MD Anderson Cancer Center
Date: December 2014
Dr. Baile: Hello, I'm Dr. Walter
Bale, director of MD Anderson Program on Interpersonal Communication and
Relationship Enhancement, or I*CARE. Today we're very pleased, to have as our
roundtable discussion, Dr. Danny Epner. Dr. Epner is Professor in the Department of Palliative Care and
Rehabilitation Medicine at the University of Texas MD Anderson Cancer Center.
He's also attending physician on the Palliative Medicine Inpatient Service, and
has a clinical practice in the Palliative Medicine Outpatient Clinic. Aside
from his clinical work, Dr. Epner has played a key
role in the education of clinicians and trainees in the area of
communication skills at MD Anderson. He co-directs the first geomedical oncology course in clinician-patient
communication and the Palliative Medicine Fellows Program on Clinical
Leadership. He's written extensively about the care of patients with advanced
disease and co-authored the module on discussing prognosis for ASCO University.
He's also directed the minicourse on communication
skills for the annual Palliative Medicine Meeting at MD Anderson. Dr. Epner has had a strong interest in the area of narrative
medicine and has published a series of reflective pieces in major medical
journals highlighting lessons we can learn as healers from our interactions
with patients and families. So thanks for coming today, Danny.
Dr. Epner: My pleasure.
Dr. Baile: So, you know, we
haven't had anyone on our roundtable interview series that's really talked
about narrative medicine. So, I'm wondering if you could tell us a little bit
about the term and how this kind of topic came to be something important now in
the teaching of reflective skills and communication?
Dr. Epner: Well, I became
interested in narrative medicine just sort of by accident, because I started to
find that I had these stories to tell, and these stories kind of percolated out
initially through conversations with other providers, and I wrote some stories
for the medical literature, and I started to appreciate the power of telling
stories. One of the main reasons I wanted to do this was not only for my own,
you know, therapy essentially, but also as an educational tool, so every story,
every short story that I've published, has some overall, overarching
educational message. So as I became interested in writing these stories, I
started to appreciate the power of narrative medicine, of telling stories and
receiving stories, and I really wanted to learn more about it. I started
reading about the field to develop more of a conceptual framework, read more
from Rita Sharon's work. She's a great leader in the field. Now she has really
formalized the study and implementation of narrative medicine over the last
couple of decades, but narrative is something that we've had that’s been an
integral part of medical practice since there was medical practice. It
permeates everything we do all this time. Everything we do in medicine is about
swapping stories basically.
Dr. Baile: So can you say
something about the stories themselves? So you're talking about stories
patients tell us about their lives or stories about physician or
clinician/patient interaction? So what's the scope of these narrative pieces
that we can find in the literature in which you've been involved with writing?
Dr. Epner: Narrative medicine is a
huge scope, and narrative is really any story, you know, with a plot, a teller,
a listener, a point, but narrative can both be in the clinical context or
outside the clinical context, and the way I like to think about it is narrative
outside the clinical context, let's say reading a great novel, watching a great
film, hearing a great story around a campfire, that is like practice. It's like
going to the gym to work out. Then we apply those reflective abilities that we
build outside the clinical arena to our work as healers in the clinical arena.
In the clinical arena, the narrative medicine piece and be either stories told
by patients or their families, stories told by a doctor or other provider to
other providers. It's both the giving and receiving of stories, and I think the
most important part about it is that when these stories are given and received,
it's a very active, reflective process.
Dr. Baile: So, you know, we know a
lot about storytelling, as you mentioned, through movies, through books,
through verbal pieces that are handed down through generations about culture
and which reflect culture, so I'm interested in knowing a little bit out how
these stories about patients and families and clinical interactions can be used
in medical education and, in particular, in teaching communication skills,
because I know that’s a main interest of yours?
Dr. Epner: Of course.
Dr. Baile: And this whole issue of
reflection, which has gotten a lot of interest and play in the medical
literature recently as a way of talking about the whole process of thinking
about how we think.
Dr. Epner: Yes. Well, you and I are always working on
new ways of teaching empathy. Teaching empathy is probably, arguably, the
hardest thing to teach people, but it is, the literature shows, at least
there's some preliminary evidence, that empathy can be taught. It's a skill, and
people have varying aptitudes for it, but empathy can be taught. Having said that, there are many different ways of teaching
empathy. One is the action methods that you have worked on with others,
and I've had the honor of working on, but also, I'm finding that this whole reflective process
around narrative medicine is also a very good way of teaching empathy. The
reason for that is because the essence of empathy is really standing in the
other person's shoes, and in order to really tell a story well and construct a
story well or to receive a story fully, one has to be in the other person's
shoes, so swapping stories, giving and receiving stories, getting into a story,
is really the essence of empathy.
Dr. Baile: So it's
really understanding the other person at a more deep level --
Dr. Epner: Yes.
Dr. Baile: Than what we kind of
maybe we do ordinarily in practice?
Dr. Epner: Right because what we
want to clinician, what we want a true healer to do is sit with a patient and
family, and let the patient and family tell their story in as much of an
uninterrupted fashion as possible and go with that story and really absorb the
story and try to seek inner meaning in the story.
Dr. Baile: So, you know, I think
that medicine up to now has not put a whole lot of emphasis upon this whole
idea of getting in the patient's shoes. In fact, that I recall, during my
training, that physicians were counseled not to get too close to patients.
Dr. Epner: Yes.
Dr. Baile: And not to get too
friendly with them because it could affect your clinical judgment. It sounds
like that's changed a lot.
Dr. Epner: I don't know. I think
it's an evolving area. It's one that I am, myself, trying to learn about. I
think there has to be a balance between emotional connection and some, what's
the word I'm looking for? Some - a little bit of - help me. Help me. A little
bit of, maybe, distance. Not distance.
Dr. Baile: Sure.
Dr. Epner: But boundaries.
Dr. Baile: Boundaries.
Dr. Epner: Because we have a job
to do. We want to be feeling people. Emotion is part of the hard work we do,
especially with grave illness, but we have a job to do, so there has to be that
balance. We have to modulate the emotion. It, too, is a very hard thing to
teach people. It's also hard to understand exactly what other people - it's
impossible to understand what people are feeling. So, for instance, teaching
other healthcare providers about communication skills. It would be beautiful if
we knew exactly how they're feeling, and then we could help them, but that's
something that none of us can really tap into fully.
Dr. Baile: Now do think there is
some therapeutic benefit of encouraging patients to tell stories about their
illness or stories about how they came to be diagnosed or other things about
patients' relationships? Is there some benefit to that?
Dr. Epner: Oh, it's a huge
therapeutic effect. People have a fundamental need to be heard, and so just
simply listening to somebody’s story
is extremely therapeutic, and that's obvious to any clinician
who's done this. You know, the other thing about it is one need not try very
hard. So a good clinician need only sit down and ask a few open-ended
questions, and the story pours forth, and then all we need to do is let that
story flow and maybe guide the story a little bit, but honestly, the story just
flows out, and if we really are tapped into the story, we can facilitate the
telling of the story.
Dr. Baile: So can someone
realistically expect to do this with patients in the course of their clinical
care, given the time constraints and busy administrative tasks that physicians
seem to have now?
Dr. Epner: That's a great
question, because I can relate to that. I'm under time pressure, a huge time
pressure, all the time. As you said in your
introduction, I have a very busy clinical practice. I do think that we can, and
I think that it's a very high-order skill for a clinician to try to manage the
clock. The analogy would be a coach managing a two-minute drill in a football
game. We have to have the same mentality when seeing our patients, because the
reality is we're under huge time pressure, but I think the more skill we have
in narrative medicine, empathy, listening skills, the more value in therapy we can
get out of those two to 20 minutes that we have.
Dr. Baile: You know, it just
occurred to me, I remembered making rounds with one of the clinical teams and a
group of doctors to give feedback on communication skills, and actually, none
of them sat down. Well, one sat down, and I thought that that's not very
inviting in terms of getting patients to tell their stories, and, of course, a
great anxiety is if you sit down with the patient, you'll never get out of the
room. So people have developed the other, kind of, technique which I call
"hand-on-the-doorknob," and patients experience that. The clinician's
halfway out of the room when they get one foot in the room, and so sitting down
can be very powerful in terms of not only inviting stories, but also making
this connection with the patient, and the other thing that struck me was that
there are lots of things in patients' rooms that you can get them to start
telling stories about. For example, pictures of loved ones. Who are those
people?
Dr. Epner: Yes.
Dr. Baile: Which go unnoticed, by
and large, in some of the interactions that our clinicians have with patients
and families, and I was wondering if you use some of those signals to kind of
open up the dialogue with the patient about things other than their disease?
Dr. Epner: Yeah, I mean, I love
what you're saying, because what you're talking about, in essence, is speaking
to and treating a person as if they're a person rather than a patient. I think
so many healthcare providers go into a conversation with the idea that the
other person is a patient not a person, and when we do the things that you
said. That is, notice that their T shirt says Pittsburgh Steelers, and here
they are in Houston. Notice that there's a portrait on their table or that
there's somebody else in the room that's important, that is having a
conversation or treating a person like a person, not a patient. That's the
essence of, really, of the healing relationship.
Dr. Baile: And that's what the
narrative is about, isn't it? In a way?
Dr. Epner: Yes.
Dr. Baile: It's getting the
patient to tell you about their personhood.
Dr. Epner: That's right. Their
authentic personhood, and, you know --
Dr. Baile: I kind of am reflecting
on this that I have heard the term that patients have used over and over again,
that they don't want to be just a number, and they don't want to be a guinea
pig. And in thinking about some of the therapeutic aspects of narration,
inviting the patient to tell something about their personhood certainly counteracts
this fear that people have of being objectified.
Dr. Epner: That's right. Well, the
other important point about this is having a conversation, at least for me,
having a conversation with the person as a person is really enjoyable for me. I
really like the process. Now, with a caveat, I don't like time pressure, and we
have to kind of put up with that, but when I have that few minutes with
somebody, I'm really enjoying the conversation. I say that because these
conversations are not just therapeutic for the patient. They're therapeutic for
us. They keep our head in the game, and you mentioned before, sitting down. You
know, sitting, we might as well have a sign on our chest that says, "I
care," when we sit at the bedside. There's a very strong message that we
send by sitting down. It really doesn't take that much extra time, and as you
know, the literature shows that when we sit, the perception is that we're there
much longer than if we stand.
Dr. Baile: So if we think of
narration not only as, you know, a story, a big story, about a patient's
experience, but also, narration can be these little snippets.
Dr. Epner: That's exactly right.
Dr. Baile: You know, I noticed
that you're wearing a Pittsburgh Steelers shirt. What about that?
Dr. Epner: Yes.
Dr. Epner: Well, I think the other
thing that happens is that when we have an authentic conversation with a person
about little things, there's a subliminal message that they're living life.
When we talk about the Pittsburgh Steelers or the Houston Texans, we're not
telling them, "Hey, you have to live life." We're living life with
them in that moment, and it is enjoyable for them to actually just experience
that and have an authentic conversation. It could be, as you said, a trivial
thing. It could be a little humor placed at the right time in the right
circumstances.
Dr. Baile: You know, narration is also so important because everything that we
do, when people get ill, contributes to depersonalization, doesn't it? You
know, we're sending them for tests. We're sticking IVs in their arms, and
there's so much objectification. Here are your lab studies, and so, I can only
imagine that being in a patient's shoes and being touched by someone who is
curious about your relatives or your job, and it makes me remember of a little
scenario that I had in making rounds with a clinician in this group when we
were going out of the room, I just stopped before everyone left and said to
this gentleman, who had advanced prostate cancer, "What did you do for a
living?" And he said, "Well, I worked in Maxwell House coffee plant
for 35 years." And, you know, he had a sense of pride, look of pride, and
his wife added in, "Yes, and he used to come home every morning from the
night shift smelling like coffee" And so it added this kind of sense of
humor, and the other odd thing is when I used to bike, I went right by this
Maxwell House coffee plant, and it was early in the morning, and I was thinking
of how nice it would be to have a cup of coffee because I smelled the coffee
beans, and this sort of other aspect of narration is that it can open up connections between you and the
patient around things that maybe you have in common, if you choose to share
that. I wonder if you found that that's --
Dr. Epner: Yeah, I can practically
smell the coffee. Yeah, that's so true,
and again, it's getting back to the personhood there. That reminds me of the
Nabisco plant in working a long time ago, when it was actually a cookie plant
and smelling the cookies, but, you know, those kind of
connections are so important, and they humanize people. So that's very
therapeutic, even though it seems trivial. I think the other thing that's kind
of interesting is a lot of times we do this, but sometimes, a learner might be
in the room and think that this is idle chatter.
Dr. Baile: Right.
Dr. Epner: That this is just sort
of - and even these kind of conversations about common
things, one has to be very. I think strategic about being highly therapeutic,
because some banter is therapeutic, and other isn't.
Dr. Baile: Right.
Dr. Epner: It depends on the
family dynamics. Sometimes a family member will come in and start taking
attention away from the patient with banter, and then one has to kind of
redirect the conversation back to the key person. Of course, the family's important, too, but the content of the banter is
very important.
Dr. Baile: Certainly, in our
teaching experience with fellows, getting over the inhibition about snooping
into people's lives or that if you ask personal questions, it's going to open a
Pandora's box to four hours of discussion. Certainly, that's proved wrong,
hasn't it?
Dr. Epner: I totally agree. I
think, as a mental health provider, you really know - you're very skilled at
how to ask very in-depth questions at the right time and the right pace. We
medical providers, either palliative or more the technical, like, medical
oncology providers, we don't have to work very hard to get that narrative
going. All we have to do is say something very nonthreatening and open ended, maybe
even ask permission to ask about something. "Is it okay if I ask you a
hard question, or a sensitive question?" And so it's really not that hard.
Whereas, I think for psychiatrists and mental health providers, you really know
how to dig even deeper.
Dr. Baile: So are you optimistic
that fellows can be taught the skills of eliciting narrations?
Dr. Epner: I am. I think it's a
natural human skill. I think before language or before, you know, written
language, I think that narration was the way we communicated, and so I think
it's in us all. It's innate. I think that the very
nuanced skills take a lot of time and practice, but absolutely, I'm optimistic
that anybody can learn these skills.
Dr. Baile: So maybe your next
piece of reflective listening or reflective writing for a journal could be,
"I See You're Wearing
A Steeler's Shirt."
Dr. Epner: That would be the
title.
Dr. Baile: Well, great. We'll look
for it.
Dr. Epner: Okay, that sounds --
Dr. Baile: Well, thanks so much
for talking with us today.
Dr. Epner: It was my pleasure.
Dr. Baile: I've been speaking with
Dr. Danny Epner, and Dr. Epner,
I hope you can view the Grand Rounds or Ace Lecture, Achieving Communication
Excellence lecture that is on our website about narration and the power of stories
to teach and inspire. Thank you for watching.
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D. Anderson Cancer Center
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