If stories are central to medicine, then Koven couldn’t be in a better place to bear witness. She is the first writer-in-residence for the Division of General Internal Medicine at Massachusetts General Hospital. The division is the largest of a dozen in the Department of Medicine at the hospital; its 350 members include primary care physicians, researchers, hospital-based physicians and geriatricians.
HMS assistant professor of medicine at Mass General, Koven is a widely published author of essays, articles, blog posts and book reviews. Her work has appeared in The Boston Globe, the New England Journal of Medicine, New Yorker.com, Psychology Today, and The Los Angeles Review of Books, among other publications.
Since February, Koven has been a coach and mentor, available to strengthen writing skills among her colleagues as they craft narratives. She also convenes small groups of physicians who read and discuss literature.
That’s where the magic happens.
“You really had to be there to feel how rich it was,” said Joshua Metlay, chief of the division and an advocate of Koven’s work. He attended a session with her that focused on George Orwell’s story “Shooting an Elephant” and explored themes of responsibility and authority.
“It was really eye-opening to watch where the conversation went, facilitated by this initially seemingly unrelated short story,” Metlay said. “It just opened up all kinds of ideas people wanted to talk about that were occurring in their everyday work lives.”
Building on a monthly discussion of literature in medicine that was supported in the past by Mass Humanities and by Mass General, Koven continues to visit primary care practices. Instead of lunchtime meetings about, say, what’s new in hepatitis C, clinicians gather to talk about an essay or poem that she brings.
Two powerful forces converge: the need to talk and a provocative vehicle for it, she said. What’s more, the participants can speak freely in a safe place.
One time they read Eugene O’Neill’s play "Long Day’s Journey into Night." People talked about the effects of addiction on a family and the inadvertent role doctors might play in fueling addiction—as Mary Tyrone’s doctor did when he gave her morphine for her nerves.
After reading Leslie Jamison’s essay “The Empathy Exams,” Koven posed this question: If you’re telling somebody terrible news about a diagnosis but you’re also watching the clock and thinking about lunch, does that make you a bad doctor or nurse? Does that mean you’re not empathic? Is it enough to act empathic or do you have to feel what the patient feels?
“These are difficult questions and I find that people who do this kind of work are very eager to talk about them and feel very grateful to have an opportunity to talk about them,” Koven said. “But here’s the thing: This is not like fluffy, after-school-special kind of stuff. This isn’t an adjunct to medicine. This is medicine, because we’re hearing from patients that they want to feel that their stories are being heard. They want to be listened to. And literature, I think, is a very fine kind of listening and very good training for listening.”
Koven has a theory about why people in primary care are so receptive to talking about the human side of their work. Medicine in general and primary care in particular seem to attract nurses, doctors, social workers and administrators who are very social in nature but whose work tends to isolate them.
Primary care practices place a socially adept, intuitive person with one other person behind a closed door in emotionally intense situations, she said. Then the professional has to write notes in cold, clinical terms. And they can’t discuss what happens freely, out of respect for privacy. Their training teaches them to bottle up these thoughts and emotions.
“When you uncork that bottle and invite people to talk about what it is like to deal with a really difficult patient over years and years, or what is really going on in the way doctors’ and nurses’ roles are changing, or what it is like to be a clinician in the early stages of Ebola, there is just this incredible opening up if you’re having that conversation through the lens of literature,” she said.