A doctor’s journey through constraints and creativity in the ER [PODCAST]

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Jay Baruch is an emergency physician and author of Tornado of Life: A Doctor’s Journey Through Constraints and Creativity in the ER.

We discuss his emergency medicine journey, poignant cases, the importance of stories in the doctor-patient relationship, why writing is so important, and how physicians can be creative.

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Transcript

Kevin Pho: All right, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. Today on the show, we welcome Jay Baruch. He’s an emergency physician and the author of the book Tornado of Life: A Doctor’s Journey Through Constraints and Creativity in the ER. Jay, welcome to the show.

Jay Baruch: Thank you very much for having me, Kev. It’s a real honor to be here.

Kevin Pho: So, we’ll get into your book and explore it a little bit. First off, briefly share your story and journey to where you are today.

Jay Baruch: Yeah, it’s a little bit of a winding journey. I’m an ER physician and professor of emergency medicine at Brown, at Alpert Medical School, and I’m going on 30 years of doing emergency medicine work, which could feel like, I think in dog years, 160. My background is that I came into medicine actually through English and writing. I was an English major in college, with every intention of becoming an English professor and a writer. As an undergraduate, I had the opportunity to take a course or two that involved going to a local hospital and talking to patients, and it provided me a different lens for understanding stories and a way to impact those stories. It felt so powerful and meaningful to me at that time that I switched course. I stayed an English major, but I applied to medical school.

My academic interests are actually in bioethics, and I look at bioethics as the high point of a challenging part of a story, and in medical humanities. I’m a writer, and Tornado of Life is my third book and my first book of nonfiction.

Kevin Pho: So, as an emergency physician, a lot of the cases that you see are relatively short. Sometimes you may never see these patients again. Tell me about the intersection of stories in the emergency department setting.

Jay Baruch: I gave a talk years ago on the power of story in medicine, and there was this emeritus internal medicine physician, this was a long time ago, who came up to me afterwards. He was like, “I don’t get it. You talk about story.”

I said, “Yes.”

“But you’re an ER doc.”

“I know, yes.”

He goes, “But you have no time for story.”

I knew exactly what he was getting at, and I hear that all the time. But the thing is, Kevin, the patients don’t stop bringing their stories to the ER. The fact that we actually have so little time means that we have to bring as many different types of tools to the encounter as we can. For me, that included actually thinking like a creative writer, thinking about how stories evolve, and paying attention to language, to what’s said and what’s not said. Because unless we get the story right, the best medicine doesn’t work on the wrong story. Some of the biggest moral harm that we do to patients is when the story that they tell us is not the one that we’re hearing, and I feel like that’s when they feel most disappointed and most unheard.

Kevin Pho: So, as the emergency department has evolved, and you mentioned you’ve been an emergency physician for 30 years now, there are a lot more constraints that really take away from the story that you can hear from the patient. So, I guess from your perspective, given all these constraints, whether it’s time constraints or bureaucratic obstacles, how do you maintain the focus on each patient’s story in the emergency department?

Jay Baruch: Curiosity. I feel like one of the first impulses that we have as clinicians, and I think it is a good impulse, is that we want to do something. We want to help. There are so many situations, especially in what I do and what you do, Kevin, where there is an identifiable problem, and we have to nail that and respond to it in a timely and accurate way. But so many of our patients’ problems are so complex, right? It’s not just that. Even the medical problem might be uncertain. It might be some sort of nonspecific chronic pain that we’re still trying to figure out, but they’re still in distress. I feel like sometimes the paradigm in which we look at problems, which is reductionist, gets in the way of us thinking more openly about multiple aspects of an experience.

Oftentimes I find with patients that even if I can’t give them any answer, just expressing the fact that, “Listen, I know what you’re going through is tough. I don’t know how you make it through the day. It’s really hard, but you’re doing a great job. This is what I can do to move things along. This is what I can’t do, but this is what I can do for you.” And thinking about not just complaints, but what the patient’s needs are. Now, of course, some of those needs can feel infinite and enormous and beyond our control. I feel like sometimes, when we face those overwhelming challenges, we pull back, instead of trying to be curious and bold enough. At least for me, that is what empathy is: being willing to go to those really challenging spaces that patients want us to go to, and at least make a step or two in that direction.

Kevin Pho: All right, let’s talk more about your book. Your book is titled Tornado of Life: A Doctor’s Journey Through Constraints and Creativity in the ER. Now, before talking about your book, tell me about the events leading up to why you wrote the book in the first place.

Jay Baruch: The book is actually just the end result of my writing practice. I’ve always written, and most of the time I’m writing for myself. A lot of times I write just to figure things out on the page. We get distressed, things happen in what we do, or there are just emotions that we’re feeling, and the written word has always been my way of encountering that, dealing with that, and identifying when I’m being too easy on myself. I also think differently when I’m writing.

So, this book is basically the end result of a lot of these small moments that we don’t oftentimes talk about in medicine, especially not in emergency medicine, where the drama and the mayhem get all the attention and not these smaller moments, when we’re facing uncertainty, when we’re not certain what the right thing to do is, or when we have to choose between two options and one of those options is not the best outcome, but we’re pressed because of the resource limitations of a situation or an institution or a system. What are the limitations that we don’t necessarily pay attention to? And those things we take for granted, Kevin, that are so hard.

For me, examples I write about are how we just move on in emergency medicine after devastating, life-changing events, or how we tell bad news to a family and just move on, and then what our response to that is. So, I try to be an n of one. We have people who do these great research clinical trials at multiple institutions. I’m taking people into just me. This is just one person trying to grapple with some really challenging situations, drawing on my background in ethics, humanities, writing, literature, and narrative, and trying to see how those tools help inform my understanding of what we do and perhaps provide a different lens into what we do.

Kevin Pho: So, you mentioned quiet moments, and you’re right, that’s not something that we normally associate with emergency medicine. Tell us a story. Give us an anecdote, an example of one of those quiet moments that moved the needle, either for yourself or for a patient.

Jay Baruch: One of the pieces I have that has lived with me for a while was about a woman who had end-stage cancer, one of those people who was in hospice and then dropped out of hospice. She comes in in the middle of the night, and she won’t talk to me, you know, and she won’t tell me what’s going on, and she looks near death. Her story in the chart was of someone who started off really lovely and nice and then became, quote unquote, difficult, the difficult patient. She wouldn’t tell me what’s going on. She refused to call. She refused to even talk to me for the longest time.

In the end, fast-forwarding, I recognized, Kevin, that what she wanted, I think, was this: She was a fighter. A relative was there. She was a fighter; she had a fighter role in her life, and I think she wanted one last fight. When I was in and out of her room throughout the night, what struck me is that all the things we were focusing on up to that point had to do with her disease and her disease course, and what was done, and what was not done, and what we hadn’t done. What I hadn’t done was actually make her the protagonist of her story and honor that, and I was trying to figure out what exactly this woman wanted and how I could meet her needs. It’s a piece that made me rethink how we sometimes take patients away from being protagonists in their own story, and we have to put them back into that position.

Kevin Pho: So, how did you go about doing that? How did you make her the protagonist in her own story?

Jay Baruch: I have this magic wand question, which I sometimes ask patients when I’m confused, trying to figure out what’s going on or how I can meet their needs. The magic wand question is, “If I had a magic wand and I could do anything for you at this moment, what would it be?” I thought that she would say, “I wouldn’t want to have cancer,” but she didn’t. It had to do with the experience of dying. A lot of it had to do with the idea of hospice. She was such a fighter, such a tough person. She raised her kids as a single mom, and she was such a fighter that the way hospice care was framed to her, and comfort care, seemed like giving up. Instead, she wanted to go down fighting, is what I expect, from talking to her and talking to her family member who was there.

Again, I’m extrapolating this and trying to figure this out, but for me it became, how do I meet this person’s needs? Because one thing that we assume when people come to the emergency department is that they come for a reason, and I think they do. I think everyone leaves their normal, their quote unquote normal life, even though it might be abnormal and difficult and challenging and sometimes horrific. But to come to the ER is a narrative event. It is an event. So there’s something, there’s a reason, there’s a motivating force that takes you out of your previous place and into this sometimes chaotic space of the emergency department and the hospital, and we have to find it.

Kevin Pho: So, after reading your book, what are some of the main messages that you want those readers to come away with?

Jay Baruch: We focus so much on following the evidence and guidelines and algorithms, and they are so important. We have to provide evidence-based, scientifically proven, recognized, legitimate care. That’s how we move science forward. That’s what’s best for our patients. But sometimes it’s at the expense of the fact that we take care of humans, and every human is different, and we have to allow ourselves to be creative. That’s one of the messages that I express in the book.

What do I mean by being creative? It’s having imagination, to think about what could be and what should be, to not just think about what patients are telling us, but what’s between the lines and what’s not said. I have a quote in the book from the actor Anna Deavere Smith, an incredible, powerful line, which I carry with me into every ER shift. It’s about how we can learn a lot about a person in the moment that language fails them.

The thing is, Kevin, and this is what happens when people say, “But what do you do when you teach students or teach residents?” I think the most important thing I do is just give them permission to be them, to not necessarily always follow a script. A lot of the talents, a lot of the skills, and I think a lot of the meaning that we want from our physicians, our young people have. We have to just give them permission to be the people that they are and bring all their talents, not just their intelligence and their science smarts, but their talents as musicians, as writers, as artists, as designers, or as architects, or whatever informs them, their religious training, whatever it is. There are multiple facets of their being, and somehow one of them is going to be the thing at a particular time that’s going to help them connect with the patient.

Kevin Pho: So, tell us an example of how you would inject that creativity, allowing the other physicians, especially the ones that you teach, to be them. What would be an example of that in the emergency department?

Jay Baruch: I think part of it begins with the fact that we’re so busy trying to be smart and have an answer. I find that sometimes the biggest mistake we make is that we’re so intent on trying to find an answer that we don’t necessarily think about whether we are asking the right questions in the first place.

So, for example, years ago we had a young woman with chest pain, and the residents were, appropriately so, worrying: Is this a PE, or is this a heart attack, or is it a cardiac cause? She has a history of anxiety. She said, “Because I think it’s my anxiety.” I feel like we all have anxiety. It’s the middle of the night, and I don’t, like, what makes this young woman come in the middle of the night? I was sitting there chatting with her, and yes, we had to worry about this chest discomfort and the symptoms she had, but for her, at least, the real issue was the fact that she had switched jobs. She was seeing a therapist or a counselor and did have medications, and she somehow was unable to get mental health care, and she needed to be put back on her medications. So we were able to give her referrals. We were able to take care of those needs.

But the thing is, Kevin, if we had dealt only with this chest pain and the shortness of breath and ruled out the other things, it probably would go down in the chart as appropriate care. We did the right thing. We made sure you didn’t have a life-threatening emergency. An objective person would look at this and say this was good care. OK, but were there needs that were not met, and did we actually truly help the patient in the long run with the issues behind the symptoms that she was having? How do you stay open to those possibilities, and how do you stay curious?

I feel like we need to model that, because so many of us, myself included, it took me years and years to finally give up and say, “You know, I’m just going to be myself.” Part of that emerged, Kevin, because I realized that with the things I was trained for, the things that scared me, that terrified me, I knew what to do in the end, whether it was a heart attack, whether it was a cardiac arrest, or whether someone was having difficulty breathing and required an airway. If it was an identifiable problem, I had the skills or the training to go about intervening in some meaningful way. That doesn’t mean I wasn’t scared or that I wasn’t apprehensive, but I had a handle on it better than I thought. The issues and situations that troubled me the most were those fraught with uncertainty, when I had to battle my own feelings of, what do I do? Like, this person’s frustrating me. Is this person frustrating because this person truly is frustrating, or is it my response to the situation, because they refuse to be an easy story? They refuse to be a question stem for which I have the answer.

I don’t know about you, Kevin, but in my practice over the last number of years, people have gotten sicker, and the issues are more complicated. The straightforward medical problem doesn’t exist anymore, it feels like to me. Then there are social issues and mental health issues and substance issues and economic woes. So there’s always going to be something; we never get rid of uncertainty. So for me, I used my writing skills and took them to the bedside, thinking a little bit like a science-using artist, if I can be so glib. I found I was able to respond in a more authentic way, and I was actually able to have conversations with patients that they appreciated, because at the end of that is some measure of curiosity.

Kevin Pho: We’re talking to Jay Baruch. He’s an emergency physician and the author of the book Tornado of Life: A Doctor’s Journey Through Constraints and Creativity in the ER. Jay, what are some take-home messages that you want to share with the KevinMD audience?

Jay Baruch: What we do is hard, and the things that are so hard about it are some of the very things that we take for granted. We don’t think about it as hard. We think about it as, this is just what we do. I feel like we don’t allow ourselves to be human and to be creative, and that also invites and encourages taking chances, and that means sometimes we’re going to fail. But I feel like meaning is found in those gestures outward. I really want my colleagues to be more forgiving of themselves.

For me, at least, too, I’ve learned to value the people around me in a way. I think I always respected them, and I was glad to see certain faces when they showed up at work, but I don’t know if I truly realized how much I count on them and depend upon them. So for my nurses, my staff, and the people who make some tough times manageable and bearable, I show gratitude towards them. So, forgiveness towards yourself, and gratitude for those people around you who, you might not realize it, really help us so much and allow us to do the work that we all want to do in a meaningful way, to serve our patients and our communities.

Kevin Pho: OK, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Jay Baruch: I really appreciate it, Kevin. Thank you very much for everything you do.

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