Conversations: Jay Baruch, MD
SYNOPSIS
Emergency medicine physician and author Jay Baruch speaks about his memoir, Tornado of Life: A Doctor’s Journey Through Constraints and Creativity in the ER, which explores ethics, stories, and uncertainty in the emergency room.
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Guest
Jay Baruch, MD is an emergency physician, medical educator, and a writer. His interdisciplinary academic work is rooted in the role of creativity, the arts, and narrative as clinical skills for embracing the uncertainty and complexity at the heart of clinical decision-making and caring for others.
Dr. Baruch is a Professor of Emergency Medicine and Director of the Medical Humanities at Brown University. His books include What's Left Out; Fourteen Stories: Doctors, Patients, and Other Strangers; and, most recently, Tornado of Life: A Doctor's Journey Through Constraints and Creativity in the ER.
CREDITS
Hosted by Emily Silverman
Produced by Emily Silverman and Jon Oliver
Edited and mixed by Jon Oliver
Assistant Produced by Carly Besser and Rebecca Groves
Original theme music by Yosef Munro with additional music by Blue Dot Sessions
The Nocturnists is made possible by the California Medical Association, and people like you who have donated through our website and Patreon page
TRANSCRIPT
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The Nocturnists: Conversations
Jay Baruch, MD
Episode Transcript
Emily Silverman
You're listening to The Nocturnists: Conversations. I'm Emily Silverman. When patients come to the ER with a heart attack or a broken bone, doctors know exactly what to do to make them feel better. But often patients' problems aren't as straightforward as they seem, and ER doctors have to turn to things like storytelling as a way to make sense of their chaotic day-to-day work. This is the subject of emergency medicine physician Jay Baruch's latest memoir, Tornado of Life: A Doctor's Journey Through Constraints and Creativity in the ER. Jay is a professor of emergency medicine at Brown University's Albert Medical School and an incredibly thoughtful writer with a background in bioethics.
In my conversation with Jay, we talk about what it means to bring a narrative lens to medicine, even to ER medicine, which is grounded in the very briefest of encounters. We also talk about the importance of embracing uncertainty, which is a very timely topic, since The Nocturnists is planning to produce an entire podcast documentary series on the topic of uncertainty next year. But before we go on, let's hear an excerpt from Jay's book, Tornado of Life.
Jay Baruch
Hug, or Ugh. Fawn was bouncing on the edge of her stretcher, a homeless woman in her late fifties, feet drumming on the scuffed tiles like that of an impatient schoolgirl. She was hurling insults at EMS when they rolled her into the ER. They had found her asleep outside the police station. The triage nurse knew her from previous visits–mental health problems and substance use, cocaine mostly, sometimes heroin. I extended my hand and introduced myself.
When I stepped into the exam room, she popped upright. "Hi, Doctor," she said, grabbing my hand. Without letting go, before I could even say another word, she looked up at me with desperate, bloodshot eyes and asked for a hug.
"A hug?" I said.
"Yes, doctor," she said. She ranted about living in shelters, and how, sure, she'd made mistakes in her life, but don't believe the EMS bullshit about drugs; maybe a little crack and a nip here and there, but she's no addict, and what can she do when she has nobody, nobody, in the world to prove them wrong. "Just a hug?" she begged.
The weight of each passing second counted against me as I took in her sun-roughened face, the wrinkles scuffed with dirt, and her dirty jeans and oversized t-shirt. The air around her smelled of someone going through a tough time–old sweat, stale cigarettes, and greasy food. In my emergency medicine education, I was trained to respond quickly to a wide variety of urgent situations. At no time did I come across one that was urgent in this way. My muscles tensed. my heart cramped.
I opened my arms.
We hugged.
To be completely honest, she hugged me.
Emily Silverman
Thank you for that reading, Jay.
Jay Baruch
Thank you. It's great to be here, Emily.
Emily Silverman
It's great to see you. I think last time I saw you, we were in Ireland.
Jay Baruch
It was fantastic.
Emily Silverman
For the audience, Jay and I have met in person a couple of times in Providence, Rhode Island, which is where you're based. And then also, most recently, this summer, in Galway, Ireland, at the dotMD conference, so... That was so much fun, to hang with you there.
Jay Baruch
It was. And your family, and to hear you speak. It was fantastic.
Emily Silverman
So, let's talk a little bit about this book, Tornado of Life. I really enjoyed reading it. And I think one of my favorite things about the book is how you continually come back to this idea of story, and of narrative. But before we get there, I thought maybe we could back up a bit, and you could share with us how you landed in Emergency Medicine.
Jay Baruch
I get that question a lot. I never intended to go into Emergency Medicine. I was an English major in college, and I thought I was going to be an English professor and, and write... And my love of stories actually emerged from a couple courses I took as an undergrad, one of them which involved going to a local hospital and talking to patients. Like, what else could I do, as an undergrad student, without being dangerous? And, one week, I was working with Pastoral Services faculty there, and I really found it profound. And then, the idea about medicine, and perhaps being in a position to impact those stories, started evolving. And then I went into Emergency Medicine, because I was terrified, and invigorated, and there was a social justice mission in Emergency Medicine. And, it felt comfortable for some bizarre reason, the chaos of the space. I felt comfortable in that space, and it felt like home.
Emily Silverman
So, how many years have you been practicing Emergency Medicine?
Jay Baruch
I am coming upon year 30.
Emily Silverman
How does it feel in your body to have been doing this work for 30 years? Do you feel like it's taken a toll? Or do you feel like it brings you energy? Or...? I don't know. I just feel like if I were in the ER that long, I would just be so tired. But I'm curious how it feels to be on this side of it.
Jay Baruch
It's both those. It's both invigorating... It still is. But, as a body that is slowly breaking down and doesn't sleep well... I'm like one of those old houses, right? That you look at, and you go, "That's not a bad looking house over there." But then you get in, and you you do the inspection, and you go, "Wow, there's a leak here. This wiring needs to be redone." As someone who still does overnights, and I'm still recovering from overnights, your body doesn't lie. Like we tell our patients all the time... I was, like, "Listen, your body doesn't lie." I can't believe I'm doing it 30 years, and I'm still trying to take a long view about this whole experience. And I don't know. It's a really tough question to answer, and I think I'm trying to answer that for myself.
Emily Silverman
So, because you've been doing this for 30 years, what was your process like writing this book? Because it's such an amazing collection of stories and patients. Are some of them from 30 years ago? Are some of them from last year? And, how did you remember all these stories? Did you keep a journal over the last 30 years? Tell me about the process of this book coming together.
Jay Baruch
For me, I'm always writing. I'm always scribbling, and not necessarily about medicine. Not necessarily about shifts. But I'm always writing. And I'm not writing to write. I'm actually writing to... to understand, and to process, and to think through things. I think differently on the page. Something happens when you start trying to take your experiences and putting language to them. And so, the short answer to your question is some of these pieces are very old. And, yes, I wrote about them, in some shape or form. And, the most recent ones are those that had to deal with COVID, because that was sort of unavoidable. But I don't know what I'm going to write about. I try to find distance, if possible, when I'm sitting down to put something in writing that might be public facing.
Emily Silverman
So you've probably seen hundreds, thousands, maybe even hundreds of thousands of patients, over the last 30 years. What do you think it is that makes certain patient encounters stay with you? Or, what makes them memorable? Because, I'm sure there's also a degree of amnesia, where you just... You're seeing so many people; there's no way you could remember them all. But what do you think it is that makes certain moments, certain encounters, really light up for you?
Jay Baruch
I oftentimes discover that by sitting down and writing, and you're finding out what it is that actually makes you write about a particular experience. Oftentimes for me, I write out of morally distressing situations. I try to figure out what I can't understand, things that I wish went better. When I behaved, perhaps in ways that I wish I hadn't, or thought things that I wish I didn't feel, and trying to play with that on the page. And, what happens is... And, I think you probably see this too, in your own writing, that there ends up being certain themes or certain fascinations that you bring, that repeat themselves. You discover certain challenges that intrigue you. And it becomes more evident when you're putting those experiences on the page.
Emily Silverman
Yeah, I think one thing that really stood out to me about each of these chapters, is just the thorny ethics of all these situations. You have a chapter about, "Should I prescribe Vicodin to this person? This is just so complicated, because they are in pain, but how much are they in pain? And what about addiction...?" And that's just such a fraught topic. You have things about caregiver burnout, and people who quote unquote, "dump" people at the Emergency Room, because they need a break. You have end-of-life stories. Even the story that you just read from, about the patient who asks you for a hug, and to see you puzzling through on the page. There's a lot of people out there who are, like, bioethicists, and they take these questions, and they explore them through research or ethical frameworks. And I'm curious if you've ever done it that way, or if you've always found that just narrative, and creative nonfiction, is the way for you to navigate those difficult ethical situations.
Jay Baruch
A lot of my early work emanated from my work in Ethics. So I did a fellowship in Bioethics, and my framing at that point in time... Because I don't consider myself a philosopher... (I probably know enough to be dangerous.)... but, it was narrative. And for me, Ethics, at least Clinical Ethics, is so rich, and so wonderful to pursue, because we're entering a situation at the high point of a story. We're getting called in at the very moment when there's tension, when there are obstacles, when there are people who will look at a particular situation with conflicting values, interests, needs, understandings of what's going on. And yes, it's important to have a moral and ethical framework from which to examine these experiences. But I oftentimes found that my understanding of how stories operate, and what motivates people, and paying attention to language and dialogue, and what's said, and what's not said, is often equally vital to understanding these moments. So, I feel like there's room for both; you need both. You need people who are thinking more broadly and more deeply. You have much bigger brains than I do. But I also feel like we need people like us, who are doing this very specific narrative inquiry, because you learn from both. From the particular, you can actually extract out some universal ideas and themes as well. I think you have to get small.
Emily Silverman
I think that's so true. And it reminds me of this profile I recently read, of the famous actress Cate Blanchett.
Jay Baruch
Yeah. I love her.
Emily Silverman
And she just starred in this movie Tar. And the journalist is doing a profile of her, and at some point, Cate Blanchett dashes off an email to the journalist, and she's like, "Hey, I really love this poem. Like, check out this poem." And so the journalist reads the poem, and she's trying to figure out what is it about this poem that got Cate Blanchett excited? And so then the next time they meet up, she's like, "Hey, Cate, you sent me this poem." And, actually, Cate Blanchett kind of forgot. Like, didn't even remember sending her the poem. And then the journalist said, "Can you tell me what is it about this poem that struck you, or that stood out to you?" And Cate Blanchett kind of got annoyed. Like, not in a mean way, but she was like, "Ugh, I don't know. Like, can't the poem just speak for itself?" Like, I think Cate Blanchett is just so smart. And she talks about how there's this irreducibility to art. Where if you try to summarize it, or put it in a framework, it loses something, something intrinsic about that complexity, or maybe those innate paradoxes that just can't be experienced or understood in any way but in that artistic form. And so... I don't know, as you're talking, I'm thinking about that and wondering if that resonates at all?
Jay Baruch
Oh, absolutely. I feel like what you're getting at, and what Cate Blanchett is getting at, is our fascination with mystery. I feel like in medicine, we're constantly trying to explain. We're trying to find the answers, trying to find solutions. And there's reason for that. It is incredibly important that we do that. There are a lot of problems that have answers, and we need to make sure we identify them, and do our best to rectify them or have some kind of solutions. But at the heart of everything, we deal with people. People going through very distressing times, or going through very distressing experiences, very complex experiences. And some of these problems don't have answers, but they still deserve our attention and our concern, and we can always have a meaningful response to them. Just honoring that; just letting the poem be a poem.
Sometimes we just have to let patients tell us about their experiences, because that's incredibly important. To dignify their stories, to dignify what they're going through, is sometimes as important, if not more so, than necessarily giving them some answer that feels false or inauthentic.
Emily Silverman
I love this comparison of a patient to a poem. I think that's so beautiful. And that brings me to what I mentioned earlier, which was how you keep bringing the lens of story into your work as an ER doctor. And, at one point, you say, "Sometimes working with patients in the ER feels like a messy first draft." Or you say elsewhere, "Sometimes an ER shift can feel like managing an endless montage of experiences, where I serve as editor." So talk a little bit about ER Medicine as story.
Jay Baruch
You asked earlier about, like, how can I do this for 30 years. And, I think at the core of that, of what keeps me going, is a fascination with patient stories and what they're going through. And I go to work and I... I listen to 20 to 30 patient stories a shift, at least. And, at the core of everything, I'm, like, a pressured story listener. And trying to get to the heart of their story, where there's so many constraints. I also called the ER "a narrative disaster zone". Unless we know what we're dealing with, we're rushing to answer. We're rushing for solutions. And so many of the challenges that patients come to the Emergency Department with are fraught with uncertainty.
We talk about physicians and medicine; we have to be more human. But it seems to be like the answers to a lot of the challenges that we're facing nowadays is actually to remove the human, and the human interaction, and to either diminish or blunt the stories that patients are telling us, through electronic medical records and various algorithms. And we're trying to take these experiences that are so vital, eliminate them, or at least putting them at a distance, in the sake of trying to... I don't even know what we're trying to do anymore, to be very honest with you.
What's so troubling about what we do, is uncertainty. I realized that when I came out, I was so nervous about... Like, I had a list of, like, diarrhea moments, things that I need to know, and, if not, I was gonna have diarrhea. And I'm so old, I had them on little index cards with prompts, and making sure I understood, like, anaphylaxis and codes and intubating drugs, and that sort of thing. And you realize the things that you thought were going to be scared of, you knew what to do. Yes, they were terrifying and frightening, but you knew what to do. And it wasn't till I was, like, a couple of years into my attendinghood that I realized that the things that frustrated me most, that gave me the most difficulty, that sent me home at night churning, keeping me up were those moments that were fraught with uncertainty. And then what was both interesting and reassuring and comforting, was that I realized that what I needed was actually to lean on the writing skills that I had developed from early on in my other life... I thought was my other life... as a struggling, evolving writer.
Emily Silverman
It's so true that physicians struggle with uncertainty. We love control; we love answers. But you also talk in the book about how much patients struggle with uncertainty in the ER as well. Even something as simple as: I'm sitting in this room, when is the doctor gonna come in this room and evaluate me? Is it two minutes? Is it twenty minutes? Is it two hours? Is it two days? You know, sometimes it even feels like that. And there was a part of your book where you say, "We must pivot from what's wrong with the body, or what's the answer to this problem to different questions. Namely, what are the obstacles and the stakes in this person's story, and why? How does what happened square with what they expected to happen? One can't care for patients without working in the fields of their expectation gaps." And I was really interested in this idea of the expectation gap because I feel like that's kind of related to uncertainty. But It's also really concrete. Like, we talk a lot about how it's so important that we work with this slippery substance of the patient's story. Tell us a little bit... Like, if you were going to teach a med student how to work with story in the ER, maybe the expectation gap is a good example. Like, how do you identify an expectation gap? And how do you honor it and address it? And, maybe, what's an example?
Jay Baruch
What's so great about the idea of an expectation gap... (It's not my idea. This is basic to storytelling.) We're really respecting the anatomy of all stories, which is you end up having a captivating character (our patients) who want something that's incredibly important to them. They have these desires. Whether it's to get better, whether it's to put mom in a nursing home because I can't care for them anymore, they want answers. But there are some obstacles in the way. And those obstacles are what our patients face, and what we all face to some degree. And so, we want to see what people do; are interested in finding out what next. It's that gap is like what happens and what expects to happen.
And if you think about it, medicine exists in that expectation gap. Not just from what patients want from us, what we expect from them, what we expect of the system. And so, when a patient gets upset... "I've been waiting two hours," for example. It's not necessarily time that is the issue. Sometimes it is. It might be the fact that two hours feels like two days (as you said) to them. But also, "God, you know, I have this terrible pain, it says "emergency". Where does waiting equate with emergency?"
Emily Silverman
Right.
Jay Baruch
And especially, two hours or four hours right now; eight hours, ten hours in some places. And, it seems untenable. And just as it's untenable and unconscionable from a patient's perspective, it's also untenable and unconscionable from our perspective. I wrote a piece once where I heard from some readers, and it goes, "I didn't realize that doctors get upset about our waiting too".
Emily Silverman
And so, maybe the lesson that flows from that, the lesson to this hypothetical med student, is... And, I think you say this at the end of that particular chapter, when you step into the room to just always say, "I'm so sorry for the wait," even if the wait was only two minutes. And maybe that is the act of honoring the expectation gap. Or, I don't know, is that a good example, do you think? Or is there a better example?
Jay Baruch
I also feel that it has a lot to do with curiosity, which we probably don't talk about enough in medicine, to understand another and try to appreciate what they might have thought was going to happen and what actually is happening. And a common challenge that we oftentimes face, is that when patients come to the Emergency Department, they don't just come to the Emergency Department. They come into the hospital, with all this big infrastructure, with all these resources. And they expect, like, they have access to all these resources, which oftentimes isn't the case.
And even something as simple as just a bed. One of the pieces in the book had to do with, like, what do you do with a patient with unstable housing and chronic alcohol use disorder, who comes in every day, if not twice a day, who has been offered services and has burned a bunch of bridges, and it's freezing out? And, you have that window of when to discharge them before they go into withdrawal. We'll give them some medicine for their alcohol withdrawal, which will sedate them and keep them til morning. But you have no beds, because all the beds are taken by admitted patients. You have like three functioning beds, and you have an Emergency Department filled with waiting patients. What do you do? What do you do?
And I coined the term "compassion confusion". Being compassionate to one person, like that person in the waiting room, means being less than compassionate to this particular gentleman, and vice versa. And I hear a lot. When that piece came out, some people were like, "Thank you very much for putting voice to something like that, 'cause we deal with this all the time. It feels terrible." And I also had people who said, You're a cold and heartless doctor. Of course, you have space in that big Emergency Department, that big hospital, for this person." And, I think it speaks to the larger issue of just the great needs that our communities have, and also the fact that, I think, the Emergency Department has become this de facto rescue safety net, but a safety net for so many different things nowadays. And it's challenging.
Emily Silverman
As you were talking, I was thinking about this idea of the expectation gap, and I was remembering when I was a hospitalist at San Francisco General. Often what would happen is somebody would come in, usually with diabetes, and they would have like a wound on their toe. Toe wound would get infected; they would get admitted, get antibiotics. And then the Podiatry/Ortho team would come to look at the wound, look at the toe, and they would say to the patient, "You need a toe amputation." And the patient did not expect that. It's kind of like that idea of the expectation gap. Like, maybe they thought they just needed some antibiotics, and the wound would heal up. Like, "You're gonna cut off my big toe? I didn't expect that!"
And the patient would actually decline, or sometimes in the chart, they would say "Patient refused." So these surgeons would come to the bedside; stand around the patient and say, "We want to cut off your toe." The patient would say like, "Well, I'm not so sure about that." And then, the surgeons would leave a note in the chart that says "patient refused surgery", so we're gonna sign off.
And I just remember thinking to myself... You know, because then I would pick up the patient. And I would say, "So what are we going to do? Just do a bunch of antibiotics for six weeks?" And often, it would just take a few days. Like, I think the patient just needed a few hours or a day or two, just to get used to the idea that they were not going to have a big toe. And I feel like we need to be accounting for that expectation gap in our care, and moving (if we can), not that much faster than the rate of them being able to emotionally metabolize. Because then you would call up the surgeons, and you would say, "Okay, it's two days later, and they're ready for the amputation." And the surgeon would say, "Oh... Well, I just looked up the note and it said that they refused." And, I don't know. Maybe that's another example of how we just ignore the expectation gap and just ignore the emotional experience, and submit to algorithms. And it's like, "This is an infected toe. It needs to be amputated. We can do it today at two o'clock," and just not...not accounting for that.
Jay Baruch
Yeah, you know, you end up having patients oftentimes who come in, like, with their gall stones, and say, "I've had enough, I need to have my gallbladder out." Or, "I need to go into rehab." Or, "I need to see a psychiatrist." Sometimes it's people who just are not ready for the terrible news. "Mom's weak and dizzy...", and you're giving them devastating news, that it's not just weak and dizzy.
But there's also, I feel, the sense that our system is failing a lot of people. It's just really hard, because you want to be able to do as much as possible for people, but I think there is an expectation in our healthcare system to... to be able to provide. But I feel what people want is oftentimes not what we think they want.
Recently, someone came in with respiratory complaints and, in the end, what they really were seeking was psychiatric help. And how do you go from a straight complaints to psychiatric help? She just went into details when I asked about medications, about her psychiatric medications. And I go, "Huh. How you doing with that?" And then she looked like she was gonna cry. And so, it's not only that we give people news that they don't expect, we rock their world a little bit. And it's not just the toe, right? It could be the fact that the toe means that this person can't do their job anymore, or they have to be away for two weeks, or their loved one is gonna be upset with them because they had been not taking their insulin. It's so multifactorial.
Like, what we think is the reason why someone may or may not want something, whether it's an amputation of their toe, or end-of-life measures, is oftentimes has nothing to do with a medical issue. Sometimes it does, but oftentimes it has to do with the contextual features around that. And, it's around the challenges that people are facing, and a pinky injury to a construction worker oftentimes is taping up, and they're going back to work. And if you're a concert violinist, it can be very, very different.
Emily Silverman
You talk in the book about this idea of narrative errors. How do you think about this idea of narrative errors? We talk in the hospital a lot about medical errors, and there's entire systems constructed to identify those errors and prevent them from happening again. To me, it feels like narrative errors happen all the time, and we just don't talk about it the way that we do about medical errors.
Jay Baruch
No, we don't. An example of that is... Like a lot of big city hospitals, we have a lot of patients who come in; who just come in because they're intoxicated. They don't have stable housing; they're on the street, they get brought in. I know it's a regular thing for you all in San Francisco, as well. And invariably, we'll miss something. Somebody had fallen, and they couldn't tell us, and we missed a brain bleed, or they were actually septic, or their electrolytes were out of whack. And then we'd go back, and we'd have these M&M's, and we'd say, "Remember to always do x." And the truth of the matter is that, oftentimes we just don't think about them as patients in the same way, because they always come in just for housing issues, who likes to sober up. And so, we're not necessarily giving them the same narrative attention that we would if we were seeing you for the first time.
Another way narrative errors, I feel, operate is that when you're listening to stories, it's not just about the story being told. It's like what we bring to the story. And, as I write about, if you have a couple of patients, let's say, who are seeking narcotics, for example. And then you have someone, a patient who's in pain, your previous experiences of those couple of patients, before this particular individual, might color your response. And even just the tone of your voice, when you're talking to this particular, this fourth or fifth patient. And we don't necessarily talk about the contextual features that impact how we understand stories.
And, you mentioned before, about stories being first drafts, we treat stories as this thing that we just get. How many times have we just told medical students or interns, "Go get the patient's story," as if it's like this jewel that we just bring back. But we know that stories evolve. Patients are trying to understand their own story, as they tell it. And oftentimes, they amend their stories to each person that they meet. Like, the story that they tell the triage nurse might be a little bit different and might evolve from the nurse when they finally get back there, and maybe the resident sees them. Then I get... And I might pick up something. And I like to think that if I picked up something that no one else did, it's because I'm old as dirt, and I've been doing this for 30 years. But oftentimes it's not. It's simply because I got the fourth draft. And so, there's so many different ways that this idea about narrative errors manifests itself, not just in how we treat stories – its not a puzzle to be solved. It's a mystery to be understood.
And also, it's like what we bring to the stories, and what we bring to the experience, and how we listen. All the time, we talk about listening, as if... You got to hear, but you have to listen better. But it's really listening as a construction. Like, we're picking out details. We're making value judgments about what's important information and what's not important information. And so, we're actually making decisions even before we think we're making decisions. And, I think all that goes into this idea: Can you construct models of understanding around sort of quote unquote, "narrative errors"?
Emily Silverman
Can we?
Jay Baruch
Yes. At one point, I thought I was onto something really brilliant. Isn't this amazing? Like, what we do, right? You come up with a brilliant idea, or what you think is a brilliant idea, and then you start exploring it in more detail. Then you realize other people have thought about it and wrote about it. Like, not just a couple of years ago, a decade ago. And I feel like we just don't pay enough attention to the complexity and uncertainty of medicine. The remedy for uncertainty isn't certainty. It's actually learning how to use uncertainty. Like, how do we alert ourselves? How do we alert our minds to when we're feeling uncertain? Because uncertainty has a feeling to it. I don't know how you feel, but I feel lousy. I joked around about how it feels like a mild allergic reaction. And, when you're in that way, what you want to do is not feel that.
Emily Silverman
Right.
Jay Baruch
But it's important. Again, let's return back to the poem. The poet Mark Doty wrote about how it's really important for a poet to exist in, and use uncertainty. Like, how do we learn to make uncertainty our ally? And again, I think it returns back to trying to pay attention to process. We're so focused on outcomes, and with good reason. But I don't think we have to put all our attention to outcomes alone. I think we have to also pay equal attention to process. And these are art space skills. People who are experts on uncertainty are artists and designers and people who actually, not just are comfortable there, but know how to use it. I think we have a lot to learn as clinicians of all types, from people who are more creative.
Emily Silverman
In your book, there's an anecdote where a dean at your medical school, who's an internist and researcher, tells you, "Emergency Medicine is to Internal Medicine, as the short story is to the novel, and there are no great short story writers." So maybe they were trying to convince you to switch over from Emergency Medicine to Internal Medicine, but talk a little bit about this idea of, like, primary care as the novel: cradle-to-grave, long, long, long story. A long narrative thread followed over the course of decades, versus this idea of the short story in the ER. I think you say somewhere else... I think it was a quote from Anton Chekhov, one of the greatest short story writers of all time, who as you point out, also happened to be a physician, talks about when he plays with his characters in the short stories, when the story ends, he returns them to life. So maybe you could share that with our audience, and I would love to hear more about the novel versus short story.
Jay Baruch
I feel like that comment is very much of its time, when the design of the healthcare system was different, and we had internists who were following their patients and caring for their patients in the hospital. And I love that. I mean, I have to tell you, like, I was one of those ER docs who went into Emergency Medicine because I loved everything. I loved Internal Medicine. What I learned from my Internal Medicine colleagues is that they're facing now the same challenges that I'm facing, which is they have very little time to do the things that they love to do. But, in that short period of time that I had with patients, you understand... Like, stress stories are like concentrated moments of someone's life, and it's incredible how much I can learn about somebody in that amount of time.
And time has often been used as a crutch. I gave a talk years ago, and one of the emeritus Internal Medicine professors who I just thought was so extraordinary, said to me, "You talk about story, but you're an ER Doc; you have no time for story." And I said, "But that doesn't stop people from coming to the ER, bringing their stories." I think you're right. But we have to bring as many tools as we can to our work, and as many tools we have in our toolbelt helps us care for patients.
And so I take the long view, which is... Like, in any story, right? Oftentimes, there's a backstory, and it's there, and you have to be mindful of when that might be relevant to this particular experience at hand, and you also to pay attention to the future. Like, and what happens when they leave you? What's off the pace, as you say, and then they go back to their lives. And I feel that patients welcome that type of attention, when you ask a particular question. So you're not just listening to their symptoms, and just regurgitating an answer, but actually want to know how you got here. And one of the challenges we have... When we're stuck as writers, one of the first things I've learned to do is not to force things forward. And again, going back to narrative errors... I made this fit. You made this fit, rather than taking a step back and saying, "Mmm. I don't like the way this is feeling, so I'm trying to force it." But really the move is actually to look backward, and to find out, "Hey, how did we get here?" What are the questions I should be asking? What don't I know, that perhaps I should? What is the patient not telling me? I think that takes practice. And I think the first step is just honoring and making space for those types of conversations and that type of inquiry.
Emily Silverman
You used the word "backstory" just now. And it reminded me of this experience I had. So one of my favorite singers, when I was in college, was this woman, Jenny Lewis. And I followed her work for a long time. Her songs are very singer-songwritery, very verbal, a lot of storytelling in her songs. And one of her songs is about insomnia, and I've heard her give interviews where she talks about this period in her life where she really just could not sleep. She talks in the interviews about how she would stay up really, really late and watch boxing on TV, and she loved boxing. It was surprising that boxing was the thing that she would watch at three o'clock in the morning, when she was dealing with her insomnia. And, at one point, she invited questions from fans. And I was a fan, so I sent her a question. And the question was, "What is it that you love about boxing?" And she said, "The backstories," and I was just like, "Oh, I get it. I get it now." Because, initially I was like, I'm not a violent person. Like, I just don't understand why somebody would want to watch two guys just murder each other. But, when she said that, I was like, "Oh, it's not about the violence." It's like, how did they get here?
Jay Baruch
That's the story. I mean, the Olympics has the backstory, when they do a little profile of where they came from, what the challenges they face that makes, what they're going through now that much more meaningful to the viewer. It's so fascinating. I love that story.
And I think that it also has to do with motivation, trying to understand somebody. And we talk about compassion, and we talk about empathy. And, I don't know. I mean, I think that those words, they're so important and so vital, but how they manifest, it sometimes feels like husks. And it's not just a script that you use to express empathy. I think it has to do with just being interested. Like, "How did you get here? Tell me a little bit about last year. Tell me about the challenges you faced up to this point." And oftentimes, I tell patients, "Listen, I want you to know and I know you're in pain; I know you're going through a tough time, but you're doing a great job. I don't know how you remember all these medications; you're taking these medications. I know you're frustrated, because you're not getting better," you know, for example. But trying to recognize what they've been doing and what they're experiencing, is manifested in who they are as people.
Emily Silverman
Okay, I have to stop you there. Because we're talking about compassion and empathy, and narrative competence, and my favorite part of your entire book is in the chapter, "Big Incision". This is the story of your own health adventure, where you end up needing heart surgery for a leaky heart valve. And you say, "My leaky mitral valve needed repair or replacement. Suddenly, I became someone in need of a cardiac surgeon." You get some recommendations, two options. Your wife and you arrange to meet these two giants. And so, you come to guy number one. You said, "He came out into the waiting room. He had a pressed white coat devoid of ink and coffee stains; he had a silk tie with a knot. He led us into his office: dark woods, soft chairs, carefully chosen words crafted into lucid paragraphs tailored to fit my ears and those of my non-medical wife. Physical exam matched that of an 'uber-internist'. By the end of the hour, I wanted him as my surgeon, friend, mentor and life coach."
And then you and your wife go into the hospital cafeteria. And you say, "Oh my God, we love this guy. We have this other meeting with the other guy. But we definitely love this first guy." So then you go to the second guy. A maze of cubicles and assistants, navy blazer, leather shoes. He's kind of rude. He gives the impression that he was squeezing you into his schedule; wouldn't bother with small talk about your symptoms. Very matter-of-fact, barely acknowledged your wife, raised your thick medical chart as if it explained everything. He drops it onto the desk and he says you need an operation. "Questions?" And then you say you felt like you were in a Monty Python skit. He discounted your questions. He goes on about everything that you'll need. And then, at the end, he says, "Remember this. Your problem is nothing special. I did two of you this morning." You said you were transported back to the intimidating surgeons at medical school.
So you and your wife leave this encounter, and you pass the framed paintings of famous heart surgeons in the hallway, with their icy stares, and you stop and you face each other. And you both say, "He's our guy." My favorite moment of the entire book. Why did you pick the asshole?
Jay Baruch
I know! I tell that story. And everyone's, like, mouth drops. Like, "What?!" Like, "What'd you do?" And, even to this day, I can't explain it. You know, you realize that sometimes you need a particular type of doctor. And, I felt at that time, I didn't need someone to hold my hands. As I write in the piece, and I go, "I wanted a formidable adversary." I knew this guy's reputation, and I felt like, "You know what? I am going to out-patient this doctor." One of my best friends, who was a cardiothoracic surgeon, told me, "Don't worry about his personality, because you'll be under anesthesia."
That's accurate.
Like, he was an amazing technician and I owe my life to him, but I really pushed myself. Like, I go, "I'm gonna get out of bed before he says I'm supposed to; I'm gonna do my physical therapy. I'm gonna be out of the hospital before he thinks." And I did. And it was the stupidest thing. It was the stupidest thing, because I so wasn't ready. But sometimes there's no neat moral to the stories that we tell. There's no ideal. There's no... We can't wrap things up in a neat package, and we surprise ourselves. And in getting back to what we're talking about earlier, I ended up writing this piece because I was trying to figure that out for myself.
Emily Silverman
Well, I love that piece, I think, because it's subverts expectations. And maybe it is the case that you needed to have that adversarial relationship with the asshole surgeon to motivate yourself. Or, I don't know...There maybe... There was something healing there, right?
Jay Baruch
There was.
Emily Silverman
There was something there, that just worked for you. And I just... I love the unexpectedness of that.
Jay Baruch
And I also was like a rebel patient, because it was like my first time being really, really sick. And before that, I felt like I was young for my age. And then, like, suddenly I was not. And it wasn't enough for me to be a patient. I felt like I was a doctor-patient and people, again, were trying to fit me into some moral parable. If you're going to be a better doctor, now, do you be a more compassionate doctor? And, in some ways that was true; in some ways, that was not. But what I resented was the fact that I just couldn't be sick. I just wanted permission to be sick. It doesn't come from a bad place. It... God, you know, we'd like our stories to come to us in a certain way, and we get uncomfortable when it usurps our expectations. And it's more like life.
Emily Silverman
Well, I think that's a great place to end. Is there anything that you would like to share with our audience? We have doctors, nurses, students and others. What would you like to leave everybody with today?
Jay Baruch
We're all going through such tough times now. Medicine is in a precarious place. And it can feel overwhelming and sometimes dispiriting. I feel like there's so much that I can't control. But what I can control is the encounter with the patients. Like these small, little moments. And to try to pay attention to those little things, and to nourish them and to recognize that it's those moments when we can be most human with another human, that I feel that we feel alive and replenished and nourished. And to just pay attention to those moments, if you can. It can be hard, when we're going through a little bit of turbulence, to think in those small ways, but I think that's where the power of longevity, and that's where our heart is.
Emily Silverman
Do you think you have another 10 years in you?
Jay Baruch
Oh, thank you so much, Emily. It's been awesome.
Emily Silverman
I have been chatting with Jay Baruch about his book, Tornado of Life: A Doctor's Journey through Constraints and Creativity in the ER. Jay, thank you so much for being here.
Jay Baruch
Thank you so much, Emily. And thank you all.
Emily Silverman
Thanks for listening. This episode of The Nocturnists was produced by me, Emily Silverman, and Jon Oliver. Jon also edited and mixed. Rebecca Groves assistant produced. The Nocturnists Executive Producer is Ali Block. Our Chief Operating Officer is Rebecca Groves. Our original theme music was composed by Yosef Munro, and additional music comes from Blue Dot Sessions.
The Nocturnists is made possible by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org. The Nocturnists is also supported with donations from listeners like you. Thank you so much for supporting our work. If you enjoy the show, please help others find us by telling your friends about us, posting your favorite episode on social media, or leaving us a rating and review in your favorite podcast app. To contribute your voice to an upcoming project or to make a donation, visit our website at thenocturnists.com. And specifically, if you’re interested in our upcoming series on uncertainty, check out our website. You can sign up to learn more information as that project goes under development. I'm your host, Emily Silverman. See you next week.