Burn the Map
Synopsis
An improv workshop transforms the way psychiatrist David Elkin approaches a patient on the psych consult service, and catalyzes a philosophical shift in his approach to patient care.
Listen
Storyteller
David Elkin earned his MD from the University of Pennsylvania, completed his psychiatric training at UC Davis, and received a Masters in the Study of Law from UC Hastings. A clinical professor at UCSF, he has worked at SF General for over thirty years on the consultation-liaison service, which he now co-directs, seeing patients with acute medical and psychiatric problems. David is passionate about education, including trainee well-being, ethics, critical thinking and clinical and ethical reasoning, and especially in the intersection of literature, arts and humanities with medicine.
In Memoriam
This story goes out in memory of Kevin Mack, just in time for his birthday. There are hundreds of us at UCSF and UC Berkeley, the WHO and other parts of the world who cherish his memory. and those who unknowingly are in his debt for his legacy of innovating and mentoring and trainees and faculty. He kept us humble, kept us innovating, and kept us laughing. This story would not have been possible without his support, encouragement, positivity and love.
— Dr. David Elkin
Be patient toward all that is unsolved in your heart and try to love the questions themselves, like locked rooms and like books that are written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer.
— Rainer Maria Rilke, Letters to a Young Poet
resources
Bibliography: Medical Improv
Poems:
Video: John Koenig, “Sonder: The Realization That Everyone Has A Story,” The Dictionary of Obscure Sorrows
Talk: Rita Charon, “Honoring the Stories of Illness,” TEDxAtlanta
Credits
Hosted by Emily Silverman.
Produced by Emily Silverman and Jon Oliver.
Edited and mixed by Jon Oliver.
Original theme music by Yosef Munro. Additional music by Blue Dot Sessions.
Illustrations by Ashley Floréal.
This version of Dr. Elkin’s story was coached by Adelaide Papazoglou and performed at The Nocturnists’ “Transitions” show at the Yerba Buena Center for the Arts, San Francisco in January 2020.
An earlier version of this story was coached by Cheryl Hamilton of Massmouth and performed at the Compassion and Action Healthcare Conference, Boston in September 2019.
Emily’s interview with Dr. Elkin was recorded at Women’s Audio Mission, San Francisco, October 2021.
The Nocturnists is made possible by the California Medical Association, the Patrick J. McGovern Foundation, and people like you who have donated through our website and Patreon page.
This episode of The Nocturnists is sponsored by Pattern.
Transcript
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The Nocturnists: Stories from the World of Medicine
Season 4 Episode 1: "Burn the Map"
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
This is The Nocturnists: Stories from the World of Medicine. I'm Emily Silverman.
Today, I talk to David Elkin. David grew up outside Philadelphia, earned his MD from the University of Pennsylvania, and after a false start in internal medicine, completed his psychiatric training at UC Davis, and received a Masters in the Study of Law from UC Hastings. A clinical professor at UCSF, he's worked at SF General for over 30 years on the Psych Consult-Liaison Service, which he now co-directs. He's also served on the hospital ethics committee, and for many years anchored both the Physician Well Being Committee and the Schwartz Rounds at SF General.
But before we chat with David, we'll hear the story of how an improv workshop transformed his interaction with a patient on the psych consult service. Here's David.
David Elkin
So, I'm standing in a doorway, in a hotel in downtown Denver. It's one of those meeting rooms that could be anywhere. It's a large ballroom—we've all seen them at conferences. This conference is on medical education. And it's the first day. I'm tired. But I'm looking through the schedule. I'm trying to decide what to go to, and I get a phone call from a colleague back home—complicated ethics consult. And I'm 20 minutes late. I looked through again. Two of the workshops seem really dry. So I think the other one, it's on improv comedy. I figure, "Okay, that might be good for a few laughs. I'll sit in the back of the dark room. Watch some PowerPoint. You know, if it's really boring, I can take a little nap."
I push open the door. And now I'm really confused. There's no dark room. There's no PowerPoint. The lights are fully up. People are milling around. And I realize to my horror: it's an experiential workshop. And I've missed the instructions.
So I turn to leave. But curiosity gets the better of me, and I try to take the whole scene in. So off to my left, there's about six people, and they're apparently forming a pirate ship with a table. And I can tell it's a pirate ship because one woman is leaning off—she's the pirate captain. She's yelling, "Arrrr!" She's hanging off the mast, which is some other guy. They're laughing.
In the middle of the room, there are about two dozen people, and they've amazingly self-organized into a ceiling fan. There are about five people in each spoke, and they're each—they're all just revolving in synchrony...in perfect harmony and synchrony counterclockwise. There's a woman in the middle and I recognize her as, like, the Assistant or Associate Dean of Education from some med school back east, and she's on her back, and she's deliriously laughing as she goes around in a spiral on her back.
To the right, there are four people, and they're forming a toaster. Someone says, "Ping!" and the two people in the middle jump up.
Okay, I've seen enough. I'm turning, but it's suddenly too late. My colleagues recognize me. They wave me over. I can't escape. The door closes with a thud behind me. I joined a group of people. I'm very trepidatious—they're making a refrigerator. They've already made the refrigerator though. So I think fast. I crouch down—I'm the freezer.
And I'm wondering, "What am I doing here?" It doesn't take long to figure out why I'm here. I'm a psychiatrist. And I remember, I'm here because of Kevin. Kevin is my charismatic and brilliant colleague from back home. Kevin was a compact man who just radiated energy and enthusiasm. He could make any task fun. And we quickly bonded over our love and passion for teaching, the fact that we were both parents of small children. We became collaborators. We ran Grand Rounds together. We became friends... And in spite of the fact that he was only recently 10 years out of medical training, psychiatric training, he became my mentor, probably the best one I ever had. His rise through the university was meteoric: he was traveling everywhere, working on medical school curriculum change in Africa, consulting with the World Health Organization in Switzerland, teaching in Italy and Japan. I worried that he would come to some kind of harm in his travels.
But that didn't happen. Instead, in 2011, he was on his way to work in the psychiatric emergency room for a routine shift—he stayed very humble and true to his roots. And his—the shuttle bus he was on collided with another bus or another truck. And he was pronounced dead at the scene. So coming to this meeting has become a ritual of sorts. It's a chance to reconnect with people who remember him, and who revere him as much as I do. And that's why I'm here at this conference. So now, I've been so distracted by my thoughts, I've missed another set of instructions. And a person to my right is nudging me. So they quickly fill me in—we're passing emotions around the room. So we take emotions like sadness, and joy, and surprise, and we pass them from one person to another. And we do this wordlessly except to say, at the end, "Thank you for giving me that gift of sadness. Thank you for giving me that gift of joy."
And as I do these exercises, something really surprising happens. I start to relax—I'm actually enjoying myself. And I'm caught up in the spirit of the moment. So now, backwards, I'm learning the principles of improv, and those include things like: respect your partner, always give them something back, use what's in the room, be spontaneous, don't judge your partner, don't judge yourself, and always, always say, "Yes, and.." to whatever presents itself.
It's three days later...I'm back at work. I work as a psychiatrist, but on consult service, which means that I see patients throughout the hospital at San Francisco General. It's our Level I Trauma Center for San Francisco and the public safety net hospital. It's busier than ever because of budget cuts—we're down to two attending psychiatrists, my colleague and myself. The residents and trainees actually outnumber us. And we're very busy because it's a Monday morning. We have to play catch up. And I've missed, of course, a few days from the previous week. We have this flood of new patients, and we have the old patients, we have to figure out who we can see, and how to triage. And we have to double-check our thinking about everything. The residents are great. We're trying to do some teaching. We've got a lot of complicated cases, and we're trying to balance the work and the teaching as well.
We've got a few new patients to see. One of them is a 20 year-old woman, and she's attempted suicide by overdose after her girlfriend broke up with her. We have a 60 year-old man with schizophrenia. He's entered renal failure. He's quite ill, but he's too paranoid to accept dialysis. My colleague, Jean, starts quizzing the residents, who in turn quiz the medical students—what dosages to use in a patient with renal failure? Which antipsychotics are safe? Which ones have the most cardiac effects? What lab tests do we have to order when someone is medically ill?
And the residents are great, fielding these questions. But as they're answering those questions, I'm thinking to myself, you know, this reminds me of my favorite adage that it takes knowledge to know that a tomato is a fruit, but it takes wisdom not to put a tomato in a fruit salad.
Medicine is part art and part science. Sometimes we're not even sure which is which. And all that medical knowledge is not going to be effective if it's not coupled with some deeper sense of the complexities and the contradictions of human nature, and not just our patients’, but our own. Our task really comes down, in my opinion, to forming a good therapeutic alliance. It's something that can potentially win over a mistrustful patient. It could keep our patient with renal failure alive if we can convince him to get dialysis.
Unfortunately, things are really busy. And it seems like the residents and the students are really consumed with checklists—they have to go through all the symptoms. That's what they're being quizzed on. That's what they're being tested on. There isn't much room for the more important work—again, in my opinion—which consists of really connecting with a sense of meaning about our patients. So I ask them questions like, "What is it like to be paranoid? What is this patient's life experience? What is it like to lose hope?" At best, those two approaches—the humanistic and the biomedical—can coexist, can inform each other, can be very powerful. But this morning, I'm not feeling that. The tension between those two poles is making me feel stressed and frustrated.
Finally, we break. We decide that we've got enough of a handle on the day we can take a quick lunch. We run down to the cafeteria before the line gets too long. We disperse to do our work, but then I get a phone call. It's Karen, the second year resident. She's half-apologetic: "Really sorry, but we've got this call. Pat just got the page. I think we're gonna have to see this person. It's a suicide evaluation." Karen is very bright, compassionate, but she's underconfident. She reminds me a lot of myself when I was a resident.
I go over to the office that she shares with several other people. It's about the size of a small closet. We sit down, very close to each other. She starts presenting the case in a crisp presentation: "Twenty-four-year-old man. Status: post-motor vehicle accident. New onset paraplegia. Evaluate suicidality." Now I allow myself to immerse myself in the story. Listen, with both ears—the medical and the humanistic. What I hear is this: A twenty-four-year-old man, barely older than my own son, has crashed his motorcycle on a darkened San Francisco street. He's brought in with spinal fractures. And the surgeons repair them. He's whisked up to the surgery suite. He's stabilized in the ICU, but the damage to his spinal cord has been done. He's lost sensation in his legs. It's unlikely that he's ever going to walk again. And at first he's sedated. He's intubated. He's in the ICU for 10 days. But gradually the tubes are removed. He starts to wake up. At first he's in good spirits. But then—probably as the enormity of what's happened sinks in—he starts to become more listless and withdrawn. And then the day before, he says to his nurse, "I don't think I want to live like this." And that's what triggered the call to our consult service.
So Karen and I look over the records on the computer and then we walk briskly towards the patient's room. But it's another building. We've got plenty of time. We rehearse the interview. The diagnostic interview in psychiatry is one of the most powerful tools that we have. We don't have good lab tests, but we can talk to people. And so we rehearse: "So, Karen, what's our objective?" "Well," she says, "we're going to assess for suicidality. Does he have a plan? Does he have intent? Does he even have the means?” “Right," I say, "but we don't want to just plunge into that. We want to ease into it a bit. Find out how he's doing. Is he in pain? Is his care good?" We talk a little bit more about depressive symptoms, acute stress disorder. I can tell she's got it.
And then we're at his room. We walk in, and then Karen starts off a little bit too briskly and a little bit too brightly and says, "Hi, we're from psychiatry. Your team sent us because we heard you were suicidal." Oh, well. So the patient doesn't seem fazed by this at all. He takes it in stride, and he says, "Yeah, I was feeling that way. But then this morning, I was able to move my leg!" He takes the blanket off his legs. And I notice, with a clinician's eye, that his legs are lean, muscular, tan from the summer sun. That makes me think about how his muscles are going to wither over the coming weeks and months as they're deprived of any kind of nerve input. I staunched the thought.
It's a strange scene—the three of us stare at his leg for about 30 seconds, and finally, there’s this tiny twitch on the inside of his left thigh. And he looks at us very brightly. He says, "See!" Karen and I make eye contact. And this is as close to telepathy as you're going to have. Karen and I have worked together for over two months, and we're similar enough. We can almost read each other's thoughts at times. And I can tell what she's thinking. If we were to step into the hallway, she would say, "Acute stress disorder. Denial. I mean, he's probably never gonna walk again." So, she resumes the questioning. And she says, "How are you sleeping? How's your appetite been?"
And the patient picks up on this. And I see his eye contact starts to slide away. And even his upper body starts to turn away from us. And I think to myself, "He's probably really disappointed. We just rebuffed him. We're not sharing in his excitement." And I feel this twinge of remorse, and I think, "Is this really the best that psychiatry has to offer this young man?"
But then suddenly, I have this thought, and it's from the workshop. It says, "Respect your partner. Give them something back. Use what's in the room." And I look around the room. And I've kind of barely noticed it before, but there are dozens—well over 100—photographs taped to the walls. Obviously, someone has put them there. And I look at them. They're photographs of the patient, swimming in a creek, or camping with friends.
And so I break in and I say, "Wow, these photographs, they're all of you!"
And he says, "Yeah."
And I said, "You... Looks like you love the outdoors."
And he brightens, and he starts to make more eye contact. He says, "Yeah, I love the outdoors. I love being outside. I love camping, I love hunting, fishing. I just want to get back out there."
And I said, "You know, I really like camping too. And it reminds me of how you light a fire in the woods." And Karen looks at me. And she's kind of quizzical, like, "What's going on here?" And frankly, I'm bewildered too, because I'm operating on intuition at this point.
And I say, "You know, when you start a fire, you can't just start a log. You can't light a log on fire. You've got to start with something really small. So you start with little scraps of paper, a little dried leaves, then you build up to twigs and kindling—the bigger stuff—and then gradually you can get the log on fire. That's what your leg reminds me of."
And he beams and he says, "Exactly! That's exactly what it's like." He said, "You know, the doctors are saying I'll never walk again. But if I can do this, and he points his leg, then who knows what I'll be able to accomplish? I know it's going to take a long time. I know, I may never get all the use of my legs back. But at least I can work towards that. And I think it's going to happen." And this time, I don't resist it. I'm just swept along by his joy and his excitement. It's a nice feeling. We talk a little bit more about his life and his plans, his support system.
And then he takes the conversation in a really different direction. He breaks in and he says, “You know, that thing you were saying about starting a log on fire—that you can't just do that, you have to start really small? Well, that reminds me. I was with my friends in Europe a few years right after college. And we decided to take this hike up this mountain. And it was going to be a day hike. So we didn't pack anything with us. We weren't really dressed for it. And we got up to the top and we'd gotten a late start. And by the time we got up to the top of the mountain, there was just this big snow-covered field. And the sun was setting, and it was getting dark. And we knew it wasn't going to be safe to stay overnight there—we'd freeze to death."
So, I got really anxious because I'd been in a few situations like that in my early 20s. And I said, "Well, what did you do?"
And he said, "Well, you know, we finally realized we had something—one thing—that we could burn. But that was our map. And if we burned our map, we'd never find our way back the next day."
So now I'm getting really anxious, I’m like, "So what happened?"
And he said, "Well, we finally figured it out!" He said, "We didn't need to burn the whole map. We just needed to burn the part that we didn't need. And that's what we did. We tore it really carefully. And we did that by the last lights of the sun, because we didn't have any flashlights. And we just started this tiny little fire, and we put some wet twigs on, and we just crossed our fingers. And eventually we started the small fire, and then it got bigger. And then eventually we were able to start some logs on fire, and then we just started bringing wet wood over and then we did that all night long. And we just kept the fire going." And he said, "You know, we were cold at times, but we kept watch. And actually, we weren't that bad, and we got through the night. And the next morning, finally, the sun came up. And we walked home with the part of the map that we still had and needed."
I'm sitting there, like, "Wow, thank you. That's an amazing story." We talked a little bit more, we're certainly satisfied that he's not depressed and he's not suicidal. And we leave the room.
And I go out into the hallway. And I say to Karen, "Wow, I've got goosebumps!" And she looks at me, and she's like, "Why?" And I said, “Because he just told us the story of his recovery.” And her eyes widen as she gets it. And we just sit there stunned with the power of that story. Our patient left two days later after we'd seen him. We were the only thing standing in the way of him going to the premier rehab facility, ironically, in Colorado. I didn't get any follow up. I can only hope that he's doing well. I'd like to think about him camping.
As for me, my interactions with patients have become a lot freer. They're much more interactive. It's a little bit more frightening, because I don't know what I'm going to get into, but it's a lot more fun. And I think about that patient's story, and I carry it—the story of the map—everywhere I go. When I meet new patients, I think about that. I think about their encounters with physical illness, with psychological distress. And I think about the map. I think about it with the students and residents as they plan out their careers and their lives. I think about it with my own life: I think about the strange turns and twists that led me to a place like San Francisco General. And all those random accidents that happen that lead us to the lives that we have. I think about retirement and aging. And I wonder whether I'll have the courage, knowledge, and the wisdom to burn parts of my map and which parts those will be.
I still feel tremendous grief about Kevin and I wish he was with us. I think especially about his children growing up without him and how much he would have wanted to have been there. But I'm also filled with gratitude—the gratitude that he gave us so much in a short life. Which is, in part, why a couple of months ago, I decided that I would organize Grand Rounds for our department featuring improv comedy. It seems like the perfect way to honor Kevin's spirit of innovation, playfulness.
So, we have people filtering into the room. A room that is normally reserved for very serious case conferences and talks about psychopharmacology. And some of the participants look excited and others look openly dubious and skeptical. And my co-presenters—a couple of medical students who have improv backgrounds—and I go through a few quick PowerPoint slides, and we leave the one up with the core principles of improv. And then we launch into the exercises. We're walking around the room, dialing joy and sadness up to a seven and down to a two.
People are really starting to loosen up and get into it. And they look to the side of the room and by the door, there's a young woman who's just come in. She's late. So I walk over to her. And I tell her what we're doing. And I want to tell her so much more—I want to tell her that these simple exercises could actually lead her to more meaningful connections with her patients, that they could unearth stories that we otherwise wouldn't hear. I want to tell her that improv could maybe even save a patient's life or it could change her own.
I don't say those things because I know she'll have to find those things out for herself. "Come join us," I say instead. "We're going to have fun."
[APPLAUSE]
[MUSIC]
Emily Silverman
I'm sitting here with David Elkin. David, it is so good to see you.
David Elkin
It's always a pleasure to see you.
Emily Silverman
David, you told this story on stage at The Nocturnists in January 2020, right before COVID hit, and we haven't seen a whole lot of each other since then. So, tell me, how have you been since that show?
David Elkin
For me, it was a really odd year. I mean, doing The Nocturnists was such a high. And I just felt like, wow, this was incredible for me and to be able to share that. And then a couple of months later, I ended up living out of my bedroom just to protect my family. Both my adult kids were there and we would gather on the deck. And that went on for about nine months, until I got vaccinated. But I've referred back to that story and that experience so many times. It's just incredible.
Emily Silverman
So when you do reflect back on that night, in January 2020, what comes up for you? Because I look at the photo of the room—hundreds and hundreds of people—and none of us had any idea what was coming. But when you think back to that night, what bubbles up for you?
David Elkin
Well, I think probably, like you, the thought that there were over 700 people gathered in an auditorium and no masks. What were we doing? What were we thinking? But, beyond that, just the excitement. Unfortunately, one of the disadvantages of going last was that I didn't get to hear the performers the way I would have wanted to. The people that preceded me, I would have loved to have been sitting in the audience hearing them, but I did get to hear them from the green room...and that building sense of excitement...and also the idea of, "I'd better not screw this one up!"
Emily Silverman
Well, it was a wonderful closer. So, in this story, you talk a lot about the value of improvisation and spontaneity in patient interactions. And I've been thinking a lot about this, and about whether it's something that we need to learn how to do, or whether medicine does something to us that we then have to unlearn. So I'm wondering what you think about that?
David Elkin
Yeah, all of the above. I think, for me, modeling this for students and residents is really important. I mean, I was really risk-averse. And the story, as I told it, doesn't really reflect the panic that I felt when I went into that room in Colorado, in the hotel, and I realized that I was going to be trapped with people that I knew for 90 minutes doing improv, because it just terrified me! I'm not a performer. And, for years, I struggled with, you know, what kind of interactions do I want to have with patients? I want it to be better. I don't want it to be a checklist. I want it to be natural, the way I saw, like my former boss doing it. He turned out to actually have theater experience and I didn't realize that. But I just wanted more. But it was always a kind of pale imitation of other people. And it wasn't really my voice that came out until I discovered, like, the whole principle of Narrative Medicine, the importance of the story. And then finally, the improv idea, which really transformed the way I look at those interactions and think about them. I mean, it still does every, every time.
Emily Silverman
You said that, in the story, you didn't have time to go into the panic that you felt when you walked into the room. Bring us into that panic a little bit. I mean, I think most people understand being shy and not wanting to perform. But I feel like there's something more than that. It's...it's also having to do, and correct me if I'm wrong, with the lack of structure? And we physicians are very comfortable with structure. So tell me a little bit more about the trepidation and then how that evolved over the course of the workshop.
David Elkin
So I went into the room, and things were underway, and I didn't have the instructions. It was like a bad dream, where you come into the room, you don't know what you're doing, and you're just forced to kind of go along with it. And I've never been much of a performer. Especially growing up, I've been a bit of a wallflower. I would retreat when there were times when we had to do debate or singing in class. I was, you know, sick or nowhere to be found, trying to get my way out of it desperately. And so when we came in, I just felt all this performance anxiety. Clearly, we were going to be asked to do all of these different improv exercises. People were already doing it and I didn't see the fun that they were having. I just saw my own hesitation, if not terror. And it was a visceral reaction. I wanted to turn and get out of the room as quick as I could.
Emily Silverman
I think a lot of healthcare workers and physicians, especially, would have reacted similarly, with fear. I think there's also quite a few physicians who would react to a workshop like that with derision. Like, they would look at it and think, "Oh, how silly. How stupid. This is such a waste." Did any of that come up for you?
David Elkin
No. It's a great question, and there's a lot of skepticism. Why are we doing this? How can this possibly relate to what we're doing? And I think it fits in with this idea that medical training is, to some extent, an attempt to shape people into a certain mold. And I see the wisdom of that. But I think it has to be balanced. We need our individual stories. We need time to play, to have fun, to do more than just run through checklists. And I guess, for those people, I would say at least try it out. But I know there were people who have resisted that, who I think it may be good for. I’ve had trainees and other people who are more advanced—and they don't see what the link is. They don't understand it.
Emily Silverman
And for you, the link was very direct, because later in the story, we have you and your resident, walking into this patient room and the interaction isn't going well. And then, the lessons from the workshop float back into your mind. And the one that you say is "Use what's in the room." And so then you look around the room, you see the photos on the walls, and you ask about them. One thing I'm wondering is, a lot of people who go into medicine are curious people, are good people, are good conversationalists. Do we need these workshops, in order to tap back into that improvisational side of our brain?
David Elkin
Yeah, I think we get a lot of messages across to the trainees about, you know, be a good person, be curious about your patients. But then, I think a lot of what's modeled for them is very much about getting the symptom list down and making sure they've done a complete job. And we fear that we won't do those things—we, obviously, are very responsible, and we want to do a very thorough workup on our patients. But I think we lose that gradually. And part of it is maybe the tyranny of what we all internalize and think, expect ourselves to do under those circumstances. And so we don't do that.
And it's interesting to me, even four days ago, I had the same experience where our resident was really struggling to connect with a patient who was growing more and more irritated. And, you know, it's a last-minute, Friday consultation, and then I happen to glance on the wall, where they list like the date and the patient goals. And under goals, someone had scrawled, "To survive another day, to fill better." Like...so it's "feel better," but misspelled. And I realized the patient must have written that. And I was just reminding myself to try to take in the entire room, like really look around. And I have to remind myself, because when I came into the room, I didn't see those things. And I think we all need those reminders. We somehow focus too narrowly. And I think that's the potential downside of any analytic field. And some of the training that I've had has actually been in things like art, where I'm really trying to train my eye to look broadly. So looking at what the patient presumably had written on the wall just a few days ago really helped me to connect with the patient. I didn't say anything about it, but I used it to inform myself: this is a patient who doesn't know that he's going to survive another day. But that's very difficult and I have over 30 years out of residency. So that's almost 40 years since my first clinical experience in medical school. And so I feel like I'm still learning.
Emily Silverman
You talk about the tyranny of the agenda—the tyranny of the checklists. I love that. And, you know, obviously, we can't discard the agenda. We can't discard the checklist. But it's so easy just to be consumed by it. And I'm wondering, like, why do we retreat into the agenda and the checklist? Is it about time scarcity? Is it about fear and using it as a crutch for interactions?
David Elkin
I think that's a great question. There's such a rich set of answers that are possible. I think a lot of things are happening simultaneously. I think people are, again, trying to do a really good job. They're trying to take on a professional mantle. And we all feel imposter syndrome. And we think that if we just act like a healthcare provider, then the rest will follow, hopefully. And it's a little bit scary to just enter into a conversation with a patient in a more casual tone.
But I've reminded myself that all those things are possible and I still managed to get the data and be thorough. I leave myself five minutes at the end, and I'll say, "Okay, here are some things we haven't talked about, but I just want to check about. Have you been feeling depressed? Have you ever felt the opposite of depression, where you felt manic? Have you ever had psychotic symptoms? Have you felt suicidal?" And I'll remind the patient, “I'm just trying to be thorough and here are the things that I forgot.” And having that gives me a sense of comfort because I know that I can quit quickly and efficiently come back to the checklist, if I need to.
But I'm also amazed at how often, I realize, I've gotten most of the information just from talking casually with the patient and just by being in the room with them. And it just makes it so much more interesting and lively. And I love that. But I also want to be clear, there are times when I get thrown off, and I get flustered, and I retreat back into the checklists. And I get very officious, like, "I'm the doctor here, I need to know what's going on." And, for the most part, patients don't necessarily respond well to that.
[MUSIC]
Emily Silverman
When we go to medical school, we learn all of these skills—we have all of these tools, checklists, but also, like, mnemonics. So there's, you know, to ask about pain, like, I think PQRST or something like that. Even for depression, there's like the SIGECAPS. You know, we kind of cram everything into these frameworks, and those frameworks are tools, and they can be really useful.
But this other stuff that you're talking about, the looking around, taking in the room, being curious, asking questions, leading into the conversation in a more casual way… we don't really talk about tools for that. You know, that's just the human stuff. Like that's just the stuff that you should be good at. But it's interesting to hear you talk about how we have tools for that, too. And how this improv workshop supplied some of those tools. So, bring us into your toolbox a bit. I know that you only did this one workshop in improv and you're not necessarily like an improv expert. But what are the tools in the toolbox? And how do we use them to toggle between the agenda and improv?
David Elkin
I think about the basic tools, maybe being the...first of all, for me the story. That I want to get the patient's story. I want to know who the patient is. And as an exercise, I've challenged myself and also the students and residents to leave a space. So, at least with one of the patients that they work with, just ask them, "Who are you as a person?" and see what they do with the question and not start with, "What brought you to the hospital?" or "What brought you to the clinic?" Because that is the way we start out and it's dehumanizing in many ways. It says, "I'm only interested in you as a disease, rather than I'm interested in who you are."
And it really is an amazing experience to interview a patient by starting out and asking them about themselves. And it doesn't have to take a lot of time—it can be five or 10 minutes. But then when you're finding out about their illness, and you're asking about how it's affected them, you really get a sense of who they are, and what that illness represents to them. And you get a sense of the challenges for them, and what are going to be the difficulties, and how you can help them.
So, I think, the story is one of the most important tools that we have. And then, other tools, I think, the arts, the humanities—I mentioned art a little while ago—but learning to look around the room, learning to take in what's there. That, for me, is always an important step, because there's so many interesting clues. Are there cards? Are there flowers? Is there nothing but hospital-provided equipment—which says a lot about a person who's very ill, right? If there's no one leaving anything for them, maybe there's no one coming to visit them. There's often so much information and data there about who the person is. And that, in turn, links to another tool, I think, which is just being aware of all the connections with the group: in the family, friends, the society, the culture, the different stresses, the different ways in which people feel uplifted.
If that sounds a little bit overwhelming, it should, because I think a lot of people would argue that's not what medicine should be about. We should have a more narrow focus, so we're good at what we do. And I guess my rejoinder is, can we be really good at what we do? Can we be effective? And can we make sure that our patients feel heard, and make sure that they're motivated, and make sure that they're really getting good care? And can we—without focus on the patient stories—can we be okay? I mean, I look at burnout in healthcare workers. And I think, "Maybe that's because they're so close to the water, but they're not allowed to drink it." We have so little time and we have to race through everything, and we just don't have time to get those needs met. A career in medicine should be an amazing thing. It should be, "Wow! I've got this time to spend with people at their most vulnerable." If you're constantly surrounded by that, but you don't have time to delve into it, or in my case, not feeling like you have the tools...how is that going to feel after five years or 10 years or 20 years, even if you've achieved what you think are your goals? I finished training. I got the job that I wanted. But if your work doesn't take you to those deeper places, what happens to you? What happens to your spirit? What happens to your conception of yourself in relation to your work?
Emily Silverman
I love those tools, you know: who are you as a person? Looking around the room, taking in the environment. And it doesn't have to be as lofty as, "Tell me your whole life story." You know, at the VA, "Tell me about, you know, this war," or even necessarily, like, "Tell me your deepest traumas." But I found that even just a simple shift can be helpful. So, for example, in your story, the resident goes in and just sits down and says, "We were called here because you were suicidal, and then proceeds to go down the checklist." And in medicine, that happens a lot, too. So we'll walk in the room. And the first thing we'll say is, "How's your chest pain? Let me see your leg. Let me see the infection… is it getting bigger? Is it getting smaller?" But a simple question, like, "What's on your mind this morning?" can really create an opening.
And I remember there was this one time that we were trying to talk about the medical issue, and the patient was distracted and not really engaging, and so that I asked this question, like, "What's on your mind?" And the patient was really concerned about their dog, and had spent the entire morning calling and texting people and trying to get care for the dog. And that was really the thing that they cared about the most—more than their medical issue. Even just becoming aware of that as a team, and then checking in every day, like, "Oh, did you ever find someone to take care of your dog?” can really help. So I like those tools a lot.
The most famous lesson of improv is "Yes, and..." and so I'm wondering how does "Yes, and..." apply in a medical context?
David Elkin
I think...one question for me is, what does the culture of medicine look like? And when I look around now, especially after that experience with improv, I just see medicine is having a lot of "Yes, buts." You know, we ask the patients to tell us about their problems, but then we interrupt and we say, "Yes, but... but I want to hear about this, I don't want to hear about all those extraneous details." And being open to "Yes, and..." means really accepting whatever happens. And there's a great poem, I think, by Wallace Stevens about open rooms and being open to all these different ideas.
So, in the case of our patient on Friday, that patient was really angry. And it would have been easy to react to that and say, "Well, this patient shouldn't be acting that way." But clearly, there was a reason they were angry. And I think the clues were on the wall—the patient feeling they weren't going to live another day. I think that's "Yes, and..." It's like, "Why is the person so angry?” Don't just react to it. But really, think about it. Embrace it. Take it on. Everyone's trying to do a really good job; the resident in the story that I told was so good—is so good. But being open to things—saying "Yes, and…”—really takes us to some pretty unknown places. Even if people are saying things and they're really psychotic or delusional, I think you have to kind of go there with them a bit. You don't want to lose your anchor into reality, because that's going to pull us all down. But I think we need to open up a little bit more to our patients sometimes. And we need time to do that. It's not just our interactions with patients. This is occurring in a context where we're all under such tremendous time pressures. I know you've been there because we work in the same place. And we work with the same trainees and they're running around as fast as they can. How can you convince them that you need to take another five or ten minutes with someone? I mean, that can throw off someone's entire day. And that's the cataclysmic fear that I think we all experience: "I'm going to fall behind." So we need systems that encourage a "Yes, and..." approach also.
Emily Silverman
I think that's a great place to end. Thank you so much for sharing the story with us. And thank you for coming in to speak with me today. Is there anything else that you'd like to share before we finish?
David Elkin
I guess just huge thanks for the opportunity. For me, performing as part of The Nocturnists was just an incredible experience. I hadn't realized the entirety of what I was sitting on with it. And I never really experienced the idea of putting this together as a story and performing it. And it's opened up so much in my life. So I want to express my appreciation to you and the rest of The Nocturnists team and to the listeners, I guess out there also, just to encourage them to hang in there, and to try to remember who you are.
Emily Silverman
Thank you. Thank you, David.
David Elkin
Thank you, Emily.