Archive for the ‘Medical School’ Category

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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 . . .

 

 

Body Team 12

Garmei Sumo, Body Team 12, Monrovia, Liberia [image source: mountainfilm.org]

Listening to these stories was hard. The first was the accounting of Garmei , the only female member of the one of the teams charged with picking up the bodies of Ebola victims in Liberia during the height of the epidemic. The second story featured Saba, an 18 year old woman shot in the face by her father as part of an attempted honor killing in Pakistan. While still recovering from these two, I heard about Manny Bobbit, executed in California in 1999 for a 1982 murder, a case complicated by his history of PTSD and a bungled defense. I left the theater drained having experienced three of the short documentaries nominated for the Oscars in 4 weeks . . . and all three stories left me with tough questions . . .

What is the point of us in Ann Arbor, far removed from the cultural contexts of all three stories, witnessing these tales? Is it so we can shake our heads somberly and say “That’s terrible” Surely, there is more to hearing such stories than well-meaning sympathy . . .

Are such stories a call to action? Should we engage in an educational effort in communities like those in Monrovia, Liberia where Garmei was deserted by her friends for taking on the gruesome but necessary task of collecting victims’ bodies? Perhaps join an activist group to draw attention to the ongoing issue of honor killings in Pakistan? Take a Criminal Justice course to learn more about the flaws within the system in securing justice for the vulnerable?

I will admit I am susceptible to the call for action interpretation. Such stories are so harrowing and so heartbreaking, that my natural inclination is to want to “fix.” It’s hard to sit with pain. But perhaps such stories are asking us to do something even more challenging. To examine afresh our own experiences and relationships where we are in light of these seemingly “foreign” experiences. Before we jump on a plane to Liberia to volunteer, or join that campus activist group to draw attention to honor killings, what about an internal taking stock? Garmei talked about joining the body team because many men were afraid to confront death. How well do we confront end of life issues here? How can we, like brave Garmei, walk into dark, hurtful places where people are afraid? Her daughter called Garmei the “Ebola hero” each day when she came home. She was willing to confront the unpopular, the uncomfortable and yes, the dangerous. Perhaps, we don’t need to be on a plane to Liberia yet. There is enough around us to confront that is unpopular, uncomfortable, and perhaps even dangerous. Will we do it?

Saba was shot in the face by her father for marrying outside the family without permission, as part of an attempted honor killing. She survived after being dumped in a  river and somehow managing to emerge for help. The incident tore her family apart as her mother and sisters were caught in the middle. She was estranged from her mother and didn’t talk to her for months. Are there not many families in disarray right here in the USA or where you may be in the world? If a mother and child are not talking to each other, do the specifics of the conflict really matter? The end result is the same, a lost relationship. Can we really categorize the pain of the mother whose son’s body was picked up by Germai, or Saba’s mother when she first saw her daughter’s disfigured face, or Manny Babbit’s mother when she got the phonecall confirming her son’s death by lethal injection? Or our own?

Stories don’t need to have an agenda, but they should provoke reflection. The tears I witnessed on those three faces today whether in Monrovia, Lahore or Sacramento all looked exactly the same . . .

 

 

 

 

 

Toys R Us GallowayCole Galloway with a rehabilitation patient and her recently modified car.

A couple of blog posts ago, I introduced the Maker Movement, a growing community centered on the idea that we can build physical solutions ourselves. Today, I want to introduce you to one of the best examples of Making in action, and that is Cole Galloway and his Go Baby Go campaign.

Galloway works in physical therapy to get children with physical disabilities mobile. The problem? Motorized vehicles for rehabilitating children’s mobility can cost as much as $20,000 and often involve long waiting periods. Galloway got inspired through trips to “Toy R Us” to try something different. He now modifies toy cars such as those you can pick up at a toy store to become vehicles for these children. The cost: $89 and most modifications can be done in an hour with his team. Children who could barely get around can now do what children naturally want to do, move!

Galloway’s case illustrates some important principles of making: First, that the best solutions are often conceived by those on the front lines, who know best the contours of the problem. Second, making is impatient in a healthy way. Making challenges the assumption that meaningful solutions must be expensive and take a great deal of time. Third, and perhaps most important, the solution is carried out in a community, patient centered way. The modifications to the cars are carried out by clinicians but also by parents and community members.

So if making is so wonderful why don’t we see more of it? Why aren’t all of us creating great physical solutions like this everyday? I think we are conditioned by the notion of expertise, the idea that we can only be good at one thing and must be consumers of everything else.There is also a certain inertia that must be overcome to create, but those who overcome this inertia are always struck by the possibilities. And word is getting around . . .

Making can in fact become a way of life. This occurred to me through an unusual path, an online karaoke app! Going back to my musical theatre days, I love to sing and discovering this app has been a revelation. The goal of this application is to promote online musical collaboration across the world. You can sing one part of a song with full accompaniment and leave the other part to be filled in by anyone else on the app, anywhere in world. One night, I recorded half a duet and woke up to find 10 new complete duets from singers who joined in from China, England and Mexico. Aside from the variety, I have never encountered such a unique blend of talent. Music made for mass media consumption must, I think, make certain stylistic concessions to be broadly palatable. But this music can be as creative, raw, spontaneous and yet high quality as it aspires to be. I don’t know if I can call this Making, because it is not strictly speaking tactile and may not be solving a pressing physical need, but the philosophy of making seems to be at work. Recording music is democratized, lack of proximity is eliminated as a limiting factor, and there is a genuine sense of community. Something beautiful can be created every day.

Where else could this go? Well, I’d like to leave you with some resources as you consider ways  you can discover your own potential for making:

  1. Parents may want to check out MakerKids.com which describes itself this way:

    “We are one of the first and only makerspaces for kids in the world.We run programs and camps on topics like Minecraft, 3D Printing, Videogame Programming with Scratch, Robotics Inventions using Arduino, Electronics and Remote Control Robotics.”

    2. The organization Maker Faire holds maker events across North America. One of the best ways to start getting into making is simply to get inspired, to see what people are doing to trigger your own ideas. For more information on maker events and ideas, you can check out, MakerFaire.com which includes event information, a magazine and further resources.

    I think one of the most important questions that Making asks is “What are you waiting for?” And it doesn’t ask this question in a sensationalized, infomercial kind of way but as a question with real tension, that makes us challenge assumptions about perceived obstacles. How do we justify NOT doing anything? The big three reasons are:  I don’t have enough time. I don’t have enough money. I don’t have enough expertise. Making proposes that all three of our grandest excuses are, in fact, hackable.

     

 

Embrace

Photo Credit: EmbraceGlobal.org

I have never considered myself a DIY, use my hands to fix stuff sort of guy. I have always assumed that inclination was part of a different personality type. I am more naturally drawn to ideas, language, music, abstract science concepts and other things you can’t hammer a nail into. But in coming home this week from an interesting event called #wemakehealth I was forced to challenge some of my assumptions. #wemakehealth is an example of the “maker movement” a growing group of people from professions as diverse as medicine, business, design, and technology united by a common purpose, to make everyone into a maker.

So, what is a maker?

I understand it to be anyone who decides that she will not wait for a solution to handed down, but will get her hands dirty and build one now. And that is physically build it.  One speaker referred to it as “democratizing engineering”; an example would be the people who helped develop a warming blanket (known as Embrace) for premature babies in developing countries; this simple device is saving multiple lives where incubators are not available. The idea for this blanket emerged from a graduate school class assignment . . .

So what assumptions does this movement challenge?

That most of us can only be consumers of something someone else has made.

That if you’re not naturally “crafty”, building things is not really for you.

That you need tremendous background in design and engineering to build something from scratch with your hands.

I think we can agree that most things are more interesting to do than to watch. Yet, we somehow accept that other people who are more talented, educated etc must do all our building for us. This doesn’t mean that we suddenly have to try building complex computers. In fact, many incredibly useful objects are quite simple in their design (that warming blanket). I feel like the perfect messenger for this message precisely because I didn’t grow up trying to fix things and build stuff. And yet, in medicine, I was strongly drawn to surgery. There is something undeniably fulfilling about physically fixing a problem and being able to look upon your work. When I was given the chance to close incisions on the babies we were operating on in Kenya, I would look over my work the next day on rounds and if the wound was “clean, dry and intact” it was a tremendous source of pride. I often side with those who argue that we are born creative but have creativity educated out of us, and conclude falsely that it is the reserve of a select few. Now, I also wonder whether if there is something fundamentally human about building, making physical creations. The creation may be a meal, a painting, a creative blood pressure monitor, but it’s something. Perhaps, we were not made only to consume or roam the halls of the abstract, however enticing. Making is also key to progress in healthcare where so many structures, devices, procedures and processes remain opaque. Can we make something better ourselves? Can we stop waiting? Incidentally, #wearenotwaiting is the hashtag for the NightScout project, comprising a group of parents who came up with a creative way to remotely monitor their diabetic childrens’ blood glucose levels on cellphones . . .

So, to explore these ideas further, I am starting a brief blog series on making. I’ll bring in voices from the maker movement as well as practical ways to explore your own potential as a maker. If can I do this, trust me, anyone can!

spelling-mistake-1

Photo Credit: TalentCode.com

Everything was going according to plan. I was putting the final touches on the latest revision of my clinical research paper when I caught something. It couldn’t be?! I had made a big mistake and substituted one bit of information for another, erroneously. All the subsequent analysis that my team and I had done was no longer applicable. It was a horrible, sinking feeling. I looked through the records to see how I had missed this error for so long. I put the pieces together, came up with a plan to fix it, and then had to write the humbling email to my team. I was direct. I explained my error, apologized for making it, and offered a plan to correct. And then I waited for their response . . .

Within minutes I heard back. The neurosurgeon leading our team simply thanked me for being honest, having integrity and for attention to detail. The rest of the team echoed those sentiments and they were repeated in subsequent messages. We were to present the data as is.

Truth matters. Even in a cultural setting in which the prevailing current of thought may favor what you can get away with or how skillfully you can bend the facts, the simple truth matters. My mistake, while real, was also interpreted as being attentive to detail when caught. The very thing we think could jeopardize our progress, can instead be a stepping stone. In a year and half, I will be making significant decisions about patients as I start residency. I will not always be right, but I can always be forthright. I owe my patients and colleagues that.

So if like me, you make a big mistake, here is what I have found works professionally (but I would argue makes sense for personal situations as well):

  1. Address the mistake in a timely manner
  2. Admit to your role in clear and active terms (not “an error was made” but “I made an error”)
  3. Have a plan to address it (even if a different plan is used; this shows initiative and further commitment to the project).
  4. Execute the fix quickly but thoroughly and circle back to your team.
  5. Reflect on how the error happened so as not to repeat it.

I feel for the medical personnel of Doctors Without Borders who had endure a bombing that killed 22 people this week in Afghanistan. The US government  said it was a mistake; DWB argue otherwise. What is the truth? We don’t know yet. But here is why developing an ethos of truth is so critical. One day, it’s a research paper, the next someone’s life is on the line. The seed of our decision making is planted long before we make the high stakes decisions. Will we be ready?

Daniel Coyle in his insightful article, How to Make Better Mistakes, refers to a study with an unusual result: Harvard Business professor, Amy Edmondson, studied a series of hospitals and found that the top hospitals reported TEN TIMES more errors than the bottom hospitals. In actuality, the hospitals were making about the same number of mistakes but top hospitals were proactive about reporting them. How did that help? That transparency created a safe zone and culture in these hospitals where employees still felt free to create and innovate without fear. The fearful approach of hiding errors because of consequences creates an atmosphere where the brain retreats and is paralyzed. Coyle puts it this way, “mistakes are not a verdict, but information to be sifted over.”

Errors should be avoided, of course, but if you have blown it, you are in good company. Of course, there will always be those who try and capitalize on our errors, but the principle is still worth it, even with temporary difficult consequences. Most of the time, though, people respond positively if given the chance. I still remember facing another actor on stage who had completely forgotten his next line (something every actor has faced) which was “What’s going on in town?” When I recognized his blank look I immediately said, unscripted, “You must be wondering what’s going on in town?” He lit up with recognition and said, also unscripted, “You read my mind!” Audience didn’t notice a thing and the play moved on smoothly. We had a good laugh about the whole thing backstage. Most of the time, people are gracious about our admitted errors because ultimately they recognize themselves.

Mephibosheth

King David was on a serious streak of military victories when he stopped everything to ask an unusual question: “Is there anyone left in the house of Saul, that I may show kindness for Jonathan’s sake?” At a moment when he was riding this wave of conquest, David chose to ask about if there was an opportunity for kindness. He went on to take care of Jonathan’s son Mephibosheth (say that fast, three times) who was lame in both feet. And by take care of, he gave him all of grandpa (Saul’s) land and invited Mephibosheth to dine with him everyday for the rest of his life. He used the words “always” and “continually.” Do we use those words when we give or otherwise act in an altruistic way? I think, instead,  we say things like “I’ve done my part.” If I’m honest, I typically think about what is a reasonable contribution, go ahead with that and give myself a little pat on the back for my generous act. Or when helping someone who is going through a tough financial patch, we say something like “I’m helping him until he gets back on his feet.” Both statements sound perfectly fair, but they also imply a limit on the generous act. Once I give my part, that’s it. Once you are back on your feet, the bank is closed. But what was interesting in David’s story was that the person he was helping was lame, in both feet. This medical fact is mentioned twice in the story. There would be no “getting back on his feet.” And that was fine with David. He simply wrote a blank check and said “You shall eat bread at my table continually.”

But today, giving blank checks makes us nervous, so we rationalize our limits on giving by saying things like “I only have so much money or time or energy” or “If I keep giving, I am enabling so and so’s dependence” or  “What about my turn?”or “This relationship is one-sided” or “I’m being taken advantage of.” And for each of these statements, there is probably a reasonable story to back up why we may  stop giving. But are we even following the rule enough to introduce these exceptions?

What if we stopped counting? What if we gave “continually” sort of offers? What if we dropped our expectation of reciprocation and gratitude and simply offered those we work and live with a permanent seat at the table? What if we just gave free refills no matter how many times we’re called to the table? I imagine a freedom from constantly assessing whether everything is balanced and fair. I imagine a different kind of impact as generosity makes people take notice, but continual generosity makes people change. Will things be unbalanced? Probably. Might we get more than our fair share of work? I think so. Will we even get taken advantage of? Very possibly. But perhaps  the point of David’s story is that we can let even that go and simply eat together at the table. And perhaps the question, then, is not “Have I done my part?” but “Have I done my whole?”

Theatre_Masks

Credit: Prince George Speech Arts and Drama


The email started with “Congratulations” and then five minutes later I received a text that began with “Sorry to let you know that” The first was an educational/career opportunity, the second was a loss in the family. I felt alternating excitement and sadness and was reminded of an acting exercise I used to do with my students in which for ten seconds they had to pretend that their partner was their long lost twin, and then that their partner was an immediate physical threat. The point of the exercise was to demonstrate that Theatre is about the extreme moments in life. Intense good or intense bad. There is not, to my knowledge, a play that has succeeded on the premise of brushing one’s teeth or sorting laundry. The moments we remember most in life also fall into one of those two categories. The Great. The Awful. And yet, what do we do when these happen so close to each other? To offer a medical example, how do I break the news to a patient that mom made it but baby didn’t, or the other way around. We talk a lot in medicine about breaking bad news, but what about breaking mixed news?

I think the answer may be found, in part,  back in the acting exercise. The exercise worked best when there was no hangover from the previous situation. When the actors inhabited the physical threat fully or the wonderful possibility of meeting a long lost twin fully. It worked, even if the switch was sudden. When faced with mixed news, I think we’re tempted to gloss over the part that makes us uncomfortable. We rush over the good news because we don’t want to seem insensitive or feel guilt about seemingly not empathizing with  the closely accompanying bad. Or we gloss over the bad because it’s hard and then strike a false cheeriness based on the good. The result is this emotional no man’s land in which we are not present because we are more concerned with what we ought to be feeling than what we are actually feeling. One of my favorite scriptures is “mourn with those who mourn” and “rejoice with those who rejoice”. There is no caveat for inconvenient timeframes or close proximity between events. All anyone expects or really needs whether it is a patient, friend, or a family member, is that you honor that particular moment, joy or pain, fully. Have you noticed how sweet the first laugh is after you have just talked about a tragic experience? We are most alive in those moments allowing for truer connection. And so, I will celebrate the good news in the first email and mourn with my family members for the bad news in the text that closely followed. May I honor both moments . . . .