Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. 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

You're listening to The Nocturnists: Conversations. I'm Emily Silverman. The emergency room is a place of intensity—a place of noise and colors and human drama. This is the setting of Dr. Michele Harper's memoir, The Beauty in Breaking, which explores how the healing journeys of her patients intersect with her own. Michele has worked as an emergency room physician for more than a decade at various institutions, including as chief resident at Lincoln Hospital in the South Bronx, and in the emergency department at the Veterans Affairs Medical Center in Philadelphia. She's a graduate of Harvard University and the Renaissance School of Medicine at Stony Brook University. The Beauty in Breaking is her first book. Before I spoke with Michele, I asked her to read an excerpt from her book. Here she is.

Michele Harper

"When I began writing this book, I had started over. My marriage to my college sweetheart had ended. I had moved to a new city to start a new job. Plagued with doubt, I found myself having to reevaluate my life. Living through such changes was difficult; now I see those junctures, when everything I had counted on came to an abrupt end, as a privilege. They gave me the opportunity to be uncertain. And in that uncertainty grew opportunity.From childhood to now, I have been broken many times. I suspect most people have. In practicing the Japanese art of Kintsukuroi, one repairs broken pottery by filling in the cracks with gold, silver, or platinum. The choice to highlight the breaks with precious metals not only acknowledges them, but also pays tribute to the vessel that has been torn apart by the mutability of life. The previously broken object is considered more beautiful for its imperfections. In life, too, even greater brilliance can be found after the mending.As an emergency medicine physician, I know how to be still for others. I know how to call down the gods of repose and silence, to take measure of their power in the moments when I need it most. This stillness I inhabit as I pause, push, breathe, and grow.The stories I tell here will, I hope, take you into the chaos of emergency medicine and show you where the center is. This center is where we find the sturdy roots of insight that can't be windthrown by passing storms. In their grounding, they offer nourishment that can, should we allow it, lead to lives of ever-increasing growth. I had to find the center for myself as I took stock of experiences that were exceedingly painful, yet that ultimately filled me with the promise of a meaningful rebirth, a rebirth that is worth the surviving, worth the healing, worth the repair.”

Emily Silverman

Thank you so much, Michele, for being here today.

Michele Harper

Thank you. It's a pleasure.

Emily Silverman

I really enjoyed this intimate memoir. And I feel like I know you, even though I don't. So, to begin, I would love to hear about how this book came about.

Michele Harper

It was a process, first and foremost. If I had to estimate, maybe six years from start to publication. And when I started, I had no idea what I was doing. I just knew that there were stories that stayed with me. Stories from residency, like a woman who was brought in as a resuscitation. She was covered in cuts and bleeding. The cuts were not deep enough to kill her, but deep enough to cause pain and grief and certainly leave her with scars.And I remember when she told me about what had happened to her, she shared that it was from an ex-partner, someone she had left. And I kept remembering, that I was thinking, "How did this happen? How did their lives come together? How did this man think this was an appropriate expression of his rage? What is in this society that creates this? And then how was she going to heal—heal physically?" Sure, she was going to make it. She would survive. We would heal her wounds, she wouldn't get infected.But then, the harder part: the emotional, psychological, spiritual. And it was these encounters and the realizations that happened after them that stayed with me over the time, and I wanted to figure out how to explore them. And that's how I started writing a book because I figured in the ER, sure, one person at a time, we could potentially help one family, one community. But with writing, there's the potential to have a larger discussion, more broader engagement, and potentially, through that work, more widespread healing.

Emily Silverman

So, the book begins with your childhood. And you had a difficult childhood. You write a lot about your father and the abuse that he inflicted on your family. And I was really struck by this experience that you describe having in childhood. This extraordinary experience, where you go into the fish room—which is the room with the fish tank—and you're just kind of playing in the room, and then you feel this presence. And then you hear a voice, or you receive a message. And I just loved that, because you don't hear physicians talk like that very often. And so I was wondering if you could bring us into that moment a bit and share how it has permeated your life ever since.

Michele Harper

The experience you're referring to, I was around seven years old. And the house was quiet. And I just remember that sense of peace I had in the moment because there was very little peace in my home when I was growing up. My father was a batterer, so there was always chaos. And if there wasn't actual violence, there was just the knowledge that at any point in time, there could be.But on this particular day, no one was home except me and my mother, who was upstairs. And so, I was in the fish room—my sister and I had named it the fish room because that's where the fish tank was—and I was playing with My Little Ponies. And I was calm. And, in that moment, I felt a presence there. I didn't see anyone. And I heard a message that we will survive. That my family—and I considered my family, my sister, my brother, my mother, and myself—that we would all survive. And then, the other part of the message was that I had to because I would go on to help many people. And when I tell that story, it still makes me very emotional because the only thing I wanted to know as a child was that we would survive.And I remember running upstairs to my mother and letting her know that we were going to get through it. I didn't know how. I mean, I was seven years old! The details didn't matter at that point in time, but that we would get through it. And I remember the second part of the message. Of course, it didn't make sense to me. I mean, it sounded nice: I will help many people. But it is a message that just buttressed me my whole childhood and adolescence, and even through college. That when times got difficult, I would draw upon that message. And it gave me a lot of strength. It was one of my most important experiences in my childhood, which is why it had to be part of the opening of the book.

Emily Silverman

And, at that point, you didn't have a lot of exposure to medicine, but you bring us into this scene where your brother suffers an injury from your father and has to go to the emergency room and you enter the emergency room. Tell us a little bit about that moment. Did you know right away that you wanted to be an emergency room doctor, or what was that like?

Michele Harper

I didn't know. I mean... So I entered, and I was a young teenager, just having received my learner's permit. So then I could volunteer to be the one to drive my brother to the ER. And I waited for him in the waiting room. And I remember seeing all manner of life converge there. Whether it was a little girl being brought in by her father, crying with a cut on her leg, or a homeless man sitting there, sleeping, presumably having a respite from the elements. And then seeing that same little girl skip out smiling. Seeing family members who had just lost a member of their family—who again, I don't know, but seemed, based upon their reaction, had just been well, and now they would have to figure out a path forward without him.And I remember feeling that seeing all these people, all wanting something better for themselves, all knowing that there was something that they were going to have to survive, and that it was possible for them to do so. And it was a glimpse for me of hope. And I wanted to be part of this: where I could be a source of assistance for people who were looking for their own path forward. That's when a seed was planted to go into ER.

Emily Silverman

There are so many memorable stories and anecdotes in this book. One that stands out to me is the young boy who comes in injured from a classmate, and you learn that he's bought a gun to defend himself, and just kind of grappling with that. And a lot of these stories illustrate how health intersects with issues like poverty, racism, crime, and so on and so forth. And today, I think rightly, many argue that physicians should be thinking about these issues and tackling them head-on, the same way that we tackle the science and the Krebs cycle and all of that. But these problems sometimes feel so big and so overwhelming. And there's a quote in your book where you say, "As a physician, I cannot fix intimate partner violence, homelessness, addiction, or their brethren in one ER encounter." I'm wondering, how do you wrap your head around this as an emergency doctor—the scope of the social determinants of health and how they play into all these patient stories? It's a big question.

Michele Harper

It is big. And I think that's part of it. Being aware, you know, the reference of the boy who comes in with a head injury—it's a minor head injury—but his parents want him evaluated because he, turns out, was assaulted by a bully at school who was threatening him and stole his sneakers. And I interview him alone. And because I, you know, I'm doing risk assessment, and, of course, you know, as physicians, we need to make sure there wasn't other abuse going on. That it really was a child, and not a family member.And then I speak to him as part of the risk assessment about weapons, or if he has access to weapons, and how he feels he will handle this, and if he has a support system. And he kind of suggests that he may have access to a gun, and I have to get the social worker involved. And so, I specifically wanted to discuss that story, because physically, he was fine. He didn't have any significant injuries at all. But there is this bigger issue of violence that may happen later. Is his school system safe for him? Will there be retaliation? Will he be the victim of gun violence moving forward?And so, with the help of the social worker, we delve into all of that. And she interviews the family, and we find out they're very hard working. The parents work multiple jobs just to make ends meet. They don't have the luxury of just sending their child to some cushy, private school, in a part of the area where they don't have shootings. They can't just pick up and leave, you know, and she says, "Doc, if you have a solution to all of this, just let me know. Keep me posted." And I end the story that way, because we don't have all the answers. But I think it was important to have that discussion with the child and family, to the best of our ability to support them for their safety, individually and as a family unit. That's the piece that I can do in the ER.But then there's the other parts of advocacy, like intentionally engaging in political processes, voting, you know, whoever amongst us wants to run for office. There's just so much more. And part of it, sure, will happen within the confines of the hospital. And then most of it won't. It's a lifestyle.

Emily Silverman

I love that. It's a lifestyle. After residency, I took a job as a hospitalist at San Francisco General Hospital, which is a safety net hospital, a county hospital in San Francisco, where we see a lot of people who are experiencing homelessness, addiction, mental health issues. And, after four years, there is a way in which I got used to it. But it's when I went on teaching service and a student would come up to me and say, "Wait, really? This is how it works?" And that moral distress. I found myself having to dedicate a pretty significant portion of my time as a teaching attending, not just to teaching concepts having to do with clinical medicine, but tending to the moral distress of these learners. And there was one part of your book, when you describe this patient who's struggling with addiction, and who came in with an infection and decided to leave the hospital. And you wonder about his inner contract with himself. And you said, if you could write it out, just imagining, his inner contract would say things like, "I am not healthy and cannot commit to healing. I am not strong enough to heal. I am fearful. I cannot be helped. I do not love myself enough to take care of myself. I do not love myself, enough to allow you to take care of me. I do not deserve wellness. And so, I return to what I deserve." And I just love this idea of the inner contract. And so I was wondering if you could speak a little bit more to this and how you think about it.

Michele Harper

And I will just say, just to add even a little more context to that, I do feel these contracts can change. I don't want to be fatalistic. And I feel that exploring that area was a way of exploring what it means to meet people where they are. And I guess this really just gets into my own spiritual philosophies, which is that this isn't personal in many ways. And when there are difficult interactions with patients, like for example, that patient and his brother were really disrespectful and condescending, insulting to the staff. And he ended up walking out, with tearing out his IV, like dripping blood everywhere, throwing dirty gauze on the floor before leaving. And it was challenging. It was a busy day in the ER. We had—myself with a nurse—stopped everything to care for him because he was sick. He was extremely sick with an infection. We stabilized him with antibiotics and fluids, and he was weeping. Now his brother was being very disrespectful to all of us. But he was concerned and just wanted help and was verbalizing that he wanted to live. And we assured him, we would do everything to make that happen. And it got to the point where we're gonna admit him to the hospital. And he ended up as we discussed, walking out in a very disruptive way.Honestly, initially, it really made us angry, because we made other patients wait, while we were caring for him. And it was appropriate to make them wait because he was the sickest at the time. But it felt like our efforts were futile. And it was a slap in the face because we were treated so poorly. And I, as I reflected on it, I had to remind myself that we perform these behaviors because it’s the right thing to do. And then what they do with it is up to them. And his behavior really had nothing to do with us. We do whatever work we have to do so that we don't take it personally, that we don't make it a power struggle. And we just keep moving forward to help the next person. And also, I would say that as a doctor, he was struggling with addiction. And, any kind of addiction, whether it's drugs, or alcohol, or shopping, or TV, or not knowing when to leave a negative relationship or job, I mean, we all have our issues. And this is what he was struggling with at the time. That does deserve compassion. And if he needs help later, we will be there later.People often ask, "Oh, do you ever get follow-up? Do you ever hear from people?" I rarely, I mean, we have our frequent fliers, of course, but I rarely get follow up. It's just the nature of the job. But I will say that I did run into him much later in the hospital. He wasn't a patient in the ER, but I saw him in the hallway. And he remembered me. And he spoke to me and told me that he was getting better. He did follow up in clinics. The infection in his leg was better, and he was doing fine. And he apologized for his behavior. He didn't have to. I never expected to see him again. But it just goes to show that you never know, right?

Emily Silverman

One of the things that struck me about this book is how rigorous an approach you have to dealing with these more spiritual aspects of care and how you frame things for yourself, to take care of yourself as you're taking care of patients. I'm wondering when you work in academic settings, do you teach learners about these internal frameworks that you hold? Like I said, I have seen a lot of students struggle with these difficult patient interactions. And I feel like some kind of curriculum about how to deal with it emotionally could be really useful, but I don't really see it talked about very often.

Michele Harper

Yeah. Right now, I'm in a community setting, but there are internal medicine residents who rotate through. So there's still a teaching aspect. It depends, how busy it is in the ER, at the time. It depends on the students. Some people are more receptive to it than others. So the answer is, yes. And it depends. If there was time, and if we were talking about a case, then yeah, we would discuss it.For example, if I was asking, "Okay, what's your treatment plan for a patient?" And a resident would say, some designer drug that they were going to prescribe for a patient to take when they got home, or maybe they needed a complicated regimen of medications. And then we would have the discussion. Okay, what is this person's lifestyle like? Are they going to be able to afford that medication? Are they going to be able to adhere to that complicated regimen? Do they have a doctor with whom to follow? Are they in an environment where they're safe? Or do they have to also factor in that they have a partner who's unstable, but they're not ready to leave, and they're trying to figure out childcare.So, it's not uncommon for me to have those conversations. I think that so much of the care is having the sensitivity to those topics, because it makes such a difference just in how you have the conversation. And people can tell whether or not you are aloof, or have an interest in their lives. They just know. And that alone can be pivotal. That can make the difference between the interaction going in a positive way, or the person leaving the ER and never coming back, and not wanting to see any healthcare provider again.I feel like this is part of what we do, or can do, no matter where we are. Because even if there are no residents around, these are conversations that I may have with a mid-level provider, or the nurse taking care of a patient, or you know, a tech overhears the conversation. And now with the writing, I'm collecting mentees all over the country—I'll hear from medical students and residents who are in distress. Like tomorrow, I have a phone call appointment set with a second year medical student who's having a dilemma because she—from what she's seeing, she doesn't know how to do this Western medicine in a way that is respectful, I don't want to say just of the patient, but of wellness in general. She's not seeing it taught to her. It's almost being beaten out of her through medical education. So I say all this to say that those mentoring moments or sharing moments where we consider humanity, and how to deliver care in a humane way, I think can happen in all settings.

Emily Silverman

Over the last four or five years, The Nocturnists has been working with healthcare workers, helping them find their voice, helping them shape their stories. And so as a result, I've come into contact with many, many different types of healthcare workers. And I've become very interested in the phenotype of, like, who becomes a doctor?

Michele Harper

Yes. It's changing, too.

Emily Silverman

And it is changing. And there was a part of your book that I really loved where you're talking about one of your ex-partners who was a police officer and reflecting on one of his previous relationships, which was very unhealthy. And you say, about the police officer, "I suppose he's just like ER physicians, psychiatrists, social workers, and all of us in the helping fields. We all nurse that same Achilles’ heel of cleaving to the damaged... What a critical life lesson: to learn to distinguish between enabling and helping, codependence from love, attachment to reenacting the grief of childhood loss from allowing for the sweetness of self-determination."And I just love that because, it was sort of like, he's one of us. So, I was just wondering if you could speak a little bit to that. All of us in the helping field—like, what is it that we have in common? And what are our issues? And how do you think about that?

Michele Harper

Right. I don't want to over generalize. But I will say that I've noticed that many physicians, whether it's ER doctors, or—everybody says this about psychiatrists how they have the most issues—but it's all of these fields where we want to save people. So, whether you're a physician, or certain police—there's issues in policing, and we'll have that discussion later—or social workers. I think that a lot of us, not all, but a lot of us, have our own trauma. I speak about my childhood in this book. My ex-partner, same thing, where he was abandoned by his father at a young age, and had a mother who was verbally abusive, and would often leave him with an uncle who was, at times, physically abusive. But then, wanting to grow up, in his case, to help people who were in pain. We can be drawn to those situations because we're used to trauma and instability. And so, I think part of the process is learning that, okay, doing this work is important, but also doing our own work. So we don't bring our baggage into the dynamic and don't end up replicating the dysfunction in our interpersonal relationships in all arenas, really.And I feel that, sometimes, the profession, sometimes it can be a distraction, because it feels so good to do and it's so honorable, that it sometimes, inadvertently, can take us away from the introspection. And for me, that has to be done if I'm going to be the most effective version of myself, not just the most effective doctor, but human that I can be.

Emily Silverman

In the book, you talk about your natural affinity for leadership, and your forays into the world of hospital administration. Along the way, you have some great ideas about how to make healthcare better, like starting a complementary and alternative medicine center at the hospital. And surprise, surprise! A lot of those ideas are rebuffed. And I know a lot of people who are interested in the medical humanities and bringing other aspects, like the arts, for example, or spirituality into medicine, really struggle to be taken seriously by people in positions of power. And so, I was wondering if you could talk a little bit about your changing relationship to leadership administration, academic medicine, like, how do you think about that?

Michele Harper

Yeah, first, I start with a sigh. Like actually... how I feel about it? Um, so it's important. We need good leaders in medicine, in terms of medical directors and residency program directors. We need all of that. I just felt like I was micromanaging minutia when I was on that track. And that I was asking permission of people to do, I guess, what was considered radical.For example, with the complementary and alternative medical center and just wanting to provide acupuncture or movement, whether it was Qigong or yoga, that actually—even in the VA, for example—their own literature, like military-funded experiments, shows it works. And they use, for example, acupuncture on the battlefield. But I'm constantly running up against barriers. And whether it was specifically in the VA setting or in academics. Literally, anything that got away from how do we meet metrics to make the most money off of people just runs into a lot of difficulty.So my answer to that was, well, I don't want to leave the field of medicine because there's so much more work to do. I also don't accept that the limitations of the field are inevitable. I just don't. I feel that it can be so much better than it is, and we can deliver care in a way that is respectful of patients and providers. I believe it is possible. I also believe that the only way for me to serve that mission is to do work outside of medicine because there aren't enough of us in the field right now who have the energy and, like, morale to pursue that. And so I think it's going to be a process of being creative and partnering with people outside of medicine to make it happen. So that's why I write, and that's why I speak.I think the pandemic has caused a shift. It's just provided this opening for many people, healthcare providers, just everyone to think about what is really important, and why am I doing what I'm doing? And I feel that at least the majority of us are starting to have these internal discussions. And I hope it's leading to action for change. And I don't think much change will happen in medicine from the inside, honestly. I think it's going to have to happen outside of the field.

Emily Silverman

We've touched a few times on the spiritual dimension to your work, both in your orientation toward your patients and your orientation. To yourself, there's one line in your book where you say, "We have spiritual pain inside where it sloshes around vital organs." And I loved that. The ED is such a chaotic environment, there's so much energy there. And I know yoga and meditation are a really important part of your practice. But I guess I still can't help but ask, how do you maintain such a sense of clarity and alignment and groundedness? How do you maintain that over time? I've just imagining this like, sort of spiritual guru, like so...like, in the emergency room?

Michele Harper

I love that you imagine that.

Emily Silverman

Yeah, how do you do it?

Michele Harper

But it doesn't always happen. That's the thing, just like yoga. It's a practice. And that's why I've been doing it for so many years. And it's not just that I can do yoga for six months and then I'm good. I am set for life! I have to keep coming back to that space. So, in the ER, where I was yesterday—these days run together—and it was just chaos. I mean, just a shit show. And we were understaffed because of healthcare in America, again, based on profits. And we were running around, and it was amazingly unpleasant. And it was hard to stay centered. It was hard to not bring that resentment around the working conditions into the room, and to still, somehow, almost graciously meet the needs of the patients who were upset that they were waiting so long. Who were upset that when we finally got there, we had maybe a good five minutes to summarize everything, get the information, tell them we're gonna have a plan. And then, you know, four hours later, deliver the results and make the final decisions. But all day yesterday, and every week, and every month, I just have to remind myself to come back to the moment and just do the best I can. And that the frustration of the patients is absolutely understandable. The frustration of my colleagues and myself are absolutely understandable. And I just have to try to not react to that and be present for myself, my colleagues, and the patients, again, to the best of my ability, while remembering that it's not sustainable. It's not okay.I am, at times, accused of being an optimist. And there's some merit to those accusations. But I believe it doesn't have to stay this way. That's why I can keep getting up in the morning. That's why I can, at times, have these terrible shifts and keep going. Because I'm hoping to bring some light to the environment while it is the way it is. But then ultimately, yes, to change it, so it's better.

Emily Silverman

I think that's a great place to end. For the listeners, I have been speaking with Dr. Michele Harper, about her memoir, The Beauty in Breaking. It's an extraordinary read. And you are an extraordinary person, an extraordinary doctor. And thank you so much for coming onto the show to chat with me today.

Michele Harper

Thank you. It was nice hanging out with you and all the listeners.

Emily Silverman

This episode of The Nocturnists Conversations was produced, edited, and mixed by John Oliver. Our Executive Producer is Ali Block. Our Chief Operating Officer is Rebecca Grovesm, and our Communications and Social Media Intern is Yuki Schwab. Our original theme music was composed by Yosef Munro. Additional music comes from Blue Dot Sessions.The Nocturnists 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 cma.docs.org. The Nocturnists is also supported by the Patrick J. McGovern Foundation and by donations from listeners like you.Thank you so much for supporting our work in storytelling. If you enjoyed the show, please help others find us by giving us a rating and a review on Apple Podcasts. To contribute your voice to one of our upcoming projects, or to make a donation, visit our website at thenocturnists.com. I'm your host, Emily Silverman. See you next week.