Reducing Patient and Healthcare Provider Stress: Using Writing as a Healing Tool in Everyday Clinical Practice

By David Thoele, MD, with contributing ideas by Marjorie Getz, PhD and Katasha Charleston, MPH

Since I started medical school, I’ve grappled with how to help people with the inevitable stress of illness, operations and potential death. A huge challenge as a pediatrician and pediatric cardiologist is what to do when I don’t have answers–which happens more often than I’d like. Human beings can be unpredictable, and technology has its limits. The questions parents ask keep me up at night.

The mother of a critically ill newborn, tears streaming down her face, asks, “What’s going to happen to my baby, doctor? Is she going to make it?”

“Evan’s already been on the ventilator for two weeks. How much more can he take?” cries an exasperated parent.

 “They told us Maddie’s heart would be fixed after the operation. And now you say she needs another operation? Do you people even know what you’re doing?” a frightened parent asks.

The Inevitable

Stress and worry are part of the territory of illness, especially when kids are involved. Part of my job is to figure out what to do about it.

I can explain ventilators, tetralogy of Fallot, oxygen saturations, Lasix doses and Fontan operations in an understandable way to my patients and their parents. Providing competent medical care is essential. But even the best pediatric cardiologists can’t answer every question.

Illness is not just stressful for the patient and her parents. It also can be tough on the doctor. When one of my patients dies, it is horrible, especially if it’s a child. Even if I have done nothing wrong, I often blame myself, and ask my own endless, unanswerable questions:

Maybe if I’d pushed harder for a heart transplant, I wouldn’t be at this funeral….

Should I have tried some different medications?

What if I’d sent him earlier for his operation?

Should I have waited a few weeks longer, so he was bigger and stronger?

Helpful Steps for Me, My Colleagues, My Patients

Talking to colleagues, family or friends can help me calm down. But I discovered the best healing tool for my own shame, suffering and sleepless nights when I started writing in a journal early in my career. By writing about difficult events, I began to understand difficult medical situations and cope with suffering and loss. Eventually, writing helped me become a compassionate partner with myself.

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Writing was so helpful for me, I began attending medical conferences that focused on expressive writing, and in 2013, along with some dear colleagues, I started a creative writing program for medical professionals at my hospital. We are a multidisciplinary group, made up of CME professionals, poets, physicians, nurses, secretaries, patients and therapists. Our self-described mission is: “We tell stories, listen closely, write and share to facilitate healing, re-humanize healthcare and increase capacity for empathy and self-reflection. We practice learning how to tell our stories and receive other people’s stories.”

Our group meets once a month, same time, same day, same place every month. We often have light refreshments. After a 30-60 minute business meeting, we spend one hour together, with the same format: We start with an opening mediation, followed by a creative writing exercise (usually with a simple prompt, such as, “Write about someone who made a difference in your life”). People have an opportunity to share what they wrote, and then we have a closing meditation. Each month, different members guide the different parts of the meeting. Just prior to the closing meditation, we provide an update from the business meeting and review plans for upcoming narrative medicine events.

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After I learned from personal experience that writing can be therapeutic, I wondered if writing might help my patients. After I reviewed the medical literature, I was amazed to find that expressive writing is beneficial for a wide variety of medical situations. Expressive writing can improve mental health, including depression (1,2), postpartum depression (3,4) and posttraumatic stress disorder (PTSD) in ICU settings (5). Moreover, expressive writing can improve physical health in a variety of other health conditions, including asthma and rheumatoid arthritis (6), hypertension (7), wound healing (8) and HIV (9).

And the benefits of expressive writing are not just for patients. Writing has also been shown to help healthcare providers, promoting resiliency, enhancing empathy and decreasing burnout (10-13).

To see if writing might help in real world time-pressured clinical situations, our writing group developed a short writing exercise, the Three-Minute Mental Makeover (3MMM) (15). This writing exercise was created within the framework of narrative medicine, which was the foundational paradigm for our expressive writing group. Narrative medicine is defined as medicine practiced “with these narrative skills of recognizing, interpreting and being moved by these stories of illness” (14). The narrative medicine approach aims to improve the effectiveness of care by encouraging empathy, by promoting authentic dialogue and by creating a shared experience for healthcare providers and patients (16,17).

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In the 3MMM, the practitioner and patient/family write concurrently, using the following prompts:

  1. Write three things you are grateful for (be specific): _____________________________
  2.  Write the story of your life in exactly six words (example: born, school, work, work, work, work): _________________________________________
  3.  Write three wishes (Pretend you rub a magic lamp, a genie appears, and says, “I will grant you any three wishes.” What would you wish for?): _________________________________

After the concurrent writing, the practitioner and patient/family have the opportunity to share what they have written with each other. The practitioner always includes something about the patient/family in their writing (i.e., “I am grateful that my patient is doing well following the procedure”).

3MMM Works

After using the 3MMM with hundreds of patients and families with apparent success, we conducted a research study at our hospital to measure its effectiveness.

In our study, eight practitioners led 96 patient/family members in 3MMM activities. All patients, family members and practitioners reported experiencing baseline stress, which decreased after participating in the 3MMM (p < 0.001). Eighty-eight percent of patients/families reported that the 3MMM activity was helpful, even though only 35 percent had used writing or journaling in the past. In our experience, the time spent on the concurrent writing and sharing minimally lengthened the appointment time, but maximally improved communication and our relationship with the patient/family.

So, what is the best way for educators, physicians and other practitioners to use expressive writing? On a personal level, you can start by writing in a journal, using the 3MMM, other writing prompts or just writing what is on your mind. If you write several times per week, or even daily, you may discover what you’re thankful for, process what you’re going through and create a new direction for yourself. Writing can help guide you through a variety of challenges, such as illness, loss and major life changes.

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You also might want to incorporate writing into your work or educational environment, including CME activities. In your CME Program, consider using reflective writing exercises in case-based discussion activities, such as Tumor Board, Morbidity and Mortality Conference (M&M) and Journal Club to enhance interaction and collaboration among learners. If your department has regular meetings, consider spending a few minutes at the start of your next meeting doing a writing exercise. Pair people up, guide the whole group in a 3MMM (see instructions above), and have people share with their partners. Writing like this can be a vehicle to create a team atmosphere in a new and fun way. If you are involved in patient care, you may want to write together with your patients, to decrease stress for them and for you.

And, if you really like writing, ask your colleagues if they’d like to join you as you start your own writing group. We would be happy to discuss ideas on how to do it. You might also wish to read this article about narrative medicine.

Author and Contributors

David G. Thoele, MD, Pediatric Cardiology, Advocate Children’s Hospital- Park Ridge; Associate Professor of Clinical Pediatrics, University of Illinois at Chicago; Co-Director, Narrative Medicine, Advocate Children’s Hospital  (david.thoele@advocatehealth.com)

Marjorie A. Getz, PhD, Program Manager, Educational Consultation and Evaluation Services, Developmental Pediatrics, Advocate Children's Hospital – Park Ridge  (marjorie.getz@advocatehealth.com)

Katasha N. Charleston, MPH Director, Continuing Medical Education, Advocate Aurora Health (katasha.charleston@advocatehealth.com)

References

  1. Gortner E-M, Rude SS, Pennebaker JW. Benefits of expressive writing in lowering rumination and depressive symptoms. Behav Ther 2006 Sep;37(3):292-303. DOI: https://doi.org/10.1016/j.beth.2006.01.004.
  2. Krpan KM, Kross E, Berman MG, Deldin PJ, Askren MK, Jonides J. An everyday activity as a treatment for depression: The benefits of expressive writing for people diagnosed with major depressive disorder. J Affect Disord 2013 Sep 25;150(3):1148-51. DOI: https://doi.org/10.1016/j.jad.2013.05.065.
  3. Horsch A, Tolsa J-F, Gilbert L, Jan du Chene JL, Mueller-Nix C, Bickle Graz MB. Improving maternal mental health following preterm birth using an expressive writing intervention: A randomized controlled trial. Child Psychiatry Hum Dev 2016 Oct;47(5):780-91. DOI: https://doi.org/10.1007/s10578-015-0611-6.
  4. de Graaff LF, Honig A, Van Pampus MG, Stramrood CAI. Preventing post-traumatic stress disorder following child-birth and traumatic birth experiences: A systematic review. Acta Obstet Gynecol Scand 2018 Jun;97(6):648-56. DOI: https://doi.org/10.1111/aogs.13291.
  5. Kadivar MK, Seyedfatemi N, Akbari N, Haghani H, Fayaz M. Evaluation of the effect of narrative writing on the stress sources of the parents of preterm neonates admitted to the NICU. J Matern Fetal Neonatal Med 20175 Jul;28(13):938-43. DOI: https://doi.org/10.1080/14767058.2016.1219995.
  6. Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: A randomized trial. JAMA 1999 Apr 14;281(14):1304-1309. DOI: https://doi.org/10.1001/jama.281.14.1304.
  7. Beckwith McGuire KM, Greenberg MA, Gevirtz R. Autonomic effects of expressive writing in individuals with elevated blood pressure. J Health Psych 2005 Mar;10(2):197-209. DOI: https://doi.org/10.1177/1359105305049767.
  8. Robinson H, Jarrett P, Vedhara K, Broadbent E. The effects of expressive writing before or after punch biopsy on wound healing. Brain Behav Immun 2017 Mar;61:217-27. DOI: https://doi.org/10.1016/j.bbi.2016.11.02.
  9. Petrie KJ, Fontanilla I, Thomas MG, Booth RJ. Pennebaker JW. Effect of written emotional expression on immune function in patients with human immunodeficiency virus infection: A randomized trial. Psychosom Med 2004 Mar-Apr;66(2):272-5. DOI: https://doi.org/10.1097/01.psy.0000116782.49850.d3.
  10. Hoyt MA, Austenfeld J, Stanton AL. Processing coping methods in expressive essays about stressful experiences: Predictors of health benefit. J Health Psychol 2016 Jun;21(6):1183-93. DOI: https://doi.org/10.1177/1359105314550347.
  11. Wald HS, Haramati A, Bachner YG, Urkin J. Promoting resiliency for interprofessional faculty and senior medical students: Outcomes of a workshop using mind-body medicine and interactive reflective writing. Med Teach 2016 May;38(5):525-8. DOI: https://doi.org/10.3109/0142159X.2016.1150980.
  12. Miller E, Balmer D, Herman N, Graham G, Charon R. Sounding narrative medicine: Studying students’ professional identity development at Columbia University College of Physicians and Surgeons. Acad Med 2014 Feb;89(2):339-42. DOI: https://doi.org/10.1097/ACM.0000000000000098.
  13. Chen P-J, Huang CD, Yeh S-J. Impact of a narrative medicine programme on healthcare providers’ empathy scores over time. BMC Med Educ 2017 Jul 5;17(1):108. DOI: https://doi.org/10.1186/s12909-017-0952-x.
  14. Charon R. The sources of narrative medicine. In: Charon R, ed. Narrative medicine: Honoring the stories of illness. New York City, NY: Oxford University Press; 2008:3-15.
  15. Thoele DG, Gunalp J, Baran D, Harris J, Moss D, Donovan R, Li Y, Getz MA. Health care providers and families writing together: The Three-Minute Mental Makeover. Perm J (in press).
  16. Charon R. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA 2001 Oct 17;286(15):1897-902. DOI: https://doi.org/10.1001/jama.286.15.1897
  17. Charon R. What to do with stories: The sciences of narrative medicine. Can Fam Physician 2007 Aug;53(8):1265-7.

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