Category: Reflection

Categories
Lifestyle Public Health Reflection

Can social justice replace medicine?

‘Social injustice is killing people on a grand scale.’
– Marmot (2)

Despite the leaps and bounds that science has made over the past century, with all its shiny new techno-gadgets and ever-advancing drugs, the primary reason for our good health today lies in something much less sexy: vaccinations, clean water and sanitation- changes that we take for granted.

We live in a world that is changing every second. Bigger cars, faster phones, all the information at our beck and call: from the education that is offered to our kids, to the healthcare that is offered to our decaying bodies.

The hospital of today is a far cry from the one half a century ago. The minute you walk into a hospital your senses go haywire. You have stepped into the world of the future. The full scale of our technological advancement greets you within these four walls. The bizarre beeping overwhelms your ear canals, screaming into your brain as the alarms screech constantly in the background. The reams of wires trail along the floor of the wards, wrapping themselves around their patients like Christmas presents, offering nourishment to bodies overwhelmed with disease. We are living in the world of machines, and it is upon them that we place our hopes of immortality.

Everyone knows of the success story of Science. We are bombarded by the media, informing us of the next new cancer drug, the gene unlocked that will solve all our problems. What we forget is that we are not merely organisms residing within a vacuum. Nor are we machines ourselves, whose very pores can be zapped with electrodes, transforming our very identity. We are human beings living and breathing on this planet Earth. We digest the world around us. We are not merely scientists of the world within ourselves, of the DNA that twirls inside our cells. We are also manufacturers of the world around us; of the houses we live in, the food we eat and the lives we live. Perhaps the answer to a better, healthier life lies here instead.

But, is this the role of the doctor? Shouldn’t we leave this task to the politicians, to those who have the power to make these important decisions? Isn’t the duty of the doctor ultimately towards her patient, towards that individual who is sitting opposite, rather than to humanity as a whole? I believe Virchow, the German Doctor, described it best when he said:

‘Medicine is a social science and politics is nothing else but medicine on a large scale.’ (1)

Of course there are diseases that can only be fixed by looking inside our own bodies – diseases that come from within, that cannot be changed by any amount of control over one’s environment; Huntington’s Disease is one example.

But if you take a quick glance at the causes of mortality in both the USA and the UK, you will find that the majority of these diseases are significantly related to one’s lifestyle. The top leading cause of death in both the UK (3) and USA (4) is Heart Disease, which has very strong links with lifestyle, including smoking (5), a high-fat diet (6) and poor exercise (7).

In the past, when tuberculosis and polio wreaked havoc upon the population, the role of the doctor was to prescribe medication; to act as the priest who offered the gift of life through his knowledge and wisdom. Yet now, this power lies upon the patient. Our lives are no longer cut short by the plague, but by the pathways we choose to make while we are still alive.

The role of the doctor continues to change along with society. The doctor is the servant of the public. As our ailments in life continue to revolve around these pathways that we choose to take, so must the doctor focus her gaze away from the leaves of her prescription pad and begin to question the foundations of such paths; the reasons behind these choices, the thoughts and actions that lead a person towards their own destruction.

It is not enough to simply inform someone by saying ‘you need to do more exercise.’ Anyone who has made a New Year’s Resolution to do so will understand this. Even in the UK, a country where healthcare is free, one’s health is still dependent upon how much one earns. The richer you are, the longer you will live (8). How is it that in this day and age, this is still the case? Healthcare is a right. And as doctors, it is our duty to ensure this edict is followed. The politician may sit upon his throne and hand down his judgments, but it is the healthcare professional who is in contact day in and day out with the most vulnerable and marginalized.

Indeed, there are some excellent examples of attempts to try and balance this injustice within our society; free school meals in the UK which lead to improved nutrition in children (9) and the ban on public smoking to try and reduce passive smoking (10) are just two examples. These changes in legislation lead to the question: how much control should our government have over our own decisions towards our health? If someone wishes to smoke and drink all their life, then that is their right. Autonomy is one of the principles the doctor must follow; today’s healthcare system revolves around the patient and her choices. No longer does the doctor hold authority over the patient’s body. Yet this does not mean we cannot improve the world around us; we are still capable of building a healthier society, a society in which we will not only live longer, but be happier in as well. Free education and housing are two examples of societal changes that do not necessarily impose upon our personal rights, yet can lead to healthier childhoods and happier families.

Let’s say you are a single working mother – you are only just reaching your rent each month. You can only work part-time because you need to pick up your son from nursery every afternoon. You have no family who can look after him. This leaves little money for food, so you mainly feed your son. His diet is very poor, not only because of the little you can afford, but you yourself have never learned how to cook. Your own childhood consisted of fast food and the occasional apple or banana handed to you by a father who you rarely saw. You live in a very deprived neighbourhood. You cannot afford heating, and your son is constantly sniffling and coughing, hiding under his hole-infested jumper that you managed to grab from a local charity shop. You are isolated – your husband has left you, you have no one to talk to and your neighbours scare you. When you’re not working, you stay at home for your own safety, and ultimately for your son’s. You try to remain happy for your son. You want the best for him. But you are scared. You are scared for the future, you are scared about your next paycheck, you are scared about being burgled, being mugged, having your son taken away from you. You are scared about becoming a failure, of disappointing your son. You start drinking a glass of whiskey each evening to help you calm these anxieties. You gradually spend more and more money on alcohol, an attempt to grasp control of these spiraling criticisms that constantly call into question your ability to be a mother. But this does not always help. As the days turn to weeks, your thoughts begin to gain a voice of their own, almost screaming through your ears; you are a bad mother. A failure. Maybe you’d be better off somewhere else. Your son would have a better life without you. He wouldn’t have such an awful mother.
You eye the packet of paracetamol lying on the table. What would happen if you weren’t here? Wouldn’t your son lead a happier life? He would no longer have this dark mark tainting his existence. He might even be happy… What do you do?

In various points throughout this story, one could take out their pen and draw a mark where someone could have intervened. Not necessarily to offer medication or money, but things such as social support; someone to help look after the son in the afternoons, advice on how to apply for jobs, or housing in a more residential area. A helpful hand to hold on to during the darkest periods, a pat on the back, a shoulder to cry on, an ear to listen. How different would this story be if these simple interventions had been available?

It is very easy for us, the next generation, to caress our mobile phones and laptops that fit in both hands. It is easy to see the world as decaying pieces of rubble to improve, gadgets to insert, wires to wrap around and transform. No doubt this way of thinking has changed our healthcare; it has saved many lives. But we must never forget that humanity is not a machine itself. It cannot be controlled by our remote controls and our drugs; we must look further afield in order to truly appreciate the complexity of the human being. When we look at the human body, at a life that has been lived hard and is ending early, we see not genes that have played havoc, but decades of depression, underlying abuse, a cigarette to cope, a bottle of beer to forget. Addressing these problems is a task that requires us to go beyond our scientific skills. It requires us to understand the emotional lives of our patients.

“How wonderful it is that nobody need wait a single moment before starting to improve the world.” 
– Anne Frank

References

  1. (with acknowledgements to Siân Anis), J. R. A. (2006). Virchow misquoted, part‐quoted, and the real McCoy. Journal of Epidemiology and Community Health, 60(8), 671.
  2. World Health Organisation. 2008. Inequities are killing people on grand scale, reports WHO’s Commission [Online[. Available at: http://www.who.int/mediacentre/news/releases/2008/pr29/en/
  3. Office for National Statistics. 2013. What are the top causes of death by age and gender? [Online]. Available at: http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics–deaths-registered-in-england-and-wales–series-dr-/2012/sty-causes-of-death.html [Accessed: 13th October 2015]
  4. Centers for Disease Control and Prevention. 2015. Leading Causes of Death [Online]. Available at: http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm [Accessed: 13th October 2015]
  5. British Heart Foundation. Smoking [Online]. Available at: https://www.bhf.org.uk/heart-health/risk-factors/smoking [Accessed: 13th October 2015]
  6. World Heart Federation. Diet [Online]. Available at: http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/diet/ [Accessed: 13th October 2015]
  7. Myers, J. 2003. Exercise and Cardiovascular Health. 107:e2-e5
  8. Royal College of Nursing. 2012. Health Inequalities and the Social Determinants of Health. London: Royal College of Nursing
  9. BBC News. 2013. All infants in England to get free school lunches [Online]. Available at: http://www.bbc.co.uk/news/uk-politics-24132416 [Accessed: 13th October 2015]
  10. Bauld, L. 2011. The Impact of Smokefree Legislation in England: Evidence Review. England: Department of Health

Featured image:
Human Genome by Richard Ricciardi

 

Categories
General Public Health Reflection

Are you listening? Using the doctor-patient relationship to curb community violence.

If you’ve paid attention to the news recently, you might share my concern that mass shootings are becoming a normalized part of American culture. According to data collected by the United Nations, America leads the developed world in firearm homicides.[1] As a college student in Washington, DC, social justice was an inextricable part of my education. I volunteered, protested, and campaigned for issues I felt strongly about. Assuming you weren’t a student in our nation’s capital, let me tell you that these are all pretty typical parts of the DC college experience. In fact, my zeal for progressivism in the arenas of health and wellness contributed to my desire to become a physician. Unfortunately, it wasn’t until two of my friends were murdered within six weeks of each other this summer that I felt compelled to take a closer look at how, as a medical student, I could better integrate my passion for social justice into my education and clinical practice.

As medical students, our education becomes our lifestyle. It’s demanding, consuming, and vigorous. My support system likes to remind me that I’m not Atlas and that I can’t hold the weight of the world on my shoulders. They tell me to keep my nose in a book and stay focused on my studies. It’s difficult for me to comply with these directives when I feel like I’m neglecting the part of myself that is aware of the world beyond medical school. It took this summer’s tragedies to remind me that even as a student doctor, I need to hold myself accountable for working to reduce social injustice, particularly community violence. What I’ve realized is that while my activism efforts may not reflect those I experienced as a college student, I can still make simple adjustments in my current practice to potentiate positive change.

Since this summer, one of the modifications I made, in an effort to merge my medical and activist identities, is to ask my patients to rate their stress on a scale of one to ten when I take their social history. On the surface, this might not seem like a significant exercise. After all, I’ve been asking my patients about their life stressors since I started school last year. What I realized is that while most people can easily spout off a list of things that make them feel strained (bills, student loans, family responsibilities, looming deadlines, etc.), it’s an entirely different exercise to ask patients to evaluate their stress from a holistic perspective. Though this practice correlates stress level to a numerical value, I have found that I can actually get a better qualitative picture of a patient’s mental and emotional wellbeing and self-awareness by using the one-to-ten stress scale. Perhaps by using this scale, we will be able to gain awareness of and provide support for struggling patients before they feel compelled to turn towards violence.

I encourage you to employ the one-to-ten stress scale into your history taking routine in the hope that it can open the door to bigger, more important conversations about wellness and lifestyle with our patients. Please feel free to let me know how the scale works for you. I look forward to spending the rest of my medical career advocating for those who are underserved by the medical community, but for now, I hope that having these conversations can be a first step in helping patients deal with problems before they resort to violence. In the weeks and months that have followed the deaths of my friends, I find myself thinking a lot about the people who committed the violent acts that claimed their lives. I wonder if they had medical professionals in their lives who they felt comfortable talking to, and I wonder what they would have said if we, the medical community, had been listening.

References:

  1.  Global Study on Homicide. (2011). United Nations Office on Drugs and Crime. https://www.unodc.org/documents/congress/background-information/Crime_Statistics/Global_Study_on_Homicide_2011.pdf

Featured image:
Brother by Fabrizio Rinaldi

Categories
General Reflection

Scholarly Pursuits

Growing up, my father didn’t get home from work until nearly 10:30 pm.  He worked full-time at Allstate Insurance while also working part time as a realtor. There were days I didn’t see my father because he had been working all day. He told me to be grateful for what I had and where I was in life. I didn’t fully understand him, until now.

My father was unable to complete his education. He had planned to become an engineer, but his dad fell ill and the responsibility for the family fell entirely upon him. My father had to pay for his sister’s wedding and his younger brother’s education. In order to do this, he quit college and started working full-time.

I look at myself now and see how dramatically different my life is compared to his. I have everything I could dream of and more. My father is willing to work hard so that I can, today, pursue my education at the best of institutions. In fact, since preschool, I have studied in private institutions and grown up in a world that is in diametric opposition, in terms of the opportunities and expectations placed upon me, to the world that my father grew up in. He has tried to prevent me from even getting a glimpse of the hardships he endured when he gave up his dreams to serve his family. I am humbled by and grateful for the opportunities my dad’s efforts have allowed me to pursue. I know that my father did not have many of the same opportunities. As the timeless and enduring quote goes, “with great power, comes great responsibility”- I know that having the access and opportunity to seek and find knowledge comes with expectations- to serve the community which has so selflessly flung all its needs and desires to serve the needs and desires of my generation. I have had the opportunity to attend both engineering and medical school. The knowledge I have gained by attending both these schools has not only empowered me, but has also reminded me of what I owe to my community and my family- the responsibility to give back.

Whenever my father sees me with a calculus or physics book, a smile comes across his face. He begins chanting the trigonometric functions and formulas he remembers. But that smile often fades as he remembers the past. My father has never talked openly about the hardships he endured while he was young, but his eyes convey it all. There was this silence that followed that chanting and smile. I knew that my father was thinking back to his past and the educational endeavors he never had the opportunity to pursue. Despite this, my father is able to provide more than enough for our family on many levels, financial and emotional.

However, despite my dad’s success, there is still a part of him that wishes he could finish his education. I have grown so much from my father’s experiences. Although he did not have the opportunity to finish his education and pursue the engineering career he had dreamt of, his sacrifices came to yield. Family has always been incredibly important to him, and the efforts and sacrifices he has made on his family’s behalf have added immeasurable value to his life.

As I tread through my final months of medical school I’ve come to realize more and more just how fortunate I am. Every day is a reminder of the advantage and opportunities I was granted due to my father’s sacrifices. I am now the same age that my father was when he left school, and I am fully aware of the advantages I have over him. But with these advantages come additional responsibilities. I will forever remember his efforts and sacrifices and do my best to honor them.   It is this passion that is the driving force of my life and my scholastic pursuits.

Featured image:
Opportunity by Susan Frasier

Categories
Narrative Reflection

Little Flickers: How Medicine Truly Connects Us

“See the little flicker?” the doctor asked, as she tilted the ultrasound screen and pointed to the tiny movement. The patient leaned forward, squinting, trying to decipher the gray and black pixels that showed she was now a mother. “That’s the heartbeat,” her doctor explained. “Right there,” she pointed again, this time zooming in even further. The patient nodded as she tried to contain her excitement. She smiled with one of those tight-lipped grins as her eyes widened, as if joy was actually bursting out of her. Her husband chuckled at her wild expression and squeezed her hand. “It’s okay,” her doctor said. “Be excited! This is exciting!” And with that word of permission, the expecting mother squealed, just a little, and calmed herself again. “It’s our first, you know, and my sister just had a girl and I wanted our kids to be able to grow up together and we just didn’t know if it would happen this fast, and,” she paused to catch her breath. “Sorry, I just can’t believe we get to start buying baby stuff!”

I looked at the screen again, at the little flicker of light, at the little piece of white against black that would someday have a lot of “baby stuff” foisted upon it. It was one of the earliest pregnancies I had seen on ultrasound – in fact, I had only seen one other scan done at the same gestational age. It was striking how identical this scan was to the first one I had seen, months earlier. The screen had looked exactly the same, with the crown-rump length of the tiny embryo measuring the same, with the same shape of black fluid around white tissue. I thought back to that day, to the tiny portable ultrasound screen so far from home. Instead of an antiseptic outpatient OB/GYN clinic in temperate California, the first scan had been done on the dirt floor of a little hut in Central America.

It was a typical clinic day in rural Panama – humid, muddy, with lines of patients waiting to be seen. Working over the summer with the non-profit organization Floating Doctors, I saw many pregnant women come to clinic for prenatal care. Traveling to indigenous island communities, where most patients have no other access to health care, we would set up makeshift clinics and see as many patients as possible. It is common for women in the Ngobe communities to have as many as ten kids; oftentimes they start having children when they are teenagers themselves. Unsurprisingly, there was a lot of prenatal ultrasound scanning to be done.

When I saw this particular patient, whose ultrasound was done so early in the pregnancy, the crown-rump length was the same as the patient’s I would see months later at home. This woman was 32 and had five children. Her youngest, a two-year-old girl, leaned on her mother’s chest as I scanned, taking a pause in her whining to stare at the screen. She didn’t understand what it was, but her mother squeezed her excitedly anyway as I pointed at the little flicker, the unmistakable heartbeat. Even though they already had a big family, even though it was miserably sweaty sitting on the floor in our little ultrasound hut, and even though the toddler was getting fussy, this woman had the unmistakable grin of sheer excitement.

Talking to the pregnant women in Panama, either during the scan or translating during the physician checkup, I imagined the lives these babies would have. It was an easy thing to think about, seeing so many children running around and playing as their parents waited in line. The kids were a handful to organize; it was no easy feat keeping them far enough away from the clinic to avoid distractions, but close enough to organize whole family visits when it was their turn. They played muddy games of soccer or baseball, chasing each other around and asking us for highly coveted stickers. They were so full of energy, so happy and so free. The mothers usually didn’t find these games as amusing as I did; they were exhausted, overwhelmed, and just trying to get the visits done so they could go home. I can’t begin to imagine the strength and resilience it takes for those mothers to care for so many children, and oftentimes other family members, with such limited resources and support.

There was a mural painted on the side of a school in one of the communities we visited. The mural was a giant world map, not particularly accurate in terms of scale or geography, but vibrantly colored and decorated. When I saw it, I thought it was quite fitting, as I was working in a team with students and doctors from all over the world, living in a country I had never been to before, speaking a foreign language every day. When I thought about its place in the community, however, I began to wonder what it meant to them. These villages are isolated, by geography and lack of transportation and resources. The children who seemed so free to me would most likely find it difficult to leave their small village, if they ever wanted to. I wondered what they thought of that colorful map on the wall, whether it was an abstract concept of the world beyond their borders, or whether they dreamed of a truly unrestricted future. The child back home in Orange County, of course, might dream of just the opposite – wishing the world were not so vast and intimidating, wishing the world stretched just to the end of the block, where everything in between was familiar and safe.

These are the things I wonder about, the things that keep me thinking about certain patients long after they’ve left. These are the things that connect patients, at least in my mind, despite the vast differences in their lives. Ultimately, the job in medicine is to focus on the patient, or the ultrasound image, but it’s not always easy, or in the patient’s best interest, to tune out the context.

We are trained to look at that little flicker of a heartbeat, measure its rhythm and pace, and watch as the baby grows and the flicker gets stronger. We are trained to look at every patient, every heartbeat, the same – without bias, without judgment, without assumptions. At the same time, we can’t ignore the world around us, the world that we are working in and the world that our patients live in. We can’t ignore the fact that differences between two patients’ cultures, communities and access to resources may make them seem worlds apart. But mostly, we can’t ignore how strikingly similar we all are at the start – just little flickers of black and white, so simply alive. Maybe if we try to remember that, all the differences we see every day will become just parts of the mural – not terribly accurate, certainly open to interpretation, but mostly just a beautiful mess of color.

 

Featured image:
Panama Clinic, courtesy of Leigh Goodrich

Categories
Disability Issues Lifestyle Reflection

Personality Disorders

In individuals, insanity is rare; but in groups, parties, nations and epochs, it is the rule.
– Friedrich Nietzsche

Personality Disorders (PDs) are defined by the DSM-V as significant impairments in the self and interpersonal functioning across time, which cannot be explained by socio-cultural environment or substance abuse (American Psychiatric Association 2012). These disorders are unique within psychiatry because, unlike many of the Axis I disorders, they did not begin to take form until the 19th century. They also tend to create controversy around their definitions, as they are molded by the behavioural standards within a society, and are therefore quite subjective. This subjectivity may be the reason why personality disorders have the lowest levels of reliability and validity among all psychiatric disorders (Alarcon et al. 1995).

There is an important difference between personality styles and disorders, and clinicians must be able to make this distinction. As society changes, roles and values are transformed, leading to the creation of new disorders. One example of this is  internet gaming disorder.

Perhaps we should start by clarifying our terms: what is personality? Is it something that is inherent and unchangeable? Or is it a malleable entity, a wisp of smoke that can never be grasped; a question to hang above the philosophers’ heads? In 1995, Alarcon et al. suggest that personality implies a way of reacting to stimuli, coping with stress and acting on one’s beliefs about oneself and the world. It has been suggested that a personality disorder is almost a caricature of the normal personality, and that it can reflect the distorted aspects of a person’s time and culture.

Society plays a very powerful role when it comes to psychological disorders. It has been suggested that prejudice can distort societies’ perceptions towards those from disadvantaged backgrounds and inflate the rates of personality disorders in these groups. For example, it has been suggested that almost half of inner city youth who have been diagnosed with antisocial personality disorder have been misdiagnosed, because their behaviors are occurring in a unique cultural context; a context which includes the prevalence of behavioral systems which value violent behavior as an acceptable survival strategy (Alarcon et al. 1995). Furthermore, antisocial behaviour could be seen as an adaptation to the excessive demands of our modern world. With the increasing expectations placed upon our youth, not only for wealth and success, but also for a ‘happy’ life with a spouse and child, a fast car and a big house, is it any wonder that many kids rebel against such idealistic expectations? Perhaps it is society that is towing the soil, encouraging the growth of such ‘pathological behaviour’ in our culture. Are we simply pushing humanity too far?

Borderline Personality Disorder (BPD) is another example of a personality disorder that has become increasingly common in the modern world (Grant et al. 2008). Those who have ever set foot on a psychiatric ward will be familiar with the label, as it is the most prevalent category of personality disorder within the mental health services (National Collaborating Centre for Mental Health, 2009).

BPD is a relatively new diagnostic entity, first described in the 20th century. Although people committed suicide in the past, self-harm in the form of wrist cutting is relatively new, only appearing on psychiatry’s radar since the 1960s (Favazza, A.R. 2011). As societies evolve, symptom banks change, and in today’s world there appears to be an increasing acceptance of self-harm as a signal of distress– a phenomenon termed ‘social contagion’ (Jarvi, et al. 2013). Traits underlying BPD are impulsivity and affective instability. In today’s world, these impulsive symptoms are one of the most common forms of expressing distress among the young. Indeed, it has been suggested that BPD risk factors are associated with modern life (Paris and Lis 2013).

Do we as a society place such high expectations on those around us that we must fall back upon psychological labels to explain away those who do not fit into our idea of perfection? I suggest that perhaps this sudden surge in personality disorders does not merely reflect our increasing awareness of such pathologies, but also a deeper issue within modern society. Perhaps we have become so obsessed with success, with money, with beauty, that we have forgotten what it means to be human. To love, to feel, to belong.

And if this is true, then the answer lies not within the leaves of a doctor’s prescription pad, nor within the four walls of a hospital ward, but in the society that we have created for ourselves. Perhaps this rise in personality disorders, this explosion of emotional distress, is a signal that the world we have created for ourselves may be doing more harm than good. The increasing emphasis on achievements, success, wealth, and fame may indeed be turning into a poison. And if this is the case, then the antidote lies beyond the physicians’ hands; it is a task that is placed on all of us, to encourage our children to create a world for themselves that is filled with love and belonging, rather than goals and desires. It is only through an increasing emphasis upon our own humanity that we can begin to combat this psychological plague.

References

  1. Alarcon, R., Foulks, E.F. 1995. Personality Disorders and Culture: Contemporary Clinical Views (Part A). Cultural Diversity and Mental Health. 1:3-17
  2. American Psychiatric Association. 2012. DSM-IV and DSM-5 Criteria for the Personality Disorders.
  3. Chavira, D.A. et al. 2003. Ethnicity and four personality disorders. Comprehensive Psychiatry. 44:483-491
  4. Favazza, A.R. 2011. Bodies under Siege: Self-mutilation, Nonsuicidal Self-injury, and Body Modification in Culture and Psychiatry. 3rd Ed. JHU Press.
  5. Grant, B. Stinson, F.S., Saha, T.D., Smith, S.M., Dawson, D.A., Pulay, A.J., Pickering, R.P., Ruan, W.J. 2008. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiological Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry. 69:522-545
  6. Jarvi, S., Jackson, B., Swenson, L., Crawford, H. 2013. The impact of social contagion on non-suicidal self-injury: a review of the literature. Archives of Suicidal Research. 17:1-19
  7. National Collaborating Centre for Mental Health. 2009. Borderline Personality Disorder, The NICE Guideline on Treatment and Management. The British Psychological Society, The Royal College of Psychiatrists.
  8. Paris, J., Lis, E. Can sociocultural and historical mechanisms influence the development of borderline personality disorder? 2013. Transcultural Psychiatry. 50:140-151

Featured image:
Female Warrior # 14 “Extinction” by CHRISTIAAN TONNIS

 

Categories
General MSPress Announcements Public Health Reflection

“Fulfillment in Practice”: Dr. Howard K. Koh, 2015 Commencement Address of the Yale School of Medicine

We are excited to publish the final contributor to this year’s Commencement Archive, Dr. Koh’s 2015 commencement speech to the Yale School of Medicine, “Finding your calling.”

Howard Kyongju Koh is the former United States Assistant Secretary for Health for the U.S. Department of Health and Human Services (HHS).  

Screen Shot 2015-10-06 at 8.08.49 PMDr. Koh oversaw the HHS Office of Public Health and Science, the Commissioned Corps of the U.S. Public Health Service, and the Office of the Surgeon General. At the Office of Public Health and Science, he spearheaded programs related to disease prevention, health promotion, the reduction of health disparities, women’s and minority health, HIV/AIDS, vaccine programs, physical fitness and sports, bioethics, population affairs, blood supply, research integrity and human research protections.

Dr. Koh graduated from Yale College and earned his medical degree from Yale University School of Medicine. He has earned board certification in four medical fields: internal medicine, hematology, medical oncology, and dermatology, as well as a Master of Public Health degree from Boston University. 

Dr. Koh previously served as the Harvey V. Fineberg Professor of the Practice of Public Health, Associate Dean for Public Health Practice, and Director of the Division of Public Health Practice at the Harvard School of Public Health.  

Dr. Koh begins his speech by advising students to find meaning and fulfillment in medicine, regardless of external expectations,

“Please listen carefully to your inner soul so that you can discover your own sacred calling.  Doing so will help you express yourself, not just prove yourself. Doing so will help you determine in your life what is ultimate versus what is merely important.”

He continues by reminding students that patients will be teachers as well, and may be key factors in finding that calling,

“One way to learn more about meaning through your journey is to respect how your patients find meaning in their own. They can teach you in unexpected and profound ways. Sometimes the patients who will educate you the most will be the ones you couldn’t cure, no matter how hard you tried.”

He concludes and advises students to enjoy every step of the way,

“So please pay great attention to how you live your lives, not just as doctors, but as individual human beings.”

Visit the Medical Commencement Archive to read Dr. Koh’s full speech here

Categories
General Reflection

Medical Conferences: Are they worth it?

Each year there are many medical conferences held around the world. These could be conferences about new research, medical education or, perhaps, a gathering of those in a specific specialty. Last year I was lucky enough to attend the American Medical Women’s Association (AMWA) Centennial Conference in Chicago, IL. After attending my first medical conference, I have made it a personal goal to attend at least one each year.

So, was it worth it? In my opinion, it is a definitive yes. I’ll break down some of the pros and cons based on my experience so you can decide for yourself if you’ll be attending a conference (or two) within your medical school years.

Pros

  1. Connections. I can’t go on long enough about how many new connections I made. I met physicians from around the nation in different specialties. I heard from speakers who had written books, gotten double board certified while raising a family of four, and even travelled to the moon (I’m not kidding, Mae Jemison was in attendance). An easy way to stay in touch with the new colleagues you’ve met is LinkedIn. After hearing from them at the conference I connected with them on LinkedIn, which allows me to see what they are doing professionally and keep them in my network for any future communications.
  2. Relationship growth within my organization. The AMWA chapter at my medical school has always been a tight-knit group, but this trip made many of us even closer. It was a great way to get the entire group motivated for an awesome upcoming year. We were able to bond over our favorite speakers and chat about some of the important issues being discussed on the women’s rights front.
  3. Stepping outside of your comfort zone. In advance, the conference paired student attendees with physicians and asked students to meet with and interview the physician. I ended up getting paired with an internal medicine physician coming from the renowned Tuft’s University. I was intimidated at first because she came from such a prestigious university, but she turned out to be incredibly down to earth and friendly. I had the opportunity to talk to her about her personal journey and how being a woman in a once male-dominated field affected her.  She told me a story of when she was involved in a patient’s care when they began coding. As if this weren’t stressful enough, she was seven and a half months pregnant and started having contractions. Womanhood presents unique obstacles, but this physician was able to overcome them with flying colors.
  4. Exploring a city! The conference allowed me to experience Chicago in a new way. We stayed right in the heart of downtown and went on quite a few sight-seeing adventures. Next year the AMWA conference is in Miami, which would be so much fun to visit! Heading out of town for a conference can feel like a mini vacation from the hectic life of a medical student.
  5. Intellectual growth. The AMWA conference placed a strong emphasis on the advancement of women in medicine. We heard from numerous female physicians about their experiences within the field and how they got onto their current path. It was empowering to listen to women who had written numerous books, founded various organizations and impacted society so greatly. Additionally, I was able to hear from numerous female physicians about raising a family and having their dream career. It gave me hope that the life I want is doable. I think this conference truly revitalized my energy after a long first year in medical school. It allowed me to see past the current grueling coursework to what my career could potentially blossom into.
Cons
  1. Money. Okay, to be honest, this AMWA conference was actually affordable, but I know many are super pricey. My advice is to seek funding from various sources. This year I’d really like to go to the conference again, so I plan to set up a Go Fund Me account that will allow my relatives to donate some money to help me attend. Last year, I was fortunate enough to get some money to support my travel. Most student organizations can get some funding from their school, which is what our AMWA group was able to do. In addition, many conferences have grants or scholarships to help students attend. I recommend looking at a few different conferences you find interesting and pick one that is the most economical. Another option is to create a poster (or research) to present and most likely you can get a grant from your school to present it at a conference.
  2. Time. The conference I went to was an entire weekend event, so I wasn’t able to study at all. In the little down time we did get, I wanted to explore the city or just relax for a few minutes. Plan ahead and study during the car (or plane) ride. Check your schedule and make sure the conference falls during a time that isn’t incredibly hectic for you. Even though conferences are a large commitment, the time “lost” I think ends up being an overall gain when you consider the benefits.
I think medical students should look further into the idea of attending a conference. Many of us are hesitant because we think it will just cost extra money we don’t have. I urge each of you to look deeper than the price tag and make a plan to go to a conference at least once during your four years of medical school. To find out more information about the AMWA Centennial conference click here.

Featured image:
Conférence NWX2012 by Frédéric BISSON


Categories
Emotion Reflection

The Power Of Crying

Last week, we started a class called “Death and Dying” (doesn’t it sound fun?).  Jokes aside, this class is a valuable component of the medical school curriculum. Physicians deal with death on a regular basis—some every day, and others every hour. During one of our discussions about a patient, a small tear rolled down my cheek. I quickly wiped it away in embarrassment, pinched myself to “get my act together,” and hoped no one had seen. Later that day, I wondered what would have happened if another student had seen me almost cry? Would their opinion of me change?

I am a “crier.” Not when I am faced with my own struggles, but when those I love go through happy or sad times, that’s when the waterworks kick in. This has me worried. I know that crying is seen as a sign of weakness. Some would even call it unprofessional, and I can’t blame them. Our profession teaches us to set personal and emotional problems aside. But what happens when our profession is the cause of these emotions?

A recent discussion we had in class answered my questions. It turns out that crying is okay. Of course, this does not mean we should break down every time a patient has to spend an extra day in the ED, but it does mean we can be vulnerable in a highly professional setting. One of the pediatric oncologists shared a special patient experience with us. She had always shied away from crying in front of her patients. However, one day after a family had received especially disheartening news, she unintentionally teared up in the clinic room. This was well received by the patient’s family—the patient’s mother told her, “It let me know you cared.” From that point on, the physician’s relationship with the family was altered—an unbreakable, unspeakable bond was formed.

This alleviated a few of my fears concerning the display of raw emotion. We are in a profession where humans care for other humans. It is natural to cry. In fact, we become physicians because we deeply care and love others. Showing this empathy is not a sign of weakness—it is a sign of power.

Yet, there are some important points to remember about crying. Though releasing a few tears is okay, you cannot become a mascara-stained mess.

  1. Your tears have to come naturally. These tears are symbols of your love and devotion. They signify your raw, genuine emotion. Don’t cry to make yourself closer to a family.
  2. You still need to be strong for your patients and their families. You want to be able to process and deliver information to them in a calm, collected way.
  3. You do not want to cry and then have your patients feel they have to comfort you. You are their robust pillar of support! They should be leaning on you for guidance and comfort—not the other way around.
All in all, I am happy to have realized that watery eyes in the clinic will not make me a pariah. Crying, like all aspects of medicine, has to be motivated by your candid empathy. Only then can it be powerful.
Featured image:
A Single Tear by Lauren C
Categories
General Reflection

Can Empathy Be Taught?

As medical students, we are taught to examine patients, recognize symptoms, and treat diagnoses. We get lost in the sea of differential diagnoses and worries of exams. I always worried that I’ll never remember all the important facts, that I’ll miss an important sign or symptom or forget an essential part of treatment in an emergency situation. When I faced my real-life patients, I realized that I was indeed not ready. Surprisingly though, it wasn’t the lack of theoretical or practical knowledge that worried me anymore, but the fact that each patient required a different approach. Some patients are serious and to the point, others are full of witty remarks about not only their condition, but all sorts of topics. Some don’t want to know much about what’s happening to them, while others have countless questions. Their behavior might be a part of their usual personality, or it could be changed because they have found themselves in a new, often scary situation. I wanted to, had to, understand why each of my patients acted and thought the way they did, so that I could adapt my manner, make them more comfortable, find out more information, and finally, earn their trust.

In observing my seniors, doctors with years or decades of experience, I have noticed their style of communication with patients comes from every part of the spectrum. Some are empathetic and communicative, dedicating a large portion of their time to their patients; others are introverted, avoid communication with patients at all costs, or can even be patronizing and show little understanding.

In the past, medical education focused primarily on academic knowledge and practical skills. Today, however, the importance of doctors’ communication skills has obviously been recognized and integrated in our education. But can empathy be taught?

We can learn to shake a patient’s hand, to ask for permission before examining them, to perform other small actions that take little effort but make our patients much more comfortable. In order to better understand our patients, to get them to open up more easily and reveal parts of their medical history they would otherwise conceal, to treat them in the most individual manner possible, we need to empathize with them. I’ve seen my colleagues to whom this comes naturally, but I’ve also seen others whose attempts at empathy take a lot of effort and energy.

Because I am at the very beginning of my medical career, I realize my point of view might be naive. Still, at this point I believe I should focus on each patient. I should empathize and understand each individual fully before attempting to tend to his or her troubles, however much energy that takes. I am also worried about the possibility that this ability can be lost. I often wonder if the more reserved senior doctors have always been that way, or if their energy and will to empathize have been lost after seeing innumerable patients.

I don’t know if empathy can be taught in classes, but I do believe everyone can develop it. Unfortunately, I think the ability to empathize can also be lost. Ultimately, this social dimension of medicine remains different for each health professional, and their ability or will to empathize remains their choice, depending on how they choose to integrate their theoretical knowledge and experience with their personality.

Featured image:
empathy by Sean MacEntee

Categories
Lifestyle Narrative Reflection

Lonely in a Room Full of People

Stock phrases:

“Hey mon, you alright?”
“You have a blessed day.”
“How is your morning walk pretty ladies?”
“Yeah mon, no worries. Everything alright.”

These ‘stock phrases’ are just a few of the things I heard each and every day while staying in Negril, Jamaica. I travelled to the island to take a short vacation and attend a destination wedding this past month. While on the island, I was pleasantly greeted by the local Jamaicans any time I left the bed and breakfast I stayed at. I was surprised at first at how friendly the locals were – I had heard from friends to be cautious of the crime in Jamaica. Nevertheless, I always responded to the locals, asking them how they were.

A few days into my trip I was with a Jamaican driver named Patcha, headed to another part of the island. I chatted with Patcha for quite a while. I asked him about his culture – his views on marriage, money, economy, etc. He was open and never held anything back. I mentioned to him how friendly I thought the Jamaicans all were. He kind of chuckled and asked if that was out of the ordinary for me. I told him America was different.

I went on to tell him that I am guilty of being unfriendly at times; not intentionally, but just by habit. He didn’t quite understand. I told him how common it is in America to be walking in a hallway or down a street with one other person and for neither of them to say hello to one another. Some people even say they feel lonely in a room full of people. He burst out laughing.

I started laughing too. Why do we do this? What stops us from just initiating a conversation with others? He asked why this is so. I started thinking and said, “Maybe it is because Americans are too stressed. We forget about other people because we are kind of on a mission each day.” Patcha responded, “Us Jamaicans are stressed too, we need to have food on the table every night.” I bit my tongue remembering Patcha had told me earlier that many Jamaicans live in poverty. He told me workers at some of the larger all-inclusive resorts on the island make only about ten US dollars a day and smaller establishments tend not to pay their workers on time or abuse their power over their employees in other ways.

Clearly, stress is a problem in Jamaica just as it is in America. So why is it only in the US where we insist on emotionally walling ourselves off? Why do we stray away from human contact when it is so easy to make a connection with another human? I couldn’t give Patcha an answer. I have been a shy person for the majority of my life, but by no means am I scared to strike up a conversation with anyone. When I returned to the United States I noticed myself falling into old habits, just politely smiling at the person next to me in line for coffee, but never saying hi or asking the how their day is going.

I wanted to write this blog post to hold myself accountable and also challenge my readers to break the silence. Say hello to strangers. Dare yourself to give someone a compliment. Make yourself more human.

As future medical professionals, part of our responsibility is to make our patients comfortable. I will count this challenge as daily practice for my career. I’ve seen many doctors put on a positive attitude for their patients, only to find them miserable when engaging in other social interactions. What makes a stranger in the grocery store any different from a patient in the hospital?

I hope this short story will help readers see that sometimes we all need a reality check. Whatever the reason is, our culture is heading down a path of loneliness, instead of solidarity. Let’s all take responsibility for this and make changes to unite one another.

Featured Image:
Humanity by Kevin Dooley