Category: General

Categories
General Literature

Frankenstein: A tale for the Modern Age

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

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

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

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

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

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

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

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

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

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

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

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

References

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

Featured image:
Frankenstein by Khánh Hmoong

Categories
General Innovation Lifestyle Public Health

A New Type of Pharmacy – On Food Pharmacies and Their Importance for Type II Diabetics

In a world where drug companies and pharmacies remain pervasive, an innovative take on the word “pharmacy” is being developed in Redwood City, CA. A new food pharmacy has just opened up, stocked with fresh fruits and vegetables. Just what the doctor ordered – literally! Instead of paying supermarket prices for these foods, all you need is a prescription from the doctor.

The first of its kind, this food pharmacy is an annex to the existing Redwood City free clinic known as Samaritan House. Patients with type II diabetes can get a prescription for fruits, vegetables, and even fish from a physician, and then pick up the free food at the pantry to help better manage their diabetes. The food is procured and delivered by the Second Harvest Food Bank, which is one of the largest food banks in the nation, feeding almost a quarter of a million people each month. Second Harvest also provides nutritious cooking demos given by local nutritionists1.

This one-year pilot program serves as a reminder that food is often overlooked as a primary method of treatment and prevention; a reminder we might need during our incessant drive to memorize pharmaceuticals and their mechanisms of action. Even when it is known that a patient’s congestive heart failure and diabetes may not be adequately controlled long term by medication alone, oftentimes physicians are strapped when it comes to options. Providing education on proper nutrition to a patient who simply cannot afford fruits and vegetables remains the passive and limited option, whereas food pharmacies such as Samaritan House are active steps in the right direction.

 

Source(s):

1http://www.sfexaminer.com/food-pharmacy-for-diabetics-launched-in-redwood-city/

Featured image credited to the US Department of Agriculture

Categories
General Reflection

Standing Outside the Match

My favorite online resource, Wikipedia, calls gambling, “wagering of money or something of value (referred to as “the stakes”) on an event with an uncertain outcome with the primary intent of winning additional money and/or material goods. Gambling thus requires three elements be present: consideration, chance and prize.”[1] It’s a funny quirk of medical student life that we all involve ourselves in gambling during our final year. The National Residency Matching Program (NRMP) can certainly fit the definition above. The med student wagers their future (“something of value”) on the Match (“an event with an uncertain outcome”) with the goal of finding the program that best suits them (“with the primary intent of winning”). The risk involved is certainly a calculated risk, as the give-and-take of applying, interviewing, and ranking allows us the opportunity to influence the outcome, but it is a risk nonetheless. In fact, it’s worth noting that much of the NRMP data was analyzed by Anna-Maria Barry Jester on the FiveThirtyEight blog last year. The major takeaway of her work was that while the system may very slightly favor the student, at the end of the day, it is the Match’s algorithm that decides.[2]

Fourth year med students are now receiving their “prizes” after going through the “consideration” and “chance” phases of the Match. As a 3rd year med student, I’m firmly rooted in the consideration phase. I’ve already decided my future specialty (family medicine), which is more than some can comfortably say, but now I have 500 programs to sort through, and how can anyone possibly decide where to apply? The consideration phase of my gamble on the Match is just as much of a lottery as anything. Sure, I get to make the final choices, but if there is a perfect program, how do I know it’s not the one I left off my list? It’s a familiar process at least, since it is similar to applying to medical school in the first place. I sent my applications out nationwide, to both osteopathic and allopathic schools. While the system didn’t rely upon an algorithm to decide, the stakes were nearly as high, with just as much uncertainty.

The process of sifting through residencies, though, is better left for another day. Currently, I just stand back and watch as my older brothers and sisters plan their futures. I’m both envious and wary. Certainly it would be nice to know, to have a clear objective. There is a lot of security in certainty. Then again, there is a reason the casinos are always so full in Las Vegas. People love the allure of any game of chance. When the dice are rolled, in that brief moment before the outcome is known, everyone has the potential to be a winner. No one puts a program as number one on their rank list hoping they aren’t selected to go there, just as no one places a bet on number 17 in roulette hoping the ball lands elsewhere.

I’m looking forward to the Match next year. I like to play the odds, always hoping that my number comes up. Luckily, while I may have no say in what cards are dealt in poker, I do have a say in how the Match ends. I get to meet with programs and all the people who populate them. I get to talk about my passions and plans and hope they get a feel for who I am on those interview days. And when I place my rank list, whatever choices I make, I hope I’ve done enough to pick a place that wants me just as much. When the Match algorithm runs, churning out the yes’s and no’s, I hope my number comes up.

Featured image:
Gambling by Alan Cleaver

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 General

A Caution Against the Extinction of Emotion

“Well, you know, I was recently diagnosed with cancer,” my friend said lightly in the middle of a spirited conversation about the merits of eating organic vegetables. She smiled as though she had just mentioned a factoid about organic kale, and not told me something earth-shattering. She continued eating her lunch while I sat there slack-jawed, trying to arrange myself. So consumed was I with the news of the diagnosis, I cannot recall a single other thing that we discussed during that lunch.

Throughout medical school, our professors have often told us to “get comfortable with being uncomfortable.” Diligent student that I am, I believed I had mastered discomfort. I believed that no matter how difficult the patient or awkward the situation, I could muster up some empathy and manage to make that prized human-to-human connection that separates the clinicians from the caretakers.

It’s an illusion to believe that we are comfortable with discomfort if we only ever experience discomfort as physicians. In this unique profession of ours, we are prepared to meet strife and pain on a regular basis. Whether we are delivering bad news or seeing a struggling patient, discomfort is no stranger to us. It is essential, however, that we recognize the power imbalance inherent in these situations. As physicians, we are the ones delivering the bad news or offering advice to our patients. As such, we must come from the position of strength. I have also detected the unspoken expectation that no matter what awaits us when go through the door to see a patient, we must remain unchanged when we come back out the other side. While we empathize with our patients and do our best to help them, ultimately, once we step out of the examining room, that bad test result or unfortunate lifestyle choice is the patient’s emotional burden to carry forward, not ours. In other words, our professional responsibilities call upon us to maintain that misfortune as ‘other.’

Even as a student, I’m already seeing how challenging it can be to disentangle my professional identity from my personal life. In my professional life, I have cultivated a sort of empathetic stoicism that allows me to connect with patients ‘in the moment,’ and then quickly wash my emotions off and redirect my focus toward whatever task comes next. It’s a survival tactic that I suspect many of us have deployed. In our personal (non-professional) relationships, however, our identities as children, siblings, lovers, and friends must come before our identities as doctors. Unfortunately, the more time we spend practicing in our professional roles, the more difficult it seems to transition from professional to personal. In personal relationships, we cannot always anticipate when we’re going to receive news, either good or bad, but when we do, we cannot expect to go through the door and come back out unchanged.

In our professional lives, we’re expected to be compassionate but composed. We’re taught to deliver bad news, perform motivational interviewing, and deal with difficult patients, but I wonder where the line is between beneficial sensitivity training and detrimental emotional taming. Before we walk into an exam room, we read through the patient’s chart so we know what to expect, and this allows us to create a sort of comfortable discomfort to protect ourselves. I would argue that this emotional fortitude is not beneficial to all aspects of our lives. Emotions are sloppy—something  that doctors cannot afford to be—but I worry that if we don’t let our feelings bleed through the lines, emotional composure could pave the way for an extinction of feeling. After having lunch with my friend, I had felt frustrated with myself for being so stunned and scared by her news. I didn’t have the emotional composure that I would have with a patient, but that’s the key difference—loved ones are not patients. It’s a testament to our most intimate relationships to express our genuine feelings however uncomfortable they may be. Perhaps, as physicians, we need to work even harder to stay in touch with these feelings so that we never lose our ability to access them.

Featured image:
Feeling. by Javi Sánchez de la viña

Categories
General Lifestyle Reflection

New Job

Every 4 weeks I start a new job. New boss, new co-workers, new hours. This is both the curse and blessing of a medical student in the clinical years. There are some rotations I just can’t wait to end, while others I wish could go on all year. (If there are any of my preceptors reading this blog wondering which category they fit into, don’t worry, yours was definitely the one I wanted to continue forever!) Since I’m a non-traditional student, I had a few jobs over the years. For instance, I worked for a couple years as a civilian contractor for the military. I was doing stuff that sounded really important on paper but was perhaps a bit more mundane in real life. In those days, I knew career civil servants who had been doing the same thing for 30 years or more, sometimes scarcely moving from their desk. I cringed at the thought, but for them, 4 weeks was like a day, and even my entire 4 years of medical school would be seen as no time at all. In fact, one old curmudgeonly co-worker once consoled me after my project was shot down by a Colonel who was also our boss: “Don’t worry, we can get that done when the next guy comes along. These military guys move on after 3 years anyway.” I remember thinking, “In 3 years?! I’m not waiting that long!” It’s no wonder I don’t do that job anymore.

There have been other jobs along the way that have been equally confounding. My first job after grad school was at a non-profit science and tech operation. I was so excited about what I was doing; I thought I really was playing a big part in the volumes of analysis that they put out. Then, a couple months after I started, my boss took me out to lunch for Secretary’s Day, which I promise is a real thing. I sat there eating my meal in utter confusion. I was apparently an assistant, and I always thought I was an analyst.

I recently started a new rotation, my ninth “new job” since beginning my third year. Nowadays it takes me just a couple hours to figure out if it’s going in the good or not-so-good category. Luckily, this one seems to fit squarely in the former. It’s a clinic position, so I have to learn where everything is, and of course most importantly, who to talk to about lunch, as in if there will be any free meals and on which days. This office is used to medical students. I can tell because they made very little initial effort to welcome me. That’s not to say they weren’t nice, indeed they very much were. But there is a different mentality for those who see faces like mine come and go every month. They already know me to a degree, since I’m just the interchangeable body inside the same white coat, with the same 3 or 4 books stuffed into my pockets, and the same questions. They won’t waste their time unless I turn out to be “one of the good ones,” whatever that means.

Sometimes as I wander through all these positions as such a neophyte, I think, does a med student even matter? Are we contributing? The short answer is probably no, until you get that one patient who starts talking maybe just a bit more because the med student seems to have a little more time. Or that patient who feels better just from having been heard, or perhaps reveals some small detail that they didn’t tell anyone else.  Then, in those few moments, I don’t mind being new on the job. I remember that being new is not always a bad thing. In fact, occasionally it can come in handy.

Featured Image:
Lost? by Susanne Nilsson

Categories
Emotion General Reflection

What We Carry

I recently stumbled upon an entry on another blogging site I follow, featuring a piece by Pamela Wible, MD. She’s a family physician who recently published Physician Suicide Letters — Answered. She also gave a moving TEDx Talk last year where she spoke about the four hundred physicians (and medical students) who commit suicide each year. She discussed some of the stressors physicians face, like losing income to hospital overhead or working incredibly long hours. Her unhappiness in the field motivated her to start what she calls an Ideal Medical Care practice.

After listening to this talk and looking into ordering her book, ironically, I felt kind of depressed. As a pre-med student, I was always so excited to become a doctor. I think I glorified this career choice for a long time, which isn’t necessarily a bad thing. As I’ve made my way through my first two years of medical school, I’ve experienced some of the heavy burdens that we can endure by choosing this career path. Long hours of studying, high-stakes exams and, ultimately, the responsibility of another human’s life.

These same stressors can be applied to many other rigorous fields. I’m sure law students spend countless hours reading up on cases. Engineers might make a decision that has a lasting impact on whether someone lives or dies in a car accident. So why does the medical field have such an epidemic of suicide on its hands?

One of the main differences I see between professional fields is the proximity medical providers have to death. I’ve become quite confused on how exactly we are supposed to grieve. Many medical students have heard that in the past you weren’t supposed to show emotion and to separate yourself from death when a patient passes. Obviously, the sentiment has changed and the values we instill in future physicians are different, but I don’t think our coping skills have drastically improved.

As early as the pre-medical years, students in this field encounter death. I worked in a cadaver lab in college where I was intimately exposed to death in a way I had never dealt with before. As first-year medical students, it becomes easy to forget our cadavers are human bodies, and in the clinical years, in the hospital, death is everywhere.

When will we stop to cope? Can we take a week off to grieve when we experience death? Will our superiors understand why we seem “off”? When you deal with death on a frequent basis, it’s easier to forget. We bury the emotions that we carry. However, keeping things in and not going through a proper grieving process can be detrimental to our health and well-being. It’s important for medical providers to understand the weight of death that we carry and its effect on our own mental health.

In my opinion, teaching proper grieving and allowing medical students time to cope would be a useful addition to the medical school curriculum. This might even lower the suicide rates in our field. The things that lead someone to commit suicide are ultimately multi-factorial, but I think this is one way we can try to improve these numbers.

Featured image:
sunrise and silence by x1klima

Categories
General Lifestyle Technology

Keyboards and Stethoscopes: A reflection on digital etiquette in medical school

February 26th marks the 47th anniversary of the landmark freedom of speech case, Tinker v. Des Moines. This case concerned a group of students who wished to wear black armbands to protest the Vietnam War. When their school banned the armbands to quash the protest, the students decided to sue, and the case made it to the United States Supreme Court. In the final ruling, Justice Abe Fortas wrote, “It can hardly be argued that either students or teachers shed their constitutional rights to freedom of speech or expression at the schoolhouse gate.” When writing his response, Justice Fortas probably didn’t imagine the digital age that we would be living in just half a century later.

Thanks to the power of the Internet, people can connect from thousands of miles away and ideas can go viral in mere seconds. The freedom of expression that the Internet affords us is practically limitless. The Internet can bring greater awareness to important humanitarian issues like ALS through the Ice Bucket Challenge, but its power as a terrorist recruitment tool can also be harnessed to spread chaos and destruction.

I wonder, as medical students, what our responsibilities are towards using social media responsibly, and how we balance these responsibilities without sacrificing our freedom of speech. In observing our class Facebook page and reflecting on my own bevy of social media faux pas, I have come up with the following five suggestions that I believe strike a balance between our professional responsibilities as medical students and our First Amendment rights.

  1. If something on Facebook offends you, have a face-to-face conversation with the person who posted the content. Avoid writing an angry response or a long rant, which can perpetuate further miscommunication. If a face-to-face conversation is not possible, give yourself a cooling off period before you respond.
  2. Never take down someone’s post without first talking to him or her about it. In our class, we’ve had a few situations where administrators of our group pages have taken down posts that they deem to be offensive or inappropriate. Conceivably, this was done to protect the integrity of the group and keep our Facebook page a “safe space”, but in reality, taking down someone’s post violates their freedom of speech and can make them feel unsafe. Before choosing the safety of the many over the safety of the few, talk to the person who posted questionable content and see if they will alter or possibly remove their post on their own.
  3. No babysitters! School administrators and faculty should not “babysit” class Facebook groups. A class Facebook page should be about fostering a sense of camaraderie amongst students, not about representing a school’s public identity. Therefore, the page should be private, and it should be the collective property of the students who chose to use it. Should disputes arise, they should be settled amongst students. Administrators should avoid getting involved in social media disputes unless they are directly asked to step in. Handling miscommunications and managing uncomfortable situations with our colleagues is important training for our professional careers.
  4. It’s okay to be a backstage comedian. Though this is likely my most controversial suggestion, I strongly believe that in our high-stress lives as students, and later as physicians, we benefit from being able to let off steam in a protected environment. A few months ago, we received a rather outrageous and somewhat distasteful lecture from some guest speakers. Not surprisingly, certain members of our class took to Facebook to share their “fond memories” of this unforgettable class. Somehow, the school administration was alerted to this content, and the students were asked to remove their posts. It’s only natural that from time to time, we’re going to find humor in something that happens in school or in the workplace. I think that it’s healthy to derive enjoyment and levity from these occurrences. In his writing, Immanuel Kant argues that laughter at an event is not a show of superiority, but rather an acknowledgement that the event differed from any reasonable expectations. Acknowledging the comedy of a situation is not at odds with our professional identities when it helps us to process and move on with overwhelming or uncomfortable events.
  5. Express yourself! I love when my classmates post articles that they find that I would have never otherwise discovered, or when a discussion from class spills over onto Facebook page. It makes me feel like I’m part of a community of people who value learning and exploration, and I have learned a lot from these posts.

Reach out to me on the MSPress Facebook page! I would love to hear your thoughts on Facebook and social media etiquette in medical school.

Featured image:
Der Blogger… by Dennis Skley

Categories
General Lifestyle

Nutrition 101

A 2011 Consumer Report found that 9 out of 10 Americans consider their diet healthy.5 People have become accustomed to reading product labels, estimating portion sizes, fashioning colorful meals, and some may even have a grocery list stored on their phone. Yet many still find themselves eating too much or too little. How many nutrients are we really getting and what are they doing once they enter the body? Are we sufficiently addressing nutrition with patients?

It has been rumored that people lie about what they eat 100% of the time. Consequently, it’s likely that patients’ eating habits are holding them back from health. According to a recent poll1, fewer than one-eighth of physician visits include any nutrition counseling and fewer than 25% of physicians believe they have sufficient training to discuss diet or physical activity with their patients.

These statistics have created a demand at the national level for reform. A few recommendations from the American College of Sports Medicine and the Alliance for a Healthier Generation include developing a standard nutrition and physical activity curriculum for medical and health professional schools, increased testing on nutrition and exercise for licensing and certification exams, and better insurance reimbursement for preventive care.2 While this will be a long-term shift, these are important strides in a beneficial direction.

Because of the relative neglect of nutrition in medical education, physicians tend to either ignore the subject or offer limited advice. For example, gastroenterologists may focus solely on fiber content, while nephrologists may focus on sodium intake.

“As long as the healthcare marketplace undervalues preventive care, health care professionals will lack financial support to address these issues with their patients and medical schools will have less incentive to train their students accordingly,” the report notes.1,2

Compared to the 20 hours devoted to nutrition in allopathic medical schools, Naturopathic medical students receive roughly 200 hours through courses such as nutritional biochemistry, science of diet and nutrition, and clinical nutrition.  This uniquely positions naturopathic doctors as physicians who not only specialize in preventative healthcare and chronic disease management, but also lifestyle and nutrition counseling.

For those looking to delve more into their patient’s nutrition status, one simple place to start is using a diet questionnaire for evaluation at baseline and to track changes over the course of treatment. Furthermore, there are an increasing number of online nutrition education programs directed towards practicing physicians. An example of one such resource is The Nutrition Source.

Why nutrition matters:

As one of my professors says, “You can be lean and mean with the illusion of health, but inside you can have raging inflammation.” The foods we eat turn on or off certain pathways and subsequently cause the release of chemical mediators. Over time this process lays the foundation for low-grade inflammation. Our enzymes convert dietary acids into prostaglandins, some of which create inflammation and pain. Therefore, based on these basic concepts, when we eat foods like sugar and flour that create these mediators, we are creating pain. Simply put: the food we eat changes our body chemistry. The more nutrients we can obtain through our food, the more building blocks are available to support the chemical reactions that take place in order for us to be alert and create energy.  While drugs like Tylenol and NSAIDS can be necessary and may help to reduce diet-driven pain, they do not treat the underlying cause.

As a naturopathic student, I hope to educate and inspire other medical professionals to learn more about nutrition in order to deliver more optimal clinical care to patients. Continuing medical education should include topics in nutrition research and instruction on how to critically evaluate new evidence in the field of nutrition. Physicians are simply one element of the much larger system necessary to promote health and wellness through nutrition. By emphasizing the influential role of nutrition in medical training and practice, we can further our ability to reduce suffering in patients.

References:

  1. Alliance for a Healthier Generation; American College of Sports Medicine; Bipartisan Policy Center. Teaching nutrition and physical activity in medical school: training doctors for prevention oriented care [white paper]. June 2014.
  2. Bernstein, Lenny. “Your Doctor Says He Doesn’t Know Enough about Nutrition or Exercise.” Washington Post.
  3. Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med. 2014 Apr 19.
  4. Katz, M.D. David. “Why Holistic Nutrition Is the Best Approach.” The Huffington Post. TheHuffingtonPost.com, 1 Apr. 2011.
  5. Ward, Tricia, and Stephen Devries. “Doctors Need to Learn About Nutrition.” Medscape, 4 Sept. 2014.
  6. http://www.consumerreports.org/cro/diet-plans/buying-guide.htm

Featured image:
National Nutrition Month Book Display by The COM Library

Categories
General Reflection

Culture and Medicine

Culture binds together the building blocks of our identity. It defines the paths we choose to walk, the people we seek to befriend, and the meaning we place upon our lives.

It is present at every job interview, every birthday, every heartbreak and every wedding. It is the voice in our ear that cautions us when we go against our values, the shoulder that nudges us with soft hands towards tradition. Whether we choose to acknowledge it or not, the fact remains that something so vital to our being also forms the roots of nourishment and support during the most trying times of our lives: ill health.

Think of the word “culture”, and many definitions come to mind. For some, it is a cage; bars that stow rigid beliefs and deep lines of division in the sands. For others, it is a sweet reminder of their childhood, their distant family. A link to their ancestors perhaps, or a nod to the countless sacrifices that so many generations past have made.

Clearly, culture is not a gleaming jewel in itself. There are walls that culture can build – stereotypes, divisions, segregation and war to name but a few. And we must be aware, in this ever-increasingly globalized world, that cultures are not typically singular. Families immigrate and pick up traditions and values as they plant their new lives upon fertile soil. Our beliefs about ourselves and those around us continue to change and transform as we step outside of our boroughs and breathe in new air. It is this mixing of values and beliefs that can help form ties with traditions long lost, offering diversity and different ways of looking at life. For example, Bhui (2011) found that there was a high risk of suicide in South Asian women, but this risk was attenuated when these women were born in the UK. What is it about growing up in the UK that has an impact upon such a profound decision? Or indeed, what is it about growing up in South Asia that directs people down the path of self-destruction? If culture can have an impact on such a deep level, perhaps it is something worth examining.

Are we looking after a sick body or a sick society?

Culture teaches us how to speak, how to act, how to think and how to breathe. The range of emotion we express to our friends, our family and to the public at large is limited by the boundaries of by our cultural habitats. Some cultures place emphasis on dignity and self-reservation – of being stoic in times of difficulty. Others may open arms wide, taking in grief and self-loathing, pity and joy, stirring these feelings into a melting pot of human life, rich in colour. The more we learn about our culture, the more we learn about ourselves – the way we think, what we think, why we think the things we think. Not only is this important for us as individuals, allowing us to grow and change, but it is also important for us as clinicians, when we are charged with the task of rebuilding and restoring these things when they inevitably fall apart.

We, as healthcare professionals may continue to learn from our textbooks about drugs and their effects, but in a world transformed by increased living, both quantitatively and qualitatively, perhaps it is no longer drugs that matter to our patients, but how we choose to approach our decaying bodies.

It is culture that shapes the way we face our woes and despairs. During the moments of agony, of aches and pains, it is culture that provides the lens through which we view ourselves. Do we remain stoical, chuckling heartily at the jokes juggled around by the nursing staff, or do we sit down with our head in our hands, so consumed by our grief that our need to wear a mask is but a luxury of a world far away. In the end, it is up to the doctor, the nurse, the healthcare professional to explore and understand how it is the patient views themselves, their body and the world around them. We can do this gently, by probing into the innermost recesses of our patients’ lives – encouraging a conversation, engaging in questions that touch at the heart of the person:

What do you do to stay healthy?

What does illness mean to you?

Who are your social supports?

How do you view doctors and medications?

We must remember that medicine is not a dogma upon which we pontificate. People may have differing beliefs about their illness, and in the end, these may be the only things left to tie their hopes to. For example, some people in India may use karma to explain illness, underlying their deeply religious and spiritual background (Fernando 2012). In the Western nations, where society has gradually built its walls between thyself and thy neighbours, people may return to their GP again and again with vague complaints, when the underlying problem may be psychosocial. This idea is illustrated beautifully in the following blog post: https://abetternhs.wordpress.com/2013/05/04/loneliness/

Although bodies have signs and symptoms, only people become sick.

Nichter 2010 described five expressions of idioms of distress:

  • Medicine-taking behaviour: requests for prescriptions, self-medication
  • Biomedical disease nomenclature: associating distress with disease
  • Diagnostic tests: expressing distress to others by taking tests
  • Healthcare-seeking: searching for a practitioner and a diagnosis
  • Changes in consumption patterns: e.g. increased smoking – distress communicated nonverbally

As we can see, people seek help for a variety of reasons. It may not be as simple as a quest for a prescription, for a scan or a blood test. By focusing only upon these rigid scientific measurements, you lose what it means to be a patient – to suffer. This is a loss not only for the patient, but for the clinician and for the healthcare system. When the physician becomes a robot, with an ever-increasing checklist to tick through, or list of procedures to complete, the vital relationship between doctor and patient is lost. This is the relationship upon which lies the patient’s hopes, fears, trust, and beliefs. When this relationship begins to wither, with it goes compliance and faith in the healthcare system – the willingness to step in front of a clinician and say ‘I need help.’

Of course, taking into account such a colossal term as ‘culture’ and applying it to each and every patient, one after another, day in day out, is not an easy task. Try as we may, the largest part of our curriculum is based on the medications we administer, the scans we perform, the blood tests we order. Our training in the scientific and technical fields gives us our title and our role. It takes a lot of courage, determination and compassion to go beyond these components of the therapeutic relationship, and explore our patients as whole persons with equal parts body, mind, and spirit. To help expand upon this, Blumhagen (1962) cited in Parry (1984) compiled some sample questions:

What do you think has caused your problem?

Why do you think it started when it did?

How severe do you think your illness is?

What do you fear most about your illness?

What are the chief problems your illness has caused for you?

What are the most important results you hope to get from treatment?

The Culture of Healthcare

I have spoken much about the cultures in which our patients present themselves. However, we too are human beings, which means we too are subject to cultural conditioning. We are part of the culture of healthcare, which has biases all its own. In a world that has become and continues to become transformed by multiculturalism, it can be easy for doctors to feel alienated from patients. After all, we cannot hold the same beliefs as every single one of our patients. It is not similarity of beliefs that is required, but an understanding and an appreciation. What patients want isn’t a parrot to recite back their own ideals, but a person who is able to accept the world in which they reside, respecting the decisions they make with an appreciation of the diversity of human life. And perhaps, through this understanding, a truly patient-centered approach can be adopted, in which it is the patient’s belief that takes precedent, and not those written down in a textbook by a retired professor. To reach this level, there is but one obstacle: ourselves. We need to become aware of our own biases –what makes us tick, what prejudices we hold, what makes us squirm, what opens our heart and makes it beat. Once we begin to learn more about ourselves, we can then take the step to learn more about our patients and the lives they lead.

If we do not take these steps to gain a greater understanding of our own being, then the outcome can only be confusion, unease and distress. One example of this is the release of the National Mental Health Program in 2002 by the Indian government, which placed emphasis on psychotropic medication. Jain and Jadhav (2009) argued that this focus on medication silenced the voices of the community. They noticed that social workers in rural villages took histories of patients, decontextualizing the symptoms into a list from which the doctors could make a diagnosis. The symptoms of the patients were seen through a biomedical lens, and clinical dialogues were structured around compliance. The medication eventually served as a boundary, with psychologists and social workers seen as assistant doctors– the power lying in the hands of the prescribers. The clinicians were alienated from the daily lives of their patients, ignoring the idioms used by their patients to describe their suffering.

What do we do?

Although physicians may memorize lists of cultural attributes, we must not forget the individuality of each patient. Families can adopt new values that may not always be tied to their heritage. Alas, culture is an ever-sticky concept – yet if it were anything else it would not be human.

So what can we do? We can acknowledge the person sitting in front of us in their entirety. We can become aware of any judgments that may cross our mind, and fix our eye on the person with open curiosity. We can learn from our patients, and allow them to teach us how we can best help them. They are the experts in the room.

 

References

Bhui, K. 2002. Explanatory models for mental distress: implications for clinical practice and research. The British Journal of Psychiatry. 181:6-7

Bhui, K. 2011. Cultural psychiatry and epidemiology: Researching the means, methods and meanings. Transcultural Psychiatry. 48:90-103

Campbell, C., Burgess, R. 2012. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcultural Psychiatry. 49: 379-395

Chau, R.C.M., Yu, S.W.K., Tran, C.T.L. 2010. The diversity based approach to culturally sensitive practices. International Social Work. 54:21-33

Fernando, G.A. 2012. The roads less traveled: Mapping some pathways on the global mental health research roadmap. Transcultural Psychiatry. 49:396-417

Ganzer, C., Ornstein, E.D. 2002. A sea of trouble: A relational approach to the culturally sensitive treatment of a severly disturbed client. Clinical Social Work Journal. 30:127-144

Jain, S., Jadhav, S. 2009. Pills that swallow policy: clinical ethnography of a community mental health program in Northern India. Transcultural Psychiatry.46:60-85

Kleinman, A., Benson, P. 2006. Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLOS Medicine. 3:e294

Lee, E. A working model of cross-cultural clinical practice (CCCP). Clinical Social Work Journal. 40:23-36

Nichter, M. 2010. Idioms of Distress Revisited. Culture, Medicine and Psychiatry.34:401-416

Parry, K. 1984. Concepts from Medical Anthropology for Clinicians. Physical Therapy. 64:929-933

Swartz, L. 2012. An unruly coming of age: The benefits of discomfort for global mental health. Transcultural Psychiatry. 49:531-538

 

Featured image:
The palace of culture – Warsaw, Poland – Travel photography by Giuseppe Milo