Good afternoon, everyone. We have another minute or so, and we will start on time. I'm very thankful to all of you for being inside the room and not on the beach this afternoon. My last time visiting Hawaii was in 2017 for SCCM, and four of the presenters did not show up. This is Hawaii, so I don't blame them. It's good to see friends from different stages of my last 12 years in the US. Beth, hi. Dr. Ashton, everyone from Cleveland Clinic is here for support, and it's good to be here. CHEST is one of those meetings that bring people together, and of all the meetings that I attend every year, this is my favorite because it brings me a sense of community. So I think at this point, we are at 131, so we'll start. First of all, I want to thank CHEST for giving me the opportunity to bring this session together. It means a lot to me and my honorable guest speakers who took the time out to participate in the session. I also want to thank all of you for being here, and especially my wife, who's handling the two little ones at home while I'm here in Hawaii. So Dr. Rana Audish needs very little introduction because most of you know her from her work as a bestselling author, as a clinician, but I want to share one aspect that most of you don't know is that she's very kind and generous with her time, not only to her fellows and residents, but to a stranger. So when I reached out to her that, will you be kind enough to spend time with me for a podcast interview or for a session at CHEST, she was like, let's just do it. Yesterday, we were at the dinner, and my co-fellows were asking, how did you get to talk to Dr. Audish? And I was like, I just sent an email, and she said yes. And same thing goes for Dr. Cooper. I have admired his work over the years. He's a gifted podcast host, writer, an outstanding clinician. The Ohio State University is very lucky to have him as a program director. Who am I? Why am I here? So I'm one of the new pulmonologists and intensivists in Southern California. I graduated last year, and I was very lucky that when I was at Cleveland Clinic, my program director and the leadership supported my vision that started as an anxiety. I was worried, what am I doing in my life? Why am I so restless? What is going to be the purpose and meaning? How am I going to achieve big things that all of us early career trainees and students always aspire to? And Dr. Ashton was very kind, he was like, hey, you have access to all of us, let's talk. So I spent countless hours with all my mentors, and I realized that I'm lucky I have access to these people, not everyone is. So I decided to reach out to all my mentors over the years and started recording those interviews and started a podcast. In the last one year, I have taken a self-claimed sabbatical because I had a newborn. So last nine to 10 months, I have not produced any new episode, but those are going to come out again. Now with that introduction, I care deeply about ICU survivorship. I care deeply about patients' and families' experience. And one of the things I will share with you is that the reason I am bringing this session together is because even though I have never met Dr. Adesh, she changed my life six years ago. I was a critical care hospitalist in Philadelphia, and I was doing that for four years. And I thought I was doing my best and I meant well, but I had realized that after reading her book, maybe I was not doing enough. Maybe the words that we use commonly in our dark sense of humor on the medicine side, maybe they should not be used the way we use it. So even though I've never met her, her book impacted me in ways that changed the way I practice clinically. It became even more apparent to me that our words matter because when I was a first-year fellow and my wife, who was postpartum in septic shock and my newborn, who was a preterm in NICU, I heard words that affected me. They said, oh, mom is not doing so well. And I was like, they're talking about my wife. So it was hard on me. And since those experiences, I have started being very careful. I mean, you know, clinical excellence, we all train, we do it, we participate in it, and we take pride in it. But often this is the side that we don't share. This is what brings peace to us. This is the human side of being a clinician as well. Day after day, night after night, we do this, and sometimes it becomes routine. But what is routine for us is the worst day of someone else's life. So with that introduction, I want to ask Dr. Adesh to share a few words about her background and why does she care so deeply about the power of narrative medicine? Thank you. Thank you. Thank you for that brilliant introduction. I fell a little bit backwards into writing as a way of processing. As some of you know, when I became critically ill at the end of my fellowship, I was left with a lot that I needed to process, but not really a clear path about how to do that. And because my illness was so debilitating and I had lost a lot of words and language, I first started with painting because that was a way that I could figuratively represent what I was feeling so that I could kind of externalize it and give it a frame so it was contained and it wasn't quite so overwhelming. And that was the first step that I was able to take towards really understanding a lot of the post-intensive care syndrome that I was left with and find a path towards healing. Later, when the words came, I felt like they were expanding circles. So first I could write to understand my own experience, but in the process of writing, I could extend that out to understand the experience of my team and what it felt like to be a physician caring for another physician who was critically ill and the pressures that we all put on ourselves to perform perfectly in those situations and what those stresses do to us as clinicians. From there, I felt I could expand the circle out again and start thinking about patient stories differently, thinking about the ways that we could use them, for example, during the pandemic for advocacy or to influence the public that certain measures were necessary, that there was a place for op-eds as physicians. There was a place for the sharings of things that were behind hospital walls that people wouldn't necessarily see. And that that allows for the kind of affiliation that we build with our patients. It allows it with the public as well. And that that affiliation engenders a kind of trust that I think we all need in this era where science is a little bit maligned in some circles. And so it's been this process of just ever-expanding circles from a core of better knowing myself to influencing policy. Thank you. What about you, Dr. Cooper? Yeah, I, you know, for me, my sort of, the beginning of my writing journey began in college where I had to make a choice between majoring in English literature or biology. And I met with my English advisor, my literature advisor, and he said, you know, you're gonna spend the rest of your life thinking about science and, you know, and being a physician. This is your chance to read and really sort of hone your skills as a writer and as a communicator. And it was a very compelling argument and I took him up on it. So I majored in English literature. I focused on poetry. And I'm really, really thankful that I did. And, you know, as I entered into medical school and started having these really sort of transformative experiences, taking care of patients for the first time, seeing someone die, seeing, you know, dissecting bodies in an anatomy lab, you know, things that were just stuff that people don't do. I realized that the poetry that I had been, you know, practicing and learning about in college was actually, could be an outlet for me. So I started writing poetry and that really instilled in me, I think, sort of a love of brevity, of concision, of imagery and the ability sort of to communicate a lot with a little. And, but then as I continued to write poetry and I, you know, and had a couple of poems published and was very grateful for that, I realized that writing was just all around me as a physician, just in my day-to-day life. I mean, I'm writing notes, I'm synthesizing information. I started to realize that different notes that I would read from different people they had their own authorial voice just in their progress notes and in their consult notes. And I came to really appreciate that, how much writing was sort of wrapped up in my identity as a physician. So then I really tried to, I tried to get better at it and I tried to really do it deliberately and not write accidentally. So I tried to write really like good notes and I cared a lot about things like grammar. And like, I just, I wanted people to like, okay, they're reading like a note by Abbie Cooper. They know like it's gonna be a good note. And then realizing, I think sort of like Renna, like that there's a power to reach people beyond your sort of local circle with the writing that you do by creating something sort of beyond yourself. And so starting to write papers about education, writing papers about things, you know, in narrative medicine, things in, you know, like writing, starting to write podcast scripts and teaching in that way, all of that sort of, this identity as a writer sort of congealed together for me, but it wasn't necessarily like a transformative moment. It was just like, I'm writing all the time in lots of different ways. And I found that it was just sort of becoming part of my identity. So haven't written a book like Renna, but I think it's certainly been a transformative thing for me to be able to communicate this way with people that I've never met. Thanks for sharing that. And I think it goes to say about the impact you have when your words reach far, right? And to follow up on your description of why you write, it also gives me a sense that you bring your true self. It's not just you write for a reason, you're just being authentic, you're being genuine. As your, with your experience, do you have suggestion for all of us? Because the room that we are in, I'm sure everyone is interested in how to bring their true self and what are different platforms we can use to bring our true selves? Yeah, I think a really, one thing that I think struggled with early on as I was starting to write deliberately was like, do I have something to say? And I think what I started to do, and I think that really helped me was I started to, when I wanted to say, write a paper about an idea and communicate some concept or write a poem, was really understanding what it was gonna be about before I did anything. And really understanding, like zooming out, thinking about themes, thinking about what my message was gonna be and really understanding that before I did really any writing. And that was something that was pretty transformative for me because writing got much easier when I started doing that because I was sort of almost like writing a prescription for myself, like, this is what this is about. And then that made it easier to like write an outline, that made it easier to write a couple paragraphs and start stringing things together. So I think that was very important for me was really just understanding themes and what my why was and starting with that. Okay, what about you, Dr. Lakish? I love that because my answer is almost the complete opposite. In that I don't always know what I'm trying to say until I do write. And in the spirit of narrative medicine, need often other people to read it to then reflect back to me that, you know, there's this theme that you're writing about. You keep making imagery of drowning that seems significant. The most powerful moment in the piece is when you describe this in a sensory way. And it can hone me in on the sort of what I call the truthiest truth, the thing that I don't know that I need to say that I'm circling a little bit because it feels safer. And with the chest journal and the humanity section that we now have, I get to edit our exhalation section, which are narrative medicine essays that are submitted by the chest community. And I get to develop mentally edit those pieces for other people. And I find I am doing the same thing where I see the story that they're trying to tell, but there's a story beneath it that's deeper and truer. And sometimes we need the courage to tell that deeper, truer story. And having someone reflect that to us can be very helpful. There can be this perception of writing as just blind catharsis, that you have an experience and you just sort of brain vomit it onto the page. And that's rarely what it is. What it more often is, is a process of sense-making where you are looking at your experience and then looking at it again and impressing on it and seeing what more it can tell you in this iterative way until you really get what's behind it. And to me, that is the reason to write, to know what you think on a very deep level that you might be afraid to even say that you think on first pass. Thank you. I think for most of us as clinicians, we are very protective of our identity, right? We don't want patients or colleagues and anyone like public in general to know who we are. We just want to be, we are the doctor, we are the clinicians and we carry this weight of sense of responsibility in a society that is also not very supportive on and off with different issues. So I think the fear of being judged is very, very apparent to most of us. How did you overcome some of those barriers that, hey, I'm going to put my true self out there and I'm not going to be scared anymore and I'm going to be fearless about who I am? Dr. Cooper? Sure. I think that's really hard. And I'll just be upfront and say, I have sort of steered clear of saying controversial things and that's sort of just a choice that I've made. And I've been told that maybe I need to lean into that discomfort more. But I think for at least the stage of career that I'm at, that's been something that I've been mindful of. Partly, I'm a program director and I have to be very sort of careful about, I represent the program that I help lead. And so that is my identity as an educator is I try to keep those not in conflict for my identity as a writer. So I think that's just been a sort of an authorial choice that I've made. I think the other sort of side of it for me is in the ways and the positions that I've taken and the things that I've written, I always have other people read my writing. I really, like it's really, really important. And it's not just at the editorial level when you say submit a journal article or something like that. Obviously it'll be read there. But really sort of with people that I trust to get honest opinions on early, early on about how is this being communicated? How is this going to be, how could this be perceived and look at it from different angles and have different types of people read it. One thing that's been helpful for me, especially for things that, the pieces where it's talked about things that affect patients, having someone non-medical read it and be like, put your mind, put yourself in the mind of a patient or a patient advocate reading this. Does this feel like it is true and honest for your experience? Or would you say, whoa, like that's not at all how I would wanna hear that conveyed. I'll just give an example. A colleague of mine, of ours, Lakshman Swamy, we published an article in chest about code status discussions in the hospital when on admission and sort of wanting that not to be a reflex. And it's like a bottom of the list thing that people check a box. And so it took us a long time to write that. And one of the things that was really challenging was how can we write this in a way that doesn't sound paternalistic, doesn't disempower patients, but also sort of feels true to our experience as people who are interns and sort of experienced that impulse to be like, did you get the code status? And so we had a number of people read it who are not in medicine. And it was very, very helpful for us as we refined what our message was and how we wanted to convey it. What about you, doctor? One of the tools that was helpful for me in deciding how to disclose controversial things was recognizing that ultimately our patients are the most powerless in the power hierarchy. We all have different levels of power at an attending level, a program director level, a medical student level. It's all different, but our patients are the most powerless. And so if I felt like something was true of their experience and that I had enough sort of contextual knowledge and awareness to be able to describe it in a way that was useful for patients, that I had a responsibility in a sense to take that on with the amount of power that I did have. That's risky. It's risky at every level. I can tell you that when I wrote my book, I assumed I would be fired. I didn't know a way forward where sharing the truth could open sort of vulnerability in other people and our ability to admit our mistakes and our wanting to be different. I just didn't know that that would be possible. So taking risks, although risky, can sometimes surprise you with what people are willing to support and to hear. And when it's in service of something that's bigger than us, I think it gives you a kind of bravery that you might not have if it was just about, well, I want to get this piece published in this paper. Thank you. I think what we are all learning is that existing or coexisting as a clinician and as a person is hard, especially when you're ready and be open for being vulnerable, but you have to integrate. You have to be open to that vulnerability to be able to do the bigger good. I think that's the message that you're sharing. Now the platform matters, right? So I think everyone here has been a victim of some sort of Twitter mob situation. That's just one example because everything is controversial. There are two different groups and from our fluid champion or lack of fluid champion in the front row who has been targeted to everyone on something as simple as discussing code status. Does platform matter? Do you shy away from one thing and then you find your true self and maybe just writing is safer because it's peer reviewed often and even if it's an op ed, there's no feedback coming to you in real time. Is that something that you choose deliberately to shy away from and protect yourself? Dr. Cooper? Certainly the Twitter or X, whatever it's called now, piece of this is challenging because it's sort of like, it's just like one big comment section, right? And so yeah, that can happen. But I think thinking about, but Twitter is also very evanescent and like that stuff passes and it's tough, but it passes. But I think from the platform question, I think we're really, really privileged as physicians. We get this really cross-sectional view of humanity, of society, right? And so everything about a patient's lived experience can be relevant to us when we care for them. And so I think we do, and I think in pulmonology and critical care, sleep medicine, like these are really holistic whole body specialties, which I think is really conducive to an understanding of someone's experience and of people's experiences in general that just goes beyond the medical. And so I think for me, that has been a very sort of powerful realization that we have been given this gift to have windows into humanity in a way that I think other professions and even other specialties in medicine don't necessarily get. And so I think that gives us a really interesting, I don't know if platform is the right word, but like sort of like there's like a mandate, I think a charge there where we, if we so choose to, that we speak with an authority granted to us by society, just by the fact that we are in healthcare. And I think that is a tremendous privilege that we've been granted. The way that I've sort of, again, tried to sublimate that for me, really, I tried to marry that with my love of education. And so a lot of the writing that I've done has been about teaching, but also knowledge transfer and finding interesting new ways to communicate knowledge to other people in healthcare and beyond. Again, with the podcasting, I think is one way that we can sort of, all the questions on the curious clinicians that we talk about are all informed by our lived experience and patients that we've taken care of and questions that have come up in the clinical realm. And it's really inextricable from the clinical work that we do. And so I really appreciate the fact, again, that we get this privileged view of sort of the human condition and we can do with it what we will, right? And so, you know, Renna is just a master storyteller and sort of meaning maker, I feel like he's just so good at that. And like for me, a lot of the writing that I've done has been on knowledge transfer, trying to communicate complex concepts to others. And yeah, it's a lot of fun. To add just a bit to that, I think that comment about Twitter being very evanescent is exactly the way that I think about these different platforms is there are some things that you put out in the world because you're looking for a kind of response in real time, a pulse check. Like, how are other people thinking about this? I'm curious about this question. And then there are things that really require a lot of self-reflection and distance and perspective. And that might be something like a longer form essay or a book where you really do need some time to process what you're believing and letting it evolve over time that wouldn't be appropriate for social media. And then I think about how during the pandemic, the podcast This American Life did a series on our experience of COVID at Henry Ford Hospital in Detroit in real time. Like we just had our audio diaries recording on our phones, and we let that into the world to be processed in real time because that's what was needed in that moment. People weren't seeing those things. And it couldn't be edited to make it sound pretty because it wasn't. And it couldn't be packaged by our marketing team. It just had to be raw and real and accessible in real time. And so thinking about the why, what is my reason for using this medium in this moment can help direct you into where your story belongs now. Thank you. I'll share that with you as well, that being raw and vulnerable again, especially with people outside of medicine, you'll be shocked and surprised that every time you share some of your own personal story with the patient, even though we were warned when we were in training and med school that, oh, you don't burden the patient and their family with your own story. The amount of relationship with the deep, meaningful relationship you develop with those patients and families, if you share some of those raw moments, it becomes a forever bond. And I've had those experiences over the last several years where I have shared my hard times being a physician and also a caregiver for my family. And that just tells them that this guy gets it. I think he has been on the other side, and he is going to take care of my family member the same way. I might just add one thing to go off of that is I don't think you need a platform to be a writer. Like I said, I think being a physician, a healthcare worker who is documenting, you are writing. I think people journal without purpose to be disseminated. It's just for themselves. It's just a processing tool. I know people that write poems to process, and they don't necessarily intend for them to be published. And that's okay. I think writing is still part of your identity if you're doing that. So I think it's more about intent than about platform. Something like Twitter, I mean, there's like dopamine there, right? You get those hits. And it's great to get like a journal article published or a book published. I mean, it's a monumental achievement. But I do think that you can identify as a writer in healthcare without doing those things. And I think you can develop, and it can bring meaning for you and have impact without a platform. What I would add to that, because I absolutely agree, is just having a reflective practice, whatever it looks like, whether it's writing, whether it's just looking back on your week and saying, these are the three moments where I really felt the most like myself and like I was a healer, not just a physician. Whatever that practice is, can be transformative in its own right, because it will bring you to other moments differently. I'm thinking of a patient that I had during the pandemic who, you know, had been my patient forever and who I adored, who absolutely berated me for wearing a mask because she thought it was all a conspiracy. And it really broke my heart in that moment. But what I knew to do because of my reflective practice was just to ask her, what has this experience been like for you? And finding out that she wasn't allowed to see her grandchildren and finding out that she felt disposable and alone and isolated allowed me to then say, you know, as a physician in this pandemic, I too have felt isolated and alone and forgotten. And we have this in common, even if our material circumstances are different. We share this thing. It opens up what's available to us in a way that we might not know about otherwise. Right. I'll ask you both this, we both are like extremely well-known writers. What percentage of your writing you just do for self that does never go out to the world? Because I think for most of us who want to write or want to express ourselves, that's the biggest fear that does anyone care? Is it just for me? I don't have a feedback loop for the podcast that I host, and it's a small one. But have you received feedback about the stuff that you have done? And then does that help you channel the work forward? There's a tremendous amount of writing that I don't publish, either because I don't feel like the story is actually mine to share, but I still need to process it. I had a very good friend have a psychotic break that was very difficult for me, but that's not my story to share. And I do write about it for myself to understand my reaction to it, but wouldn't put it in the world. There are a lot of patient stories that I think make people vulnerable that I wouldn't put into the world. But without writing about it, I don't really know enough about what I'm thinking. So probably 90%. That's very reassuring for everyone here, right? So I think it gives us hope that our writing is not for everyone to see, it's for us also. Yeah, I think that for me that the areas that probably are probably that have the lowest percentage of intent to be published would be some of the poetry, especially when you're sort of playing around with imagery, feeling, processing and experience. Sometimes it's like not a good poem, right? Whatever that means. Sometimes it's not a good poem, but that doesn't... And so I may not try to publish it, but I'm glad I wrote it and it had meaning for me and helped me process something, even if it's not good from like, you know, again, however you would define that. I think the other sort of piece of this too is I write a lot of really bad first drafts on stuff that that language doesn't get seen, but it is meant to be sort of as a developmental process. I'm going to shout out Gabe Bosslett, who pointed me toward Anne Lamott, who's an author from the West Coast and had me read a book called Bird by Bird, which was very transformative for me, very powerful. Basically she talks about that the writing process, it's not just like the sort of fountain of wisdom and brilliance that pours out of someone. It really starts with like, almost like, you know, you're making a statue from a block of granite and it starts with a block of granite and you find the statue inside. The sculpture inside. And that like her process for writing is really like very bad draft, slightly less bad draft. Okay, maybe now it's starting to look like it's going to be maybe an okay draft. Nope, it's still really bad. And then like, that's what the process is that she goes through. And that was very validating for me because I was like, yeah, like it usually comes out not so great initially. And then just with a lot of refinement and again, carving, finding the sculpture inside the rock. That's, I think, how it's done. And I'll ask you a follow up question because you are the podcast host, right? So that comes with a very different set of skills. You have to be, you know, on the spot in real time, follow up questions, and you have a script that you plan. What other technical skills that you have that said, oh, I can do a podcast because you do have the one hour podcast and it takes eight to 10 hours of editing. Yeah, I so I was I actually hosted a radio show in college that like nobody listened to. Nobody listened to this. I actually confirmed that once I had you could like it was like an Internet based cloud streaming thing. And so you could see how many people were. And I remember I was advised to not check. And I was like, you know, I'm just going to check. And there were zero people listening. So I was like, and this wasn't being recorded. So I was just sitting in a room. Talking into the into the into the ether, and I had a choice, I was like, I could keep doing this or I could not check anymore, so I stopped checking. And so, you know, when when the opportunity to form a podcast came along, that really grew out of the teaching that Tony Brew and Hannah Abrams, my co-host, that we were all doing on Twitter, and we found that there were more stories there in like a single tweet that like could you could have a five minute discussion about the paper that was referenced there or the story that we sort of very, very succinctly referenced that you could there was a lot more to explore. So that was the reason that we started the podcast, because we wanted to expand some of these stories and do it in a little bit more long form and create some permanence to it. Because, again, the evanescence of Twitter and so that that's how it grew out. And I think from a podcasting perspective, the challenge is to make it sound not scripted and to make it sound like you're having a conversation. And it took us a little bit of time to find our rhythm on that. But that's really a very, very important piece for us because it's it is it's 100% scripted. I mean, there's a little bit of stuff in there that we, you know, ad lib, but for the most part, we know what we're going to say. And the writing process, it's really interesting because you're not writing a screenplay. But at the same time, there has to be some flexibility, some bendability to how we're going to do it. And so I think for us, it's it's it's been a focus of ours to create that sense that we are having a conversation, which we are, but it's very much scripted. And, you know, we decided that this session is one of those sessions without PowerPoints. And this is a conversation with everyone. We deliberately chose that platform because we wanted to have a conversation with our audience. Before we go there, I was going to ask you, most of us are not taught how to write. This is something that we start doing maybe in med school or residency or fellowship because we are very scholarly driven. But what about mentorship and scholarly opportunities for people who are not gifted, but they can be coached? What kind of some of those opportunities that exist around? One that I found that was really helpful to me was the narrative medicine community that grew out of Columbia University that has a number of online sessions that are virtual that anyone can sign up for, which I did quite a lot of during the pandemic, where it's always the same format. They'll pick a piece, you'll do a close reading of it, the group will reflect on what they notice in it, and then you write in the shadow of what you've just read together and then people share and there's no obligation to share. And there's no obligation to share. But what that process that Rita Sharon developed really teaches is that close attention to word choices, to symbolism, to metaphor can really expand your notion of what's possible. It's it definitely made me more aware as a writer. We all develop our own communities. So I can tell you my first reader of anything is my best friend, Jim, from seventh grade, who remembers when I had a Lionel Richie Afro and has no problem telling me when something is terrible because we've been friends for a million years and I'm not ashamed to show him my early first drafts. I have other friends who are professors of literature who can give me a more critical eye on things when they're more developed. But you build your community and we all write together and share. And it's really incredibly helpful, even though sometimes you see a piece and it has one author's name on it. There are always many, many people who have contributed to that process and that can be invisible, but it's real. Yeah, I think for me, sort of connecting with someone named Renna has been very powerful for me as a as a sort of an author trying to find my voice. You have read a lot of my writing, which I'm incredibly appreciative of and given incredible feedback and pointed feedback. I think something there's a few things I think that have helped me. A lot of it's been a little bit self-guided. One, editing has really been helpful. And so I think if you're given the opportunity to work as a reviewer or as an editor and to sort of think critically about other people's writing, you sort of get a sense, OK, like that's how that's why that worked really well. Or no, like this is how I think this could be improved. And you have to create help, create solutions for that writer for them. And that actually helps with your own development. I think reading a lot is very important, but reading with intent and really sort of understanding like different authors, why you like their writing and why it speaks to you. So I'll just give two examples, two of my personal sort of patron saint authors. One would be Oliver Sacks. I, you know, I realize that I love the way that he was able to he had sort of this all seeing eye that could, you know, just notice so much detail from a clinical encounter or concept. And he married that with his incredible curiosity and his ability to tell stories that for me has been very inspiring. The other would be Bill Bryson, who writes with these sort of rosy tones and sort of invites you in like a like a, you know, like he's sitting next to you and he's explaining it to you and you're just talking to each other and that I have, you know, and so I love reading his writing and but I don't just read it to have him teach me something or to have a positive experience reading this book, but also to learn from him. Like, how did he communicate that? How did he tell that story? How did that link back to something that he said earlier in the book? So I think those two things have been very, very helpful for me. So yeah. I'll tell you that most of us who write papers and scholarly articles, there is a structure to it so we can follow. But when you're writing a narrative piece, you just don't know when is the first draft worth sharing with people that you want feedback from because that's the hardest part. Is this really the best draft? I can send it to someone I trust and I want their opinion or this is absolute garbage because it just came out of my mind and I put it down there. So I think having that army of friends and family or colleagues who you trust and who can kind of give you a good initial feedback that you can build upon makes sense. We have another 15 minutes and we want to keep it open for everyone. So as people start having questions, we can direct it to any one of us. Thank you so much for sharing. I've been writing for myself for a long time about some of the observations of racism and implicit bias in healthcare system and training and I want to transition into publishing some of this to help advocate for change. And so can you please share with us your process for discussing your experiences, patient experiences, kind of from your perspective? Is there something that you do to honor HIPAA? Like what does this look like from a practical standpoint? So what you're speaking to is a very broad area of medical ethics really around writing and the sharing of patient stories and I think it's probably more than what I can hope to cover now, but my rule for myself in my writing is always that the patient's experience exists behind a door that I only have this much access to. I only know my lens on it. And I can write from that perspective, but if I find myself trying to write from the patient's experience of what happened, that is not my story to tell. And I try to keep myself on my side of the door and I try to talk about what I've learned because I think in medicine there is this notion that we are the holders of all of the stories, right? The stories are ours and that's an evolving narrative and we're still on this side of it where I think over time we'll realize that maybe we weren't the owners of all of those case reports that we thought we were. And figuring out what your message is and what the best story to tell that message is I think is where the hard work is because sometimes the story can be attractive but not the best vehicle for the message and uniting those two can be very difficult but it's worth spending time trying to do that. Thank you. Javi's like nothing. I have a question for both of you actually, separate questions. So Avi, you guys have done I think 78 podcasts, which is a lot. It's a lot. And you've talked a little bit about the process of learning how to do it. And I wonder, and this is a bit of a whimsical question I suppose, but have you listened back to your first few and does it make you cringe or what is your response when you hear them? Yeah, juvenilia, right? It's like, it's a real thing. It's, so I've always been fascinated with juvenilia actually. Like I love listening to like, so I love classical music. Like I love listening to like the sort of really early compositions that people do because like you could see where they grew out of and certainly we're not on that level but it is from a technical standpoint I would say hard to listen to, to our first few episodes cause like we just didn't have our act together at all. Like there's, we're over gained and like the transitions are a little awkward. And so the, from the technical standpoint, it's sort of like, wish we sort of had done that differently. But from like a messaging standpoint and like, I don't know, like it was really early in COVID when we started and I was like recording in our linen closet because that was, our apartment was like the most, so you want to avoid like hard surfaces when you're recording. And so that was like the sort of most clothy place to go. And so I think it's, yeah, it's sort of like tied up with like the memory of starting this thing that's been really fun to nurture and grow. So I think that part, I have a lot of, I'm very nostalgic about how we started but from a technical standpoint, it's a little cringy. I think on a meta level, the fact that you had a word for what I was describing says for anyone who doesn't know Avi, that describes you perfectly. Renna, can you talk about the story of when you realized you had a book? Did someone have to sort of tell you that that was the case or did this just sort of spontaneously birth out of this writing you were doing to process what you went through? Yeah, no, I had started speaking about my experience just at my own hospital sepsis day. One of our fellows, Kami Boka, who's probably here somewhere recorded it. He posted it, it circulated and a literary agent reached out to me and said, you have a story there and you clearly love words. Do you want to write a book? And I was like, nope, sure don't. And then I had this idea that if I wrote the book, I'd never have to talk about it again. And that was wildly appealing to me. I was like, that's it, I'll write it. And then I'll never, I'll just hand it to people and walk away. And it turns out if you write a book, you keep talking about it. So that didn't work out at all. But sometimes you need somebody else to tell you something they see. I wouldn't have set out to do it unless I knew that there was a need for this story to be told. And I think sometimes we need other people to tell us that that exists. I'm sorry. I'm okay now. I was speaking of people who have to tell you what you do. I just want to thank you for empowering us to be writers in our own EMRs. I do have a question about being a writer in an EMR system that kind of pushes all of us to do as much work as possible as fast as possible. And it's all about templated notes and just putting out there so I can hand over and all that stuff. How did you guys inspire trainees into putting themselves in there in that program? Yeah, that is such a great question. Sorry about that. No, it is. Because I think the deck is stacked against us because you're right, the priority is not on nuance. The priority is on efficiency and throughput. And I would say I'm probably not so good at this. So I don't know if I'm the best person to answer the question. But I think what I try to do is provide, when I do provide feedback on this, it's through the, we're in a pulmonary clinic, right? Say, or consult note in the inpatient setting, trying to put yourself in the mind of the reader and saying like, is the person that's reading this gonna be able to get out of it what they need to take care of this patient? So I think I've tried to be concrete in my feedback through that lens, because ultimately that is the audience of this. I think the other thing that I've tried to, that I've provided some feedback on recently, like in the last few years, is with patient access to notes. We have to be really, really thoughtful about how our ideas are conveyed because they're now the audience too. And they're empowered in that. And so I think we have to be very, very careful and thoughtful about the way we talk about possibilities and things that we're considering. And I've actually started in my own practice, prepping my patients actually, and sort of sharing my differential with them. And maybe in a way that I wouldn't have done if I didn't know that they were gonna read the note in terms of like, this is something I'm considering. I think it's really unlikely and my note will reflect that. But to be complete, I'm sharing all the things I'm considering and in case you read the note. And I think that's been helpful because otherwise, I mean, you don't want someone to get scared or read something that they think is maybe more likely than it is. And what I would just add is just an acknowledgement that the way we tell stories about our patients to each other is sometimes intended to bias them, the consultants one way or another, to bias people against surgery. And even just that awareness of, am I using language that is intended to diminish or bias? That's a lot further than we've been in the past. Which brings me to my last questions. I was reading the test news the other day and there was a four minute talk about how physicians should show up in social media. And it was pretty intended and clear message about physicians not having to have an opinion about religious, political, hot topics. And I'm curious to hear what you think of that. Gabe could answer that better than us. Yeah, seriously. So I had a question. I guess you guys both kind of already touched on this when you were saying when you were gonna publish your book and will I get fired? Or you're saying if I'm gonna put things on social media and kind of thinking about how this will be interpreted. Because I think that's the part I wanted to hear a little more about. How did you decide I'm going to finally publish this? Even just, I don't know, going up in training, I always, you start out as a med student or an intern and you're like, oh, I don't wanna say these things because it'll impact my career. But oh, I'll say it when I'm in attending. And then I'm applying to college and I'm like, oh, this is not gonna go away. And this is gonna still be things that will impact. And it is just your narrative. And you understand that you only know your view point through your lens. And I can try to see what it looks like from another person's point of view, but I don't know that. But I can't state that in everything that I put on social media or that I publish outside. And I still struggle. And unfortunately, because of that, I think more often than not, I just end up being silent because it seems safer. But as you said, I think that's also how you express these things and how you impact the world. So maybe talking to trainees as they're moving up and then even people who are attendings now and how to address that and do that. I don't know if I articulated that well. Yeah, no, you did. The question I ask myself when I feel like that is who does my silence serve? If I'm silent, who is it empowering and who is it disempowering? And that often clarifies a lot for me because everything is a risk-benefit analysis. Everything is how risky is this thing and what are the potential outcomes and what am I willing to absorb? When people in power are silent though about horrible things, we allow it. And so at least understanding my own intention and the systems I'm working in helps me to filter out what is important enough for me to take the risk. I guess the only thing I would add to that, I think the advice that I might give is to be very sort of just mindful of the why, but also how it fits into your own sort of narrative as a physician, as a trainee, as a person. And if those things are sort of lined up and it's like you're speaking from an earnest, honest self in that position and it sort of makes sense for you with your own identity, then I think it's very different than a situation where it's impulsive and it's just like, I'm just gonna put this idea out there and we're gonna see what happens. It's more that it's coming from you, from inside, and it's really reflective of you as a person. And I think sort of to Rene's point, then it is empowering. It's empowering for you. It's empowering for whatever it is you're lifting up. And it's coming from that place. I'm mainly curious about how you guys empower your current trainees, residents and fellows to also reflect with narrative medicine. If you guys have like organized groups or if you kind of just, because you guys have produced so much, you're just kind of leading or you're role modeling by what you've already done or if you have more organized things at your institutions. So we started integrating narrative medicine into the institutional curriculum for our residents about three years ago. So every incoming resident or fellow goes through about a two and a half hour narrative medicine, a little bit about the history and the mechanics of it, but also just the experience of it. And then we've worked to insert it in programs that already exist. So it can be very hard to just sort of start a narrative medicine program. The facilitation is really a very highly skilled facilitator can still struggle to do this. It's something that we partner with outside people to do well. It's been sometimes really well-received and sometimes not because it's part of the institutional curriculum. That means our orthopedic surgeons do it. It's just different, right? Like depending on the group, it's different. And so I see the value in it and I keep pushing forward. I also wonder if maybe we're doing it wrong. I think for me as a program director, it's been more about empowerment and sort of if someone shares something or has an experience, or even if it's not necessarily narrative medicine, they just have a powerful idea to sort of suggest, hey, like, have you thought about maybe writing this up and sharing it? And yeah, I mean, some take you up on it and then I think part of my job is helping them find a way, find the outlet, find the platform or whatever it is that they are looking for. You know, like, okay, this journal has a format that you really could write for and aim at and then try to make it happen. So I think it's been more on the one-on-one thing. We have two last questions because we're running out of time, but please make sure you give us the evaluation that will allow us to do it again in the future. Thanks to y'all for putting this session together. So I think one thing that probably comes up as a barrier for people when they think about writing is really not having done it. And so it probably feels like going from sitting on the couch to trying to run a marathon. So do y'all have like a daily practice or some other kind of incremental way to work up in this process to the stages that you've all reached? So as a card-carrying incrementalist, that definitely speaks to me because I do think it can be really intimidating. One of the ways, again, that's been helpful for me cognitively is to, again, to start with themes and ideas and even single words that sort of reflect the larger thing that I'm trying to say. And then it sort of unfurls from there. I think a practice that I've done for myself, because I have a lot of roles, both inside and outside the hospital, is to try to find even a small amount of protected time on a daily basis. So actually one thing that Renna suggested that I do is to set a calendar reminder just to write. And so I did that. So every day I get a little reminder that says write and whatever it is I'm working on. But what I do now is I actually start my day with it. And so the first 30 minutes of my working day are writing. And that could be something creative. It could be something for a paper, whatever it is. But I really try to protect those first 30 minutes because once I get into my Outlook inbox, whatever it is I'm doing, responding to patient communications, starting the seven meetings that I have that day, it's like the most energized, caffeinated self is gone. And so I try to preserve that for those first 30 minutes when I really am fresh. So one thing I've started doing is I don't check my email. That's not the first thing I do because I found that once I'm in that, I get task oriented and I'm gone and I'm just off to my day. So I don't, I really don't open up an email. I don't even get an alert that like stuff's coming in until I have sort of finished that first little, little like, I don't know, aliquot of writing. Yeah. I have a journal that I write in that is literally unfiltered thoughts because I, like all of us, will self censor until I reach the most like appropriate thing to say. And that's just the place where I truly write what I think. And I don't ever intend for anyone else to see it. And I'll go back to it and see if themes emerge and then block off time. For me, it's usually Saturday mornings. I can write in a nice block, but I need that journaling to inform it. Great, thank you. I really appreciate all of your hard work. It's amazing. But like you said, Randall, there are multiple different forms. Me, for instance, let me tell you a story. I was on call in the NICU and almost lost the baby, but did not. One of my outlets is photography. So I like shooting birds. I like shooting butterflies. Happened to be at that moment, I wanted to go shoot hummingbirds. So I went up to Mederic Union, a migration place for hummingbirds, and no hummingbirds were there. But what I did find was a Mexican jay. I got a picture of it and its shadow, it and its shadow, and then it went like this. And it was a blue angel. I'll leave you with that. Thanks for sharing that. This brings us to the end of our session. We are very grateful for all of you to spend your time with us. We hope to see you in Boston next year. Thank you.

narrative medicine

writing

reflection

self-expression

empathy

healthcare

patients

healthcare professionals

vulnerability

personal experiences