Archive for the ‘Medicine’ Category

Photo Credit: HealingwithDrCraig
The look was the same . . . trembling lips, searching eyes, streaming tears, furrowed brows. The only difference between the grieved face of the father of slain officer, Patrick Zamarippa, and Alton Sterling’s son was the hue of their skin. The pain was identical. This was a harrowing week in America and I won’t cheapen the moment by offering political viewpoints on how we find ourselves here. I have appreciated the calls by both black and white people to love not hate, but I think we all know that Facebook statuses alone are not going to change the situation. In medicine, when patients present with medical conditions that are years in the making, a diseased lung following years of smoking, we understand that no medication no matter how powerful will simply erase the problem. The most effective solution is twenty years past its time. So, I humbly submit that the most potent forces for change were the babies born on each of the days that these men died and left holes in their families. Death can only be overcome by life. These babies do not yet know hate; we can teach them something different. We can dare to move past the natural discomfort we all feel with unfamiliarity and connect. 

And what about the rest of us? Can we change? Absolutely. But it will take something radical, beyond ourselves. When our heart has a major physical problem, we recognize that we need expert help in the form of a cardiologist or cardiothoracic surgeon. Why then would we think that spiritual heart defects are do-it-yourself projects? I realize that not all who read this may agree with my spiritual framework, but I have realized that real change in my heart requires God, who called himself “the great physician.” There is a wonderful verse in the Bible in which the Word of God is referred to as able to “pierce to the division of soul and spirit, joints and marrow.” Sounds like a surgical instrument to me. In fact, one translation describes the Word as a “surgeon’s scalpel.” I recognize that I am a surgical candidate, requiring both the operation that can transform my heart as well as the supportive care of people of goodwill thereafter. Change is possible.

I want to leave you with an image that came to me as I was praying this morning for the families of those lost. I imagined light challenging the darkness of violent acts, a light we can call carry. But I remembered that even those carrying light may still be carrying pain. So perhaps there are tears streaming down the face of light. But the light shines through those tears and, as physics teaches us, a rainbow is created. Not only is darkness dismissed, but color as beauty, not as color as divider, is introduced. This is our opportunity . . . 

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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 . . .

 

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!

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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.

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 . . . .

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Photo Credit: Steve-eilertsen.com

The line fell flat and I didn’t get why. Just the previous night, the same line with the same pace, inflection and volume got huge laughs from the audience but that night, nothing, except perhaps a polite chuckle. The only difference? I paused for an extra second to deliver the punchline and that killed it. The following night I used my original timing and the laughs were back. Could comedy be that clinical? Apparently so. And if timing proved to be important in my Acting, that only increased in medicine.

If a patient has a heart attack or a stroke, the two expressions you will hear are “Time is (heart) muscle” or “Time is brain.” The same intervention delivered too late and the effect is lost. I still remember pounding on the chest of a 32 year old heroin addict brought into the Emergency Room in cardiac arrest after an overdose. Every chest compression was filled with the knowledge that time was slipping away and when our team could not revive him, time stood still as the time of death was called. A young life gone too soon. Could a phonecall have prevented this overdose? Could a visit have come sooner and found him in better shape? We’ll never know.

Here’s what we do know. Timing is not simply about chance:

tim·ing
noun
noun: timing
  1. the choice, judgment, or control of when something should be done.

“Choice” “Judgment” and “Control” all imply deliberate action. Although we are not always in control of when certain things happen, we are in control of the timing of most things we do in our lives. But how conscious are we of that responsibility? Timing matters. Have you ever sent a text with either really good or bad news and had that one person who responds two days later saying all the right things, but somehow it doesn’t have the same effect? Timing.

I’m reading a provocative book right now “A Path Appears” which lays the case for how to make a meaningful difference. In the current chapter, the authors describe how tough the conditions are in a certain Native American reservation where up to two thirds of the male population are alcoholics. The unemployment and drop-out rates are unbelievable. So where do you time your intervention? The authors argue that trying to address unemployment before you’ve dealt with the fact that many children are born with fetal alcohol syndrome affecting their cognitive abilities is bad timing. Intervention can work but must be timed correctly.

As important as timing is, it is not adequately taught in school where the focus is on bodies of knowledge. But that knowledge is useless if not delivered in time to prevent a suicide or simply make a moment or day meaningful.

With timing in mind, I have taken a new approach to weekend activities with my boys. I used to schedule things I did with them where it made sense in the day, usually after taking care of my business earlier in the day. Reasonable right? But there was room for other things to interfere with the plan or I would get tired and I would not always get to things I wanted to do with them. Now, I start with them. Today we did big waffle breakfast, chores, an hour of reading together, countries of Africa pop-quiz and swimming back to back. This change in timing makes a difference in two ways: I am more likely to spend more time with them and that’s always a win, but I also convey implicitly that my time with them is so important that I start my day with it before anything else.

Timing makes a difference and it is a choice I am learning to be more deliberate about. And where it is not in my control, I have found peace in these words “He makes everything beautiful in its time.” Ecclesiastes 3:11

Guitar Brain Surgery

Photo Credit: Today Show

Many years ago, when I was engaged in hand-to-hand combat with the ferocious winters of Montreal, I was introduced (virtually) to a speaker who shared these thought-provoking words “What makes you angry? It is a clue to something you were purposed to address.” The words have echoed in my mind since then, especially when I see something upsetting. And that happened this week.

I was watching a run of the mill news story featuring German Chancellor, Angela Merkel, holding a town hall meeting in which a young immigrant girl, living in Germany, expressed her desire to continue her studies in Germany. The problem? She was a refugee from Lebanon, now facing deportation. As she spoke of how painful it was to watch her friends go on to study when she could not, she cried. Merkel’s response:

When you stand in front of me and you are a very nice person, but you know . . . there are thousands and thousands [of people] and if we say you can all come and you can all come from Africa… We can’t manage that.”

Immigration is a loaded topic and there are reasonable arguments both for being lenient and selective in policy. What got to me is that the simple desire of this girl to study where she lived was being held hostage to a policy and to the limitations of her home country. It reminded me of my experience at a Kenyan hospital earlier this year when a mother presented her child with a spinal birth defect at 9 months instead of the recommended 48 hours which caused lower limb paralysis and incontinence. Why not earlier? Cost. The mother could not afford it. It is frustrating when people do not have access to basic education and health. But what is more upsetting is when we settle for sensible answers and say things like “There are not enough resources to go around.” or “We can’t take everybody.” Where is the creativity? Where is the resolve that says this is unacceptable and sensible answers are not enough?

It was not sensible to suggest fighting malaria with a fence that shoots out lasers to kill mosquitoes . . . a “Phototonic Fence” is almost ready for market.

It was not sensible to have a patient play guitar during brain surgery, but that’s how a neurosurgeon recently conducted an operation to ensure the patient’s brain function was not being compromised.

It was not sensible to suggest that the nation with the highest percentage of its population engaged in mobile banking would emerge from sub-saharan Africa . . . today, that nation is Kenya.

It was not sensible to suggest that internet service can be provided to a rural community without electricity. The creative thinkers at Mawingu Networks are doing just that using solar energy and “television white space,” unused television frequencies.

No one is saying these problems are easy, but we won’t solve them by conventional thinking. This could be reduced to another “thinking outside the box” message but this imperative goes deeper. I think we all harbor real doubts about whether some problems can ever be solved, but if we see something isn’t right, it should drive us to do something about it regardless.  The creative knowledge is there and our access to each others’ thoughts is unprecedented.

You’d be amazed what you can find.

Consider a silly experiment that I carried out this week. First, let me say that I am always astounded when I look up something on Google at how many people have asked the question before, even when it’s quite obscure. So I decided to make up a highly ridiculous search request, just to see if the question had been asked.

I typed in the question “Do onions make good pillows?” I did not find a hit with that exact question, but someone did ask whether he should sleep with an onion in his armpit. Why??? Apparently, in some regions of South Asia, it’s a trick to cause a fever for kids to get out of school. I have no idea if this works and have no (immediate) plans to test it. But if it is true, how was that discovered?? Minds are churning every day and we have access to these minds.

It bothers me when we settle and use words like “reasonable”, “realistic” and yes, “sensible”. This is not arguing for rebellion for rebellion’s sake, or self-indulgent attention seeking. And, of course, there is a place for planning and counting the cost. But, there are real heart wrenching issues we face today that are costing lives and hope that can only be confronted successfully if we’ll take the risk. Spectacular success begins with the willingness to fail, spectacularly.

Let’s stop being sensible.