Three summers ago, I signed up for Columbia University’s Summer Institute in Narrative Medicine. It was a lazy summer. I had finished my post-bac pre-med program in June and had already been accepted to medical school. All there was to do was wait, and prepare.
Most of my preparations weren’t that unusual. I had to find an apartment in my new neighborhood, apply for financial aid, and fill out a form for my short white coat. However, filled with a healthy respect for the loftiness of the medical tradition, some of my preparations were existential. I’d taken a roundabout way into medicine because I wanted to be sure that I could live up to its responsibilities. I wanted to be sure that it was a calling and not just a career. (Just years later would I come to understand that there’s nothing wrong with wanting a career.) As an avid consumer of healthcare-related news, I knew what I was up against. According to a landmark 2012 Mayo Clinic study published in Archives of Internal Medicine, 46 percent of all U.S. physicians agreed that they were “emotionally exhausted, feel cynical about work or have lost their sense of personal accomplishment… or all three.” It was hailed as the first major study to quantify the prevalence of professional burnout in medicine.
No patient in her right mind would want to be under the care of a burned-out physician.
The study defined professional burnout as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.” Recent studies, the authors wrote, seemed to implicate burnout in everything from decreased quality of care and increased risk of medical errors, to “adverse personal consequences for physicians, including contributions to broken relationships, problematic alcohol use, and suicidal ideation.”
In medicine, we love our gold standards — which is why you’ll eventually need that colonoscopy — and the gold standard for measuring burnout is the Maslach Burnout Inventory (MBI). It’s a 22-question survey that asks the respondent to rate how often, on a scale from “never” to “every day,” they “doubt the significance of my work,” for example. However, researchers at Mayo discovered that you can pare down the MBI to two statements: “I feel burned out from my work” and “I have become more callous toward people since I took this job.” These represent the emotional exhaustion and depersonalization, respectively, of burnout syndrome.
No patient in her right mind would want to be under the care of a burned-out physician, and what’s more, physicians were starting to send the message that no student in her right mind should want to become a doctor. The 2012 Physician’s Foundation Survey of America’s Physicians found that almost 60 percent of physicians “would not recommend medicine as a career to their children or other young people.” Even though I decided to ignore the grim prospects ahead and apply to medical school anyway, I wanted to use that summer before it began to shore up my emotional reserves. I also wanted to learn about what I could do before medical school started to prevent the downward decline into burnout.
Hence, the Summer Institute in Narrative Medicine. Narrative medicine was pioneered by internist Dr. Rita Charon at Columbia University in the early 2000s, and seeks to combine narrative competence — that is, “the ability to acknowledge, absorb, interpret, and act on the stories and plights of others,” with medical practice. Try as we might to break down the body into smaller and smaller parts, medicine is at its core a practice of stories. The patient comes to the doctor with a story of their troubles, and the doctor serves first and foremost as a trained listener.
Traditionally, medical training has focused on the facts of a patient’s story that fall neatly into the rigid history and physical, or H&P, with the goal of discovering a diagnosis. Narrative medicine, on the other hand, recognizes the complexity of relationships in medicine and argues for a more nuanced, humane approach informed by narrative competence. According to Charon’s 2001 introduction to narrative medicine in JAMA, “by bridging the divides that separate the physician from the patient, the self, colleagues, and society, narrative medicine can help physicians offer accurate, engaged, authentic, and effective care of the sick.”
Try as we might to break down the body into smaller and smaller parts, medicine is at its core a practice of stories.
It makes sense then that many of the conference attendees seized upon narrative medicine as a weapon in the battle against burnout. If emotional exhaustion and depersonalization were the encroaching enemies, then it seemed reasonable to equip oneself with tools to stay meaningfully engaged with the self, patients, and colleagues.
Beyond a general feeling of enjoyment and empowerment, I don’t remember the conference very well. I undoubtedly drank the Kool-Aid, but whatever narrative competence I gained in those three days faded over the next three years of relative narrative laziness. However, one sentence uttered by a wiser participant stuck with me. It felt important when I heard it, and that sense hasn’t faded with time. In fact, I don’t think I’m alone when I say that it’s the ultimate answer to the field of medicine’s emotional exhaustion. She said, “The opposite of burnout is wonder.”
Wonder, which I use synonymously with awe, is interesting. Noted social psychologist Jonathan Haidt believes that, “Awe is the emotion of self-transcendence.” It’s the feeling of being a part of something larger than oneself. It’s what I’ve felt when singing Brahms’s hallowed A German Requiem in the still, acoustically magical Troy Savings Bank Music Hall, my voice one of a hundred coming together to create a moment awash with beauty. The most common sites of awe are probably associated with religion — certainly many of Western civilization’s written encounters with awe take place in relation to the divine.
Narrative medicine was suggested at my conference as a tool to recapture wonder, thus fending off burnout. A Harvard Medical School student recently argued in the New England Journal of Medicine that one response to burnout is to organize, to participate in a space where your voice joins many in collective activism. However, another pathway to awe exists, one that has certainly been around as long as organized religion, and which happens to be in the midst of a scientific renaissance: psychedelics.
Psychedelics have been making the media rounds lately, with write-ups in the New Yorker, the New York Times, Vox, and multiple other outlets that don’t immediately bring to mind the counterculture of the 1960s. A major contributor to the ongoing excitement is author Michael Pollan’s book, How to Change Your Mind.
Underpinning the media attention, however — and this is where it really gets exciting — is research. Actual rigorous, scientifically-sound, double-blind, randomized placebo controlled trial research.
My personal drug history is most significant for a few bad episodes of caffeine withdrawal. When I was old enough to learn about capital-D Drugs, it seemed like marijuana was the only one anyone cared about (perhaps also the result of a firmly suburban upbringing). The first time I really paid any attention to psilocybin or LSD was in January of 2018 on my third-year psychiatry rotation, when a well-informed young resident used Tuesday morning Grand Rounds to ensure that our department at least feigned interest in the latest news in psychedelic psychotherapy research. While I couldn’t recall to you the point of the resident’s lecture, it introduced me to the study that Pollan ranks among his “three 2006 events that helped bring psychedelics out of their decades-long slumber.” The study, “Psilocybin Can Occasion Mystical-type Experiences Having Substantial and Sustained Personal Meaning and Spiritual Significance,” was published in 2006 in the well-respected journal Psychopharmacology by a team headed by well-respected addiction and pharmacology researcher Roland Griffiths. I recommend reading it for yourself, if only to partake in the history of science, because that’s how big this feels. If you don’t believe me, consider that after reading the paper, Herbert D. Kleber, a former deputy to George H. W. Bush’s drug czar said there might be “major therapeutic possibilities in psychedelic research meriting NIH support”.
In his book, Pollan details the behind-the-scenes work that took place in order to make the study possible. It’s no accident that the study was conducted on normal subjects. The goal was not to study psilocybin as a disease-specific therapeutic, in the way that past studies had looked at MDMA for PTSD or cannabis for seizure disorders. No, the very deliberate purpose of the study was to interrogate the spiritual potential of these drugs. Pollan managed to interview some of the original study subjects for his book. Even decades after the experiment took place, many that he interviewed credited it with being one of the most meaningful experiences of their lives. Ineffability is one of the hallmarks of a mystical experience as described by the literature Pollan presents, and indeed, many of the subjects had trouble finding words to recount their journeys. However, two words that came up again and again despite their insufficiency were — you guessed it — wonder and awe.
Flash forward to my second year of medical school, and I’m in the audience at one of our rare required lectures. The topic is “Wellness and Resilience.” As talented as my classmates and I are at appearing engaged while doing test-prep flashcards, it’s hard for us to ignore the video we’re shown:
The video hit home the idea that burnout is real and widespread. Even medical students aren’t immune to emotional exhaustion and depersonalization in their work, which, if left unchecked, can have the wrenching consequences we hear about in class videos, on front pages, or in locker room whispers. It seems like wonder, whatever we take that word to mean, has a protective effect on burnout. It also seems that research into psychedelics holds incredible potential not just for treating conditions of the body, but also those of the soul. Am I suggesting every healthcare professional should have a mystical experience on LSD? Of course not — though I won’t disagree that more research is needed.