EP. 163: RECLAIMING NARRATIVE IN MEDICINE
WITH SUZANNE KOVEN, MD, MFA
An award winning author and primary care physician explains why her English and poetry classes were more relevant to her clinical work than her science classes.
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Most medical encounters are structured as transactions. The patient comes in with a specific complaint, the medical expert identifies a discrete problem, and a specific intervention is prescribed. But at the heart of a medical encounter is a story. When a patient comes in with a medical problem, the problem cannot be disentangled from their life’s narrative — doing so risks hollowing out the essence of what it means to care for another person.
Our guest on this episode is award-winning author, and primary care physician Suzanne Koven, MD. Following the completion of her residency at Johns Hopkins Hospital, Dr. Koven joined the faculty at Harvard Medical School and practiced primary care medicine at Massachusetts General for 32 years. In 2019, she became the inaugural Writer in Residence at Mass General. Her writings have been published broadly—including in The Boston Globe, The New England Journal of Medicine, The Lancet, and The New Yorker. As a teacher and public speaker, she highlights the relationship between literature and medicine, and is a powerful advocate for female medical trainees.
In this episode, Dr. Koven shares her journey to medicine at a time when few women were represented in the field and why she finds her undergraduate English classes to be more relevant to her clinical work than her science classes. We discuss narrative medicine, its value to patients and physicians alike, and how the modern healthcare system struggles to value the patient story. Finally, Dr. Koven leaves us with her advice for up-and-coming trainees: find a place in medicine where you can be yourself – for your own good and for your patients’.
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Suzanne Koven received her B.A. in English literature from Yale and her M.D. from Johns Hopkins. She also holds an M.F.A. in nonfiction from the Bennington Writing Seminars. After her residency training and chief residency in medicine at Johns Hopkins Hospital, she joined the faculty of Harvard Medical School and practiced primary care internal medicine at Massachusetts General Hospital for over 30 years. She is an associate professor of medicine at Harvard Medical School and holds the Valerie Winchester Family Endowed Chair in Primary Care Medicine at Mass General. In 2019 she was named inaugural Writer in Residence at Mass General. Her essays, articles, blogs, and reviews have appeared in The Boston Globe, The New England Journal of Medicine, The Lancet, NewYorker.com, Psychology Today, The L.A. Review of Books, The Virginia Quarterly, STAT, and other publications. Her monthly column “In Practice” appeared in The Boston Globe and won the Will Solimene Award for Excellence in Medical Writing from the American Medical Writers Association. At HMS Dr. Koven co-created and co-directs the Media and Medicine certificate program at and teaches in the Media, Medicine and Health masters program. She speaks to a wide variety of audiences on literature and medicine and the role of women in medicine. Her essay collection, Letter to a Young Female Physician, was published by W.W. Norton & Co. in 2021. Her memoir, The Mirror Box, will be published by W.W. Norton in 2026.
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In this episode, you’ll hear about:
3:00 - Dr. Koven’s motivations for going into primary care medicine
15:49 - The impact that Dr. Koven’s English degree has had on her approach to medicine
19:36 - What narrative medicine is
24:34 - What is lost when human connection and human story are deprioritized within the practice of medicine
31:15 - The benefits doctors experience when cultivating an appreciation for the arts
37:21 - How gender representation in medicine has shaped Dr. Koven’s experience as a physician
42:54 - The need for the culture of medicine to adapt to changing demographics in the medical workforce
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TDA 163 final1.mp3
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine, we will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Tyler Johnson: [00:01:02] Most medical encounters are structured as a transaction. When a patient comes in with a medical problem, they are often hoping that it can be solved by a medical expert, and both the patient and the doctor will be pleased if a solution can be found for the lower back pain, heartburn, or chronic cough that just won't go away. But at the heart of a medical encounter is a story. When a patient comes in with a medical problem, the problem cannot be disentangled from their life's narrative, and both the patient and the doctor will feel more human if the patient's suffering is approached in the context of the patient's life. Our guest on this episode is award winning author, professor, and primary care physician Dr. Suzanne Koven. Following the completion of her residency at Johns Hopkins Hospital, Dr. Koven joined the faculty at Harvard Medical School and practiced primary care medicine at Massachusetts General for 32 years. In 2019, she became the inaugural Writer in Residence at Mass General. Her writings have been published broadly, including in The Boston Globe, the New England Journal of Medicine, The Lancet, and The New Yorker. As a teacher and public speaker, she highlights the relationship between literature and medicine and is a powerful advocate for female medical trainees. In this episode, you'll hear about Dr. Koven's journey to medicine at a time when few women were represented in the field, and why Dr. Koven finds her undergraduate English and poetry classes to be more relevant to her clinical work than her science classes. We discussed narrative medicine, its value to patients and physicians alike, and how the modern healthcare system struggles to value the ineffable. We explore some of the many untenable situations that women face in medicine. And finally, Dr. Koven leaves us with her advice for up and coming trainees. Find a place in medicine where you can be yourself for your own good and for your patients.
Henry Bair: [00:03:00] Suzanne, thank you so much for taking the time to join us and welcome to the show.
Dr. Suzanne Koven: [00:03:03] Thanks so much for having me.
Henry Bair: [00:03:05] So I came across your work as a writer first and foremost. You know, in your writings, you've you've often referenced that as a young female entering medicine in the 80s, you didn't always see yourself reflected in the people around you in the workplace. And yet, you know, you were obviously drawn to medicine. So I'm wondering what were your original motivations?
Dr. Suzanne Koven: [00:03:26] What a great question. Particularly the part about not seeing myself reflected. And I should skip ahead to say that I didn't see myself reflected, but I wasn't aware of not seeing myself reflected for many years. But I'm getting ahead of myself. So, you know, going way back. My dad was a doctor. He was an orthopedic surgeon in private practice, and I liked, as I write about in the book, I loved tagging along with him to his office and holding down the babies while they got their legs casted and, you know, dipping the x rays in the vats of, uh, developer fluid, which is how they used to do it back then. I think it did cross my mind that I might want to be a doctor, but I really had two problems or two roadblocks that I saw. One was that I really, with maybe one exception, I just didn't know any women in the 60s who were doctors. All of the doctors I knew, in fact, were married to women like my mom, who were housewives. The other roadblock for me was that I didn't particularly like math or science, nor did I excel in those subjects. So I thought, well, you know, this is nice. Uh, and I might be good at it if I actually, uh, you know, could ever get over that hump of organic chemistry and so forth.
Dr. Suzanne Koven: [00:04:49] But I could never get over that hump, so it's not going to happen when I was in college as and English major. I tried to take intro chemistry three times, dropped it three times, always the day before the deadline so that it wouldn't appear on my transcript. And I thought, well, it just wasn't meant to be. And then I really was very few weeks out of college and in my first, uh, rather lowly job as an editorial assistant when I thought, you know, I bet I really could do this. I mean, dumber people than me must have done okay in organic chemistry. I've got to give it a try. So I went back to school and I took the classes piecemeal. And it turned out that, number one, they weren't really all that hard. But it also turned out once I got into medicine that especially in terms of what I did, which was primary care, they really had very little to do with day to day practice. And in fact, as I've often said, what I learned as an English major reading novels, reading poetry was much more useful to me as a primary care doctor than organic chemistry, which I learned took the test and immediately forgot.
Henry Bair: [00:06:01] Our long time listeners will know all this all too well, but we have managed to to find physicians who have spent former careers or early in their education, done anything, everything other than the sciences. You know, I myself a medieval studies major in college. I like that Tyler was an American Studies major, so that is totally welcome here. The way the way that your path played out. So you mentioned that you are in primary care. Can you tell us initially as you entered medicine, what did you want your career to look like? What kind of practice? What kind of patient populations? What kind of interactions?
Dr. Suzanne Koven: [00:06:37] Well, I'm tempted to give you a very noble answer that will make me look really wonderful or sound really wonderful to your audience. But I'm afraid, at least at the beginning, that's not what it looked like. I went into medicine because I chickened out. I wanted to be a writer. I wanted to be a journalist. The path seemed uncertain and unclear. You know, I thought, well, here's the thing. If you go to medical school, then you know what you're doing. You know you'll have a job. You know you'll be doing good, and you know your path will be laid out for you. So my motivations initially were not very noble. However, it became clear to me pretty quickly, especially when I started seeing patients and when I went to medical school at Hopkins. You know, the path in medical school was quite traditional. It was a year and three quarters of lectures and labs, and then you went on the wards, and it's still like that in some places. But that was sort of the fairly traditional route. So the first couple of years or so, I thought, gee, what have I gotten myself into? This isn't what I wanted at all. This is biochemistry, and most of my classmates had been science majors. But once I started talking to patients and thinking about their problems, I thought, oh, okay, I think I know how to do this.
Dr. Suzanne Koven: [00:08:05] I think I can learn how to do this well. And then when it came time to choose a specialty, I had a little bit of a zigzaggy route again. I matched in neurology, which meant that I committed to doing neurology residency after one year of medical internship. But it became clear to me within a few months of my internship, I not only wanted to be an internist, I wanted to be a general internist. The part of my internship I loved the most was the part that most of my fellow interns liked the least, which was outpatient clinic. You know, outpatient clinic isn't exciting. You know, it's not dramatic. But what I figured out is that excitement and drama were not what I loved best. What I loved best were my patients. Stories were getting to know patients over time, having seen someone in the hospital in a crisis and then seeing them fully dressed with a family member. I really loved that. And I never stopped loving that. I practiced primary care for 32 years in the same practice. So by the end of those 32 years, I was taking care of the grandchildren of my original patients. What I loved about it initially is what I loved about it when I finished.
Henry Bair: [00:09:32] So I'm wondering if you can share some stories, patient experiences, or work experiences that really elucidate or highlight or epitomize why this work is meaningful for you.
Dr. Suzanne Koven: [00:09:42] So many. So every doctor, every nurse, every emergency room has certain patients. The very sight of their names causes a kind of inner sense of dread. They're demanding. They come in a lot. They're hard to diagnose. They're hard to satisfy. Doctors, particularly, are sort of acculturated to fix things, to know things, rather than to simply bear witness, to simply bear witness. Though it's incredibly valuable, I think the way we are trained makes us feel inadequate. We don't like feeling inadequate. So who do we take that out on? The patient who we decide is a problem patient. But there really aren't any problem patients. They're just problematic situations for both doctor and patient. Usually more for the patient than the doctor. Anyway, I'll call the patient. Mary. I took care of her for many years. I always dreaded seeing her name on my schedule if it wasn't a headache, it was dizziness. And if it wasn't dizziness, it was her back hurt. Her feet hurt. Everything hurt. Everything was wrong. None of the medications worked. But she came in again and again and again very frequently, as I think is often the case in primary care, even as I dreaded seeing her, even as she made me feel inadequate. I also developed over time, seeing her so frequently. I had a kind of affection for her, and one day I do not know why I did this, but I asked her to remind me how many grandchildren she had now, a thing that a primary care doctors do commonly, which we shouldn't do, but I think is something we do, is we ask about family and social history when we first meet someone, but then maybe we don't update that quite as thoroughly as we might.
Dr. Suzanne Koven: [00:11:47] You know, we'll ask somebody if they've quit smoking and so forth. But we we may not ask or remember to ask, you know, so what's going on with, you know, this family situation or that. Anyway, tears came to her eyes. She pulled out a couple of photographs that were clearly from a long time ago of very young children, and she told me that she had not seen them in years because of a conflict with her son. And then she told me that her daughter was also angry with her. By the way, I'm changing the details of this story to protect confidentiality. That her daughter was also angry, but at least would give her transportation to the doctor. And then 20 years into our relationship, I realized, wow, that's why she comes here so frequently. Because that's the time she gets to spend with her daughter. And obviously, the story must have been more complicated than that, but it was impossible thereafter since I now knew more about her story. It was impossible for me to feel the kind of resistance to her that I had always felt. I think I became a better doctor to her once I knew her story.
Henry Bair: [00:13:18] Yeah. To your point about how we get social history and family history at the first visit and then just kind of just disappears in subsequent visits, it brings to mind, I'm in ophthalmology and there is a retina specialist at my hospital who's very, very famous, and all his patients seem to love him. Even before I came to this hospital or before I started really working as a resident here, I'd known of his reputation when I worked in the non ophthalmology side of the hospital. I would have I would encounter his patients and they would all just have such amazing things to say about him. The thing with retina is that in the retina clinic, especially in a very high volume retina clinic that treats a lot of, say, diabetic retinopathy or age related macular degeneration, these attending physicians are so, so busy. Their schedule is so crammed with patients that often they come in literally for like two minutes for for an encounter. It's just, you know, check the vision, check the whatever, do the injection, you know, in their eye to treat the diabetes in the eye and then that's it.
Henry Bair: [00:14:18] And I remember thinking, what is this person's secret? How is it that every person, every one of his patients, despite these two minute long visits, have such amazing things to say about him? And then I got to shadow him and observe him in clinic, and. And I figured out his secret, which was, you know, he would go into the patient's room and one patient, he would say, you know, like, how did your husband's surgery go? The next patient is like, oh, how was your kid's birthday party last? You know, last month, you know, things like that. And I was like, how is this person doing these things? And turns out, you know, he would ask them about their personal lives, they would provide an update, and he would actually type that in as, like a sticky note into the chart. And then that would feed into like the next visits conversation. So he's like, you know, getting to know patients over time, over very, very incrementally. And then yet, you know, obviously it's making a huge impact on all of his patients.
Dr. Suzanne Koven: [00:15:09] It's a fascinating example because a cynical listener to that story might say, well, you know, it's very formulaic. You know, he asked one question. He put it on a sticky note. He spat out that question. But it's not formulaic at all. You know, people aren't stupid. They know that he doesn't, you know, know their entire life story. But what they do know is that he was acknowledging that there was a person attached to the retina. And that is not only like a mushy, squishy feel good thing. That's the kind of thing that really affects outcome, you know, adherence to therapy. Return visits and so forth.
Henry Bair: [00:15:49] So during college, you were an English major. And obviously, as we know much later on, you develop this career as a physician writer.
Dr. Suzanne Koven: [00:15:56] Yes. Rather late in my career.
Henry Bair: [00:15:59] Mhm. That's good to know for context, rather late in your career. But I'm wondering as you think about your career even before you became, you know, regularly published writer, in what ways did your English language or English literature training, creative writing training inform how you practice medicine?
Dr. Suzanne Koven: [00:16:16] Yeah. So I think I was practicing narrative medicine long before I ever heard that term, and perhaps long before that term was coined, which was around the turn of the century by Rita Sharon at Columbia. I was just always very interested in language, in the way people tell stories. Toned metaphor. Themes. You know, I just always had an ear for that. Uh, from reading. And of course, the exam room is just full of all of that because human beings are just natural storytellers. It's a quote I came across recently from the evolutionary biologist Stephen Jay Gould, who says that humans are primates who tell stories. Storytelling is essentially what makes us human. So, you know, when our patients come in and we say, you know, so what brings you here today? They don't give us bullet points. They don't give us data. They tell us a story. And it's a story that usually has a lot in common in structure with all Western storytelling, you know, starting with Aristotle. They introduced themselves as a character. They say something happened. You never have a story in which nothing happens. Something happened. And then there was the big thing that happened that brought them in. This is particularly an acute visit, an emergency visit and so forth. So I was always my ear was attuned for story. Once I went back to graduate school in my early 50s to get an MFA in nonfiction writing, and I started learning about things like narrative theory, and I started writing a lot myself.
Dr. Suzanne Koven: [00:18:03] And then I was really attuned to it and the sticky notes that I was writing on. I was filling with things that patients said to me that I, I found fascinating, and usually I found them fascinating because I found them poetic in a sense or surprising in some way. For example, I shared with a patient the very hard news that her cancer had metastasized. She said, oh, doctor. And then she said, three times. What do you say to a patient like me? What do you say to a patient like me? What do you say to a patient like me? Nearly in iambic pentameter. Bup bup bup bup bup bup bup bup bup. Without even thinking about it, she fell into a kind of a verse rhythm. Uh, now, why did she do that? I think because the moment was so potent. And this was not a writer or a poet or anything like that. The moment was so potent, it seemed to call for nothing less. Uh, and I was just deeply, deeply moved by that and, and felt the need to make space for that moment. I think most good doctors and nurses would in a moment like that. But the way she said that, not just what she said, the way she said. It felt very profound to me.
Henry Bair: [00:19:36] I want to pick up on a thread. You said that you were practicing narrative medicine before it became coined. Before it was a thing.
Dr. Suzanne Koven: [00:19:42] Yeah, and I'm not unique in that at all. I'm sure Hippocrates practiced narrative medicine.
Henry Bair: [00:19:47] Right. Which begs the question, so what is non-narrative medicine? Like, what are you juxtaposing narrative medicine with like this as opposed to what.
Dr. Suzanne Koven: [00:19:56] You know, literature and medicine. Arts and medicine were really not considered separable until about the turn of the 20th century. You know, Osler instructed medical students to read for 30 minutes every night. And what did he instruct them to read? It wasn't medical textbooks. It was Shakespeare, Homer, Milton, the Bible.
Henry Bair: [00:20:20] And this was the Osler who had created. Oh, he had created the first medical school in North America.
Dr. Suzanne Koven: [00:20:25] Not the first, but some would say the inventor of modern medicine, modern medical training. Founder of the Department of Medicine at Johns Hopkins. This was in the 1890s. Essentially invented the residency program. Of course, it was called the residency program because you lived in the hospital and you were an unmarried man. But anyway, that's another subject. So literature was considered part of medical training at that point. And then what happened is we just knew more science. We had germ theory, we had x rays. We had tools and knowledge that caused us to think that medicine was really a science and not an art. And so when you get to 1910, there's something called the Flexner Report, which was this commissioned report that was meant to make medical training more standardized and more rigorous. There were at the time what were called A proprietary schools that were basically fly by night, for profit schools that were run by charlatans and stuff like that. And Flexner comes along and he says, well, we don't need any literature. We just need chemistry, biology and physics. Flexner did a lot of bad things in that report, including recommending the shutting down of medical students that served black medical schools.
Henry Bair: [00:21:51] Who was this Flexner like? What was his?
Dr. Suzanne Koven: [00:21:54] So he wasn't interestingly, yeah, he wasn't a doctor. He was commissioned to study. How can we make medical training more standard? Anyway, 15 years later, Flexner is now in 1925. Flexner himself says, you know, maybe we went too far. Maybe there's something missing. And the thing that's missing is, I think, appreciation of the art of medicine, of storytelling, you know, sort of the emotional basis of medicine and of healing And even today, you know, health, humanities. Of course, it's very strong at Stanford, but health humanities is very a narrative medicine and sort of all these things that, in a sense are a, um, attempts to rebalance the art and science of medicine are quite inconsistently adopted across the country. There are excellent schools, hospitals where there's no need seen for this. Um, you know, what do we need that for? We don't need it to be part of the curriculum. We need our students to first learn organic chemistry, uh, and then learn anatomy and microbiology. Uh, and then somehow or another, they're going to go see patients, and they'll know enough about diseases to take care of people with diseases, Osler famously said, though it it's sometimes attributed to Hippocrates, it's more important to know the person who has the disease than the disease the person has. But I think there are a lot of, uh, physicians, physician scientists and medical educators to this day who don't really believe that, who think that the things in medicine that feel ineffable, unprovable, they're simply remaining to be proved. And if they can't be proved in a lab or with a with a p value, then they're probably not going to be worthwhile. And yet, what do we do with studies that show, for example, that if a patient has a good rapport with their primary care doctor, their diabetes numbers are better. What do we do with studies that show that if a patient journals 15 minutes a day, they're less likely to have an asthma flare. What do we do with that? You know, I think we sort of go back and say that maybe Osler was on to something.
Henry Bair: [00:24:34] Yeah. I mean, there's there's also a more I understand that there are definitely people who are so, so wed to empiricism that they, like I said, they're true materialists to the point where it's like everything is just waiting to be proven with some theorem, with some equation. But there's also playing devil's advocate here. There's also, I guess, a more prosaic view or counterargument to that, which is that when a patient comes in and they have a sore throat, they want that sore throat taken care of. When they come in with a cataract, they want the cataract taken care of. You know, when a patient comes in with cancer, they want to make sure that they're with someone who can prescribe the right chemotherapeutic agents to get rid of the cancer. There's one way to see medicine as very transactional. Patient has a problem. And you, as the very highly skilled physician who knows the ins and outs of the mechanics of the human body. You're positioned to fix that problem.
Dr. Suzanne Koven: [00:25:29] I don't buy it.
Henry Bair: [00:25:30] Okay, tell me more. What are we. What are we losing by adopting that viewpoint?
Dr. Suzanne Koven: [00:25:34] I'm going to push back on it hard. I think it implies that you have to choose one or the other. And you don't, you know, witness your retinal specialist. He knows a lot about retinas, and he spends a lot more time fixing retinas than he does asking about, you know, the prom pictures. But it is of value for him to acknowledge that that person is a person. Let's take your example of cancer. If you have cancer, you don't just have a disordered cell division. You don't go to an oncologist and say, hi, I need some help with my disordered cell division. You go in with a personal catastrophe and you need no less help with your personal catastrophe and perhaps a employment catastrophe, a family catastrophe, an identity catastrophe. And you need no less help with those things than with the tumor. Now, you could say, how about if the oncologists deal with the tumor and will send you to a therapist or a social worker for the rest of that mushy stuff, except that you need more from your oncologist than transaction. You need to feel at least acknowledged and held and witnessed. So I'm not accepting that it's an either or, or that somehow the art of medicine can be farmed out to other people. And here's the other thing. Let's forget about the patients for a moment. I would argue it is so much more satisfying to practice medicine non transactionally if all you do all day is take out cataracts and never think about how losing vision affects people. It's pretty boring after a while. I mean, it's sort of like time to make the donuts. So I feel that we can have both, and I think it's a win win for us and our patients when we do have both.
Henry Bair: [00:27:49] Thank you for making that case. As an aside, when I think about the terms narrative medicine or humanistic medicine, coming from my perspective, it's always seemed a little bit funny because humanistic medicine implies there's a non humanistic medicine. And to me medicine is so obviously humanistic pursuit because you're dealing with people. So it's always been kind of interesting to note that like we somehow think of humanistic medicine as like a different kind of medicine as opposed to conventional medicine, you know.
Dr. Suzanne Koven: [00:28:15] So no, it's it's not different. And it's worth pausing to sort of define narrative medicine, because I think there are really two ways to define it, or two ways in which it's used. Yes, of course, all medicine should be humanistic medicine, but sometimes it's not practiced humanistically, it's practiced transactionally or worse. And, you know, if you ask patients what they're concerned about, they're not concerned that you won't know enough or that you'll chop off the wrong arm. They're worried that you won't listen to them. And you know, when we think about the current crisis in medicine and particularly in primary care, that's what patients are worried about. They want to go to people who know them now. They know more than them. They also know medicine. They want both. Right? Okay. But that's an aside narrative medicine. Let's talk about that for a minute. So what it means most broadly is very simply it's practicing medicine with an awareness and an attunement to storytelling, to the fact that the patient is telling a story that you are going to listen to. Write down, interpret, tell to others, tell to consultants. Tell it. Grand rounds. I mean, we do this all the time, but it's a matter of sort of being aware of it. Here's an example. You know, if three people come in with a sore throat on a winter day in Boston, let's suppose they all three of them have strep, except the three of them start their stories differently.
Dr. Suzanne Koven: [00:29:55] One says, oh, yeah, you know, the kids have strep. I'm always catching something. One says, I think I might have strep. I need a doctor's note. I'm afraid I'm going to lose my job. And one person says, I catch everything I always have. I've always had a weak immune system. Now you could say, well, if the rapid strep is negative and you give them antibiotics. And what does it matter what they how they started their story? Again, the cancer patient doesn't only come in with disordered cell division. And the strep throat patient doesn't only come in with strep throat. They come in with fears and anxieties and concerns that make them suffer. We are not there just to cure strep throat. We are there to address suffering. So there's just in general, it's an attunement to storytelling, which again, I'll say it from the doctor or nurses. Therapists point of view is much more fun to think about than to avoid. Specifically, what Sharon meant by it is that if we study literature, if we read literary texts closely, that that is very good training for listening to patients stories. That principle informs a lot of the work I do at the hospital and the medical school. Now.
Henry Bair: [00:31:16] That's precisely where I wanted to head next, which is I've long been interested in medical education, and I'm interested in thinking about how do you actually teach these things. You know, I understand that not everyone's going to be a writer. Not everyone, not everyone's born equally, you know, with an equal gift in prose and language and poetry and all those things or artistic appreciation. And that's okay. But I've often thought about, once we are putting it out there, that narrative medicine is good, that practicing medicine humanistically is a good thing. Okay, then how do you train that? How do you improve people's capacity to do that? I know there are lots of efforts to bring med students to the art museum and look at art there. Okay, sure, you can tell people to go read some Tolstoy or Dostoyevsky. You can tell people to go listen to nice music and go to concerts and listen and watch opera and all those things. But part of me wonders when you give opportunities like that to medical students or trainees, to pre-medical students, there are people who are just naturally more inclined to do those things. Are you not just self-selecting for people who would have already done those things if they had just the chance? Versus how are you actually cultivating artistic appreciation and an artistic sensibility in people who maybe just are not so inclined and not wired that way?
Dr. Suzanne Koven: [00:32:31] Yeah. So I would come at this from a completely different angle. And, you know, even the way you sort of gave that list, well, you could take them to a nice opera or something. I mean, you're clearly, you know, saying it as if it's all very kind of extra and maybe not for everybody. But, see, I don't come at it that way. Opera may not be for everybody. Museums may not be for everybody. Reading may not be for everybody. But narrative is for everybody. Because we are human and we tell stories. It's how we communicate. You know the groups that I do. Some are self-selected, some are completely non self-selected. You know, I will take a poem and go on to the ward in the middle of the day and meet with a bunch of nurses or chaplains or, you know, doctors and nurses and so forth. And many of them have not read a poem since they had to in high school. And I've been doing this now for almost 20 years. I have never once had anyone say, I don't know why you're here, and I don't know what this is all about. In fact, poetry is our birthright. It is who we are. We may not say we like poetry, but language is who we are. So what I feel like I do, and others who do the kind of work that I do, is I simply give people permission to be human. And what I find is healthcare workers, doctors particularly, are in this sort of very funny conundrum, which is on the one hand, we tend to be people.
Dr. Suzanne Koven: [00:34:07] People, you know, at least we write on our, med school applications that we want to help people. And then what does the system do to us? Well, we're locked up in rooms, usually with one other person at a time. We don't have the time, nor is it legal to talk about what happened in that room to other people, except in a very limited sense. We have a medical record which is completely fragmented and non-narrative and tells stories very poorly. Oh, and by the way, you know, we don't work in the bank. We're exposed to incredible trauma and pain and suffering all the time. So what does that do to us? It means that we're bottled up. So I find what happens in in the groups that I work with is that people are just dying to talk. And if you create a structure in which it's okay to talk, then people talk. What does it feel like when you don't like a patient? What does it feel like when you know they press the nurse call Bell for the 10th time? What does that feel like? What is going on in that moment? If you give someone the opportunity to tell stories about that, they will. And specifically in terms of the question of, well, not everybody likes poetry, not everybody is a reader. It doesn't matter if you like to binge watch Netflix and you're, you know, pressing next episode, next episode, next episode, or if you love podcasts, that is a narrative exercise.
Dr. Suzanne Koven: [00:35:46] If your podcast is successful, it's because it contains good storytelling. People like stories, and they don't just like stories because they're entertaining and they're diverting and they, you know, they make the commute go faster. They like stories because we recognize our own humanity in stories. It's why we like to read novels about people we've never met and who never existed. Why would we do such a thing? There's no other animal that does such a thing. We do it all the time. Why? Why do we go to movies? Why? It's not just to be entertained. It's to connect with a sense of humanity. And I think that if we practice medicine and somehow ignore that, we ignore our humanity. We ignore the patient's humanity. I think it makes us less effective healers. Patients know it when you're being transactional. Patients know it when you don't care and you don't express that you care. Other than being a really great surgeon, patients know that. And I really think it affects the healing process. And I think it really affects us. So again, I'll say it. It's a win win, uh, to practice narrative, to practice, uh, humanistic medicine. I don't think there really is any other kind. I agree with you, except that somehow we want to shove it away because it just feels we're too busy. It's too much. It feels too fluffy. It feels too irrelevant. And yet, when you create space for it, it feels very urgent.
Henry Bair: [00:37:21] That's a beautiful summation of what we've discussed up to this point. I want to shift gears a little bit, because I know there's this whole other area which we. We said we would come back to, and now we're coming back to it, which is the idea of of role models. And specifically, in your case, the lack of female physicians who you feel like, well, I'll let you tell me how it felt. So you already told us that around the time when you were entering medicine, there weren't too many females out there. Things are changing, obviously, but I'm wondering if you could share some reflections. How has your journey as a physician been shaped by what you've seen around you in terms of gender representation?
Dr. Suzanne Koven: [00:38:01] So I'll first pick up on what you said. It. You know, there are more women and non-binary folks in medicine, but not in levels of leadership. So right now there are more women or identifying as women in medical school, in certain residencies, in certain fields at the junior faculty level. But if you look across the board at Deanships Division chiefs department chairs still majority male, even in fields like ob gyn and pediatrics that are becoming majority female. You know, if you think about various measures of gender inequity, we haven't made a whole lot of progress since I was an intern 40 years ago. In terms, we still have a gender pay gap. There's still a lot of harassment. Women are less likely to have mentors, less likely to get promoted, less likely to be first authors, less likely to be editors of medical journals and so forth. And we could talk about why that is. I have my own thoughts about that. But going back to your question about so what did I think was happening? I think I was oblivious. Evidence of this is that when, years and decades later, I picked up a photograph of my residency class, I was shocked when I counted the men and the women to realize that women were barely a quarter of that class. I would have guessed. Yeah, maybe 45.
Dr. Suzanne Koven: [00:39:38] 55. So why was I oblivious? For the same reason that when I got pregnant as a junior resident and I didn't ask for any accommodation and work hours, and this was before duty hour restrictions, we were working over 100 hours a week. I'm not saying that like it was the good old days. It wasn't. It was bad. And I ended up with pre-eclampsia, which is a very serious complication of pregnancy, potentially fatal for both mother and fetus. Nobody questioned whether that was a bad idea. Nobody questioned it. I didn't question it. And it took me until I sat down and wrote that book to ask myself, why in the world would I have submitted myself to that? One of the things I love best about writing and about coaching writers in the healthcare community, is that you write to solve mysteries, including mysteries about yourself. I really didn't know. And as I wrote, I realized what the answer was. I loved being a doctor, and I thought that being a doctor meant that I had to suck it up and never complain and be a team player. I wanted that so much that it didn't occur to me that I was doing something self-destructive, and I was operating in a in a system that was pretty hostile to women and certainly to pregnant women.
Henry Bair: [00:41:13] So, I mean, now you have so much benefit from hindsight. What would you have done differently? Right. Because, I mean, I understand it's very noble to hear again, like I all all the so impressed when you say that you just realized that you just love medicine so much, even though the system was so hostile to your situation.
Dr. Suzanne Koven: [00:41:33] That was not that was not a noble thing. I think that was born out of fear. Fear of oh, no, no, not that was not oh, I love medicine so much. And my patients are so important to me. I would sacrifice anything for them. No, I mean, you know, I worked hard. I was a good doctor. But, no, it was born out of fear. Fear of being the wounded deer who would be left behind the pack. It was a very primitive kind of wanting to belong. It was the ultimate FOMO. Okay, so what would I have done differently? I mean, of course, what I would have done differently is I would have said, this is not healthy. I not only shouldn't I be doing it, no one else. Uh, you know, no other woman who gets pregnant in this program should ever do it. And furthermore, you know, I'm going to spearhead all new policies. Except at the time, I was operating in a system that did not have a maternity leave policy for residents. I was asked to write my own maternity leave policy. Oh, and plus I was working 100 hours a week, so I was not particularly expansive or imaginative at the time. Or rebellious. But yeah, no, it was not nobility. It was fear. It was fear of being excluded from the circle.
Henry Bair: [00:42:54] So, I mean, you spent so many decades in this his career and you're seeing some changes. Where do we go from here? What else are you not seeing that you hope to bring about?
Dr. Suzanne Koven: [00:43:04] Well, so a couple years ago in the New England Journal, two colleagues and I wrote a piece called Pregnancy and Residency Overdue for equity. I had my first baby in the 80s, one of my colleagues in the 90s and one in the early 2000. And we talked about the fact that though these were different times, we were essentially faced with untenable choices, which were, you know, press ahead and risk your health and the baby's health. Take time off from your career and sort of fall behind professionally or delayed childbearing, which increases risks of fetal anomalies, pregnancy complications, and infertility. So these were the untenable choices. You know, when I went around the country after my book came out and I spoke to a lot of medical school and residency audiences, I really thought that my experience of pregnancy as a resident in the 80s would be kind of ancient history, but that's not the response I got. The response I got was, it's not that much better now. So your question is, where do we go from here? It's not enough just to have more equitable, you know, parental leave and breast pumping rooms and stuff like that, all of which are good things. I think we really need to change the whole culture. These same two colleagues and I are working on a piece now about what it would look like to change the whole culture of medicine to reflect the changing demographic of the physician workforce.
Dr. Suzanne Koven: [00:44:36] You know, we're operating in the same system that Osler, God bless him, designed over 100 years ago, where, you know, it's total devotion to your patients, where meetings and surgeries are held at six in the morning, seven in the morning, where, you know, beepers are 24 over seven. You know, that's one of the reason why so many women are leaving medicine or cutting back and why women I mean, I think men and nonbinary people suffer too. It's because it's essentially an unsustainable situation, except that what we know from studies that have shown this is that the women are more likely to be picking up the slack at home, not in every home, but across the board. If you have male female professional couples, it's the woman who's doing more of the childcare. It's the woman who's more likely to stay home when the kid is sick. And we really saw this during Covid. Surprise, surprise, Covid drastically increased the gender income gap among physicians. So what would it look like if we redesigned medicine and medical training to reflect that within a few years, way more than half of physicians are going to be women. And the current system that Osler designed and the current culture that Osler designed is not going to work anymore.
Henry Bair: [00:46:05] To your point about a lot of female physicians leaving the workforce, I have colleagues who have commented that back when they were in med school, they really, really loved orthopedic surgery. They looked forward to training to become an orthopedic surgeon. But the big hang up, the big thing, the big consideration they couldn't help but notice, was that it's a very rude specialty in medicine as far as gender representation goes and the whole culture of specifically orthopedic surgery. Again, like, I've never worked in that environment. I'm hearing is just firsthand accounts of what it's like. But it sounds to me like in many places, the environment of orthopedic surgery still skews very much like masculine.
Dr. Suzanne Koven: [00:46:50] That's true, except that surgical subspecialties across the board, the percentage of women in them is increasing. And in departments where the chair is a woman and where there are more female residents, there are going to be less burroway, for lack of a better word, you know, to describe that. So I don't think we want to give up hope. It's there's nothing inherent about orthopedic surgery that makes it burroway. And this is true in in other surgical specialties and even in specialties that would surprise you like anesthesia is very male that, um, it's a bit a little bit of a self-fulfilling prophecy where it's majority male women are put off by the culture of it, so therefore it's majority male. That's something that's being chipped away at and is capable of changing.
Henry Bair: [00:47:40] Yeah. I mean, specifically the colleague I was thinking of, she ended up not going to orthopedic surgery, mostly because of the culture she was worried about. And to me, that just I felt really sad. I felt sad for her, obviously for not really doing the thing that she thought she. I mean, now she's very happily in a different specialty, but still sad nonetheless that she couldn't at the time explore what she really wanted to do. But also sad for the specialty for like, missing out on people. I mean, how many more people are put off for whatever specialty because of these concerns?
Dr. Suzanne Koven: [00:48:07] Well, not only not only for being women, but for example, um, a younger colleague of mine named Jack Turbin wrote a piece in the New England Journal just a few years ago about being a gay medical student and resident, and feeling that his specialty choices were limited by his sexual orientation, that he was not going to be comfortable in a specialty where people needled him for not having a girlfriend. Uh, so to speak. So, you know, these kind of biases, uh, have real career implications, not even to mention harassment. I mean, why would you go into a specialty or work at a hospital or join a practice where you're being harassed? And what we know about women in medicine and harassment is that, again, because of this culture of don't make waves, be a team player is that women are more likely to leave than to complain. And that limits choices.
Henry Bair: [00:49:10] Right? This is, I guess, a good place to put this, which really brings it down to like a one on one, like a personal basis. So we've talked about the culture needs to change. Programs need to change. We need to rethink how medical training is done, but bring it down to a very personal level. If one of your mentees comes to you, a student comes to you. And again, doesn't have to be women just so and so, they feel they are concerned about not feeling represented or not feeling like they have advocates for themselves in whatever specialty or whatever program that they're looking for. What advice do you have for them?
Dr. Suzanne Koven: [00:49:44] Well, you know, I hear this a lot, but the context in which I hear it is regarding writing, because the main teaching I do now is in writing with faculty, staff, trainees, students, and so forth. And the way it comes up is, oh, I can't write about that because then I fill in the blank, won't get into that med school, won't match at that program, you know, won't get that promotion, etc., etc. and I mean, those are perhaps realistic concerns. But, you know, what I always say is, do you really want to be someplace where you can't be who you are? You know, you deserve to be someplace where you can be who you are and where you can write what you want to write. And such places do exist. And so I would say find your people. You know, it's less important. This comes up a lot in terms of choosing specialties. Medical students get very bent out of shape about choosing specialties and, oh, you know, if I choose this versus this, you know, my whole life could go a different direction and it probably will. The fact of the matter is that you're I think you're the content of your specialty is probably less important than a feeling that you have that, oh, these are my people.
Dr. Suzanne Koven: [00:51:03] These are the people I want to be with. This is the culture I want to be part of. If you feel great in the operating room, be a surgeon. If you feel great in the primary care clinic, then do that. I think these are things we know, but then we fight them like, oh, I loved my psychiatry rotation. But I mean, I can't be a psychiatrist because, you know, what will mom think? Or what will everybody think or what will? Whatever. But if that's what you loved, then that's what you should probably do. Here's the other thing. And this really is the piece of advice I'm parroting. Advice I was given by an older colleague of mine who's still a dear friend in his 90s. When I went into practice, he said, don't ever forget that the most valuable tool you have as a physician is yourself. If you can't be yourself at work, it will not only hurt you, it will hurt your patients. And we all know what it feels like to not be yourself. And that little voice in your head that says, uh, are not your people, not your place. Listen to that and listen to the other voice that says, yeah, this is my place. These are my people. I can be myself here.
Henry Bair: [00:52:26] Oh, well, that we want to thank you so much again, Suzanne, for taking the time to join us for all the work that you do in both writing and creative writing and medicine, as well as sharing your experiences, your personal experiences as a physician and as a writer. Thank you very much for all the advice that you've shared, all the stories you've told. I'm sure it'll be very valuable to listeners everywhere, regardless of where they are in their training.
Dr. Suzanne Koven: [00:52:49] Thanks so much, Henry. It was a great conversation. I really enjoyed it.
Henry Bair: [00:52:55] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:53:14] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:53:28] I'm Henry Bair.
Tyler Johnson: [00:53:29] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
Explore Dr. Koven’s writing here.
Read Dr. Koven’s New England Journal of Medicine article advocating for trainees who are pregnant during residency.
