Tag: medicine

Categories
Clinical Emotion Empathy General Humanistic Psychology Opinion

Let Me Be Brief: A Proposal to Refrain From Eating Our Young

A series of briefs by the Texas Medical Students

By: Elleana Majdinasab and Rishi Gonuguntla

Medicine has its unspoken mores, does it not? Certain specialties are notorious for their personalities, and the idea of foregoing food and sleep are deemed signs of strength and resilience. Upperclassmen advise against getting in Dr. X’s way, lest you become subject to a tailored diatribe, and you hear whispers of Dr. Y’s career-crushing evaluations. Your roommates do not bat an eye over your tears every  evening, because chances are they are no stranger to such days themselves. It doesn’t require a detective to identify that the above are the direct result of mistreatment in medical school.

Per the AAMC, mistreatment occurs when there is a show of disrespect for another person that unreasonably affects the learning process. Public humiliation and belittlement by doctors are the most common forms of mistreatment in medical school.1 The practice of aggressive “pimping,” or the act of doctors disparaging students for not knowing information, potentially in front of patients or fellow classmates, is a phenomenon too many medical students needlessly experience.2 Other examples of mistreatment include the shaming of students for asking questions and being subjected to offensive names and remarks.1 According to one 2014 study, over three-fourths of third year medical students reported being mistreated by residents, with over 10% of those responses citing recurrent mistreatment.2

Given the omnipresence of these events, one may consider whether there exists a common denominator among guilty attending physicians. Indeed, mistreatment of medical students can  occur secondary to a multitude of reasons. Physician burnout is still rampant as ever, and ironically, often occurs partly due to the same toxic culture attendings themselves experienced as budding residents.3 The doctors in question blissfully perpetuate the cycle, humiliating and pimping, justifying  their behavior with the mentality of, “I went through it back then and turned out just fine.” Thus, the vicious cycle continues. What doesn’t kill you makes you stronger, right?

As medical students, we are quietly told by the older and wiser to improve our resilience – to grow tougher skin. We are advised to expect, or even welcome, microaggressions and impatience from our superiors while we work toward our lifelong dreams.4 We take deep breaths and smile through the jabs because we are fully aware of the consequences of speaking out against the deeply ingrained practice of mistreatment.4 Mistreatment in medical school matters because doctors eating their young further propagates the toxic reputation of the career’s culture while contributing to the development of many future doctors’ unhappiness.3 It is the accumulation of years of pressure, competition, and negative experiences that leads to feelings of burnout in students and physicians alike.5 Even worse, medical students act on these feelings, and they are three times more likely to commit suicide than their similar-aged peers in other educational settings in the general population.6 The hazing of medical students is in no way constructive or beneficial to anybody involved. Stress and toxicity in the learning environment prevents students from being themselves and asking questions, thus damaging their confidence during the formative years of their training.7

Even more alarming is that mistreatment is more commonly directed towards minority students, including female, underrepresented in medicine, Asian, multiracial, and LGBTQ+ students, than it is toward their white, cis-gendered, heterosexual, male counterparts.8 In the same vein that we encourage and recruit people   from minority communities to join medicine, we must be aware of the potential mistreatment they will experience and take clear, targeted steps to protect them. If we, as a community, fail at this task, then we are complicit in perpetuating the systemic inequities and inequalities that are currently prevalent in medicine.

The reality is that the culture of medicine doesn’t have to be this way. It is certain that mistreatment has been inadvertently ingrained within the culture of medical training, so attempting to address this problem feels daunting. There is a current lack of literature regarding what interventions successfully reduce mistreatment, but introspective analysis yields some steps we may take in an attempt to slowly chip away at the current social infrastructure.9

First and foremost, students must realize and acknowledge the negativity they have been subjected to is not ‘all in their head,’ but instead a universal and rather unfounded experience. The next step is to seek support from classmates, friendly administration, and trusted professors and physicians who can provide guidance and vouch for students’ justice. Addressing mistreatment is at its core a collaborative effort, as we cannot expect only the bravest, most outspoken students to carry this initiative to fruition. Each and every person in medicine can enjoy a role and responsibility in this endeavor. School administrations can create interventions aimed at educating faculty and students about recognizing mistreatment and the harmful effects that public humiliation can have on student learning.10 It is only when students recognize abuse and have a strong support system that they may finally gain the confidence required to be vocal against toxic behavior and speak out for both themselves and classmates. Schools can further assist efforts by ensuring students are aware of their rights in this context, and offering guaranteed protection if mistreatment does rear its head.11 Current physicians may also positively contribute by gently and constructively pointing out questionable behavior among their colleagues to create a more effective learning environment. Finally, our generation of medical students is tenacious, progressive, and outspoken. We can weaken, and even break the cycle, by remembering our roots, exercising our rights, and manifesting the golden rule: to always treat others the way you want to be treated.

  1. 2020 GQ All Schools pdf. (n.d.).
  2. Cook, F., Arora, V. M., Rasinski, K. A., Curlin, F. A., & Yoon, J. D. (2014). The Prevalence of Medical Student Mistreatment and Its Association with Burnout. Academic Medicine : Journal of the Association of American Medical Colleges, 89(5), 749–754. https://doi.org/10.1097/ACM.0000000000000204
  3. Major, (2014). To Bully and Be Bullied: Harassment and Mistreatment in Medical Education. AMA Journal of Ethics, 16(3), 155–160. https://doi.org/10.1001/virtualmentor.2014.16.3.fred1-1403
  4. Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation | Medical Education and Training | JAMA Internal Medicine | JAMA Network. (n.d.). Retrieved March 16, 2021, from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2761274?guestAccessKe y=5b371de5-4978-4643-b125-f26972348616&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=022420
  5. Dyrbye, N., Thomas, M. R., Massie, F. S., Power, D. V., Eacker, A., Harper, W., Durning, S., Moutier, C., Szydlo, D. W., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2008). Burnout and suicidal ideation among U.S. medical students. Annals of Internal Medicine, 149(5), 334–341. https://doi.org/10.7326/0003-4819-149-5-200809020-00008
  6. Markman, D., Soeprono, T. M., Combs, H. L., & Cosgrove, E. M. (2019). Medical student mistreatment: Understanding ‘public humiliation.’ Medical Education Online, 24(1), 1615367. https://doi.org/10.1080/10872981.2019.1615367
  7. Full article: Exploring medical students’ barriers to reporting mistreatment during clerkships: A qualitative study. (n.d.). Retrieved March 16, 2021, from https://www.tandfonline.com/doi/full/10.1080/10872981.2018.1478170
  8. Hasty, N., Br, M. E., ford, Lau, M. J. N., MD, & MHPE. (n.d.). It’s Time to Address Student Mistreatment. American College of Surgeons. Retrieved March 16, 2021, from https://www.facs.org/Education/Division-of-Education/Publications/RISE/articles/student- mistreatment
  9. Markman, D., Soeprono, T. M., Combs, H. L., & Cosgrove, E. M. (2019). Medical student mistreatment: Understanding ‘public humiliation.’ Medical Education Online, 24(1), 1615367. https://doi.org/10.1080/10872981.2019.1615367
  10. Stone, J. P., Charette, J. H., McPhalen, D. F., & Temple-Oberle, C. (2015). Under the Knife: Medical Student Perceptions of Intimidation and Journal of Surgical Education, 72(4), 749–753. https://doi.org/10.1016/j.jsurg.2015.02.003
  11. Mazer, M., Bereknyei Merrell, S., Hasty, B. N., Stave, C., & Lau, J. N. (2018). Assessment of Programs Aimed to Decrease or Prevent Mistreatment of Medical Trainees. JAMA Network Open, 1(3), e180870–e180870. https://doi.org/10.1001/jamanetworkopen.2018.0870

 

Categories
Empathy General Medical Humanities Opinion Reflection

Visual Arts as a Window to Diagnosis and Care

With the rapid advancement of knowledge and technology in medicine, physicians alienate themselves from the core purpose of their profession. A grounding in the humanities as well as a strong foundational basis understanding the medical sciences is required to establish well-rounded physicians. Art inspires medical students and physicians to observe detail they otherwise wouldn’t. With patients in the emergency room, before any physician-patient interaction can occur, the sounds of bilateral crackles, the sight of neck muscles contracting and of the nostrils flaring indicate a patient in respiratory distress. This very detail in observation is needed for split-second decisions of utmost importance in the emergency theatre.

Art is the projection of our experiences, memories and has the power to record reality and fantasy. These altogether add to the artistic memory of an artist and allow them to add adaptations based on their life’s observations. Artists have captured the human body through the pursuit of conveying human experience, of the human’s appearances, shapes, and sounds all reflecting their state of health. Artists must see the details of a picture and reproduce it, and only once they’ve mastered observational art can they move on to more abstract forms conveying emotions of the real world.

When dissections were forbidden centuries ago, artists together with doctors snuck out to examine human corpses for a closer look. This was important for them to accurately reproduce representations as they not only had to know the inner workings of the human body just as physicians did but they needed the eye for their artistic creation. Unfortunately, today the acquisition of life-drawing skills has lost its traditional importance due to increased demands for the more conceptual art forms.

In medicine, observational skills provide insight into a patient’s problem.  From observing, not only do we see it as is but we recognize patterns, are able to analyze context and make connections. Despite knowing everything about a disease or illness, learning how to see pathologies, and diagnostic criteria is important to avoid missing all the signs. The four steps of physical examination are inspection, percussion, auscultation and palpation. Inspection or observation is often overlooked but is so crucial to patient care and treatment as is to the creation of art.

The artwork of Piero di Cosimo, A Satyr Mourning over a Nymph (1495) depicts a young woman killed accidentally during a deer hunt by a spear. Upon analysis of the painting and deep observation, evident is that there is no spear wound but instead the women’s arms are covered with long cuts as if acting in self defense from her assailant. Her left hand additionally is placed in position with her wrist flexed and fingers curling inwards known as “waiter’s tip”. Fundamentally at large, di Cosimo used the girl’s corpse as a model and because as an artist he had no understanding of medicine and injury, he portrayed exactly what he saw. Unintentionally, he captured the girl’s true injuries dictating to a medical practitioner the likely theory of the young woman’s actual cause of death.

A Satyr mourning over a Nymph by Piero di Cosimo
https://www.nationalgallery.org.uk/paintings/piero-di-cosimo-a-satyr-mourning-over-a-nymph

Appreciation for paintings by physicians even reveal medical diagnoses given the structural facial characteristic changes that occur in different diseases. The Old Woman by Quinten Massys depicted an exaggerated ugliness due to the pattern of facial deformations; bossing forehead, prominent cheekbones, enlarged maxilla and increased distance between the mouth and nose all consistent with leonine faces of Paget’s disease stemming from accelerated bone remodeling. Another example is that of Peter Paul Rubens, The Three Graces, displaying symptoms of benign hyper-mobility syndrome, an autosomal dominant disease. Scoliosis of the spine, a positive Trendelenburg sign and double jointedness as well as lax upper eyelids is evident in the artists painting.

Fascinating nonetheless is that the medical diagnoses in both paintings were unknown to doctors at that time. Paget’s Disease and benign hyper-mobility syndrome were discovered just a couple years ago while these paintings existed long before them. 

Compared to artists however, doctors have stopped putting their skill of inspection into practice and with all the expensive tests available to help doctors make diagnoses, the necessity of individual, physician observation has decreased. Thus raises a question, will the dependence on tests rather than investigation through the senses define the future of medicine?

As medical students, this urges us to hold true to the art of observation. Technological advances were directed to improve patient care and not impede the physician-patient relationship. The personal touch of a doctor and the direct communication through movement, and language has been lost. Remembering the feelings of our patients allows us as future physicians to be mindful that no patient manifests the same way despite presenting with the same disease. Neither are patients aware of the manifestations of disease and overtime naturally adapt to the abnormal posture, gait, and lifestyle changes often overlooking the skin changes, mood or weight fluctuations.

When doctors are trained to “see”, observe and infer from signs alone a basic diagnosis, will they understand the whole human being. Therefore, arts education in medicine helps humanize science and connect medical theory into the patient’s journey. In analyzing art pieces, students are able to connect clinical skills and improve their ability to reason with the physiology and pathophysiology of the human body from visual clues alone causing them to become more emotionally attuned to their patients and aware of their own biases as physicians.

The skills of observation requires improvement and practice from physicians to both diagnose and understand the underlying concerns of a patient. Only when doctors have mastered the art of observation and trained their eyes to truly see, will they ultimately return to a world of greater human connection in medical practice.

References
McKie R. The fine art of medical diagnosis. The Observer. 2011 September 11;Culture. 
Berger L. By Observing Art, Med Students Learn Art of Observation. NY Times. 2001 January 2;Health
Christopher Cook. A Grotesque Old Woman. BMJ 2009;339:b2940
Dequeker J. Benign familial hypermobility syndrome and Trendelenburg sign in a painting “The Three Graces” by Peter Paul Rubens (1577–1640). Annals of the Rheumatic Diseases 2001 September 01;60(9):894-­‐895.
Pecoskie T. Improving patient care with art. The Spec. 2010 December 2;Local. https://www.mcgill.ca/library/files/library/susan_ge_art__medicine.pdf

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

Discontinuity in Care

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

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

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

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

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

 

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

Categories
Clinical Emotion Empathy Humanistic Psychology Reflection

The Enigma of Empathy

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

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

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

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

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

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

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

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

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

Photo Credit: Sean MacEntee

Categories
Empathy

Properly Unprepared

It was late afternoon, and the current nursing shift would be relieved in less than ninety minutes. The feeling of impending Friday freedom was palpable on the floor of the intensive care unit. I was on my way to meet with my last patient of the week, who had been brought in for an unintentional drug overdose. My goal was to determine whether the overdose was truly accidental, and if she was a candidate for compulsory psychiatric hospitalization. I passed by a large bank of computers without stopping, and knocked on the patient’s door. When I walked in that room, all I knew was the patient’s name, her age, and the reason for her hospitalization. Other than those preliminary facts, she was a complete mystery to me. I spent fifty minutes with the patient, and had a relatively pleasant conversation. When I walked out of her room, I opened her medical chart for the first time.

Unfortunately, that day, the story that I received from the patient and the information that I got from her chart told two different stories. Numerous providers had noted that she was irresponsible with medications, and I got the sense from the chart that she only sought medical care to gain access to controlled substances. Now that I had established a good relationship with my patient, I would have to re-interview her in an attempt to reconcile the information I had seen in her chart with the picture she had painted for me in the moments prior. My Friday freedom would just have to wait.

I would not be surprised to find out that the ICU staff was laughing at me that day. After all, I ended up spending more than two hours with this patient when I could have conducted only one brief interview. Even though the majority of my first hour with the patient was pure confabulation, I viewed it as a valuable component of my assessment. That first hour represented my sole opportunity to get to know my patient without any bias. Had I looked at her chart before walking into the room, I unquestionably would have written her off as an irresponsible, drug-seeking troublemaker. I would have asked her pointed, perhaps accusatory questions about her behaviors, and worse, I would have known exactly when she was lying to me, further eroding any respect I may have had for this patient.

Electronic medical record systems help to facilitate the sequestration of large amounts of information about our patients with minimal effort, and it’s largely considered taboo to meet with patients without first researching their medical record.  The information physicians can learn from the medical record can be undoubtedly beneficial in many situations, but extensive chart reviews can also lure us into a false sense of security, allowing us to preconceive an identity for our patients before ever having met them.

Had I read my patient’s chart that afternoon, I am certain that I would have made judgments about her that would have influenced my interview. Instead, I learned about my patient by allowing her to tell her own story. I thought about the information she shared with me, and, perhaps more importantly, what she failed to tell me. Because the patient never discussed her well-documented mishandling and possible dependence on prescription medications, I felt confident in making an assessment that this patient had relatively poor insight about her problems.

Featured image:
hGraph: patient + clinician looking together by Juhan Sonin

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

Categories
Lifestyle Public Health Reflection

Can social justice replace medicine?

‘Social injustice is killing people on a grand scale.’
– Marmot (2)

Despite the leaps and bounds that science has made over the past century, with all its shiny new techno-gadgets and ever-advancing drugs, the primary reason for our good health today lies in something much less sexy: vaccinations, clean water and sanitation- changes that we take for granted.

We live in a world that is changing every second. Bigger cars, faster phones, all the information at our beck and call: from the education that is offered to our kids, to the healthcare that is offered to our decaying bodies.

The hospital of today is a far cry from the one half a century ago. The minute you walk into a hospital your senses go haywire. You have stepped into the world of the future. The full scale of our technological advancement greets you within these four walls. The bizarre beeping overwhelms your ear canals, screaming into your brain as the alarms screech constantly in the background. The reams of wires trail along the floor of the wards, wrapping themselves around their patients like Christmas presents, offering nourishment to bodies overwhelmed with disease. We are living in the world of machines, and it is upon them that we place our hopes of immortality.

Everyone knows of the success story of Science. We are bombarded by the media, informing us of the next new cancer drug, the gene unlocked that will solve all our problems. What we forget is that we are not merely organisms residing within a vacuum. Nor are we machines ourselves, whose very pores can be zapped with electrodes, transforming our very identity. We are human beings living and breathing on this planet Earth. We digest the world around us. We are not merely scientists of the world within ourselves, of the DNA that twirls inside our cells. We are also manufacturers of the world around us; of the houses we live in, the food we eat and the lives we live. Perhaps the answer to a better, healthier life lies here instead.

But, is this the role of the doctor? Shouldn’t we leave this task to the politicians, to those who have the power to make these important decisions? Isn’t the duty of the doctor ultimately towards her patient, towards that individual who is sitting opposite, rather than to humanity as a whole? I believe Virchow, the German Doctor, described it best when he said:

‘Medicine is a social science and politics is nothing else but medicine on a large scale.’ (1)

Of course there are diseases that can only be fixed by looking inside our own bodies – diseases that come from within, that cannot be changed by any amount of control over one’s environment; Huntington’s Disease is one example.

But if you take a quick glance at the causes of mortality in both the USA and the UK, you will find that the majority of these diseases are significantly related to one’s lifestyle. The top leading cause of death in both the UK (3) and USA (4) is Heart Disease, which has very strong links with lifestyle, including smoking (5), a high-fat diet (6) and poor exercise (7).

In the past, when tuberculosis and polio wreaked havoc upon the population, the role of the doctor was to prescribe medication; to act as the priest who offered the gift of life through his knowledge and wisdom. Yet now, this power lies upon the patient. Our lives are no longer cut short by the plague, but by the pathways we choose to make while we are still alive.

The role of the doctor continues to change along with society. The doctor is the servant of the public. As our ailments in life continue to revolve around these pathways that we choose to take, so must the doctor focus her gaze away from the leaves of her prescription pad and begin to question the foundations of such paths; the reasons behind these choices, the thoughts and actions that lead a person towards their own destruction.

It is not enough to simply inform someone by saying ‘you need to do more exercise.’ Anyone who has made a New Year’s Resolution to do so will understand this. Even in the UK, a country where healthcare is free, one’s health is still dependent upon how much one earns. The richer you are, the longer you will live (8). How is it that in this day and age, this is still the case? Healthcare is a right. And as doctors, it is our duty to ensure this edict is followed. The politician may sit upon his throne and hand down his judgments, but it is the healthcare professional who is in contact day in and day out with the most vulnerable and marginalized.

Indeed, there are some excellent examples of attempts to try and balance this injustice within our society; free school meals in the UK which lead to improved nutrition in children (9) and the ban on public smoking to try and reduce passive smoking (10) are just two examples. These changes in legislation lead to the question: how much control should our government have over our own decisions towards our health? If someone wishes to smoke and drink all their life, then that is their right. Autonomy is one of the principles the doctor must follow; today’s healthcare system revolves around the patient and her choices. No longer does the doctor hold authority over the patient’s body. Yet this does not mean we cannot improve the world around us; we are still capable of building a healthier society, a society in which we will not only live longer, but be happier in as well. Free education and housing are two examples of societal changes that do not necessarily impose upon our personal rights, yet can lead to healthier childhoods and happier families.

Let’s say you are a single working mother – you are only just reaching your rent each month. You can only work part-time because you need to pick up your son from nursery every afternoon. You have no family who can look after him. This leaves little money for food, so you mainly feed your son. His diet is very poor, not only because of the little you can afford, but you yourself have never learned how to cook. Your own childhood consisted of fast food and the occasional apple or banana handed to you by a father who you rarely saw. You live in a very deprived neighbourhood. You cannot afford heating, and your son is constantly sniffling and coughing, hiding under his hole-infested jumper that you managed to grab from a local charity shop. You are isolated – your husband has left you, you have no one to talk to and your neighbours scare you. When you’re not working, you stay at home for your own safety, and ultimately for your son’s. You try to remain happy for your son. You want the best for him. But you are scared. You are scared for the future, you are scared about your next paycheck, you are scared about being burgled, being mugged, having your son taken away from you. You are scared about becoming a failure, of disappointing your son. You start drinking a glass of whiskey each evening to help you calm these anxieties. You gradually spend more and more money on alcohol, an attempt to grasp control of these spiraling criticisms that constantly call into question your ability to be a mother. But this does not always help. As the days turn to weeks, your thoughts begin to gain a voice of their own, almost screaming through your ears; you are a bad mother. A failure. Maybe you’d be better off somewhere else. Your son would have a better life without you. He wouldn’t have such an awful mother.
You eye the packet of paracetamol lying on the table. What would happen if you weren’t here? Wouldn’t your son lead a happier life? He would no longer have this dark mark tainting his existence. He might even be happy… What do you do?

In various points throughout this story, one could take out their pen and draw a mark where someone could have intervened. Not necessarily to offer medication or money, but things such as social support; someone to help look after the son in the afternoons, advice on how to apply for jobs, or housing in a more residential area. A helpful hand to hold on to during the darkest periods, a pat on the back, a shoulder to cry on, an ear to listen. How different would this story be if these simple interventions had been available?

It is very easy for us, the next generation, to caress our mobile phones and laptops that fit in both hands. It is easy to see the world as decaying pieces of rubble to improve, gadgets to insert, wires to wrap around and transform. No doubt this way of thinking has changed our healthcare; it has saved many lives. But we must never forget that humanity is not a machine itself. It cannot be controlled by our remote controls and our drugs; we must look further afield in order to truly appreciate the complexity of the human being. When we look at the human body, at a life that has been lived hard and is ending early, we see not genes that have played havoc, but decades of depression, underlying abuse, a cigarette to cope, a bottle of beer to forget. Addressing these problems is a task that requires us to go beyond our scientific skills. It requires us to understand the emotional lives of our patients.

“How wonderful it is that nobody need wait a single moment before starting to improve the world.” 
– Anne Frank

References

  1. (with acknowledgements to Siân Anis), J. R. A. (2006). Virchow misquoted, part‐quoted, and the real McCoy. Journal of Epidemiology and Community Health, 60(8), 671.
  2. World Health Organisation. 2008. Inequities are killing people on grand scale, reports WHO’s Commission [Online[. Available at: http://www.who.int/mediacentre/news/releases/2008/pr29/en/
  3. Office for National Statistics. 2013. What are the top causes of death by age and gender? [Online]. Available at: http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics–deaths-registered-in-england-and-wales–series-dr-/2012/sty-causes-of-death.html [Accessed: 13th October 2015]
  4. Centers for Disease Control and Prevention. 2015. Leading Causes of Death [Online]. Available at: http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm [Accessed: 13th October 2015]
  5. British Heart Foundation. Smoking [Online]. Available at: https://www.bhf.org.uk/heart-health/risk-factors/smoking [Accessed: 13th October 2015]
  6. World Heart Federation. Diet [Online]. Available at: http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/diet/ [Accessed: 13th October 2015]
  7. Myers, J. 2003. Exercise and Cardiovascular Health. 107:e2-e5
  8. Royal College of Nursing. 2012. Health Inequalities and the Social Determinants of Health. London: Royal College of Nursing
  9. BBC News. 2013. All infants in England to get free school lunches [Online]. Available at: http://www.bbc.co.uk/news/uk-politics-24132416 [Accessed: 13th October 2015]
  10. Bauld, L. 2011. The Impact of Smokefree Legislation in England: Evidence Review. England: Department of Health

Featured image:
Human Genome by Richard Ricciardi

 

Categories
Law Opinion

Medicolegal Issues – Medical Personnel as Expert Witnesses

The role of physicians and scientists within the legal system is ever expanding. Medical and scientific personnel are frequently called upon to analyze evidence in a wide variety of legal cases, ranging from worker’s compensation claims to felony trials. The expertise of physicians and scientists is often so valuable that the result of cases hinge on their professional opinions. While the importance of medical involvement in the legal field is implicit, certain ethical issues do arise. This is especially true when physicians are on retainer or are compensated by certain parties in a legal dispute. The importance and intricacies of medical involvement in the legal process has inspired curiosity in me. What is the history of the use of expert witnesses in common law? Where do scientific and medical expert witnesses fit into our legal code? Most importantly, how are these witnesses used in current court proceedings, and what are the prospects for the future?

The Origin of Expert Witnesses

The origin of expert witnesses is in England. According to English law, the first expert witness was used in a 1782 case involving the silting up of Wells Harbor in Norfolk. In that case, renowned civil engineer John Smeaton testified, signifying the first use of an expert witness’ opinion in common law. In the United States, expert witnesses were codified into US law in 1975, under the Federal Rule of Evidence (FRE) 702. The FREs represented general rules passed by congress governing how evidence is presented in both civil and criminal cases.

Scientific and medical witnesses have greatly helped to shape the rules governing expert witnesses. Prior to FRE 702, rules for admissibility of scientific evidence were established in Frye v. United States (1923). In Frye, the question at hand concerned whether scientific evidence in the form of a systolic blood pressure deception test was admissible in court. The Frye ruling indicated that such evidence was admissible as long as the test or theory was “generally accepted” among a meaningful portion of the scientific community. To prove that something was “generally accepted,” parties often put a number of scientific experts on the stand to verify certain tests or theories. This rule for establishing the admissibility of scientific evidence is colloquially known as the Frye Test.

After the adoption of the FREs in 1975, they, along with the Frye Test, remained the seminal rules governing scientific expert witnesses. However, in 1993 a new case would open those rules up to interpretation and eventual amendment. In Daubert v. Merrell Dow Pharmaceuticals (1993), two citizens born with birth defects sued Merrell Dow Pharmaceuticals claiming that Dow’s drug Bendectin caused their conditions. Both opposing parties relied upon scientific expert witnesses to prove their claims. A district court ruled that the testimony from the citizens’ expert was inadmissible because the evidence came from methodologies, such as in vitro and in vivo studies, that were not “generally accepted” at the time.

After the Ninth Circuit Court upheld this decision, the citizens’ took their claim to the Supreme Court. The citizens’ reasoned that the Frye Test was no longer the governing standard for admissibility of scientific evidence as soon as FRE 702 was passed. The court agreed, reasoning that, since FRE 702 made no mention of “general acceptance,” the Frye Test was not to be applied in discerning the validity of scientific evidence.

The implications of the Daubert ruling were significant in amending the rules for the admissibility of scientific evidence given by experts. No longer was evidence only judged on its “general acceptance” among the scientific community. Under Daubert, scientific evidence can be admissible if it is “relevant to the task at hand” and “rest(s) on a reliable foundation.” In determining what makes up a “reliable foundation,” conclusions made from evidence must be based on sound scientific methodology. Sound scientific methodology rests in using proper scientific method, including empirical testing of evidence, peer review, proper controls, and determination of potential error rates. In order to prevent the presentation of “pseudoscience,” judges are given the power to be the final arbiter of any submitted scientific evidence. These guidelines outlined in the Daubert ruling were eventually added as amendments to FRE 702.

Understanding the history of expert witnesses allows us to determine how science and medicine shaped one aspect of the US legal code. In the next part of this series, I will provide an overview of current medical and scientific involvement in court proceedings. I will examine not only common case-types in which physicians testify, but also case types in which physicians are directly involved in. Check back soon!

References
1. http://www.law.cornell.edu/rules/fre/rule_702
2. http://www.casebriefs.com/blog/law/torts/torts-keyed-to-prosser/causation-in-fact/daubert-v-merrell-dow-pharmaceuticals-inc-4/

Featured image:
Cast Aluminium Doctor with Stethoscope (Ne Kensington, PA) by takomabibelot