“How is your sleep?”
I’ve posed this question to hundreds of patients.
“Terrible,” I often hear in response. “I always feel tired.” I follow up with the questions I was taught in my medical training: Do you have difficulty falling asleep, staying asleep, or both? Do you wake up early? How long does it take to fall asleep? Do you snore?
By following the script I inherited from doctors before me, I can recite the precise times a patient goes to bed and wakes up; the number of times they wake up at night; whether they use their continuous positive airway pressure machine to help them breathe at night; and more. I can report the severity of their symptoms on a scale from one to ten.
But I can’t tell you how the insomnia makes them feel. And that’s important. Understanding the emotions associated with their symptoms — despair, frustration sadness, and more — has a powerful impact on the empathy and connection I feel as their doctor, and may even affect their treatment and outcomes.
Then I met Penelope, a fictional pig. She made me rethink everything I had been taught about asking patients about sleep.
Our meeting place was a creativity class for adolescents with depression, part of an outpatient program I was observing as a psychiatry resident. One afternoon, the class read a poem about trying to fall sleep and the rituals the mind creates in this suspended time. Pretty Pink Paper Pig Penelope becomes a mantra the poet, Yuko Taniguchi, repeats in her mind. When she still can’t sleep, she closes her eyes and visualizes the steps of folding the origami pig “like a prayer repeated, until it’s all Penelopes in my mind.”
After the class discussed the poem, each student responded to this writing prompt: “How does your sleep arrive? Describe how you connect to this territory called sleep.”
What they shared was unlike anything I’d ever heard before in medicine.
Sleep buries me like a rockfall tumbling down the cliff of a highway.
Each restless turn under the sheets is like pulling the lever on a slot machine; hope and resolve to win (fall asleep) followed by mounting disappointment. The stakes are higher with each failed crank.
Listening to these vivid metaphors, I understood sleep difficulties in a way I never had in the clinic or hospital, even after exhausting every insomnia-related question I’ve been taught.
Why hadn’t medical school taught me to elicit rich descriptions of symptoms like this? It’s not that they aren’t trying to teach this skill. A rapidly expanding field called the medical humanities incorporates into clinical training literature, art, philosophy, and the social sciences. The field was developed to deepen clinicians’ understanding of the human condition and enrich patient-clinician communication. Most U.S. medical schools have now integrated medical humanities into their science curricula.
As a medical student, I eagerly signed up for these opportunities. I raced from the library to a dark studio for a dance performance and then discussed how improvisation can be applied to patient-clinician interactions. I was shepherded through the local art museum and pondered what the art revealed about the human emotions. I attended a narrative medicine workshop to learn how to carefully attend to language to become a better listener.
I was determined to find an antidote to the increasingly prescriptive checklist approach to medicine — to find a way to truly connect with patients in the exam room. In oft-cited studies, the average time it takes a physician to interrupt a patient is anywhere from 11 to 22 seconds. I was sure I would be a different kind of physician.
But once I began doing clinical rotations, I learned there is little room to veer off course from the traditional interview structure. After seeing a patient, medical trainees are expected to present their story to a supervising physician. I quickly realized that in the short time allotted to see a patient, I could almost never collect the information I needed for this presentation without cutting off the patient and asking pointed questions. There is no time for tangents.
When I evaluated a patient for insomnia, my supervisors expected a presentation that included, among other things, how many times the patient wakes up or when she was evaluated for sleep apnea. I can only imagine their surprise if I were to present a metaphor or image to represent the patient’s experience.
To document the visit in the electronic medical record, my supervisors taught me how to access hundreds of fill-in-the-blank templates for notes.
To stay afloat in training, I learned to interrupt and redirect patients when they began speaking about something that didn’t fit neatly into one of the templates. To be sure, the classic interview structure has value: efficiency, thoroughness, and easy communication between providers. Yet over time I internalized the templates and lost how to connect with the person in front of me.
Even after wholeheartedly embracing medical humanities during medical school, I was unable to bring what I learned from them into my conversations with patients. Visiting an art museum or spending an evening at the symphony does little to change practice when I am expected to follow the same rigid structure for clinical interviews when I’m face to face with patients.
All patients deserve a chance to express their symptoms in ways that capture their unique and textured experiences. It is time for the medical humanities to move beyond the sidelines and get into the exam room. The traditional approach has its value, but we need to invite new ways of discussing symptoms: What song conveys your chronic pain? What color is your despair?
At a time when patients feel misunderstood and dismissed, and clinicians are burning out at unprecedented rates, health care needs new ways of connecting with people. Studying medical humanities may help me make sense of a patient’s experience, but first I have to ask questions that allow the story to emerge.
In so many cases, the most potent medicine available is the experience of being heard. Providing this connection requires bringing the medical humanities off the sidelines and using them to reimagine how we collect patient histories, the very foundation of medicine. Sometimes only metaphors can evoke the pain of bodies and minds gone awry.
Penelope the pretty pink paper pig — and the teenagers she inspired to write — showed me how swiftly I could be brought into a patient’s inner world if only I asked a new type of question.
Rebecca Grossman-Kahn is a resident physician in psychiatry at the University of Minnesota.
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