29. What Has Storytelling to Do With Avoiding Physician Burnout

July 26, 2016

I thought I was done writing for the day, having participated in an on-line discussion about voice dubbing by singers for famous films of 20th Century, which I had triggered with a couple of stories about my early accidental discovery of Marni Nixon, “the ghostess with the moistest” in the world of studio vocalists.

Marni died yesterday at the age of 86, of breast cancer. Back when I was 75 and she was 80, I had looked up her web site and had shared a story with her via e-mail about discussion I had when I was in my late teens and she would have been under 25.  I had been discussing singers  with a then already well known TV music director and the father of a friend, both named Irv Kostal. On a weekend visit to their suburban Long Island home, I took along a children’s record to which my little brothers had been listening called, “The Mother Magoo Suite” — a play on Ravel’s “Mother Goose Suite” (Ma Mere L’Oye), and the then popular cartoon character, Mister Magoo.

I had been doing a lot of singing in college, and had heard on the record what I thought was an absolutely gorgeous voice. “Big Irv” scoffed gently at my offering, saying anybody could sound good using an echo chamber, and countered with a record of a woman singing German tone poems written in Arnold Schoenberg’s 12-tone scale. The woman was hitting intervals that were entirely unexpected to the western ear, and therefore practically impossible to sing. And she was dead on pitch every time.

But the voice was sounding familiar. When I checked the record jackets, both were sung by Marni Nixon. Who, a dozen years later, sang the lead for West Side Story, “ghosting” for Natalie Wood, under the musical direction of… the very same Irv Kostal!

On that day in Long Island, Mister Kostal had also not paid adequate attention, I thought, to the other voice I had thought he might enjoy, a recording with the 19-year-old ingénue singing the lead role, of “The Boyfriend”, a British musical that had just appeared on Broadway, and which voice, from the first note, had pierced my soul in the last row of the top balcony a few weeks earlier. But Big Irv said he had grown to detest the ‘20s flapper music he had spent years playing on the road in an itinerant dance band. In consequence, I thought at the time, didn’t really give a fair hearing to young Julie Andrews either.  Of course, later when he was the music director for Mary Poppins and Sound of Music and I loved teasing him about that on the few occasions we met over the following decades.

Well, you will not have guessed from the foregoing, but what captured my attention this morning were two seemingly unrelated articles: one in an on-line medical news journal about physician burnout and a suggested method to prevent it, and another from Science Daily about whether reading and viewing fiction is good for our mental health.

The connection, for me, was storytelling. Like the stories above, about Marni Nixon and Julie Andrews.

First, the anti-burnout article from the Cleveland clinic, to which my immediate reaction was that it reminded me of the joke about Irish fiddle tunes. To the question of how you tell all these nearly identical tunes apart, the answer is… by the title.

The Cleveland Clinic Neurological Institutes research suggests a way of, “rekindling physicians’ job satisfaction”, and calls it “relationship-centered communication”, a nebbish of a title that could mean anything or nothing.

Looking the phrase up on line I discovered that it is merely a new Title for an ancient tune.

One course that purports to teach this “new” idea offers these goals:

• Understand the importance and value of effective communication
• Build rapport and relationships with others
• Acknowledge communication barriers
• Recognize another’s perspectives and concerns­­
• Negotiate an agenda for an encounter
• Ask questions using skilled open-ended inquiry
• Elicit another’s story
• Listen reflectively and respond with empathy
• Collaborate on a plan that others can follow

Oh, c’mon, really? People who have graduated from medical school don’t know how to talk to a person? Well, I guess that if they don’t, and think that talking doctor to patient is different from talking person to person, the work would soon become lonely and boring.

Now that I think back, I came back to pre-med, medical school and medical practice with an unusual advantage. First, I had been advised by Dorothea Starbuck Miller, my undergraduate advisor at the University of Chicago, and later dean of the Biological Sciences, that I should stay and finish law school and not transfer back to pre-med, because testing had indicated that my aptitude for language and communication was somewhat higher than my aptitude for science.

Second, at the end of my first year after transferring from law school to pre-med, I had stayed in summer school to raise my inorganic chemistry grade and had run out of money in the Fall Quarter. So I took off the Winter Quarter to replenish my savings, not realizing that taking off any quarter but the summer one would void my draft deferment. As a result of which I was drafted into the Army in 1957.

They looked at my liberal arts degree, law school and pre-med, and instead of the medical corps I had hoped for, decided to make me a journalist.  About the only thing the Army didn’t know about me was that I had been the Editor in Chief of my high school paper, a two-page mimeographed bimonthly, so how they landed on ‘journalist’ is beyond my ability to imagine.

But they sent me for 16 weeks of training at the bar-none best, most efficient and effective school I ever attended, the Army Information School at Fort Slocum, New York. And I spent the following two years interviewing people in Germany and Holland, and composing short news stories about them. These stories and features were published every day on the wire services, hometown newspapers and the Stars and Stripes.  And this process of asking questions, listening to answers and composing a story, it could be said, I continued to do for the succeeding forty years in interviewing and listening to patients, and writing their histories into the charts.

Abstracted to simple terms, the common feature was that when I sat down with someone, whatever was going on with them was of vital importance to them and I was very curious to understand it in detail in order to figure out what was going on within the contexts of the relevant medical metaphors.

My impulse from the beginning was, from the first moments of the encounter, to find points of similarity between my own life and that of any new patient. I was a young father with three kids even when I first started practice, and later a fourth. I had endured many sleepless nights when my kids were babies. I had done dozens of summer and part-time jobs when I was a student, had been in the Army overseas, had been in the Merchant Marine. I played the guitar, sang folk songs and was a folk dancer. I spoke a little German and French. I was an amateur astronomer and ham radio operator. When I was a boy I helped my family build a house in which we later lived. I drank beer. My father was a recovering alcoholic who had died young when I was in medical school. I cannot remember a single patient with whom I was not within seconds able to identify, automatically and without any conscious effort, some common interest or experience, some place in the world we had both been, some aspect of work or family life, some hobby or interest.

These things helped me feel that I was spending my days with people I knew; with people who knew me, and when I made my notes I was writing stories about people who had shared stories with me that were vitally important to their lives. I assisted at surgery practically every day for the first three decades, so in addition to all that transpired between us, in addition to the more than a hundred babies I had delivered as an intern and palpating and listening to my patients’ exteriors, to their limbs and joints, I had had my hands on my patients’ lungs and hearts, their stomachs, livers and kidneys, their very brains. After each surgery I dictated a couple of pages of operative reports, each another little story about the patient.

The Cleveland Clinic can call that ‘relationship-centered communication’ if they like, and believe it is a new thing. I just thought I was being a doctor, hearing and retelling the patients’ stories.  But then, my own family doctor, the one I had known from birth, was William Carlos Williams, a famous writer and poet, although his patients didn’t know it at the time.

Which brings me to the Science Daily report on psychologist Keith Oatley’s article suggesting that reading fiction that stimulates the imagination somehow helps in the development of empathy.

Reading certain kinds of literary fiction simulates a social world, fostering understanding and empathy in the reader.

In studying neuroscience for three years, when I became a psychiatrist in the last decade of my medical career, I gradually developed what was for me a useful metaphor, that there is somewhere in the brain a function I called, “the storyteller”, that has to do with the establishment of reality.

For example, while on long road trips I have not infrequently awoken in a motel, where I usually leave a light on in the bathroom and the door cracked open, so that I will have enough light to orient myself if I awake in the dark. Actually, I do the same thing at home, so, after driving for 12 or 14 hours and going to bed exhausted, I had sometimes awakened a bit confused when the light is on the wrong side of the bed from home.  At which point my storyteller, probably in the frontal lobe somewhere, searches through some old and some new memories, examines what little sensory input there is, and then concludes, “I am Denis. I have been driving for several days. I am in a motel. The bathroom is over to the left.”

Which proves to be the case.

This is an example of what neuroscientists are coming to believe we all do in order to construct or “confabulate” what we think of as “reality”.

When we have disrupted the train of memory with drink or some trauma causing unconsciousness, the first thing we ask when we open our eyes is……

You got it… “Where am I?” We already remember who we are.

If we have experienced some sort of amnesia and we awake, we first want to know… “Who am I?” Because whenever we awaken, we first reconstruct reality by a process of telling ourselves a story about who and where we are, and whatever else we remember and is relevant, like, “Who is this in bed with me?!”

When we read a story or watch a movie, it is an active process, wherein we are taking in the information provided and simultaneously telling ourselves the story of what is going on? Contrary to our assumption, it isn’t the page or the screen that tells us what is going on, it is the brain’s storyteller making up a story consistent with the perceived visual and auditory sensations coming in through the sensory switching center, or thalamus.

Emeritus Professor Oatley concludes:

“What’s a piece of fiction, what’s a novel, what’s short story, what’s a play or movie or television series? It’s a piece of consciousness being passed from mind to mind. When you’re reading or watching a drama, you’re taking in a piece of consciousness that you make your own. That seems an exciting idea.”

If a particular person’s brain is capable of generating feelings, which some are not, a feeling may be elicited in the reader similar to the one experienced in the circumstances described by the writer. Oatley reports that experiments indicate that the level of these empathetic feelings can be enhanced by social experience, even one simulated by a writing or a film.

It seems to me that this may be because the brain developed long before any experience was possible beyond the limits of vision, hearing, or the other commonly understood senses. Therefore anything sensed is considered by the brain to be real and immediately and concurrently present. If we see a film about another culture, that culture becomes that much more real to us, and our limbic (emotional) system may regard it as more trusted and safe than strange and frightening.

By the same token, humans judge risk by their immediate experiences. But they do not distinguish between TV and real experience. Therefore in the presence of ever-increasing 24-hour world-wide coverage of mostly bad news we conclude that the world is becoming more dangerous, whereas according to Steven Pinker in, “The Better Angels of our Nature”, the world is safer now than it has ever been.

So if Oatley is right, we are just as likely to be affected by adverse images in books and movies as we are by favorable ones. In other words those who have been telling us that the content of TV can have a bad effect upon our beliefs and behaviors are right, and violence in the media begets violence in life.

Meanwhile by asking and listening and writing stories about people all day long, I have always felt bathed in intimacy with other humans during my work hours, and have not experienced the need to get away from work in order to assuage the pain of a lonely, depressed and exhausted inner child.