Category: Emotion

Categories
Clinical Emotion Empathy General Patient-Centered Care

Opinions Aren’t Facts

I wanted to discuss an experience I had in the newborn nursery. I was assigned to Baby K—a small baby girl who was delivered by emergent cesarean section because her mother abused cocaine during her pregnancy. Looking through Baby K’s chart, an unsettling feeling came over me. This was one of the first times I directly saw how a mother’s behavior impacted her child. Before this, all my clerkships had dealt with adults who were responsible for their own health. Seeing an innocent newborn enter this world with a disadvantage because of her mother’s actions was disheartening.

With this in mind, I went to talk to Mother K the next morning. The chart stated Baby K was going to be given to her great-grandmother, and I needed to confirm this information. I could immediately tell that Mother K was upset when I asked her to confirm. She said, “Yes, she’s going to her great-grandma, but I’m still going be involved! I’m NOT giving up on her!” I realized that just asking the question caused her emotional pain. Especially since the social worker, the nurse, and probably several others, had also asked this question. She again assured me that she loved Baby K, but that she just needed to get her life together before she could care of her. After talking more to Mother K, I realized she was trying her best.

This experience opened my eyes to my perception of patients. After browsing Mother K’s chart and reading that she continued to abuse cocaine while pregnant and was planning on giving Baby K to another caretaker, I may have made the assumption that she didn’t want anything to do with Baby K at all. This assumption may have been reflected in the way I asked her questions, leading her to become distraught. Many patients, especially those who suffer from substance abuse, have lost complete control over their actions. Their mind is controlled by an addiction, and they need help before they can take care of others. After talking more with her, I learned that Mother K actually planned to enroll herself in a treatment center that has housing. After getting better, she yearned to resume care of Baby K. These are details that were never mentioned in any notes, but if they had been mentioned, may have altered my first impression of Mother K before I met her. I also learned that Mother K continued to use cocaine during her pregnancy because she didn’t realize its impact on Baby K. She used cocaine during her prior pregnancy with her older son, and he remained “normal and healthy.” Even though we, as medical professionals, can understand how abusing cocaine during pregnancy is directly detrimental to the fetus, many individuals may not understand this basic concept of maternal-fetal physiology. We thought Mother K’s use of cocaine was due to her lack of care for Baby K, when in reality it was fueled by her lack of knowledge.

The most important lesson I learned was not to judge patients based on chart review alone. I know this seems like “common sense,” but it can be easy to jump to certain perceptions after reading the tone of some of the notes in a patient’s chart. My goal in the future is to enter every patient’s room with a blank slate. Our duty has always been to provide the same quality of care for all patients, regardless of their actions or beliefs, but sometimes we let our feelings get in the way of this duty. I have struggled with this in pediatrics more than I have in any other specialty. When I talk to parents who are willing to move mountains for the health of their children, I feel endearment towards them. There is nothing stronger or more special than a parent’s love. In contrast, with parents like Mother K, it is easy to become frustrated. After examining Baby K, I kept thinking about her fragile little arms and small shrunken head. Baby K may grow up to have health consequences that could have easily been prevented. All I can do is allow this experience to shape future patient encounters. I’m going to try to place myself in each parent’s situation and ask myself: what information or advice would I find the most helpful right now? At the end of my time with Mother K, I gave her a tight hug—I’m rooting for her. I hope she is able to complete her treatment and be reunited with Baby K soon.

 

Photo credit: Weird Beard

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

Categories
Emotion Empathy General Narrative

Repost: Stories of Suffering

As the MSPress Executive Board transitions, we bring you a post from past! Enjoy the work of one of our emeritus writers, Sara Rendell.

I am a medical student because I love questions. After a blood vessel takes a punch, what causes the platelet pile-up? What makes people blink, gag, cough, or sneeze? Why is cat litter as scary as alcohol for a pregnant woman?

Some medical questions are unanswered. Yet, science promises progress. With enough grant-funded work in labs and clinics, scientists can describe new diseases. Medicine will show where illness happens, researchers will explain how it happens, and epidemiologists will predict who it is more likely to happen to and when it could happen to them. Even with all of this knowledge, there is one question I do not expect my medical training to answer.

While I go to lectures, practice interview skills, and learn how to diagnose and prescribe, people endure pain, distress, and loss, and I can’t explain why. Why do people suffer?

Photo courtesy of drp
Photo courtesy of drp

I can look to people who suffer for answers. It is not hard to find written first-person narratives of suffering. In these narratives, protagonists are often cast in two roles: the suffering fighter and the wise sufferer.

As Kathlyn Conway discusses in her essay, “The Cultural Story of Triumph”, the narrative of a “suffering” fighter dominates over other stories of illness. Illness becomes a journey to physical cure. Where physical cure is not possible, illness is cast as a path to wisdom, a form of moral development. The patient becomes a traveler who should somehow be “uncomplaining, strong, and brave” on this journey (Conway, 2007).

“Illness is a chance to show us your guns and triumph!” the medical culture seems to say.

If society expects sick people to be “fighters” what else do we expect from them? I think of S, a 62-year old woman with osteosarcoma, who put on lipstick while her skin was sinking deeper into the spaces between her bones. “Can’t let this cancer make me ugly honey,” she said as she applied her makeup in the mirror. What does it mean that S’s fight against cancer involved cosmetic routines?

The idea that people grow in strength or wisdom while suffering is familiar to me. As essayist, Pico Iyer describes in “The Value of Suffering”, suffering can be a doorway to compassion, loss can be an invitation to appreciate nuance. Yet, my intestines tangle when I imagine telling a patient who suffers, “What an opportunity to unfurl in wisdom!” Even if I did not say this out loud, I wonder what my expectations might communicate.

Untitled 2 copyLast year, my close friend J died of metastatic breast cancer while 27 weeks pregnant with a boy. During her first trimester, we would lie on my floor and look up at the ceiling when retching woke her in the morning. Over the next few months we went to her prenatal visits and giggled over possible baby names. Then, she stopped eating and her nails turned yellow. Her doctor said, “Hopefully it’s hepatitis.” He didn’t bother to tell us what it hopefully wasn’t. Her yellow vomit and “liver nodules” explained. She was 24 years old when she passed away and left behind her husband and 3-year old son.

That was an inexplicable catastrophe. But J’s husband needed to believe that somehow God had planned this. If he believed that her death was one example of many forces that roll over us the way tires would ants trying to cross a highway, then how could he continue with day-to-day life? How would he keep being his son’s Papa?

Even after I gather years of experience with suffering, I do not expect to be able to explain it. I do know that the stories we tell about suffering can influence how we relate to patients.

My expectations form the questions I ask and the things I attend to.  Imagine me telling a patient, “Fight your cancer, but stay pretty.  Also, grow spiritually so you can teach me through your suffering.”  That feels like a lot of pressure to put on someone who is ill, even if it is unspoken. If I look for a suffering fighter in a patient who cannot cast herself in that role, I risk disrespecting her experience. If I try to learn wisdom from a patient who does not see his illness as a journey to moral development, I might disregard his life story.

Medical school teaches me to synthesize and simplify information.  The more narratives I hear, the more I feel a desire to string them together along a unifying theme.  Cultivating attention to less common stories about suffering and loss reminds me to listen when I long to explain.

Sources:
Conway, Kathlyn. 2007. Beyond Words: Illness and the Limits of Expression. University of New Mexico Press. Albuquerque

Iyer, Pico. 2013. The Value of Suffering. New York Times.
Featured image:
“After a Night Shift” by Stephanie Scott

Categories
Emotion Empathy General Law

Gratitude: A Good Recipe for Holiday Cheer

The “most wonderful time of the year” is often filled with stark contrasts. While glitz and opulence surround us, sorrow and despair seem to grow emboldened. Nowhere is this truer than in a big city, where poverty and privilege so closely intermingle. Minutes after I walked down Fifth Avenue, basking in the glow of the Christmas lights infinitely multiplied in the facets of glittering diamonds displayed on shop windows, I found myself peering down into a simple metal container full of school supplies. This school-in-a-box, provided by the United Nations Children’s Fund (Unicef), was on display as part of an exhibit called “Insecurities: Tracing Displacement and Shelter”. Insecurities represents one installation in the Citizens and Borders series organized by the Museum of Modern Art (MoMA) in New York City. The Citizens and Borders project aims to highlight experiences of migration, territory, and displacement[1]. Standing in front of this school-in-a-box, I thought of our medical school, replete with its high-tech anatomy lab, treadmill desks, and air conditioning system so powerful it sometimes forces us to use blankets in our lecture halls for warmth. I thought of my comfortable bed at home, and of the night table that stands next to it, teeming with books, and of the shelf above it filled with movies.

Once more, we find ourselves in the midst of the holiday season, awash with bright lights and commercial cheer. This year’s winter holidays occur on the heels of an extremely draining presidential election season that left over fifty percent of Americans feeling stressed and anxious.[2] Already this month, I have seen patients who have related somatic complaints to the election, cooking, and spending time with their extended family To add insult to inury, the commercialism of the season which suggests we ought to see the world through the rosy hues of a colored ornament can exacerbate feelings of stress and anxiety in those who are already overwhelmed and not feeling their healthiest.. As a caregiver, I realize that it is important for us all to be especially sensitive this year to patients who may be feeling a bit less than the usual holiday cheer.

Peering down into the school-in-a-box reminded me of how grateful I am for the many privileges in my life. Some of these privileges, like a loving and supportive family, or being born in a country with free speech and democratic elections, are pure happenstance. Others I have worked hard for, like the privilege of attending medical school and caring for patients. It is important, now more than ever, that we have gratitude for our privileges in life, and help our patients extend an outlook of gratitude in their own life.

Gratitude has11522685876_5d27ebdb25_o consistently been shown to have a positive impact on mental health. Dr. Martin E. P. Seligman, a psychologist at the University of Pennsylvania, asked study participants to write letters of gratitude to people in their lives whose important contributions had previously gone unacknowledged. He then quantified the impact of these letters on the study participants’ letter writers by providing them with a happiness score. Unsurprisingly, the mere act of writing the letter and expressing gratitude was found to boost each participant’s happiness score.[3] As physicians, we ought to support many outlets for creative expression, from yoga to painting, as ways to contribute to our patients’ well being, but we also need to consider gratitude as its own kind of healing salve. Whether we encourage our patients to write expressions of gratitude to special people in their lives, or just to reflect on the small blessings in their everyday lives, gratitude should have a place in our roster of medical advice. We cannot and should not strive to take away the things in our patients’ lives that cause them discomfort, anxiety, and sorrow, whether they be personal events or national political outcomes. Good medicine is not about making the world a more comfortable place, but rather, making our patients more comfortable within the world.

[1] https://www.moma.org/calendar/exhibitions/1653?locale=en

[2] http://www.npr.org/2016/11/06/500931825/how-to-deal-with-election-anxiety

[3] http://www.health.harvard.edu/newsletter_article/in-praise-of-gratitude

 

Photo credit: Timo Gufler

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
Clinical Emotion Reflection The Medical Commencement Archive

Compassion, The Heart of Medicine

Dr. Rob Horowitz is an Associate Professor of Clinical Medicine and Pediatrics, and is board-certified in Internal Medicine, Pediatrics and Hospice & Palliative Care Medicine. After 14 years of working as a rural Emergency Physician, in 2012 he moved his professional come to the University of Rochester Medical Center division of Palliative Care, where he cares for children and adults who have serious illness. Dr. Horowitz also established and served as Medical Director of URMC’s Adult Cystic Fibrosis Program from 1999 until 2015.

In addition to his clinical duties, Dr. Horowitz is Director of the Medical School’s Year 2 and Year 3 Comprehensive Assessments, which are longitudinal formative assessments of student communication skills, medical knowledge and professionalism utilizing patient-actor interviews, multi-source feedback, peer- and self-assessments, and other modalities. He also teaches medical students in multiple other small and large group settings and facilitates several groups for clinicians, including Balint groups for physicians and Nurse Practitioners, and a support group for Palliative Care Unit nurses, techs and others.

Hello Class of 2016 and hello to your family, friends, colleagues and dignitaries. What an honor, that you invited me to deliver your Last lesson from the University of Rochester School of Medicine and Dentistry faculty. It will be a brief one, less than ten minutes; and it will be a review, a reminder of what you already know. Or, and I say this with sadness and some urgency, it may be a reminder of what you once knew, and may be in the process of forgetting. This Last Lesson is grounded in words from Francis of Assisi, which I paraphrase here:

Work of our hands is labor.
Work of our hands and our head is a craft.
Work of our hands, our head, and our heart is an art.

THIS is the last lesson: doctoring is an art, a work of your hands, head and heart, or more prosaically, a work of skills, knowledge and humanity. This reminder is important, even for you, who were socialized here in Rochester, the home of biopsychosocial medicine. In fact, it’s a response to recent conversations I’ve enjoyed with many of you, who, poised for internship, wondered whether health-care-the-business has taken the heart out of medicine- the-calling. The answer is a resounding NO. But let me respond directly to your words, first about hands and head. Here are two quotes from you, representative of many others:

I just don’t know enough to be a good doctor.
I’m about to be revealed as a phony.

I respond with a story from long ago and yet not so long ago: twenty three years ago I was a Med-Peds intern here in Rochester, just completing my first Medicine rotation at Strong Memorial Hospital, when in Morning Report the chief resident asked me to offer a differential for the case. I was paralyzed. I had no idea how to explain the patient’s symptoms. I tried to smile and charm my way through it, but I stumbled and fumbled, until a fellow intern completed the task that I couldn’t. I felt ashamed…revealed as a phony, an imposter.

As you know, aversive conditioning is deep, and this experience stuck with me. In the succeeding years, whenever I saw a particular colleague who witnessed my humiliation on that day long ago approaching down the hall, I was tempted to, and sometimes DID, turn in the opposite direction, so I wouldn’t have to feel his scorn.

Sounds silly from this vantage, nearly a quarter century later, doesn’t it? In fact, a medical student suggested so last year in response to me sharing this story. He challenged me to find out if my impression was accurate. And so I did. Last June, seated behind me in Grand Rounds was that well-admired physician. I took a deep breath, turned around, and asked him what he recalled about that infamous incident, my unmasking. His response was, “Are you kidding, Rob? I was too busy feeling like a fraud myself to take
in anyone else’s difficulties! Sounds like we were in the same boat.”

What a gift of relief his words were! A few minutes into Grand Rounds, he put a ribbon on the gift when he tapped me on the shoulder and whispered, “Y’know, Rob, I’ve always thought you were a pretty smart guy.”

There are two morals here: First, you can’t pack all the information you will ever need into your head. In 1950 the doubling time of medical knowledge was 50 years; in 1980, 7 years; in 2010, 3.5 years. This means during your tenure here—whether 4 years or 13 years—the base of medical knowledge has more than doubled and, for some of you, several times over! So, of course, please learn from your knowledge gaps, and master how and where to seek answers. And please recognize that knowing it all is not the most important  measure of our competence as doctors.

Second, the collision between our cognitive limits and our inherent drive and perfectionism, which made this professional  achievement possible in the first place, is a perfect recipe for self-doubt and self-judgment. And if these become our lifestyle, we will live a  disheartening and depleted life. Please be kind to yourself, and find in your community colleagues and mentors who are open to genuine reflection. Don’t wait 25 long years, like I did, or forever, to make peace with your humanity.

Now, what about the Heart component of Doctoring? I will share two quotes from you, similar to many others:

I know empathy is important, but there isn’t enough time to be empathic.
I’m working so hard to be smart and productive, I’m afraid I’m losing my caring.

Let me respond with a second story, a fresh one about the profound opportunity for compassion in simple moments. Last Friday morning, into the exam room stormed my new patient, a 50-something year old woman I’ll call Wendy, who has widely metastatic cancer and severe pain, for which she was referred to me. You see, I’m a palliative care physician, and as such, I am a pain specialist. She sat opposite me and as she launched into her agenda, she leaned forward so far that I was forced to lean back.

She damned the medical system, and she cursed the siloed subspecialists, and she asked why the hell she should trust me, yet another siloed subspecialist, to help her, or to even care. I asked if I might share an observation with her. She nodded. I told her, “I want
to help make sense of what’s going on, and to care for you and help you, but your manner appears so angry, so critical, I am not sure how to reach through it to you. Can you help me?” She softened a bit, and responded, “I’m afraid that if I stop being angry, I’m going to cry.” I inched closer, until our knees were almost touching, and looking into her now moist eyes, I said, “Then cry.” She gasped and her head bowed, tipping forward as if she was collapsing, and to stop her descent, I reflexively leaned forward, until the tops of our heads were gently touching. We were posed like an A-frame, and she wept. I put my hand on her shoulder and told her, “I am with you, Wendy.” And between sobs, she stuttered, “Yes…now… I know.”

There are two morals here. First, you can choose to cultivate the habit of compassion. Indeed, I share this story not to show off my compassion-finesse, but to demystify, to define and to normalize it. We respond compassionately to suffering simply by witnessing it, approaching it, and inquiring about it. And by that alone, we offer healing. And it doesn’t have to take a lot of time.

Second, it is vital to be compassionate to both your patients AND to yourselves. Because just as you can’t possibly know everything that matters, neither can you possibly tend to all those in need. Please remember that you actually DO need to sleep and to eat,
to tend to your spouse, your partner, your children, your friends, your inner life, and your pleasures.

So, this last lesson is a reminder of what you knew when you first came here to enter this amazing, privileged profession: Hands, head and heart are all three essential to the art of doctoring. If you choose to make compassion your default mode, then you will know definitively—in your own heart—that health-care-the-business CAN’T take the heart out of medicine-the-calling.

You can only imagine how inspiring it is, from this stage, to look upon you, our colleagues. To celebrate you, to be awed by you, and to know with great confidence that your skillful hands, your brilliant heads, and yes—your loving, beautiful hearts will be a blessing to your countless beneficiaries, your patients, who now await your arrival. For this we are forever proud and grateful. Congratulations.

 

The Medical Commencement Archive, Volume 3, 2016

Dr. Rob Horowitz, MD
University of Rochester School of Medcine
Commencement Address

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
Emotion Lifestyle

Could mindfulness meditation help us to care for patients?

“We can only give away to others what we have inside ourselves”-Wayne Dyer

Empathy is the ability to understand and experience life from another person’s perspective, which allows an individual to care for others in a genuine way. In medicine, it is arguably one of the most crucial qualities required to be a good doctor. Research shows that empathetic doctors are perceived as better caregivers, and are less likely to face malpractice suits. (1-4) In another study, which looked at how physicians’ empathy affected clinical outcomes for diabetic patients, it was found that the physicians perceived as more empathetic were more likely to have patients with blood sugars and cholesterol levels under control. (5)

Demonstration of caring and altruism during the medical school application process is almost essential for entry. However, several studies have shown that student empathy is negatively affected by medical education, particularly on entering the clinical years of training. (4, 6, 7) Various factors have been explored to explain this. The higher workload of the clinical years, exam pressures, as well as facing the realities of medicine on the wards (as opposed to previously idealised media images), could all be contributing to the phenomenon.

Moreover, medical students come from a background of overachievement, and stress and anxiety can result from not performing to the standards they expect of themselves. (4) Perhaps as medical students we have also learnt to put on a mask of compassion, kindness and emotional distance to protect ourselves from the realities of life; or maybe it is emotional blunting from just meeting too many ‘people with problems’. (7) Whether the reason for our rise in cynicism is attributed to one or all of these explanations, it seems apparent that the care and compassion we are able to show to patients is primarily associated with our own mental state. With a continuous backdrop of studying and time pressures, the stresses of all life events are heightened.

There has been a large amount of research into the stress, burnout rates and psychological consequences of medical school training. In one multicentre study at American medical schools, burnout was found to be common amongst medical students, and it increased by year of study. (8) The general consensus is that the medical school experience is challenging and demanding, requiring resilience and a balanced lifestyle.

Could medical schools provide more support to ensure students are well equipped to face a career filled with emotionally demanding situations, whilst maintaining the levels of empathy and emotional understanding crucial for strong doctor-patient relationships? All schools offer some level of student support, such as counselling sessions for those students that are experiencing mental difficulties or life challenges. Unfortunately, it has been shown that a clear stigma continues to exist against mental health and guidance in simple life matters. This has been described as “the hidden curriculum”, a culture that exists where doctors and students are led to believe that we are invincible and cannot become ill, either mentally or physically. (9) Often the first signs of vulnerability to mental health issues manifest at medical school, which actually leads to breakdown much later on. (10) Rather than allowing our future doctors to reach their breaking point before seeking help, we could build strong foundations and encourage introspection alongside academic learning. This would help our medical students and doctors truly reach their potential.

One avenue that has been explored to prevent ‘compassion fatigue’ and burnout is through the practice of mindfulness meditation. One study found that post-intervention levels of anxiety and depression were significantly reduced. (11) Mindfulness is currently taught at 14 medical schools and is continually gaining popularity. The University of Rochester School of Medicine and Dentistry (USA) and Monash Medical School (Australia) are unique in that they have fully integrated mindfulness into their core curricula. (12) One study found statistically significant reductions in tension-anxiety in students on a mediation-based stress reduction (MBSR) program (from 14.5+/-7.2 pre-intervention to 12.4+/-7.0 post-intervention) in comparison to controls (11.3+/-6.3 pre-intervention to 13.4+/-6.9 post-intervention). (13)

What is Mindfulness?

Meditate by Caleb Roenigk
Meditate by Caleb Roenigk

Mindfulness is a process to become more conscious of the present moment in order to manage thoughts, feelings and strong emotions. (14) Although it was historically known as a Buddhist practice, with the aim to alleviate suffering and cultivate compassion, it can be practised without spiritual or religious affiliation. In the late 1970s, Jon Kabat-Zinn, a physician at the University of Massachusetts Medical Centre, developed Mindfulness-Based Stress Reduction (MBSR), which takes away the esoteric aspects of the practice while retaining the core elements.  This has gained considerable popularity, particularly in the field of pain relief. (15)

 

A study into the effects of meditation practice on the brain, conducted at Harvard School of Medicine, found that with meditation there was increased gray matter in the frontal cortex, an area associated with working memory and executive decision-making. There was also thickening of three key regions displayed in the table below. (16)

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Furthermore, the amygdala, the area of the brain associated with the fight-or-flight response, and thus a key contributor to feelings of anxiety or stress, became smaller. (16) A second study by the same group found that practice for only 8 weeks appears to enhance regions of the brain associated with memory, sense of self, empathy and stress. (17)

Medical school and life as a doctor is a demanding career path. Thus, it can be argued that it is the responsibility of medical educators to both equip students with the academic knowledge required and the emotional intelligence to handle the day-to-day challenges. Mindfulness offers a method to teach medical students how to practically handle stressful emotions and situations, which helps them to become more centred, caring and empathetic. We can only give as much as we have, so it seems intuitive that students who are happier and mentally strong will provide better patient care. The evidence for mindfulness practice is very encouraging and it is interesting to see that two medical schools have already incorporated these practices into their curriculum.

Will mindfulness become as core to the medical school curriculum as the study of anatomy? If we value the mind as much as we do our bodies, then maybe it should.

Meditate and Prosper by Juhan Sonin
Meditate and Prosper by Juhan Sonin
  1. 1. Halpern J. What is clinical empathy? Journal of general internal medicine. 2003;18(8):670-4.
  2. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. Jama. 1997;277(7):553-9.
  3. Brownell AKW, Côté L. Senior residents’ views on the meaning of professionalism and how they learn about it. Academic Medicine. 2001;76(7):734-7.
  4. Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Academic Medicine. 2008;83(3):244-9.
  5. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine. 2011;86(3):359-64.
  6. Ren GSG, Min JTY, Ping YS, Shing LS, Win MTM, Chuan HS, et al. Complex and novel determinants of empathy change in medical students. Korean journal of medical education. 2016;28(1):67-78.
  7. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Academic Medicine. 2009;84(9):1182-91.
  8. Dyrbye LN, Thomas MR, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. Personal life events and medical student burnout: a multicenter study. Academic Medicine. 2006;81(4):374-84.
  9. Sayburn A. Student BMJ: Why medical students’ mental health is a taboo subject. London: Student BMJ; 2016 [accessed 4 Apr]. Available from: http://student.bmj.com/student/view-article.html?id=sbmj.h722.
  10. Marshall EJ. Doctors’ health and fitness to practise: treating addicted doctors. Occupational medicine. 2008;58(5):334-40.
  11. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. Journal of behavioral medicine. 1998;21(6):581-99.
  12. Dobkin PL, Hutchinson TA. Teaching mindfulness in medical school: where are we now and where are we going? Medical education. 2013;47(8):768-79.
  13. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003 15(2): 88-92.
  14. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. Jama. 2008;300(11):1350-2.
  15. Kabat‐Zinn J. Mindfulness‐based interventions in context: past, present, and future. Clinical psychology: Science and practice. 2003;10(2):144-56.
  16. Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893.
  17. Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging. 2011;191(1):36-43.

Featured image:
Meditation by Sebastien Wiertz

Categories
Emotion General Lifestyle Reflection

Loneliness: The Epidemic of the Modern Age

“God, but life is loneliness, despite all the opiates, despite the shrill tinsel gaiety of “parties” with no purpose, despite the false grinning faces we all wear .. Yes, there is joy, fulfillment and companionship – but the loneliness of the soul in its appalling self-consciousness is horrible and overpowering.”
– Sylvia Plath (1)

Who amongst us has not felt the hand of loneliness? The first breakup as a teen, the rejection letter lying on the kitchen table, children moving away for the first time, the little cracks in a marriage beginning to show. If loneliness is so widespread, so ‘normal,’ why do we need to talk about it? Aren’t we generally attracted to the more rare and wonderful aspects of life? Aspects like the documentation of  odd and wonderful medical conditions, the extremes of human behaviour that we can analyse with such voyeuristic enthusiasm. The topic of loneliness has instead been taken over by the arts; a subject for novelists and philosophers to dissect rather than scientists and clinicians.

Loneliness can be defined in a couple of different ways: emotional and social loneliness. Emotional loneliness occurs in the absence of an attachment figure, while social loneliness occurs in the absence of a social network. Emotional loneliness has been compared to a child’s feeling of distress when they feel abandoned by their parent, while social loneliness is the feeling of exclusion by a child whose friends have left. Thus, loneliness can be described either as a devoid outer world, or an empty inner world.

On the other hand, the cognitive approach suggests that loneliness stems from one’s social expectations not being met. Could it be that through our reliance on social media, our expectations for relationships have become exaggerated? As we scroll through our Facebook feeds, we become an outside observer to the fruitful lives around us; to parties we have missed, weddings we have declined. And so we draw a comparison to our own lives, thinking of ourselves as hollow shells in comparison to these roaring waves we see around us.

But what is the opposite of loneliness? Is it social connection? Is it the number of contacts we display on our phones? The number of parties we are invited to every month? Or the feeling we have of being valued? Is it being able to share a chuckle while watching a movie, reading a novel with a soft hand by your side, or simply being present in another’s life and being acknowledged?

Loneliness is different from solitude. Solitude can be an enlightening experience, leading to increased creativity and growth. Some of the best ideas have come through hours of sitting at an office desk, staring at a piece of paper. Just because more people in today’s society are living alone, does not mean that loneliness is on the rise. We must be careful not to mix these terms together. Loneliness is very different from solitude. Loneliness is the feeling of despair and alienation. It develops from the need for intimacy, and from the feeling of rejection when one fails to find it. It is described as a social pain; what is the equivalent of morphine for the pain of loneliness?

The power of loneliness can be illustrated through the effects of solitary confinement. It has been suggested that prisoners who have been through solitary confinement develop psychiatric disorders such as depression and anxiety, often turning to self-harm as a means of escape. Solitary confinement is described as a form of psychological torture, with one Florida teenager describing his experience as “the only thing left to do is go crazy.” Humans are social creatures. Without stimuli and control, is it any wonder that depression, hypersensitivity, and psychosis develop? This isn’t just an abstract concept that we are talking about, something for the philosophers to discuss at their round tables. It has implications with regards to disease, happiness, and relationships. It can be found in every aspect of our lives, in every infant and every adult – it is something that needs to be examined more closely through our microscopes.

“The most terrible poverty is loneliness, and the feeling of being unloved.” 
― Mother Teresa (2)

The topic of loneliness has fascinated novelists, poets, theologians, and philosophers, all attempting to give meaning to this beast. Yet psychoanalyst Shmuel Erlich suggested that the meaning of loneliness remains “an enigma” (3).

The concept of loneliness looks deep at the need for human connection. Through the rise of science and technology, a result on our emphasis on empirical modes of thought, we have gained considerable scientific knowledge and a whirlwind of medical technology. Yet what has happened to the conversation involving spirituality, social customs, and personal relationships? What has happened to the human perspective? Dig as deep as you like into the functions of the human body, the junctions between the cells and the DNA mutations – just remember that the knowledge that is discovered needs to be applied to a living, breathing human being. Can we quantify the despair of loneliness, the cracks of a thirty-year marriage, the grief of a mother who has lost her child? We may spend our lives pursuing wealth and status, but ultimately it is meaning that we all search for in the end.

“Existential aloneness is necessarily a part of serious illness.”
– S. Kay Toombs (4)

How does it affect us as doctors?

As healthcare professionals, we are trained to be objective, to look at the statistics, and arm ourselves with the jargon of relative-risk and correlations. But walk into any hospital, and you will not see wards filled with numbers and graphs. You will see vulnerability, the eyes of loss, of angst and fear. You will see people tested to their limits, people whose lives are cracked and crumbling – people who have entered the threshold of loneliness.

Is loneliness a pathological condition? Intolerance for being alone was once a criterion for the diagnosis of Borderline Personality Disorder in DSM-III, while more recently, loneliness was found to increase risk of mortality by up to 26% (5). It can be argued that loneliness can have a purpose in our lives; it can form the path towards self-acceptance, growth and spiritual transcendence. The existential perspective goes so far as to say that loneliness is what it means to be human. It argues that through loneliness, one can begin to question one’s own existence, and thereby create meaning for oneself in a world that has lost all meaning. Western literature paints loneliness as a vital part of being human. It is seen as an obstacle one must climb through during the various experiences of life – through change, bereavement, love and loss. It has been argued that just as joy is made brighter through the experiences of sorrow, loneliness shines a light on the meaning of our life. Yet loneliness has also been linked to alcoholism, depression and suicidal ideation. At what point do we as healthcare professionals need to step in and help someone climb out from this abyss? Where do we draw the line between self-discovery and pathology?

Loneliness can also manifest itself through illness, both physical and mental. The feeling of a broken body, of being a burden on one’s family, can lead to helplessness. Roles that were once worn with pride are now cast aside: the mother, the carer, the provider. These can lead to a loss of self-identity and raise questions about how one can contribute to society. Ultimately, being ill can be an isolating experience, raising questions about one’s reasons for existence and the value of one’s life. As healthcare professionals, it is our duty to guide our patients through this journey. It is our responsibility to help them discover their own meaning for this loneliness, to help them affirm their identity. It is not always distraction or drugs that a patient needs, but an open conversation, which can help patients to gain new perceptions on what it means to be human. The role of the professional is not to provide answers or interpretations, but to listen, to share and to understand. It is a difficult task, filled with uncertainty and anxiety for both practitioner and patient, but it is also human.

We often cast aside people who are deemed lonely; they are the shy recluses, the self-pitying. We suggest that the cure for loneliness is simple: join clubs, create hobbies, meet new people.

By following such advice, we forget something vital: you do not have to be alone to be lonely. It is more than just being independent or respectful of others’ privacy; it is a feeling of distress. Loneliness illustrates our need for human intimacy. So where can we find this painkiller to drug us against such distress? Which specialist will take away our aches and pains? You do not need to be a trained medical professional to combat loneliness. Just remember, Hello is the most powerful word against loneliness.

As a final thought I want to leave you with this person’s experience of loneliness: https://www.youtube.com/watch?v=6-usOHfSQuA#t=23

To the one who set a second place at the table anyway.
To the one at the back of the empty bus.
To the ones who name each piece of stained glass projected on a white wall.
To anyone convinced that a monologue is a conversation with the past.
To the one who loses with the deck he marked.
To those who are destined to inherit the meek.
To us.

– Flood: Years of Solitude by Dionisio D. Martinez (6)

References

  1. Plath, S. 2002. The Unabridged Journals of Sylvia Plath. Anchor Books.
  2. Silouan, M. 2011. The Poverty of Loneliness [Online]. Available at: http://wonder.oca.org/2011/11/16/the-poverty-of-loneliness/ [Accessed: 8th January 2016]
  3. Erlich H. Shmuel, “On Loneliness, Narcissism, and Intimacy,” American Journal of Psychoanalysis58, no.2 (1998): 135-162.
  4. Toombs, S.K. 2008. The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Springer.
  5. NHS Choices. 2015. Loneliness ‘increases risk of premature death’ [Online]. Available at: http://www.nhs.uk/news/2015/03March/Pages/Loneliness-increases-risk-of-premature-death.aspx [Accessed: 8th January 2016]
  6. Dionisio, D., Martinez. 1992. Flood: Years of Hope; Years of Solitude; Years of Reconciliation; Years of Fortune; Years of Judgment; Years of Vision; Years of Discourse. 22: 159-162

Featured image:
Maré vazia no mar de Wadden by Luis Estrela

Categories
Emotion Opinion Poetry

A poem

With our white coats on we feel the aura of pressure.
Pressure to be professional, to act accordingly.
We walk through the hospital with our heads held high, knowing we have a duty.

Tossing our white coats aside, true personalities shine through.
Most are gleaming of kindness and enthusiasm to learn,
Others are tainted.
These souls strive to reach a level of professionalism behind their white cloak,
but fail to reach expectations while unhidden.

What I see frightens me,
because these individuals will one day be responsible for the lives of others.
They lie to professors to get what they want.
They come to mandatory sessions, only to depart minutes later.
They cheat.
They sell prescription drugs.
They abuse prescription drugs.
They get intimate in the study spaces.
They do it all with a cheerful face.

What I see frightens me,
because I never want to be like them.

What can be done?
I’ve tried to approach them,
it ended friendships.
Administration knows,
yet I see no change.

Perhaps most terrifying,
these individuals exist at all medical schools.
They hide amongst the rest of us,
polluting the image of our profession.

So here I stand, turning a blind eye,
but what can I do?
I can’t change the mindset of others.
I can’t change their actions.

I only hope they aren’t my doctor.

Featured image:
Rainbow pollution by gambler20