Month: June 2015

Categories
Literature

The Spouter-Inn: let’s see what’s inside

Photo courtesy of Tony Sun
Photo courtesy of Tony Sun

The third chapter of Moby Dick, “The Spouter-Inn,” is all about how to interpret new things. Ishmael, who settled on staying in the hotel called “The Spouter-Inn:–Peter Coffin,” tells readers about what he sees upon entering the hotel. Let us compare Ishmael to a medical student, first entering a new floor, say the neurology floor of a hospital. Ishmael and student are both faced with the task of making meaning from whatever presents itself. On that floor, the student wonders: who are the people sitting in the center of the floor? What is the meaning of the NPO signs next to some room entranceways? On entering Spouter-Inn, Ishmael wonders: what is this painting I see? What are the “monstrous clubs and spears” doing on the wall? I draw this comparison between Spouter-Inn and the neurology floor because I remember thinking about Ishmael’s first visit to that inn when I entered the neurology floor, where my physical diagnosis practice took place. I wasn’t sure what to expect, and there is not much to do for preparation. Like Ishmael, I just walked in and did my best to make sense of what I saw. If there was any “preparation” on my part, it was reading Moby Dick and knowing about the analogous situation of walking into a foreign Spouter-Inn.

For Ishmael, a painting hanging on the wall caught his attention, though he couldn’t make sense of what the painting was about. However descriptive he was about what he saw in the painting, he couldn’t give readers a definite sense of what the painting was. While you might see a painting at the Metropolitan Museum of Art and text your friend what you saw (Washington crossing the Delaware, or the like), Ishamel tells readers this:

A boggy, soggy, squitchy picture truly, enough to drive a nervous man distracted. Yet was there a sort of indefinite, half-attained, unimaginable sublimity about it that fairly froze you to it, till you involuntarily took an oath with yourself to find out what that marvellous painting meant. Ever and anon a bright, but, alas! deceptive idea would dart you through.–It’s the Black Sea in a midnight gale.–It’s the unnatural combat of the four primal elements.–It’s a blasted heath.–It’s a Hyperborean winter scene.–It’s the breaking-up of the ice-bound stream of Time…But stop; does it not bear a faint resemblance to a gigantic fish? even the great Leviathan himself?

Remembering Ishmael’s struggle to make sense out of that painting, I felt a comfort of familiarity, the best feeling I think that someone can feel when thrust in a new situation. It’s OK that Ishmael couldn’t make sense of the painting he saw on the wall, just as it’s OK that I didn’t know what to make sense of the labels telling me: NPO, or D5 0.45 NS. It’s no big deal to look those acronyms up on my smartphone, or just simply ask someone, the latter of what was done in Ishmael’s time: “based upon the aggregated opinions of many aged persons with whom I conversed upon the subject. The picture represents a Cape-Horner in a great hurricane.” This comfort of familiarity I mentioned earlier arises not necessarily from previously seeing the acronyms “NPO” and “D5 0.45 NS,” though seeing them before certainly does add to familiarity–no, this comfort comes from knowing that it’s not uncommon for someone, someone even as smart as Ishmael, to see something and be entirely uncertain what it is and to have several guesses as to its meaning.

Featured Image:
Silver Bank Outtakes by Christopher Michel

Categories
MSPress Announcements

Announcing: The Free Clinic Research Collective

On behalf of the entire MSPress Team, I am very proud to announce a call for papers for the newest MSPress publication, The Free Clinic Research Collective (FCRC). The FCRC is currently accepting: original research, brief communications, narrative/reflection essays, and viewpoint articles.  Since the FCRC’s official online debut in February 2015, we have received enthusiastic responses from medical students across the nation.  We are still reviewing and accepting submissions, so please do not hesitate to contact me, Elizabeth C. Lee, the FCRC Associate Editor, at freeclinic@themspress.org with any questions!

As we have received numerous inquiries about the FCRC, I thought it would be helpful to write a blog post to provide further information about this new publication.  Here are some FAQs that I have received:

#1 What is The Free Clinic Research Collective (FCRC)?
The FCRC is a new peer-reviewed, open-access publication from The MSPress that aims to establish a national collective of student-run free clinics.  Almost every medical school in the U.S. has at least one student-run free clinic, and yet there is currently a paucity of literature about these clinics.  With the launch of the FCRC, our goal is to improve the distribution and accessibility of information relating to student-run free clinics by creating a centralized publication hub for easy information retrieval.  Additionally, the FCRC encourages medical students to share their experiences in working with underserved populations in interprofessional settings at their schools’ student-run free clinics.

#2 What types of submissions are accepted by the FCRC? 
The FCRC accepts the following: research articles, brief communications, narrative/reflection essays, and viewpoint articles.  (NB: In the future, we will also be accepting correspondences. More on this in #3 below!)  As we are firmly committed to embracing all medical student original work, please contact freeclinic@themspress.org if your work does not “fit” into any of the above categories, and we would be happy to work with you to help get your work published!

#3 Why should I submit my work to the FCRC?
Thank you for asking!  Here are 5 reasons:

  1. Get your research published in a peer-reviewed journal.  (Tip: If you’ve already given an oral presentation or made a research poster on a topic related to student-run free clinics but have not yet published your findings, then simply translate your work into a research article format, and send it to us!)
  2. You are/have been a student leader at your school’s student-run free clinic, and you have insight into your clinic’s organization, management, services, and limitations.  Sharing this information by writing a brief communication would help your peers across the nation improve efficiency in their own home clinics, leading to better patient care.
  3. You have a particularly exciting or memorable patient encounter or experience at your school’s free clinic, and you would like to share your experience with your peers by writing a narrative/reflection essay.
  4. You have an opinion about the role of student-run free clinics in addressing issues, such as: health disparities, access to quality care, primary care physician shortage, medical education, etc.  If you have an opinion on a topic involving student-run free clinics, then write a viewpoint article!
  5. You enjoy the art of debate.  (Not a joke!)  If so, then write a correspondence article!  This is one particularly unique aspect of the FCRC, which is not just a simple one-way information portal.  Through correspondence articles, the FCRC encourages intercommunication between authors and readers by establishing an open dialogue.  The correspondence article gives readers the opportunity to comment on any previously published article in the FCRC.  If your correspondence is accepted for publication, then a copy will be sent to the author of the original article, allowing for the opportunity of a brief reply.

At the MSPress, we have a highly dedicated team of editors and peer reviewers, and we ensure that each submission undergoes a blind peer review process and receives full consideration for publication.  I have deep confidence in the launch of our new publication, The Free Clinic Research Collective, and am proud to launch this wonderful platform for the benefit of medical students across the nation to exchange ideas and share their research findings regarding student-run free clinics.

Again, please do not hesitate to contact me, Elizabeth C. Lee (FCRC Associate Editor), at freeclinic@themspress.org with any questions. Thank you for your hard work out in the clinic, and we look forward to reading your submissions!

Consult the Free Clinic Research Collective Author Guidelines

Categories
Disability Issues Lifestyle Opinion

Hearing Voices

“In examining disease, we gain wisdom about anatomy and physiology and biology. In examining the person with disease, we gain wisdom about life.”
― Oliver Sacks

Hallucinations are a window into the mind. They illustrate the complexity of the human mind and the pathways that can lead us astray. Art has explored the idea of madness over the centuries, translating paranoia into tragedies, delusions into dramas. It is only in the 20th century that hallucinations have been described as a sign of illness. In the past, hearing voices used to be linked with saintliness and spiritual enlightenment: a path towards God. Hallucinations are also heavy with cultural meanings: we can look back at Moses and the burning bush or Buddha beneath the Bo tree. Different cultures prescribe meaning to different senses: Protestants emphasise hearing while Catholics emphasise vision. Perhaps most interestingly, West Africans partake in kinesthesis; Westerners distrust unusual sensory experiences and label them as pathological.

The term auditory verbal hallucination refers to hearing a voice in the absence of an external stimulus. Auditory hallucinations are more common within the general population than many of us may think, especially in times of stress: up to 70% of people have been found to hear the voice of their dead relative during bereavement. Most of the people who report auditory hallucinations within population studies do not report any distress or impairment; they are able to live happily alongside these voices within their heads. Some people find that their voices can give them guidance through difficult times, while others see them as a companion or a best friend. After all, we do not consider it abnormal for a child to report that they have an imaginary friend. This relationship between the person and their voice is incredibly complex – as complex as any other relationship we may encounter, and we must tread softly when we deal with such intimacy.

Hearing Voices as a Disease
Hearing voices is not the same as having a sore throat. Hearing a voice can have a deep significant meaning to the person in a way that a sore throat cannot. So what makes the voice pathological?

Western Society sees hallucinations as pathognomonic of a serious mental health disorder. Serious psychotic disorders are however recognized across all cultures with a similar pattern of symptoms. Hallucinations that are linked with serious psychotic disorders are described as ‘pathoplastic’ – that is, they are shaped by local meanings. Behind the response to voices is the attitude of society. The society we grow up in has a lot to say about the meaning of these voices: Mexican-American relatives are more likely to display tolerance and sympathy for a relative hearing voices compared to Euro-American families, who are more likely to display criticism and hostility. If you grow up in a society where you are taught that hearing voices is wrong, this will affect your relationship with them. Imagine if you were a child hearing voices, and you turned to your parents to support and found they were even more afraid of the voices than you. Would you see your voices as an enemy, or a friend?

People experience the mind and its underlying symptoms differently depending on where they grow up. Prof Luhrmann found that US patients self-identify as schizophrenic, using the diagnosis to describe their condition through textbook definitions. They accept the medical diagnosis and are even able to recite the medical criteria – for them, the meaning of the voice is “to be crazy.” In general, the American sample did not treat their voices as a person and many of their voices were filled with violence. On the other hand, in Accra people described voices as a spiritual attack. Half of patients reported hearing only positive voices. Even when hearing negative voices, individuals also described good voices telling them to ignore these negative influences. Some people in Accra even said these voices kept them alive. In India, hearing voices is viewed differently yet again. Many of the doctors don’t mention a diagnosis and families don’t ask. None of the patient’s believed they had a devastating illness, and thus compared to the West, most of them expected to get better. Does this suggest that people suffering from hallucinations in the developed world have a better quality of life?

It has been suggested that within the Euro-American culture, an individual who is unable to distinguish between reality and imagination is labelled as pathological, while in many non-Western societies such rigidities do not exist. But this labelling goes beyond cultures; it transcends time. Mitchell and Vierkan compared hallucinations in an East Texas hospital both in the 1930s and then in the 1980s. They found that command hallucinations of the 1930s were found to be more religious, such as “lean on the Lord,” while those of the 1980s were more destructive, such as “kill yourself.” Perhaps such changes reflect the hostile environment we have created for our patients, and thus leads onto the questions: are we treating our patients with a dignified and open manner? Do we treat them as fellow individuals?

If you do not envision schizophrenia as a life sentence, you increase the chance that patients will be able to discover their own resilience.
– Prof Luhrmannn

Hearing Voices as a part of Life
In 1987 psychiatrist Marius Romme appeared on Dutch television with his patient Patsy Hague, a voice hearer, to publicise his new approach to voice hearing – that attributing meaning to one’s voices changed the way one responded to them. Four hundred and fifty people responded to this television appearance, reporting that they heard voices. More than half of the people who responded had never sought professional help: they lived happily with their voices. From this stemmed the world’s first Hearing Voices Congress held in Holland that year, and from this then grew the Hearing Voices Movement.

The Hearing Voices Movement states that hearing voices is part of human variation. It rejects the pathologising of auditory hallucinations and emphasizes empowerment of the individual. The Movement combats the stereotype of the “all-powerful psychiatrist” by giving more control to the voice-hearer and viewing the hallucinations not as a disease but as a key part of their identity. Eleanor Longden, a lady diagnosed with Schizophrenia is one example of how such a movement can have a significant impact on a person’s life. Below she describes how her meeting with the psychiatrist, Pat Bracken, became a turning point:

“[he] didn’t use this terrible, mechanistic, clinical language but just couched everything in normal language and normal experience”

Her story illustrates the road from “schizophrenic” to “voice-hearer” – from the clinical language of disease to the everyday language of emotions and experience. The stories of those diagnosed with schizophrenia can often be seen as disordered and incoherent, lacking any meaning. They are seen as having a defect. They are not entitled to a story. Hearing Voices Groups across the UK give people the opportunity to come together and share such stories in an open and trusting environment. The narrative contexts are the foundation blocks upon which these voices grow. It has been suggested that the inability to share stories about the self is part of the origins of psychopathology. We as healthcare professionals need to emphasize the point that hearing voices does not always lead to a life-long sentence of medication and institutionalization, as described eloquently by Eleanor Longden below:

If someone is reporting that they do not want their voices to stop then we must not automatically jump to the conclusion of poor insight. When the voices are distressing it is important to develop coping strategies that address this distress rather than the symptoms themselves. The problem is not the voice but the relationship one has with them. The goal of the Hearing Voices Network is for people to learn how to deal with their voices as one would deal with annoying roommates: with respect.

It has been argued that in Western medicine, doctors focus too much on a person hearing voices and not on what they say. Thus, anti-psychotics are seen as the answer with the devastating side effects described as a sacrifice for bringing someone back to the ‘norm.’ In order to understand the voices heard by our patients, we must first improve our knowledge of the cultural and social environments in which our patients reside and the practices and beliefs that our patients hold dear. If a clinician cannot take into account the cultural context of his or her patient, they cannot respond appropriately to their distress. And if a clinician is unable to respond appropriately to their patient’s distress, how can they ever hope to alleviate it?

“People with thought disorders do not keep a list of famous and successful people who share their problem. They can’t, because there is no such list. Comparatively few schizophrenics lead happy and productive lives; those who do aren’t in any hurry to tell the world about themselves.”
– Elyn Saks

 

References
1. Woods, A. et al. Interdisciplinary Approaches to the Phenomenology of Auditory Verbal Hallucinations. Schizophrenia Bulletin. 40:S246-S254
2. Laroi, F. et al. Culture and Hallucinations: Overview and Future Directions.Schizophrenia Bulletin. 40:S213-S220
3. Luhrmann, T.M. 2011. Hallucinations and Sensory Ovverides. Annual Review of Anthropology. 40:71-85
4. Woods, A. 2013. The voice-hearer. Journal of Mental Health. 22:263-270
5. Vaughan, S., Fowler, D. 2004. The distress experienced by voice hearers is associated with the perceived relationship between the voice hearer and the voice. British Journal of Clinical Psychology. 43:143-153
6. Ritsher, J.B., Lucksted, A., Otilingam, P.G., Grajales, M. 2004. Hearing Voices: Explanations and Implications. Psychiatric Rehabilitation Journal.27:219-227

Featured image:
Sound Waves: Loud Volume by Tess Watson

Categories
Humour Lifestyle

Study Strategies: The Good, The Bad, and The Ugly

The Tortoise
The tortoise is in it for the long haul. He studies for a fixed amount of time, every day. He has a routine. He never has to worry about cramming or catching up, because he’s always on top of things. The med school years for him are simple years; he studies and refrains from indulgence. Indulgence is too time consuming, and throws him off his rhythm. “If I party on Friday night,” he says, “then how will I get up at 6:30 to study on Saturday?”

The Hare
The hare is usually a social butterfly. So much energy, and so productive . . . in spurts. But the hare also enjoys taking time for herself. She takes evenings or maybe even whole days off studying. If she didn’t do this, she would fall victim to the dreaded burnout. At least that’s what she tells herself. Although she is often behind, her ability to catch up is second to none. Many of us have probably heard the adage that it’s impossible to cram in medical school. Well, not for the hare. Cramming for the hare just starts a few days earlier than it did in college. It really is impossible to cram for a neuro test the day before the test, but it is possible to pull 3 consecutive 20-hour cram days and still do well. As for long-term retention, who knows? Only boards will tell.

The Moocher
The moocher is lazy. He keeps to himself most weeks. He does not make study guides or contribute to anyone else’s learning. If at all possible, he will not show up to lecture. When a test is not looming, he can be found in his underwear at home, drinking beer and cruising the interwebs. Then, when a test looms near, he breaks free from his filthy cocoon of lethargy and can be seen on campus and social media snatching up all the condensed study guides everyone else in the class has made in the previous weeks. The moocher usually does okay on the tests, but one wonders how he will perform during rotations and residency when he does not have such helpful resources on hand.

The Memorizer
The memorizer is the queen of facts. Her ability to absorb large tables of seemingly random bits of information is unparalleled. While some may struggle to recall even the names of different medications, the memorizer will calmly recite all of the generic drug names, all of the brand names, how to spell them, how each of them is metabolized, their side effects, and which are contraindicated under what circumstances. She can do this after only going over the material once. Her classmates are in awe of her. Truly she is blessed.

The Reader
The reader… reads! Truly he is a rarity in our times. While he abhors the brute memorization of random facts, he loves to read textbooks. Bringing together a large body of knowledge into a logical system is what the reader enjoys most. He is a systematic learner who loves finding out how the little details fit into the bigger picture. The reader also must have strong shoulders, for textbooks are not known for being lightweight.

The High Yielder
The high yielder is focused first and foremost on the next exam. Perhaps it is a flaw, or maybe just an efficient allocation of her resources, but the only thing she cares about is information likely to be on the next test. She might be heard on campus saying something resembling the following: “Did the professor say that’s going to be on the test? No? Then I’m punting it. I’ll learn it later for boards if I have to.”

The Recluse
The recluse is only seen on mandatory days. Nobody really knows what he does. The only thing known for certain is that he does not go to class or social events. He doesn’t have a Facebook, and certainly shuns the company of others when he is forced to be on campus. The recluse may either be an actual loner, who would much rather be alone than in a group, or he may just be an older, married father of 3 who spends his time with family and studying at home. Either way, whenever he shows up, everybody turns and whispers to each other “Who IS that? Is he in our class?”

The Deity
The deity is revered by all. She is at the top of the class. Her study methods are mysterious. She somehow gets top scores on tests, actively participates in multiple clubs, is on student government, volunteers regularly at free clinics, and conducts research. She has a strong presence at social events and on social media. All of the students and professors adore her. Many have tried to discover her secret, but it remains a mystery. The current hypothesis is that she only sleeps 3 hours per night.

Featured image:
Studying in Starbucks by Nicola Sapiens De Mitri