Inaugural Swigart Fellows, Celestine Warren ’20 and Lauren Kascak ’20, are launching individual projects this summer exploring medical ethics issues around shared decision making and narrative medicine.
Both medical students are working with a Geisel School of Medicine faculty mentor.
Warren’s project looks at influences on a physician’s decision whether or not to utilize shared decision making, and how that decision is communicated to patients. And Kascak’s is concerned with how end-of-life conversations and decision-making between patients and their care teams may or may not change when a different facet of narrative medicine becomes part of palliative care.
“There were several competitive applications from outstanding student and faculty pairs,” says Bill Nelson, PhD, an associate professor of psychiatry and a co-director of the fellowship. “Lauren Kascak and Dr. Kathy Kirkland, and Celestine Warren and Dr. Glyn Elwyn, each developed outstanding innovative proposals that ultimately can have a positive impact on the quality of patient care.”
Neither Kascak nor Warren is unfamiliar with this turf. As Rodis Fellows, their joint project tackled helping medical students handle feelings of discomfort that arise while witnessing patient suffering, and the need to acknowledge and navigate those feelings in order to provide compassionate patient care. Using art works representing the circle of life and the tension between order and chaos to evoke issues related to human growth and development and illness and death, prompted conversations about tolerating ambiguity and how to transition back to medicine in the face of patient suffering,
Warren came to Geisel with an interest in medical communication, having focused on this field in her undergraduate studies at Harvard College. “For me, the aspect of medical care that most interests me is making sure that patients, their families, and their care teams are all on the same page,” she explains. “This requires the doctor to be clear while communicating with patients and to create an environment where it is comfortable for the patient to ask questions. This is the type of doctor I want to be.”
Warren’s project addresses the prospect of recording patient visits with providers. She is curious about how medical students and physicians would respond if a patient requested to record the visit. “Where is the spectrum of patient empowerment alongside the clarity of mind in being directed to take a certain course of care? How does a doctor know that a patient has understood what is happening and the course of care? It is easy to nod along during a medical visit, but could we develop a tool for a patient to be able to go back and listen to a recording of the visit, in case they missed something? These are the questions I will be addressing,” says Warren.
This project builds upon the work currently being conducted at the Preference Lab of The Dartmouth Institute (TDI) and with Glyn Elwyn, MD, MSc, FRCGP, PhD, a professor and senior scientist at TDI who examines the implementation of shared decision making into clinical settings, and investigates the design and impact of patient decision aids and evidence-based tools to facilitate better clinical conversations.
“The Swigart Fellowship will allow me to learn about current techniques in shared-decision making and to evaluate their impact on patient autonomy and the traditional patient-physician relationships,” Warren says. “I’m interested in how doctors explain their clinical judgment to their patients in a way that makes sense. The art of medicine draws on doctors’ clinical expertise, technical prowess, and honed judgment. It also involves the physicians’ ability to have a conversation about patients’ hopes and fears. Then, it is possible to respond and reassure.”
When she first arrived at Geisel, Kascak says she was frequently told she needed to meet Kirkland, who was recently named the Dorothy and John J. Byrne, Jr. Distinguished Chair in Palliative Medicine and who has training in narrative medicine, because of their intersecting interests. Kascak completed Columbia University’s Master’s Program in Narrative Medicine, and is passionate about the ways in which clinicians’ skilled interpretations of patient stories can promote healing and affect clinical care.
“We met for breakfast one morning and started talking about our shared interests in narrative medicine and palliative care, and my interest in photography,” Kascak says. “We came up with this project—to use photography as a new medium to elicit and understand patient narratives in palliative care. Dr. Kirkland has already been a fantastic mentor, and I’m so grateful that this fellowship gives us an opportunity to work together.”
Their Swigart proposal, which is now pilot project, uses portrait photography to prompt conversations about patients’ lives that may inform end-of-life decision making between patients and their care teams.
“Telling one’s story is important during times of suffering and chaos—but there is another requirement for finding meaning in our own lives through storytelling, which is that our stories be witnessed by others,” Kascak says. She also notes the value that unique prompts can serve in elucidating nuanced and complex stories from individuals.
During the first phase of the project, Kascak will photograph participating patients throughout their journeys in palliative care. The portraits will then become part of their medical charts and carefully discussed with the patients, their loved ones, and their palliative care providers.
“When looking at the photos with their families and/or their care providers, we are interested in evaluating whether these photographs will provide any new information to the patient’s narrative, and potentially, their treatment,” Kascak says. “We are hopeful that the portraits, and discussions around them, will add an additional layer to patients’ stories and perceptions of self.”
“These proposals are a wonderful learning experience for each student-faculty team,” says Nelson, “as well as a great opportunity to strengthen ethics related scholarship at Geisel and Dartmouth-Hitchcock Medical Center.”
The Olive M. & Joseph F. Swigart Fund for Practical Education in Medical Ethics was established in 1997 through a bequest from the Swigarts to support the teaching of clinical ethics at both Geisel School of Medicine and Dartmouth-Hitchcock Medical Center. The Swigart Ethics Fellowship is co-administered by the Dartmouth-Hitchcock Clinical Ethics Committee, the Section of General Internal Medicine, the Geisel Health and Values Program, and the Department of Medical Education. Each student fellow receives a stipend for the yearlong ethics project, and each faculty partner receives an honorarium.