Categories
Emotion Empathy General Law

Gratitude: A Good Recipe for Holiday Cheer

The “most wonderful time of the year” is often filled with stark contrasts. While glitz and opulence surround us, sorrow and despair seem to grow emboldened. Nowhere is this truer than in a big city, where poverty and privilege so closely intermingle. Minutes after I walked down Fifth Avenue, basking in the glow of the Christmas lights infinitely multiplied in the facets of glittering diamonds displayed on shop windows, I found myself peering down into a simple metal container full of school supplies. This school-in-a-box, provided by the United Nations Children’s Fund (Unicef), was on display as part of an exhibit called “Insecurities: Tracing Displacement and Shelter”. Insecurities represents one installation in the Citizens and Borders series organized by the Museum of Modern Art (MoMA) in New York City. The Citizens and Borders project aims to highlight experiences of migration, territory, and displacement[1]. Standing in front of this school-in-a-box, I thought of our medical school, replete with its high-tech anatomy lab, treadmill desks, and air conditioning system so powerful it sometimes forces us to use blankets in our lecture halls for warmth. I thought of my comfortable bed at home, and of the night table that stands next to it, teeming with books, and of the shelf above it filled with movies.

Once more, we find ourselves in the midst of the holiday season, awash with bright lights and commercial cheer. This year’s winter holidays occur on the heels of an extremely draining presidential election season that left over fifty percent of Americans feeling stressed and anxious.[2] Already this month, I have seen patients who have related somatic complaints to the election, cooking, and spending time with their extended family To add insult to inury, the commercialism of the season which suggests we ought to see the world through the rosy hues of a colored ornament can exacerbate feelings of stress and anxiety in those who are already overwhelmed and not feeling their healthiest.. As a caregiver, I realize that it is important for us all to be especially sensitive this year to patients who may be feeling a bit less than the usual holiday cheer.

Peering down into the school-in-a-box reminded me of how grateful I am for the many privileges in my life. Some of these privileges, like a loving and supportive family, or being born in a country with free speech and democratic elections, are pure happenstance. Others I have worked hard for, like the privilege of attending medical school and caring for patients. It is important, now more than ever, that we have gratitude for our privileges in life, and help our patients extend an outlook of gratitude in their own life.

Gratitude has11522685876_5d27ebdb25_o consistently been shown to have a positive impact on mental health. Dr. Martin E. P. Seligman, a psychologist at the University of Pennsylvania, asked study participants to write letters of gratitude to people in their lives whose important contributions had previously gone unacknowledged. He then quantified the impact of these letters on the study participants’ letter writers by providing them with a happiness score. Unsurprisingly, the mere act of writing the letter and expressing gratitude was found to boost each participant’s happiness score.[3] As physicians, we ought to support many outlets for creative expression, from yoga to painting, as ways to contribute to our patients’ well being, but we also need to consider gratitude as its own kind of healing salve. Whether we encourage our patients to write expressions of gratitude to special people in their lives, or just to reflect on the small blessings in their everyday lives, gratitude should have a place in our roster of medical advice. We cannot and should not strive to take away the things in our patients’ lives that cause them discomfort, anxiety, and sorrow, whether they be personal events or national political outcomes. Good medicine is not about making the world a more comfortable place, but rather, making our patients more comfortable within the world.

[1] https://www.moma.org/calendar/exhibitions/1653?locale=en

[2] http://www.npr.org/2016/11/06/500931825/how-to-deal-with-election-anxiety

[3] http://www.health.harvard.edu/newsletter_article/in-praise-of-gratitude

 

Photo credit: Timo Gufler

Categories
General MSPress Announcements

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Categories
Reflection

The War Against Aging

‘Back in elementary school, I realized we all have a genetic, lethal disease called aging. I remember being frightened that my mother would die and terrified that my existence was ephemeral and meaningless. At the time, it felt like I was being told I had terminal cancer or some other horrible disease. Death was inevitable. No matter how rich or successful I could be in life, it would all be lost in the end. So, still a child, I found an objective, a purpose for my life: to cure human aging.’
Joao Pedro de Magalhaes (1)

Of all the diseases we have left to conquer, one raises its voice above all others: the disease of aging. From anti-wrinkle creams to advertising billboards, from our conceptions of beauty to our desire for youthful skin, our fear of aging is present in all walks of life.

But is aging a disease? Is it a demon that must that be conquered, lurking beneath our skin, crumpling up our genes until our skin sags and our hair turns grey? Or is it a natural part of life – something that needs to embraced with humility? Is our preoccupation with aging a cultural phenomenon, a type of ignorance or obsession that needs to be tackled by changing social attitudes, or is it primarily a problem of medical science?

Eternal Youth vs Immortality

What is it that we are actually fighting for – do we want to live forever, or do we want to be forever young? Most of us would not wish to live a longer life if it meant we continued to age. What we long for is a good quality of life while still holding on to more years. This is best highlighted in the Greek myth known as Tithonus Error. Tithonus was a mortal who was granted immortality by Zeus but was not granted eternal youth. As a result, Tithonus became increasingly debilitated and demented as he aged (2). This is a fate no one would wish to have. The quest, it seems, is to extend one’s years upon this earth while retaining quality of life, looks, and independence. If this is so, we must ask ourselves: is this something worth fighting for?

One argument against the idea of ‘fighting aging’ is the concept that aging is a natural process. For those making this argument, the insistence on limiting aging is uncomfortable; who are we to go against nature? In fact, some would even argue that it is aging that makes us human. Indeed, without the knowledge of mortality placed upon our fragile shoulders, we would never value those things which are so important in our lives and yet so transient – our first kiss, our first day at school, our first date. If we were to extend our lives infinitely, then the value of the present moment may disappear.

As emotively tempting as this argument may be, if one takes a step back and takes a look at the history of medicine, one begins to see that battling nature is something that science has always done; from antibiotics to vaccinations, from the eradication of smallpox to the application of technology, fighting the natural world is an inevitable component of science. Indeed, battling the features of aging makes up a large part of modern-day medicine; we battle stroke and heart disease, insidious cancers, and debilitating degenerative diseases every day within our hospitals and with our surgeries. What makes ‘fighting aging’ any different?

The Cultural Phenomenon

This question ultimately goes back to the cultural phenomenon of aging. Aging is a rather new phenomenon. At the beginning of the 20th century, only 5% of the population was over 65 years of age, while today people are able to lead active and independent lives well into their 90s (3). With this rise in aging has come new prejudices and stereotypes. It has been argued that our negative attitudes against ageing emerged relatively recently, in the 18th century. Prior to this era, the elderly were often held in high regard, seen as carriers of wisdom and knowledge thanks to their years upon this earth. But as more and more people began to survive into their 80s and 90s, the idea of being a ‘nuisance’ began to take hold. Employers felt that the elderly were holding on to jobs that could be taken over by the “young and fit.” This change in attitude is reflected in our vocabulary with words such as ‘codger’ (meaning an odd, old fellow), and the change in meanings of certain words over time, such as ‘fogey’, which previously meant a wounded war veteran but now is used more pejoratively to describe those who are old and thought to hold ‘old-fashioned’ views.

The social role of the elderly has changed dramatically as well. With fewer multigenerational families living under one roof, the role of the elder within the family structure has been lost (3). This gradual change in society is reflected in the way we view age. We equate youth with beauty and aspire to look as young as possible. Yet on a grander scale, the way we view age has also corresponded to a larger shift in our society’s policies, in our public expenditures, and in our healthcare.

Within medical care, conditions such as depression are often ignored in the elderly and often seen as a part of aging itself. From a social perspective, discrimination in social care is evident in the assumptions that people may have about how older people should live their lives and what constitutes a life worth living for the elderly. On a public health level, there is a strong suspicion that the use of Quality Adjusted Life Years, a tool used in the UK to assess the costs of treatments, will often discriminate against treatments for diseases such as Alzheimer’s Disease, Osteoarthritis and Age-related Macular Degeneration, most of which would mainly benefit older people with few remaining years. Within the research sphere, the elderly are often excluded from clinical trials, with this under-representation of the elderly affecting the number of available treatments for them. Most importantly, from the patient’s perspective, older people are more likely to feel talked over compared to other patients when they are in the hospital, often feeling ‘as if they weren’t there’ (5). All of these examples illustrate how our culture of youth has manifested itself within the sphere of medicine, where it is our responsibility to be non-judgemental. Yet this is the world in which we live. If we want to make a change, we must become aware of such uncomfortable realities and understand what has given birth to them.

Even if we wish to view aging as a biological phenomenon, for example by looking for “anti-aging” genes within our laboratories and for drugs that can reverse the damage done to DNA over time, we still have to take into account society’s perception of the elderly. We still have to ask the difficult, philosophical questions. For example, are we battling aging because it will allow us to be healthier and have more fulfilling lives, or because of our modern obsession with youth and beauty? Likewise, how would we evolve or change as human beings if we were able to slow, stop, or even reverse the process of aging?

Perhaps conquering aging is not the same as vanquishing cancer, for growing old is an intricate and natural part of our lives. Indeed, perhaps it is part of what makes us human. These are questions that no one person can answer, and which need to be debated within the public sphere. The discussions that arise from asking these questions will undoubtedly impact the direction medicine takes with respect to its interaction with aging; maybe more resources will be dedicated to ‘diseases of the elderly’. If we are lucky, maybe this will all cultivate an attitude of acceptance and empathy within a culture that sees aging as a part of life. Maybe we can change a culture. Maybe we can even save a life.

“We have added years to life; it is time to think about how we add life to years.”
Robert Kennedy (6)

 

References

  1. Magalhaes, J. P. Fearing Death and Curing Ageing [Online]. Available at: http://www.senescence.info/death_and_aging_fears.html [Accessed: 14th September 2016]
  2. Magalhaes, J. P. Should we cure Ageing? [Online]. Available at: http://www.senescence.info/physical_immortality_myths.html [Accessed: 14th September 2016]
  3. Big Picture. 2014. Ageing and Society [Online]. Available at: https://bigpictureeducation.com/ageing-and-society [Accessed: 30th September 2016]
  4. Jones, R. 2007. A Journey through the Years: Ageing and Social Care. Ageing Horizons. 6: 42-51
  5. Centre for Policy on Ageing. 2009. Ageism and age discrimination in secondary health care in the United Kingdom. Department of Health.
  6. Steinsaltz, D. 2016. Become the New 60;. Nautilus; 36 [accessed 28th May 2016]. Available from: http://nautil.us/issue/36/aging/will-90-become-the-new-60

Featured image:
Age by Iburiedpaul

Categories
General

Our Thanks

We have had an incredible four years here at the Medical Student Press. Thank you to each of our executive editors, associate editors, editors, bloggers, peer reviewers, and readers! There are over 100 students across the globe currently involved with the MSPress with over 3,000 website views monthly. A huge thank you to you all this Thanksgiving holiday!

With appreciation,

The Medical Student Press Executive Team

Screen Shot 2016-11-22 at 8.41.34 AM

 

Image courtesy of Jeff S. PhotoArt

Categories
Empathy Technology

Robots: Not just for kids any more

Years ago, my brother and I shared a metal robot with moveable arms and legs. This plaything belonged to the same fantasy realm as Barbie dolls and Power Rangers, and the idea that it might one day be a colleague was not only unfathomable, it was laughable. Fast-forward two decades to the present day, and robots have a very real role in medical care. At present, hundreds of thousands of surgeries are performed each year using robotic technology[1]. This past June, two Belgian hospitals began employing robotic receptionists that can understand up to twenty languages[2]. In Japan, robots have been used to lift and transfer patients from their hospital beds[3].  And right here in America, Watson, the same robot that won Jeopardy in 2011, is being put through his medical residency in the University of North Carolina Lineberger Comprehensive Cancer Center[4]. Just a few months ago, Watson, who has never experienced the years of grueling drudgery to which we have subjected ourselves as medical students, correctly identified the cancer of a patient whose diagnosis had stumped physicians across the globe[5]. As humankind continues to create technologies with the potential to outsmart their creators, it’s hard not to wonder whether we, as doctors, may soon become obsolete.

While mulling over this very question, I saw a young patient who needed blood work. Upon finding out that she was being sent to the lab, the young girl was filled with sheer terror. After much crying, kicking, and screaming, her mother eventually managed to drag her down to the lab. After we had seen our next patient, the doctor with whom I was working decided to go down to the lab to check on our very petrified young patient. At that moment, I was reminded that our ability to care for people in the most trying times of their lives makes us as doctors unique from most other professionals. As doctors, we will have the privilege of making human connections with each of our patients. Robots can digest huge amounts of information, stay up to date on the most current medical practices, and make correct diagnoses in puzzling patient histories, but they will never eclipse physicians because they do not have a reliable set of ethics, nor do they have the shared human experience that underlies the doctor-patient relationship.

The prospect of artificial intelligence in medical practice may be heralded by some as a major scientific breakthrough, but it is important not to hyperbolize the role of robots on a medical team. Though the prospect of finding forms of artificial intelligence in your local hospital is becoming increasingly likely as time passes, many of us can only speculate what it would be like to work alongside a robotic colleague. No matter what, artificial intelligence should only be viewed as a physician aid, not a physician replacement. While it is true that forms of artificial intelligence may certainly help us with diagnoses and complex surgical procedures, these tasks are only one small part of the care that we as physicians have agreed to provide to our patients. The other part of this care is the genuine concern that we show to our patients. Robots may be more knowledgeable and more hardworking than some human doctors, but until a robot can sense human suffering, walk down to a lab, and hold the hand of a little girl who is scared senseless by the idea of having her blood drawn, they are still incapable of providing the most important medical service of all: empathy.

Featured image:
robot! by Crystal

Categories
Opinion Psychology Public Health

Take a Stand against Domestic Violence

October is Domestic Violence Awareness Month. This is particularly relevant at the moment, because on October 7th the Washington Post published a 2005 recording of President-Elect Trump bragging about kissing and grabbing women without permission. Since the leak, the president-elect has consistently referred to such comments as “locker room talk.” In a recent interview with Anderson Cooper, Melania Trump further dismissed the seriousness of her husband’s comments by stating, “I heard many different stuff—boy’s talk. The boys, the way they talk when they grow up and they want to sometimes show each other, ‘Oh, this and that’ and talking about the girls.”

It is time to be clear. Trump’s comments may echo in locker rooms or be the status quo among young men, but that does not make it forgivable to joke about sexual violence. And to imply that joking about sexual violence against women is somehow more tolerable when it is said by an immature male or in a sporting environment only further encourages the perception that men have an implicit ownership of a woman’s sexual rights.

In a 2010 report entitled “Preventing Intimate Partner and Sexual Violence Against Women,” the WHO emphasizes the need to understand and target the factors that commonly lead to intimate partner violence and sexual violence against women. Unfortunately, an overwhelming burden of intimate partner violence and sexual violence against women occurs at the hands of men. This becomes unsurprising when one identifies the factors that promote violence against women. The WHO lists “patriarchy, power relations, and hierarchical constructions of masculinity and femininity as a predominant and pervasive driver of the problem.” The paper further argues that “dismantling hierarchical constructions of masculinity and femininity predicated on the control of women, and eliminating the structural factors that support inequalities are likely to make significant contribution to preventing intimate partner and sexual violence.”

Several examples of such social and cultural norms are cited in the report, but one appears to be particularly relevant in the setting of Trump’s recent comments: the idea that a man has a right to assert power over a woman and is considered socially superior to her. In the leaked video, Trump supports his right to kiss and grab women with the argument that “when you’re a star, they let you do it. You can do anything.”

No, Mr. Trump, you cannot.

The WHO highlights methods to prevent intimate partner violence and sexual violence against women, stating that there are three main approaches for changing social and cultural norms: correcting misperceptions that the use of sexual violence is normal and common among peers, media awareness campaigns, and directly working with men and boys to educate them on the topic. I hope that the media storm surrounding the video’s release, as well as the responses to it by prominent figures will serve to raise awareness, because women, men, and children alike should be able to live a life free of violence.

Readers, take a stand against domestic violence of all forms. Challenge jokes that diminish the seriousness of such acts. To fail to question only perpetuates the pervasive social and cultural acceptance of violence against women. Do not tolerate the perception that men are socially superior to women. Educate others that domestic violence, including intimate partner violence and sexual violence against women, is a global epidemic that affects us all.

I encourage current and future medical providers to seek the education they need to be a first resource for survivors of domestic violence. Make preventing and responding to intimate partner violence and sexual violence a priority in your clinical practice.

The National Intimate Partner and Sexual Violence Survey (NISVS) 2010 Summary Report defines five types of sexual violence:

  • Rape – “any completed or attempted unwanted…vaginal, oral, or anal penetration through the use of physical force, threats to be physically harmed, or when the victim was drunk, high, drugged, or passed out and unable to consent.”
  • Being made to penetrate someone else
  • Sexual coercion – “unwanted sexual penetration that occurs…after being pressured in ways that included being worn down by someone who repeatedly asked for sex or showed they were unhappy; feeling pressured by being lied to, being told promises that were untrue, having someone threaten to end a relationship or spread rumors; and sexual pressure due to someone using their influence or authority.”
  • Unwanted sexual contact
  • Non-contact unwanted sexual experiences – “unwanted experiences that do not involve any touching or penetration, including someone exposing their sexual body parts, flashing, or masturbating in front of the victim, someone making a victim show his or her body parts, someone making a victim look at or participate in sexual photos or movies, or someone harassing the victim in a public place in a way that made the victim feel unsafe.”

According to the NISVS, nearly 1 in 5 women (18.3%) and 1 in 71 men (1.8%) in the United States (U.S.) have been raped at some point in their lives. And nearly 1 in 2 women (44.6%) and 1 in 5 men (22.2%) in the U.S. experienced sexual violence other than rape. Worldwide, this rate is higher, with 1 in 3 women (35.6%) experiencing either physical and/or sexual intimate partner violence or non-partner sexual violence.

Domestic violence can refer to intimate partner violence, but also encompasses child abuse, elder abuse, or abuse by any member of a household. The World Health Organization (WHO) identifies four forms of intimate partner violence: acts of physical violence, sexual violence; emotional (psychological) abuse; and controlling behaviors.

Intimate partner and sexual violence disproportionately affects women worldwide, and can significantly impact a woman’s reproductive health and the health of her baby if she is pregnant. Women who have been physically or sexually abused by their partners have a 16% higher risk of having a low birth weight baby (16%). They are twice as likely to have an induced abortion, and almost twice as likely to experience depression.  In some regions, women who experienced partner violence were 1.5 times more likely to acquire HIV and 1.6 times more likely to have syphilis. Of women who experienced non-partner sexual violence, they were 2.5 times more likely to have alcohol use disorders and 2.6 times more likely to have depression or anxiety.

In 2013, the WHO produced a clinical and policy guideline entitled “Responding to intimate partner violence and sexual violence against women,” noting that health care providers are identified by survivors of intimate partner violence as the first and most trusted professional contact they would seek. These WHO guidelines emphasize the need for undergraduate medical curricula to include education on how to recognize, manage, and treat issues of IPV and sexual violence. Providers need to be prepared to give survivors immediate access to post-rape care, ideally within 72 hours, which includes psychological support, emergency contraception, and HIV and other STD prophylaxis.

For more information about domestic violence or how you can help please see the resources below:

If you are in immediate danger, please call 911.

If you or a loved one think that you are a victim of abuse in any form, please call the National Domestic Violence Hotline at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY) now for anonymous, confidential help available 24/7.

REFERENCES

  1. Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T., Chen, J., & Stevens, M.R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
  2. WHO/LSHTM. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva/London, World Health Organization/London School of Hygiene and Tropical Medicine, 2010.
  3. WHO/LSHTM. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva/London, World Health Organization/London School of Hygiene and Tropical Medicine, 2013.
  4. Violence against women: Intimate partner and sexual violence against women. Fact sheet. Reviewed September 2016. Accessed on 10/14/2016 at http://www.who.int/mediacentre/factsheets/fs239/en/

Featured image:
utopia banished by kr428

Categories
Opinion Public Health

Is health a moral responsibility?

L0070041 Public Health Centre

“The preservation of health is a duty. Few seem conscious that there is such a thing as physical morality.”
Henry Spencer (1)

We are in charge of our lives. We choose what job we go into, what friends we invite, what clothes we wear and what food we eat. This is what we tell ourselves every morning as we drag ourselves out of bed, every night when we gaze up at our ceilings and think back on our day with pride. After all, if we were mere puppets on a string, what would be the point of it all?

For the past few decades more and more money has been pumped into public health campaigns (1). Our health is not based solely on our wealth, our family or our doctor, but upon the choices we make, and public health campaigns aim to nudge our choices in healthier directions.

Knowing that we are responsible our health, how does it feel to have such a responsibility? How do we react to this immense control that we hold in our hands; this ability to decide how many years we will live, how quickly we will age – the knowledge that the health choices we make today may well have an impact five years down the line? And how much responsibility do we really have for our own actions, considering all of the external forces acting on us, many of which are acting at a subconscious level?

To illustrate my point, allow me start with an example. If I knew I was going to die of lung cancer in twenty years if I continued to smoke, would I be encouraged to give it up? This simple question illustrates how very complex our lives really are. Giving up a habit – whether it is smoking tobacco or eating fast food – is rarely simple. Some of us may well choose to place the responsibility upon the smoker, but such a simplification masks the more intricate webs of that person’s life: what made them start in the first place, what made them continue and where does their motivation now lie? Are they smoking as a way to escape their feelings? To chase after a certain persona? If we place responsibility at the person’s feet, then we ignore the more subconscious desires that have led them towards their supposedly autonomous choices. We all engage in risky behaviours to some degree. A quick glance at the past few days will highlight many ‘unhealthy’ decisions that we have all made on the spur of the moment. Are we to blame for our decisions?

The idea of being in charge of our health has become particularly popular in the mainstream media. A quick Google search will uncover articles on how to build the perfect body, ten-minute guides to eating more fruit and vegetables and quick tips to help us lead more healthy lives (2). Even closer to healthcare, the idea of patient-centeredness has become almost an ideology within healthcare circles; words that are repeated ad infinitum to both students and professionals. This idea of being responsible for our own bodies illustrates our desire to place the power to determine our health back into our own hands, as opposed to relying wholly on the modern medical apparatus to do everything for us.

The numbers back this up even more. The World Health Organization (WHO) has stated that lifestyle-related diseases accounted for 86% of deaths and 77% of disease burden within the WHO European Region. This includes diseases such as cardiovascular diseases, cancers, chronic respiratory problems and mental illnesses (3). Furthermore, leading geneticists have pointed out that the “current increase in obesity has nothing to do with genes and everything to do with how we live” (4). These statistics are further supported by the fact that prevention is far more cost-effective than any intervention that healthcare professionals can undertake; from health education within our schools to exercise regimens into our forties – these are the most impactful activities we can do to positively impact our health. And because these are activities that we choose to participate in, it follows that we are sitting in the pilot seat; we have the power to get off our sofas and put on those Lycra shorts.

So what would it mean if we believed that we are all 100% responsible for our bodies? On one end of the spectrum, it may encourage people to lead more healthy lives – to perhaps avoid that drive to McDonald’s on the way home, or to insist on an early morning run despite the rain pattering on the window outside. But at the other end of the spectrum you have those people who have simply stumbled down the black hole of unhealthy lifestyle, whether it is drugs, fast food or a sedentary lifestyle. And the more we push for a culture of individual responsibility, the more needless blame we may place upon those who ultimately need help and not judgment. Do you think you would treat a person differently if you believed their illness was entirely their choice?

By placing responsibility on individuals, we walk down the road of assuming that to be ill is to be guilty, thereby further stigmatizing the unwell. A good example of this is mental illness, which has a long history of blame ranging from the relationship with the mother to the relationships within an entire family, until eventually we decided to fall back upon neurobiological theories in an attempt to absolve people of blame altogether.

As human beings, we are creatures of habit; as much as we would like to believe that becoming healthy is as simple as creating a New Year’s Resolution, half of all individuals who begin an exercise regimen quit within six months (4). The environment in which we grow up as children has a profound influence upon our behaviours. The habits we learn from our parents and those closest to us, whether they be about smoking, exercise or eating unhealthily, can stay with us subconsciously (3). When we decide to stay at home and watch another episode of Game of Thrones rather than go out for a run, how much of that decision was ours? How much control do we have over our personalities, whether they be impulsive or habitual?

Health is more than just a decision. It lies at the center of many threads: genetic, environmental, social and psychological. Although we live in a world where six of the ten leading factors contributing to the burden of disease are lifestyle related (5), we must appreciate the fact that these are indeed factors, not a solid line that we can draw across other peoples’ lives to claim that they are wholly responsible for what happens to their bodies and mind.

So what do we do about these opposing forces acting on us? On one end of the spectrum lies the idea that we have a dictatorial control over and responsibility for our decisions, while on the other end there lies the more deterministic way of viewing things, where ‘whatever happens, happens – I can’t do anything to change it’ is the prevailing belief. Which one is right? Which one should we accept?

The answer, I believe, lies not within abstract philosophical questions about morality and free will. Rather, I believe the answer is different for each and every one of us. It is up to us to decide how we view our bodies, our minds and the world in which we live. Do we want to live healthily? Why? Are we doing it for ourselves? To be able to fit into our new wedding dress? To allow our children to live in a smoke-free house? We all have our own reasons for the choices we make, and no doctor can make these decisions for us. Instead, we need to take a step back and think about what is most important in our lives, and do what we can to realize our goals with that in mind.

“Freedom is but the negative aspect of the whole phenomenon whose positive aspect is responsibleness. [..] That is why I recommend that the Statue of Liberty on the East Coast be supplemented by a Statue of Responsibility on the West Coast.”
Viktor Frankl (6)

References

  1. The Lancet. Is health a moral responsibility? The Lancet; 1996. 347:1197
  2. Cappelen, A.W., Norheim, O.F. Responsibility in health care: a liberal egalitarian approach. Journal of Medical Ethics; 2005. 31:476-480
  3. Brown, R.C.H. Moral responsibility for (un)healthy behaviour. Journal of Medical Ethics; 2012. 10.1136
  4. Minkler, M. Personal Responsibility for Health? A Review of the Arguments and the Evidence at Century’s End. Health Education & Behaviour; 1999. 26:121-141
  5. Resnik, D.B. Responsibility for health: personal, social, and environmental. Journal of Medical Ethics; 2007. 33:444-445
  6. Frankl, V. Man’s search for meaning: the classic tribute to hope form the holocaust; 2013. Ebury Digital.

Featured image:
L0070041 Public Health Centre by Wellcome Images

Categories
Emotion Empathy Reflection

Notes from the Road: A Letter to my Future Self

Think back to the very first time you ever drove a car alone. You were probably sixteen, freshly-printed license in hand, putting a foot on the gas pedal for the first time with an empty passenger seat. No parent telling you to check your mirrors, no driving instructor reminding you to keep your hands at ten and two. That first drive was a rush of freedom and excitement, but also of fear.

You probably don’t think about that drive very often, and certainly not every time you get into a car. There are moments in life that seem so incredibly momentous you think you’ll never forget them. But, as time goes by and distance clouds the memory, you have trouble remembering exactly how you felt. You can remember the sequence of events, the people involved, the way you described your feelings at the time, but it becomes more and more difficult to recreate the unique combination of emotions that flooded and overwhelmed you at that precise moment in time. That moment you swore you would never forget….

Ultimately, we never know what lays on the road ahead, what might become routine in a medical career, or what combination of emergencies we might become desensitized to. So I’m writing this down to put into words something that I struggle to articulate, but something I think is worth remembering vividly.

This is my way of putting down a mile marker, of recording my experience, and all that comes with it – I hope you find a way, too, so that at the end of the drive you can see how far you came.

 

Dear Future Self,

Today you saw a patient die.

Today was the fourth day of your first clinical rotation in the hospital and today you saw a patient die.

You saw a patient die, briefly. It was just long enough for you to think she was really going to die, permanently, and then she was resuscitated back to life.

This woman was responsive, albeit uncomfortable, just a few hours beforehand. And now here she was in an operating theater undergoing an emergency C-section for a ruptured uterus. She lost her pulse.

Chest compressions. Pushing epi. Giving her blood.

But she came back- she didn’t die permanently.

As her blood pressure plummeted and the anesthesia team noted weaker and weaker pulses, there were a million things running through your head. When they lost her, though, all those voices in your head went silent. You became numb, as time seemed to slow. These are the things you will forget, and these are the things you should remember.

You were so scared.

Everyone in the room seemed confident, following protocols and executing each step in a methodical and calm way. You felt terrified. You couldn’t believe what you thought you were about to witness. While you tried to stay outwardly calm, you were inwardly panicking. You felt the blood rush from your head to the pit of your stomach. You felt nauseous, flushed. But you mostly felt immensely sad and scared for her and her family. She had come into the hospital with nobody, and you couldn’t bear the thought of her leaving with nobody. You couldn’t handle the thought of her dying alone, in her 30s, in an emergency procedure her family could have never predicted.

You felt so powerless.

There was nothing you could do. You realized there was also a limit to what anyone could do in that moment. Even the attendings, even the best doctors, faced the reality of this woman dying. Remember how you thought to pray in that moment, how even though you aren’t religious, you prayed. You wondered if the doctors were silently praying too, even as they called the code and ran through their crash protocols. Were they whispering to some greater power to help them save this patient? Did they also, in this moment, feel powerless?

You were so impressed by the team.

You become accustomed to seeing well executed medical care. Sometimes it’s hard to appreciate because you are in such awe of what you are witnessing that you almost can’t believe it. You forgot, until this moment, how much of a privilege it is to watch and work alongside people who are uniquely trained to be the absolute best at their jobs. You watched as the OB and the anesthesiologist communicated clearly and coordinated care. As the patient continued to bleed, both teams prepared for an emergency C-hysterectomy. The scrub techs and nurses moved swiftly, efficiently, anticipating directions and keeping meticulous record of everything happening in real time. The entire OR buzzed with an energy that was never frantic, even at the direst point, yet still never completely free of tension, even with the closing stitch. This team thrived on that energy.

And then it was over, the patient made it through.

You came back the next day, your fifth day in the hospital, and nothing had changed. Nothing but you, because you felt different. For a few days, those moments of panic and powerlessness replayed on an endless loop in your mind. Those moments of shock and fear and overwhelming emotion.  And you should remember this day, those terrifying moments, because those are the moments that come to define us.

Sincerely,

-Your Past Self

 

Featured image:
road by Victor Camilo

Categories
Psychology Reflection

Reassessing Resilience

Recently, I had the opportunity to work with a young female patient whose healthcare history could rival that of an octogenarian in complexity. At the end of our 70-minute intake interview, the physician with whom I was working asked our patient a question that made my head snap up from my notes: “What are your hopes and dreams?”

What a simple question to ask, and yet, with my medical student mindset, medication interactions and pending test results were more prominent on my radar than ever considering this patient’s future goals. According to the CDC, half of all American adults live with a chronic health condition, and 25% of American adults live with two or more of these conditions[1]. We are living in an age of chronic disease, and this state of unwellness is never more apparent than when we see patients with healthcare records and medication lists thicker than a Tolstoy novel. With so many health issues to track in just a single patient, it can be a challenge to see the patient through the problem list.

After the physician asked his question, I thought about how easily a member of the healthcare team could fail to foster patient resilience. Resilience is defined as “the ability of systems to mount a robust response to unforeseen, unpredicted, and unexpected demands and to resume or even continue normal operations.” [2] Even for patients with multiple healthcare concerns, including those with multiple adverse childhood experiences (ACEs), it is not unreasonable to believe that resilience can act as a protective factor against those concerns. Asking this patient about her ambitions allowed us to learn about the person that existed outside of the hospital. Understanding that this patient had a plan for her life, and had some notions about how to manifest those plans into reality proved that despite her numerous medical concerns and previous history, the capacity for resiliency was still there. For the first time in that hour-plus interview, I thought about her health conditions as interruptions of her regular life, rather than letting her life be defined by her illnesses.

Most of the research about resilience can be found in psychology literature. The American Psychological Association created a guide called the Road to Resilience, which lists ten recommendations for developing and maintaining characteristics of resilience. These include maintaining relationships with friends and family members, as well as desire and ability for one to improve their life circumstances. [3] It would be appropriate to inquire about these characteristics while taking a patient history. Another tool that we can use to assess patient resilience is the Resilience Questionnaire created by psychologists Mark Rains and Kate McClinn of the Southern Kennebec, Maine Healthy Start program. [4]

There is still plenty of room for research on resilience in the medical literature, but we need not wait for this research to develop our own understanding of the importance of resilience in our care delivery. In the case of our patient with the convoluted medical history, we were not seeing a difficult, diseased, bedridden patient with several chronic illnesses. We were seeing an artist and future psychologist whose life had been set off course by a series of medical misfortunes. It is certainly easier to think of resilience in terms of our younger patients, and while resilience may seemingly be less applicable to certain groups of patients who cannot necessarily overcome their medical concerns, it is still appropriate to help patients set reasonable goals and maintain their support systems. Furthermore, it is always appropriate to understand our patients’ identities outside of their hospitalizations or medical concerns, and it may be helpful to use this personal information to inform our medical therapies.

As medical students, we are rarely able to follow patients over time, so it can be difficult to think of them beyond the confines of their hospital rooms. It is easy to relegate patient “bonding” to the nurses who spend countless hours with these patients. I think one of the most meaningful things we can do as students is to periodically pause to remind ourselves, and our patients, that their hospitalization is only a freckle on their identity as a whole person. At one point, all of our patients had hopes and dreams that likely never involved illness. Part of our delivery of patient care ought to be reflective of helping patients work toward these hopes and dreams, and to identify, and foster, resilience traits whenever possible.

References:

  1. http://www.cdc.gov/chronicdisease/overview/
  2. http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Nemeth_116.pdf
  3. https://philosophy-of-cbt.com/tag/resilience/
  4. https://acestoohigh.com/got-your-ace-score/

Featured image:
Slope Point by Ben

Categories
General Psychiatry Psychology

The Case Against Global Mental Health

‘We have become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams.’
– Jimmy Carter

Western culture is taking over the world; from supermodels on television screens, to fashion accessories in shopping outlets around the world, to the movies made in Hollywood and disseminated worldwide online. Globalization has opened new doors. It has allowed us to build new relationships and learn about new cultures. It has opened our eyes to the worlds beyond our borders – to different languages, religions and beliefs. It has had an impact on every aspect of our lives, including medicine and healthcare.

The pathophysiology of most disease is similar throughout the globe. The diagnosis of a myocardial infarction will have similarities across different continents; an ECG that is normal in the UK will likely be deemed normal in the USA. But when it comes to our inner thoughts and our minds, a similar comparison cannot be made. The Western model of mental illness, of the divisions of neurosis, psychosis and personality disorders yields more than just mere categories. It also produces a set of values and beliefs – namely, that these thoughts and behaviours are outside the remit of social norms. Does a person with a diagnosis of Major Depressive Disorder in the USA show the same symptoms as someone in South Africa? Does this diagnosis hold the same meaning on the other side of the continent? My answer: no, it does not.

Mental health problems go beyond human anatomy and pathophysiology, and treating them like they do not leads to inappropriate therapies. Culture and mental health have close ties that are not addressed when treatment involves only the prescription of a drug. Our mental health colors how we view the world around us; how we view ourselves, our failures and our successes. It defines our identity. In the West our society is based upon science and rational thought. Such a focus has placed a large emphasis on the ‘biomedical model,’ i.e. that symptoms can be clustered together into categories, leading to a diagnosis and a form of treatment. Yet in other countries the idea of being labeled with a ‘disease’ seems bizarre. In many cultures, mental distress is explained through a spiritual lens, based upon the power of one’s ancestors or a curse placed upon one’s family. Who are we to step into this other world and banish such beliefs in the name of the ‘superior’ Western thought?

It can be argued that by placing people within a scientific category, one is filtering out a person’s lived experiences. Sure, a diagnosis may be appropriate in certain circumstances, allowing appropriate support and treatment to be offered to those who are in distress, but we must remember that the diagnoses written in the textbooks do not always correlate with the chaos that is human life.

What is it that makes someone ‘mentally unwell?’ More than anything else, it is a social judgment; it is based upon the idea that everyone over this line is unwell, while those of us who are able to follow the norms of our society are deemed ‘sane.’ Every society is different, and every society has its own ideas of what an illness is and is not. We can often be so determined to get out there and ‘save lives’, that it can be easy for us to forget that when it comes to mental health, it is they (the patients) who have the far superior knowledge of what they are going through. They are the ones who know what emotions they are feeling, what thoughts skip through their mind, what fears drench their hearts. They are the masters of their lives. What is needed is not a rush to produce pills, to prescribe, to diagnose and to medicalize – no, what is needed is humility. The appreciation of our own ignorance in a culture that is different from our own – an understanding that human beings are different. Only then can we begin to take that step to alleviate the distress of mental health problems worldwide.

If we were to take out our Diagnostic Statistical Manuals and set about drawing boxes in other countries, we would find that such a rigid classification system does not translate well to other cultures; a person who fits the criteria for Major Depressive Disorder in London, UK does not necessarily experience the same illness as someone in New Delhi, India. We need to go beyond the symptoms and think about the person’s suffering and pain; what is it that has led them to feel such despair? For some it may be the loss of a job, or status, or wealth. For others, it may be a fall within their social circle, the death of a spouse, or the belief that they are being cursed or punished. We need to be able to understand another person’s suffering if we want to help them. A setback within someone’s life needs to be seen within its context. This involves sitting with people, attempting to understand their lives, eating their food, conversing in their language and understanding what it means to be a citizen in their country. It is not a process that can be ticked through in a few minutes based on a checklist of symptoms. Such arbitrary methods do not capture the emotional and spiritual parts of mental distress, nor do they take into account the vastly different cultural contexts in which patients may live.

Remember that the labels we put on our patients are often value-laden. These criteria we use from our diagnostic manuals are often drawn from the concept of right and wrong – what each society chooses to accept and reject as the norm. When it comes to mental health, what is most important is not the structure of the neurons, nor the actions of their neurotransmitters; it is the effect on the individual, the person within, the person who breathes and feels and cries and laughs.

All of these issues can be illustrated with the worldwide response to the Tsunami in 2005. Following the disaster, many NGOs provided ‘mental health assistance’ by using the Western psychological models of distress, particularly to describe the response to trauma. Most of the workers were ignorant of the local cultural beliefs and traditions, which resulted in a set goals that were more in line with the charities than the victims.

“We are fishermen and we need space in our houses – not only to live but also to store our fishing equipment. After the tsunami we have been living in this camp, which is 12 kilometers away from the coast and in this place for reconstruction. When the international agency came and started building a housing scheme, we realized that they are building flats, which is not suitable to us. But when we try to explain this to the foreigners who are building this scheme, they looked at us as if we were aliens from another planet. What are we supposed to do?”
[..] We have lost our families, now we are having our homes stolen too.”
– Action Aid International 2006 (8)

Such interventions have raised questions as to whether this ‘external mental health aid’ is actually harmful, leading to a division between the ‘superior’ external workers with their Western knowledge, and the locals who have been left helpless and vulnerable.

I am not suggesting that we place a hold on Global Mental Health. I am not suggesting that we stop giving aid. What I am suggesting is that when it comes to mental health, we acknowledge the diversity of the human race. We accept that to be mentally unwell means more than to have an imbalance of chemicals. And by accepting that mental illness affects not just a brain but a person, an identity, a family and a society, we are able to put on our boots and trudge deep into the mud alongside those who we are hoping to help, and perhaps we may even help ourselves along the way.

References

  1. Gilbert, J. 1999. Responding to mental distress: Cultural imperialism or the struggle for synthesis? Development in practice. 9:287-295
  2. Aggarwal, N.K. 2013. From DSM-IV to DSM-5 an interim report from a cultural psychiatry perspective. British Journal of Psychiatry. 37:171-174
  3. Alarcon, R.D. 2009. Culture, cultural factors and psychiatric diagnosis: review and projections. World Psychiatry. 8:131-139
  4. Canino, G., Alegria, M. 2008. Psychiatric diagnosis – is it universal or relative to culture? The Journal of Child Psychology and Psychiatry. 49: 237-250
  5. Harpham, T. 1994. Urbanization and mental health in developing countries: A research role for social scientists, public health professionals and social psychiatrists. Social Science & Medicine. 39:233-245
  6. Kirmayer, L.J. 1989. Cultural variations in the response to psychiatric disorders and emotional distress. Social Science & Medicine. 29: 327-339
  7. Thakker, J., Ward, T., Strongman, K.T. 1999. Mental disorder and cross-cultural psychology: A constructivist perspective. Clinical Psychology Review. 19: 843-874
  8. Gilbert, J. 2007. Mental Health: Culture, Language and Power. Global Health Watch 2.
  9. Gilbert, J. 2007. What is it to be human? Finding meaning in a cultural context.
  10. Gilbert, J. Cultural imperialism revisisted. Counselling and globalization. Critical Psychology.
  11. Gilbert, J. 2006. Cultural imperialism revisited: Counselling and Globalisation. International Journal of Critical Psychology, Special Issue: Critical Psychology in Africa. 17:10-28
  12. Gilbert, J. 2000. Crossing the Cultural Divide? The Health Exchange. April 15-16

Featured image:
Mental Health Conditions by amenclinicsphotos ac