Month: June 2016

Categories
General Reflection

Meaningful Community Involvement

The second semester of the first year of medical school, here and at schools across the country, represents a time when first-year students take charge of interest groups and community projects. Not long ago, we were all inexperienced newcomers to our respective schools. But now, we have since taken over the reins of all of the pre-clinical year activities from the second-year students, as they each burrow away to prepare for the ominous Step 1 exam.

Sandwiched neatly between loading up my resumé for medical school applications, and loading up my resumé for residency applications, the outright requirement to have a curriculum vitae that is robust and full of interesting community service activities weighs heavily on my extra-curricular activity decision-making. Burned into my psyche from the competitive nature of the pre-med undergraduate lifestyle is the relentless worry of “Am I doing enough?”, subsequently followed by a persistent voice inside my head insisting “More! More! More!”

The most logical course of action appears to be for every student to: ace every class, have your name in several publications, and participate in as many interesting-sounding community service projects as possible in your time as a medical student. With the latter segment of this strategy, we accomplish the double-sided advantage over our competing residency applicants by demonstrating our efficacy as providers, in addition to proving that we aren’t self-centered egomaniacs. Maybe an application officer will find one of our activities particularly interesting, which then might lead to an extended and hopefully memorable conversation.

For most of us students, medical school is the first position of real responsibility that we have over the wellbeing of others in our local communities. We certainly don’t expect this time to be our last; as future physicians we all have at some point demonstrated a desire to perform acts of altruism for those in need. The shocking turn of events is that the general public endows a great deal of trust in us once we don our white coats, even coats that clearly state our amateur, student status.

We find ourselves at risk of a costly combination of a position of real power and responsibility matched with misguided effort and enthusiasm. If one’s goal is simply to maximize their free time with an array of activities they only half-heartedly care about, then there is a more than likely chance of some level of harm being done. Even if no actual clinical mistakes are made, or no false information is distributed, there likely exists a missed opportunity. Rather than take the time and effort to create significantly improved health outcomes for a community in need, which requires full engagement and innovation, a tepid enthusiasm for the project at hand is more probable to leave a population at its status quo.

Let’s all pledge to choose quality over quantity. Let’s create and collaborate on projects that will actually matter. If chosen correctly, these opportunities for us as students will be the first steps towards making the remarkable impacts on the lives around us that we all aim to achieve. Collectively, let’s worry less about how we appear on paper and more about the people we intend to serve.

Featured image:
Theory and Practice by Carl Mueller

Categories
Clinical Reflection

No Time For Error

In November 1999, the Institute of Medicine released a study entitled “To Err is Human: Building a Safer Health System.” Within the first line of that study, a sobering statistic was revealed: between 44,000 and 98,000 hospital deaths each year are attributable to preventable medical errors.[1] We have been taught about the communication shortcomings that can easily occur between members of a medical team who may be stressed, sleep-deprived, rushed. Even though we have been warned about the potential dangers that can result from the use of abbreviations and imprecise communication, it took a recent misunderstanding for me to leave my Boards-bubble and comprehend, on a personal level, just how misleading certain abbreviations can be.

A few weeks ago, I sat down at my desk and began going over the first lecture of the day. This was 6:30 am:  pre-coffee, pre-sunlight, pre-hair combing. At the time, we were studying the gastrointestinal system. As I reviewed the first few slides of this lecture, I became very confused. I kept seeing the abbreviation ‘LES,’ and I really couldn’t figure out what it was referring to – you have my full permission to laugh at me right now; like I said, it was pre-coffee. As a born and raised East Coaster, LES means one thing and one thing only to me: the Lower East Side of Manhattan. If you are unfamiliar with New York City, please allow me to take a brief detour here to tell you a bit about the wonders of the Lower East Side (LES). The LES has a rich history, greatly influenced by the fact that many Eastern European immigrants settled into tenement housing in the area after coming through Ellis Island. When I think of the LES, I think about deli sandwiches that are too large  to fit through a human mandible, knishes, amazing donuts, and macaroni and cheese pancakes. I do not reflexively think about acid reflux, vomit, and esophageal cancer, although the association may make sense considering the indulgent foods just mentioned. As you might imagine, when I finally figured out that LES was intended to stand for ‘lower esophageal sphincter,’ it was a bit of a letdown. And since I couldn’t get the aforementioned amazing donuts out of my head, my whole morning was pretty much lost when I spent 45 minutes on the phone trying to coordinate a cross-country delivery of them to the West Coast.

Despite the ambiguity, and in my case, potential hilarity, of using abbreviations, one thing is clear: there is an abundance of statistics and data to back up the assertion that medical errors cost lives. Just run a Google search for ‘medical error abbreviation deaths’ or some variation thereof and you will see thousands of hits about the health hazard of medical miscommunication. It’s easy enough to find data  showing how detrimental some timesaving charting techniques can be. As newly-minted members of the medical profession, we have the responsibility to act as the new guard and to usher in safer communication and documentation practices. We can begin to advocate for better safety practices by trying to limit our use of abbreviations in our charting, and we can ask our professors to do to the same in their lectures and test questions. Though becoming a physician is a long and rigorous journey, we should never take shortcuts along the way that have the potential to put our patients at risk of harm.

Featured image:
Doctors Chart – Hospital Chart by wp paarz

References:

[1] Institute of Medicine. To Err is Human: Building a Safer Health System. November 1999. https://iom.nationalacademies.org/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

Categories
Clinical Public Health

Health Care Responsibilities: Zika

While attending a residency application question and answer meeting, I learned that 2016 marks the first year in over a decade that my mentor will not be taking medical students on an international health elective. She emphatically explained that it would be unethical to expose students to known Zika virus-infected areas, and irresponsible to potentially create a reservoir of Zika virus to bring back to the United States. Her second point resonated with me, because I had just examined a patient in clinic who commutes every two weeks between Puerto Rico and Orlando, Florida. He is a 30-year old male who engages in sexual activity with women only and reports inconsistent condom use. This worries me.

Puerto Rico has been hardest hit by the Zika virus pandemic, and is ground zero for Zika virus infection in the United States and territories. Between index case documentation on November 23, 2015 and January 28, 2016, there were 155 suspected Zika virus disease cases in Puerto Rico (Thomas, 2016). As of May 18, 2016, there are 544 reported travel-associated Zika virus disease cases (10 sexually transmitted; 1 Guillain-barré syndrome) in the United States and 0 locally-acquired vector borne cases (http://www.cdc.gov/zika/geo/united-states.html). The U.S. Zika virus infection in the United States and territories (USZPR) and the Zika Active Pregnancy Surveilance System (ZAPSS) registries are tracking cases of pregnant women with any laboratory evidence of possible Zika virus infection in the U.S. and territories, and reporting data every Thursday at the following website: http://www.cdc.gov/zika/geo/pregwomen-uscases.html  As of May 12, 2016, there were 157 pregnant women in the U.S. and District of Columbia with laboratory-suspected Zika virus infection.

Zika virus can spread from a pregnant woman to her fetus and is known to cause microcephaly and other brain abnormalities (ACOG Practice Advisory, March 31, 2016). The virus can also be transmitted through unprotected sex with a male partner, spurring the Centers for Disease Control and Prevention (CDC) HAN (Health Alert Network) advisory for the prevention of sexual transmission of Zika virus (Oster, 2016). Clinical criteria for Zika virus disease include the presence of (Simeone, 2016):

  • Guillain-Barre syndrome;

OR

  • in utero findings of microcephaly or intracranial calcifications in a mother with clinically compatible symptoms or epidemiologic risk factors (eg. sexual activity with a known Zika infected man) for Zika virus infection;

OR

  • one or more of the following symptoms
  1. fever;
  2. rash;
  3. arthralgia;
  4. conjunctivitis

Zika virus disease is not the first maternal virus infection to cause or be associated with congenital abnormalities, but it is the first known mosquito-borne infection to cause congenital anomalies in humans. The virus’ current behavior and long-term health consequences are still poorly understood, imparting urgency to disease control efforts. The CDC travel advisory for the country of interest by our international health elective recommends the following:

  • Women who are pregnant should not travel to areas in which there is known vector-borne disease;
  • Women who are pregnant should use condoms or not have sex (vaginal, anal, or oral) during the pregnancy with a male who has been exposed to a Zika-infected area;
  • Women and men who are trying to become pregnant should consider the risks of a Zika virus infection and strictly follow steps to prevent mosquito bites;
  • Men who traveled to or live in an area with Zika, and who have a pregnant partner, are recommended to use condoms or not have sex (vaginal, anal, or oral) during the pregnancy.

Reflecting on my clinical encounter with the Puerto Rican male who commutes regularly between known-Zika infected areas and the imminently vector-infected United States, I wonder if he is aware that he poses a risk. Does he believe, as so many often do, that he could not possibly be the one to acquire or sexually transmit an infection? Has he considered the possibility that he could serve as a viral reservoir?

In light of current evidence regarding Zika virus disease and the significant risks, I agree with my mentor’s decision to limit medical student international travel to Zika-infected areas. And I ask myself and readers, what is the responsibility of medical professionals in regards to communicable disease containment?

For more information, please see the American College of Obstetrics and Gynecology (ACOG) and CDC websites for clinical updates. An updated practice advisory by ACOG and the Society for Maternal-Fetal Medicine can be found at this link: http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak

 

References

Thomas DL, Sharp TM, Torres J, et al. Local Transmission of Zika Virus — Puerto Rico, November 23, 2015–January 28, 2016. MMWR Morb Mortal Wkly Rep 2016;65place_Holder_For_Early_Release:154–158. DOI: http://dx.doi.org/10.15585/mmwr.mm6506e2

Oster AM, Brooks JT, Stryker JE, et al. Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65place_Holder_For_Early_Release:120–121. DOI: http://dx.doi.org/10.15585/mmwr.mm6505e1

American College of Obstetrics & Gynecology. ACOG Practice Advisory: Updated Interim Guidance for Care of Women of Reproductive Age During a Zika Virus Outbreak. March 31, 2016. Available at: http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak  Retrieved May 23, 2016.

Simeone RM, Shapiro-Mendoza CK, Meaney-Delman D, et al. Possible Zika Virus Infection Among Pregnant Women — United States and Territories, May 2016. MMWR Morb Mortal Wkly Rep. ePub: 20 May 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6520e1

Featured image:
Zika Mosquitoes (05810440) by IAEA Imagebank

Categories
Emotion General Public Health

What a Horse Named Lightening Taught Me – Equine Therapy and its Unconventional Uses

Lightening is a beautiful white mustang who enjoys back massages. He loves being around his older brother Lincoln, but shies away from people. Lightening came to Hopewell Ranch in Michigan a few years ago, after barely escaping death. He was abused by his previous family, who disciplined him with a metal two-by-four and cracked his skull. Then they tried to starve him to death. Fortunately for Lightening, he was rescued and became a therapy horse at Hopewell Ranch.

What is equine therapy? Horses like Lightening, with troubled pasts, are used in unique psychotherapy for women and children recovering from domestic violence, cancer patients, veterans, and the list goes on. Equine therapy can also be used for professional development, by teaching the importance of using body language rather than verbalization to elicit responses.

Recently I had the opportunity to visit Hopewell Ranch and participate in one such professional development session. Having never been around horses in my life, I was quite nervous prior to the session. As soon as I stepped in the arena, the horses took notice and the silence between us was powerful, but made me even more nervous. The horses studied my body language, determined that I was not going to harm them, and slowly came over to me. While I was still very cautious, the gentle nature of the horses helped calm my nerves.

After the horses got to know me, I was tasked with identifying some of their personality characteristics based on their reactions to my touch or command. Lincoln, another beautiful Mustang, was clearly the leader of the herd and quite protective of Lightening, who was very nervous and cautious around strangers. Responding to my touch, Lincoln remained steadfast and was no longer nervous around me; however, Lightening continued to shy away from me and recede into the shadow of his brother.

Next, I was placed on a team in order to perform a physical exam on Lincoln, our assigned horse, and finally, we were tasked with getting him to maneuver through a self-made obstacle course. Each task focused on cultivating different skills, such as learning to read body language, working in a team, and leading. Physicians are often required to read a patient within the first 30 seconds of entering the exam room. They must be able to work well in a team and step back when necessary so others can get the job done. A physician must also exude confidence as a leader so a patient has confidence in him or her; equine therapy helps integrate all of these important physician skills.

The most powerful part of this session for me was, again, the silence. Many times, we take speech for granted and believe that because patients can verbalize their thoughts and feelings, they will tell us everything we want to know. However, working with these horses, particularly Lightening, revealed to me the necessity of gaining the trust of my patients. If there isn’t a trusting patient-doctor relationship, they will not feel comfortable sharing their life circumstances or the challenges that need to be overcome to successfully implement therapy. For example, a patient may be homeless, abused, or depressed, but there may not be outward signs at first glance. Learning to read a patient and being able to get him or her comfortable enough to share information are great assets to have in the physician tool belt, because they will help make accurate diagnoses and enable successful treatment.

Beyond professional development, equine therapy is an incredible resource for an array of psychotherapy candidates including, but not limited to, addicts and the handicapped. The founder of Hopewell Ranch, Jodi Stuber, has an incredible story of her own that led her to open this ranch. She lost her daughter at five months in utero, but named her Hope, and then decided to name the ranch after her. In Hope’s memory, Jodi has helped people fight drug addiction, has helped cancer victims learn to ride and experience joy while they endure intensive chemotherapy, and has helped children faced with abuse and disabilities feel empowered, all through the teachings of horsemanship.

Equine therapy is a lesser known, but phenomenal, therapeutic method, and my first experience with Lincoln and Lightening will definitely not be my last. I encourage everyone to seek out equine therapy – for fun, for mental health, and for professional growth and development.

Learn more about Hopewell Ranch in Weidman, MI.

Featured image:
Picture taken by author at Hopewell Ranch. Lightening (left) and Lincoln (right)

Categories
General Literature

Frankenstein: A tale for the Modern Age

“I succeeded in discovering the cause of generation and life; nay, more, I became myself capable of bestowing animation up on lifeless matter.”
– Dr Victor Frankenstein, Frankenstein (2)

Frankenstein is a science fiction novel published by British author Mary Shelley in 1818 that has become an integral part of modern day culture. It follows a Swiss scientist named Dr Victor Frankenstein who becomes obsessed with alchemy and the idea of creating life. His indelible curiosity gradually leads him down the path towards atrocious experiments in the name of science, to the point where he creates a creature – a ‘monster.’

This novel, which has captured our imaginations since its release almost two centuries ago, has led to several famous film adaptations and has become one of the cornerstones of the Horror genre even to the present day.

The inspiration for this novel came from the early 1800s when scientists awed audiences with their ability to use electricity to stimulate the nerves of dead animals, a process called galvanism (1). In 1803 the body of murderer George Foster was attached to a large battery, and witnesses tell us that ‘the adjoining muscles were horribly contorted, and the left eye actually opened’ (3).  It was during this era that science started to take over the reins, stepping onto its pedestal as the fountain of knowledge.

Interestingly, the subtitle of Frankenstein is ‘Modern Prometheus’ (3). Prometheus is the Greek God who brought knowledge to humanity, and later paid for his ‘crime’ through eternal torment. In a similar fashion, Victor Frankenstein brings further knowledge to humanity through his obsession with the life sciences, leading to his creation of a ‘monster’ that ultimately torments him to his dying day. The novel, despite being written at a time when science was just learning to walk, is as relevant today as it was when first published. Yes, it may just be a work of fiction, but the deeper warnings contained within its fine pages speak to us in a way that no scientific journal can.

Frankenstein reminds us that the humanities are the seat belt for the sciences. They have been there to remind us of our morals when all we want to indulge in is our supreme power as human beings. They remind us to stay humble, to think and to question, and not merely to set fire to everything that surrounds us.

History is littered with examples of how scientific discoveries can lead us astray. From the splitting of the atom, which led to the creation of nuclear weapons, to the rise of technology, which has led to the dehumanization of everyday life. But of course, this is a simplification. Science has also given us so much that we now take for granted: organ transplants, heating, the latest iPhone, the very roof over our heads. Science has given us our healthy years, filled with food, shelter, safety and comfort. What Frankenstein highlights is our human desire to go further; to extend our years beyond our imagination, so that not only do we never die, we never grow old either. This hubris is perhaps part of human nature.

What Frankenstein teaches us is that we must take responsibility for our creations, and remember that every gleam of hope also betrays a darker path; ultimately, it is not the ‘monster’ that leads to his masters’ demise, but the lack of empathy and responsibility that is displayed. By continually digging deeper and deeper, searching for a way to transform the cells that create us and the organs that give us life, we must not forget the power that lies in our hands, the ever-human desires of greed and selfishness that can take over our quest.

“I might in process of time, renew life where death had apparently devoted the body to corruption”
– Dr Victor Frankenstein, Frankenstein (2)

Many may question how relevant such warnings are in the present day. Perhaps these messages do not apply to our times. Very few of us would turn our backs upon science, casting our technologies aside and turning to the fire to heat our food and the rock to give us shelter. The issues that Frankenstein brought up, of using nature to bring about life, can be found within any hospital across the world. The use of the defibrillator – a device that uses electricity to shock the heart back into rhythm – could be described as the answer that Frankenstein worked so hard to find – to bring people back from the dead, to introduce life so to speak. Would one call this abominable?

Perhaps we are being unfair to Frankenstein – looking at ourselves as medical students and doctors, how many of us would not do the same as him; sitting hours within a cramped room, reading textbook after textbook, trying discover the intricacies of the human body: how does it breathe, how does it sleep, how does it eat, how does it live? Isn’t this what we do every day – delve deep into the human body so that we can learn how to shock it back to its original state?

We can choose to see both ourselves and Dr Victor Frankenstein as lights that shine onto pathways of future knowledge, discovering new cures and assembling fresh treatments along the way. But we must remember that we cannot rely on science alone to answer all of our problems. Ultimately, science cannot work in a lab by itself. It must work within the context of our greater society, and it must be made morally accountable for its actions. By continuing one’s endeavors out of pure selfishness and greed, one may tread down a path from which there is no return. In the end, it is the monster created from Frankenstein’s obsessions that kills him, and this can serve as a warning to us all.

References

  1. Brown, A.S. 2010. How early experiments with electricity inspired Mary Shelley’s reanimated monster [Online]. Available at: https://www.insidescience.org/content/science-made-frankenstein/1116 [Accessed: 8th January 2016]
  2. Shelley, M. 2010. Frankenstein. William Collins.
  3. Pires, V.M. 2013. Shelley’s Monster: A Lesson on Scientific Hubris [Online]. Available at: http://piresphilosophy.blogspot.co.uk/2013/07/shelleys-monster-lesson-on-scientific.html [Accessed: 8th January 2016]

Featured image:
Frankenstein by Khánh Hmoong