A doctor’s journey through constraints and creativity in the emergency room

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Jay Baruch is an emergency physician and professor of emergency medicine at Brown University’s Alpert School of Medicine, where he directs the academic concentration in Medical Humanities and Bioethics.

Below, Jay shares 5 key insights from his new book, Tornado de vie: a doctor’s journey through constraints and creativity in the emergency room. Listen to the audio version, read by Jay himself, in the Next Big Idea app.

1. People are their stories, not data with faces.

In the ER narrative disaster zone, my main focus is to make sure the story the patient is telling is the story I’m hearing. In a rapidly changing environment, a supplier is facing unprecedented challenges while being burdened with increasing constraints. But every patient deserves to feel heard.

Patients are challenged with an arduous task: constructing a deeply personal story and confiding in a caregiver who, until then, was an outsider. I am unable to care for patients without caring about their unique stories.

Narrative researcher Kathryn Montgomery expressed this challenge beautifully: “Clinicians are working to perfect the maps of disease, but every patient, every case of disease, is uncharted territory.” In medicine, evidence from rigorous research studies informs clinical decisions. However, getting to the heart of a patient’s problems or needs means listening to their symptoms while being alert to less obvious social and psychological burdens. This becomes easier by focusing on the anatomy of great stories, which center compelling characters with desires and expectations, who then encounter problems or obstacles. Patients are the writers and characters of profound stories of live a life. Body issues are often complicated by a host of other issues, such as relationships, money, mental health, addictions, and loneliness.

Cognitive psychologist Jerome Bruner said the narrative is an “invitation to problem-finding, not a problem-solving lesson. It is deeply about distress, about the road rather than the inn to which it leads. This road may take me into uncharted territory, but healthcare providers need to be willing and prepared to go there. The linguistic lineage of the word “emergency” goes back to the Latin word meaning “to bring to light”. Patients come to the emergency room for a myriad of reasons, but every patient has a story that needs to be told.

2. Uncertainty is our ally.

Uncertainty is everywhere in medicine, from diagnosis and prognosis to communication. Uncertainty, however, does not always mix. To alleviate these feelings, we seek more data, which usually means more diagnostic tests. However, I learned with my patient Jill L. that more data does not promise more certainty.

“If we don’t value uncertainty, we might reduce the type of issues to consider, limit what we listen to, or only value details that support our preconceived beliefs.”

Jill L. had vague symptoms on a Saturday night that included chest pain and shortness of breath, so I looked for issues that included a possible heart attack or a blood clot in her lungs. I was a young doctor, diligent, courteous and devoid of imagination. Unfortunately, I was so focused on “what” that I never asked “why?” Finally, she told me why she had come to the emergency room: she had been the victim of interpersonal violence. The night she arrived, she had finally had enough and didn’t know where to turn.

Studies have shown that physicians who are uncomfortable with uncertainty are prone to excessive diagnostic testing and are less likely to include uncertainty in conversations with their patients. Excluding uncertainty in conversation can cause psychological distress. Poet Mark Doty said, “It’s not always easy to remember that in any process of inquiry, our uncertainty is our ally.

Becoming comfortable with uncertainty requires changing our relationship with it. We shouldn’t ignore it, pretend it doesn’t exist, or adapt our problem solving to questions with answers. If we resent uncertainty, we might restrict the type of issues to consider, limit what we listen to, or value only those details that support our preconceived beliefs. It is not enough to tolerate uncertainty. We must learn to leverage and take advantage of uncertainty as markers for further investigation.

3. The cure for uncertainty is ignorance.

Becoming comfortable with uncertainty is facilitated by accepting the importance of not knowing. I borrowed this notion of “not knowing” from the essay of the same name by the writer Donald Barthelme. Barthelme describes the act of writing, and the creative arts in general, as a process of dealing with non-knowledge. Problems are essential to not-knowing. Without problems, there would be no invention.

It’s hard to feel comfortable with uncertainty and ignorance when doctors are pressured to have the answers, not to admit what they don’t know. Unknowing is a muscle that can become stronger and stabilized through training and questioning our thought process, starting with the decisions we make before we even thought we were making decisions.

We cannot forget that we seek information, it does not choose us. For example, why do I have to select specific details to focus on in a patient’s story – or any story – like chest pain and difficulty breathing in the case of Jill L? What other details am I not focusing on? With Jill L, I felt stuck. Getting stuck in medicine may imply failure, but through the prism of not knowing, we welcome being stuck. This could be our cue to slow down and think differently.

“It’s hard to feel comfortable with uncertainty and ignorance when doctors are pressured to have the answers, not to admit what they don’t know.

How do we recognize when something is wrong, that we need to shift gears and look at a situation with a different eye? For me, it starts with a feeling, a pressure that feels like when a story I’m writing feels disorganized. I find myself pushing him forward; force this. Since then, I have learned to take a step back. The solution to “what next?” begins with a deep breath and question; How did I get here and why? Where is the tension? What don’t I know? The invitation to question our thinking process is more likely to occur in institutional cultures that value willingness to tackle problems.

4. The best medicine won’t work on the wrong story.

As an emergency physician, I am a professional listener caring for a storyteller under pressure under stressful conditions. Stories are not always solid, complete entities exchanged between patients and clinicians. Instead, they often feel like first drafts. It’s not uncommon for suboptimal results or miscommunication to result from smart people who simply got the story wrong.

It is difficult to create stories. It’s not easy to put language into tender, complicated, and embarrassing experiences and share them with strangers, even under ideal circumstances. Imagine you are a patient: anxious, tired, trying to be understood, and terrified of what this might mean.

By writing sentences, you develop a different relationship to language. Not only are you aware of what was said and how it was phrased, but you also begin to notice what is left unsaid, critical silences or evasions that might contain the very thing you need to hear but is unspeakable. Anna Deavere Smith wrote, “We can learn a lot about a person just when the language fails him.”

Our brain craves narrative coherence. Experts from Daniel Kahneman to Jonathan Gottschall write about how we’re hardwired to take cognitive shortcuts. Unconsciously, we weave random and incomplete data into a story. We have to be careful. Our mind is likely to create a different story than the patient is trying to tell.

Modern medicine, with its fascination with technology, often ignores the power of stories. He will not tell us when our questions and thoughts are out of place. The best medicine won’t work on the wrong story.

5. How we react to stress says a lot about us.

Years ago, an esteemed professor of medicine remarked after I gave a lecture at his medical school: “You are an ER doctor. You don’t have time for the story. And he’s right. There are many constraints, and they have been amplified due to the unprecedented pandemic pressures.

Obvious constraints include lack of time, constant interruptions, having to make decisions based on incomplete information, and overcrowding. There are also other less explicit constraints, such as emotional exhaustion, limits of compassion, and adapting to a healthcare system that seems to have forgotten that patients come first.

“Stories serve as portals of social interaction that emotionally direct us to the experience of another.”

These constraints will not prevent patients from bringing their stories to the emergency room, I told the professor. In fact, these constraints serve as an argument to bring as many tools as possible into these pressurized spaces. Since that conversation years ago, the pressure to spend less time with more patients has spilled over into other areas of medicine.

The stories reveal how people face, succumb and overcome obstacles in their lives and navigate their way through a world we all share. Stories serve as portals of social interaction that emotionally direct us to the experience of another. The pandemic has revealed that preparedness requires everyone, in healthcare and in society, to be adaptable, flexible and creative. It starts with a willingness to understand the unique experiences of others. This can only happen if we recognize the constraints of our own thinking. We need to let our guard down, gather our courage, and invite people into our lives, even if it’s just a few steps. When others are slowly creaking that door, we must muster the courage to take those steps ourselves.

How we react to stress reveals something about us.

If I’ve learned anything in my three decades as a professional listener and storyteller, in the ER and on the page, it’s the importance of humility. It’s not always easy to understand another human, but it is possible and necessary. We’re not going to be perfect, but the effort counts.

To listen to the audio read by author Jay Baruch, download the Next Big Idea app today:

Hear key information in the next big idea app

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