Month: October 2016

Categories
Emotion Empathy Reflection

Notes from the Road: A Letter to my Future Self

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

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

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

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

 

Dear Future Self,

Today you saw a patient die.

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

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

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

Chest compressions. Pushing epi. Giving her blood.

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

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

You were so scared.

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

You felt so powerless.

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

You were so impressed by the team.

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

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

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

Sincerely,

-Your Past Self

 

Featured image:
road by Victor Camilo

Categories
Psychology Reflection

Reassessing Resilience

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

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

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

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

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

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

References:

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

Featured image:
Slope Point by Ben

Categories
General Psychiatry Psychology

The Case Against Global Mental Health

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

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

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

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

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

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

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

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

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

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

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

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

References

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

Featured image:
Mental Health Conditions by amenclinicsphotos ac

Categories
General Pharmacology

A Quick Lesson in Supplement Quality

An increasing number of patients are now taking nutritional supplements on a daily basis, believing that they are boosting their health. Choosing the best supplements to take can be nothing short of overwhelming for the majority of patients. It’s not only a question of supplement type, but also of knowing how to identify which product is safest and most effective.  As more patients are taking their health into their own hands, vitamin sales are expected to grow by 8% to a total of $9.2 billion over the next year, according to Nutrition Business Journal.1

It is important for patients to be aware that the U.S. Food and Drug Administration (FDA) does not analyze the content of dietary supplements. However, the FDA has issued Good Manufacturing Practices (GMPs) for dietary supplements. These are a set of requirements and expectations by which dietary supplements must be manufactured, prepared, and stored in order to ensure quality. One of the best ways to know if a supplement contains what the label says it does is to choose a product that has been manufactured at a GMP facility. The GMPs are in place to prevent the inclusion of the wrong ingredients, the addition of too much or too little of an ingredient, contamination (i.e. by pesticides, heavy metals, bacteria, etc.), and the improper packaging and labeling of a product. A GMP facility must comply with the same standards required of pharmaceutical companies, as mandated by the FDA.2

Additionally, it is best if the supplement manufacturer has a Certificate of Analysis (COA) for each ingredient. Having a COA means that the raw material has been tested by an independent lab and determined to be contaminant-free.

Another sign of high supplement quality is for a product to be National Sanitation Foundation (NSF) certified. NSF is a respected third-party quality assurance organization. It verifies that a facility complies with GMPs and takes proper steps to ensure product safety and accurate labeling.

There are four “grades” of supplements/vitamins:3

  1. Pharmaceutical grade –The highest-quality grade, typically sold by a health care provider and may require a prescription.
  1. Medical grade – Still good quality but not as high as pharmaceutical grade.
  1. Cosmetic or nutritional grade (“consumer grade”) – Mostly “over-the-counter” products sold through health stores, pharmacies and grocery stores. Consumer-grade supplements are optimized for extended shelf life.
  1. Feed or agriculture grade – Not recommended for human consumption.

One good resource is the Dietary Supplement Label Database (DSLD). This site contains label information from thousands of dietary supplement products available in the U.S. It can be used to search for a specific ingredient in a product, a particular supplement manufacturer, text on a label, or a specific health-related claim.

Patients and doctors alike want to know whether a supplement has been clinically proven to support health. In general, it is a good idea to encourage patients to check with a healthcare provider before taking nutritional supplements. Dietary supplements may not be risk-free under certain circumstances, such as during pregnancy or for those who have a chronic medical condition.

Although this piece is about supplements, it is important to keep in mind that we all can benefit from improving our diets naturally, rather than by adding pills and powders. Supplements can be beneficial, but should not be used to replace a well-balanced, healthy diet.

References:

  1. “Nutrition Business Journal.” New Hope. http://newhope.com/nutrition-business-journal
  1. “Office of Dietary Supplements – Frequently Asked Questions (FAQ).”Frequently Asked Questions (FAQ). https://ods.od.nih.gov/Health_Information/ODS_Frequently_Asked_Questions.aspx
  1. “Fool-proof: How to Choose the Best Quality Supplements/vitamins.” Virginian-Pilot. http://pilotonline.com/life/fitness/quick-tips-for-wellness/fool-proof-how-to-choose-the-best-quality-supplements-vitamins/article_353a05ec-a4ed-5b6e-a3f7-01f14cd7bbd6.html

 

Featured Image:
Pills by Jamie