Reading Between The Lines

By Hannah Brown, MD, Duke University, and David Wu, MD, Johns Hopkins Medicine

Stories are how people make sense of the world and they have tremendous power. Narrative medicine aims to use the ability to absorb, interpret, and respond to stories as a means of giving excellent care. One helpful way to approach stories is to look beyond the text to the context and subtext. The text is the story, context is the larger circumstances and life experiences of the person, and subtext is the powerful emotions and values beneath the surface. Drs. Young and Rodriguez comment, “All three components–text, subtext, and context–are crucial to understanding the central theme of an individual’s narrative and the decision-making processes associated with it.” But often, the context and subtext hide between the lines of text, and it takes purpose, attention, and skill to bring them to light.  

The clinical encounter is the crucible where stories of a patient, their family and friends, and the members of their care team, intermingle. As palliative care providers, we often find ourselves entering the story of a patient when the narrative has broken down. Often, the breakdown occurs when the layers of the story get reduced to frustrated words with all parties involved saying of each other, “They just don’t get it.” If we settle for the text, the story, at face value, we may miss critical parts of our patient’s story. With this in mind, we offer the following original story–a dialogue, with each speaker’s unspoken thoughts in brackets. 

A phone conversation between Dr. S, ICU physician, and Ms. A, daughter of an elderly patient with severe COVID-19:

Dr. S: Do you have time to talk about your father? [I’m dreading this.]  

Ms. A: Sure. [Finally – I’ve been waiting all day for an update.]  

 Dr. S: As you know, we had to intubate him last night because his oxygen levels were so low. He’s now on a ventilator. [He’s been in the hospital for 10 days, and this is a massive setback.]   

Ms. A: Yes, I know he’s on the breathing machine, but the nurse told me he doesn’t have a fever anymore and his blood pressure is better now. [I know Dad’s sick – but give me some good news. Please.]  

Dr. S: That’s right, since we added new medicines through the central line, his blood pressure is better but not great.  [We’re doing everything but getting nowhere.]   

Ms. A: Yeah, someone called at midnight to ask if they could put that IV in his neck . . ..” [I’m glad they called, but then I couldn’t sleep, which doesn’t help with homeschooling my kids and figuring out how to pay the bills when I’ve been laid off by the hotel. I’m so tired.]  

Dr. S: Even with all we are doing right now, his blood pressure is still soft. [It feels like we’re losing this battle.]  

Ms. A: Isn’t there another drug he can have to help with that? [He’s always had high blood pressure. Can’t they control it? Unless “soft” blood pressure is something different?]  

Dr. S: He’s already on two powerful medications. I’m concerned his body can’t handle a third. [Doesn’t she know he could code any minute?!]  

Ms. A: What do you mean “can’t handle” it? [Who is this doctor? They don’t know my dad. My dad’s always been there for me. Always. Ever since Mom died when I was 12, we’ve been a team. He worked two jobs to feed my brothers and me, and I took over cooking and cleaning and keeping the boys in line. I need him, especially now.]  

Dr. S: These medications can cause heart arrhythmias. When someone is as sick as your father, their heart might stop. [How blunt can I be? I hate these conversations.]  

Ms. A: <Silence> [Dear God, please…]  

Dr. S: Have you thought about what he might want in a situation like this? Did he ever talk about it? [Please tell me he talked about DNR. At least be reasonable. CPR isn’t like on TV. Especially not with severe COVID.]  

Ms. A: Umm . . . no. [Who thinks about situations like this? Dad’s full of life. He’s the best grandfather ever, an elder in the church, and knows everyone in town. He has so much to live for. Why would he have brought this up?]  

Dr. S: Do you think he’d still want to get CPR given how sick he is? [Like I said, your father may be dying. Or did I say that?]  

Ms. A: What? [They are giving up on him. They don’t know him, and they’re giving up.]  

Dr. S: Do you think he’d want those things? The compressions, the shocks . . .. [The chance he’d survive is so low. And I hate to think this, but does she realize doing CPR would put staff at risk? Am I allowed to bring that up?]  

Ms. A: He’s a fighter. He’s gonna get through this. [Why are you giving up on him?]  

Dr. S: Uh . . .ok, sure. We’ll let you know if anything changes. [Are you in denial? What do you really mean? I want to help. I just don’t know how.]  

By exploring the unspoken context and subtext of difficult conversations, we can make stronger human connections with our patients, improve communication, and give better care for both our patients and ourselves. Below are some ideas for how to do this. 

1. Approach the clinical encounter as an opportunity to humbly enter our patient’s story. Include discussing goals-of-care.  

2. Enlist the help of colleagues, like chaplains, social workers, and palliative care providers.  

3. Use technology, like an audio-video platform, to help forge connections between patients, families, and care teams. 

4. Engage in self-reflection through journaling and by contemplating the stories of others.   

We must make sure we’re reading and listening between the lines, for the sake of our patients and ourselves.   

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.