Finding Purpose: Honing the Practice of Making Meaning in Medicine

Finding Purpose: Honing the Practice  of Making Meaning in Medicine

 

Lois Leveen, PhD

Perm J 2017;21:17-048 [Full Citation]

https://doi.org/10.7812/TPP/17-048
E-pub: 09/22/2017

ABSTRACT

Despite decades of advances in diagnosing and treating a broad range of illnesses, many changes in our health care system impede true caregiving, leaving patients and practitioners dissatisfied and creating an emotional burden for practitioners that contributes to the staggering rates of physician burnout. Given this dissatisfaction and disconnection, practitioners and patients alike can benefit from structured opportunities to explore the expectations, assumptions, and emotions that shape our understanding of health and illness, and thus our experiences within the health care system. This article demonstrates how group discussions of poetry—something that might seem irrelevant to medical practice or physical wellness—can foster communication, connection, and collective reflection for physicians, interprofessional health care teams, and groups that include practitioners, patients, and families, allowing participants to once again find meaning in medicine.

INTRODUCTION

What is the purpose of a poem? The question might seem esoteric and, within the pages of this journal, irrelevant, especially given the daily demands made of health care practitioners and the emotional distress too many practitioners (and patients) feel in the current health care system. But as much of what physicians do becomes “mechanized work, often menial, squeezed of human emotion, meaningful moments, and personal conversation,”1 it behooves us to understand how discussing a poem facilitates emotional openness and meaning-making through personal conversation. Ultimately, the purpose of a poem in the world of health care is to reconnect practitioners to their own sense of purpose.

WHY POETRY?

This process can be most clearly demonstrated not by explicating a particular poem, but by explicating how to guide discussions of poetry, drawing on examples from workshops I lead for physicians, interprofessional health care teams, and groups that include both practitioners and members of the public. Poetry is in part a practical choice; most poems are short enough that groups can read them together during the workshop, requiring no advanced preparation—a boon for busy practitioners. But the real power of poetry stems from the way a poem depicts experience. Poetry is typically indirect, even indeterminate. Poems demand careful deciphering. They can be daunting. Working together to understand a poem, to uncover and explore its possible meanings, provides an exceptional opportunity for the connection and reflection that is too often missing from health care today.

Unlike narrative medicine, which focuses on developing a clinical “narrative competence” in which diagnosis and treatment depend on understanding the stories actual patients tell,2,3 poems provoke us to contemplate in ways that contrast with yet complement conventional clinical competence. Brief yet densely laden with content, a poem—as a physician in one of my workshops noted—can seem like a clinical encounter with a complicated patient. But a poem does not require us to arrive at an irrefutable diagnosis to determine the best treatment. Instead, an encounter with a poem treats us, by pushing our tolerance for ambiguity and uncertainty, deepening our comfort with collaboration, and enhancing our cognitive flexibility. These traits are increasingly identified as integral to true caregiving; they are also important for patients and their families to cultivate as they navigate the emotional and physical vagaries of illness.

DISCUSSING POETRY TO ADDRESS DIFFICULT EMOTIONS

My role in leading these discussions is not to reveal what the poem means; it is to pose questions, to coax participants into conjecturing, and to mediate the process through which we collectively deepen our understanding by probing multiple possibilities. Consider Denise Levertov’s “Talking to Grief”a,4:

Ah, Grief, I should not treat you
like a homeless dog
who comes to the back door
for a crust, for a meatless bone.
I should trust you.

I should coax you
into the house and give you
your own corner,
a worn mat to lie on,
your own water dish.

You think I don’t know you’ve been living
under my porch.
You long for your real place to be readied
before winter comes. You need
your name,
your collar and tag. You need
the right to warn off intruders,
to consider
my house your own
and me your person
and yourself
my own dog.

The first question I might pose is why Levertov uses the extended metaphor of a dog to embody grief. What is the connotation of a dog? Of a homeless dog? Even in a small group the answers to these questions vary, and we take our time discussing each of them, our first indication of how subjective meaning can be. (I invite you, the reader, to pause to contemplate your own possible responses to such questions as you read this article, to gain a better sense of the process of reflection that participants experience in these workshops.)

Then I broaden our consideration from the analytical to include the physical, directing participants to repeat the word dog together three times, followed by grief, also three times. I invite them to describe the different corporeal sensations experienced when saying each word aloud. As participants detail the bodily effects of hard versus soft consonants and long versus short vowels, we connect these observations to their earlier postulations about what the metaphor, and the poem as a whole, might mean.

Even as I offer yet more prompts to spur discussion, I invite participants to pose their own questions, identifying what strikes them as interesting or odd and then allowing the group to riddle out possible interpretations. In each workshop, participants put forward new questions and original observations. Why is the word Grief capitalized? Why is I should trust you the only sentence set entirely in its own line? How do the stanza breaks divide different ideas in the poem? What’s the effect of ending not one but two lines with You need? Who are the intruders, and how will Grief, the you addressed in the poem, warn them off? What’s the effect of addressing the poem to that you? Would the final line express the same thing without the word own; what does that addition emphasize? As the facilitator, I draw attention to the steps involved in collective meaning-making by commenting on how each participant’s contributions—whether s/he is posing questions or hypothesizing responses—expand our shared understanding of the poem. Although reading literary fiction on one’s own may increase empathy, mentalizing, and other emotional competencies,5 as the guide I emphasize how this collaborative process of deciphering, interpreting, and discussing a challenging poem improves the capacity for interpersonal connection as well as individual reflection.

Only after we have collectively honed our close reading of the poem do I ask what this literary work has to do with medicine. This is a big leap, and I never know where we will land; it depends on what connections the participants in a particular workshop make. Perhaps the most literal-minded respond that grief follows a death, and death is what happens when medicine fails. We can then unpack those assumptions by asking new questions: Is death the only thing that causes grief? Must we presume that death is a “failure” of medicine, rather than a certainty that we should help both the dying and those who care for them to navigate? Or participants might use the poem to reflect on the effects of metaphor in medicine, considering how the metaphors used to describe diseases and treatments shape the expectations of patients and practitioners, in ways that can be edifying, empowering, obfuscating, or even unintentionally harmful.6-9 At a conference on alleviating burnout, physicians spoke candidly about personal and professional griefs they carry, griefs that they seldom have opportunities to speak about, let alone to ameliorate through the kinds of connections we forged while discussing the poem.

BROADENING THE MEDICAL MINDSET

Most physicians choose medicine because they seek a meaningful career, yet 21st-century medical training and practice offer few opportunities for meaning-making.10 This, ultimately, is what a poem can provide. Premed and medical school courses, residency, and the continuous pressures of modern medical practice all emphasize getting swiftly to the right answer, to the detriment of practitioners and patients.11,12 By contrast, poetry provides a way to hone a tolerance for ambiguity, what physician-poet Angela Andrews13 terms “the capacity to not know,” as a means to restore both the creative and the caring aspects of medicine. Cultivating this capacity collectively—whether in a group composed of physicians, of interprofessional teams, or of pracitioners, patients, and patients’ family members—can have profound effects on our expectations and thus our experiences of illness and of health care.

Although reading for meaning is as important in medicine as it is in the humanities, the process is quite different. As we introduce poetry—or other humanities content—into medicine with the intention of enriching practitioners’ (and patients’) ways of thinking and interacting, we need to acknowledge that becoming adept at humanities approaches to analyzing and discussing this content can be challenging. My role as a humanities-trained educator and facilitator is to model a willingness to learn the language and practices of a new field (in my case, medical education and medical practice) as I guide participants through practices that may be quite new to them.

ANALYZING POETIC FORM TO UNDERSTAND THE PRACTITIONER-PATIENT RELATIONSHIP

Poems cannot be read the way patient histories are, even when they are by or about patients; poems yield such rich material for contemplation and discussion precisely because they are not intended as factual reports. This becomes especially apparent when we consider the formal aspects of poetry, which might include anything from alliteration, assonance, or imagery to rhythm and rhyme scheme. Although this sort of analysis may be unfamiliar to many health care practitioners, they often find it extremely edifying. Focusing on these tools poets use to convey theme and emotion along with information allows us to fathom some of the most challenging aspects of medicine, as in “Recurrence” by Judy Rowe Michaelsb,14:

Won’t meet my eyes, doesn’t offer his hand,
jaw’s locked down grim as a TV surgeon’s.
My return has marked me failure.
Only two years ago that hand, gloved,
was probing me for tumor every month,
his mantra, gently, “I’m sorry, I’m sorry”
each time I flinched. Three years ago those hands
took out my ovaries, sampled tissue. Those eyes
broke the bad news to me when I woke up.
“Inoperable,” he says now, heads for the door
muttering “Chemo.” I block him: “Couldn’t the scan
be wrong?” He pushes past. “Hell, why?
Thing lit up just like the Fourth of July.”

This is a difficult poem. Not difficult because it is hard to determine what is going on; it’s actually a straightforward account. What is difficult here is the emotional valence, for both patient and practitioner, which is why it is so powerful to discuss. Focusing first on formal aspects allows us to approach the difficult emotional content slowly, through deep reflection.

We might begin with simile, a poetic technique that initially appears in the second line. Why use simile to juxtapose one’s own surgeon with a TV surgeon? What does the grimly locked jaw convey to the patient, and what should it convey to us? Here the ambiguity of poetry allows us to probe what is often hidden, even insidious, in such scenes: “He doesn’t know how to show real emotion,” lamented one workshop participant, a woman who had been treated for cancer. “They taught us that in medical school,” replied another participant, one of the many physicians trained to mask her own feelings in front of patients. The poet’s simile thus opens up a crucial conversation about what both patients and practitioners feel regarding care—a word that can refer to either deep compassion or coldly “clinical” treatment.

Participants may be even more distressed by the simile that closes the poem, finding Thing and just like the Fourth of July inappropriate and disturbing. How, they wonder, could a doctor speak this way? To answer that question, I guide the group through an examination of the lines between the two similes, considering how the poet deepens what we can learn about this surgeon and about the patient’s relationship to him. As we discuss the way his jaw, his hand, his eyes are represented, I might share an example or two of blazon, a poetic form dating to the Renaissance, which catalogs each feature of the beloved’s body. Is the idea of blazoning the surgeon apt or ironic? We might also consider how repetition and alliteration, two more techniques used in the poem, emphasize the shift from I’m sorry, I’m sorry—soft sounds conveying compassion—to the aggressive p of pushes past. The poet’s unusual inclusion of italics leads us to postulate about whose failure the recurrence might be, and what surgeon and patient each might feel about this failure. The poem thus prompts us to discuss what support patients, families, and practitioners need when facing undesirable prognoses.

We might then reconsider the final lines: “Hell, why?/Thing lit up just like the Fourth of July.” Although rhyme is a feature we often associate with poetry, this end-rhyme sets these two lines off from the rest of the unrhymed poem. What is the effect of the rhyme? How does it further or challenge themes we’ve already identified in the poem? What, ultimately, should we conclude about the similarities or the differences between reading a scan and reading a poem? If the purpose of poetry is to imbue us with a tolerance of ambiguity, does “Recurrence” require us to understand a medical scan as something that brings certainty or that evokes uncertainty, or both?

The answer to that question might depend on whether we are talking about the physical evidence of illness or the emotional effects that evidence will have, not only on patients and their families but on the practitioners who treat them. This returns us to the fundamental purpose of a poem in health care: its potential to allow us to come together to explore such challenging questions, in meaningful ways.

CONCLUSION

There are many ways to create opportunities for practitioners, patients, and patients’ families to experience the reflection and connection that comes through discussions of poetry. The examples cited in this article draw on discussions I have led at medical conferences, during interprofessional brown-bag lunches in a primary care practice, and in public settings such as an art museum. Even in a single session in which participants have never met before, nearly everyone attending volunteers contributions to the conversation, sharing insights and emotional responses. Multiple sessions, which may be organized around a theme, can be even more effective, because they allow trust, camaraderie, and compassion to build among participants, while encouraging the habit of reflection and connection to be practiced over time. Varying the selection of poems enriches these discussions. Although some poems might directly address health, illness, or medical care, as “Recurrence” does, others can allow participants to contemplate complex topics such as race, family, language and cultural difference, or violence, or to probe powerful emotions such as fear, hope, love, or, as Levertov’s poem so effectively shows, grief—all of which shape our experience of health and health care.

Whatever the format or specific literary content, the success of these discussions depends on assuring participants that they do not need particular expertise to contribute; they need only notice whatever strikes them in a poem and then work as a group to explicate the poem on the basis of those observations. Leading these discussions does require expertise, as any good teaching does, although in defining that expertise it is important to remember that what is being taught here is not mastery of content, it is a way of thinking and communicating. Understanding the formal structure of poetry allows me to help participants reflect on the effects of metaphor, assonance, rhythm, and similar elements, to deepen our exploration of the themes these elements convey. Nevertheless, it is important that I do not assume that I know what a poem means. Instead, what might be termed a “humanities-based proficiency” allows me to facilitate these discussions with genuine curiosity and a belief that what participants contribute can and should shape my own interpretation along with theirs. In this way, I guide the group by modeling the practice of deepening my understanding through our collective contemplation. These are all skills that can be honed, in much the way leaders of Balint groups, Schwartz Rounds, or The Healer’s Art courses learn the facilitation skills needed for those approaches.

One practical-minded reviewer of this article, noting that “the challenge of modern medicine is how to find the time,” asked, “After attending your workshop, how many providers implement any aspect of what they learned … when they return to work?” This question is understandable, given the emphasis on performance measures and quantifiable outcomes that has come to dominate how we think about medical practice. But it grows out of the same pressures that produce the “mechanized” conditions described by Janisse.1 Paradoxical though it may seem, only if we resist the demand that any intervention must have an immediate, measurable clinical impact, can we discover ways to bring back caring practices that will restore some of what has been lost in medicine. Indeed, the most important lesson learned in these poetry engagements is that although it may seem as if 21st-century medical training and our current health care system do not allow time for meaning-making, in truth we can create these opportunities with just an hour once a week or even once a month. As this article demonstrates, such opportunities for shared reflection allow participants to forge a sense of connection, enabling them to understand one another’s perspective—and to appreciate something about themselves they may not otherwise have contemplated. That is the purpose of poetry. And through that purpose, we can find our own.

a “Talking to Grief’’ copyright ©1978 by Denise Levertov is reprinted by permission of New Directions Publishing Corp.
b “Recurrence” copyright © 2010 by Judy Rowe Michaels is reprinted by permission of the poet.

Disclosure Statement

The author thanks Lori Wiviott Tishler, MD, who coplanned and cofacilitated one of the physician workshops discussed in this article, and provided feedback on an early draft of the article. The author also thanks Chuck Barnes; Kathy Immerman, MD; Martin Kohn, PhD; Rich Rubin, MD; and the anonymous reviewers of The Permanente Journal for thoughtful suggestions in revising the article. The author especially acknowledges the candor and insights of the many patients, family members, and practitioners who have participated in her workshops; it is an honor and a pleasure to keep learning with them.

The author(s) have no conflicts of interest to disclose.

Acknowledgements

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Leveen L. Finding purpose: Honing the practice of making meaning in medicine. Perm J 2017;21:17-048. DOI: https://doi.org/10.7812/TPP/17-048.

References
1.    Janisse T. Relationship of a physician’s well-being to interactions with patients: Practices of the highest performing physicians on the art of medicine patient survey. Perm J 2008 Fall;12(4):70-6. DOI: https://doi.org/10.7812/TPP/08-041.
2.    Charon R. The patient-physician relationship. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA 2001 Oct 17;286(15):1897-902. DOI: https://doi.org/10.1001/jama.286.15.1897.
    3.    Charon R. At the membranes of care: Stories in narrative medicine. Acad Med 2012 March;87(3):342-7. DOI: https://doi.org/10.1097/ACM.0b013e3182446fbb.
    4.    Levertov D. Poems: 1972-1982. New York, NY: New Directions Books; 1982.
p 111.
    5.    Pino MC, Mazza M. The use of “literary fiction” to promote mentalizing ability. PLoS One 2016 Aug 4;11(8):e0160254. DOI: https://doi.org/10.1371/journal.pone.0160254.
    6.    Hanne M. The binocular vision project: An introduction. Genre 2011 Fall;44(3):222-37. DOI: https://doi.org/10.1215/00166928-1407504.
    7.    Plug L, Sharrack B, Reuber M. Metaphors in the description of seizure experiences: Common expressions and differential diagnosis. Lang Cogn 2011 Jun;3(2):209-33. DOI: https://doi.org/10.1515/LANGCOG.2011.008.
    8.    Periyakoil VS. Using metaphors in medicine. J Palliat Med 2008 Jul;11(6):842-4. DOI: https://doi.org/10.1089/jpm.2008.9885.
    9.    Penson RT, Schapira L, Daniels KJ, Chabner BA, Lynch TJ Jr. Cancer as metaphor. Oncologist 2004;9(6):708-16. DOI: https://doi.org/10.1634/theoncologist.9-6-708.
    10.    Leveen L. The hidden dying of doctors: What the humanities can teach medicine, and why we all need medicine to learn it [Internet]. Los Angeles, CA: Los Angeles Review of Books; 2016 May 25 [cited 2017 Jul 13]. Available from: https://lareviewofbooks.org/article/the-hidden-dying-of-doctors-what-the-humanities-can-teach-medicine-and-why-we-all-need-medicine-to-learn-it/.
    11.    Luther VP, Crandall SJ. Commentary: Ambiguity and uncertainty: Neglected elements of medical education curricula? Acad Med 2011 Jul;86(7):799-800. DOI: https://doi.org/10.1097/ACM.0b013e31821da915.
    12.    Simpkin AL, Schwartzstein RM. Tolerating uncertainty—the next medical revolution? N Engl J Med 2016 Nov 3;375(18):1713-5. DOI: https://doi.org/10.1056/NEJMp1606402.
    13.    Andrews A. Lean forward and listen: Poetry as a mode of understanding in medicine. Perspect Biol Med 2015 Winter;58(1):9-24. DOI: https://doi.org/10.1353/pbm.2015.0015.
    14.    Michaels JR. Reviewing the skull: Poems. Cincinnati, OH: WordTech Editions; 2010. p 40.

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