50 year-old male with daily aspirin use presenting with melena and hematochezia and abdominal pain.
I met Shane after he arrived in the Emergency Department with his wife to be seen for having tarry stools which he had tried to “tough out”. He was perched on the corner of his Emergency Department bed and was craning his neck to sneak a peek at the football game on the TV when I entered the room. The instant he saw me, he tried to make me feel welcome in his tiny corner of the Emergency Department. He told me how he had tried to “soldier through it ” the abdominal pain he experienced over the last whole day prior to coming in. Shane mentioned he had not seen a doctor in nearly 30 years, which greatly befuddled me. While he mentioned his lack of previous hospitalizations and his general good health, I privately wondered if the pandemic played a role in his new bleeding and abdominal pain. I excused myself and compiled notes about Shane and tried to create a comprehensive narrative to share. When I reported back to my resident, I felt my brief summary had not done Shane justice when a team member referred to him as “the GI bleeder in 308”.
Watching residents fly through placing orders and placement requests, I realized the team was focused on efficiency viewing Shane’s case as a diagnosis rather than a complete person with a story. As the team’s furious typing continued, Shane slowly left their minds as the next patient was discussed and addressed. One of the residents saw my additional notes about Shane and told me “when you are a student you have the luxury of time so please keep learning as much about your patient as you can!”
When I visited Shane the following day, he told me about the furlough and eventual loss of his job due to the pandemic. After joining the Marines right after high school, Shane suffered a serious head injury on his second tour of duty. This made finding new work especially challenging for him even before the pandemic happened. Between his loss of his job, having four school age children, and concern for his wife’s safety as a healthcare worker, Shane had multiple sources of stress. He had occasionally experienced GI distress throughout the pandemic but kept quiet about it to avoid being seen as a burden. He instead managed the discomfort by drinking ginger ale.
Shane’ hospital stay grew longer when esophagogastroduodenoscopy failed to reveal ulcers or a clear source for his presumed upper GI bleed. This gave me the opportunity to learn more about Shane’s life and his values. Simply put, Shane was a gentle giant passionate about family, faith, freedom, and football. Day by day, I would talk to him about his diagnosis and troubles, and slowly added the details of Shane’s social history into my presentations. Each morning, I would tell Shane what I was sharing with the team, and as Shane got to know me better, he easily started to jump in and supply more information that he thought would be helpful. One day, while discussing his medication use at home, I discovered that Shane took nearly three times the charted aspirin dose of 81 mg. He stated “I don’t really have extra money to see a doctor too often and my dad started taking an aspirin a day when he was my age, so I figured I’d do that too! Since I’m a big guy I figured why not take a little more.” After uncovering these deeper concerns Shane had about his health, I used some motivational interviewing to encourage regular visits with a doctor and to get medical advice before self-medicating.
During medical training, we constantly learn to triage information and make decisions regarding what is most pertinent and informative for the current diagnosis and development of a treatment plan for the patient. In a patient’s case like Shane’s, focusing on his hemoglobin levels and consulting the GI team would have been the efficient route. However, as I gradually got to know him and presented him as a whole person, my resident team stopped referring to him as the “bleeder in 308”. We all learned the names of his children and his wife, and made sure to congratulate him when the Packers won. After multiple transfusions and several days, Shane asked us to “level with him” about how he would fare after leaving the hospital. He wanted to know if he would be able to play football with his sons or give his youngest child piggy-back rides. As his frankness about his fears for his future health increased, Shane became more comfortable voicing his opinions about the progress of his care. By taking the time to learn more about Shane, we all became more invested in his care because we understood why he needed to get better.
Even after placing consults to GI, Surgery, and Interventional Radiology services, our team remained enthusiastic and active in Shane’s care. As I became his ally, I personally felt much more confident advocating for Shane through my charting and discussions with specialists who appreciated and capitalized on the small details I provided them about Shane’s personal or family history. We strove to ask care coordinators and social workers if there were any resources or things that Shane and his family could take advantage of. We were very invested and wanted to set Shane up for success after he left the hospital. We were truly determined to go the extra mile for him and his family because we understood what motivated Shane’s recovery, and we supported the key cornerstone of his foundation for wanting to be healthy for his family and to be able to provide. Uncovering the root reason for his aspirin use through pursuing his story allowed us to set him up with appropriate outpatient follow-up thus demonstrating how narrative medicine actively improves patient care.
I know that all patients will not be as forthcoming and sharing as Shane was, and I know that I was lucky to have extra time to spend with him. However, I feel that using a narrative medicine approach to Shane’s care benefitted not only my patient but also the entire healthcare team. At the end of his stay, Shane said he appreciated my transparency and my desire to share his full story with the team, and I learned more about his medical history and built a stronger relationship with him. While searching for social resources to offer Shane, I encountered many different specialties and providers including chaplains, care coordinators, and OT’s who taught me about their roles in patient care. In addition to developing stronger professional relationships with other providers, I garnered knowledge about their resources which I will use to support my future patients. Modern medicine focuses on efficiency and evidence based care, but by taking even a small amount of time to learn about what makes a patient tick, we can foster a longer lasting trusting relationships with patients while making them feel heard. For patients like Shane, our practice of narrative medicine improves their outpatient follow-up and trust in the medical system. Incorporation of the powerful tool of narrative medicine would progress the field of medicine towards a more holistic approach to patient care, and thus would cultivate an extra layer of compassion which would be felt by both patient and provider. This would go a long way towards forging connections which will last a lifetime.