Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman: Support for The Nocturnists comes from the California Medical Association.

Team The Nocturnists: At The Nocturnists, we are careful to ensure that all stories comply with healthcare privacy laws. Details may have been changed to ensure patient confidentiality. All things expressed are those of the person speaking and not their employer.

Emily Silverman: This is The Nocturnists Conversations. I'm Emily Silverman. Today, I'm joined by Dr. Susan Nathan, a palliative care physician at the Boston VA, and Thor Ringler, a therapist, poet, and longtime storyteller at the Madison VA. Together, they lead My Life, My Story, a simple yet revolutionary program that invites veterans to share their life stories in their own words. Volunteers sit down with veterans for in-depth, open-ended interviews, carefully write up their stories in the first person and then read the narratives back for the veteran's approval. Once finalized, these stories are added to the medical chart, where clinicians can access them and see the person behind the patient. In my conversation with Susan and Thor, we explore how a small idea in Madison grew into a national program across 80 VA sites, the art of deep listening and writing stories that truly reflect a person's voice, and how these narratives are changing the way clinicians see and care for their patients. I hope you enjoyed this conversation as much as I did, but first, let's hear Susan read one of the first-person narratives from the My Life, My Story program. Here's Susan.

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Susan Nathan: I was born in Panama as the second of six boys. If you include half-siblings from my father, you would get all the way up to 12 boys and 2 girls. My mother has been a teacher for as long as I can remember, and still, even at 80 years old, she is a teacher. Three of my brothers came to the United States in the late 80s, and I, along with my two remaining brothers, came shortly after them, along with my mother. Initially, we were here on student visas, but quickly obtained green cards.

Rather than waiting for the long process of naturalization as a civilian, I decided to join the military. On the day I was naturalized, I was a part of the National Guard and was on the USS Kennedy in Massachusetts. My naturalization card was handed to me by none other than Senator Ted Kennedy. When it came time to celebrate everyone's American citizenship, Senator Kennedy handed me a sword to cut the cake.

Shortly before I was scheduled to go to Iraq, a private was carving a stick with a knife as I walked by. It first felt as if someone slapped my hand, but when I looked down to see what had happened, his knife had flown out of his hand and stuck into mine. When I pulled the knife out, on instinct, I lacerated three tendons. Because of this, I required three surgeries and was unable to go to Iraq.

When my friends returned, they made fun of me for my lack of combat experience. To show them that I could fight too, I immediately signed up for active duty. I chose to be stationed in Hawaii. Shortly after arriving, I was chosen at random to be assigned to Fort Shafter to serve the general as his driver. I think the branch forgot that I existed, because I ended up staying there for six years.

Unfortunately, while in Hawaii, I had a very challenging experience with the sergeant that has shaped much of my life since. The sergeant made my life a living hell and put me on his list of bad soldiers that he sent to the oncoming captain. Since I was labeled a bad soldier, I was constantly berated and treated poorly. Unfortunately, due to a miscommunication with my sergeant, I quickly found myself in even more trouble. When I tried to explain to the platoon leader what had happened, my sergeant and captain overheard my conversation and said I would be fired from the army for disrespecting them. For the next several months, I was constantly walking on eggshells.

I was so overcome by the stress and anxiety of the situation that I became suicidal. When I went to seek help from the military therapist on the base, my problems were dismissed because I had never been in combat. I vowed to myself at that time that I would become a therapist and would make sure that when a person sought help, they would find it. This promise to myself helped me make it through this time in my life.

My first experience as a therapist was while I was still in the army. During my later years in Hawaii, I was a manager of other soldiers and also acted as a counselor. Whenever new soldiers arrived, I told them, "We come from all over the world with so many different backgrounds, but we all need help sometimes." I remember one night, a female soldier came to me to talk. She told me that she had been sexually assaulted by a higher-ranking official. When she tried to tell others about her experience, she was dismissed. She told me she wanted to commit suicide that night, but she would give me a chance to listen.

I told her this could not stand, and as a mandatory reporter, I had to tell others about her situation. I called everyone I knew in a position of authority and shared her story to initiate an investigation. The perpetrator, as well as everyone involved in covering up this assault, were either sent to prison or dishonorably discharged. That soldier is one of my very best friends to this day.

Once I left the military, I studied psychology. As a Black, bilingual man, I knew how valuable I could be. I knew how much it meant to talk to someone who looked like you and spoke your language. I've been able to work with many people, including those struggling with addiction in Boston. To all of my patients, I share the same core insights that I acquired during my time in the military and through my own experience with trauma and mental illness. I ask them to imagine an apple on the table between us, with one rotten side and one side that is shiny and red. Depending on how I place that apple on the table, they may see the beauty in life, or they may only see the hardship.

In reality, life has plenty of both beauty and hardship. The only way we see both haves and see life for what it really is is by connecting deeply with others and seeing the world from many perspectives. I've noticed that men, especially, don't always seek out that help and don't want to share their trauma. I make it my mission to help them open up, and in doing so, move forward with their lives. I'm so lucky to now have six children who I am incredibly proud of. Among these, include a daughter who loves to paint like me and who is going to school to be an artist, and a son who is training to be a therapist. I also have five grandchildren and another one on the way.

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Emily Silverman: Thank you, Susan, for that reading. I am sitting here with Dr Susan Nathan and Thor Ringler. Susan and Thor, thank you so much for coming on the show.

Susan Nathan: Thank you.

Thor Ringler: Thank you.

Emily Silverman: I'm still letting your reading sink in. I have to admit, I got very sucked in, and now I'm just processing that. Let's start with the two of you. Tell us, each of you, about your individual backgrounds and how you got into medicine and storytelling.

Thor Ringler: You're pointing at me, Susan.

Susan Nathan: Yes, Thor, why don't you go first?

Thor Ringler: Okay. Very circuitously, I've been a person with a lot of different careers, different jobs over my life. I initially thought I was going to be a teacher. I wanted to teach poetry, so I got an MFA in poetry. That was my first higher degree after bachelor's. Tried teaching for four or five years to realize I wasn't a teacher, and then just floated around doing IT stuff for quite some time. 15 years, I was doing web development, web programming. Decided I wanted to do something that had more of an impact on people directly. I decided to go back and get a degree in marriage and family therapy. That's actually what brought me to the VA.

During that internship year, I worked at a vet center, which is a part of the VA. It's a counseling center for combat veterans, separate from the VA hospitals, and they only provide therapy and counseling. Not being a vet myself, not coming from a military background, I was actually a little frightened about it. Honestly, I was like, "Oh my gosh, scary military people. What are they like?" Of course, I was amazingly surprised, or pleasantly, how much I loved it, how much I love the vets I talked to, and was determined to work at the VA after that.

Then this job came up randomly, in Madison, where I live, and someone who had been at the Vet Center, who worked there, sent me this job posting for-- they were looking for writers who were therapists, who would interview people and write up their stories. I was like, "Oh, wow, that job is made for me." I had just started another job two weeks earlier, and I quit it. It was a full-time permanent thing at the university here, and I quit that for a six-month pilot.

Emily Silverman: How about you, Susan?

Susan Nathan: I'm a palliative care attending, and I'm also a geriatrician. I'm also with the internal medicine base. I run My Life, My Story here. Part of what drew me to geriatrics to begin with was that I always just had more fun talking to my older adult patients. I found them more interesting and often had a more pragmatic approach to basically everything relating to healthcare. In contrast to some of the general internal medicine for my geriatrics patients, there was no checklist that would cover them, because then they'd be on 50 medicines and all had counteracting side effects. A lot of creativity. I was creative problem-solving. I love working in a team.

Then I had somehow never done any VA rotations in all of my programs. We just weren't affiliated. Similar, like Thor, I was very new here and had a patient. He was in the hospice unit. He was dying. He couldn't talk. Family was not really accessible. I just stumbled. You're looking through the chart, and I just want to know who are you before today. I read and I read and I read and I read, a lot of notes. I just stumbled on this, which was his story, his words, just like the story I read from three or four months before. It just obviously told such a different story.

While the facts that I had were accurate, there was no context. I think a lot of my medical training, especially internal medicine residency, and chief residency, and such, I work with first-year medical students. It's always, "Summarize. What's the chief complaint, what's the one-liner?" We're making a list. We're reducing, reducing, and in contrast to geriatrics and certainly palliative care, where we're trying to re-expand, go back, be on the list. Then I just saw the story, and they're short, so it probably took me one or two minutes, really, to read it. It just changed everything.

Then we just started doing it here. I didn't even know that this was a project. It was months later that a colleague said, "Oh, I think this is a VA program." Literally, maybe six months later, I emailed Thor. He's like, "Yes, this is an established program." Then it just went from there.

Emily Silverman: Tell us about the origins of the program. How did it get started, whose idea was it, and where did it come from?

Thor Ringler: It was originally a project by a resident psychiatrist at the Madison VA, and he worked with his supervising clinicians there. One of the ideas that he had was it, sure, would be nice for psychiatrists to be able to remember who their patients were, since they have 1000 people on their panels, and they see them for 30 minutes, and there are a lot of folks who have similar backgrounds. That was the genesis of the project.

They initially tried doing a PowerPoint list of the things that people like, their favorite ice cream, their favorite color, what kind of dog they had. They found that that didn't really help them remember the person very well. The second iteration was having people write their own stories, having veterans write their own stories. That was successful for the 1% of veterans who were interested in doing it. Then they stumbled on the idea of, "Well, let's just see. What if we got some people who are writers to do these interviews, interview people about their lives, write up the stories, and then have that be the item that would be in the chart?"

That's when I came out of the project. It wasn't my idea, but I think what I brought to it, my sensibility, was just that it should definitely be completely patient-centered, and it should be in their voice, and they should get to review it, and it could never go in the chart without them reviewing it, and basically giving them implicit ownership of it. It wasn't ours, it's theirs. Those were core things for me.

Emily Silverman: I love what you said that initially the idea was, let's have the veterans write their own stories, and then the barriers to that, because some of them may not consider themselves writers, or may not be interested in putting pen to paper or typing, but having writers come in and sit down and interview the patient with that openness and that curiosity, almost like a journalist. Then, going and writing it up. It's a brilliant model. I'm wondering who are the writers, typically, and how do you recruit them into the program?

Thor Ringler: I'll turn over to Susan here for the writers at Boston, because it actually varies from VA to VA.

Susan Nathan: In Boston, we're a little bit different in that the vast majority of our writers are our trainees who are rotating with us, so anywhere from pharmacy students, PT students, residents, speech language pathology, nursing, nurse practitioners, geriatric fellows, palliative fellows. We've just built it into their activities that they're already doing. Because what we're trying to say is that this is routine care, being curious, listening non-judgmentally, making sense of complex, nuanced, nonlinear information, and also writing clearly. These are all core skills. Almost 2000 trainees have participated in this at VA, Boston, just as part of their routine rotations. It's a little different than, and Thor, maybe you can talk about the other writers.

Thor Ringler: Sure. At Madison, it's more based on volunteering. We have community volunteers who reach out to us, who are writers, interested in writing, also really particularly interested in using their particular skill set in a volunteering role. There's actually some very talented people out there who want to volunteer, but there's not many places you can volunteer as a writer and actually use your writing skills. This is a unique opportunity. We got some amazing volunteers locally. Some of them have been with us for over 10 years now. The volunteers do two-thirds of the stories at Madison, and then the rest are my staff, like myself.

Emily Silverman: How many VAs have this program?

Thor Ringler: We're at 80 VAs now.

Emily Silverman: Wow. How many VAs are there in the United States?

Thor Ringler: 150 is the number that I have.

Emily Silverman: You're more than half.

Susan Nathan: Yes, it ebbs and flows, but I think that's a good estimate.

Emily Silverman: Wow. Huge impact. Bring us into the experience of collecting one of these stories. Let's say I'm a volunteer. I'm in the hospital, VA Madison, or wherever it might be, and I'm assigned to Mr. Jones, the patient in Room 9. Walk me through the steps of how the story is collected, written, edited, and put into the chart.

Thor Ringler: Most of our inpatient interviews are done cold calling, we call it. We go room to room, finding folks who are awake and bored, and see if they're interested in telling their story. That's really our recruitment method. I think Susan uses the same.

Susan Nathan: Yes. Not being discharged that day and cognitively intact. That's it.

Thor Ringler: That's the selection process. There's an informality to it right from the beginning, which I think is lovely. It's kismet. It's like, you're going to go into the room and you don't know who you're going to interview, you know little about them. You just walk in and say, "Well, I'm here with this program. I want to talk to you about your life. We're going to write a story for you." People are like, "What?" Some people are like, "Yes." Some people are like, "Yes, what?" Some people are like, "No, get out." Other people are like, "Sit down." Other people are like, "Huh?" There's a really fun quality to it of just saying, "Yes, I'm here to talk." I'm going to turn it back to you, Susan, for the interviewing part. How do you feel the interviewing part goes?

Susan Nathan: The pitch, if you will, is that you don't have to talk about anything you don't want. It's not military-focused. We'd never presume to get your whole story. That's impossible. About half the people say no, so it's not for everybody. How I coach the trainees is that it's almost like a non-interview interview, in that there's no agenda, there's no question that needs to be answered, there's no check boxes, we're not going to get everything, and we're just here to receive whatever story that person wants to share on that day.

I'll suggest maybe a first question. Let's begin at the beginning. Where'd you grow up, and what was it like? Most of our interviews are in acute care, so people are so primed to tell their medical story, sometimes you have to steer. Sometimes you only ask one question, and then the person tells you their life story. The big thing that I frame is that it's more of an intensive listening exercise, and that by allowing the person the time, the story will unfold.

We do not audio record any of the stories. It's note-taking, whether it's handwritten notes in a notepad or typing notes on a laptop in the room. Then it's just from those notes then, that the story is made. There is some crafting to it, because it's not a transcript, it's a story. Some people tell their life story in a very, very linear fashion, and some people tell their story hither and thither, and some people will tell their life story, and they actually won't talk about themselves at all. They'll talk about their brother or their father, or flying plane. They'll talk about not themselves, but that's their story. Then we don't do any fact-checking. It's not journalism.

The other, I think, the writing coaching, which is an important thing, certainly with the trainees, because we're so used to writing in the third person, that's the biggest switch, is that writing in somebody else's voice can feel different, sometimes uncomfortable, and sometimes nerve-racking.

Emily Silverman: I instead of he.

Susan Nathan: Exactly. Then the read back, while it's the shortest part of the activity, often, it is a lot of times the most meaningful. A lot of times, the response when we offer this to the veteran, I'd say the most common response is, "Why would you want to talk to me? I'm boring. I'm sure there's someone more interesting or better." Then you read the story back, and now the person is laughing, or now they're crying, or they say, "I'm going to take this home and I'm going to frame it and put it on my wall."

We've definitely had veterans who have asked the writer to sign the story, like by Susan, and then the writer doesn't want-- It's not my story, it's your story. I just wrote it down. That's happened more than once, so this idea of something really being made together.

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Emily Silverman: Tell us about the read back. They sit down, they collect the story. Do they go type it up and then print it and bring it back same day, or what's the turnover time, and when does the read back happen?

Susan Nathan: As much as we can here, as soon as possible, is ideal. I'd say the majority of ours get a same-day read back just because the future is uncertain, and people who are in the hospital, things change. When people are at home, and then there's more of a back and forth sometimes, more time can lapse. The farther you are from the initial interview, the less likelihood that that final read back and completion will occur.

Thor Ringler: I think it's great to get the read back done as quickly as possible. I'm such a crazy perfectionist that I take way too long on my story, so I end up phoning people and reading them back over the phone [unintelligible 00:22:09] to. I would really agree with Susan that the read back is probably the most amazing part of it, maybe for both. I can't decide, but there's something really surreal about reading someone's story back to them in their voice, with your tongue and teeth and everything. It's just a very strange, strange thing. They're sitting there, and you're wondering, "Are they going to like it?"

I think the choice of first person for me was really important, because I feel like, and Susan spoke to this, it changes how it's interpreted and how it's done by the person. For me, at least, it really increases my sense of responsibility to get it right. Third person is just like, "Oh, this is my perception of the world. It's over here, da, da, da. Joe said this. Bob said that." First person, you're really taking on the responsibility to represent somebody. To me, that feels like big stakes. You want to do it right. I feel like there's a built-in component to the process that just really urges people, and requires people to do the best job they can.

I think, like Susan said, that the emotional reactions, for me, it's when I repeat the veteran's favorite swear word. It like always gets a big laugh because they're like, "Oh yes, that's me." [laughter] [unintelligible 00:23:33] guaranteed. Then the sadness, too. There's definitely really sad things, and it's just amazing sometimes to see how people cry as you read the story back. It's very powerful.

Emily Silverman: After the read back, the veteran approves of the story to go in their medical chart. Tell us, where does it live in the chart, and how can clinicians see and click on and interact with the story like you did, Susan, when you saw that patient?

Susan Nathan: For any VA providers out there, you might even have a My Life, My Story program at your VA and not know it, like I did. It's in the postings. It's in that same place as things like advanced directives or allergies, life-sustaining treatment notes. The note title is just called My Story. The whole idea, and the hope is that even if you don't know what it is, much, again, like how I found it, you just see this note title, and you click on it, and it'll bring it up. Even if it was 1000 notes ago or three years ago, you don't have to be digging to find it.

I also just want to add another important piece is that it's only up to the discretion of the veteran, whether or not it goes in the chart at all. They can decide that they would like to do this, that they want the story for themselves, but they do not want it in the medical record. That's totally fine. I suspect the numbers and the reach is probably greater, but there's a lot out there, and the veteran just didn't want it to go in the chart.

Emily Silverman: You said, Susan, that with your patient. You found the story, you read it, and it changed your approach to the patient. I'm wondering if you could speak a bit to that. How does having this rich context, this often, I'm sure, voicey, more relatable story in the chart, how does it change the way clinicians see and interact with and direct the medical care of veterans?

Susan Nathan: Even the story that you read, the content that comes out, often really, really concretely, can lead to very actionable clinical interventions. What are sources of strength that you've used in the past? How have you gotten through hard times? Things about family members that we didn't ask, that very specific question that would get to that very specific answer.

I've had a patient. He was being listed for an LVAD, and he had had some early self-directed early discharges. By doing his story and then getting context around why he was doing those early discharges, it was very concrete, and he did actually ultimately get those therapies. There's a lot of actionable content, commonly about trauma and PTSD, and things about being in the hospital.

Thor Ringler: I could just add on to that, just from not being a clinician myself, but just feedback from nurses and other folks who are on the units regularly. A couple of times, I've heard the stories of the difficult patient, and the difficult patient happens to have a story. People read the story, and they understand why he's difficult. Not that he stops being difficult, but they have empathy for his difficulty because of what they read. I've heard a couple of times that that's just changed the whole vibe on the floor around that person. It really can have an impact relationally, I think, in healthcare, and empathy can almost be a game changer in terms of connection and in terms of patients feeling like they matter and you matter.

Emily Silverman: Throughout your years doing this, do you have any favorite stories about the program? It could either be a memorable veteran, or a memorable moment of a trainee, or a nurse, or somebody coming to you and saying how much the program meant to them on their end as the caregiver, or any other memorable moments related to this program?

Thor Ringler: I can start with a funny one that I love to share, because this just just just really touched me and really made me laugh. I read the wrong story back to a patient. I think I'm the only person to have done this that I know of. What was funny about it wasn't just that I made the mistake, but just that he was so good-natured about it. He just let me go. I'm sitting there reading the story, and I'm like, "Wow, he really likes it. He's smiling. He's got this big smile on his face." He's smiling because it's not his story. He waits till I get to the end, after I've read my emotional, powerful story, and he says, "That's a really great story, but it's not mine." It was so funny.

I don't know why, but that experience sticks with me forever, just because I-- I don't know why. I felt like he was somebody who was telling me that our stories are all very close, actually, and anybody in the world is really only a half step away from us in terms of who they are as human beings. When he said that, that really reminded me of that. It's like, "It's close enough, it's a good story. It's not mine." That's a funny one that I always think about.

Susan Nathan: I think one that's a little different is I had a veteran from the community who I didn't know he wasn't patient, but he emailed our group, and he said that he's in a veteran peer support group, and that he heard about My Life, My Story, from one of the veterans in his group who had done it, and that that veteran said it was a good thing and that he should consider doing it.

I was so excited, and I emailed him very promptly with lots of materials. I never heard back from him, but the fact that out in the community, that one person who did this [unintelligible 00:29:53] in his group, which is a safe group of people who trust each other, that he told that other person that this was a good thing. I thought that was pretty meaningful.

Emily Silverman: What's next for the program? Any plans to spread to other institutions, any plans to spread outside the VA system, anything storytelling-related that each of you individually are taking on as creative projects, or what's next for the two of you in storytelling?

Thor Ringler: Well, Susan's leading the charge outside the VA, I would say. You want to speak to that?

Susan Nathan: Sure. Because many of our trainees come from academic affiliates, and then they might come here on a rotation, and they will do one interview, or they'll read an interview on a patient, and they say, "Wow, this is a good idea. Can we bring this back to our home institution?" The answer is, "Of course, yes. None of this is proprietary in any way, shape, or form, and all we want to do is share it." We have an ever-growing network, and we do national meetings for education and sharing ideas, and building community. More and more medical schools also, are building this into the full curriculum. My hope is that maybe in 10 years that this is incredibly boring and that this is just standard. I think it could happen, but this is culture change, and so how long does it take to do that? It takes a while.

Thor Ringler: I think I'm slowly strategic, like you, Susan. It's like the long term has been about 12 years, and we're at the VA. Another 10 years, the goal is to have it easily available to every veteran in the system. Then, outside of that, just having a way at some point to share the stories. We do have a book of veteran stories with accompanying photos that just came out last year. We're in the process of distributing those freely to libraries around the country, just so people, not even in the medical setting, but just outside, can get a different take on the veteran experience, the military experience, rather than the one that's presented to them in the in the media or in movies, because it's so limited and narrow, actually. It's such a tiny sliver of what veterans really experience. Our goal, if anything, is to make sure that every story is completely different and written in a different way, done by a different interviewer of a different person's life. When you go into the chart to read it, you really don't know what to expect, which is a lovely thing.

Emily Silverman: I have been speaking with the wonderful Dr Susan Nathan, physician at the Boston VA, and Thor Ringler, therapist and poet in Madison, Wisconsin. Susan and Thor, thank you so much for coming on to talk about My Life, My Story, and for that beautiful reading at the top of the episode. Glad to have you.

Thor Ringler: Thank you. It was an honor to be here

Susan Nathan: Thanks, Emily.

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Emily Silverman: This episode of The Nocturnists was produced by me and Producer and Head of Story Development Molly Rose-Williams. Our executive producer is Ali Block, and Ashley Pettit is our program director. Original theme music was composed by Yosef Munro, and additional music comes from Blue Dot Sessions. The Nocturnists is made possible by the California Medical Association, a physician-led organization that works to ensure the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org.

This episode of The Nocturnist Conversations is sponsored by the Physicians Foundation, which supports physician well-being practice, sustainability, and leadership in delivering high-quality, cost-efficient care. The Nocturnists is also made possible by donations from listeners like you. In fact, we recently moved over to Substack, which makes it easier than ever to support our work directly. By joining us with a donation of $2, $5, or $10 a month, you'll become an essential part of our creative community. I'm your host, Emily Silverman. See you next week.