Category: Reflection

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Clinical Emotion Empathy General Humanistic Psychology Narrative Palliative Care Poetry Psychiatry Psychology Reflection Spirituality

The Dying Man

The Dying Man
Written by Janie Cao
Edited by Mary Abramczuk
A few years ago, I spent half my day with a dying man. I remember these things about him: his name, his past profession, and that he was dying alone.

I never saw his résumé, the size of his house, or how much money was left in his bank account. I was not curious to know, either. But I bet they seemed significant once upon a time, at a dinner party, maybe. He worked as an engineer.

On that day—the day he died—no one who had cared about those things was there.
I was a stranger, yet I saw his last breaths. It was a curious day.

This world teaches us to do many things. To set goals (S.M.A.R.T ones, in fact) and to meet them. To maximize profit and minimize loss, and to use other people, to our advantage. We learn to build storage houses and efficiently fill them with glorified trash; to talk like we matter, and live like it, too.

Someday, we will all be that dying man. Not fully here, and not quite there; mere wisps of breath. When that day comes, will this world be at your bedside? 
Sometimes, I wonder.




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Dedicated to a friend: May you find what you are searching for.
Photo credit: Jörg Lange
Categories
Emotion Empathy General Humanistic Psychology Literature Opinion Patient-Centered Care Psychiatry Psychology Public Health Reflection

Book Review: Loose Girl by Kerry Cohen

Hi MSPress Blog Readers!
……
We didn’t have a blog post scheduled for this week, so here’s a book review instead 🙂 I read this book last week for my Adolescent Sexual Health MPH course and enjoyed it.There’s a lot of interesting tidbits on sexual health issues. I mention two.
Even if you don’t agree with everything the author says, I think memoirs can be helpful in showing you unique life perspectives based on true experiences that you may never have experienced yourself. Furthermore, reading memoirs can get you acquainted with potential resources to help others. Ever heard of bibliotherapy, anyone? 🙂
……
Your Blog Associate Editor,
Janie Cao

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

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

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

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

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

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

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

 

Photo credit: Open Grid Scheduler / Grid Engine

Categories
Clinical General Healthcare Costs Law Opinion Patient-Centered Care Primary Care Public Health Reflection

Discontinuity in Care

My resident tries fairly hard to take care of his patients. When he is with them, I catch him paying attention to all sorts of details that he could have easily let slip past. So it made it all the more difficult when I saw him enraged. When he opened up his list of clinic appointments one morning, on the list was a patient he did not want to see. It was not just that she was a new patient to him. It was not just that her problem list went on like a run-on sentence. It was that both were true, and my resident was still expected to see her in only 15 minutes.

While chart reviewing, he learned that the only consistency in this patient’s medical care at our clinic had been a history of inconsistent providers—and based on their notes, none of them had the complete story. “Why am I even seeing her?!” my resident asked rhetorically, as he frantically searched for answers he knew he did not have the time to find. I wondered, too. This visit seemed to benefit no one except the Billing Department, and even that would depend on whether the Medicare reimbursements actually made it through.

That patient’s experience was hardly unique, though. While rotating through various specialties as a medical student, I have met several patients who were passed from one provider to another. Maybe the provider had to switch services. Maybe they left the institution for better opportunities elsewhere. The reasons were myriad. Stories like those suggest that continuity of care may still only be a priority in primary care literature.

I think one reason for this reality is a lack of incentives to keep doctors and patients together. In any field, including medicine, we see money driving people’s attention and vice versa. Since our country has historically kept primary care on the back burner, there is little evidence to believe that practical incentives for continuity of care will spontaneously appear in the near future.

So, for the primary care fans out there, it might be worth it to start speaking up.

 

Photo credit: Norbert von der Groeben/Stanford School of Medicine, posted by National Center for Advancing Translational Sciences

Categories
Clinical Patient-Centered Care Reflection

“Listen to understand” not “listen to reply”

A two-month stint at the oncology department in a Singapore government hospital has provided me with vivid examples of the importance of doctor-patient relationships and communication. Cancer, in many societies, is still widely regarded as medical taboo – a condition people closely associate with death. While I got to witness very sensitive and depressing conversations in relation to end-of-life care, the most impactful conversation I experienced had nothing to do with end-of-life care. Rather, it was a complaint from a patient about his team of allegedly negligent doctors.

It took place in a private ward room with just Mr. C and his wife. When I first entered the room, Mr. C gave me a hostile look and asked me who I was. Feeling awkward given the cold welcome, I persisted to introduce myself as a medical student who wanted to take his history. Although reluctant, he agreed to talk to me. What started as a cold introduction turned out to be an hour-long avenue for Mr. C to vent his anger and frustrations. It became etched in my mind for the important lesson that came with it.

I understood from Mr. C that it was not the diagnosis that brought about his unhappiness, but how the diagnosis came about.  Mr. C presented with a 6-month history of progressive dull epigastric pain and loss of weight with no co-morbidities. He had no associated fevers, nausea or vomiting. The conversation went well until I asked him the question, “Did you bring this to your doctor’s attention?”

Immediately, there was a change in his facial expression. I divined from his grim expression that the news was not good. He started shaking his head, somewhat in disappointment. His wife started tearing. I had inadvertently asked a sensitive question and was caught helplessly in that moment of grief and sorrow.

Mr. C then explained that he actually went to the Emergency Department (ED) thrice as his abdominal pain worsened. Unfortunately, on the first two occasions, they sent him home after establishing that his vitals were stable with no abnormalities in his test results. He was sent home with a stack of medications but without a diagnosis.

Interestingly, Mr. C actually suspected himself that he had gastric cancer given his strong family history; he expected that he would suffer from it one day. The doctors shook it off despite his persuasion. On the third visit, however, the doctors finally admitted him and performed an endoscopy. It was later confirmed to be Stage 3 gastric cancer. It was at this point in the conversation when emotions started running wild.

The atmosphere heated up. I was shot with questions and complaints by both Mr. C and his wife.

“I would not have been denied earlier detection and treatment if doctors listened to my history,” Mr. C said.

“That period of 6 months could have made a huge difference to his disease stage and prognosis!” Mr. C’s wife added.

“Do you think the doctors have done the right thing for me?” he asked.

“Doctors never bother to hear patients out!” he shouted.

It felt as if the blame was on me, and I felt angry for a moment. I was on the edge of questioning his accusations, and refuting his comments. I was conflicted inside. On the one hand, the manner in which he was treated at the ED seemed unjustified. But at the same time it did not seem fair for me to blame the doctors without understanding what their line of thought was.

I further understood that Mr. C had explained his case to a senior consultant, who was also the surgeon who performed his gastrectomy. The surgeon brushed Mr. C off, and told him rudely to switch to another hospital if he did not like it here. It was at this point that I stood in favor of Mr. C. I actually could not believe such an insolent comment would come from the mouth of a senior doctor, whom I thought was supposed to possess the maturity and authority to handle such a complex matter.

Mr. C and his wife were evidently distraught with how the diagnosis came about, compounded by the fact that he was still relatively young to suffer from stage 3 gastric cancer. He explained that gastric cancer is one of the most aggressive and treatment-resistant cancers with the highest mortality rate, as evident from the young deaths of his family members who succumbed to the illness. My heart immediately sank after coming to terms with his bleak prognosis.  I recalled what was taught in my clinical skills classes, and took on an empathetic coat to try and calm them down. I felt an ephemeral sense of shame for the apparent lack of professionalism Mr. C’s doctors had displayed. Furthermore, I was sunk in guilt for initially doubting his comments.

I continued with the rest of the history and thanked Mr. C and his wife for their time. I walked out of the room and told them, “Thank you for sharing with me. Both of you have taught me about the kind of doctor whom I do not want to emulate in the future”.

It was an eventful hospital experience for Mr. C, and a rather eventful conversation for me with him and his wife. Despite the awkwardness and negative emotions, it taught me a great deal about the nature of difficult situations, the qualities a doctor should possess, and the importance of communication.

It was no doubt a challenging conversation. It was unlike all the other conversations I have had with patients, that were full of praise for their doctors, which always reassured me of my choice to become one.  My limited exposure to issues that arise from the lack of proper doctor-patient communication caught me off guard during this particular conversation.

When I mentioned to Mr. C that I was a medical student, his facial expression and body language conveyed his bitterness and dissatisfaction. It was almost as if he had something against me. I was filled with self-doubt and hesitancy. I was unsure if I should persist with the conversation given his hostile appearance but I knew that he had a story that he was dying to tell. Mr. C’s experience at the ED has probably altered his perception of doctors, and it was worth it to hear him out.

In hindsight, I am consoled by the fact that I had that conversation with Mr. C because he gradually opened up to me, treated me as an avenue to vent his frustrations, and perhaps subconsciously, taught me a lesson or two about being a doctor. I have learned that patients are always keen for a listening ear, be it to share their joy, or to pour their sorrows. It is hence important for medical students like me to not be doubtful when approaching patients for the fear of intruding in their privacy or taking up their needful rest time. Never be afraid that you are just an unqualified medical student.

Communication is the crux of medicine. As Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” History-taking is not just about the whims and fancies of signs, symptoms, investigations, and differentials. It is in fact a conversation, an opportunity to build rapport and trust with the patient. We are not community health surveyors ticking off boxes in our questionnaire; we are there to hear our patients out by expressing their problems and concerns. There is no better opportunity than in medical school, where you are not confined by the “rush hour” situation in hospitals, to hone these human skills.

Fortunately, patients tend to given you their trust, and willingly share their most personal information with you. This has shown me the power imbalance of the doctor-patient relationship, which arguably has been exploited in Mr. C’s case – i.e. doctors sometimes do not give patients enough attention.

Another issue that I struggled with was handling the complaints that were hurled my way. My lack of maturity was evident from my agitation, and the urge I had to refute Mr. C. Deep down, I was conflicted and defensive. Mr. C’s story contradicted my own impression that all doctors do their best for patients. It felt as if I was taking the blame on behalf of all doctors. However, I decided to stay quiet about it. I learnt that doctors aren’t  “super-humans” who will never make mistakes. It was only when I started consolidating my thoughts and weighing out the situation that I was eventually convinced that Mr. C’s care was indeed compromised by the negligence of his various doctors.

Admittedly, I handled the situation rather poorly. I reckon it was largely due to lack of exposure to such situations, especially given the sheltered, cozy environment we enjoy in medical school. Clinical interactions are based around simulated patients who, more often than not, have simple presentations that are short enough for us to take a history and perform a physical examination. Everything is staged for us to learn in a protected environment. Even in hospitals, the patients we see are recommended by interns as “cooperative enough” for us to take a history.

Medical students should be taught how to deal with complicated cases through the use of simulated patients. When I say complicated, I mean in a psychosocial sense rather than in a medical sense. The skills needed to deal with these situations are those that cannot be taught through textbooks, but through practice. These are human skills; skills that define the art of medicine. These non-scientific skills may not be as interesting as pathology, physiology or anatomy, but are equally, if not more important than the scientific aspects that students are often keener about.

Students are often enthusiastic to ask senior doctors about the scientific aspects of a patient’s presentation. Similarly, they should not be shy to ask them about approaches they should adopt when such situations arise. I am inclined to believe that most students underestimate the importance of communication, which often takes a backseat in their learning priorities.

Medical schools can no longer assume that their students are equipped with the necessary communication and social skills from just clinical skills examinations, which are often not representative of an actual hospital setting. Rather, explicit emphasis on the mastery of such complicated yet common social presentations, should be made an integral part of the curriculum.

I have learned the importance of giving patients the space to talk. For example, in my encounter, I was close to interrupting Mr. C when he was complaining about his experience. Having done so, however, would have prevented me from comprehending the entire situation in context. As medical students, we need to appreciate the difference between “listening to reply” and “listening to understand”. Practice the latter, not the former. Never be too quick to cut off your patients halfway through, and jump to conclusions. Let them tell their whole story, and you will be surprised to find that it contains most of the answers you need.

Photo Credit: Ky

Categories
General Opinion Public Health Reflection

Feminine Hygiene: My Own Struggle at the Airport

Surrounding me in the Barcelona airport this past winter was the latest technology—new scanners and gadgets directed at catching radioactive and explosive material more quickly and safely than before. Large plasma screen TVs were on every corner, and numerous retail shops caught my eye at every glance. With an expansive collection of restaurants and shops, one would think this is more of a mall than an airport. Given the mini-mall appearance, I felt I would have no trouble finding a place to purchase a tampon or pad, as Mother Nature had unexpectedly paid me a visit and I was unprepared. After first checking the bathroom for a tampon dispenser and finding none, I went from store to store looking for a personal hygiene section. To my dismay, there were an assortment of shaving creams and toothbrushes and even diapers, but there were no tampons or pads to be found. After scanning all the stores in my immediate vicinity, I decided to inquire at the cashier desk, which was occupied by a female clerk. When I asked her about where I could potentially find some feminine hygiene products, she informed me that I was out of luck. Her and other female colleagues all kept tampons and pads in their bags because there was no place to purchase them in the area. Fortunately for me, they kindly provided me with a few from their stash for my long journey home.

While this may be expected in a less developed area with few resources, an airport that boasts being “among the top 30 busiest airports in the world”1 should have several places to purchase feminine hygiene products. I was incredulous that an airport outside a major hub in Europe in the 21st century had no place for female employees or travelers to purchase a pad or tampon. This is an issue that must be corrected—whether by adding tampon dispensaries or vending machines, or simply by increasing inventory in the numerous retail shops lining the terminals. The Barcelona airport, along with any other major public areas that are traversed daily, should be required to carry these products.

While I was fortunate enough to receive some aid from the female clerks at one of the retail shops, I know there have been many other women who have been inconvenienced by either lack of menstrual products or their cost. In the same month, another traveler at the Calgary YYC airport reported that she had to pay a whopping $15 for a box of tampons at the airport2. Of course, it is a known fact that prices in the airport are always much higher than in retail shops outside – same goes for museum gift shops and others located near tourist attractions. However, for a product that is a basic hygienic necessity for half of the globe’s population, it is prejudicial that it is also priced almost double what it is in a regular grocery store. That traveler’s post sparked a global dialogue as to why these products are not easily found or are not affordable in places that millions of women work or travel.

While a dialogue is an important start, we need to continue to bring this issue into the spotlight. No woman in 2018 should be forced to pay egregious prices for basic hygiene and even more importantly, there should be access to feminine hygiene products in all institutions, including schools, airports, and workplaces.

Source(s):

1https://www.barcelona-airport.com/eng/information.php

2http://www.metronews.ca/news/calgary/2017/12/04/viral-post-blasts-tampon-price-gouging-at-yyc-airport.html

Photo credit: Sor Cyress Source: Flickr

Categories
General Lifestyle Reflection

Running

For just split seconds, I am floating, flying, feeling the space pass by. Then the flying ends, subtalar joint and plantar fascia absorbing the first impact of my landing. Gastrocnemius, soleus, and Achilles tendon maintain my stance, and along with my hamstring orchestrate takeoff. Then I am flying again, rectus femoris and iliopsoas swinging my leg forward.

My feet beat the drum of the earth, sarcomeres lengthening and then shortening, orchestrating flight and breath and blood flow. They lengthen and shorten, again and again. Intercostals and diaphragm labor rhythmically, cycling through hunger for air and fleeting relief.

As re-oxygenated blood returns to my left atrium, my attention returns to my thoughts. At first they fought for an audience, demanding my attention as I focus instead on the world around me, but soon it’s just me and my thoughts, as the air streams across my face. My legs stay strong, but beg me to stop. As I finish my run, my thoughts are with me, but whispering politely instead of shouting for attention, willing to leave as quietly as they came.

It isn’t the running, it’s the calm, the quiet, the peace in the cacophony. It isn’t the running, it’s the brisk morning breeze, the bronze fall leaves, the stars between the stars in the night sky. It isn’t the running, it’s me passing through space – a shooting star in the night sky trying to shine bright in the milliseconds I have to add a little light to the world. It isn’t the running, it’s the feeling of perfect harmony as the rhythm of my legs and arms and breath seems to match the rhythm of the world. It isn’t the running, so it is the running.

In the singularly focused chaos of medical school, running was just what I needed to reconnect with nature and the city around me. Earlier in medical school, a friend had asked me if I ran, and I answered, “Nope! Why would I run? I only chase soccer balls and cookies”. I am grateful that we are able to change, and I am now able to see beauty where I could see none before.

Photo Credit: Mark Hesseltine

Categories
General Reflection

Gender Application Gap

Gender stereotypes are pervasive in medicine. Last year, JAMA reported on the gender pay gap in medicine, and I found myself wondering if other stereotypes in medicine were true. I have seen some of it and heard more of it – from Scrubs, to blogs, to my own preceptors – ortho-bros, Ob/gyn girls, etc. According to a report using 2015 data from the AAMC and a study in the Journal of the American College of Surgeons that used the same data, these stereotypes seem to fit. The top male-dominated specialties by resident in the GME class of 2013-2014 were orthopaedic surgery (87%), radiology (73%), anesthesia (63%), emergency medicine (62%), and general surgery (59%). Women made up 85% of Ob/gyn, 75% of pediatrics residents, 57% of psychiatry residents, and 58% of family medicine residents. What I was really interested in, though, was whether there is any sort of advantage or disadvantage in being a male or female applicant in a sex-dominated field.

Luckily, this must have been on the minds of the ERAS stats department beacuse one of the headline charts on their FACTS web page is a table of specialty application data broken down by sex. The table includes the total number of applications per specialty and average number of applications per specialty broken down by sex. The data included all types of applicants – IMGs, DOs, and MDs. In working with the data, I chose to focus on Family Medicine, OB/gyn, Urology, Orthopaedic Surgery, General Surgery, and Family Medicine based on the AAMC data for sex-dominance as well as the stereotype of the field. I’ll admit that the latter is not a scientific method, but I don’t think I’m going out a limb here to say that there are (rightly or wrongly) generally agreed-upon stereotypes in medical fields. The modified table can be found below:

Specialty Female Applicants Mean Number of Female Applications Male Applicants Mean Number of Male Applications
Anesthesiology 1268 28.5 2524 30.9
Family Medicine 7168 49.4 7260 51.8
Obstetrics and Gynecology 2019 47.7 758 41.1
Orthopaedic Surgery 193 79.2 1116 74.8
Pediatrics 4576 36.7 2490 33.6
Surgery-General 2606 37.2 4871 37.7
Urology 110 64.2 383 62

Nothing shocking here. Male-dominated specialties like urology and orthopaedic surgery have more male applicants, female-dominated specialties like OB/gyn and pediatrics have more female applicants, and more evenly distributed fields have about an equal number of applicants.

What is more interesting is the average number of applications submitted per applicant by sex to the different specialties. Urology and orthopaedic surgery, probably the two specialties most culturally male-dominated both have higher number of applications submitted per female applicant. This seems to fit. Perhaps female applicants, knowing that the culture is male-dominated, feel pressure to submit more applications in order to be more certain that they will secure a residency in the male-dominated field. Ob/gyn, though, is the opposite. The most female-dominated specialty (both culturally and by AAMC data) has fewer applications per male applicant than female applicant. Even though 85% of the residency class of 2013-2014 was female, and even though far more women applied to OB/gyn than men, men do not seem to feel the need to overcome any sort of cultural disadvantage like women do when applying to male-dominated specialties.

This trend of male advantage in overcoming residency stereotypes holds true among other female-dominated fields like pediatrics where there are likewise more female applicants, but men submit fewer applications per applicant. I should note that this data does not include matriculation – only applications – so it is possible that men submit fewer applications and then do not get residencies. Also, this trend is not universal. Anesthesia is a male-dominated field where women submit fewer applications per applicant, though culturally it is not stereotyped to the same level as orthopaedic surgery or OB/gyn.

The New York Times wrote about this trend in 2001, noting that while men still made up the majority of practicing OB/gyns, upwards of 80% of residency applicants were female. But, according to the article, female OBs were taking a stand. They did not want OB/gyn to become a women-only field with some even supporting the reverse sex-descrimination argument that a few male OBs had taken to the courts. What is amazing in this scenario is that in spite of patient preference being the driving factor in making OB/gyn female-dominated, residencies see this as a problem and appear to be giving male applicants an advantage for residency positions. Meanwhile, male-dominated fields do not appear to have a problem with their male to female ratio. What does it say when women physicians are advocating for more men in their field over the preference of their patients?

Photo Credit: European Parliament

Categories
Lifestyle Public Health Reflection

#BoPo: Body positivity in the age of obesity

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

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

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

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

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

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

References:

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

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

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

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

Photo Credit: Crystal Coleman

Categories
Clinical Emotion Empathy Humanistic Psychology Reflection

The Enigma of Empathy

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

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

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

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

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

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

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

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

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

Photo Credit: Sean MacEntee