A mystery on the medical wards

When I first met Ms. Baptiste, she smiled—the kind of smile that deepened the wrinkles around her eyes. Her eyes were gentle and intense all at once. A faded blue gown draped around her neck, its armholes gaping large around her sides. Everything in the hospital room appeared drab—except her. She wore a headwrap that showcased a kaleidoscope of colors; it was a bold pattern of red, yellow, and green and told stories of faraway lands and ancient traditions. She looked calm, graceful, almost regal. She reminded me of a Frida Kahlo-esque print of a Haitian woman that hangs in my hallway at home—the wall of women, I call it. Her face always had a slight smile, even at rest, the kind that stands firm in the face of adversity.

Her cancer was everywhere. It had started as a mass in her lungs, but now her bones and liver and adrenal glands were riddled with metastases. Thick cancer fluid accumulated underneath her rib cage, collapsing her right lung down like a balloon. She always moved slowly and deliberately, her face suffused with calm, but her staccato breathing betrayed the cancer’s extent.

“No matter,” she told me, “I have lived a good life, come what may.” She reached out and stilled my hand as if she were comforting me. She was like that for several days. Though a barrage of tests and imaging studies only ever seemed to bring bad news, she always seemed at peace.

Then, one day, I received several messages from her medical team. “She’s decompensating,” my colleague said. “She seems to be having a seizure.” Though the hospitalist physician did not say so, I knew what he was implying: Is now the time for hospice? As a palliative medicine specialist, I see patients with serious illnesses, much like Ms. Baptiste. I follow along as their journey unfolds, seeking to mediate between their values, the complexity of their condition, and the limits of medicine. When we get to the end of the road, it’s often my job to sit with patients and share we’ve reached the end. Was now the time?

I hurried to her room and found it filled with people. Several residents crowded over a computer, reviewing labs and tests and images. Several nurses and techs were at bedside. One placed a blood pressure cuff around her arm, the other monitored her oxygen level continuously; they called out to nurses in the hallway to bring more supplies. It was disorienting to see her this way. She appeared small and pale. She was rocking back and forth in a hypnotic rhythm. “Ms. Baptiste!” I called, shaking her shoulder. She didn’t stop. She moved back and forth, her whole torso bobbing forward, eyes closed, mouth open. She moaned rhythmically, repeatedly. She wailed the same syllable over and over, but I couldn’t understand her. I kept my hand on her shoulder. I couldn’t stop her from shaking.

The medical team hovered around her, their brows furrowed with concentration. “A partial seizure?” someone suggested, half-heartedly, but didn’t seem to believe it. “Maybe she’s delirious,” offered a resident. My brain scanned through a litany of diagnoses but only arrived at one: anguish.

The phlebotomist came and went, hurrying blood samples down to the lab. I pulled up a chair and sat. I placed my hand over Ms. Baptiste’s and willed a sense of calm and comfort. She continued to shake. Tears formed streams on her cheeks. Eventually, when the busyness of the rapid response ended and left us alone in her room, her wailing turned into a syllable I recognized—“Why? Why? Why? Why? Why? Why?” she cried over and over. Later, she began to say, “Why me?” over and over, rocking back and forth. An hour passed like that, with grief possessing her.

Outside her room, the medical team’s pace had slowed considerably, reassured that the cause of her current state wasn’t physical. Not medical. Not in their purview to change or intervene. “Not a seizure,” the doctor said, visibly exhaling. “She’s just grieving.” He seemed sympathetic but relieved.

I think of that day often. I consider how slow we were to recognize her anguish, how myopically we searched through our mental catalogues for a physical diagnosis to make sense of her. I thought of her days and weeks of composure and silence. I imagine her attempt to translate her suffering. This has always seemed to contain some truth about humanity, some word about suffering, some wisdom about lament; she needed someone to bear witness to her anguish. As I’ve turned this day over in my mind, I’ve realized that these moments for Ms. Baptiste reached beyond medicine, or at least the way medicine is traditionally thought of. It was something else, something deeply human. The medical team succeeded in their response to her medical illness; we kept her physical body safe, we didn’t miss a diagnosis. And yet, she needed something more. Her grief was intensely human, intensely personal, and yet she needed us to see it. She needed a compassionate witness amid her angst, not because she was a patient, simply because she was human.

Now, when I pass through that hallway in my house with the gallery wall that portrays strong women, I remember Ms. Baptiste. Last Halloween, I searched that same wall for a place to hang a Nightmare before Christmas spoof on Edvard Munch’s iconic artwork The Scream. I found myself contemplating this original piece of artwork in remembrance of her case. The Scream, painted by Norwegian artist Munch (1893), embodies anxiety and isolation, much like what I saw in the hospital that day.

Contemplating Munch’s The Scream

Munch’s famous masterpiece entitled The Scream depicts a solitary figure standing on a bridge and gazing straight at the viewer. In the background of the painting, there are two other human figures from whom the central figure is isolated. The central figure is characterized by a gaunt face, with open circles for eyes, two dots for nostrils, and a vertical oval forming an open mouth. Its hands are clasped against each side of its face as if to cover its unillustrated ears. The figure embodies a sense of profound distress and inner turmoil. It appears distorted, with an elongated face, elongated hands, and wide, terrified eyes; its body is shaped as an undulating wave. The figure appears to be standing on a wooden walkway overlooking the land or perhaps the sea. The sky is characterized by yellow and blood-orange wavy lines; the sea is mostly a deep blue-black. The swirling patterns of the sky and water enhance the feeling of chaos and instability. In contrast, the figure’s face is a stark white. Though the wave-like form of its body suggests it is being swallowed up in its natural environment, the white of its head portrays a disconnect or dissonance.

As I contemplate this work of art, many questions arise. Who are the figures in the background? Are they friends of the main figure from whom he feels estranged?Footnote 1 Given Munch’s impressionistic style and their facelessness, it’s hard to determine whether the people are walking towards him or away from him. Did he leave them? Did they leave him? Do they represent all of humanity, from whom the figure feels isolated?

And the main figure looks like a corpse. Is he a ghost or a spirit, completely unseen by passersby? Clued by the artwork’s title, I wonder, is the scream audible? Can the others hear it? Or is the scream the worst kind of scream, the one that plagues the sufferer alone while the rest of the world carries on unknowingly?

Perhaps the most haunting question is: Why is the figure screaming? Is it something specific, something that can be guessed from the rest of the scene? Or is his suffering more diffuse, more evasive, invading every moment of his life, and he arbitrarily finds himself in this scene when his scream can be contained no more?

Art may intend a plurality of interpretations; in this way, art becomes a living thing, changed by each viewer’s perspective, circumstances, and place in time. While The Scream may lend itself to questions like those above, Munch was known to pen accompanying narratives to much of his artwork, offering context, clues, or reflections of his own. Below is an English translation of Munch’s diary entry dated January 22, 1892, which offers guiding answers to some of the questions above:

One evening I was walking

out on a hilly path

near Kristiana—

with two

comrades. It

was a time when life

had ripped my

soul open.

The sun was going down—had

dipped in flames

below the horizon.

It was like

a flaming sword

of blood slicing through

the concave of heaven.

The sky was like

blood—sliced with

strips of fire—

—the hills turned

deep blue

the fjord—cut in

cold blue, yellow, and

red colors—

The exploding

bloody red—on

the path and hand railing

—my friends turned

glaring yellow white—

—I felt

a great scream

—and I heard,

yes, a great

scream—

the colors in

nature—broke

the lines of nature

—the lines and colors

vibrated with motion

—these oscillations of life

brought not only

my eye into oscillations,

it also brought my

ears into oscillations—

so I actually heard

a scream—

I painted

the picture Scream then.Footnote 2 (Munch, 2005, pp. 64–65)

The history and creation of The Scream

Discussing the history and creation of The Scream necessitates a dose of humility and uncertainty (perhaps even humor) as Munch was known for his indifference to chronologizing and titling his artwork. There are multiple versions of The Scream itself, four known color versions and one lithograph, all believed to have been produced between 1893 and 1910 (Prata et al., 2018). The National Museum of Art, Architecture and Design in Oslo, Norway, currently holds two of the color versions, both which are signed and dated 1893. One version of The Scream is undated but is thought to have been painted in 1910, and it is held in the Munch Museum in Oslo (Prata et al., 2018).

In addition to several versions of The Scream itself, there are multiple versions of the narrative that accompanies it, written in Norwegian and French (Prata et al., 2018). It is uncertain whether the description details an actual event or experience. Munch was known to write ‘prose poetry’ to accompany much of his artwork, though he himself emphasized that his ambition was to paint his “soul’s diary” (Prideaux, 2005, p. vii). Biographer Prideaux (2005) suggests that he chronicled his reactions to the events of his life, which differs from chronicling the objective events themselves. Regardless, there is circumstantial evidence that suggests The Scream may depict a physical location in a commune called Ekeberg, outside the city of Oslo, that overlooks the Oslo Fjord (Prata et al., 2018). Interestingly, this location, during Munch’s lifetime, was near a slaughterhouse and a mental asylum, leading some to speculate that The Scream bore the influence of the sound of animals being slaughtered nearby. Munch’s sister was a patient in the asylum, which may be why Munch visited or frequented this area (Prideaux, 2005).

Munch loosely chronologized his work but did not have a penchant for exactness. Prideaux notes that Munch was known to keep his paintings around him, adding a brushstroke here and there, but would typically wait to date his artwork until he believed the piece completely finished. Occasionally, he would backdate a picture by 10 or 15 years, explaining that the picture had been finished in his mind for a long time though he hadn’t had the time to physically finish it until now, and he dated it accordingly (2005). Additionally, he displayed similar indifference to the titles of his works, feeling that the piece of work was what mattered, not the title attached to it. Because of this, some of his paintings were called by several names simultaneously or took on different names over time (Prideaux, 2005). These ambiguities lend uncertainty as we study his body of work.

Prideaux (2005) describes the 1890s as an experimental period for Munch, during which time he explored paint recipes; before and after this time, he primarily used tubes of oil paint that were purchased from art suppliers. Additionally, Munch’s selection of the paint surface was very important due to its contributions to the tone of his final artwork. He frequently painted on cardboard (a cheap medium) as well as on unprimed canvas, which contributed to the final texture of his finished works. All four colored versions of The Scream were painted on cardboard; he mixed up painting materials as he worked, combining paint, chalk, charcoal, crayon, or whatever lay at his painting table (Prideaux, 2005). This experimentalism and inventiveness did not produce finished-looking paintings that were easily accepted by his contemporaries but would become fundamental to his allure to the artists that came after him.

Reviewing Munch’s earlier works suggests that he created The Scream in an iterative process; his repeated efforts suggest he intended to portray something specific. Prior to the creation of The Scream, he made three similar drawings of a man in an open landscape with a similar motif:

  1. 1.

    An 1890 drawing entitled The Path of Death pictures a lone figure in the foreground, cloaked in dark clothes and a hat, facing away from the view, journeying down a long road with deep perspective. The landscape is barren, notable for naked branches on either side of the road in the far background. A feeling of loneliness and despair permeates the drawing.

  2. 2.

    A drawing entitled Ljabru Chaussee. Man Leaning Against a Railing (1891) is a light pencil sketch of a figure leaning against a railing, with a fjord in the background and on the right side of the painting. This seems to be an obvious precursor of Sick Mood at Sunset. Despair.

  3. 3.

    An 1892 painting entitled Sick Mood at Sunset. Despair (colloquially titled Despair) is the most obvious precursor to The Scream. Despair’s composition is like The Scream in that it features three characters, one in the foreground and two in the background. The lower part of the painting is composed almost entirely of blue tones; the intense, red sky is separated by a narrow band of pale yellow. It is painted with the abbreviated brush strokes of impressionism. The character in the foreground, appearing to resemble a man, is wearing a hat and facing away from the viewer, his face mostly featureless. (Pettersen, 2022)

In contrast to its precursors, The Scream is a stark stylistic departure, both in motif and form (Pettersen, 2022). The Scream shifts from the muted, impressionistic colors of its precursors to a bold, colorful image with a new main figure. The figure marks the most notable change in composition—it is no longer a man but a bizarre creature, facing the viewer directly. Its skull-like head evokes images of death. The feeling of sadness embodied by its precursors has been transformed further into an image aiming to express extreme, incomprehensible anguish.

The Scream would later become part of Munch’s collection entitled Frieze of Life, which includes Munch’s other works Anxiety (1894) and Despair (1894). These paintings have a strong stylistic resemblance to The Scream, all depicted on a similar walkway with a red sky and blue fjord on the right side of the painting. These paintings—The Scream, Anxiety, and Despair—create intrigue about the life of Edvard Munch himself. Munch’s journal entry suggests that The Scream is partly autobiographical. Where did this anguish come from? What suffering was Munch familiar with?

The life of Edvard Munch

Edvard Munch, born in 1863 in a Norwegian farmhouse to parents Christian and Laura, was small and sickly at birth, prompting his parents to send for a priest to baptize him urgently. His mother, Laura, suffered from tuberculosis, and she ultimately succumbed to the illness when Edvard was only five years old. His childhood was characterized by an incredibly close bond to his sister Sophie, which may represent his seeking of a maternal figure after his mother’s death (Prideaux, 2005).

Following his wife’s death, Christian Munch withdrew from his children. His fondness for reading the children fairy tales was replaced with Bible reading. He would often punish the children harshly and remind them that mother looked on from heaven and grieved their bad behavior (Skryabin et al., 2020).

Munch’s relationship with his father was complicated. His father was a Pietist, believing strongly in humanity’s state of natural depravity and viewing life as a trial to prepare one for the day of judgment. Christian led a life of religious fervor, befriending a series of priests and pastors who took on increasingly influential roles within the Munch family. About his father, Edvard wrote:

[My father] was temperamentally nervous and obsessively religious—to the point of psychoneurosis. From him I inherited the seeds of madness. The angels of fear, sorrow and death stood by my side since the day I was born. They followed me when I played—followed me everywhere. Followed me in the spring sun and in the glory of summer. They stood by my bedside when I shut my eyes, threatening me with death, hell, and eternal damnation. Often I awoke in the middle of the night gazing around the room in wild fear—was I in Hell? (Munch, as cited in Prideaux, 2005, p. 2)

Edvard’s childhood was notable for his persistent, life-impacting difficulties with his health. He describes spending every winter in bed, unable to participate in the typical carefree activities of youth. His father sent him to a highly regarded cathedral school, and though Edvard excelled academically, he missed so many days of school due to his sickness that he was invited to leave.

Edvard’s diaries describe a vivid memory of his own illness: at 13 years of age, around Christmas, he began to cough up blood and became certain that he would die. In his journal, Edvard details a prolonged exchange with his father, who urges him to believe in God who can save:

He read from the Good Book. ‘He who believeth shall be saved, but he who believeth not shall be damned. You will be saved, my boy, because you believe. Come to me all ye who labour and are heavy laden,’ Father continued. ‘How kindly He invites you. Go to Him,’ he told me.

If only I could believe completely, but I had doubts. I wanted time. If only I had time—just a day—to prepare myself for death. Just one day. But now I was dying. The blood was boiling inside my chest. Just to take each breath filled my mouth with blood. Aunt took the handkerchiefs away; she hid them quickly. The blood ran out onto the sheet. I lay there whispering, “Jesus, Jesus, I’m frightened of dying.’ They all folded their hands in prayer—some knelt—

‘Jesus, Jesus,’ susurrated round the room.

‘If God hears this now,’ Father said, ‘if He allows you to live a few more years, will you promise to love Him and to live according to His laws?’

‘Yes, yes. Don’t let me die now.’ I wouldn’t mind having to do that, just as long as I didn’t die now . . .

Now I was in a pact with God. I had promised to serve Him if I survived, if He allowed me to escape the tuberculosis. Now I could never be as before. I looked at my brothers and sisters, and I envied them. Why should I be chosen for this sickness, this punishment? Was I, then, more wicked than they? —That was a thought sent by the devil—I folded my hands and begged God’s forgiveness. (Munch, as cited in Prideaux, 2005, pp. 25–26)

Sophie, his favorite sister, later became ill as well, joining Edvard in his typical routine of working on his lessons at home, drawing, and painting. The next winter, after his own near-death experience, he watched as Sophie died of a similar illness. Edvard never fully recovered from her death. Biographer Prideaux (2005) describes this as a pivotal moment for Edvard:

The inutility of God and the inadequacy of Papa had been exposed in the face of the grim injustice of sickness and death. But Edvard did not rant or threaten, deny his God or curse his blood. The gulf between his interior and exterior life merely became wider and more permanently fixed. (p. 32)

His diaries no longer mentioned Sophie, but he kept the chair she had died in for the rest of his life.

I wasn’t surprised to discover that Edvard Munch’s childhood was steeped in fervent religiosity; I also feel that the deepest angst is deepened by questions of God. A God who is all-powerful, omniscient, and diffuse is difficult to refute or speak back to; I’ve always found my mind’s spirals wind tighter and tighter when God is involved. I imagine a younger Edvard battling with this too—longing to believe in the teachings of his parents, desiring to be morally good, and hoping to be reunited to his mother in heaven. I envision his perplexed relief that God had spared him from his own death in response to prayer. Perhaps Edvard felt heartened by this apparent evidence for a belief system he so earnestly tried to adopt. I can relate, most of all, to the splintering of faith that at first occurred gradually but then happened all at once, pivoting around Sophie’s inexplicable death. As I read Edvard’s diary entries, I see a child searching for the meaning behind his suffering, questioning the character of an all-powerful God.

As an adolescent, Munch was drawn to painting, which his father did not support. Christian hoped Edvard would become an engineer, and to his delight, Edvard was accepted into a competitive school called the Technical College and began his studies in the fall of 1879 (Prideaux, 2005). His engineering studies included instruction in technical drawing, and here Edvard learned a wide range of techniques that he would later use as an artist. Unfortunately, Edvard’s health again interfered with his studies, and he began his second year as a part-time student. Though the pages from that fall are ripped out of his diary, a journal entry on November 8, 1880, states: “I have again signed off from Technical School. I have decided to become an artist” (Munch, as cited in Prideaux, 2005, p. 39).

Munch traveled throughout Europe in his early career, initially without much success; one exhibition in Paris earned him the nickname “Bizarro.” The critic Andreas Aubert questioned Munch’s mental stability, noting that insanity ran in his blood, and described him as “neurasthenic, decadent, fragile, delicate, seeking sickly joyfulness in life” (Aubert, as cited in Prideaux, 2005, p. 124).

In 1889, Munch was still in Paris when he received news that his father had died in Norway after a stroke (Skryabin et al., 2020). The letter from home arrived late, preventing Munch from attending his father’s funeral. He soon fell into a depression and heavy alcohol use. He returned to Norway a year later, suffering from homesickness, poverty, anguish, and apathy. During this time, he created a series of paintings with titles that elucidate his mental state: Melancholy (1891), The Lonely Ones (1891), Despair (1892), The Scream (1893), Death in the Sickroom (1893), Anxiety (1894), and Separation (1896). Within the next 10 years, from 1905 to 1909, Munch was repeatedly admitted to hospitals for alcoholism, depression, and suicidality. Although biographers have not formally examined his psychological problems, some scholars have asserted that he may have suffered from both schizophrenia and alcohol use disorder (Skyrabin et al., 2020).

I think again on Munch’s iconic art—The Scream—and its many iterations and accompanying journal entries. Perhaps Munch was a man obsessed, tormented by his inability to reconcile his view of God and his experience of suffering, setting paintbrush to canvas again and again. I’m struck most of all by the piece’s title, The Scream. And by its German title, The Scream of Nature. While the title suggests an auditory component, the question remains: Who is screaming? Is it the central figure, with its mouth agape? Is it all of nature, represented by the blood-red sky, causing the figure to cover its ears? Is the scream heard? Is the scream silent? His painting evokes, but does not answer, these questions.

Silence and lament as responses to suffering

When theologian John Swinton contemplated The Scream, he felt that the power of the painting comes from the possibility that the scream was not expressed but rather was internal and inaudible. This painting, he suggests, reflects the voicelessness and disorientation that comes from suffering, the type of suffering that defies language. In his book Raging with Compassion, Swinton (2007) notes that the experience of suffering is often compounded by questions of theodicy, such as “Why would a good God allow suffering to exist?” These questions, which are often unanswerable, can alienate the sufferer relationally from God. Swinton asserts that because God is the true source of hope, this relational isolation can transform suffering from that which is tragic to that which is evil. He contemplates the voicelessness of suffering and asserts that Christians should reclaim the biblical practice of lament, which validates suffering, allows an individual to move from silence into transformative speech, and creates possibilities for reconciliation with God (p. 118). It is through lament that such suffering can be experienced (not minimized) and a genuine relationship with God remain intact. 

Swinton spent decades working as a mental health nurse and mental health chaplain, but his thesis on lament is not drawn solely from personal experience; it also comes from the example of Jesus portrayed in the Bible. Swinton observes that Jesus’s own experience on the cross was marked by silence. Though the Gospels are famous for red-lettering Jesus’s words, the story of the crucifixion is mainly scribed in black. The Gospel of Mark suggests that Jesus’ death lasted about six hours, during which time Jesus speaks only seven sentences. Swinton asserts that Jesus’s silence is notable; Jesus experienced the kind of pain, abandonment, and isolation that insists on silence. Swinton (2007) asserts that Jesus’s silence in the presence of evil and suffering legitimizes the experience of every human who suffers.

We can understand the experience of suffering only when we learn how to listen to the silence, when we learn to interpret and understand the meaning of silence and the dangers of breaking that silence with words that can be harmful even when intended to be healing. Suffering is a meaningful experience, but the meaning of silence is not always accessible through language. In solidarity and awkward presence with the sufferer, we must learn the practice of listening to silences . . . only when we learn to listen to the silences can we prevent suffering, which is often tragic, from moving into suffering that is evil. (p. 101)

Though Swinton marks the importance of silence, he similarly emphasizes the importance of speech. He asserts that recovering the practice of lament is imperative—that the silence of the sufferer needs to be “heard into speech.” Though Jesus’ journey to death was marked by profound silence, at one point he cried out: “Eloi, Eloi, lama sabachthani?” which translates to “My God, my God, why have you forsaken me?” (Matthew 27:46 NIV). Swinton (2007) suggests that Christ’s movement from silence to lament embodies a faithful response to suffering, a response we can emulate. He suggests that lament—“a repeated cry of pain, rage, sorrow, and grief”—is a practical way for us to rage with compassion, to express genuine grievances, and to pray with the brokenness of the human experience (p. 104).

Swinton (2007) writes that “the crisis of theodicy should not be framed as a crisis of faith, but rather a crisis of understanding... lament has a purpose and an endpoint beyond the simple expression of pain: reconciliation with and a deeper love of God” (p. 111). Additionally, Old Testament scholar Brueggemann (1977) suggests that lament, as a genre, provides a form to suffering, which otherwise may be formless, disorienting, and chaotic:

Such regularized speech activity serves both to enhance the experience so that dimensions of it are not lost and to limit the experience so that some dimensions are denied their legitimacy. This suggests, applied to the lament form, that its regularized use intends to enable and require “sufferers” in the community to experience their suffering in a legitimate life-world. It is this form which enhances experience and brings it to articulation and also limits the experience of suffering so that it can be received and coped with according to the perspectives, perceptions, and resources of the community. (p. 265)

Fowler (2020), a nurse with a doctorate in social ethics, describes lament as a structured way to respond to overwhelming grief and suffering, both personally and nationally, in the context of the COVID-19 pandemic. Like Swinton and Brueggemann, she asserts that lament is a form of protest that enables the naming of the tragic, fearful, and unjust; this allows the lamenter to move from denial and avoidance to a place of acknowledgment and clarity. She reviews a structure for writing an individual lament, which might involve religion but doesn’t require it, and provides many guiding examples for those wishing to reclaim the art of lament. I revisit Fowler’s work at the end of this article to illustrate how lament may be adopted in the medical setting.

Lament is a particular form that offers transcendence of spiritual suffering, but that transcendence comes, at least in part, from the move from silence to speech. As I think about lament as a form, I realize that the act of lament necessitates a witness. The witness may be God, it may be a reader, or it may be an observer (as in the case of art). Just as silence requires a compassionate witness, lament requires a compassionate witness. Lament requires solidarity in the recognition that suffering is shared, and this can mitigate feelings of isolation and anguish.

As a physician, I began to wonder about lament’s analogue in modern medicine. Even though medicine seeks to answer, cure, and solve disease, we fail to prevent death 100% of the time. In the hospital, the speaking and hearing of an illness narrative may be imperative as we reclaim the physician’s call to heal, not just cure.

The imperative to reclaim the illness narrative

Reclaiming the illness narrative is essential to the practice of medicine in modern times. Since technology has transformed the practice of medicine to a profession where doctors are now called “providers” and patients are now thought of as “customers,” Dr. Egnew (2009) believes that physicians need to reclaim the utility of a healing narrative. He writes that “the authority of the patient’s story of illness now competes with the doctor’s story of disease” (p. 170). Advances in medical treatments for acute illnesses mean that patients now live longer with chronic illnesses. Egnew asserts that through prolonging life the physician incurs the obligation, beyond curing disease, to accompany patients on their illness journeys.

How might one do this? In his memoir about his own battle with cancer, physician-author Broyard (1993) writes: “My initial experience of illness was a series of disconnected shocks and my first instinct was to bring it under control by turning it into a narrative. Always in emergencies we invent narratives” (p. 19). Broyard asserts that “beside talking himself, the doctor ought to bleed the patient of talk, of the consciousness of his illness” (p. 53). Because some aspect of suffering may arise from the looming destruction of one’s personhood (Cassel, 1982), physicians can help patients develop a healing narrative by connecting the disease story to their illness narrative.

Anecdotally, I have seen more discussion about illness narratives in recent years, though only a handful of actualized attempts to incorporate it within the medical system. In Veterans Affairs (VA) hospitals across the United States, a program titled My Life, My Story (MLMS) offers a systemized effort to incorporate narrative medicine into hospital care (Kesling, 2019). In this program, VA staff and volunteers sit with veterans for one-on-one interviews, allowing veterans to tell their story. The interviewer then constructs a first-person 1,000-word narrative and reads it back to the veteran, adding corrections or edits if necessary. Once approved, the narrative goes into the patient’s electronic medical record. In a five-year follow up study of this narrative intervention, Roberts et al. (2021) reviewed its many benefits for patients, including promoting the patient’s sense that they are heard, cultivating pride, providing therapeutic relief to process trauma or disease, and helping patients identify their legacy and personhood. Additionally, most of the medical staff felt that these stories helped them know more about, understand, connect to, and empathize with their patients.

While VA hospitals have utilized spoken interviews as they have tried to incorporate illness narratives into patient care, other research has assessed the impact of patient participation in narrative writing. James Pennebaker, a social psychologist, has studied the effect of expressive writing widely. His initial research with his colleague Beall was conducted in healthy college students. This study assigned students to write for fifteen minutes per day for four consecutive days, prompting groups of students to write either about traumatic experiences or superficial topics (Pennebaker & Beall, 1986). This study found that the students who engaged in emotional writing about their traumatic experiences subsequently made fewer visits to the student health center compared to those that wrote about superficial topics. These students additionally reported, in surveys following the experiment, a greater sense of value and meaning due to their writing. Psychologist Joshua Smyth expanded on Pennebaker’s work. Smyth et al.’s (1999) research revealed that expressive writing interventions improved lung capacity in asthmatic patients assigned to the intervention group. Smyth (1998) also conducted a meta-analysis of expressive writing interventions, determining that written emotional expression leads to improved physical health, psychological well-being, physiologic functioning, and general functioning.

Utilizing the lament form in end-of-life care

Despite a growing sense that engaging in illness narrative may have significant health benefits, the implementation of this therapy in the hospital setting remains limited. It is one thing to instruct patients to write or reflect; it is another thing entirely to provide a form and a space for them to do so. Utilizing the form of lament offers something beyond an exercise for engaging in expressive writing—it offers a “blueprint” to the patient to access a high level of emotional disclosure and to engage with their own spiritual and existential distress. The form encourages patients to move beyond cataloguing their traumatic experience of illness; it asks them to contemplate their illness’s spiritual and social impact and to express their hopes and petitions.

Healthcare professionals can draw on the work of biblical theologians who have studied the historical forms of lament and adopt this practice for their use with patients suffering from serious illness. Westermann (1981), a German theologian, studied the psalms and proposed a framework for lament that has recently been adapted by Dr. Marsha Fowler. Dr. Fowler’s (2020) work includes a table that provides both secular and religious examples of lament; I have utilized her framework to brainstorm examples of lament that I commonly see in patients suffering with a serious, terminal illness, such as cancer (see Table 1).

Table 1 Examples of a Lament Structure in a Cancer Patient. The form of lament is based on Westermann (1981, pp. 52–55)
Full size table

I can envision the form in Table 1 being utilized by chaplains, social workers, and even other members of the medical team to assist the patient in processing their serious illness. By normalizing and expecting the process of lament, medical professionals can reduce the shame or guilt that patients may have as they try to “stay strong” for their families. This will allow patients the freedom to express their grief, lament, and anguish in a way that is supported. Expressive writing can be implemented at a low cost to clinicians and will likely benefit our patients as they process and live through their illnesses. Though I believe this will have medical and psychological benefits in the field of healthcare, it is also important to recognize and respond to lament simply because we are human.

Incorporating lament into the future of healthcare

Utilizing lament in the healthcare system is an action, not an answer. It doesn’t answer its own questions. Writing a lament will not answer the question “Why is this happening?” It can, however, offer a space to express sincere, authentic grief. Lament draws on a traditional oral and written practice, as well as on the anguish expressed in contemporary art, to offer a pathway to process illness and suffering and author our own narratives.

As I reflect on Munch’s The Scream and on Munch’s life, about whether or not the scream he painted was heard or silent, and whether or not such grief or lament needs to be “heard into speech,” I remain convinced that there is value in articulating anguish into words—whether heard by a doctor, heard by a friend, read anonymously online, or heard only by God. I think The Scream was Munch’s attempt to express his own anguish. He sought a compassionate witness, one that he did not have in his childhood. He set paintbrush to canvas over and over, trying repeatedly to capture a type of anxiety or angst that resonated with his own experience. The painting itself is both silent and loud.

The paradox that extreme suffering necessitates both silence and speech continues to inform how I practice medicine. I think often of Ms. Baptiste and how chaotic, isolating, and confusing her anguish seemed that day; I wonder if providing a structure and form for lament would have offered her comfort, peace, or healing. I continue to think of forms, such as the model of lament shown in Table 1, that may aid patients in meaning making while suffering and assist in the transition from silence to speech. This ancient practice of lament is essential to our collective humanity.