Month: February 2016

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

Categories
General Lifestyle Reflection

On Professionalism

I solemnly pledge to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude that is their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honor and the noble traditions of the medical profession;
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I will maintain the utmost respect for human life;
I will not use my medical knowledge to violate human rights and civil liberties, even under threat;
I make these promises solemnly, freely and upon my honor.

-The Declaration of Geneva

My white coat ceremony changed many things for me, most notably the responsibilities I would have moving forward. I recited the Declaration of Geneva, along with my fellow colleagues. The weight of the term “colleague” laid heavily on me; those who were once classmates were now colleagues. Classmates to colleagues, such a drastic, but intentional elevation in word choice. Many things are expected of me as a medical student, but one of the top priorities is the demand to carry myself as a professional.

Professionalism can mean treating others with respect, upholding a certain academic standard, or leaving personal issues in a personal space. Cultivating a professional attitude isn’t always easy. I have screwed this up several times, like disrupting class through meaningless chatter or allowing my personal dilemmas seep into my professional work. Regardless of the mistake, I always try to learn from my shortcomings. I believe that the majority of medical students strive to act as a professional when encountering difficulty in medical school.

Recently, I wondered how this professional attitude so quickly fades when we meet colleagues of different disciplines. Although my experience is mainly anecdotal, I think we have all heard of negative interactions between physicians and nurses, physicians and physician assistants, and so on. In medical school, some of us have participated in attempts to get medical and other professional students to interact at an earlier point in their training. I personally interacted with both nursing and physical therapy students during my first year of medical school. Although I thought the reasoning behind this choice was good, it didn’t work out exactly as planned. The medical students overheard a few nursing students talking negatively about the medical student cohort. Feelings got hurt and from there the overall atmosphere worsened.

Why did this happen? I believe we forget to act professionally when outside of our immediate, comfortable setting. We know a professional attitude is demanded between colleagues within our medical school, but we don’t often carry it over to other disciplines. Yes, you could argue that interacting with other disciplines at an early career stage helps break down some common stereotypes and issues, but will early interaction really solve everything? I’m skeptical.

I believe a constant effort must be maintained throughout our training; as I stated before, a professional attitude is not easily mastered. Regardless of one’s career stage, working harder at cultivating a professional demeanor among those in our field as well as among those in others will foster teamwork within medicine. If we, as medical professionals, hold ourselves to a certain standard, then catty arguments or negative comments will never be made, because we constantly demand higher of ourselves. Hopefully, by being more self-aware and practicing on a daily basis, we will create a professional attitude that won’t break down so easily when confronted with the newness of the ever-growing medical field.

Featured image:
teamwork staffetta by Luigi Mengato