Understanding More than the Patient’s IllnessJun 5, 2014
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Dr. Harriet Hopf: I'm Harriet Hopf, professor of anesthesiology at the University of Utah. I'm talking today with Gretchen Case. Dr. Case is an assistant professor at the University of Utah in the division of medical ethics and humanities. She received her PhD in performance studies from UC Berkeley. I asked Dr. Case to sit down with me today to talk about medical humanities and why it is important for educating our future healthcare providers. But first I have to ask: how does someone with a PhD in performance studies come to be on the faculty of a medical school?
Dr. Gretchen Case: Probably most of the listeners don't know what performance studies is. Let me just tell you briefly that you can think of it as a blend between anthropology, theater, literature, and a bunch of other things, but what performance studies does as a field is look at all human endeavors as performance. So we do perform on stage but also perform in everyday life. One of the things that I've been particularly interested in is how people perform in a medical setting. How do doctors know what it means to behave as a doctor? How do patients know what it means to behave as a patient?
To say that someone is performing is not to say that they're faking it or that they're acting in the sense of acting that we think of someone taking on another character, but performing means to make something happen. How are they making something happen, responding to particular cultural scripts of this is the way it should be? If you think about it, doctors even have costumes, right? They put on their coat, their stethoscope, and suddenly they are a doctor. So there are lots of ways that looking at medicine through a lens of performance is really useful.
Dr. Harriet Hopf: Actually, you just made me think about how important our white coat ceremony is every August. Our first-year medical students get sort of inducted into being doctors by being given a white coat and a stethoscope.
Dr. Gretchen Case: Right. That's a very performative moment in that that makes it so, right? It makes something happen. They are given a coat and they are kind of inducted into this group. They are now, if not doctors, they are physicians in training.
Dr. Harriet Hopf: So what is the value of theaters and stories in medical education?
Dr. Gretchen Case: Humans are storytelling creatures. We use story and narrative to make sense of everything in our lives. Using theatrical approaches, using dramatic approaches, techniques to teach communication, for example, can be really, really valuable. The Mayo Clinic, Northwestern University, they both teach improv in their medical schools. Improvisational theater says you have to be in this moment listening to the other person or people and you have to respond in the moment. The first rule of improv is always, always, "Yes, and..." right? That's what you have to do in a clinic or in a hospital setting, is meet the person where they are, listen to them, and react in the moment and not be working from some script that is kind of preset or not be waiting for your turn to talk.
Dr. Harriet Hopf: How is the University of Utah using stories and theater in medical education?
Dr. Gretchen Case: I recently brought a panel together of, I think, six people who are in various ways using theatrical approaches in medical education or in medical practice. Some of them are using the idea that patients tell stories and how do we change stories that are not helpful? Or how do we adjust our stories as caregivers? Some of them are bringing in actors to play important roles. This becomes especially important when you're doing something like learning how to give bad news, learning how to disclose an error. That's the kind of thing you want to rehearse and practice when the stakes aren't as high. So if you can bring in a well-trained actor who can play that person in distress, that patient who's about to get the bad news, that's a much better way of rehearsing and practicing that.
Then others are using an approach called forum theater which is an interactive kind of theater which means that you present a problem and the audience helps solve it. So it's a way of getting a whole healthcare team together and saying we seem to have a problem at this point in the care. Can we think together about what the problems are? You get a much better idea of problems and how the solve them than either a bottom-up or a top-down kind of approach to that.
Dr. Harriet Hopf: A typical medical student in our program, do they get a chance to practice giving bad news through theater?
Dr. Gretchen Case: A typical student in our program, possibly, depending on electives they take, depending on what tract they are in. I believe that going forward all of them will be doing the inter professional experience, the IPE. That uses actors. The summer session that they do in IPE is about disclosing an error, so they will all get the experience of disclosing an error to an actor who is playing someone who is in great distress.
Dr. Harriet Hopf: How can physicians interpret patient stories effectively? How can we do a better job of providing information so that we get stories back that make sense to us as well as to the patient? How can we somehow use these stories that seem incorrect to us to improve how we communicate with our patients?
Dr. Gretchen Case: It's so often not about facts. It's about truth. Those are different things, right? The patient who is telling you a story that sounds untrue may be telling you a story that is factually wrong but to them is true. Stories aren't static. That's the other thing. You might hear a story from a patient, you might be able to add to it to change it, to give a prologue, to give an alternate ending.
People usually don't cling so tightly to their stories that they wrote. They are ready to hear more, to add more to it. So I think that's actually one thing that's really important for clinicians to know is: how can you be a co-narrator? How can you be a part of this story? How can you go back to that improvisational, "Yes, and.." "Okay. That's the story you're telling me. Let me add to it," and not, "but..." Not, "Yes, but..." and not, "No," but, "Yes, and..."
Dr. Harriet Hopf: I just got a great insight from this conversation because I'm an anesthesiologist and so I meet patients all the time for five minutes before they go off to have an operation and I usually don't have complete information. They often tell me something that makes completely no sense to me and I have to decide if gets in the way of going to the operating room? Does it get in the way of their being comfortable with having care?
What I hadn't thought about before was the stories physicians tell and how they're not always accurate either. I think we like to pride ourselves on our accuracy but part of the problem is what people hear and how they construct it into their own story, but part of the problem is what we say and whether it's accurate or not. That's actually something I'm going to take with me the next time I'm meeting a patient who tells me a story that makes no sense. I'm going to say, "Yes, and..." and try to figure it out, but I'm also going to think about the stories I'm telling that might be making no sense whatsoever to the patient.
Dr. Gretchen Case: Sometimes those stories that don't make sense are due to uncertainty, right? There's uncertainty in medicine. As much as we don't want there to be, there's a lot of uncertainty, and sometimes that's due to something like jargon, that what you think you're saying is very clear and it sounds very different to the patient. It could be a word that you don't even think of as jargon but it is to the patient. Even saying a word like obese, that's a medical term. If you say "obese" to a patient you may have just deeply insulted them and changed the entire nature of your relationship or what the story is.
Dr. Harriet Hopf: What I'd like to know is what's important about using theater in medical education? What's the ultimate outcome? What is it we're trying to achieve?
Dr. Gretchen Case: So much of what people are talking about when they raise concerns about things like bed side manner is how the physician presents him or herself and how they communicate. That's what theater and performance are about, is how do you present yourself to the world? How do you communicate to the world? So if we can take some of those lessons, some of those techniques that are kind of native to performance and theater and transfer them over to medicine so that every clinician, every researcher is thinking, "How am I presenting myself? How am I communicating?" What an amazing difference that would make in the way that we provide care and the way that patients receive that care and kind of understand why and how we want to help them and care for them.
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