Story and the “Healthcare Industry”
N. Stuart Harris (MD, MFA, FRCP Edin.)
Chief, Division of Wilderness Medicine
Department of Emergency Medicine, Mass General Hospital
Associate Professor, Harvard Medical School
Faculty, Belfer Center Arctic Initiative
Harvard Kennedy School of Government
In my essay for last year’s Generation C symposium, I spoke to the power of narrative, the importance of embracing our own health as a part of a fantastically complex biosphere and the need for medicine to avoid the myopia of relentlessly advancing pixelization of care. As physicians we need to remember that our charge is not to care for individual organs but to care for human beings.
Now, a year further into the pandemic, I find myself returning to my faith in the “self-righting mechanism” of narrative with a more jaundiced eye. Story still is the coin of the realm (“content” as my MBA-friends in the entertainment industry call it—something people are willing to spend mightily to buy), but its role as a moral clarion is increasingly undervalued.
The pandemic has been harrowing, with reverberations that will play out for decades to come. My grandmother’s recollections of young adulthood in the Great Depression influenced my own childhood decades later. Habits of fiscal conservatism are given physical form: I can still smell the collection of saved string and rubber bands in her front hall drawer. We create durable habits from experiences not even our own. As Faulkner famously quipped, “the past isn’t even the past.” And so I continue to collect rubber bands nearly a century later.
Now, in 2021, vaccinations offer some hope of stemming the tide of suffering. Even as we celebrate the power of scientific inquiry to solve many of our problems, I keep returning to a more fundamental question: How do we as healthcare professionals create grace and meaning and best serve our patients?
Recent trends do not give me hope. Healthcare administrators talk more about revenue streams than patient care, or story, or mission. Professional authority earned at the bedside one patient at a time by responsible clinicians is claimed by central corporate offices housed far from patients in shiny granite and glass structures worthy of Fortune 500 board rooms. I have no trouble with the rough and tumble of power dynamics, and I love my work. But I’m sleeping less well than I used to.
My teenage son and daughters tell me I’m a dinosaur. Even as I make friends with our Business School faculty and am won over by their wit, analytic capacity and common sense, I remain skeptical of the rapid ascendency of the glossy (if ultimately anemic) weltanschauung that is the toast of MBAs flowing into healthcare administration. The well-meaning, suit-wearing acolytes of the “healthcare industry” (who do not see the oxymoron in the term) offer me little hope for a mission-driven moral compass that keeps patient care at the center of competing “cost centers.”
As a lover of the elegance and resilience of the natural systems on which our lives depend, I see beauty in early human efforts to mimic this systems-thinking. Solvency and efficiency are the hull of our ship of medicine. But a spreadsheet is no compass. In addition, the ship increasingly has worms in its timbers, operating with a dangerous misconception that our actions in medicine have value only if they are either: 1) quantifiable or 2) billable. Yet the ability to manipulate revenue streams has little to do with discerning mission or purpose at the bedside of each individual patient.
Instead, on questions of fundamental moral purpose and meaning, I turn for guidance to what we’ve done as a species for tens of thousands of years. We tell stories.
Well before Hippocrates introduced storytelling as the primary diagnostic engine of modern medicine—which he did under the plane tree at Kos in 2400 CBE—the fires of narrative discernment were co-evolving with our species. The discernment is so universal and critical as to go unrecognized. “What water?” the fish asks. Humans depend on our narrative genius to make both diagnoses and sense of ourselves—and inhabit our world with meaning. We need a story of purpose to get out of bed in the morning—and also to guide the future of our healthcare institutions.
Good storytellers are the terror of bad governance. Administration begets more administration. Without storytellers willing to speak truth to power, we drift into bureaucracy that designs systems to serve administrators and their systems rather than patients and the healthcare professionals who ultimately provide care.
Encouraged from within and without, our healthcare institutions begin to forget the obvious: that medicine’s professional authority isn’t a gift of powerful administrators, but rather is derived through patients’ trust and the accumulation of institutional authority earned in caring for each individual patient. That includes the 87-year-old grandmother in the ED arriving terrified from her crushed car, strapped to a hard board by EMS; the 46-year-old son waking disoriented in the PACU after his coronary bypass; the newly diagnosed 14-year-old diabetic carefully tended to by her endocrinologist.
Stories orient us. Stories tell us that it is OK to be afraid and remind us that we must be brave enough to stand outside of power structures when discerning a moral course. Stories make obvious self-dealing and (eventually) fools of those “too powerful to fail.” We remember that the emperor had no clothes long after the emperor is dead.
The healing “transaction” occurs one patient at a time.
I keep returning in memory to an older male patient who came to Mass General’s Emergency Department in the worst, early days of the pandemic. For both of us, the fear was warranted. He was DNI/DNR (do not intubate/do not resuscitate) and his lungs were failing under the assault of this novel virus. We knew nothing. The lived experience of the world as we knew it (cumulatively 130+ years between the two of us) was no longer predictive. We were both walking forward into a hostile landscape.
But this was something he had experience with. He was a veteran of WWII. Too modest to volunteer his story (even as he volunteered to serve in early 1942), in answer to my questions, he told me stories of his “walk east from Normandy.” He led me from the beaches of France to Berlin, through the frozen hell of the Battle of the Bulge, while I sat in my N-95 mask, fully covered in protective gear inside the tightly-closed, negative-airflow-equipped Bay 12 in my ED, sweat-soaked and tired after a long shift—but engaged. For once we were both outside the pandemic, if just for a few moments. He had broken us free!
My being there was selfish. I had thrown the full complement of modern medical technology into his care. There was nothing else to do. We both knew it stood little chance of altering his course.
In addition, he was alone, separated from his loved ones—by me, his doctor. And yet he smiled at my questions. I don’t know if he could sense my moral distress in being forced to keep his family at bay, but like a good soldier, he took the news with grace and asked for nothing. Whatever risk I inherited in additional exposure to COVID was one I was willing to bear. This was all I had left to give.
In his short story Heartache, the physician and renowned author Anton Chekhov tells the story of a snow-covered sleigh “taxi” driver, working to support himself in hard times (not unlike any Uber driver in 2021) . Even as he simply seeks to do his job—and is physically assaulted for his efforts—he stoically carries his burden and holds some faith in humanity. He is compelled to reach out—to someone, anyone with whom he can share even a few words about the immensity of his grief due to the recent death of his son. Rebuffed by all of his patrons, he returns to the drivers’ quarters; certainly, someone will listen there. But the other drivers all are asleep, or uninterested. So in the dead of night, unable to bear not sharing his story, he returns to the barn to the one creature who will listen: his horse. There “she nuzzles his hand. He feeds her oats. He tells her everything.”
At 3 AM our patients are pulled from the darkness to the clean, well-lit space of our Emergency Department. When faced with the vague complaint of a traumatic “knee pain” in an older veteran (whose exam tells me this is a well-functioning knee), I try to remain aware that sometimes pain is more than orthopedic and suffering is best eased not by technology but by a few minutes spent truly listening to whatever experience my patient wants to share with me.
In our frenetic age, people are scared to death (especially if death is imminent) by reflective attention. I tell myself that when it comes to healing, it is poor form to be outdone by an old Russian horse. The answer to fundamental human questions isn’t inevitably to order a test or place a tube in a patient. Sometimes it’s just a matter of listening.
We call our senior-most clinicians “attendings.” As the pandemic’s waves of suffering continue to reverberate, the aspirations of the title weigh heavily. But it also offers solace. Attend comes from the Latin attendere, meaning “to bend to, to notice.” In medical school we are taught to bend to and notice anatomy and pathology, but all too rarely to find joy and healing in seeing and celebrating the unique human story in front of us. This ability might make our jobs that much easier and more rewarding—and offer exactly what our patients most desire and deserve.
My kids are likely right. I might well be a dinosaur, but I am not alone in my trust that stories heal and that the alchemy of narrative is more likely than the venture capital arms of our healthcare institutions to turn the base metals of the pandemic into more valuable coin.