Conversations: Rachel Kowalsky, MD

Emily Silverman
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You're listening to the nocturnist conversations. I'm Emily Silverman. The ER in New York City can sometimes feel like the Tower of Babel. Both the patients and the people taking care of them arrive from all different backgrounds and often speak very different languages, either literally or metaphorically. Today's guest, doctor Rachel Kowalski, navigates the ER daily as a pediatric emergency doctor, a three time nominee for the Pushcart Prize in fiction and winner of the inaugural New England Journal of Medicine Fiction contest.

Rachel's writing brings the hospital alive in such a fresh and magical way. Today we'll be discussing her short story, the Delivery Boy, which shows us the ER through the eyes of a young boy from Guatemala, as well as the team of clinicians who care for him. Rachels work has appeared in publications like the Missouri Review, the Atticus Review, and the Intima. She teaches health humanities at Weill Cornell Medicine, and in our conversation here today, we talk about the scrupulous research that she did to put together this piece, as well as what is lost and what is gained when things get lost in translation. Take a listen to Rachel reading a passage from her story.

The delivery boy.

Rachel Kowalsky
Alta Gracia, the mexican intern who had been educated in the United States. Tuesday, 08:30 p.m. The trouble with english speakers was that they always made you wait for the noun. The girl was having an unprovoked, first time afebrile seizure. But by the time Iris got to seizure, precious moments had gone by, and Alta Gracia had ridden a rollercoaster of uncertainty, from dog bite to migraine to asthma attack.

Unmoored, with no noun. She had forgotten what she hoped for in this world, let alone the sentence. This was how they wore you down. Let's go, said Iris. Fast.

She hesitated. Safe, correct. Fast. That was her hierarchy of intention. Fast was for bandits and birds of prey.

When she'd first entered the delivery boys room, the psychiatrist hadn't arrived, so it was just herself and de los Santos Marcos. She'd meant to bring ice cream to room five on her way, but Bonifacio what's apt her faced with competing urgencies, her boyfriend, room five, the delivery boy, and a sudden, oppressive hunger shed chosen to do her work. I'm doctor Tierrafuego de la Paz. Please call me Alta Gracia. I'm from Yucatan, Mexico, and I've brought you ice cream.

That's very good, he said. The boy on the bed was awkward, out of context, fidgeting with the stress ball they gave teenagers at triage. His eyes darted around the room from countertop to ceiling to floor, as though following an insect's flight. They were dark and serious, close set. His upper lip was the cupid's bow of a movie star, a bird in flight.

He reached for the ice cream. She handed him a plastic spoon from the breast pocket of her coat. He wiped it carefully on the sheet, pulled up the top of the single serve container, and peered inside with interest. She tore open another package, fished out a spoon, and fell to eating. Her patient wore the uniform of New York City delivery boys, worn jeans, clean but faded, a t shirt and cheap sneakers.

His thick hair stood straight up and had dust in it. Or maybe lice. Where, she wondered, were the Latinx prep school boys, the lacrosse players, the heirs of rum and sugar? They had pediatricians and bicycle helmets de los Santos. Do you remember how you got here, Odye?

He said, looking up from his untouched ice cream. It was an invitation to listen, a turn of phrase she loved in her grandmother's mouth. But not in this mad place. Do you know San Lucas Toleiman? He asked.

No, I'm sorry. But do you remember colliding with a taxi? It is my town. He glanced up above the supply cabinet, then back at her. Well, there was a mudslide in Santa Clara.

My uncle died, and my aunt and cousins came to live with us. Aricelli Glades, Evie. Ila Gorda. You can imagine we needed money. But that was not today.

No, he agreed. She glanced up at the clock. The boy chucked the ball hard at the far wall of the room. It bounced off and struck the trash can. De los Santos.

I have been told you see a demon. Is that true? A messenger. He pointed into the corner. There.

He nodded. She stepped around the stretcher. I dont see anything. No demon, no messenger. Bien, he said.

Rendable. Either as good or yes, you do. She opened another ice cream. What is the message? Te voia conta runa historia, he said.

I'm going to tell you a story. No, a history. A lengthy tale with roots and context. Such a thing could never live or breathe here. Her phone buzzed.

Bonifacio. She stepped out.

Emily Silverman
Thank you so much for that reading, Rachel. And thank you so much for coming onto the show today. Thank you so much for having me. I'm a huge fan. So one of the questions I love to ask people who come on this show is about their physician origin story.

So tell us how you came to medicine. So I was never a science person. I was a comparative lit major in college, and I focused on latin american literature and also took a lot of creative writing classes. And at a certain point, I was thinking, okay, how is this going to translate into a career? What am I going to do with my life?

Rachel Kowalsky
I love to read. I love to write, but how can I make a career out of that? So I started thinking, well, maybe I'll do psychology. And in order to apply to grad school and psychology, you had to take a few prerequisite classes, and one of them was neuroscience. So I took a neuroscience class and it blew me away.

I had never thought that I was a stem person, never had been interested, but I was so amazed by the concepts that were introduced in that class, from just how neurons communicate with one another to how emotion can inflect our memories. And I got really excited about science. I took a biology class, and I really started thinking, maybe I want to take literature and the themes of literature and apply them to another person, using medicine as that way of applying it. So I slowly did all of the pre meds. I was very intimidated by the pre med coursework.

I worked with tutors, just did my best, and found that if I really applied myself, I could do well in those classes. And so I wound up going to medical school. But I wasn't one of those people who knew from childhood, oh, I'm a doctor. No, I've always thought I'm a writer and a reader. And you landed in the ER, of all places, the pediatric er.

Emily Silverman
So how did you get there? I think the ER is the best place in the hospital. It's a very, very creative place because anyone can walk through your door at any, any time. Nothing is predictable. And we live in an uncertainty that I think is not acceptable in most of the rest of medicine, where you really need to have the answers.

Rachel Kowalsky
Most of the time in the ER, we can wonder and say, boy, I wonder why my patient has fever, rash and hand swelling or some combination of symptoms. You have to think about it, talk to them, talk to their parents, get a sense of their life, their exposures, and be a little creative and a little flexible in deciding what to do for each patient. I also really love the abundance of story in the ER. Every single person who comes in. This is true, I suppose, in all of medicine has a life story, and it's unfolding in a particular context, cultural, spiritual, and you get to be there to hear about their lives and how they understand whatever it was that prompted them to come to the ER, what they're afraid of, what they're worried about.

So once I got into residency and saw what the pediatric ER was all about, I think I was drawn to it right away. Yeah. We had on an ER doctor, Jay Baruch, who practices at Brown, and he thinks a lot about story and the ER and had a mentor once say to him something along the lines of the internist is like the novelist, and the ER doc is the short story writer, and there are no good short story writers. He and I were laughing about how that's completely not true and talking about Anton Chekhov and how he was a physician and a short story writer. And the piece we're going to discuss today is not a novel.

Emily Silverman
It's a short piece. And it packs such a punch. I feel like even within that short word count, you were able to bring to life so many different characters. And there's a sweetness, I think, to the shorter format, too, that lends an ephemerality that maybe reflects something about the ER. So I'm curious about your writing history.

Do you normally write more short form? Do you have long form projects as well? And how do you see that mirroring your clinical work, if at all? Well, first I'll say Jay Baruch is a great friend and mentor of mine. He's written the collection of essays, tornado of life.

Rachel Kowalsky
He's also a short story writer. And I really loved your episode where you interviewed him and spoke about his writing. So what do I write about and how does it relate to my work? I'm very interested in narrative medicine. The field was developed by Rita Sharon.

She's an internist in New York City. And I'm actually taking some coursework at the narrative medicine program at Columbia. And she talks about the idea that, let's say, you want to support conversation around, let's say, medical errors or the death of a patient or any medicine centered concept. You don't necessarily have to pick a story or poem about that thing to discuss that concept. It might be better to just pick a poem in general about loss or about shame or grief.

So Rita Sharon is always very strong on that point, that medical stories are stories about people. And so I feel like, in a sense, I'm always writing about medicine because I'm always writing about the big themes that we confront in medicine, life, death, fear, safety, shame, and redemption. But it doesn't always take place in the ER. One story, God's green earth, takes place in a New York City deli. But to me, it's so much about my work and the patience that I see every day.

Emily Silverman
And even this piece, the delivery boy, which does take place in the ER, felt really different, felt really fresh. It was unlike anything I had ever read before. That takes place in a hospital. And I think some of that had to do with the characters and the perspective and whose eyes we were viewing the encounter through at any given time. And you do shift point of view a few times.

And also there was a sense of enchantment or magic in this story that was so wonderful to see. I think hospitals and clinics and ers often feel like such dead places, so sterile and so scientific and so disconnected from any kind of mysticism or anything like that. And I loved that you brought that into this piece. Thank you. I see the ER as so ripe for writing about magic, transformation, the surreal, because it's a really unusual place.

Rachel Kowalsky
There's no windows, you can't see the weather, there's no natural light. It's all artificial. There's no time. Night is day is weekend, doesn't matter. You're there.

And a lot of times you're so busy that you miss out on major news stories. And it's not until you're leaving that chaotic place of the ER that you realize something major has happened in the world. So it can feel very surreal. And I also think there's this sense of transformation that takes place there that also makes it feel magical. Something goes from broken to fixed or from painful to no longer painful.

It's a locus of change that can feel magical sometimes.

Emily Silverman
Well, let's talk about the piece, the delivery boy. It's about Delos Santos. He's an indigenous boy from Guatemala who has been in the US for about nine weeks and lands in the ER. And I'm curious where you got the idea to write this. Where did it come from?

Rachel Kowalsky
So, yes, Delos Santos is indigenous guatemalan. He's Kakchikal. My dad's guatemalan and I grew up with 1ft in each country. I grew up and was born in the United States, but there was constant flow of family members between countries. So cousins would come and stay with us, we would go and stay with them.

Vacations, summertime and later. I also did field work for my masters in public health in Guatemala. So I spent a lot of time there and a lot of time during formative years. It's an amazing place. There is a large indigenous population there.

About 80% of the country is indigenous, and they speak about 20 different dialects. So it's a very natural place to think about language because there's so many different languages spoken. There's the languages of people who were conquered but still speak their indigenous language as often as they can. There's the language of the conquerors. Then there's all of the english speakers.

And many people who live and work in Guatemala speak English. So it's already a little bit of like a tower of Babel. And I noticed, working in the ER in New York City, it's been really helpful to speak Spanish, because we have so many people who speak Spanish from all parts of the world who come into the ER. And I would always notice, like, in the section that I read when I meet a Guatemalan in the ER, they're not the educated, affluent Guatemalans. They're people who are disconnected from care, people who have come to the US under really tough circumstances and maybe don't have a pediatrician, don't have a bicycle helmet, had to take whatever job they could get.

And typically, what I see is boys who work in a kitchen and have cut, like, a finger, and so they'll come in for that injury. Or delivery boys. I've seen so many delivery boys who were guatemalan or from other spanish speaking places, and it just got me thinking, what is it like for them to come into this space? What is it like when I walk into the room? Are they shocked that I'm guatemalan?

Are they shocked that a woman is a doctor? What do they think about all the things in this room? And it made me feel curious. And curiosity is a great portal into a story. I couldn't agree more about curiosity being a portal.

Emily Silverman
And one thing I'd love to ask you is about fiction, because I feel like there are certain brains that are just really, really good at fiction. My brain, I think, tends to want to slip into nonfiction. It tends to want to slide back into facts. And if I were in your situation, I could see myself thinking, okay, what is it like for them? Maybe I should ask them.

Maybe I should go out and interview them. Maybe I should collect primary data. But, of course, there's also the route of imagining. Maybe it's feasible just to kind of put yourself in someone's shoes and imagine what they might think and say. And so I'm curious how you approached writing this.

Did you start asking your patients about their experience, or was this pure Rachel imagination? Well, the concept was pure imagination. For me, fiction feels very truthful sometimes I feel like fiction and even magic realism is the best way that I can really describe what I think and feel. Because things can be so heightened in the ER, emotions can be so big, there can be so much at stake. Not all the time.

Rachel Kowalsky
Some of the times it's just coughs and colds, but because it's a place that often is at high volume, high amplitude. I like to use fiction to get ideas across. So, for example, you don't always have all the characters that I put in my story in one place at one time. Gary, the senior resident, he's kind of a jerk, but he's also very hungry, so we feel sorry for him. Alta Gracia, who is mexican but educated in the US, and this particular delivery boy, de los Santos Marcos, and the two nurses at triage.

But it really served my message to put them all in the same place at the same time. It made it much easier to show what happens when there's so much difference in one place, trying to solve a problem together. But in terms of the fact gathering, I had to do a ton of research for delivery boy, and that's part of why it took me years to write, even though I had spent time in San Lucas, Toleiman a lot of time, I had to talk to people who were indigenous, Kakchikel, and who lived there or had lived there most of their lives. And so I actually found, through different contacts, three people who I interviewed over years and showed versions of the manuscript to try to understand. Would he even know how to ride a bicycle?

Would he have had ice cream? Is that a common thing? Is that a treat? What does a pair of shoes cost to help build the world of de los Santos? I needed a lot of information.

One thing that I was listening for as we spoke was, what are the ways of describing loss? What are the ways of describing grief? I remember there was one woman who I interviewed who kept using the word des. Arrigado, unrooted, uprooted. And as soon as I got off the call with her, I thought like, this is about roots, and it's about a physical, painful pulling of roots from the earth and putting them somewhere else.

So I thought a lot about language and concept as I spoke to them. I also thought about the messenger, because in the story, there's a messenger that appears to the main character and follows him around and is trying to tell him about the death of a friend, but he misinterprets and he thinks wants to tell him about the death of his mother. He's very anxious about her back at home. And it started out as the angel of death. But the first person I interviewed said, it's not going to be an angel of death.

We don't have the angel of death. That's from a whole other tradition. So I changed it to a demon. And the next person I interviewed said, it's not going to be a demon. A demon is more of a devil.

It's really terrifying. It signifies pure evil in people. And I don't think that's the concept that you're going for. So I finally settled on messenger, but it took a long time, and I did a lot of talking and thinking about what kind of messenger. The messenger is an owl, and it has terrifying teeth, because the owl is a messenger in mayan folklore, and teeth have a lot to do with life and death, particularly of your parent.

So I fit those things together, and that's like one paragraph. It took so much time to figure out and write properly. You can feel the density of research and density of experience in the piece. These people you were interviewing, were they friends? Were they family?

Emily Silverman
Were they random people you pulled off the street? How did you get them to talk to you? A long time ago, in college and in med school, I used to volunteer with a group of doctors from Brown, where I was an undergrad. And our home base was San Lucas Toliman. And there I met lots of volunteers and contacts from the US who did work there, and one of them, who's very young, we were all very young then, and he was training to become a priest or a reverend or.

Rachel Kowalsky
I can't remember exactly what. And he fell in love with someone from San Lucas Toleiman, and they got married. And now they live together in New York and have a beautiful family. But I got in touch and I said, is there anyone you think I could talk to back in San Lucas Toleiman? So he put me in touch with my first contact, who works with youth in San Lucas Toleiman.

The second and third contacts came from a professor of anthropology at Connecticut College, Joyce Bennett, who I found literally just by searching on the Internet. And Joyce is particularly interested in anthropology of mayan women and spends a lot of time in the Kachiquel world in Guatemala, and speaks Kachiquel and is married to a kachiquel man, Celestino. So he was my second contact. And then Joyce also introduced me to Eischnal, who was my third contact, who was someone she had collaborated on projects with in the past. So all those three people spoke Kakchiquel, but also spoke Spanish, and that was very helpful because we could communicate in Spanish to talk about the manuscript and the characters.

Emily Silverman
And a lot of what you researched was these ancient texts, these historical records and myths from the indigenous culture there and then bringing those into an ER in New York City. And I just want to read this one section because the piece is funny in a lot of places, but I thought this part was especially funny where you have the med student Britney. She begins to speak. She has a british accent with a hint of island in it, and she says, de los Santos Marcos is a 17 year old guatemalan male who reports that he saw a messenger or a demon, then got on his bicycle in search of a large idol to help save his mother, and was struck by the opening door of a taxi. Alta Gracia sat up.

Gary's face went tight. I'm sorry, what? It is his chief complaint. Britney said in a serious voice, saw a demon struck by a taxi. How did you think about bringing some of those mystical elements into the fluorescently lit, windowless, modern er?

Rachel Kowalsky
The person who delos Santos is seeking the idol is Mashimon. Mashimon is a folk figure in Guatemala. If you're from Guatemala, you know about him. He's pretty controversial. You could ask ten different people in Guatemala who's Mashimon?

And they might all tell you something a little bit different. He's kind of a God and kind of an image and kind of just a folkloric character, but his function is that you go to where he is and he's usually living in somebody's house. He goes from house to house. It's an actual kind of mannequin or doll, but it's life sized, dressed differently in different homes, sometimes in a black suit with a black hat, sometimes an indigenous garb, and you ask him for help. You make sacrifices of candles and incense and cigarettes and liquor, and you ask him to help you.

And people who believe in Mashimon believe fervently, very strongly, that he helps them with anything. A dispute with a neighbor, the illness of a loved one, that he's there to help. So he's de los Santos guiding light. And as soon as he becomes afraid for his mother's health, he knows he needs to find Mashimon. The only problem is he'll never find Mashimon in New York City.

I do think there's one in California. I looked it up, but I think that might be the only one in the US. But I wanted it there because I think so often we don't actually know what will make our patients feel better. He really was just afraid. And it was so hard, even for those who spoke Spanish in the story, to understand that as soon as his mother reaches him on his cell phone, he feels better and he's done.

He doesn't need consults. He doesn't need a CT scan. He doesn't need a talk screen. He was worried about his mom. So I used Mashimon as a way of illustrating.

We don't know unless we ask what medicine or healing really is for our patients. And we have de los Santos encountering many different people in the ER. We have Alta Gracia, the US trained doctor originally from Mexico. We have Gary. We have the redhead psychiatrist.

Emily Silverman
We have Brittany, the medical student. And we have Iris, the charge nurse. And there's another nurse. Talk about how you created that little core group of characters and just thinking about how they collide against each other and how they approach the patient and vice versa, because it was just such a great swirl or tornado of personalities. Yes.

Rachel Kowalsky
Those were the characters that had the most staying power over the years. I started with many more. I would take the story to writers workshop, and my teacher would be like, this is way too complicated. You need to stay organized. You need to pick a few voices.

And ultimately, I picked these people because I think that together, they really do represent different facets of the ER. Gary is a jerk, but also, you kind of get how overwhelmed he is. He's a senior resident who's been left in charge of the ER. Who knows why? He's totally overwhelmed.

He's totally out of his league with this young man from Guatemala. He doesn't know how to think about him or approach him, but he knows he's got to solve the problem. And he's hungry. He's just dying for the Graham crackers that he finally finds and the crams in his mouth. And you kind of know Gary.

And sometimes we're all Gary. Sometimes I'm really cranky and grumpy, and sometimes I want to get a head CT because I just need to figure it out. And I think it's important to show that we're not all great all the time. We're flawed and we feel pressed to be correct and fast and safe at the same time. And you just can't always do that gracefully.

So that's Gary. Alta Gracia. I liked because I could use her to show that even if you share a language with somebody, you still can't necessarily understand them. And she's dealing with her own stuff. She's slow.

And that is a problem in the ER. So Gary sees her coming and he's like, oh, no. This is the slowest person I've ever worked with. But she's slow because she's thoughtful. She can't just pop into room five, because first she needs to check the child's weight and think about, is this the right weight?

And then she needs to make sure they haven't taken any tylenol that day. Ask about it a few different ways. Like, that's me all the time. I always feel like, you know what? I need to find out a little bit more before I make a decision.

And so I totally get it. She feels stuck between really understanding all of these facets of a case and being fast enough to get to the next patient. She even talks about her hierarchy of intention in the section that I read. Safe, accurate, fast, safe matters. Most accurate matters next Fast is at the end.

But she feels so pressured to be fast. It would have been so easy for these characters to be caricatures, you know, to have the jerk senior resident and the noble intern. But you do show us their strengths and weaknesses and their complexity, and we get to a place in the end where we see ourselves to an extent and each one of them, and that really humanizes them. And I think just made the piece feel so strong. And you also decided to write from different points of view.

Emily Silverman
So it's not like it's all through delos Santos. And then we have these characters popping in and out, but we actually shift into Gary's perspective a couple of times. We shift into Alta Gracias perspective a couple of times. How did you think about POV in this piece and who to speak from and who not to? The POV was the hardest part.

Rachel Kowalsky
I actually took a whole workshop on POV to help me finish the story. I wanted to give each person a voice. I wanted the reader to be able to really get into their heads and empathize with them, understand them from a first person point of view. There were some that I cut out because I thought, I'm never going to be able to accurately get inside this person's head. Like, Brittany Brathwaite was a character whose head I was in early on as I started writing the story and I ordered Guyana's cookbooks and read people's memoirs.

And I had worked with a student before who was guyanese and did research with her, and I spoke to her, and she was the person who taught me that Spanish isn't spoken there. And I was like, I'm not going to be able to write with her voice. She's just not going to let me in. And I think I have to respect that and not try to write from inside her head, but honor her as a character who's seen through somebody else's eyes. I think that's the closest I can get here, but I think the other three, I really felt like I could get to know enough that I could represent them with humility and some degree of accuracy.

Emily Silverman
Let's talk about language, because that's such a big theme here. The paragraph you read at the top of the episode was one of my favorites, and it starts with a sentence. The trouble with english speakers was that they always made you wait for the nouns. There's a bunch of spots in the story where you translate Spanish into English through delos Santos ears. So, for example, the psychiatrist walks in and says, hello, I'm a doctor of the sentiments.

Do you have intimate knowledge of this place? And it was just so funny. As somebody who does have a little bit of Spanish, I'm like, oh, my God, that's totally probably how I sound when I try to speak Spanish to people. And you mentioned earlier the Tower of Babel and the different languages, the richness that that brings, but also the divisions and the bridges that we can't cross. So walk us through how you think about language in the ER.

And in this piece, I do think. Of the er as a tower of babble. There are so many patients and families whose primary language is not English. And even though we always do our best and work through translators, ideally, I still think there are things that are missed even through the translator. Even the translator in this story can't quite translate.

Rachel Kowalsky
Mashimon. He can't quite translate what the messenger is demon idol, doll language justice is a big topic in the ER. I speak Spanish, but not perfectly at all. I'll tell patients we can do English or Spanish. I'm not perfect in Spanish, but I'm okay.

What do you want to speak? In one time, the surgeons asked me to help them translate for a patient who had swallowed a bunch of toys, the kinds of toys that, like in water, they expand. They had been, like, on a table at a wedding, and a child ate a few of them, and they expanded inside that child. And I was translating for the surgeons who were going to take the child to the OR, and they got to the part about a possible ileostomy or having to do something that I don't really understand in English, let alone Spanish. And I had to stop there and I was like, ileostomy?

I'm not going to be able to do, like, you're going to have to get on the phone with a medical translator and really explain this to them, because all I'm going to say is, hole in the stomach, and it's just not even going to make sense. So I think we owe it to our patients to do our very best to communicate with them in the language that they understand. Not only foreign languages, but even when we're speaking in English, sometimes I'll come out of a room and think, I don't think I really understood what they were talking about, or I don't think they really understood what I was talking about. I need a new way to express this. Like, I need a way to explain bronchiolitis.

I need a way to explain croup that makes sense to people. I've had that thought a lot over the years. What is the best way that I can say this so a person will understand it? We do a lot of reductions in the ER. You know, we'll do the sedation and the orthopedic surgeons do the reduction, and I'll be talking to the family, and then I'll think, like, they don't know what a reduction is.

That makes no sense. We're reducing your broken arm. What do they see when we say that, okay, we're reducing the distance. The incorrect distance between two bones is what we're doing. But, yeah, I think there's so many opportunities for better communication in the ER.

Emily Silverman
What you're saying about translating ideas from one language to another and also translating medical ideas from Medicalese into English, and then another language makes a lot of sense. And you also talk in this piece about the impact of language on how just somebody's general story gets communicated. So, for example, there's a line where you say, considering the vagaries of word choice, things omitted or worse, assumed, and the fogginess of context and perspective, it was amazing that any patient's story survived at all. You also talk about the linearity of storytelling and how, for delos Santos, there may not be the linearity that Alta Gracia wants. And in your section that you read, she asks him, do you remember how you got here?

And she's trying to ask him about the bicycle accident, and he starts going on and on about his town and why his family moved. And she goes, but that wasn't today. And he goes, no, you can feel her frustration. She's trying to elicit a very linear narrative from him. And hes not giving it to her.

And then later you write about this ancient mayan text and how its chronologically impaired, full of time warps and dead ends. The text began with creation, jumped to an intrepid set of hero twins, then backtracks to their father and uncle, barely remembering to finish up the world it had so painstakingly begun. Later you say, mayan narrative is associative, not chronological. And so how do you think about the interface between language and storytelling in the ER? It's so much at the heart of what we do.

Rachel Kowalsky
People represent themselves to us and then we have to make sure we've understood the story. And the mayan perspective isn't really of events that start at point a and go straight to point b and straight to point c. There's a lot of contextualizing that takes place, a lot of setting the scene, and also there's a lot of talking in a circular way around and around the point, making smaller and smaller circles, and then finally getting to what you meant to say as the crowning piece of your discourse. It's not the opening piece. Like when we do a presentation, that first sentence should contain in it the answer.

Ideally, that's what we're taught, but not so in the way that De los Santos thinks, or lots of our patients. I loved the book. The spirit catches you and you fall down, and the author describes how among family may start their story way back with something that happened years ago. This is a question that we pose to ourselves in fiction and in the ER. Like, where does the story start and where does the story end?

Does the story start during your pregnancy when you got really stressed out or you ate all of the wrong foods, and now you're noticing this thing in your child that you think is related. Does the story start last week when your child was exposed to the flu? Does it start today? Where does the story begin? And so often when I was doing the interviews with Ishnal and minor and Celestino, especially, Ishnal would say, like, I'm going to tell you a story.

She prefaced so many of her responses with that, like, I'm not just going to give you a one word answer here. I need to tell you about an event that happened. I can't just say like, oh, it's really hard to be away from my family when I come to the US to work on different collaborations. No, I'm going to tell you about a time that I did that and why I did it and what it felt like and what I was supposed to be teaching but the fact that I missed my family so much, I didn't feel like myself. It's a real story.

I really love that about the ER. And it also can be tough as an ER doctor because it takes a long time to represent a person's story accurately. I think I'll write notes for like 2 hours after an eight hour shift because it's like you want to get it right. And it seems like there's a lot we can learn from this way of communicating and storytelling. I think a lot about the medical note and how destoryfied it's become when you open up a note and it's like, this is a 65 year old woman with COPD who presented with shortness of breath.

Emily Silverman
And then it's like problemless. Hashtag COPD, hash depression. You know, it's like, right? You really don't leave with any context of who this person is. And I think people, I hope are starting to get better at weaving some of that into the note.

And the reality is we have limited time, especially in the ER. We just have such limited time. And for people listening who are trying to balance that tension between speed and completion, do you have any thoughts or tips or how do you approach it so that you keep your sanity but also do your best to honor the stories of the people who are coming in? I've just cut myself some slack and understood. I'm the one who takes a long time to write her notes.

Rachel Kowalsky
It's been that way since her residency. I'm always the one who the incoming doc is like, what can I do to get you out of here? And I'm like, nothing because leave me alone. I'm just sitting here now for 2 hours and think about all the people I just met and what they said to me. I think I have to save time in other ways.

It's not going to be in note writing because everywhere that it says patient, I put their name. Everywhere that it says denies, I change to no. Even if it says PMD, I really prefer to write pediatrician. It's not that many more letters. And it's a person who has trained for a long time, sometimes even beyond the three years of pedes residency, they've done a residency in hospital medicine.

It just feels a little more respectful to actually write it out. I think I've just accepted it. I'm slow when I write notes, but it feels better when I'm done. I want to ask you about trust because there's this moment in the story that just, oof. I'm feeling in my chest now just thinking about it, where they tell Delos Santos that they want to scan his head because he just fell off his bike and they don't know what's going on, and he's seeing things, and they don't know if he's off his rocker or whatever, and he agrees to do it.

Emily Silverman
And then he adds, I trust you. And they're on speaker and the words are quite loud, I trust you. And then you write, people turned to look, and I just would love for you to bring us into that moment. We've been talking a lot about things getting lost in translation and misunderstanding each other, and there's just so many reasons not to trust, and yet there's this moment of trust here. Talk to us about that.

Yeah. I think we're in a moment of deep distrust between patients and clinicians. I think often patients and families worry that we have other motives besides caring for them, like getting that ct scan just to cover ourselves or to make more money. You know, there's always this concept, it's not correct, but that I will make more money if I order more tests. I think there's always that worry if I'm going to sew somebody's laceration, it's always like, have you done this before?

Rachel Kowalsky
I'm like, yes, every day, a lot. But there's always that, well, maybe we should be asking for the plastic surgeon. And you just feel it so often, and we don't always trust our patient stories either. We'll say, like, well, I don't know if it's really been nine days of fever. That seems like a long time.

It's probably three days. And they're exaggerating because if feels like nine to them. So there's always this mistrust. And when a patient says, I trust you, whatever you decide, it is shocking to me. A lot of the times we find ourselves talking through different imaging options for appendicitis, because, especially in children, we want to minimize radiation, and appendicitis can look like so many different things.

It's not always fever, vomiting, right lower quadrant pain. It would be great if it always presented like that, but it doesn't. So we're always trying to figure it out using some combination of ultrasound and MRI, and then if we really have to CAT scan, and those conversations can be so delicate, what's going to be the most high yield? What's going to be the safest? I had one of those conversations, and the parent was just like, let's do whatever you think we should do.

I trust you. And I was like, you do. Don't you want to call, like, your uncle the dermatologist and check with them? Don't you want to, like, call your pediatrician? The fact finding that happens before people really make decisions about choices that matter in their healthcare and their children's healthcare.

It's amazing. When somebody puts their trust in you, it feels surprising, and it feels great.

Emily Silverman
So what's next for you? You're still writing? Mm hmm. Do you have more short pieces? Might you try out something longer form?

And I love your voice and your writing so much. And whatever you write, I will read. So just tell me what to expect. What's coming down the pike. Okay.

Rachel Kowalsky
So deep in my heart, I think I'm a novelist, but I juggle a lot of things at this stage in the game, and that's okay. I like all the things that I juggle, but I can't write a novel right now. But that is on the horizon. I already know what it's about. I already know most of the characters, but right now it's short stories.

I have one that I'm sending out right now that I'm really excited about. It's also an ER story. It also has magic realism in it, so that one's going to be a lot of fun, and I have lots of ideas. The lovely thing about working in medicine is writer's block is not the problem. Lack of material will never be the problem because it's so rich and there's so much symbolism in working with children.

Like, it's just so meaningful. But I have the one that's out to different magazines right now, and then one that's almost done and ready to send. That one's about being a camp doctor. So excited about that one. And two more that are mapped out in my mind but are going to need some research before I really start writing them in earnest.

I'll be an association of writers and writers programs. The AWP meeting this week, actually, with Jay Baruch, who you've hosted before, doing a panel on writing about trauma, how we take the trauma that either we've experienced or we've witnessed and get it onto the page. So that's all coming up. Amazing. Well, I encourage everybody listening to check out the delivery boy.

Emily Silverman
It's just so much fun to read, and I loved it. Thank you so much. I'm so, so glad that you wrote it and that you came onto the show to speak with me today. I've been wanting to meet you and speak with you for some time, and it's just really wonderful to be able to see your face and chat. So thanks again for coming on.

Rachel Kowalsky
Thank you so much. Thank you.

Emily Silverman
This episode of the Nocturnist was produced by me and John Oliver. John also edited and mixed. Our executive producer is Allie Block. Our head of story development is Molly Rose Williams, and Ashley Pettit is our program manager. Original theme music was composed by Josef Munro and additional music comes from blue Dot sessions.

Anoctronus is made possible by the California Medical Association, a physician led organization that works tirelessly to make sure that the doctor patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org dot. The nocturnus is also made possible by donations from listeners like you. Thank you so much for supporting our work in storytelling. If you enjoyed this episode, please like, share, subscribe, and help others find us by giving us a rating and review.

In your favorite podcasts app. To contribute your voice to an upcoming project, or to make a donation, visit our website@thenocturnist.com I'm your host, Emily Silverman. See you next week.

See you next week.

See you next week.

Conversations: Rachel Kowalsky, MD

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1: Introduction to Rachel Kowalsky

2: The Delivery Boy

3: The Role of Fiction in Medicine

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