Archive for the ‘Clinical Practice’ Category

Image Credit: Pinterest.co.uk

There are many reasons to love 90’s hip-hop and R & B. Only recently, I offered a brief lecture to my ward team in which I deconstructed the iconic music video “Motownphilly” by Boys II Men. The exercise provoked teenage memories of working on synchronized high energy dance moves with one of my good neighborhood friends, Martin. The moment when your conscious effort fades away and the music takes over your body as you execute the moves to the building cheers of friends at a party is one of those great life feelings. 
Residency feels like learning a dance . . . 

But, I don’t always learn the steps in order.

There are many steps! 

I can be asked to perform at any time “What do you want to do for the patient?”

The music is always changing, from the steady mid-tempo of the wards to the upbeat Emergency Room to the slow dance of clinic (of course, the music can instantly change within all three settings as well). 

I can’t lead all the time- sometimes I only get to the best part of the room by letting my patient lead. 

I sweat, I get tired, I wonder how many minutes are left in the song. Can’t I leave the dancefloor for a minute? Then, this little dancer in clinic shows me a new move: It’s called “Hug the Doctor.” It’s a great move and easy to learn. It also gets me to the end of the song . . .

And sometimes, the music skips. I can’t figure out the problem or what to do next or how to get past an impasse of opposing lyrics. 

And sometimes, I’m back on the dance floor with Martin. The patient presentations flow with energy and purpose. Everyone recognizes the beat of a good plan. The steady drum of knowledge is overlaid with a couple of compassion tracks and we have a hit. The team may not be dancing on the desks of the nursing stations, but they’re thinking about it . . .

image

Alicexz.deviantart.com

One of the interesting things about being in medicine is that friends and family consult you with all kinds of medical questions at any time. The questions span speciality (I was asked about a brain tumor, cramping and a bad cough in the same week!) Honestly, I enjoy it: it’s like an unplanned case of the day, and it’s a chance to be helpful. In many cases, I can simply put someone at ease. The movie “Dead Poet’s Socity” spoke about two kinds of professions, the “life sustaining” ones like medicine and engineering and the “life enriching” ones like literature, music and the fine arts. My reward in Acting was to (ideally) give my audiences a meaningful emotional experience by the end of the play through the life of my character, that is enrichment. In medicine, my reward is to use medical knowledge and skills to help patients feel better, sustainment. So, I appreciate the inquiring phone calls and texts and I would like to take you back to one in particular . . .

Last week, my sister texted me, concerned that her daughter (my ridiculously cute niece:) had a high fever and a cough. As I gathered the history and started working through the mental algorithms for what could be wrong, I happened to catch my niece’s voice in the background. She simply asked “What is that?” I think I have may have gotten more information from that audio signal than almost anything else in her story. Why? People who feel very sick are not curious. One of the things we learned in evaluating pediatric fever is that the exact tempertature is not as important as how the child appears. That takes observation, attention. I appreciate that because it feels clinical. A computer can work through algorithms but a only a clinician can be a medical Sherlock Holmes and notice personal, intangible atrributes that crack the “case.”

Paying attention matters not only in diagnosis but treatment. While on a neurosurgery service last year, I encountered a patient who required an operation to remove a brain tumor. Due to the tumor size and location, the patient had a devastating choice, to either lose the ability to read or to hear on that side, depending on which surgical approach was taken. Losing hearing or reading is more than a medical choice, it is a human one. One must ask the difficult question of which option would reduce one’s sense of self more profoundly. This question is approached by a patient who pays real attention to who she is, as well as family members and yes, doctors, who have done the same. No matter our profession, we will learn the same algorithms: law students learn the law, pharmacy students learn the drug mechanisms, but effective decision making in the grey areas seems to reward those who pay close attention to the nuances that no curriculum can adequately capture. Even in the enrichment professions, the actor who not only knows the lines but pays attention to the demands of the performance moment will respond with that spontaneous artistic choice that we recognize as brilliance . . .

By the way, I think we made the right call on my niece. She is doing well . . .

 

Apple World

Photo Credit: W Yuting, University of Oregon

If I were to ask you right now to list the most important qualities you want in a doctor, you would probably start with “Competent” and “Empathetic.” The first word out of your mouth would probably not be “Creative.” And yet, there is a growing trend in the medical literature and medical school curricula toward incorporation of the arts and humanities in physician training. Why?

Dr. Danielle Ofri, in her excellent article in the New York Times points out that creativity in medicine would not be unheard of: “Medicine is a field with a strong history of creativity, but its daily practice feels less and less so.” Creativity is tied to innovation and so should always be welcome if a field wishes to progress. But is getting medical students to read poetry and looking at paintings just a bunch of fluff? Not according to two well respected physicians at the University of Georgetown who offer this concrete example of how humanities sensibilities enhance medical clinical skills:

“Selected viewings of art with trained art historians,” in which medical students “learn context, practice description, and note emotion.” This could help to understand and identify “the different cultural and historical lenses through which images are filtered”—an important way to understand the assumptions they bring to their interpretation of a set of symptoms.”,

But what about at the day to day level, real patient, real person. What difference does it make when a doctor gets creative? Dr Ofri gives a  great example from Dr. Oliver Sacks in which a patient had Tourette’s syndrome with debilitating tics that were negatively affecting his home and professional life. He was prescribed Haldol, which eliminated the tics but also flattened his ability to improvise as a jazz drummer, one of his favorite activities. The non-creative doctor response would have been “You have to take the good with the bad”, as Ofri notes. But the creative doctor proposes “Take Haldol during the week so you can do your job, and hold at the weekends so you can play your drums like you used to.” The solution is not only creative but empathetic. And this is where I think the link is crucial. Because of how much I care about the entire health of my patient, my empathy fuels my creativity.

If there is one clear lesson I learned from my years in Theatre it is that people have many layers. Often, these layers contradict each other. I want to eat healthily, but have you tasted that burger or chocolate mousse? I want to give but I also want to take. I want to create but sometimes, I also want to destroy. Contradictions are part of who we are. That is why I think that Ofri proposes that computers can never effectively treat people:

“If all patients and their diseases presented in exactly the manner of the textbooks, then the algorithms would be sufficient . . . but the human condition is far messier — in health and even more so in illness.”

Anton Chekhov, a doctor, became one of Russia’s most celebrated playwrights precisely because of his fascination with human frailty or weakness, first physical and then psychological and emotional. He wrote characters who were compelling not because they were eloquent, morally outstanding or successful but because they were profoundly human, aspiring to be something greater even if they did not always succeed. The creative doctor is one who looks at this person first and the disease second.

That’s not easy. Using standard treatments and keeping on schedule in a pressurised healthcare environment is far more efficient. Stopping the world to “create” for your patient demands so much more from the doctor, often within a system that does not encourage it. And yet, if we are to stay true to the ideals of medicine, we must swim against the tide and be creative for our patients. Creativity is an act of empathy.

Do you want your doctor to be creative? I hope so.