S Y N A P S I S

Sarah Berry // This interview series features educators, scholars, artists, and healthcare providers whose work is vital to the growth of the health humanities. On Thursday, May 12, I interviewed Dr. Jay Baruch about his forthcoming essay collection Tornado of Life (MIT Press, August 2022), as well as medicine, narrative, and the role of writing in his practice.

Sarah Berry: Tornado of Life is a tour de force. It features patient narratives, sketches of the ER, self-portraits of your development as a provider throughout your career, and your reflective and analytical essays on the multidirectional relationships between narrative and healthcare. It’s a many-faceted collection. What inspired this book?

Jay Baruch:  People think the toughest part of my job or emergency physicians’ work is the high-wattage drama, the mayhem and blood that is portrayed in popular media and even in books. But I’ve discovered that over the course of my career, the toughest part of what I do is actually getting to the heart of a patient’s story and trying to respond to it. 

If someone came in with cardiac arrest, I know what to do. If someone comes in with breathing difficulty, gasping for air, I know what to do. The problem is evident, and the solutions are oftentimes obvious, if not algorithmic. 

But the biggest challenge and the biggest part of my work has been caring for people who come in with not just problems with their body, but also social issues and emotional issues and substance use issues, and oftentimes all of them. Sometimes their wounds are less obvious, and yet that doesn’t excuse me from taking the time and having the skills to probe those less obvious challenges.

SB: These challenges are highlighted under many different filters in each piece. Many of the pieces are compact and economically crafted, and reflect different wavelengths like the facets of jewels. They’re works of art in and of themselves. And they also seem like a way of working through the cumulative traumas and stresses of helping so many people who are having complex problems, many of which are structural and preventable. The three sections, “Vulnerability,” “Constraints,” and “Possibility,” portray that full arc of being an emergency physician really well. Can you tell us more about your intention behind this structure?

JB: The overarching design of the book, which is made up of very short narrative essays, is purposeful. I didn’t want to talk about situations; instead, I wanted to take the reader into the situation. My primary purpose was not to just share this experience with you, but rather, I want you to feel this experience. I want to engage the reader at some kind of visceral level. I wanted the reader to feel a little of the instability of it all, from story to story, and there’s not always an answer at the end of each one. 

I really love work that leaves space for the reader, and I want readers to have a chance to enter into these pieces, to try to make sense of them and also [reflect on] what it means to them. Not all of us are in healthcare and not all of us are teaching medical students or future medical students, but all of us are vulnerable. All of us have had encounters with physicians or other healthcare providers or the healthcare system or have family members or friends who have. We’re all impacted by many of these experiences, even though we might think that we are not. 

The three sections were not intentional or designed at the outset. After the book was written, my wonderful editor Bob Prior at MIT Press thought we needed more structure, that I should be kinder to readers even if I sought to destabilize them a little. [a little laugh] 

These three thematic areas also serve as a narrative arc.

“Vulnerability” we put up front [as the first section] because that’s something we all experience if not acknowledge openly. You can define vulnerability in many different ways, including exposure and susceptibility to either physical or emotional harm. 

It’s also a call to duty. Okay, so how are we going to respond to that?  What’s the duty of others to support or to help? The “Vulnerability” section set up the rest of the book. 

“Constraints” is the heart of the book. There are many types of constraints, from too little time, too many interruptions, being expected to make high stakes decisions with incomplete information, healthcare system obstacles, resource limitations, and the expectations that the ER will be the safety net for problems, not just medical problems, that the system and communities can’t or don’t want to handle. There are less obvious constraints as well, like emotional limits, limits in compassion, trying to uphold a social justice mission in an unjust system.

The third section, “Possibility,” was just a beautiful way to frame the book, I felt, because there’s not always an ending to our experiences, a conclusion, or as physicians, no  “Aha! I solved it!” moment.

However,  I love the Sam Shepherd quote that opens this section, about considering endings as new beginnings.  How we define an ending is very different for everyone, and can be very subjective. Possibility presents the reader with thoughts of alternative endings, or alternative new beginnings.

I like a book that continues to breathe a little bit after I finish it, that I carry around in my head.  I think all writers want to write books that do that. By moving from story to story, section to section, I was striving for that possibility for the readers of Tornado of Life. 

SB: I love the idea of putting the reader of these patient and healthcare narratives into the feeling of moment-to-moment, and also the idea that patients’ and caregivers’ narratives don’t often neatly resolve at the end of the chapter. In the essay “Tornado of Life” you explain Arthur Frank’s theory of illness narratives, and restitution—a neat, medically-controlled restoration of health and functionality—is one form. But the cover features a huge scribbled graphic and the large block- letter title, “TORNADO OF LIFE,” and inside are many chaos narratives, including the eponymous essay about Cheryl, who enters the ER after an overdose that is only one point in a line of disruptions and vulnerabilities stretching back through her life. Can you tell us about your deep dive into chaos narratives in this book, and your literary decision to use Cheryl’s phrase “tornado of life” for the title?

JB:  It actually wasn’t a literary decision. It was desperation. I call myself an accidental academic because I simply translated how my writing skills and humanities-informed pedagogy and conversations served the care of patients. It was absolutely necessary, not so-called soft skills,  drawing on those tools, being open to different framings. Years and years ago, when I first read Arthur Frank’s work [The Wounded Storyteller] theorizing different forms in which patients tell their stories—restitution, chaos, and quest narratives—it blew my mind. This was the first scholarly work I read in health humanities, along with Kathryn Montgomery Hunter’s Doctors’ Stories, and they are still two of my touchstones to this day. When we think of problems this way, in terms of a restitution narrative that centers on finding an answer, it impacts what you consider important information. It also pathologizes the fact that you don’t have an answer instead of framing uncertainty as an ally.

I was listening to Cheryl [a pseudonym] tell her story in the ER, years and years ago, and suddenly realized, “I am listening to a chaos narrative.” Up to that point, I was aware that I was listening to chaos narratives, but I didn’t internalize it in the way that I did at that moment. She was challenging, and all over the place, and very desperate and hurting—really, really hurting. And I just realized, she’s telling me a chaos narrative.

More importantly,  I remembered what  Frank said. The worst thing you can do with chaos narratives is to push them into a different story, or to give an answer, and to not respect the chaos and value what the patient is saying. [It’s necessary to] give them room to tell their story. I found that incredibly powerful at that moment.  I had taught about it before, but at that moment, it hit me like a sledgehammer. It’s the health humanities in action. This is why we need to be informed by different modes of thinking. There’s huge importance to scholarship like this because it has clinical applications in the care of our patients.

SB: In the story “Tornado of Life,” the crux of that narrative skill in action is in your response. Instead of a pill or a surgery, you “prescribe” a writing technique: you asked Cheryl, “What’s next? . . . Can you write that line?” It was a narrative turn in the clinical encounter, and then you describe sitting quietly and waiting. 

JB: Well, she struggled to take that in and try to think about it, so you’re sitting with her silently, uncomfortably, in this space. 

SB: That resonated with me really deeply, because the kind of teaching I do is often asking uncomfortable questions and waiting, resisting the impulse to provide more thoughts in order to empower learners’ thinking, so in that moment, your roles as a teacher and writer and doctor seemed to be working in synergy, in my view. You mentioned earlier that this book is for everyone, not only for healthcare providers, and I could relate to that interaction, not as a physician, but as somebody who wants to help make things better for other humans as well. 

JB:  First of all, thank you for that. In that moment, I did not expect to say what I did, but it came to me. If you’re an artist or a writer, in particular, you’re open to language. I don’t know if I even would have taken this turn if she hadn’t first said this line [“I’m stuck in a tornado of life.”] That was such … [pauses ] I mean, our patients speak to us in poetry, language that surprises and shocks and gets at life in ways that resonate in profound ways.. That line and phrasing made me pause and think, “My God, that’s amazing!” 

When I asked her to write the next line of her story, it was tough to sit in silence. You want to say something and fill the silence. You want to be smart and helpful. You want to move things along because you have other patients to see. But when I asked, “Can you write that next line?”, I didn’t want to imply that she needed to be thinking about the future when she’s mired in a forever-present. But asking her to write the next line just felt like a simple move, something manageable, while also recognizing that it could be difficult. 

I think she was surprised by that. 

SB: That moment really stuck out to me as a mode of care for Cheryl in the complexity of her situation. And it also made me think about how I would react if a healthcare provider asked me the same question. It would really take me by surprise, also. This question has behind it so many dynamics that are atypical in clinical encounters—it’s mutual meaning-making, a back-and-forth, sort of breaking down that hierarchy of doctor-authority, patient-subject. The act of asking “what’s next for you?” is trusting that the patient has the ability to write another line for her life. In other words, it’s empowering, even as a possibility or to introduce a new path to someone who is overwhelmed. It’s very different from directing someone to closure or prescribing something and dismissing them. It’s co-creation of a narrative that has transformational potential for both people in that relationship. 

Your writing about the practice of emergency medicine and storytelling with patients is part of your larger political perspective on medicine and healthcare, which is highlighted in many of these essays. What links or motivates your different writing projects?

JB:  What animates both my fiction and nonfiction is a sense of trouble and a general dissatisfaction with the easy answers that we claim to have for big challenges. We often find cozy or neat responses or try to make it simple or more reductive rather than to really explore the messiness of a particular situation. Most of my regular writing never sees the light of day in any shape or form, but generally, that energy is always there.

For example, [in “Moving On”], in emergency medicine, the thinking is that we just have to put our head down and move on [constantly], that this is what we do. We’re always busy. But our normal in the ER is far from normal. And this mindset feels too glib for me. I wanted to explore that more. “Why do we move on?” and looking at all the excuses we use. 

I’m not a health policy or data expert. I use what I have available at my disposal, which is a set of narrative skills and a curiosity about small, complex, everyday moments and a desire to make those moments palpable. 

We need to think deeply and critically about the challenges we’re facing in healthcare, while accounting for multiple voices and multiple perspectives.  These are humanities tools. The COVID pandemic highlighted the achievements our system is capable of, and its tragic shortcomings. We were able to get vaccines up in record time. We were able to come together and understand this virus [medically] in record time. There were so many players in this effort: public health experts, physicians, politicians, sociologists and anthropologists, epidemiologists, and economists. We drew on so many specialties that all came together, and that was a huge achievement.

But the challenges we’re seeing now is in part the result of who wasn’t at the table with these experts—narrative experts.  What we are facing now is a narrative crisis. We relied so much on data and statistics and the experts didn’t do as thorough a job of trying to appreciate  the experiences of others on a very individual and granular  level.  I don’t think we did a great job understanding the experiences that numbers and data can’t capture. I don’t know if we can make that up. 

SB: Is it too late to apply narrative perspectives in the pandemic? Can storytelling save medicine?

JB: I don’t think it could save medicine, but I believe it can create a deeper understanding of what we’re all experiencing and what we all hope to achieve. Clinicians, caregivers and patients, to administrators, politicians, and our leaders. I think our way out of this, or our way forward in a more productive manner is going to be on the platform of story. We all have stories to share. I think, in the end, we all want to be heard and recognized and understood.  Authentic communication is a dialogue.

SB: That would be a revolution in healthcare and pandemic responses, for sure. The ecology of interdisciplinary teams could create space for narrative work to come forward. There have been a few efforts to center the role that humanities has played in translational health work, such as the Translational Humanities for Public Health database at Rice University, and new research such as Professor Keisha Ray’s “Going Beyond the Data: Using Testimonies to Humanize Pedagogy on Black Health” is making the case urgently for healthcare and medical education to balance statistics with person-centered ways of understanding the lived effects of inequity. I agree that we need many more such efforts and the platform of story, as you say, to address these great challenges. 

In Tornado of Life, acknowledging vulnerability, privileging narrative, and understanding yourself as a physician is at the heart of each essay and story. What is your favorite piece?

JB: I can’t say which is my favorite; I have many, and they change over time. What’s your favorite?

SB: Every single piece in this collection grabbed at me. I read the book in two or three sittings, and couldn’t put it down! Every page has underlining and annotations. You have several generative essays on the ways in which narrative and practical medicine clash (but ought not to) and enrich each other (and ought to do so all the time); one of my favorites was “Why Medicine Needs More Not-Knowing.” 

As for some of the patient stories, one that really dug in deeply was “The Ashtray.” That made my eyes well up a little, and it made me laugh uproariously. This is about Mrs. Andrews, a patient you met on your first day as an intern, whose family wanted her breathing tube removed against your medical advice. You wrote this beautiful sentence: “In their eyes, the issue wasn’t our medical expertise, but everything we didn’t’ know about Mrs. Andrews.” What really lit me up was Mrs. Andrews’s triumph, emblematized in her hand-crafted gift to you of a cross-stitched caduceus labeled with your name and encased in a plastic ashtray. The other part of the essay that lit me up was your reflection on your lifelong relationship to that gift, which you’ve kept on your desk since your internship and which has subtly changed in meaning as you have cared for more and more patients over your career.

[Dr. Baruch beams, stands up and leaves the screen for a moment, returning with the ashtray].

Tornado of Life: A Doctor’s Journey through Constraints and Creativity in the ER by Jay Baruch, MD, will be available from MIT Press on August 30, 2022. Pre-order options can be found here: 

https://www.penguinrandomhouse.com/books/710646/tornado-of-life-by-jay-baruch/