“I feel like his dealer”: Narratives Underlying a Case Discussion in a Palliative Medicine Rotation

“I feel like his dealer.”

The resident’s remark caught my attention. This resident (whom I will call Nick)¹ was presenting the details of a case that was troubling him at the bimonthly meeting for the palliative medicine rotation in the internal medicine residency program at a major university medical center. Nick’s frustration was clear, and the discussion that ensued was an anomaly in what were otherwise uneventful rotation discussions. Most of the time, the residents were quiet, seemed tired after long days, and were clearly ready to go home. But on this occasion, everyone became unusually invested in the case. As was typical of these evening meetings, which were held in a classroom above the research library and included pizza and drinks for the residents who had just finished a long day in the wards and clinics, the discussion was centered upon particular issues the residents were facing in treating their assigned home hospice patients rather than the more formal case presentations of other rounds. Throughout two years of ethnographic fieldwork I had been attending these meetings to discover how resident physicians were learning the knowledge and skills particular to the care of dying patients.

The significance of the case discussion I will analyze here did not become clear to me until much later. Though I found the exchange to be interesting at the time, and I knew I would write about it in my attempt to understand the importance of pain management in palliative care, I did not immediately recognize the competing narratives underlying the exchange between the residents and their attending faculty. Initially, the discussion was interesting because it seemed connected to a finding from my early interviews, in which several residents reported a need to become more “comfortable” with prescribing opioid medications. When probing the issue in subsequent interviews, other residents had shared with me their concern about creating addiction through such prescribing. As one resident explained it, she didn’t want to prescribe opioid medications to her patients because it might “get them on an addictive type of pattern.” Some also mentioned not wanting to facilitate existing addiction, and it seemed clear to me when Nick claimed to feel like a “dealer” that there was more than concern for the patient connected to this fear. I observed the residents working to find the boundaries of their role as physicians while following the prime directive of palliative medicine—to relieve the pain and suffering of the dying patient.

The main finding of my fieldwork (which I analyzed from a symbolic/interpretive theoretical orientation) was that these internal medicine residents were learning not only the knowledge and skills particular to palliative medicine but were also needing to make a paradigm shift from the norms of curative medicine (into which they had been enculturated already) to the norms of comfort-oriented palliative care in the hospice context. I saw the case discussion to be one of many instances in which the residents were learning to make this shift, for the usual rules of medical thought and action do not always apply in delivering optimal palliative care. But the incident stuck with me, and I now wish to suggest that there were narratives embedded in it which raised barriers in the learning process and which may have an impact in a variety of clinical discussions and interactions.

Anthropologists have examined the role of narrative in American medicine in various ways, for example, elucidating how medical students and residents learn to speak and write in particular ways,² or how occupational therapists use narratives as a form of clinical reasoning.³ I build upon such work in this piece to examine how cultural narratives can be evoked or invoked in a medical discussion, revealing the power of narrative even when physicians are not explicitly “narrativizing.” I wish to be clear that my goal here is not to critique the resident physicians or the attending faculty, but rather to uncover the narratives embedded in one case discussion, to examine their impact, and to suggest that this kind...