Author: Jordan Metsky

Categories
General Healthcare Cost Humour Lifestyle Opinion Pharmacology Psychiatry Psychology Public Health Reflection

Well, Well, Well: Products and services compete for shelf space in trendy wellness market, but are they worth your money?

When a friend recently asked me to join them for a class at Inscape, a New York-based meditation studio that New York Magazine described as the “SoulCycle of meditation”, I was skeptical. On the one hand, I usually meditate at home for free, so paying almost $30 for a meditation class seemed a bit silly. On the other hand, my meditation practice had dropped off considerably since the beginning of the year. Maybe an expensive luxury meditation class was just what I needed to get me back into my regular practice. Stepping off bustling 21st Street into the clean modern space, I heard the sounds of, well…nothing. It was incredibly quiet. Before getting to the actual meditation studios, I had to pass through Inscape’s retail space. The minimalistic shelves hold a variety of supplements, tinctures, and powders that include unique ingredients like Reishi medicinal mushrooms and cannabidiol extract. Many contain adaptogens, herbal compounds that purport to increase one’s resistance to stress, though their efficacy has never been quantitatively proven.[1] These products’ promises run the gamut from shiny hair and stress relief to aura cleansing. I may be a super-skeptic, but even I am not immune to the lures of top-notch marketing. With great consideration, I purchased one of the many magical powders for sale labeled as ‘edible intelligence.’

Since wellness has become trendy, a considerable space in the retail market has opened for associated products dedicated to helping people live their best lives. As Amy Larocca pointed out in her June 2017 article The Wellness Epidemic, “[In the wellness world] a loaf of bread may be considered toxic, but a willingness to plunge into the largely unregulated world of vitamins and supplements is a given.” Even a recent episode of Modern Family poked fun at the wellness trend when Haley Dunphy applied for an ultra-competitive job with fictional wellness guru Nicole Rosemary Page. During her interview at Page’s Nerp company headquarters, Page laments, “People say that Nerp is nothing more than a con-job, a cash grab vanity project from a kooky actress. I want to turn Nerp into the next Disney-Facebook-Tesla-Botox. It’s a world changer.” Though Page is a fictional character, I can’t help but wonder whether the character was inspired by the very real Amanda Chantal Bacon, the founder of Moon Juice, which bills itself as an adaptogenic beauty and wellness brand. Bacon’s Moon Dusts retail for $38 a jar and come in varieties such as Spirit, Beauty, and Dream.

The bottom line is that a sense of well-being needn’t come at the price of thirty-plus dollars an ounce. In fairness to those who choose to spend lavishly, I believe that plunking down a chunk of cash might create an intention to use and derive value from a product, thus positively influencing one’s perception of how well the product works. Rest assured, however, that living with intention and gratitude can be just as easily accomplished without spending any money at all. Carving out time in the day to create a small ritual for yourself can be as simple as spending a few minutes in the morning listening to jazz as you drink your first cup of coffee or allowing yourself to become immersed in a good book before drifting off to sleep. These simple acts allow us to bestow kindness upon ourselves that is especially important in our stressful and busy lives as medical students. My suspicion is that by performing such rituals with intention, we derive much of the same benefit whether our mug is filled with the trendy mushroom coffee or just plain old Folgers.

I’m always thinking about ways I can improve my own well-being, but as graduation approaches I also find myself thinking about how these practices might help my patients as well. One of my fundamental goals as a future psychiatrist will be to help my patients see the value in themselves and in their own lives. I predict that for many of my patients, achieving this goal will depend perhaps on medications but also on the deployment of simple wellness tactics such as I described. I’m not going to lie…I’m still intrigued by many of the wellness products that can be found in places like Inscape, Whole Foods, and the Vitamin Shoppe, especially when I think about the potential benefits they might have for my future patients. I figure that if these products do even half of what they promise to, some of them might even be worth the money. So what happened when I added a sachet of intelligence powder to my usual morning smoothies? Pretty much nothing. At one point, I got excited when I began to feel my fingers getting tingly. Then I realized I had been leaning on my ulnar nerve. Not so brainy after all.

[1] Reflection Paper on the Adaptogenic Concept, Committee on Herbal Medicine Products of the European Medicines Agency, May 2008.

 

Photo credit: Open Grid Scheduler / Grid Engine

Categories
General Law

Not Science Fiction: American immigration politics threaten scientific advances

The year 2017 was an anti-science roller-coaster ride. From the plentiful deniers of climate change to the seven words rumored to be banished from the CDC’s vocabulary[1] to Energy Secretary Rick Perry’s questionable words equating fossil fuel consumption with the prevention of acts of sexual violence,[2] science seemed to be the biggest loser of 2017. Even the tax bill, the capstone of the year, appeared to be steeped in anti-science rhetoric, with several proposed provisions aimed at dismantling research. Among these were the taxation of tuition assistance for graduate researchers and increased taxation of companies examining renewable energy sources, both of which thankfully failed to make it into the final bill.[3]

Alongside all the powerful and disturbing hits to science, the country continues to see our administration make tactical maneuvers against immigration. As a humanitarian, I feel a deep sense of indignation that we have forgotten our history as a nation of immigrants and turned our backs on people who enrich our country both by strengthening our workforce and adding to our cultural melting pot. As a member of the medical community, however, I am worried that the disassembly of our immigration program will act as yet another catalyst to dismantle the country’s scientific endeavors.

From 1960 to 2014, 28 of the Nobel Prize winners in medicine have been scientists and physicians who immigrated to America. The numbers are similarly high in the fields of chemistry and physics, with 23 and 22 immigrants winning in these fields, respectively. Thankfully, nobody in our political administration has openly come out against cancer research, but considering that in 2014, 42% of the researchers in the top seven American cancer research centers are from 50-plus foreign countries, the administration placing severe restrictions on immigration deals a huge blow to science in our country and is in effect a stance against cancer research. Even the inventor of chemotherapy, George Clowes, immigrated to the United States from England to conduct research on chemotherapy and went on to found the American Association for Cancer Research.[4] In terms of the contemporary research landscape, American graduate institutions award approximately 30,000 doctoral degrees in the fields of science and engineering each year. Foreign-born researchers are responsible for 40 percent of these degrees. A high number of academic institutions coupled with more job opportunities in the fields of science and technology, as well as higher wages, are some of the factors attracting researchers from abroad to the US.[5]

So what would the American scientific landscape without immigrant scientists and medical researchers look like? In a word: prehistoric. The Nature Index ranks America as the number-one research-producing country, and had immigration restrictions prevented the aforementioned individuals from completing their research on American soil, perhaps we would still be learning about the four humors and spending our clinical years of medical school bleeding people with leeches. Most of us completing medical school will be entering into clinical practice that would not be possible without the contributions of researchers, many of whom are foreign-born. I hope that as a medical community, 2018 is an opportunity for us to recognize and celebrate the efforts of our colleagues who come from faraway lands to conduct valuable and potentially lifesaving research here in America before Jurassic immigration policies further threaten the well-being of our patients.

[1] http://www.cnn.com/2017/12/16/health/cdc-banned-words/index.html

[2] http://time.com/5007787/rick-perry-fossil-fuels-sexual-assault/

[3] http://www.sciencemag.org/news/2017/12/researchers-win-some-lose-some-final-us-tax-bill

[4] https://www.nafsa.org/_/File/_/ie_mayjun15_front_lines.pdf

[5] https://www.scientificamerican.com/article/does-the-us-produce-too-m/

Photo Credit: Victoria Pickering

Categories
Clinical Patient-Centered Care Psychiatry Public Health

If you don’t ask, you’ll never know

On the first day of my first rotation as a medical student, my preceptor shared this bit of wisdom: if you don’t ask, you’ll never know.  In the nearly 18 months that have followed, I think about those words on a daily basis. To my mind, asking questions does more than just help us gather data. Asking questions establishes the type of relationship we are going to have with our patients. There are so many questions I wish I would never have to ask, whose affirmative answers are often indicative of the cruelty of this world. But when I ask about things like whether a patient has been the victim of abuse, I hope it sends the message that the relationship we are about to embark upon is one that can withstand such unpleasantness.

Not only can it be excruciatingly frustrating when other practitioners don’t share this point of view, it potentially has grave consequences. Unfortunately, patients with mental illness often seem to be the victims of physician “brush-off.” As someone who plans to devote her life to working with the mentally ill, I can only hypothesize as to why the same patients I find so much joy in working with are often given sub-par medical care as compared to their non-mentally ill peers. Perhaps physicians feel uncomfortable providing care for patients who come across as different than the norm, or perhaps their medical problems are too frequently attributed to psychiatric causes.

I recently cared for a patient who was two weeks post-partum from the birth of her first child. Though she was being seen for psychiatric admission, multiple aspects of her health were addressed during our initial evaluation.  When asked about her post-partum health, she denied having been scheduled for a post-partum visit with her obstetrician. Casually, she mentioned that she was having some malodorous green discharge since giving birth. It doesn’t take a medical degree to know that green, foul-smelling discharge is not a good sign, let alone when it occurs in the immediate post-partum time period. We were able to secure a next-day appointment with our hospital’s obstetrical practice, and with the patient’s permission, called ahead to the clinic to alert them of her complaints.

The next day, the care team gathered around to read the note from the obstetrician who had seen our patient. The note comprised all of five lines.  There were no pending labs. There was no mention of a physical exam.

There was no mention of the discharge at all.

The American Congress of Obstetricians and Gynecologists (ACOG) states, “It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.”[1] The issue here, though, isn’t really about post-partum care. The issue here is about how we as health care providers need to provide equal care for unequal bodies and minds, and how we need to protect and advocate for our patients.

Patients with mental illness undeniably have poorer overall health. The average lifespan for an American adult with mental illness is a striking 30% shorter than for a non-mentally ill individual.[2]  While it is known that mental illness itself creates difficulty in accessing the healthcare system, for mentally-ill patients who do access healthcare, their quality of care is demonstrably lower than it is for those without mental illness. Literature consistently demonstrates that patients with psychiatric diagnoses receive fewer preventative health measures and have overall poorer quality healthcare than patients without psychiatric diagnoses.[3],[4] No matter what field of medicine you are in, you will see patients with mental illness. For these patients who sometimes cannot speak for themselves, the role of the physician in patient advocacy becomes even more crucial.

I will never know exactly what transpired during that appointment between my patient and the obstetrician, but I do know that obstetrician did not ask the questions that needed to be asked, and therefore did not ascertain the information necessary to appropriately care for the patient. At our request, a different practitioner saw the patient again. This time, the appropriate questions were asked, the appropriate testing was completed, and ultimately the patient was diagnosed with a sexually transmitted infection. Left untreated by the first obstetrician, this infection could have caused my patient systemic symptoms and permanent infertility.

As future physicians, it’s important for us to keep asking questions. So often, I have been surprised by the information I find when I ask a question about which I almost kept silent. Equally as important as asking the questions, however, is doing something with the information that you receive. The good doctor isn’t necessarily the one that stops the green discharge; they’re the one the identifies the problem in the first place and advocates on behalf of the patient to get the best people for the job.

[1] https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

[2] http://europepmc.org/abstract/med/19570498

[3] http://journals.lww.com/lww-medicalcare/Abstract/2002/02000/Quality_of_Preventive_Medical_Care_for_Patients.7.aspx

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951586/

Photo credit: airpix

Categories
General Lifestyle Opinion

Too Many Eyes Between the Thighs: Sex and Surveillance

There’s a special bond between students and their teachers. As someone who used to teach young children, I know firsthand how students can trust teachers with certain aspects of their lives that they don’t feel comfortable disclosing to other adults. But, students in the Salem-Kaiser school district in Oregon may want to think twice about what they tell their teachers. That’s because district policy stipulates that teachers are mandatory reporters of all student sexual activity. This policy means that teachers who have knowledge or suspicion of students’ sexual activities must file a formal report with the Department of Human Services, local law enforcement, or a school resource officer. What’s more, because they are mandatory reporters, a teacher could actually face disciplinary action and fines if they fail to report known student sexual activity. This law even applies to faculty members making reports on their own children if they are students in the district. The year is 2017, but this puritanical policy is straight out of the 17th century.

As a former high school student, I’m appalled by this policy. As a future doctor, I’m deeply troubled. When culture permits our libidinous drive to become an object of surveillance, sex becomes a deviant activity. In criminalizing the natural and healthy exploration of sexuality, we imbue sex with shame.

I could not help but see a link between this policy and the reports of sexual violence that have been dominating the media over the past month. My immediate reaction was that this attitude of surveillance around sex is the fertile soil from which the Harvey Weinsteins of the earth spring forth. In an article about the Harvey Weinstein scandal published in New York magazine, Rebecca Traister writes “What we keep missing, as we talk and reveal and expose, is that this conversation cannot be just about personal revelation or speaking up or being heard or even just about the banal ubiquity of abuse; it must also address the reasons why we replay this scene, over and over again.” Traister sees the perpetuation of crimes of sexual abuse as indicative of a foundational gender injustice; I see them as the result of a culture that was built upon austerity.

America is littered with vestiges of our Puritanical culture. The very fact that we can’t show the bare breast on Instagram, or that we’re still trotting out the story of Janet Jackson’s costume malfunction from Super Bowl 2004 is, to me, an indication that the body is subjected to surveillance when it’s recognized as a vessel of sexuality. Sarah Silverman’s June 2017 appearance on Jimmy Kimmel Live! illustrates this. She holds up a picture of a penis that she drew while hospitalized and correctly assumes that the picture is intentionally blurred to viewers at home, per FCC regulations. She then facetiously tells producers that what she actually drew was a stalk of asparagus, and the picture instantly becomes clear. The image is, in a way, treated as criminal, and is subject to surveillance via pixelation, and yet that surveillance is instantly removed when the association with sexuality is removed.

In a way, we’re all responsible for allowing crimes of sexual violence to occur. My intention here is not to negate the free will of an individual who chooses irresponsible, repugnant behaviors, but to suggest that we have fostered a culture which, in a way, suggests that abhorrent sexual behaviors may be the basest way to get one’s needs met. When two 16-year-olds are in a healthy, consensual sexual relationship, and this relationship gets reported to the authorities, we are sending the message that even an appropriate sexual encounter is considered an act of deviance. And it starts even at a more localized level than the school. If kids are not hearing about sex in their households and are not raised with the understanding that sexual appetite is as normal a bodily function as urination or defecation, the overwhelming message is, at the very least, that sex is something that needs to be hidden away, or more damaging still, that sex is shameful.

Sexual violence is borne from the “sex = shame” mentality. When we classify the perpetrators of these crimes as being “sex addicts,” it excuses these damaging and vile behaviors as an unfortunate error of biology rather than viewing them as a product of learned behavior. This is not to say that sex addiction isn’t a real pathology, but rather to point out that we may be confounding biology with behavior. Though sex addiction has never been classified as a diagnosis in the Diagnostic and Statistics Manual (DSM), most experts agree that the diagnosis of a sex addiction would require a higher-than-average sex drive coupled with compulsive sexual behaviors even in the face of negative consequences. Sexual drive is a difficult feature to quantitatively measure, but I suspect that a high sex drive is not the cause for most crimes of sexual violence. I strongly believe that by committing acts of sexual violence, perpetrators are primitively attempting to meet their needs. In other words, while the sexual appetite is normal, the internalization of the “sex = shame” mentality is so embedded in the psyche that the sexual act becomes a part of this narrative. When one believes that one’s sexual drive is shameful, libidinous urges cannot be openly discussed, and instead may be dealt with in a way that is clandestine and non-consensual. Larger issues of power and privilege, though out of the scope of this writing, come into play when individuals are enabled to act out these violent behaviors.

Sexual violence is systemic. If we don’t change our cultural attitudes toward sex, we will continue to foster an environment which is likely to create sexual criminals. Young people who are just beginning to explore their identities as sexual beings through relationships with others are most susceptible to the internalization of the “sex = shame” narrative. If we don’t learn to shed our Puritanical vestiges and celebrate the healthy, safe, and consensual sexual exploration of these young people, we will continue to support a society of people who are reduced to committing crimes of sexual violence.

References:

YThe Conversation We Should Be Having: https://www.thecut.com/2017/10/harvey-weinstein-donald-trump-sexual-assault-stories.html

Internet sex addiction: A review of empirical research: http://www.tandfonline.com/doi/abs/10.3109/16066359.2011.588351

Is Sex Addiction Curable? http://www.newsweek.com/sex-addiction-curable-kevin-spacey-seeks-rehab-condition-does-not-exist-703541

Salem-Keizer staff told to report student sexual activity, including own kids: http://www.statesmanjournal.com/story/news/education/2017/10/31/oregon-mandated-reporter-salem-keizer-staff-told-report-student-sexual-activity-including-own-kids/798865001/

Sarah Silverman on Near Death Experience: http://abc.go.com/shows/jimmy-kimmel-live/video/featured/VDKA3871414

Photo Credit: Wyatt Fisher

Categories
Lifestyle Public Health Reflection

#BoPo: Body positivity in the age of obesity

When I was younger, I loved watching the televised broadcasts of New York Fashion Week. I grew up in the heyday of heroin chic, which meant that the runway was a seemingly endless parade of vampire-pale, stick-thin waifs. I knew I would never grow up to look like these women, no matter how hard I tried. Even though I was perfectly happy to develop my own unique sense of style, I had an awareness that no one on television looked like me.

Fast forward two decades. The landscape of beauty has changed dramatically. I can’t yet say we’re living in a whole new world, but as a society, we’re making steady progress toward diversifying our expectations of beauty. More colors, shapes, sizes, and sexual identities are being beamed over the airwaves and into our living rooms.

The strides we’ve made toward diversifying our media did not just happen overnight. They occur as part of a larger historical context that has rebelled against normative standards of beauty for decades. The Fat Acceptance Movement, started in the mid 1960’s, is considered to be an offshoot of Second Wave Feminism. In 1967, the group held a 500 person “fat-in” in Central Park, NY wherein people carried signs of pro-fat messages and burned diet books. This was followed in 1969 by the creation of the National Association to Aid Fat Americans (NAAFA) which held a yearly summer convention until 2015. More recently, in 1996, the Body Positivity Movement was started by friends Connie Sobczak and Elizabeth Scott. Their goal was to help girls and women foster positive self-images so they could lead more fulfilling lives. Today it exists as an organization known as the Body Positive. Just a few weeks ago, this organization hosted the third annual CurvyCon. This convention was organized by two self-described plus size fashion bloggers to help women “chat curvy, shop curvy and embrace curvy.” All of these organizations and movements undoubtedly have their own platforms, but what they all share is a desire for bodies of all appearances to be accepted into society.

I firmly believe that every body is worth loving, but moreover, that every body is a body worth caring for. I see care as being a balance between the emotional and physical aspects of well-being. While I am hopeful that the shifting tide of acceptance in media translates more broadly to mean that us non-Hollywood folk also find value in ourselves and others no matter our physical appearance, as a health care provider, I am concerned that the Body Positivity Movement may be construed as an acceptance of obesity. If we accept ourselves for who we are, and who we are is unhealthy, then I question whether we are really showing ourselves the love that we claim.

I think what the Body Positivity Movement does well is emphasize self-value on the emotional spectrum of care. Where body positivity endeavors seem to lag, however, is in the promotion of physical health. Physical health can be just as challenging to realize as emotional health, yet it is just as important. Diabetes, hypertension, and hyperlipidemia are real diseases whose prevalence strongly correlates with obesity. They do not discriminate between people who love their bodies and those who don’t. They can affect and ultimately kill anyone whose body mass index falls into an unhealthy range. Our government makes the realization of physical health all the more difficult by setting up barriers for people to receive quality health insurance. Financial barriers are only one aspect of this problem. Any policy that allows for the proviso of health barriers, in the form of exclusions, special criteria, and added financial burden for people with pre-existing conditions, is a policy that does not believe all people to be equally worthy of care and is therefore an injustice.

Even though a key focus of the Body Positivity Movement is self-love, this does not mean people have to go it alone. As future physicians, we can partner with our patients and aim to help them strike a balance between their emotional and physical care. To me, this means helping our patients foster emotional self-love while also being conscious of physical health. While monitoring sensitive aspects of our patient’s physical health such as weight, infectious disease, and heritable conditions may be challenging, perhaps in part because they may draw on our own personal insecurities, we can discuss these topics using sensitive, collaborative approaches that are respectful of the patient’s emotional well-being. Ultimately, our goal should be to meet our patients where they’re at in terms of care and be a supportive force to propel them forward.

References:

The Body Positive: http://www.thebodypositive.org/about

Brief History: The Fat-Acceptance Movement: http://content.time.com/time/nation/article/0,8599,1913858,00.html

The Curvy Con: http://www.thecurvycon.com/about

Overweight and Obesity: Signs, Symptoms, and Complications: https://www.nhlbi.nih.gov/health/health-topics/topics/obe/signs

Photo Credit: Crystal Coleman

Categories
Clinical Emotion Empathy Humanistic Psychology Reflection

The Enigma of Empathy

“My mother says I’m a piece of shit.” My 18-year old patient sits at the head of a conference table, her face stony with resolve. The members of her care team are surrounding her. She asks, “Why do you all care about me when I don’t even care about myself? That’s just weird.” Her resolve crumbles and tears begin rolling down her cheeks.

The attending physician stares at her before responding. “We don’t know you,” she says. “But we do care about you. You’re right-it’s a weird concept.”

It took this exchange-during my final year of medical school-for me to fully grasp the unusual nature of the empathy that we have for our patients. As medical students, most of us have described ourselves as empathetic or compassionate at some point. But I’ll wager that most of what we know about empathy comes from close relationships, be they with friends, family members, or even repeat clinic patients. It’s not difficult to understand how these established relationships could be colored with empathy. After all, these are relationships that we usually choose to have, or at least, choose to continue having, and in many cases, they’re relationships of mutual benefit.

As medical students, much of our experience is gained on the inpatient units in the hospital, with patients who are thrust into our service. While it is possible that the relationships we have with those who are closest to us serve as templates for empathy, the relationships that we develop with our hospitalized patients are different in several ways. First, we do not choose these relationships. Generally, patients are assigned to us regardless of our desire to have them as patients. Part of being a physician in training implies consent to treat patients. Another reason why our relationships with patients are unique is that we rarely can choose to terminate a relationship with a patient who we are treating. Finally, the relationship between the hospitalized patient and the doctor is not mutual. Hospitalized patients cannot and should not offer any direct benefits to their treatment team. My relationship to this 18-year old patient fit all the aforementioned parameters: I did not choose her as my patient, I could not stop my service to her, and I enjoyed no direct benefit from her as my patient. And yet, even accepting the above as true, even recognizing that I had only known this person for 48 hours at the time of this discussion, my empathy for her was not any less genuine than my empathy for my best friend or closest family member.

Does being a physician mean that we are forced to have empathy for near-complete strangers? Or does it mean that the people who choose this profession are characterized by an ability to freely give empathy to those who cross our path?

Interestingly, the word “empathy” did not reach the English language until 1909. Derived from the German word “einfuhlung” (or “feeling into”), it has been a continually enigmatic concept that has eluded any simplistic definition. Philosophers have described empathy as a central emotive descriptor that characterizes the feeling one has when they recognize the human spirit in another.[1] Even neuroscientists have taken up the job of trying to define empathy, noting that mirror neurons, which are neurons that fire when one living creature acts and then observes the same action in another living creature, may play a role in the development of empathy.[2]

Reflecting on my patient’s remarks has given me serious cause to contemplate what empathy means to me as a soon-to-be physician. While I can speak only for myself, I think the thing that makes me different is not my capacity to give empathy, but my desire to foster relationships with my patients. Even though my relationship with that patient may have been only days old, the quality of that relationship and therefore my ability to feel empathetic towards her, is a direct reflection of my desire to have that relationship. While I did not choose the patient, I chose to get up that day and practice medicine, and empathetic medicine is the only kind of medicine I know how to practice.

[1] https://plato.stanford.edu/entries/empathy/

[2] https://www.ncbi.nlm.nih.gov/pubmed/18793090

Photo Credit: Sean MacEntee

Categories
Innovation Lecture

Drinking from a Fire Hydrant: Musings on Active Learning in Medical School

Almost everyone has seen a doctor at some point in their lives. Yet, for most, what actually goes on in medical school remains a mystery. Chances are that if you’re reading this, you have experienced the delightful experience that is medical school. Sleeping in late, eating well, and relaxing with friends and family on the weekend are just a few of the joys that we medical students get to experience. Just kidding. Medical school, as most of us know, is beyond challenging. At my school, faculty members fondly liken the medical school experience to drinking from a fire hydrant. As medical students, our pre-clinical days are comprised of hours and hours of lectures and power points. Then, when class is all over, we get to top off the day with several additional hours of studying. It’s challenging, it’s overwhelming, and at times, it seems downright impossible.

Part of what makes medical school such a unique challenge is the fact that medicine is a tactile discipline and yet, pre-clinical education is traditionally taught in a classroom setting. In response to this dichotomy, the University of Vermont’s Larner College of Medicine recently made headlines by announcing that it would become the first public American medical school to completely eliminate lectures from its curriculum, joining private Case Western Reserve University School of Medicine in Ohio (https://www.washingtonpost.com/news/to-your-health/wp/2017/07/29/medical-school-without-the-sage-on-a-stage/?utm_term=.6847516c2b31.) This change, which is expected to be fully implemented by the year 2019, comes in response to concern that the traditional lecture format does not promote knowledge retention and instead relies on “passive” learning where the learner is not actively engaged in their education. To draw an analogy, passive learning is like being fed while active learning requires learners to pick up the fork to feed themselves.

Although the University of Vermont and Case Western Reserve University seem to be the only two institutions whose medical schools have committed to becoming completely lecture-free, it’s interesting to realize that other schools have moved towards a more active learning format as well. In my school, the College of Osteopathic Medicine of the Pacific (COMP) , students pick their own small groups. These small student-led groups meet several times a month and work together to complete assignments and discuss scenarios that are based upon real clinical scenarios. Northwestern University’s Feinberg School of Medicine is one of several schools that employs a problem based learning curriculum, and in 2015, Harvard Medical School also restructured their curriculum to become more problem-based. Ultimately, medical school curriculums exist on a spectrum from passive to active curriculum styles and the continuum seems to be shifting to favor active learning styles at many medical institutions.

Moving away from a traditional lecture setting certainly presents its own unique challenges that affect learning. The non-lecture curriculum requires more self-reliance on the part of the students, who must teach themselves new material. The small groups used at COMP, for example, are completely student-led. A faculty member may pop in for a few minutes to make sure that the group is running smoothly, but often these faculty members are not experts in the subject matter at hand and are present to deal more with administrative issues than to teach content.  It also means that students are required to participate in groups, whereas many schools may have optional attendance for lectures. Perhaps the biggest challenge of the active learning curriculum, however, is the necessity for different personalities to work together to achieve a common goal. The traditional classroom setting involves one teacher who employs a specific style to reach multiple students. In the active learning curriculum, small groups are often used, in which each member has a different personality. Students in these groups must work together, sometimes despite personality differences, to master the curriculum and achieve common goals. Although the group setting closely resembles the team-based approach taken in most healthcare settings, it can undoubtedly be frustrating, especially for someone like myself who tends to be more introverted and likes to study on his/her own. In my personal experience, the members of my small group were incredibly supportive and had a variety of strengths, yet there were many days when I couldn’t wait to return to the comfort of my own room to be able to really learn the material myself. Sometimes trying to learn unfamiliar concepts with others was a distraction, and despite the best of intentions, small group was like the blind leading the blind when we were all confused on certain concepts. There were some times that the small group felt comforting, like someone holding my hand, and other times when it felt too overwhelming, like someone pressing my face up against that proverbial fire hydrant. Ultimately, I felt like the combination of both lectures and small groups was actually more dynamic than relying solely on one or the other. While the University of Vermont and Case Western Reserve University have both made the bold move to abstain from lectures altogether, they join the company of many medical schools, both allopathic and osteopathic, that have recognized the importance of active learning for the medical school curriculum. Let me know what alternatives your medical school offers to traditional lecture-style learning!

Categories
General Law Lifestyle Public Health

Keeping Abreast of Lactation Laws

“Infant forced to go without milk, Mom says it’s not her fault.” This seems like the kind of terrifying headline that would be on the five O’clock news. Yet this is exactly what happens every day when the rights of women to breastfeed or express milk on the job go unprotected. One politician, Representative Carolyn Maloney (D-NY), has made it her mission to make sure that women can breastfeed without repercussions. I have to admit that when I first heard about Representative Maloney’s Supporting Working Moms Act, I was baffled to think that in the year 2017, breastfeeding in the workplace could cost a woman her livelihood. With a little research, I started to realize just how ill-informed I was on the legality of breastfeeding.

I was surprised to learn that currently, no federal legal protections exist to protect public breastfeeding. Furthermore, only 47 states have laws that legalize public breastfeeding.[1] Of those states, Michigan’s law is a mere three years young. Astonishingly, Iowa offers no legal protections for breastfeeding. Even though public breastfeeding might be legal in most states, it wasn’t until 2010 that breastfeeding in the workplace received its own set of protections. A federal breastfeeding provision called “Break Time for Nursing Mothers,” which was added as an amendment to the Affordable Care Act (ACA), makes it mandatory for companies with 50 employees or more to provide “reasonable” break time for women to express milk during the first year of their child’s life. This same provision also requires companies to provide a clean and dedicated space for breastfeeding in the workplace.[2] However, this provision only ensures the rights of “nonexempt” workers, meaning only those who earn hourly wages as opposed to salaries are protected. Even with the laws that protect the right to breastfeed in public, women can still face repercussions that range from fines to docked pay to even termination as a direct consequence of breastfeeding in the workplace . With the ACA in jeopardy of being repealed (possibly by the time this article is published), the future of breastfeeding is more vulnerable than ever. The Supporting Working Moms Act is meant to provide federal breastfeeding laws independent of the ACA, as well as expand protection to 12 million additional women, including public school teachers.[3]

The issue of breastfeeding is close to my heart, not only as someone who hopes to one day become a mother, but also as a future physician: I know the powerful impact that breastfeeding can have on a child’s health. In their policy statement on the use of human milk, the American Academy of Pediatrics affirmed their position that infants should be breastfed exclusively for the first six months of their lives whenever possible.[4] Breastfeeding can be challenging for a number of reasons, and it is important to respect the fact that not all mothers are able to breastfeed their children. However, for those who can and choose to do so, the benefits can be profound for both the mother and the child. According to the National Institutes of Health, breastfeeding helps infants fight infection, lower their risk of Sudden Infant Death Syndrome, and could possibly serve as a protective factor against developing asthma, allergies, and even diabetes.[5] Studies show that babies who are breastfed attain better educational achievement than their non-breastfed peers by the age of five.[6] From an economic perspective, breastfeeding has been shown to lower healthcare costs by reducing disease burden in the population.[7] Even though many of us will not be pursuing careers in obstetrics, at some point in our careers, we will all establish some connection to a new mother, whether she is your patient, your partner, or yourself. Being informed about the legality of breastfeeding can help us to provide these women with support and guidance and make sure that our littlest patients have the healthy start in life that they deserve.

References:

[1] http://www.ncsl.org/research/health/breastfeeding-state-laws.aspx

[2] https://www.dol.gov/whd/nursingmothers/Sec7rFLSA_btnm.htm

[3] https://maloney.house.gov/issues/womens-issues/breastfeeding-0

[4] http://pediatrics.aappublications.org/content/129/3/e827

[5]https://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/Pages/benefits.aspx

[6] https://ora.ox.ac.uk/objects/uuid:13bde0c7-0070-43c6-9ae3-307478e8c42c

[7] http://www.reuters.com/article/us-breastfeeding-study-idUSTRE6342ZG20100405

Photo Credit: Roberto Saltori

Categories
Clinical General Lifestyle Narrative Opinion

In the Business of Medicine, Be Your Own Boss

As medical students, we exist between two worlds. On the one hand, we’re tasked with learning as much as we can about the practice of medicine from our preceptors, many of whom have decades of experience. On the other hand, we’re always thinking about our place in the future of medicine and fantasizing about what our unique style of practice will look like. While I feel indebted to the seasoned physicians who graciously give of their time to teach us, a recent interaction reminded me that I am the boss of my own practice of medicine.

It started out as a morning just like any other. I needed to finish rounding on my patients before a noontime meeting where I was slated to give a small presentation. The last patient on my roster had been particularly troublesome for our service. She had been admitted for worsening congestive heart failure and although she was relatively young, and had a very supportive family, she did not seem willing to make any of the lifestyle changes that would improve and possibly prolong her quality of life. Nurses, doctors, and respiratory therapists had been trying to get her to wear her CPAP mask during this hospitalization, but for reasons that we didn’t completely understand, she had been refusing to wear it for the past two months.

After a quick exam and what seemed like a futile imploration to try her CPAP again that night, she started telling me a bit about her life prior to becoming ill. I knew the time was coming closer and closer to my meeting, but I couldn’t leave while she in the middle of divulging such personal information. Our conversation dwindled, and I stepped toward the door, when she tearfully mentioned that her dog had recently died. Again, my thoughts drifted toward the upcoming meeting, but I also wanted to be sensitive to this very meaningful event in my patient’s life. Trying to be polite, I asked when her dog had died.

“Oh, about two months ago,” she replied.

I paused. “Is that about the time when you stopped wearing your CPAP mask at home,” I asked.

She stopped to think. “Yes, I think it was exactly around that time.”

Thinking that the timing of her dog’s death coinciding with when she stopped using CPAP might be more than coincidental, I offered my condolences for her loss, and assured her that I wanted to come back later in the day to talk more about her dearly departed pet. I felt relieved to see that I had only run a minute late, so I hightailed it to the meeting. As I stopped to pick up the materials for my presentation, I heard my attending calling my name from the hallway. I couldn’t wait to tell him that I had stumbled upon a very useful piece of information to help us understand why she stopped using her CPAP machine.

“I know I’m a minute late-I got stuck with our patient,” I explained. “I couldn’t just couldn’t leave when she started talking about her dog who recently died, but I may have a clue as to why she won’t wear her sleep mask.”

He looked dismayed. “You have to figure out how to get out of those conversations,” he told me curtly. “That’s just the business that we’re in.”

His last words “the business that we’re in” struck me so profoundly that I can still replay them in my head as clearly as if he was standing right across from me. I have not had a temper tantrum since childhood, and yet, in that moment, everything inside me wanted to shake my head and bang my fists in passionate disagreement. I understood immediately that whatever business this physician is in is not the same business I’m planning to go into. As a student, I still have a lot to learn, but one thing I know for certain is that patients should always take precedence over meetings. After all, without fostering the relationships we have with our patients, medicine would be a business in bankruptcy.

Medicine has a rich history of being passed down from generation to generation, but like anything else, aspects of medical practice may become antiquated. As the next generation of physicians, it’s up to us to hone our judgment and decide whether we will accept the status quo or make a new path forward. We get to decide what the business of medicine means to us. Whether we work for a large corporation or go into private practice, each one of us is a boss-in-training of our own future practice. It took some not so sage advice from a preceptor to remind me that meaningful and collaborative relationships with my patients are the cornerstones of my business of medicine.

 

Photo credit: Christophe BENOIT

Categories
Clinical Emotion Empathy General Patient-Centered Care

Are you a cheerleader or a fan? Examining motivation in medicine

One of my favorite aspects of medicine is the relationship between health and lifestyle. I think of lifestyle as all of the “stuff” that affects patients outside of the exam room, including diet, exercise, family relationships, and living accommodations. All of these things affect the physical body in ways that are not always immediately apparent. In my most recent rotation, my preceptor and I treated several obese women complaining of low back and hip pain.  Thinking about the relationship about weight and musculoskeletal pain, I was surprised that my preceptor never made suggestions to patients about increasing their activity level or improving their diets. “I’ve realized that I’m not a cheerleader,” he told me, when I questioned him. “Trying to make people change only ends in heartache for me.”

It’s difficult to think about how patients can change their lifestyles without first thinking about their motivation for change. January happens to be the perfect time talk about motivation since this is the time of the year when people are making those pesky New Year’s resolutions.  W.D. Falk, a philosopher, writes about motivation as a direct product of one’s morals, and divides motivation into two subtypes: motivational internalism and motivational externalism. Motivational internalists believe that one’s motivation for doing something is directly linked to how the activity in question relates to one’s morals. In other words, if a patient is convinced that exercise is a good, morally correct thing to do, that moral conviction will be enough to motivate them to exercise. On the contrary, motivational externalists see no link between one’s moral convictions and their motivation. No matter how important or morally correct our patients think something is, their motivation for changing their lives has to come from some external source. A patient may believe that exercise is a morally good activity, but this belief alone is not enough to actually motivate them to exercise.

Acknowledging the existence of these two groups (and of course, many shades of grey in between!) will allow us to understand how we may best help our patients without using a “one size fits all” methodology. Some patients may able to find the impetus for change within themselves. These patients may articulate specific plans to achieve a goal or they may have independently improved their own wellbeing in the past. Other patients may need external motivating factors to make changes necessary to improve their health, most often in the form of a trusted confidant. We need to use our best clinical judgment to decide which approach would work better for each patient.

My preceptor’s comments also helped me recognize that in addition to understanding our patients’ capacities for change, we also need to think of our own capacities for motivating our patients. Some physicians are cheerleaders willing to stand on the front lines with their patients. These practitioners feel energized by helping people make positive changes and are willing to make an emotional investment in their patients’ lives. They help their patients set goals, consistently communicate with patients about their progress, and are willing to act as an emotional support whether or not the goals get met. Other physicians may not see themselves as cheerleaders for change. These physicians still have a responsibility to discuss aspects of their patients’ lifestyles that need improvement; however, their role might take form as a “fan” in the stands, rather than a cheerleader on the sidelines. They can still cheer on their patients and check in with them about their lifestyle changes, but may need to help patients find someone else in their healthcare team who is willing to do the ground work that it takes to help patients set and reach goals. In fact, I believe that it is far better to honestly acknowledge that you are a lousy cheerleader than to try to help your patient, only to become disheartened by their lack of progress and abandon them out of sheer frustration before their goal is met. It’s only through an honest acknowledgement of our own abilities and limitations that we can help our patients change their lifestyles for the better.

 

Photo credit: Jeff Turner