a bibliography of publications by Charon and her colleagues in the Program in Narrative Medicine—some of which can be downloaded—are available online, here. And be sure to check out the program’s Narrative Medicine Rounds, where you can find a link to an iTunes U archive of free podcasts.

Jim Stubenrauch is a writer and editor with 15 years’ experience in medical publishing, health care, and education.

As Republicans in the House of Representatives move this week to repeal the Affordable Care Act, I thought it would be worthwhile to follow up on my previous post about Wendell Potter, author of Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans. Potter, a whistleblower and former head of corporate communications for insurance giant CIGNA, spoke last week at an event held by the New York Metro Chapter of Physicians for a National Health Program (PNHP). (Potter’s presentation is available on YouTube in four parts, beginning here.)

Addressing about 200 people at CUNY’s Murphy Institute, Potter began by reading from a chapter in Deadly Spin called “The Playbook,” in which he describes the tactics lobbyists use to pressure politicians and mislead the public. The reading focused on recently thwarted proposals in Philadelphia and Washington, D.C., to tax soda and other “sugary beverages,” and their relevance to the struggle over health insurance reform soon became clear. Many tactics the tobacco industry developed to evade regulation and manipulate public opinion have since been adapted, very successfully, by lobbyists for other industries, including oil, banking, foods and beverages, and health insurance.

From “The Playbook,” page 233:

All of the tactics used by the oil, beverage, and banking industries to influence lawmakers at every level of government were pulled straight from the cigarette makers’ playbook: Distract people from the real problem; generate fear; split communities with rhetoric, pitting one group against another; encourage people to doubt scientific conclusions; question whether there really is a problem; and say one thing in public while working secretly to do the opposite.

Sound familiar? Potter describes one of the most powerful weapons in the lobbyist’s arsenal—the false-front grassroots or “astroturf” organization. These lavishly funded coalitions of manufacturers, distributors, wholesalers, retail chains, unions, and industry associations, organized by lobbying firms, pass themselves off as groups of ordinary citizens and small businesses concerned about jobs and the rising cost of living.

One such group is Americans Against Food Taxes (AAFT), originally formed to fight a sweetened-beverage tax proposed as part of an early version of the national health care reform legislation. AAFT also waged campaigns against the proposed soda taxes in Philadelphia and Washington, D.C. The group’s Web site is registered to Goddard Clausen, the public relations firm that produced the infamous “Harry and Louise” commercials that helped defeat the Clinton administration’s health-reform efforts in 1993-94.

According to reporting by Anemona Hartocollis in the New York Times this past July, Goddard Clausen is also behind another astroturf organization, New Yorkers Against Unfair Taxes, that has been working to defeat the soda tax proposed by former New York governor David A. Paterson. Like AAFT, the New York astroturf group set up its own Web site. Both are worth a visit for their folksy rhetoric that’s both instructive and disturbing.

At the PNHP meeting Potter also addressed the concern that the Republicans are planning to undo the health insurance mandate within the Affordable Care Act. He said:

You can rest assured that the lobbyists for the insurance companies have already had meetings with the new members of Congress and said, “Here’s the way things are: you might believe, actually, the talking points we’ve given you, that this is a government takeover of the health care system, but forget that. This is actually legislation that will keep us in business.” The insurance companies cannot go on without this legislation. They needed this, because you cannot continue to shift more and more of the cost of health care to individuals and expect them to continue buying the products. . . . The real objective is to attack the consumer protections. They will try to strip them out one by one, and they will be using language that will try to make us think it’s good for us. They will tell us that what we need is “a common sense, market-based approach to health care reform.” Remember those words, because you’re going to be hearing them more and more.

It will be interesting to see whether Potter’s prediction is accurate.

Photo Credit/Remote Area Medical

For my first blog post, I want to alert readers to an interview aired this past Tuesday on The Brian Lehrer Show on WNYC. Anyone concerned with the ways in which the media and other players shape the public’s understanding of health care practice and policy is likely to find this fascinating and, perhaps, infuriating.

Lehrer interviewed Wendell Potter, until 2008 the head of corporate communications at insurance giant CIGNA, who quit the industry and became a whistleblower. Now a senior fellow at the Center for Media and Democracy, Potter is the author of Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans. The interview can be heard here.

Potter discussed the enormous influence insurance companies and lobbyists have on the political process and on public opinion, including their use of astroturf organizations—funded by consumers’ insurance premiums—to misinform the public and control the health care debate. Toward the end of the interview, Lehrer asked Potter about his experience, as a corporate spokesman, in working with the media. Potter’s response: “I saw the media change a lot in those 20 years. At the end of my career, I could pretty much have my way with the media. There just were not probing questions being asked. I was never really challenged that much. I was able to send a statement, just by email, to shut down a conversation. The media is not doing an adequate job and part of that is because the media has declined, or the mainstream media has. There are fewer reporters covering health care. It’s not as good as it used to be.” He said his hope is that his book will help people become more sophisticated consumers and make them “more aware of spin and how it affects their thinking and their actions and, frankly, our democracy.”

Potter began speaking out when he realized the insurance industry and others were again using the same fear tactics they had used to derail health reform during the Clinton administration. He testified before a Senate Commerce Committee hearing in June, 2009, saying then that he was worried that “the industry’s charm offensive, which is the most visible part of duplicitous and well-financed PR and lobbying campaigns, may well shape reform in a way that benefits Wall Street far more than average Americans.”

You also might want to check out this in-depth interview conducted by Bill Moyers. Potter seems to have undergone something of a moral awakening after visiting a “health care expedition” held at a fairground in rural Virginia, where he saw hundreds of people from all over the region waiting in line for hours in the rain to receive free health care in makeshift clinics housed in tents and animal stalls. Moyers takes pains to establish that Potter left the insurance industry of his own accord—no sour grapes over a missed promotion or other grievance, no being shown the door for cause. Indeed, he was at the top of his field. Moyers then sounds almost incredulous, asking repeatedly why it took Potter so long to realize the human costs of the policies he helped implement. Said Potter: “You don’t think about individual people. You think about the numbers, and whether or not you’re going to meet Wall Street’s expectations.”

The good news in the story was the organization that mounted the health care expedition in Virginia. Remote Area Medical describes itself as “a non-profit, volunteer, airborne relief corps dedicated to serving mankind by providing free health care, dental care, eye care, veterinary services, and technical and educational assistance to people in remote areas of the United States and the world.

Jim Stubenrauch is a Senior Fellow, writer and editor with 15 years’ experience in medical publishing, health care, and education.