Category: Reflection

Categories
General Reflection

Meaningful Community Involvement

The second semester of the first year of medical school, here and at schools across the country, represents a time when first-year students take charge of interest groups and community projects. Not long ago, we were all inexperienced newcomers to our respective schools. But now, we have since taken over the reins of all of the pre-clinical year activities from the second-year students, as they each burrow away to prepare for the ominous Step 1 exam.

Sandwiched neatly between loading up my resumé for medical school applications, and loading up my resumé for residency applications, the outright requirement to have a curriculum vitae that is robust and full of interesting community service activities weighs heavily on my extra-curricular activity decision-making. Burned into my psyche from the competitive nature of the pre-med undergraduate lifestyle is the relentless worry of “Am I doing enough?”, subsequently followed by a persistent voice inside my head insisting “More! More! More!”

The most logical course of action appears to be for every student to: ace every class, have your name in several publications, and participate in as many interesting-sounding community service projects as possible in your time as a medical student. With the latter segment of this strategy, we accomplish the double-sided advantage over our competing residency applicants by demonstrating our efficacy as providers, in addition to proving that we aren’t self-centered egomaniacs. Maybe an application officer will find one of our activities particularly interesting, which then might lead to an extended and hopefully memorable conversation.

For most of us students, medical school is the first position of real responsibility that we have over the wellbeing of others in our local communities. We certainly don’t expect this time to be our last; as future physicians we all have at some point demonstrated a desire to perform acts of altruism for those in need. The shocking turn of events is that the general public endows a great deal of trust in us once we don our white coats, even coats that clearly state our amateur, student status.

We find ourselves at risk of a costly combination of a position of real power and responsibility matched with misguided effort and enthusiasm. If one’s goal is simply to maximize their free time with an array of activities they only half-heartedly care about, then there is a more than likely chance of some level of harm being done. Even if no actual clinical mistakes are made, or no false information is distributed, there likely exists a missed opportunity. Rather than take the time and effort to create significantly improved health outcomes for a community in need, which requires full engagement and innovation, a tepid enthusiasm for the project at hand is more probable to leave a population at its status quo.

Let’s all pledge to choose quality over quantity. Let’s create and collaborate on projects that will actually matter. If chosen correctly, these opportunities for us as students will be the first steps towards making the remarkable impacts on the lives around us that we all aim to achieve. Collectively, let’s worry less about how we appear on paper and more about the people we intend to serve.

Featured image:
Theory and Practice by Carl Mueller

Categories
Clinical Reflection

No Time For Error

In November 1999, the Institute of Medicine released a study entitled “To Err is Human: Building a Safer Health System.” Within the first line of that study, a sobering statistic was revealed: between 44,000 and 98,000 hospital deaths each year are attributable to preventable medical errors.[1] We have been taught about the communication shortcomings that can easily occur between members of a medical team who may be stressed, sleep-deprived, rushed. Even though we have been warned about the potential dangers that can result from the use of abbreviations and imprecise communication, it took a recent misunderstanding for me to leave my Boards-bubble and comprehend, on a personal level, just how misleading certain abbreviations can be.

A few weeks ago, I sat down at my desk and began going over the first lecture of the day. This was 6:30 am:  pre-coffee, pre-sunlight, pre-hair combing. At the time, we were studying the gastrointestinal system. As I reviewed the first few slides of this lecture, I became very confused. I kept seeing the abbreviation ‘LES,’ and I really couldn’t figure out what it was referring to – you have my full permission to laugh at me right now; like I said, it was pre-coffee. As a born and raised East Coaster, LES means one thing and one thing only to me: the Lower East Side of Manhattan. If you are unfamiliar with New York City, please allow me to take a brief detour here to tell you a bit about the wonders of the Lower East Side (LES). The LES has a rich history, greatly influenced by the fact that many Eastern European immigrants settled into tenement housing in the area after coming through Ellis Island. When I think of the LES, I think about deli sandwiches that are too large  to fit through a human mandible, knishes, amazing donuts, and macaroni and cheese pancakes. I do not reflexively think about acid reflux, vomit, and esophageal cancer, although the association may make sense considering the indulgent foods just mentioned. As you might imagine, when I finally figured out that LES was intended to stand for ‘lower esophageal sphincter,’ it was a bit of a letdown. And since I couldn’t get the aforementioned amazing donuts out of my head, my whole morning was pretty much lost when I spent 45 minutes on the phone trying to coordinate a cross-country delivery of them to the West Coast.

Despite the ambiguity, and in my case, potential hilarity, of using abbreviations, one thing is clear: there is an abundance of statistics and data to back up the assertion that medical errors cost lives. Just run a Google search for ‘medical error abbreviation deaths’ or some variation thereof and you will see thousands of hits about the health hazard of medical miscommunication. It’s easy enough to find data  showing how detrimental some timesaving charting techniques can be. As newly-minted members of the medical profession, we have the responsibility to act as the new guard and to usher in safer communication and documentation practices. We can begin to advocate for better safety practices by trying to limit our use of abbreviations in our charting, and we can ask our professors to do to the same in their lectures and test questions. Though becoming a physician is a long and rigorous journey, we should never take shortcuts along the way that have the potential to put our patients at risk of harm.

Featured image:
Doctors Chart – Hospital Chart by wp paarz

References:

[1] Institute of Medicine. To Err is Human: Building a Safer Health System. November 1999. https://iom.nationalacademies.org/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

Categories
General Reflection

Standing Outside the Match

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

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

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

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

Featured image:
Gambling by Alan Cleaver

Categories
Emotion General Lifestyle Reflection

Loneliness: The Epidemic of the Modern Age

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

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

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

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

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

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

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

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

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

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

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

How does it affect us as doctors?

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

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

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

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

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

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

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

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

References

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

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

Categories
Lifestyle Narrative Reflection

Latest Entry

The in-class assignment was simple: write a short paragraph of your thoughts about narrative medicine. But after ten minutes, my paper was a mess; pen lines angrily crossed out sentences that had been started but not finished, my usually neat penmanship was messy, my vocab unsure. My writing screamed hesitation. After begrudgingly turning in my assignment, I realized just how long it had been since I had written in my journal, which I had left tucked away in a nightstand in my childhood bedroom. I thought it was an appropriate place to leave the book—covered in cheesy flowers with a creased binding—that had chronicled my high school and college years. As I was packing for medical school, it seemed almost off-putting at the time to continue to chronicle the next chapter of my life—what I naively perceived to be the real challenges of medical school—on the same page as my previous entry, in which I complained about the trials and tribulations of learning how to drive stick shift and tackling organic chemistry. Instead, tucked away in my new bedroom, is a leather-bound journal, a gift I received for medical school, emblazoned with the words “FOLLOW YOUR DREAMS.” Every inch of it is covered in cartoon birds. It has been sitting in a drawer since I moved in, untouched.

As I juggle this new chapter as a busy first year med student, that seemingly simple assignment reminds me how much I miss, and clearly need, a nightly journaling routine as my outlet to find peace with my hurried thoughts at the end of a hectic day. It is all too easy to fall into the daily hustle and bustle of med school life such that every day seems almost like the one before. Study, extracurriculars, preceptorship, sleep. Lather, rinse, repeat. All too often, before I fall asleep, I find myself falling into the trap of using my phone to mindlessly relax; catching up on my Facebook newsfeed, scrolling through photos on Instagram—or, if we’re being totally honest here—catching up on celebrity gossip (let’s just say, I’ve definitely been keeping up with the Kardashians). But by the time I “unplug,” my brain is often wired. So much for unwinding.

Yet, even as I write this entry (yes, write, not type!), I understand how relaxing it is to unwind and take the time to process the day’s events with the written word. To really chronicle how every day is not like the one before, but how each day actually brings a new perspective as a result of what I had done that day: conversing with a new classmate, grasping the latest material in class, practicing the hands-on skills I’ve obtained in my preceptorship, etc. I see how important writing about these experiences is for me; to have something tangible to look back upon, years after medical school. To read through each chapter—to remember how I had stumbled when learning to measure blood pressure and take a patient history—just as I reflect now when I read back on my teenage struggles.

It’s important that we, as future physicians, find whatever it is that provides us with this sense of mindfulness, whether it be exercise, meditation, spirituality, etc., and hold on to it. It is through this self-awareness that we can see not only how we have changed, but even more importantly, to find a moment’s peace in the midst of the commotion that each day brings as we pursue careers in medicine.

So, when I go back to my childhood home to visit my family, I’ll be sure to pack up my journal.

Featured image:
12.2.2010 <homework> 321/365 by Phil Roeder

Categories
Public Health Reflection

The Flint Water Crisis – The Physician’s Role

Flint, Michigan is a community of 100K residents, the majority of whom are African-American or of lower socioeconomic status. In the recent Democratic debate held in Flint, one mother spoke to the huge challenges that plague the community, including mold in classrooms, unqualified teachers, and the water crisis. In 2014, city officials decided to switch from the Detroit water supply, which gets fresh water from Lake Huron, to the Flint River, which has a long history of contamination, particularly with lead.

Flint residents knew of this contamination and saw brown water flowing in from their taps. They complained for years, long before the media hype, but city officials ignored their voices. Some residents noticed clumps of their hair falling out and an odd taste and smell to the water they were drinking.1

To investigate these claims, Dr. Mona Hanna-Attisha, a pediatrician at Hurley Medical Center and assistant professor at Michigan State University, conducted a city-wide study on the water in Flint. When she recognized that there were alarming levels of lead in the water, she alerted the Environmental Protection Agency (EPA).2 Only then did elected officials start taking residents’ complaints to heart.

Dr. Hanna-Attisha earned the Freedom of Expression Courage Award as well as the respect and gratitude of her patients and peers by speaking up. However, the brave doctor tells CNN in an interview that she was attacked viciously by the state of Michigan when she first presented her research and tried to warn officials of the ongoing crisis. She says she felt “physically ill”3 because of the backlash and professionally vulnerable because her reputation as a physician and researcher was at stake.

Despite the potential professional consequences, Dr. Hanna-Attisha fought for her patients and for the children of Flint, Michigan. In doing so she sent out an important message to physicians: sometimes we must be the voice of the people. It is our responsibility to fight for our patients, whether that means exposing a public health crisis, or more mundane daily tasks like calling health insurance agents to get a patient’s medication covered.

Flint is not the only city in the United States that is dealing with public health crises. However, this particular crisis and Dr. Hanna-Attisha’s role in bringing it to light serves as a reminder for all physicians and medical students: we are public servants and have an obligation to report public health issues in order to ensure the safety of our patients and the general population.

As the notable English physician Sir Henry Howarth Bashford once said, “After all we are merely servants of the public, in spite of our M.D.s and hospital appointments”. Let us not forget this role as we continue through medical school and enter into our practices.

Sources:
1http://www.motherjones.com/politics/2016/01/mother-exposed-flint-lead-contamination-water-crisis
2http://www.freep.com/story/news/local/michigan/flint-water-crisis/2016/01/30/flint-water-lead-health-qa/79475642/
3http://www.cnn.com/2016/01/21/health/flint-water-mona-hanna-attish/

Featured image:
The Flint River, August 2014 by George Thomas

Categories
General Lifestyle Reflection

New Job

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

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

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

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

Featured Image:
Lost? by Susanne Nilsson

Categories
Clinical Disability Issues Reflection

Asperger’s & Neurodiversity

“He who is different from me does not impoverish me – he enriches me. Our unity is constituted in something higher than ourselves – in Man… For no man seeks to hear his own echo, or to find his reflection in the glass.” 

–  Antoine de Saint-Exupery (11)

We live in a world of increasing diversity and acceptance. With more efficient travel, greater connections and more robust discrimination laws, never before have so many opportunities been laid out for us to endeavor. Women can vote, same-sex couples can marry; we are on the cusp of entering a new era. Yet amongst all these historical, cultural and economical changes, what we often forget is the psychological. If we are to accept people for who they are, with respect and dignity, then why do we then choose to label them with terms such as ‘Asperger’s’ or ‘Autistic’ and to then reduce the paths they may be able to follow?

What is Neurodiversity?

‘My brain is a jewel. I am amazed with the mind that I have.’ – Muskie, diagnosed with Asperger Syndrome (2)

In the late 1990s, sociologist Judy Singer invented the term neurodiversity; a term that described conditions such as Autism and ADHD (5). This neurodiversity movement was born out of the autistic civil rights movement in the 1990s, and has grown rapidly thanks to the internet. The movement consisted mainly of members who had been diagnosed with Asperger’s, but did not wish to be ‘cured.’ This perspective, a step away from the mainstream method of  categorization, led to books (12) and articles (13) being written, the launching of groups such as the Autism Self Advocacy Network, and a novel  perspective of human thinking.

Neurodiversity is a term very similar to cultural or biological diversity; it takes into account the wide variety of human experiences, and respects people for their differences. Such an approach steps away from the medical model of viewing disability, instead focusing on the talents and perspective that each person can bring to the world. The implications of such a movement are widespread; the right to be treated with respect and dignity, regardless of the way one thinks.

What is Autism?

‘Autism is pervasive, colors every experience, every sensation, perception, thought, emotion, and encounter, every aspect of existence’ – autistic activist Jim Sinclair, 1993 (2)

Autism is found under Pervasive Developmental Disorders in the International Classification of Diseases-10. The criteria listed include impairment in social communication and social attachments (6). First used in 1910 by a Swiss Psychiatrist named Bleuler, it was transformed into its modern-day meaning in 1944 by the Austrian paediatrician Hans Asperger, when he published its first definition. The disorder has been termed Asperger’s Syndrome ever since (7).

Since its first use, the incidence of Autism has increased, leading to increased public attention both in the media and within the medical circle (1). This gradual increase has often led to the question: is this a disease of biology, or of society? Indeed, as our society has become more medicalized, Autism has entered into an era fixated with treatment and cure.

What is ‘normal’?

By continuing to medicalize a different way of looking at the world and of interacting with others, we must first define what it means to have a ‘normal’ perspective of such things.

This question brings to light the very fact that no one is normal. From the way we dress, to the jobs we undertake. From our hobbies to our distractions, our loves to our hates, our desires to our ventures, we are all different. How do we then take out our marking pen and draw a line between those who are ‘normal’ and those who are not? In fact, from an ‘autistic’ point of view, people who are non-autistic are easily distractible, obsessed with social interaction and suffer from profound deficits in attention to detail. The idea of normality changes with time, place, date and gender; what is normal here in the UK may well be considered unacceptable in Sub-Saharan Africa.

Rather than focusing on the normal, we should be focusing on individuality; on what each person can contribute to our society, and to themselves. This boundary between normality and disability is an artifact, a division drawn by man that merely reflects the values of the society in which he resides. For example, dyslexia is based upon our value to read sufficiently, something that would  not have been as significant hundreds of years ago. So what does our medicalization of Autism tell us about ourselves?

As the modern era continues to be transformed by technology, perhaps what we build in the future –with the internet in our laps and a screen at every corner – will become a haven for those who have difficulty with eye contact and with body language. The diagnosis of Autism today may well be different from the diagnosis tomorrow.

Is Autism an identity or a disease?

In the absence of any biomarkers for diagnosing psychiatric illnesses, psychiatry often utilizes behavioural deviations instead (4). Using this argument, one could suggest that psychiatry may end up ignoring advantageous behaviors that are outside the ‘norm’ (4). What we may see instead are the difficulties that entrench a person. Rather than encouraging a young child to develop their interests and their hobbies, instead we may focus purely on their intense obsessions on the minutest details. Imagine what this means for a child. Instead of being seen as a building block of opportunities for ideas and growth, these children may instead see themselves as having un-breakable boundaries.

Yet, a label can have a lot of power. A diagnosis places upon the person a special status within society. It opens the doorway to specialist interventions and support from multiple sectors, helping the individual to succeed in certain areas of life that they may find more demanding than others.

There are clearly many things that children with Asperger’s have difficulty with; areas where they require intensive support and management. It is through these interventions that children may then be able to better integrate with society and feel valued. But the idea of finding a cure seems a step too far. As science continues to delve into our lives, we gradually begin to see everything with a different lens; that there must be pathology in everything that is different, and there must be an answer – a pill, an operation, a test.

But it is not all bad. The medical model has brought with it huge shifts within science – new drugs, new insights and a new life for many, many people. By medicalizing something, by using physiology to explain a condition, you are then able to destigmatize it. Thus, a person is no longer a schizophrenic, but instead suffers from schizophrenia – a disease entity of its own.

Whether or not such a viewpoint can be used for a diagnosis such as Autism is a difficult question to answer. For some, the explanation that Autism is an ‘atypical wiring of the brain’ (2) may help them to understand the difficulties that they face. Yet others may strongly identify with such a diagnosis, claiming that it is a gift that allows them to view the world through a different lens, giving them the opportunity to appreciate the depths of the human mind. They may choose to see themselves not as pathological, as wiring gone wrong, but as privileged beings who have been granted a gift of insight that others cannot fully appreciate.

Different vs Defective

As with many things in life, Autism falls on a spectrum. One could argue that by focusing on those who are high-functioning, and therefore able to have this debate, you are minimizing the true suffering of those who do not have this privilege. Indeed it can be argued that because it is on a spectrum, one should be careful not to blanket everyone with Autism as either having a ‘disability’ or simply being ‘high-functioning.’ The aim is to view Autism with a more open mind, rather than as something that requires a gene to be unlocked. This has received appreciation by the American Psychiatric Association, who recently converted the diagnoses of ‘Autism’ and ‘Aspergers’ into one simple diagnosis of ‘Autism Spectrum Disorder.’ Through the creation of this diagnosis, the emphasis has been placed on the idea that people do not fit into boxes, but lie upon a continual line that can encompass a wide range of behaviour.

Neurodiversity is the idea that neurological differences such as Autism are due to normal variation, rather than a sign of pathology. This point of view emphasises the fact that these people do not necessarily need to be ‘cured’ but helped and accommodated. If we look at the progression of science and the humanities, we see that the breakthroughs have been developed by minds that think differently; create links where others have drawn their blinds. If we are to grow as human beings, then this is the approach that is required; not just to grow scientifically, but also morally. Unfortunately, we are currently drawn towards questions of causation and cure – the link between Autism and MMR by Wakefield being just one example (8); an attempt to find blame, and ask the question: why is my child the way he/she is?

And to people with these conditions themselves, surely the idea of being part of a natural variation is much more appealing than being seen as something that is broken and needs to be ‘fixed.’ To describe someone as defective is to take away the essence of who that person is, and what they can bring to the world, to their family, to themselves.

Instead of creating a world focused on finding cures, on ridding the world of autism, we should be building the foundations to allow people to receive the support they deserve, to have their rights heard. Such efforts include early interventions for speech and behavior therapies, and building more accommodating home and work environments.

If we are to accept the fact that equality has been applied to race, religion, gender and sexual orientation, then why can it not be applied to people with different ways of thinking and interacting as well?

We are already seeing glimmers of this in our current society. Mark Haddon’s novel, The Curious Incident of the Dog in the Night-time, written from the point of view of a young boy with Autism, helps readers to transcend their lives and view the world from eyes that see differently, a mind that whirs at a different tone. This novel  is studied by English students across the UK (9), and perhaps by encouraging these types of empathetic endeavours, rooted in the humanities rather than the sciences, a new way of thinking can be formed, where we can focus on acceptance rather than on cure.

‘An autistic child can only be helped if a serious attempt is made to see the world from his point of view.’ (10)

References

  1. Baker, D.L. 2006. Neurodiversity, neurological disability and the public sector: notes on the autism spectrum. Disability & Society. 21:15-29
  2. Ortega, F. The Cerebral Subject and the Challenge of Neurodiversity. 4:425-445
  3. Jaarsma, P., Welin, S. 2012. Autism as a Natural Human Variation: Reflections on the Claims of the Neurodiversity Movement. Health Care Analysis. 20:20-30
  4. Kapp, S.K., Fillespie-Lynch, K., Sherman, L.E., Hutman, T. Deficit, Difference, or Both? Autism and Neurodiversity. Develeopmental Psychology. 49:59-71
  5. Silberman, S. 2013. Neurodiversity reqires conventional thinking about brains [Online]. Available at: http://www.wired.com/2013/04/neurodiversity/ [Accessed: 1st January 2016]
  6. World Health Organisation. 2016. ICD-10: International statistical classification of diseases and related health problems. Geneva: World Health Organisation
  7. McGuinness, S. 2015. History of Autism [Online]. Available at: http://www.autismuk.com/home-page/history-of-autism/ [Accessed: 1st January 2016]
  8. Godlee, F., Smith, J., Marcovitch, H. 2011. Wakefield’s article linking MMR vaccine and autism was fraudulent. The British Medical Journal. 342:c7452
  9. 2013. Subject Content [Online]. Available at: http://www.aqa.org.uk/subjects/english/aqa-certificate/english-literature-8710/subject-content/why-choose [Accessed: 1st January 2016]
  10. Stanton, M. 2006. What is Neurodiversity? [Online]. Available at: https://mikestanton.wordpress.com/my-autism-pages/what-is-neurodiversity/ [Accessed: 1st January 2016]
  11. Evans, T. 2015. Counselling Skills for Becoming a Wiser Practitioner: Tools, Techniques and Reflections for Building Practice Wisdom. Jessica Kingsley Publishers.
  12. Silberman, S. 2015. NeuroTribes: The Legacy of Autism and the Future of Neurodiversity. Avery
  13. Solomon, A. 2008. The Autism Rights Movement [Online]. Available at: http://nymag.com/news/features/47225/ [Accessed: 28th January 2016]

Featured image:
Diversity by Séb

Categories
Emotion General Reflection

What We Carry

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

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

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

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

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

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

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

Featured image:
sunrise and silence by x1klima

Categories
General Reflection

Culture and Medicine

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

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

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

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

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

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

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

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

What do you do to stay healthy?

What does illness mean to you?

Who are your social supports?

How do you view doctors and medications?

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

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

Nichter 2010 described five expressions of idioms of distress:

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

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

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

What do you think has caused your problem?

Why do you think it started when it did?

How severe do you think your illness is?

What do you fear most about your illness?

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

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

The Culture of Healthcare

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

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

What do we do?

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

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

 

References

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

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

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

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

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

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

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

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

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

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

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

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

 

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