Categories
Clinical Narrative

Did you hear any zebras in there?

“Every child you encounter is a divine appointment.” – Wess Stafford

I made a new friend today. He was sitting on the floor organizing puzzle pieces. I took a seat beside him to take in his perspective. It had been awhile since I joined a patient on this level, but it set the tone of our relationship immediately.

I made a new friend who was excited to share with me. He looked over at me and asked if I wanted to help him sort. “It’s more fun down here, isn’t it? I can teach you where these go,” he offered.

I made a new friend whose favorite things about himself are his freckles, despite what the kids at school say about them. He winked at his mom as we continued to sort the puzzle pieces. “I think your best thing is your smile. It is almost like my mom’s!” he remarked.

I made a new friend who is stronger than most adults I have met. He pointed at a puzzle piece and told me that he has “been sick since he was as tiny as this puzzle piece.”

I realized my new friend just wanted someone to include him in his case. As he recounted his story with vigor, he nodded toward his mother and critiqued, “Usually people like you only want to know what she has to say.”

My new friend showed me the scar on his head and the one across his chest. “I am proud of them,” he stated. “Mom told me I am the superstar of the family… but I think she does more than I do.” He shrugged.

I made a new friend who saw me as an ally. I was amazed at how quickly he trusted me; after all of the doctors he had met before me. “I am not afraid of you,” he said. “Mom says that you want to help me feel better, and mom is always right.”

My new friend had many questions and I did my best to explain why we were meeting. He looked at me with trusting brown eyes and asked, “So are you going to listen to my insides with your special headphones?” I nodded and he held his shirt up for me.

I made a new friend who found humor in a hard situation. “Did you hear any zebras in there?” His eyes were wide with excitement as I put my stethoscope back around my neck.

My new friend challenged me to adapt my exam routine and inspired me to work on my creativity. I let him try my “headphones” out on me. “I think you have some monkeys in you! Let’s see what mom has!” he cheered.

I made a new friend whose heartbeat was weak, but whose heart was full of kindness. As he held the bottle of gummy vitamins above his head, he exclaimed, “These are way cooler than the pills my mom tries to hide in my applesauce! I am going to make you my favorite snack sometime. I won’t put anything bad in it, don’t worry.”

When it was time to say goodbye to my new friend, he gave me a big squeeze and told me he thought we would be good friends. “Next time I will feed the zebras before we come so you can hear them better!”

Featured image:
zebra by SigNote Cloud

Categories
Public Health Reflection

The Flint Water Crisis – The Physician’s Role

Flint, Michigan is a community of 100K residents, the majority of whom are African-American or of lower socioeconomic status. In the recent Democratic debate held in Flint, one mother spoke to the huge challenges that plague the community, including mold in classrooms, unqualified teachers, and the water crisis. In 2014, city officials decided to switch from the Detroit water supply, which gets fresh water from Lake Huron, to the Flint River, which has a long history of contamination, particularly with lead.

Flint residents knew of this contamination and saw brown water flowing in from their taps. They complained for years, long before the media hype, but city officials ignored their voices. Some residents noticed clumps of their hair falling out and an odd taste and smell to the water they were drinking.1

To investigate these claims, Dr. Mona Hanna-Attisha, a pediatrician at Hurley Medical Center and assistant professor at Michigan State University, conducted a city-wide study on the water in Flint. When she recognized that there were alarming levels of lead in the water, she alerted the Environmental Protection Agency (EPA).2 Only then did elected officials start taking residents’ complaints to heart.

Dr. Hanna-Attisha earned the Freedom of Expression Courage Award as well as the respect and gratitude of her patients and peers by speaking up. However, the brave doctor tells CNN in an interview that she was attacked viciously by the state of Michigan when she first presented her research and tried to warn officials of the ongoing crisis. She says she felt “physically ill”3 because of the backlash and professionally vulnerable because her reputation as a physician and researcher was at stake.

Despite the potential professional consequences, Dr. Hanna-Attisha fought for her patients and for the children of Flint, Michigan. In doing so she sent out an important message to physicians: sometimes we must be the voice of the people. It is our responsibility to fight for our patients, whether that means exposing a public health crisis, or more mundane daily tasks like calling health insurance agents to get a patient’s medication covered.

Flint is not the only city in the United States that is dealing with public health crises. However, this particular crisis and Dr. Hanna-Attisha’s role in bringing it to light serves as a reminder for all physicians and medical students: we are public servants and have an obligation to report public health issues in order to ensure the safety of our patients and the general population.

As the notable English physician Sir Henry Howarth Bashford once said, “After all we are merely servants of the public, in spite of our M.D.s and hospital appointments”. Let us not forget this role as we continue through medical school and enter into our practices.

Sources:
1http://www.motherjones.com/politics/2016/01/mother-exposed-flint-lead-contamination-water-crisis
2http://www.freep.com/story/news/local/michigan/flint-water-crisis/2016/01/30/flint-water-lead-health-qa/79475642/
3http://www.cnn.com/2016/01/21/health/flint-water-mona-hanna-attish/

Featured image:
The Flint River, August 2014 by George Thomas

Categories
Emotion Opinion Poetry

A poem

With our white coats on we feel the aura of pressure.
Pressure to be professional, to act accordingly.
We walk through the hospital with our heads held high, knowing we have a duty.

Tossing our white coats aside, true personalities shine through.
Most are gleaming of kindness and enthusiasm to learn,
Others are tainted.
These souls strive to reach a level of professionalism behind their white cloak,
but fail to reach expectations while unhidden.

What I see frightens me,
because these individuals will one day be responsible for the lives of others.
They lie to professors to get what they want.
They come to mandatory sessions, only to depart minutes later.
They cheat.
They sell prescription drugs.
They abuse prescription drugs.
They get intimate in the study spaces.
They do it all with a cheerful face.

What I see frightens me,
because I never want to be like them.

What can be done?
I’ve tried to approach them,
it ended friendships.
Administration knows,
yet I see no change.

Perhaps most terrifying,
these individuals exist at all medical schools.
They hide amongst the rest of us,
polluting the image of our profession.

So here I stand, turning a blind eye,
but what can I do?
I can’t change the mindset of others.
I can’t change their actions.

I only hope they aren’t my doctor.

Featured image:
Rainbow pollution by gambler20

Categories
Emotion General

A Caution Against the Extinction of Emotion

“Well, you know, I was recently diagnosed with cancer,” my friend said lightly in the middle of a spirited conversation about the merits of eating organic vegetables. She smiled as though she had just mentioned a factoid about organic kale, and not told me something earth-shattering. She continued eating her lunch while I sat there slack-jawed, trying to arrange myself. So consumed was I with the news of the diagnosis, I cannot recall a single other thing that we discussed during that lunch.

Throughout medical school, our professors have often told us to “get comfortable with being uncomfortable.” Diligent student that I am, I believed I had mastered discomfort. I believed that no matter how difficult the patient or awkward the situation, I could muster up some empathy and manage to make that prized human-to-human connection that separates the clinicians from the caretakers.

It’s an illusion to believe that we are comfortable with discomfort if we only ever experience discomfort as physicians. In this unique profession of ours, we are prepared to meet strife and pain on a regular basis. Whether we are delivering bad news or seeing a struggling patient, discomfort is no stranger to us. It is essential, however, that we recognize the power imbalance inherent in these situations. As physicians, we are the ones delivering the bad news or offering advice to our patients. As such, we must come from the position of strength. I have also detected the unspoken expectation that no matter what awaits us when go through the door to see a patient, we must remain unchanged when we come back out the other side. While we empathize with our patients and do our best to help them, ultimately, once we step out of the examining room, that bad test result or unfortunate lifestyle choice is the patient’s emotional burden to carry forward, not ours. In other words, our professional responsibilities call upon us to maintain that misfortune as ‘other.’

Even as a student, I’m already seeing how challenging it can be to disentangle my professional identity from my personal life. In my professional life, I have cultivated a sort of empathetic stoicism that allows me to connect with patients ‘in the moment,’ and then quickly wash my emotions off and redirect my focus toward whatever task comes next. It’s a survival tactic that I suspect many of us have deployed. In our personal (non-professional) relationships, however, our identities as children, siblings, lovers, and friends must come before our identities as doctors. Unfortunately, the more time we spend practicing in our professional roles, the more difficult it seems to transition from professional to personal. In personal relationships, we cannot always anticipate when we’re going to receive news, either good or bad, but when we do, we cannot expect to go through the door and come back out unchanged.

In our professional lives, we’re expected to be compassionate but composed. We’re taught to deliver bad news, perform motivational interviewing, and deal with difficult patients, but I wonder where the line is between beneficial sensitivity training and detrimental emotional taming. Before we walk into an exam room, we read through the patient’s chart so we know what to expect, and this allows us to create a sort of comfortable discomfort to protect ourselves. I would argue that this emotional fortitude is not beneficial to all aspects of our lives. Emotions are sloppy—something  that doctors cannot afford to be—but I worry that if we don’t let our feelings bleed through the lines, emotional composure could pave the way for an extinction of feeling. After having lunch with my friend, I had felt frustrated with myself for being so stunned and scared by her news. I didn’t have the emotional composure that I would have with a patient, but that’s the key difference—loved ones are not patients. It’s a testament to our most intimate relationships to express our genuine feelings however uncomfortable they may be. Perhaps, as physicians, we need to work even harder to stay in touch with these feelings so that we never lose our ability to access them.

Featured image:
Feeling. by Javi Sánchez de la viña

Categories
General Lifestyle Reflection

New Job

Every 4 weeks I start a new job. New boss, new co-workers, new hours. This is both the curse and blessing of a medical student in the clinical years. There are some rotations I just can’t wait to end, while others I wish could go on all year. (If there are any of my preceptors reading this blog wondering which category they fit into, don’t worry, yours was definitely the one I wanted to continue forever!) Since I’m a non-traditional student, I had a few jobs over the years. For instance, I worked for a couple years as a civilian contractor for the military. I was doing stuff that sounded really important on paper but was perhaps a bit more mundane in real life. In those days, I knew career civil servants who had been doing the same thing for 30 years or more, sometimes scarcely moving from their desk. I cringed at the thought, but for them, 4 weeks was like a day, and even my entire 4 years of medical school would be seen as no time at all. In fact, one old curmudgeonly co-worker once consoled me after my project was shot down by a Colonel who was also our boss: “Don’t worry, we can get that done when the next guy comes along. These military guys move on after 3 years anyway.” I remember thinking, “In 3 years?! I’m not waiting that long!” It’s no wonder I don’t do that job anymore.

There have been other jobs along the way that have been equally confounding. My first job after grad school was at a non-profit science and tech operation. I was so excited about what I was doing; I thought I really was playing a big part in the volumes of analysis that they put out. Then, a couple months after I started, my boss took me out to lunch for Secretary’s Day, which I promise is a real thing. I sat there eating my meal in utter confusion. I was apparently an assistant, and I always thought I was an analyst.

I recently started a new rotation, my ninth “new job” since beginning my third year. Nowadays it takes me just a couple hours to figure out if it’s going in the good or not-so-good category. Luckily, this one seems to fit squarely in the former. It’s a clinic position, so I have to learn where everything is, and of course most importantly, who to talk to about lunch, as in if there will be any free meals and on which days. This office is used to medical students. I can tell because they made very little initial effort to welcome me. That’s not to say they weren’t nice, indeed they very much were. But there is a different mentality for those who see faces like mine come and go every month. They already know me to a degree, since I’m just the interchangeable body inside the same white coat, with the same 3 or 4 books stuffed into my pockets, and the same questions. They won’t waste their time unless I turn out to be “one of the good ones,” whatever that means.

Sometimes as I wander through all these positions as such a neophyte, I think, does a med student even matter? Are we contributing? The short answer is probably no, until you get that one patient who starts talking maybe just a bit more because the med student seems to have a little more time. Or that patient who feels better just from having been heard, or perhaps reveals some small detail that they didn’t tell anyone else.  Then, in those few moments, I don’t mind being new on the job. I remember that being new is not always a bad thing. In fact, occasionally it can come in handy.

Featured Image:
Lost? by Susanne Nilsson

Categories
Clinical Disability Issues Reflection

Asperger’s & Neurodiversity

“He who is different from me does not impoverish me – he enriches me. Our unity is constituted in something higher than ourselves – in Man… For no man seeks to hear his own echo, or to find his reflection in the glass.” 

–  Antoine de Saint-Exupery (11)

We live in a world of increasing diversity and acceptance. With more efficient travel, greater connections and more robust discrimination laws, never before have so many opportunities been laid out for us to endeavor. Women can vote, same-sex couples can marry; we are on the cusp of entering a new era. Yet amongst all these historical, cultural and economical changes, what we often forget is the psychological. If we are to accept people for who they are, with respect and dignity, then why do we then choose to label them with terms such as ‘Asperger’s’ or ‘Autistic’ and to then reduce the paths they may be able to follow?

What is Neurodiversity?

‘My brain is a jewel. I am amazed with the mind that I have.’ – Muskie, diagnosed with Asperger Syndrome (2)

In the late 1990s, sociologist Judy Singer invented the term neurodiversity; a term that described conditions such as Autism and ADHD (5). This neurodiversity movement was born out of the autistic civil rights movement in the 1990s, and has grown rapidly thanks to the internet. The movement consisted mainly of members who had been diagnosed with Asperger’s, but did not wish to be ‘cured.’ This perspective, a step away from the mainstream method of  categorization, led to books (12) and articles (13) being written, the launching of groups such as the Autism Self Advocacy Network, and a novel  perspective of human thinking.

Neurodiversity is a term very similar to cultural or biological diversity; it takes into account the wide variety of human experiences, and respects people for their differences. Such an approach steps away from the medical model of viewing disability, instead focusing on the talents and perspective that each person can bring to the world. The implications of such a movement are widespread; the right to be treated with respect and dignity, regardless of the way one thinks.

What is Autism?

‘Autism is pervasive, colors every experience, every sensation, perception, thought, emotion, and encounter, every aspect of existence’ – autistic activist Jim Sinclair, 1993 (2)

Autism is found under Pervasive Developmental Disorders in the International Classification of Diseases-10. The criteria listed include impairment in social communication and social attachments (6). First used in 1910 by a Swiss Psychiatrist named Bleuler, it was transformed into its modern-day meaning in 1944 by the Austrian paediatrician Hans Asperger, when he published its first definition. The disorder has been termed Asperger’s Syndrome ever since (7).

Since its first use, the incidence of Autism has increased, leading to increased public attention both in the media and within the medical circle (1). This gradual increase has often led to the question: is this a disease of biology, or of society? Indeed, as our society has become more medicalized, Autism has entered into an era fixated with treatment and cure.

What is ‘normal’?

By continuing to medicalize a different way of looking at the world and of interacting with others, we must first define what it means to have a ‘normal’ perspective of such things.

This question brings to light the very fact that no one is normal. From the way we dress, to the jobs we undertake. From our hobbies to our distractions, our loves to our hates, our desires to our ventures, we are all different. How do we then take out our marking pen and draw a line between those who are ‘normal’ and those who are not? In fact, from an ‘autistic’ point of view, people who are non-autistic are easily distractible, obsessed with social interaction and suffer from profound deficits in attention to detail. The idea of normality changes with time, place, date and gender; what is normal here in the UK may well be considered unacceptable in Sub-Saharan Africa.

Rather than focusing on the normal, we should be focusing on individuality; on what each person can contribute to our society, and to themselves. This boundary between normality and disability is an artifact, a division drawn by man that merely reflects the values of the society in which he resides. For example, dyslexia is based upon our value to read sufficiently, something that would  not have been as significant hundreds of years ago. So what does our medicalization of Autism tell us about ourselves?

As the modern era continues to be transformed by technology, perhaps what we build in the future –with the internet in our laps and a screen at every corner – will become a haven for those who have difficulty with eye contact and with body language. The diagnosis of Autism today may well be different from the diagnosis tomorrow.

Is Autism an identity or a disease?

In the absence of any biomarkers for diagnosing psychiatric illnesses, psychiatry often utilizes behavioural deviations instead (4). Using this argument, one could suggest that psychiatry may end up ignoring advantageous behaviors that are outside the ‘norm’ (4). What we may see instead are the difficulties that entrench a person. Rather than encouraging a young child to develop their interests and their hobbies, instead we may focus purely on their intense obsessions on the minutest details. Imagine what this means for a child. Instead of being seen as a building block of opportunities for ideas and growth, these children may instead see themselves as having un-breakable boundaries.

Yet, a label can have a lot of power. A diagnosis places upon the person a special status within society. It opens the doorway to specialist interventions and support from multiple sectors, helping the individual to succeed in certain areas of life that they may find more demanding than others.

There are clearly many things that children with Asperger’s have difficulty with; areas where they require intensive support and management. It is through these interventions that children may then be able to better integrate with society and feel valued. But the idea of finding a cure seems a step too far. As science continues to delve into our lives, we gradually begin to see everything with a different lens; that there must be pathology in everything that is different, and there must be an answer – a pill, an operation, a test.

But it is not all bad. The medical model has brought with it huge shifts within science – new drugs, new insights and a new life for many, many people. By medicalizing something, by using physiology to explain a condition, you are then able to destigmatize it. Thus, a person is no longer a schizophrenic, but instead suffers from schizophrenia – a disease entity of its own.

Whether or not such a viewpoint can be used for a diagnosis such as Autism is a difficult question to answer. For some, the explanation that Autism is an ‘atypical wiring of the brain’ (2) may help them to understand the difficulties that they face. Yet others may strongly identify with such a diagnosis, claiming that it is a gift that allows them to view the world through a different lens, giving them the opportunity to appreciate the depths of the human mind. They may choose to see themselves not as pathological, as wiring gone wrong, but as privileged beings who have been granted a gift of insight that others cannot fully appreciate.

Different vs Defective

As with many things in life, Autism falls on a spectrum. One could argue that by focusing on those who are high-functioning, and therefore able to have this debate, you are minimizing the true suffering of those who do not have this privilege. Indeed it can be argued that because it is on a spectrum, one should be careful not to blanket everyone with Autism as either having a ‘disability’ or simply being ‘high-functioning.’ The aim is to view Autism with a more open mind, rather than as something that requires a gene to be unlocked. This has received appreciation by the American Psychiatric Association, who recently converted the diagnoses of ‘Autism’ and ‘Aspergers’ into one simple diagnosis of ‘Autism Spectrum Disorder.’ Through the creation of this diagnosis, the emphasis has been placed on the idea that people do not fit into boxes, but lie upon a continual line that can encompass a wide range of behaviour.

Neurodiversity is the idea that neurological differences such as Autism are due to normal variation, rather than a sign of pathology. This point of view emphasises the fact that these people do not necessarily need to be ‘cured’ but helped and accommodated. If we look at the progression of science and the humanities, we see that the breakthroughs have been developed by minds that think differently; create links where others have drawn their blinds. If we are to grow as human beings, then this is the approach that is required; not just to grow scientifically, but also morally. Unfortunately, we are currently drawn towards questions of causation and cure – the link between Autism and MMR by Wakefield being just one example (8); an attempt to find blame, and ask the question: why is my child the way he/she is?

And to people with these conditions themselves, surely the idea of being part of a natural variation is much more appealing than being seen as something that is broken and needs to be ‘fixed.’ To describe someone as defective is to take away the essence of who that person is, and what they can bring to the world, to their family, to themselves.

Instead of creating a world focused on finding cures, on ridding the world of autism, we should be building the foundations to allow people to receive the support they deserve, to have their rights heard. Such efforts include early interventions for speech and behavior therapies, and building more accommodating home and work environments.

If we are to accept the fact that equality has been applied to race, religion, gender and sexual orientation, then why can it not be applied to people with different ways of thinking and interacting as well?

We are already seeing glimmers of this in our current society. Mark Haddon’s novel, The Curious Incident of the Dog in the Night-time, written from the point of view of a young boy with Autism, helps readers to transcend their lives and view the world from eyes that see differently, a mind that whirs at a different tone. This novel  is studied by English students across the UK (9), and perhaps by encouraging these types of empathetic endeavours, rooted in the humanities rather than the sciences, a new way of thinking can be formed, where we can focus on acceptance rather than on cure.

‘An autistic child can only be helped if a serious attempt is made to see the world from his point of view.’ (10)

References

  1. Baker, D.L. 2006. Neurodiversity, neurological disability and the public sector: notes on the autism spectrum. Disability & Society. 21:15-29
  2. Ortega, F. The Cerebral Subject and the Challenge of Neurodiversity. 4:425-445
  3. Jaarsma, P., Welin, S. 2012. Autism as a Natural Human Variation: Reflections on the Claims of the Neurodiversity Movement. Health Care Analysis. 20:20-30
  4. Kapp, S.K., Fillespie-Lynch, K., Sherman, L.E., Hutman, T. Deficit, Difference, or Both? Autism and Neurodiversity. Develeopmental Psychology. 49:59-71
  5. Silberman, S. 2013. Neurodiversity reqires conventional thinking about brains [Online]. Available at: http://www.wired.com/2013/04/neurodiversity/ [Accessed: 1st January 2016]
  6. World Health Organisation. 2016. ICD-10: International statistical classification of diseases and related health problems. Geneva: World Health Organisation
  7. McGuinness, S. 2015. History of Autism [Online]. Available at: http://www.autismuk.com/home-page/history-of-autism/ [Accessed: 1st January 2016]
  8. Godlee, F., Smith, J., Marcovitch, H. 2011. Wakefield’s article linking MMR vaccine and autism was fraudulent. The British Medical Journal. 342:c7452
  9. 2013. Subject Content [Online]. Available at: http://www.aqa.org.uk/subjects/english/aqa-certificate/english-literature-8710/subject-content/why-choose [Accessed: 1st January 2016]
  10. Stanton, M. 2006. What is Neurodiversity? [Online]. Available at: https://mikestanton.wordpress.com/my-autism-pages/what-is-neurodiversity/ [Accessed: 1st January 2016]
  11. Evans, T. 2015. Counselling Skills for Becoming a Wiser Practitioner: Tools, Techniques and Reflections for Building Practice Wisdom. Jessica Kingsley Publishers.
  12. Silberman, S. 2015. NeuroTribes: The Legacy of Autism and the Future of Neurodiversity. Avery
  13. Solomon, A. 2008. The Autism Rights Movement [Online]. Available at: http://nymag.com/news/features/47225/ [Accessed: 28th January 2016]

Featured image:
Diversity by Séb

Categories
Emotion General Reflection

What We Carry

I recently stumbled upon an entry on another blogging site I follow, featuring a piece by Pamela Wible, MD. She’s a family physician who recently published Physician Suicide Letters — Answered. She also gave a moving TEDx Talk last year where she spoke about the four hundred physicians (and medical students) who commit suicide each year. She discussed some of the stressors physicians face, like losing income to hospital overhead or working incredibly long hours. Her unhappiness in the field motivated her to start what she calls an Ideal Medical Care practice.

After listening to this talk and looking into ordering her book, ironically, I felt kind of depressed. As a pre-med student, I was always so excited to become a doctor. I think I glorified this career choice for a long time, which isn’t necessarily a bad thing. As I’ve made my way through my first two years of medical school, I’ve experienced some of the heavy burdens that we can endure by choosing this career path. Long hours of studying, high-stakes exams and, ultimately, the responsibility of another human’s life.

These same stressors can be applied to many other rigorous fields. I’m sure law students spend countless hours reading up on cases. Engineers might make a decision that has a lasting impact on whether someone lives or dies in a car accident. So why does the medical field have such an epidemic of suicide on its hands?

One of the main differences I see between professional fields is the proximity medical providers have to death. I’ve become quite confused on how exactly we are supposed to grieve. Many medical students have heard that in the past you weren’t supposed to show emotion and to separate yourself from death when a patient passes. Obviously, the sentiment has changed and the values we instill in future physicians are different, but I don’t think our coping skills have drastically improved.

As early as the pre-medical years, students in this field encounter death. I worked in a cadaver lab in college where I was intimately exposed to death in a way I had never dealt with before. As first-year medical students, it becomes easy to forget our cadavers are human bodies, and in the clinical years, in the hospital, death is everywhere.

When will we stop to cope? Can we take a week off to grieve when we experience death? Will our superiors understand why we seem “off”? When you deal with death on a frequent basis, it’s easier to forget. We bury the emotions that we carry. However, keeping things in and not going through a proper grieving process can be detrimental to our health and well-being. It’s important for medical providers to understand the weight of death that we carry and its effect on our own mental health.

In my opinion, teaching proper grieving and allowing medical students time to cope would be a useful addition to the medical school curriculum. This might even lower the suicide rates in our field. The things that lead someone to commit suicide are ultimately multi-factorial, but I think this is one way we can try to improve these numbers.

Featured image:
sunrise and silence by x1klima

Categories
General Lifestyle Technology

Keyboards and Stethoscopes: A reflection on digital etiquette in medical school

February 26th marks the 47th anniversary of the landmark freedom of speech case, Tinker v. Des Moines. This case concerned a group of students who wished to wear black armbands to protest the Vietnam War. When their school banned the armbands to quash the protest, the students decided to sue, and the case made it to the United States Supreme Court. In the final ruling, Justice Abe Fortas wrote, “It can hardly be argued that either students or teachers shed their constitutional rights to freedom of speech or expression at the schoolhouse gate.” When writing his response, Justice Fortas probably didn’t imagine the digital age that we would be living in just half a century later.

Thanks to the power of the Internet, people can connect from thousands of miles away and ideas can go viral in mere seconds. The freedom of expression that the Internet affords us is practically limitless. The Internet can bring greater awareness to important humanitarian issues like ALS through the Ice Bucket Challenge, but its power as a terrorist recruitment tool can also be harnessed to spread chaos and destruction.

I wonder, as medical students, what our responsibilities are towards using social media responsibly, and how we balance these responsibilities without sacrificing our freedom of speech. In observing our class Facebook page and reflecting on my own bevy of social media faux pas, I have come up with the following five suggestions that I believe strike a balance between our professional responsibilities as medical students and our First Amendment rights.

  1. If something on Facebook offends you, have a face-to-face conversation with the person who posted the content. Avoid writing an angry response or a long rant, which can perpetuate further miscommunication. If a face-to-face conversation is not possible, give yourself a cooling off period before you respond.
  2. Never take down someone’s post without first talking to him or her about it. In our class, we’ve had a few situations where administrators of our group pages have taken down posts that they deem to be offensive or inappropriate. Conceivably, this was done to protect the integrity of the group and keep our Facebook page a “safe space”, but in reality, taking down someone’s post violates their freedom of speech and can make them feel unsafe. Before choosing the safety of the many over the safety of the few, talk to the person who posted questionable content and see if they will alter or possibly remove their post on their own.
  3. No babysitters! School administrators and faculty should not “babysit” class Facebook groups. A class Facebook page should be about fostering a sense of camaraderie amongst students, not about representing a school’s public identity. Therefore, the page should be private, and it should be the collective property of the students who chose to use it. Should disputes arise, they should be settled amongst students. Administrators should avoid getting involved in social media disputes unless they are directly asked to step in. Handling miscommunications and managing uncomfortable situations with our colleagues is important training for our professional careers.
  4. It’s okay to be a backstage comedian. Though this is likely my most controversial suggestion, I strongly believe that in our high-stress lives as students, and later as physicians, we benefit from being able to let off steam in a protected environment. A few months ago, we received a rather outrageous and somewhat distasteful lecture from some guest speakers. Not surprisingly, certain members of our class took to Facebook to share their “fond memories” of this unforgettable class. Somehow, the school administration was alerted to this content, and the students were asked to remove their posts. It’s only natural that from time to time, we’re going to find humor in something that happens in school or in the workplace. I think that it’s healthy to derive enjoyment and levity from these occurrences. In his writing, Immanuel Kant argues that laughter at an event is not a show of superiority, but rather an acknowledgement that the event differed from any reasonable expectations. Acknowledging the comedy of a situation is not at odds with our professional identities when it helps us to process and move on with overwhelming or uncomfortable events.
  5. Express yourself! I love when my classmates post articles that they find that I would have never otherwise discovered, or when a discussion from class spills over onto Facebook page. It makes me feel like I’m part of a community of people who value learning and exploration, and I have learned a lot from these posts.

Reach out to me on the MSPress Facebook page! I would love to hear your thoughts on Facebook and social media etiquette in medical school.

Featured image:
Der Blogger… by Dennis Skley

Categories
General Lifestyle

Nutrition 101

A 2011 Consumer Report found that 9 out of 10 Americans consider their diet healthy.5 People have become accustomed to reading product labels, estimating portion sizes, fashioning colorful meals, and some may even have a grocery list stored on their phone. Yet many still find themselves eating too much or too little. How many nutrients are we really getting and what are they doing once they enter the body? Are we sufficiently addressing nutrition with patients?

It has been rumored that people lie about what they eat 100% of the time. Consequently, it’s likely that patients’ eating habits are holding them back from health. According to a recent poll1, fewer than one-eighth of physician visits include any nutrition counseling and fewer than 25% of physicians believe they have sufficient training to discuss diet or physical activity with their patients.

These statistics have created a demand at the national level for reform. A few recommendations from the American College of Sports Medicine and the Alliance for a Healthier Generation include developing a standard nutrition and physical activity curriculum for medical and health professional schools, increased testing on nutrition and exercise for licensing and certification exams, and better insurance reimbursement for preventive care.2 While this will be a long-term shift, these are important strides in a beneficial direction.

Because of the relative neglect of nutrition in medical education, physicians tend to either ignore the subject or offer limited advice. For example, gastroenterologists may focus solely on fiber content, while nephrologists may focus on sodium intake.

“As long as the healthcare marketplace undervalues preventive care, health care professionals will lack financial support to address these issues with their patients and medical schools will have less incentive to train their students accordingly,” the report notes.1,2

Compared to the 20 hours devoted to nutrition in allopathic medical schools, Naturopathic medical students receive roughly 200 hours through courses such as nutritional biochemistry, science of diet and nutrition, and clinical nutrition.  This uniquely positions naturopathic doctors as physicians who not only specialize in preventative healthcare and chronic disease management, but also lifestyle and nutrition counseling.

For those looking to delve more into their patient’s nutrition status, one simple place to start is using a diet questionnaire for evaluation at baseline and to track changes over the course of treatment. Furthermore, there are an increasing number of online nutrition education programs directed towards practicing physicians. An example of one such resource is The Nutrition Source.

Why nutrition matters:

As one of my professors says, “You can be lean and mean with the illusion of health, but inside you can have raging inflammation.” The foods we eat turn on or off certain pathways and subsequently cause the release of chemical mediators. Over time this process lays the foundation for low-grade inflammation. Our enzymes convert dietary acids into prostaglandins, some of which create inflammation and pain. Therefore, based on these basic concepts, when we eat foods like sugar and flour that create these mediators, we are creating pain. Simply put: the food we eat changes our body chemistry. The more nutrients we can obtain through our food, the more building blocks are available to support the chemical reactions that take place in order for us to be alert and create energy.  While drugs like Tylenol and NSAIDS can be necessary and may help to reduce diet-driven pain, they do not treat the underlying cause.

As a naturopathic student, I hope to educate and inspire other medical professionals to learn more about nutrition in order to deliver more optimal clinical care to patients. Continuing medical education should include topics in nutrition research and instruction on how to critically evaluate new evidence in the field of nutrition. Physicians are simply one element of the much larger system necessary to promote health and wellness through nutrition. By emphasizing the influential role of nutrition in medical training and practice, we can further our ability to reduce suffering in patients.

References:

  1. Alliance for a Healthier Generation; American College of Sports Medicine; Bipartisan Policy Center. Teaching nutrition and physical activity in medical school: training doctors for prevention oriented care [white paper]. June 2014.
  2. Bernstein, Lenny. “Your Doctor Says He Doesn’t Know Enough about Nutrition or Exercise.” Washington Post.
  3. Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med. 2014 Apr 19.
  4. Katz, M.D. David. “Why Holistic Nutrition Is the Best Approach.” The Huffington Post. TheHuffingtonPost.com, 1 Apr. 2011.
  5. Ward, Tricia, and Stephen Devries. “Doctors Need to Learn About Nutrition.” Medscape, 4 Sept. 2014.
  6. http://www.consumerreports.org/cro/diet-plans/buying-guide.htm

Featured image:
National Nutrition Month Book Display by The COM Library

Categories
General Reflection

Culture and Medicine

Culture binds together the building blocks of our identity. It defines the paths we choose to walk, the people we seek to befriend, and the meaning we place upon our lives.

It is present at every job interview, every birthday, every heartbreak and every wedding. It is the voice in our ear that cautions us when we go against our values, the shoulder that nudges us with soft hands towards tradition. Whether we choose to acknowledge it or not, the fact remains that something so vital to our being also forms the roots of nourishment and support during the most trying times of our lives: ill health.

Think of the word “culture”, and many definitions come to mind. For some, it is a cage; bars that stow rigid beliefs and deep lines of division in the sands. For others, it is a sweet reminder of their childhood, their distant family. A link to their ancestors perhaps, or a nod to the countless sacrifices that so many generations past have made.

Clearly, culture is not a gleaming jewel in itself. There are walls that culture can build – stereotypes, divisions, segregation and war to name but a few. And we must be aware, in this ever-increasingly globalized world, that cultures are not typically singular. Families immigrate and pick up traditions and values as they plant their new lives upon fertile soil. Our beliefs about ourselves and those around us continue to change and transform as we step outside of our boroughs and breathe in new air. It is this mixing of values and beliefs that can help form ties with traditions long lost, offering diversity and different ways of looking at life. For example, Bhui (2011) found that there was a high risk of suicide in South Asian women, but this risk was attenuated when these women were born in the UK. What is it about growing up in the UK that has an impact upon such a profound decision? Or indeed, what is it about growing up in South Asia that directs people down the path of self-destruction? If culture can have an impact on such a deep level, perhaps it is something worth examining.

Are we looking after a sick body or a sick society?

Culture teaches us how to speak, how to act, how to think and how to breathe. The range of emotion we express to our friends, our family and to the public at large is limited by the boundaries of by our cultural habitats. Some cultures place emphasis on dignity and self-reservation – of being stoic in times of difficulty. Others may open arms wide, taking in grief and self-loathing, pity and joy, stirring these feelings into a melting pot of human life, rich in colour. The more we learn about our culture, the more we learn about ourselves – the way we think, what we think, why we think the things we think. Not only is this important for us as individuals, allowing us to grow and change, but it is also important for us as clinicians, when we are charged with the task of rebuilding and restoring these things when they inevitably fall apart.

We, as healthcare professionals may continue to learn from our textbooks about drugs and their effects, but in a world transformed by increased living, both quantitatively and qualitatively, perhaps it is no longer drugs that matter to our patients, but how we choose to approach our decaying bodies.

It is culture that shapes the way we face our woes and despairs. During the moments of agony, of aches and pains, it is culture that provides the lens through which we view ourselves. Do we remain stoical, chuckling heartily at the jokes juggled around by the nursing staff, or do we sit down with our head in our hands, so consumed by our grief that our need to wear a mask is but a luxury of a world far away. In the end, it is up to the doctor, the nurse, the healthcare professional to explore and understand how it is the patient views themselves, their body and the world around them. We can do this gently, by probing into the innermost recesses of our patients’ lives – encouraging a conversation, engaging in questions that touch at the heart of the person:

What do you do to stay healthy?

What does illness mean to you?

Who are your social supports?

How do you view doctors and medications?

We must remember that medicine is not a dogma upon which we pontificate. People may have differing beliefs about their illness, and in the end, these may be the only things left to tie their hopes to. For example, some people in India may use karma to explain illness, underlying their deeply religious and spiritual background (Fernando 2012). In the Western nations, where society has gradually built its walls between thyself and thy neighbours, people may return to their GP again and again with vague complaints, when the underlying problem may be psychosocial. This idea is illustrated beautifully in the following blog post: https://abetternhs.wordpress.com/2013/05/04/loneliness/

Although bodies have signs and symptoms, only people become sick.

Nichter 2010 described five expressions of idioms of distress:

  • Medicine-taking behaviour: requests for prescriptions, self-medication
  • Biomedical disease nomenclature: associating distress with disease
  • Diagnostic tests: expressing distress to others by taking tests
  • Healthcare-seeking: searching for a practitioner and a diagnosis
  • Changes in consumption patterns: e.g. increased smoking – distress communicated nonverbally

As we can see, people seek help for a variety of reasons. It may not be as simple as a quest for a prescription, for a scan or a blood test. By focusing only upon these rigid scientific measurements, you lose what it means to be a patient – to suffer. This is a loss not only for the patient, but for the clinician and for the healthcare system. When the physician becomes a robot, with an ever-increasing checklist to tick through, or list of procedures to complete, the vital relationship between doctor and patient is lost. This is the relationship upon which lies the patient’s hopes, fears, trust, and beliefs. When this relationship begins to wither, with it goes compliance and faith in the healthcare system – the willingness to step in front of a clinician and say ‘I need help.’

Of course, taking into account such a colossal term as ‘culture’ and applying it to each and every patient, one after another, day in day out, is not an easy task. Try as we may, the largest part of our curriculum is based on the medications we administer, the scans we perform, the blood tests we order. Our training in the scientific and technical fields gives us our title and our role. It takes a lot of courage, determination and compassion to go beyond these components of the therapeutic relationship, and explore our patients as whole persons with equal parts body, mind, and spirit. To help expand upon this, Blumhagen (1962) cited in Parry (1984) compiled some sample questions:

What do you think has caused your problem?

Why do you think it started when it did?

How severe do you think your illness is?

What do you fear most about your illness?

What are the chief problems your illness has caused for you?

What are the most important results you hope to get from treatment?

The Culture of Healthcare

I have spoken much about the cultures in which our patients present themselves. However, we too are human beings, which means we too are subject to cultural conditioning. We are part of the culture of healthcare, which has biases all its own. In a world that has become and continues to become transformed by multiculturalism, it can be easy for doctors to feel alienated from patients. After all, we cannot hold the same beliefs as every single one of our patients. It is not similarity of beliefs that is required, but an understanding and an appreciation. What patients want isn’t a parrot to recite back their own ideals, but a person who is able to accept the world in which they reside, respecting the decisions they make with an appreciation of the diversity of human life. And perhaps, through this understanding, a truly patient-centered approach can be adopted, in which it is the patient’s belief that takes precedent, and not those written down in a textbook by a retired professor. To reach this level, there is but one obstacle: ourselves. We need to become aware of our own biases –what makes us tick, what prejudices we hold, what makes us squirm, what opens our heart and makes it beat. Once we begin to learn more about ourselves, we can then take the step to learn more about our patients and the lives they lead.

If we do not take these steps to gain a greater understanding of our own being, then the outcome can only be confusion, unease and distress. One example of this is the release of the National Mental Health Program in 2002 by the Indian government, which placed emphasis on psychotropic medication. Jain and Jadhav (2009) argued that this focus on medication silenced the voices of the community. They noticed that social workers in rural villages took histories of patients, decontextualizing the symptoms into a list from which the doctors could make a diagnosis. The symptoms of the patients were seen through a biomedical lens, and clinical dialogues were structured around compliance. The medication eventually served as a boundary, with psychologists and social workers seen as assistant doctors– the power lying in the hands of the prescribers. The clinicians were alienated from the daily lives of their patients, ignoring the idioms used by their patients to describe their suffering.

What do we do?

Although physicians may memorize lists of cultural attributes, we must not forget the individuality of each patient. Families can adopt new values that may not always be tied to their heritage. Alas, culture is an ever-sticky concept – yet if it were anything else it would not be human.

So what can we do? We can acknowledge the person sitting in front of us in their entirety. We can become aware of any judgments that may cross our mind, and fix our eye on the person with open curiosity. We can learn from our patients, and allow them to teach us how we can best help them. They are the experts in the room.

 

References

Bhui, K. 2002. Explanatory models for mental distress: implications for clinical practice and research. The British Journal of Psychiatry. 181:6-7

Bhui, K. 2011. Cultural psychiatry and epidemiology: Researching the means, methods and meanings. Transcultural Psychiatry. 48:90-103

Campbell, C., Burgess, R. 2012. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcultural Psychiatry. 49: 379-395

Chau, R.C.M., Yu, S.W.K., Tran, C.T.L. 2010. The diversity based approach to culturally sensitive practices. International Social Work. 54:21-33

Fernando, G.A. 2012. The roads less traveled: Mapping some pathways on the global mental health research roadmap. Transcultural Psychiatry. 49:396-417

Ganzer, C., Ornstein, E.D. 2002. A sea of trouble: A relational approach to the culturally sensitive treatment of a severly disturbed client. Clinical Social Work Journal. 30:127-144

Jain, S., Jadhav, S. 2009. Pills that swallow policy: clinical ethnography of a community mental health program in Northern India. Transcultural Psychiatry.46:60-85

Kleinman, A., Benson, P. 2006. Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLOS Medicine. 3:e294

Lee, E. A working model of cross-cultural clinical practice (CCCP). Clinical Social Work Journal. 40:23-36

Nichter, M. 2010. Idioms of Distress Revisited. Culture, Medicine and Psychiatry.34:401-416

Parry, K. 1984. Concepts from Medical Anthropology for Clinicians. Physical Therapy. 64:929-933

Swartz, L. 2012. An unruly coming of age: The benefits of discomfort for global mental health. Transcultural Psychiatry. 49:531-538

 

Featured image:
The palace of culture – Warsaw, Poland – Travel photography by Giuseppe Milo