Chronic Illness

Humanizing The White Coat

A Moth-style storytelling series for physicians aims to show that doctors are just as human as their patients.

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The sleep-deprived doc who is green with envy of his operating room patients’ chance to rest while undergoing surgery.

The first year med student who is the child of refugees and struggled to treat veterans coping with the guilt of torturing captives—the very thing people in her family fled.

The idea behind The Nocturnists is deceptively simple: the notion that doctors are just as fragile, funny, and human as their patients.

Emily Silverman of the Nocturnists

Emily Silverman, a third-year resident at the University of California, San Francisco, launched the cathartic Moth-style storytelling series for physicians in January 2016. Since the initial 40-person event in someone’s living room, the event has grown to fill small theaters in San Francisco, drawing an audience of 250.

Silverman says that when patients meet physicians in a crisis or even during a checkup, it can be difficult to see the whole person behind the diagnostician. But the stories from past performances have been a wrenching look at how medical professionals deal with their work. Physicians and patients are all human beings, and the series is meant to provide community to medical professionals while also illuminating both sides of the doctor-patient relationship.

The next Nocturnists event will be a fundraiser for a local reproductive health non-profit, and in addition to high-priced tickets that will benefit the cause, a few seats will be available to the general public. Silverman says the best way to stay in the loop about events and tickets is to join The Nocturnists email list.

She spoke with Folks about telling the stories of medicine from the physician’s side, obtaining consent, and what she’s learned from fellow medical professionals in slightly different fields than her own.

What was your path to medicine?

It sounds cliché, but I was one of those 5-year-old kids running around the playground saying I wanted to be doctor. I don’t know where it came from because parents weren’t physicians. My dad didn’t finish college and ran a hardware store, and my mom was social worker. But I had a pediatrician I idolized, and I always wanted to understand the machine of the human body and how it works. My parents bought me books filled with colorful diagrams and pullout tabs to learn about organ systems, and I watched Ms. Frizzle on The Magic School Bus. I simply had to understand how my body works. Even today, when there are things I don’t really understand like the economy or the Internet, when I look at non-physicians, I think: how can you not know where your uterus is?

Even today, when there are things I don’t really understand like the economy or the Internet, when I look at non-physicians, I think: how can you not know where your uterus is?

I was drawn to science, but in parallel, I had this creative side—not so much social science but purely artistic, in that I loved drawing and ended up majoring in art history. In college, I flirted with not being a doctor and going into the art world. I always had these two parallel threads in my life and wanted to find ways to overlap them.

How was med school for you?

I’m passionate about science and have a lot of curiosity, so I got interested in the humanistic side of medicine and the importance of shepherding people through certain life experiences. Medical school reinforced that.

In med school, it was difficult to keep up with my creative side because I was studying all the time. I met a kindred spirit, Alessa, who also had a hidden artistic side and is extraordinarily funny. To keep our creative sides alive, we’d write scripts and make silly videos, and we always had a dream we’d write a film script about this stuff.

Physician burnout is being recognized more now, as are the skyrocketing rates of depression and suicide among physicians.

The intern year during my residency was very immersive, very intense, and a lot more difficult than I expected it to be. The sheer number of hours and the sleep deprivation and lack of time to process the experiences you’re having and the suffering that you’re witnessing—I actually think it’s really problematic. I dealt with emotional lag: like two weeks out of some intense experience, it would all come rushing back at an inopportune time. There’s not much time to talk with colleagues.

Physician burnout is being recognized more now, as are the skyrocketing rates of depression and suicide among physicians. Some programs set aside time to talk to colleagues, but that’s still not a cure-all for working 80 hours a week.

By the second and third year, the schedule opens up a little, and I was looking for a project to speak to the human side of medicine. There’s a lot happening in medicine right now on the scientific or business side, whether it’s in economics, digital health, genomics, or big data. That’s great, but I worry that stories of medicine are getting lost. I wanted to do something about that.

Backstage at the Nocturnists show. Photo: Jen Olenik

Where did the idea for a storytelling series come from? Do you solicit stories from fellow physicians?

I was at a live taping of The Moth in San Francisco, and I thought, “Oh, that’s what I’ll do.” It just felt right.

Going around SF, getting a sense of the cost to rent a space, it seemed daunting. I finally found a shared living space that has a parlor room that rents for something like $90 a night.

That first event was about 40 people. I had to twist some arms to get people to show up, and especially to share. It wasn’t extraordinarily difficult, but it wasn’t people emailing to volunteer back then. I sent targeted emails to people who I thought were talented and who would have a good narrative sense with some wisdom underneath.

The first event was very intuitive—there was no coaching—and people were very open to making themselves vulnerable. I lined up eight or nine residents but also faculty, and it was so helpful to have both, and it set a precedent for faculty to feel involved, and then we didn’t have a hierarchy where people didn’t want to participate in the same thing together.

We use stories all the time in medicine.

At first, my motivation was for therapeutic effect, telling stories in way very different from being in the hospital. We use stories all the time in medicine. A patient goes to the doctor and says, “I was fine, but then I was walking and I fell short of breath.” Patients bring that narrative to the doctor, who interprets it and strips away the inessential information so that the notes can become sterile and scientific, which is fine; Our job is about medicine and efficiency. It’s much more reductionist practice than expansionist practice. When we’re presenting a case on rounds, we retell patient story. We also tell stories and use metaphors with patients.

I was wondering about all of this, because now electronic medical records are templated, and they are very hard to read and it can be very hard to extract narrative from a digital record.

I thought, if we could get together and tell stories in a more expansive way in a theater with art all around as opposed to under the glare of the florescent lights of hospitals—and in normal clothes, not scrubs—and sit next to each other, shoulder to shoulder, and hear stories of our lives and jobs, that would be a good thing. That was the crude thought I had initially.

As our events grew, I received emails from physicians but also nurses, social workers, paramedics, and physical therapists across the Bay Area. I realized there is a hunger for a narrative in healthcare, for the chance to come together to digest and absorb experiences from the hospital and to foster inter-professional understanding. In an academic institution, the atmosphere often feels fragmented and impersonal, and I wanted to bring people together. After the 2016 election, I also felt stories are important for advocacy.

Are there any story topics that surprise you?

We had an event in March 2017 with a justice theme, and some of those stories surprised me. In October 2016, our theme was death and dying, and I feel like I know those types of beautiful and powerful stories. In my work, I see people suffer and die all the time.

At the justice-themed event, a clinical social worker told a story about a homeless woman who was his client and had a lot of psychiatric problems—someone is so vulnerable and so psychiatrically sick that she would have outbursts that made it difficult for her to go through life and get the things she needed. There was also this tenderness to their relationship—she referred to him once as her best friend—and when she could, she told him stories of how she helped others during the last major earthquake in San Francisco. Initially, he thought his job was to fix her, but getting to know her, he learned that his job is to make life easier for her, to make her more comfortable.

There was another story from a psychiatry resident, Jake, who was essentially taking care of a young, schizophrenic black man who wouldn’t take his medication because of the side effects, and he had delusions about the police wanting to throw him in jail because he’s black.

Jake talked about how difficult it was to talk to his client about this, given the real threat of police brutality and the Black Lives Matter movement. It was a complicated, nuanced story about being yet another white man trying to tell his black patient what’s good for him, and it brought to light the complexity of what we do that one can never do with data. Jake said after this experience, he will look for truth in delusion.

What do you envision for the future? How hard would it be to replicate in other cities?

I think a lot about whether to turn outward or to turn inward. By turning outward, I mean taking the show on the road to other cities, especially those potentially different from the Bay Area, or trying to get the stories on National Public Radio or a podcast. To turn inward and focus on my community, I ask myself: do I want to leverage this to make California or even San Francisco better?

I think I would like to try turning out first, especially as people from other cities and states are interested in collaborating.

Are there misconceptions about the series you find yourself explaining?

First, there’s a lot of fear around making yourself vulnerable as a physician. We’re treated like super-humans, from working long hours to the fact we’re expected to operate on minimal sleep. We’re essentially operating at extremes at all times: emotional, physical and physiological.

There’s a lot of fear around making yourself vulnerable as a physician…

The white coat causes a certain power dynamic, and there’s also this idea that the physicians should be neutral, that we shouldn’t insert ourselves into the narrative. I understand the argument, but overall, I believe it is beneficial to recognize physicians are human beings, just like patients. Sometimes physicians are patients; physicians get sick, too.

We talk a lot about humanizing the patient, but events like this have a role in humanizing physicians.

We also talk about confidentially, which is hugely important. There’s no universal moral code but in general, we say to obtain written permission if you’ll be sharing anything identifiable. Or, you change the details. For example, if the patient is wearing a backpack, now it’s a necklace. If he’s from Nicaragua, now he’s from Mexico.

You have to think: why am I telling this story? There should be a reason, and it should be your story, not someone else’s. I have to coach some people on that, that you have to put yourself in the story. I say things like, think about when you felt scared or vulnerable, or something that happened that changed your mind. Narrate your inner life. If you stick to that principle, it turns out pretty well.

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