Category: Reflection

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Emotion Empathy General Humanistic Psychology Narrative Patient-Centered Care Psychology Reflection

Immigrant’s Suitcase: Ordinary people with the will to do extraordinary things

A mother separated from her missing husband flees a war-torn country, her homeland, to provide a brighter future for her children. She’s a dentist by training and practiced dentistry back home; but here, here she’s cleaning homes for a living. Why? When she left her home with her four children by her side, headed to a safer place, to America, what was in her suitcase? Alongside the picture of her missing husband and the few possessions that remained after the destruction of her home, in her suitcase, she has hopes and dreams, fears and doubts. She looks to her children for strength, but she’s terrified every time she looks them in their eyes. She is not optimistic, but she is hopeful; she looks the odds straight in the face and proceeds anyway. Because hope is not logical, it is powerful.

She’s cleaning the home of a happy family; the father is an engineer and the mother is a doctor and the children play piano. Their life, their hopes, goals and dreams are dependent on the stability of their country, but they cannot see it. The same hands that used to place crowns to relieve the pain of the suffering are now scrubbing the floor of another woman’s bathroom. But hope is powerful, and she lives through the dreams of her children. Two of her daughters want to be doctors. Her third daughter wants to be an artist. Her son is eight and he loves math. In her suitcase, she brought with her the dream of a better education for her children. “In Syria, we ate grass. In Egypt, we didn’t have food. In Indiana, I love school.” These are the words of her eight-year-old son.

A man runs to catch the bus. He can’t miss the interview; he really needs this job. It is his third interview in as many days. His last job got him enough money to get his family off the streets for a couple weeks. But motels are more expensive than he ever imagined. He’s homeless. His family is homeless. This wasn’t a possibility he considered when he graduated with his MBA. He had a great job, but the hurricane took everything away. And he hasn’t been able to get back on his feet. He catches the bus and pays the $1.75 in quarters. He checks the email that he printed; the interview is in room 4015. He runs up the stairs; he really hates being late. As he enters his interviewer’s room, a bead of sweat runs down his forehead. What’s in that bead of sweat? Desperation and nervousness, humiliation and self-pity, purpose and resilience.

His interviewer gives him the job offer. He smiles and shakes his head. A tear runs down his face. He can’t take the job; he can’t manage the branch that makes most of its revenue through alcohol sales. Another day and another interview, but his family remains homeless. He needs the job, but rejecting the offer was an easy decision. He believes that although alcohol may have small benefits to people and society, the harm it causes is much larger than its benefits, and wants to play no part in its distribution; he will not be a co-creator in the intoxication of his neighbor’s mind.

A young woman sinks into herself on the examination table. Her husband is holding, squeezing her hand. The doctor is still talking. He looks very sympathetic. The young woman just learned that she has a cancer growing inside of her lungs, an aggressive cancer. The doctor thinks ‘we can fight it.’ The young woman’s mind is overwhelmed into quietness. All she can think about is her daughter’s play after school that she doesn’t want to miss, even for this. The doctor brings her back, ‘Do you feel comfortable about our next step? I think that’s the best place for us to start.’ The young woman shrugs. What is in that shrug? Fear and uncertainty, peace and tranquility, ambivalence, a need for normalcy, a desire for time to make meaning.

The young woman is herself a physician, trained and licensed as a radiologist. She knows enough about cancer and the late stage non-small cell lung cancer she has been diagnosed with to know that the longevity of her future has been called into question. And yet this is not the topic of discussion with the doctor. Instead, he discusses treatment options, which is fancy talk for a long list of big words in different orders and combinations. When asked about the next step, she shrugged. She shrugged because there didn’t seem to be room for her in that room. (Insert young woman with terminal cancer here). Although it is more comfortable for the doctor to rattle off treatment options, the patient wants to take time to acknowledge the inexorability of our life cycle. To the doctor, it was the end of a beginning, and they were, together, supposed to begin a new chapter of strength and resilience. While he rattled off treatment options, she just wanted to catch her daughter’s play after school, and she was running late.

In the words of HL Menken, ‘For every human problem, there is a solution that is simple, neat, and wrong.’  Without taking a moment to explore what’s inside the immigrant’s suitcase, the homeless man’s bead of sweat, the sick young woman’s shrug, we stand a sorry chance to witness, help, and learn from ordinary people with the will to do extraordinary things. This is the power of narratives; the power of listening. I call myself to look inside the suitcase, to investigate the bead of sweat, and to ask about the shrug; I call myself to listen.

I find myself in an imperfect world, full of injustice and oppression. I find myself an imperfect man perfectly given the ability to alleviate suffering, on a personal level with a smile or a hug, and on a larger scale by fighting injustice and refusing to stand idly in the face of oppression. Poverty belongs in a history museum. And hunger…we have enough food in the world for every member of the human family to eat a balanced 3000 calorie meal. When we eliminate poverty and hunger, there will be many other injustices for us to face. I want to make facing these injustices my mission. My mission is to be ‘human’ as best I can; to work to establish justice in any capacity that I can, from a generously given smile to an honest political campaign.

Photo Credit: Robot Brainz

Categories
Clinical Narrative Reflection

Red Rash

As I sat in the audience, I stared up at the image being presented on the screen. It was what looked to be another red rash. The content for the Dermatology grand rounds was admittedly beyond my clinical training. Nevertheless, I found it fascinating to slowly discover the complexities of the skin as each case was presented. As I thought about each slide I began to ponder Dermatology as a specialty. I wondered what it meant to be a dermatologist. I briefly reflected on the stereotypes associated with the profession and then realized that every specialty had stereotypes. My brief daydream was interrupted as the next image on the screen appeared. I was anxious to see what it was in hopes that I could identify it, but to my dismay it looked like just another red rash.

Later, as I scurried behind the attending in my official looking, yet noticeably shorter white coat, I wondered what type of red rash I would be observing next. As I entered the exam room the woman sitting there immediately shocked me. Her face read of complete sorrow and hopelessness. However, it was not her face that struck me, it was her skin. It was red, dry, and seemed to be peeling off of her as if she was shedding her skin. It looked terrible and seemed to feel even worse. It was then that I saw the attending spring to life. He began discussing her symptoms with her. When he had gathered the information he needed she began to tell him how the illness has been affecting her life. Skin diseases or issues with the skin can sometimes be viewed or reduced to something inconsequential or unimportant compared to other serious diseases such as diabetes, heart disease, or cancer. However, as I looked at this woman, I imagined her waking up in the morning and standing in front of the mirror and being unable to focus on anything other then this rash covering her entire body. It was then that she described the shame, embarrassment, and humiliation she experienced when others would stare at her, whisper about her, or when she would occasionally catch a glimpse of herself in a store window. The thought of her disease staring at her in the face when she brushed her teeth each morning made other serious illnesses that hide under the skin seem preferable.

After listening to her describe her quality of life it made complete sense as to why she felt so hopeless. It was in the moment that I had a strong desire to help this woman. I wanted to relieve her of this suffering. Fortunately, the attending was already in action. He began to describe his treatment plan while validating every one of her feelings and concerns. It was as if he knew what it was like for her to lose sight of herself and only see her skin. As the sorrow slowly drained from her face, I saw something incredible, hope.

It was then I realized that every slide I causally coined as a “red rash” belonged to actual people who have lives, families, and most importantly feelings. I assigned them a label that they never asked for and most likely hide from everyone they encounter. Assessing and treating the human body is an immense responsibility, but so is connecting with people. Now when I see the images at grand rounds I no longer see a red rash. I see a person who with the proper treatment and compassion can become whole again.

 

Photo credits:

Featured– Jean-Pierre Dalbéra

In-text- Taylor Thomas

Categories
Clinical Emotion Empathy Narrative Reflection

Takotsubo

Valentine’s Day is not typically kind to medical students. While many couples share flowers and romantic dinners, my fiancé and I looked forward to escaping the hospital just long enough to exchange sweet-nothings over take-out sandwiches. Though lacking in outward displays of affection, this Valentine’s Day was imbued with something different. A few weeks ago, a patient taught me that love, it turns out, can exalt us and confound us, but it can also, literally, break our hearts.

He was a thin man in his late seventies, a mop of unruly gray hair on his head. He came into the emergency room one evening, unable to catch his breath and complaining of severe chest pain. An EKG was rapidly obtained and showed concerning peaks and valleys of electrical activity. Troponin levels were rapidly increasing in his blood. TC, it appeared, was having a heart attack.

Image courtesy of Med Chaos

Though still in the early stages of my medical training, I knew what would come next. In rapid succession, TC would be rushed to the cardiac catheterization lab, and a stent would be placed in his coronary arteries, restoring desperately needed blood flow to his heart. He would recover. His loving wife and adult children would visit him in the hospital. In a few days he would return home.

I was wrong. Try as they might, TC’s doctors were unable to find any blocked arteries in his heart. With nothing to stent open, TC was admitted to the medicine ward for careful observation. Miraculously, his condition stabilized.

The next morning he was feeling better. Not wanting to forego his calisthenics, I found him walking along the bustling hospital corridor, pausing briefly outside each room to greet his fellow patients. As I corralled him back to his room for morning rounds, I couldn’t help but notice the gold wedding ring hanging from a length of frayed twine around his neck. He caught my gaze and smiled, “pretty, isn’t it?”

Lowering himself carefully to his bed, he explained why he no longer wore the ring on his finger. His wife, he lingered on the word, had died almost three months ago. His children, long since grown, had come home for a while, but were now back to their own lives. He’d considered moving into a smaller place—less lonely he figured—but he couldn’t bear the thought of discarding any of her things.

Later that day, TC went for an echocardiogram which immediately revealed his diagnosis.

He had Takotsubo cardiomyopathy, also known as “broken heart syndrome.” It is a rare condition, but strikes most commonly after a period of great emotional turmoil. Marked by chest pain and shortness of breath, the initial presentation is not at all dissimilar to a heart attack, so committed in its mimicry that the EKG and blood findings are often identical.

Although the pathogenesis of Takotsubo cardiomyopathy is not completely understood, it is postulated that adrenaline, released in times of great emotional distress, may overwhelm and eventually damage the heart. With enough damage, the heart breaks, contorting itself into a characteristic shape—wide at the bottom with a distinctively narrow neck. The shape resembles a Japanese takotsubo pot, a vessel historically used to trap octopus.

As a trainee in the field of medicine, my classroom preparation taught me to be objective—to plumb the pertinent facts of a patient’s history and physical exam in order to provide effective treatment. But it is patients like TC who teach me that good doctoring requires something more. Though less tangible, it is clear that one’s physical and emotional well-being are inextricably linked.

Several days later, heart ostensibly healed, TC was ready to return home. He stepped into the elevator, turned, and waved goodbye. A gold ring shone brightly on his finger.

Photo credit: Chandrahadi Junarto

 

Categories
Reflection

The War Against Aging

‘Back in elementary school, I realized we all have a genetic, lethal disease called aging. I remember being frightened that my mother would die and terrified that my existence was ephemeral and meaningless. At the time, it felt like I was being told I had terminal cancer or some other horrible disease. Death was inevitable. No matter how rich or successful I could be in life, it would all be lost in the end. So, still a child, I found an objective, a purpose for my life: to cure human aging.’
Joao Pedro de Magalhaes (1)

Of all the diseases we have left to conquer, one raises its voice above all others: the disease of aging. From anti-wrinkle creams to advertising billboards, from our conceptions of beauty to our desire for youthful skin, our fear of aging is present in all walks of life.

But is aging a disease? Is it a demon that must that be conquered, lurking beneath our skin, crumpling up our genes until our skin sags and our hair turns grey? Or is it a natural part of life – something that needs to embraced with humility? Is our preoccupation with aging a cultural phenomenon, a type of ignorance or obsession that needs to be tackled by changing social attitudes, or is it primarily a problem of medical science?

Eternal Youth vs Immortality

What is it that we are actually fighting for – do we want to live forever, or do we want to be forever young? Most of us would not wish to live a longer life if it meant we continued to age. What we long for is a good quality of life while still holding on to more years. This is best highlighted in the Greek myth known as Tithonus Error. Tithonus was a mortal who was granted immortality by Zeus but was not granted eternal youth. As a result, Tithonus became increasingly debilitated and demented as he aged (2). This is a fate no one would wish to have. The quest, it seems, is to extend one’s years upon this earth while retaining quality of life, looks, and independence. If this is so, we must ask ourselves: is this something worth fighting for?

One argument against the idea of ‘fighting aging’ is the concept that aging is a natural process. For those making this argument, the insistence on limiting aging is uncomfortable; who are we to go against nature? In fact, some would even argue that it is aging that makes us human. Indeed, without the knowledge of mortality placed upon our fragile shoulders, we would never value those things which are so important in our lives and yet so transient – our first kiss, our first day at school, our first date. If we were to extend our lives infinitely, then the value of the present moment may disappear.

As emotively tempting as this argument may be, if one takes a step back and takes a look at the history of medicine, one begins to see that battling nature is something that science has always done; from antibiotics to vaccinations, from the eradication of smallpox to the application of technology, fighting the natural world is an inevitable component of science. Indeed, battling the features of aging makes up a large part of modern-day medicine; we battle stroke and heart disease, insidious cancers, and debilitating degenerative diseases every day within our hospitals and with our surgeries. What makes ‘fighting aging’ any different?

The Cultural Phenomenon

This question ultimately goes back to the cultural phenomenon of aging. Aging is a rather new phenomenon. At the beginning of the 20th century, only 5% of the population was over 65 years of age, while today people are able to lead active and independent lives well into their 90s (3). With this rise in aging has come new prejudices and stereotypes. It has been argued that our negative attitudes against ageing emerged relatively recently, in the 18th century. Prior to this era, the elderly were often held in high regard, seen as carriers of wisdom and knowledge thanks to their years upon this earth. But as more and more people began to survive into their 80s and 90s, the idea of being a ‘nuisance’ began to take hold. Employers felt that the elderly were holding on to jobs that could be taken over by the “young and fit.” This change in attitude is reflected in our vocabulary with words such as ‘codger’ (meaning an odd, old fellow), and the change in meanings of certain words over time, such as ‘fogey’, which previously meant a wounded war veteran but now is used more pejoratively to describe those who are old and thought to hold ‘old-fashioned’ views.

The social role of the elderly has changed dramatically as well. With fewer multigenerational families living under one roof, the role of the elder within the family structure has been lost (3). This gradual change in society is reflected in the way we view age. We equate youth with beauty and aspire to look as young as possible. Yet on a grander scale, the way we view age has also corresponded to a larger shift in our society’s policies, in our public expenditures, and in our healthcare.

Within medical care, conditions such as depression are often ignored in the elderly and often seen as a part of aging itself. From a social perspective, discrimination in social care is evident in the assumptions that people may have about how older people should live their lives and what constitutes a life worth living for the elderly. On a public health level, there is a strong suspicion that the use of Quality Adjusted Life Years, a tool used in the UK to assess the costs of treatments, will often discriminate against treatments for diseases such as Alzheimer’s Disease, Osteoarthritis and Age-related Macular Degeneration, most of which would mainly benefit older people with few remaining years. Within the research sphere, the elderly are often excluded from clinical trials, with this under-representation of the elderly affecting the number of available treatments for them. Most importantly, from the patient’s perspective, older people are more likely to feel talked over compared to other patients when they are in the hospital, often feeling ‘as if they weren’t there’ (5). All of these examples illustrate how our culture of youth has manifested itself within the sphere of medicine, where it is our responsibility to be non-judgemental. Yet this is the world in which we live. If we want to make a change, we must become aware of such uncomfortable realities and understand what has given birth to them.

Even if we wish to view aging as a biological phenomenon, for example by looking for “anti-aging” genes within our laboratories and for drugs that can reverse the damage done to DNA over time, we still have to take into account society’s perception of the elderly. We still have to ask the difficult, philosophical questions. For example, are we battling aging because it will allow us to be healthier and have more fulfilling lives, or because of our modern obsession with youth and beauty? Likewise, how would we evolve or change as human beings if we were able to slow, stop, or even reverse the process of aging?

Perhaps conquering aging is not the same as vanquishing cancer, for growing old is an intricate and natural part of our lives. Indeed, perhaps it is part of what makes us human. These are questions that no one person can answer, and which need to be debated within the public sphere. The discussions that arise from asking these questions will undoubtedly impact the direction medicine takes with respect to its interaction with aging; maybe more resources will be dedicated to ‘diseases of the elderly’. If we are lucky, maybe this will all cultivate an attitude of acceptance and empathy within a culture that sees aging as a part of life. Maybe we can change a culture. Maybe we can even save a life.

“We have added years to life; it is time to think about how we add life to years.”
Robert Kennedy (6)

 

References

  1. Magalhaes, J. P. Fearing Death and Curing Ageing [Online]. Available at: http://www.senescence.info/death_and_aging_fears.html [Accessed: 14th September 2016]
  2. Magalhaes, J. P. Should we cure Ageing? [Online]. Available at: http://www.senescence.info/physical_immortality_myths.html [Accessed: 14th September 2016]
  3. Big Picture. 2014. Ageing and Society [Online]. Available at: https://bigpictureeducation.com/ageing-and-society [Accessed: 30th September 2016]
  4. Jones, R. 2007. A Journey through the Years: Ageing and Social Care. Ageing Horizons. 6: 42-51
  5. Centre for Policy on Ageing. 2009. Ageism and age discrimination in secondary health care in the United Kingdom. Department of Health.
  6. Steinsaltz, D. 2016. Become the New 60;. Nautilus; 36 [accessed 28th May 2016]. Available from: http://nautil.us/issue/36/aging/will-90-become-the-new-60

Featured image:
Age by Iburiedpaul

Categories
Emotion Empathy Reflection

Notes from the Road: A Letter to my Future Self

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

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

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

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

 

Dear Future Self,

Today you saw a patient die.

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

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

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

Chest compressions. Pushing epi. Giving her blood.

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

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

You were so scared.

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

You felt so powerless.

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

You were so impressed by the team.

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

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

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

Sincerely,

-Your Past Self

 

Featured image:
road by Victor Camilo

Categories
Psychology Reflection

Reassessing Resilience

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

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

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

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

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

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

References:

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

Featured image:
Slope Point by Ben

Categories
Empathy Humanistic Psychology Patient-Centered Care Psychology Reflection

Applying Humanistic Psychology to Medical Practice

“People are just as wonderful as sunsets if you let them be. When I look at a sunset, I don’t find myself saying, ‘Soften the orange a bit on the right hand corner.’ I don’t try to control a sunset. I watch with awe as it unfolds.” –Carl Rogers1

We as human beings love categories. We enjoy dividing the body into its constituents, from the bones to the muscles to the skin, from the heart to the vessels to the blood cells. The more we can break something down, the more we can dissect it, understand it and build from it. It can be argued that this method of reductionism is what has led to many of the insights of the present day. It is by becoming so specialized within one area that one is able to build upon one’s expertise and develop novel ideas.

This method of classification, however, cannot be used to explain everything around us. While insightful in some areas, it can be destructive in others; namely, the human mind.

Look back at the history of Psychology and we see ourselves jumping through the same hoops of categorization, attempting to reduce our inner worlds into hierarchies and models. From the psychodynamic theories of Freud to the behavioristic perspectives popularized by Pavlov and Skinner, we are led to believe that if we can merely slice apart the human mind into chunk-sized pieces, perhaps we can gain insights into humanity itself.

But unlike the heart or the lungs, the way we choose to see a particular human mind can have profound effects upon that person. Tell someone that they are a mess of electrical impulses and chemicals, and they may see themselves and the world around them far differently than a person who believes that it is they themselves who have control over their lives.

There is a reason Psychology and Psychiatry garner so much criticism from the general public in a way that no other specialty does.  There is a reason that an anti-psychiatry movement exists, but there are no anti-surgery or anti-cardiology movements. It is because these theories, these categories, have an impact on how we see ourselves. They touch upon what it means to be human.

The argument I wish to propound is to urge us all to go beyond these categorizations, be they biomedical, psychological or social, and to take a more holistic approach, which I believe can best be viewed through the lens of Humanistic Psychology.

What is Humanistic Psychology?

Humanistic Psychology arose in response to the more mechanistic views of human behaviour that were gaining popularity in the 1950s2. Rather than focusing on one aspect of a person, be it our childhoods or our innate animalistic needs, Humanistic Psychology proposes that what is important is how the person themselves experiences the world around them. The human being is central. It is not the objective measurement of chemicals, electrophysiology or set questionnaires that lies at the heart of humanity, but how we think and feel.3

There are many contributors to the Humanistic canon, but I wish to focus on just one aspect of it: Carl Rodgers’ person-centered therapy. Although the word “therapy” implies a form of treatment for those with mental health problems, I wish to apply these principles to the arena of healthcare as a whole. I believe the therapeutic relationship between therapist and client can teach us much about our own relationships with patients within hospitals, emergency rooms and clinics.

Person-centered therapy is built upon three principles4:

  1. Congruency
  2. Unconditional Positive Regard
  3. Empathy

I will go through each of these in turn and focus on how they can transform our relationships with our patients.

Congruency

Congruency refers to genuineness, that is, displaying ‘your actual self’4 when dealing with a patient. This involves letting go of one’s mask and revealing one’s true feelings as they come and go. It requires a level of self-awareness, which allows us to fully experience the moment instead of remaining walled-off from our true inner state.

Do not think of yourself just as a doctor, a medical student or a healthcare professional. Undoubtedly there are professional boundaries that must always be maintained, and a profession that you represent every day. But be careful that you do not let this professional façade get in the way of your relationship with your patients. Remember that you are only human and the last thing a sick patient needs is a robot. By displaying an open and trusting character, you give your patient the opportunity to relax, to feel at ease and to be open about what is truly troubling them.

Congruency takes us back to our humanity, reminding us that there is little difference between ourselves and the patient sitting opposite. If we can come to terms with our own thoughts and emotions as we deal with the chaos that occurs in the world of healthcare, then we will be able to display a level of respect and understanding that will allow our patients to appreciate that they are speaking to a human being and not just a title.

Unconditional Positive Regard

Unconditional Positive Regard refers to the belief that people should be accepted as they are. For the professional, it involves displaying a non-judgmental attitude that is provided unconditionally, i.e. without limitations or expectations.

Although this is a concept well known to most of us, it can be difficult to put into practice. We all have our prejudices and our own rigid lines that we draw across our horizons. The expectation is not to get rid of all prejudice, but to be aware of how they impact our behaviour towards others.

Do we at times place blame on our patients?
Does our heart sink when we go to speak to certain people?
Do we have certain beliefs about people based on their clothing, their lifestyle, or their occupation?

Of course we do. Think back to a time when any of these thoughts have come to your mind and think about their effects. It may not necessarily mean that you throw everything in the air and scream your prejudices out loud. But it does mean that the way you regard your patient may be subtly altered; you may show less enthusiasm towards certain patients or display less sympathy than you would for someone else. It is by being aware of these little discrepancies that will make us all better clinicians.

Undoubtedly, healthcare places us all into positions where we come face-to-face with lifestyles that we disagree with and behaviours that we feel uncomfortable around. The idea is to go beyond these actions and see the human being lying beneath the layers. We must accept them as they are, and may be surprised to find that the patient responds with gratefulness at being treated as an equal.

Empathy

Perhaps the term most popular out of the three, empathy refers to the ability to understand what the other person is feeling. It involves having an understanding of the other person’s beliefs and values, and being cognizant of why they care about the issues that are important to them – in other words, it involves fully stepping inside another person’s private world.

Within healthcare, it is important that we do not go through a list of tick boxes and forget that our versions of events are not the same as theirs. All too often we may accept simple words such as ‘I’m frightened’ with a mere nod of the head and a simple smile on our faces without digging deeper and asking, ‘What is it you are frightened of?’ Our job does not merely consist of diagnosis and treatment, but of going further into our patients’ lives and understanding what their illnesses mean to them. What it means for them to be in hospital, to be a patient, to lose their role as a parent or a provider. Without this aspect, we may well cure a disease with our drugs and our technology, but we will never get to the heart of the matter.

What does it all mean?

These are all terms that most of us are familiar with. They are words we may write time and again upon reflection, sayings that we repeat year after year during our interviews. But the idea is to put this into practice, which can only happen if we first take a step back and think about the times when perhaps these three concepts were not fulfilled. Those times when the relationship broke down, when the patient closed up, when we walked out of the consulting room thinking that could have gone better.

Remember that patients do not always come to us with a collapsed lung or a broken rib. They come to us as a whole. The idea behind Humanistic Psychology is to go beyond the reductionist theories that focused on one aspect of a person’s being, and to appreciate the totality of human experience.

Why do I think these three concepts are important? Because I believe these are concepts that make all of us much better clinicians, and ultimately much better people. I believe that almost all of the problems we face within healthcare, and indeed outside of it, revolve around our ability to relate to others. How differently would we act if we could truly see through the eyes of the person sitting next to us, feel their pain and suffering, think their thoughts as they swirl between their children, their loved ones, their aims and their worries? These concepts, although integral to person-centered therapy, transcend the therapist’s room and can be practiced in every dialogue across every hospital and by every person, including you and I.

“In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” –Carl Rogers6

References

  1. Culture of Empathy. Carl Rogers Empathy Quotes. [Accessed: 28th May 2016]. Available from: http://cultureofempathy.com/references/Experts/Carl-Rogers-Quotes.htm [Accessed: 27th May 2016]
  2. com. Humanistic Approach in Psychology: Definition & History. [Accessed: 29th May 2016]. Available from: http://study.com/academy/lesson/humanistic-approach-in-psychology-definition-lesson-quiz.html
  3. McLeod, S. Humanism; 2007. [Accessed: 27th May 2016]. Available from: http://www.simplypsychology.org/humanistic.html
  4. McLeod, S. Person Centered Therapy [Online]; 2008. [Accessed: 27th May 2016]. Available from: http://www.simplypsychology.org/client-centred-therapy.html
  5. Gillon, E. A Person-Centred Theory of Psychological Therapy. In: Person-Centred Counselling Psychology: An Introduction. SAGE Publications Ltd; 2007. p.43-67.
  6. BrainyQuote. Carl Rogers Quotes. [Accessed: 28th May 2016]. Available from:                          http://www.brainyquote.com/quotes/quotes/c/carlrogers202206.html

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Genetic inheritance by Patrik Nygren

Categories
Clinical Reflection

The Importance of Geriatric Medicine

When the infamous question “what kind of doctor do you want to be?” has been thrown my way, I have typically responded by throwing out three fields of medicine that I currently find interesting: pediatrics, endocrinology, and geriatrics. However, while the usual response includes much satisfaction about 2 of my potential career choices—with lots of oohs and ahhs about the joys of treating children, and the approving nod for endocrinology because, hey, diabetes—the standard, usually skeptical, follow up question I receive is: why would you want to take care of old people if they are just going to die soon anyway? Isn’t that…depressing?

Despite these ageist misconceptions, the importance of the growing need for trained geriatricians in the U.S. cannot be denied. According to the Association of American Medical Colleges, the latest studies are suggesting that by 2025 the number of American baby boomers over the age of 65 will double, and become the fastest-growing age group in the country. This demographic will soon account for 20% of the nation’s population! We can see the practical results of this trend today, as Americans are clearly living longer, requiring assistance in managing chronic health conditions like hypertension, heart disease, diabetes, dementia, etc.

The most alarming fact? The American Geriatrics Society has estimated that 25,000 certified geriatricians are needed in order to provide quality care to this growing population, but currently there are fewer than 7,500 geriatricians in the U.S. In fact, only 44% of the nation’s 353 geriatric fellowship positions are even filled. Geriatrics is considered to be one of the most underrepresented specialties, even though geriatricians have been found to have high career satisfaction.

So, why the disinterest from budding physicians? Financially, geriatrics is often not considered attractive, particularly with nascent residents facing a looming amount of debt right after medical school. Most elderly patients have either Medicare or Medicaid, which have traditionally lower rates of reimbursement for physicians than that of private health insurance. Indeed, geriatricians, despite the extra years of training, have traditionally received less compensation than other subspecialists.

What can be done to help entice young physicians to this challenging field of medicine? While a restructuring of the current reimbursement difficulties would be an ideal fix to this situation, and would help entice young physicians to geriatrics, perhaps more immediately realizable goals should be considered in the meantime. For example, emphasizing the importance of geriatric medicine within medical school curricula is one alternative and realistic way in which to effect change. Students could learn of the intricacies and complexities involved in providing care to this population. This would be particularly relevant for students, as they are the generation of doctors which will be faced with treating a larger population of older individuals, given the statistics mentioned above.

Here is an even simpler idea: help people realize their passion for the field. Dr. Mitchell Heflin, MD, an associate professor of medicine at Duke University School of Medicine, said it best, “People in geriatrics are called to it.” A commonly cited influence for this career choice is meaningful interactions, particularly in childhood, with older populations. I personally can see why I am drawn to this field of medicine, as much of my happiness as a child (and up to the present day), has revolved around my experiences with the elderly. I remember every Sunday I would cross the street and have a spaghetti dinner with our elderly neighbor, affectionately known as Auntie Eva. She was a chain smoking, fiercely opinionated and loving German lady from Buffalo, who could make a killer homemade marinara sauce and meatballs. Even more influential, however, is the relationship I have with my now 83 year old maternal grandmother who has lived with my family since my birth. She not only always babysat me, but also taught me how to fish, ride a bike, tie my shoes, and crochet. Watching her gracefully age with a high quality of life through her 60s and 70s, and then seeing her current struggle with the beginning stages of dementia, has really made me reflect upon the importance of geriatric care in our society and my potential role in it.

So, while I’m not yet sure if geriatrics is in the cards for me, it is obviously a complex field of medicine, critical for the health of the older population and for the health and dignity of our society at large.

 

References:

https://www.aamc.org/newsroom/reporter/april2015/429722/fewer-geriatricians.html

http://health.usnews.com/health-news/patient-advice/articles/2015/04/21/doctor-shortage-who-will-take-care-of-the-elderly

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Categories
Clinical Emotion Reflection The Medical Commencement Archive

Compassion, The Heart of Medicine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

The Medical Commencement Archive, Volume 3, 2016

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

Categories
Clinical Reflection

Could I be wrong?

Physician overconfidence is thought to be one contributing factor to diagnostic error, and occurs when the relationship between accuracy and confidence is mis-calibrated.1 The relationship between diagnostic accuracy and confidence is still indefinite, but it is hypothesized that if confidence and accuracy are aligned, then appropriate levels of confidence could cue physicians to deliberate further or seek additional diagnostic help.2

A recent study by Meyer and colleagues, aimed at evaluating the relationship between physicians’ diagnostic accuracy and their confidence, found that physician confidence was related to how often they requested a critical additional resource. Additionally, the study found that diagnostic accuracy decreased when physicians were faced with more difficult cases, while confidence decreased only slightly with difficult cases. They noted that diagnostic tests were requested less often when confidence level was higher, regardless of whether or not that confidence was correctly employed. “In essence, physicians did not request more second opinions, curbside consultations, or referrals in situations of decreased confidence, decreased accuracy, or when diagnosing difficult cases.”3 The findings from this study suggest that physicians might not request the required additional resources when they most need it.

Students are often so sensitive to criticism that they are reluctant to give any to their colleagues. This is one area where the culture of medicine can be improved. By using feedback from others and self-reflection, we may be able to improve our diagnostic reasoning.

We are taught to think that everything needs to be rechecked and reconsidered when it comes from an outside source. But what if we turned that clinical skepticism inward? When you are right, you are going to save lives and figure out the patient’s problem. When this happens, it’s always going to be a wonderful thing. But how many more times can we get it right if we make it a habit to ask ourselves, “how could I be wrong here?”

Jason Benham said, “Your greatest weakness is often the overextension of your greatest strength.” Essentially, when a strength is over-extended, you get breakdown. But when a strength is turned into a stretch, and you’re flexible enough to bend, you will not break. Take time to occasionally step back from a difficult case, consult a textbook or run a different test, and make sure you are solving the correct problem. Mistakes will happen. When errors occur, acknowledge them, discuss them with colleagues and the patient, make efforts to correct it, and move on. In medicine, where the consequences of shortcomings and misjudgments can be dire, we can all benefit from encouraging more of these types of discussions.

References:

  1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5)(suppl):S2-S23.
  2. Graber ML, Berner ES, Suppl eds. Diagnostic Error: Is Overconfidence the Problem? http://www.amjmed.com/issues?issue_key=S0002-9343%2808%29X0007-5.
  3. Meyer, Ashley N. D., Velma L. Payne, Derek W. Meeks, Radha Rao, and Hardeep Singh. “Physicians’ Diagnostic Accuracy, Confidence, and Resource Requests.” JAMA Internal Medicine JAMA Intern Med 173.21 (2013): 1952.
  4. Schiff GD. Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med. 2008;121(5)(suppl):S38-S42.

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