Archive for the ‘Medicine’ Category

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 . . . .

perfect-timing

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.

Labels Graphic

“The moment they diagnosed me, I disappeared.” This was the striking statement of a man who went extremely public with his experience of carrying brain cancer. By “disappear” he meant that he was now labeled by his disease “brain cancer.” His name, his history, his persona all evaporated. Isn’t a terrifying diagnosis enough? Should patients have to lose themselves as well? It is ironic that a label, which should by definition offer identity, instead often strips it away.

Let’s dispense with the obvious: labeling others is dehumanizing and fails to recognize the complexity and full humanity of each person. We shouldn’t label others, but we do. An interesting social experiment was carried out recently in which 6 strangers met each other for the first time in the dark and had a conversation. When the lights were flipped on, their jaws dropped. The participants were shocked at how different each person looked from the perception each had created in their minds. The participants included a heavy metal rocker dressed in a suit and a tattooed professor.

But is moving beyond labeling even a winnable battle? Our brains are designed to categorize. It is how we make sense of the world. It is helpful to be able to assess quickly who is a friend or foe, for example. Even the most intense politically correct “training” will never stop our brain from forming an instant impression, that may in fact be false or superficial. But maybe this is not the point where intervention is needed. We all label and will continue to do so, but can we become “fluid labelers”, ready to release a false impression in a second and embrace the dissonance that comes with the unexpected image? I once had a Chemistry professor (what do you picture?) who looked and sounded like a football coach. To hear this bald headed, stocky, brash teacher talk about electrons with the intensity of a Super Bowl final pep talk was wonderfully bizarre. It shattered every label I would have placed on him. And I just chose to run with it. Chemistry class was never the same.

But to be fluid with labels is to leave your brain naked for a moment. Bereft of convenient categories how will your brain feel at ease? I would submit that this discomfort is healthy and in fact important. I once saw a patient with liver problems instantly ascribed to alcoholic cirrhosis simply, because he presented with alcohol on his breath. He was not in fact an alcoholic; his liver disease had another cause entirely but he was quickly labeled. Jerome Groopman tells similar stories in his excellent book How Doctors Think about how medical mistakes are made by labeling patients in two-dimensional ways.

All this does not mean we should ignore impressions. We should look out for subtle clues in people and certain categories make sense. The real question is not whether we label but how tightly we hold onto that label. There is a word for refusing to let go of a label no matter how much we know . . . prejudice.

And this is the exact place I was going to end this blog post, but I had to get all over-achieving and look up a few quotes on labeling! Most of what I found was predictable, in the vein of not letting others define you, resisting society’s labels and so on, an important point of view, of course. But somewhere in the middle of all those quotes was this:

“I have always been taught to be proud of being Latina, proud of being Mexican, and I was. I was probably more proud of being a “label” than of being a human being, that’s the way most of us were taught.”

Erin Gruwell, The Freedom Writers Diary

Erin’s words stood out because she is not talking about other people’s labels, she is talking about her own. Can our own labels be just as problematic, maybe even more so because they seem benign? I’m extremely proud of my Kenyan and Scottish heritage. What’s wrong with these labels? Nothing except, as Erin reminds us, when these labels become more important to me than the humanity I share with people who don’t happen to Kenyan, or Scottish, or American or in medicine, or in Theatre, or . . . what’s your list?

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.

yes_no_by_thisisgalaxy
What makes you say “Yes”? I have begun my journey into the book Hidden in Plain Sight by Jan Chipchase. So far, Chipchase is interested in how we respond to new things and what leads us to adopt or reject them. He argues that adoption is not a one step process but rather a 5 step sequence: Awareness-getting to know about the existence of new things  Interest-wanting to find out more Evaluation-imagining one’s life with this new thing Testing- giving it a trial run and finally Adoption- a commitment to use. He further argues that we can be early adopters who are typically, but not always, innovators or the young and highly educated; medium stage adopters who are slightly older, perhaps less educated and late adopters or laggards and flat out rejectors.
Why do you adopt some things and reject others? The biggest factor seems to be what everyone else is doing. And why does this matter? For me, it matters because I want be part of the effort to effect widespread change in healthcare delivery and knowing what makes people behave a particular way seems central to that vision. Take a simple example: I was skeptical about joining Twitter for a long time. I wondered what was really worth saying in 140 characters. It seemed superficial and an excuse to spout fluff about bacon for breakfast (although, it should be noted that bacon is indeed delicious). Then, I found out people and organizations I respect were on it, and some of the dynamic ways it was being used and I began to reconsider my opinion. I have since joined Twitter and now integrate it in both personal and professional areas of interest. But did I simply have a limited understanding of Twitter or was my perception altered by those around me, even though the platform stayed the same? What was the “reality” of the usefulness of Twitter?
twitter-evolve
On the subject of reality, can we take a quick detour for a moment? I heard something thought provoking this week from a cognitive scientist who argued that we often do not perceive reality as it really is (optical illusions, misread social cues etc) but that this may not actually be a bad thing in every instance. This scientist ran some evolutionary experiments on his computer and found out that accurate perception of reality did not necessarily translate to increased survival. Is there an evolutionary benefit to believing certain illusions? Are we witnessing the triumph of tact?
Truth matters of course and I don’t think anyone would argue for living in a fantasy world defined by illusion, except perhaps actors, but that’s the job;) Is it in our benefit (or others’ benefit) to know everything accurately and share everything accurately at all times? For the die-hard “tell it like it is” types, this question may seem obvious, but consider the Alzheimer’s patient who keeps forgetting her husband has died. Every time we confirm that he has, she feels fresh grief. The next time she asks “Is my husband still at the store?” Is “Yes” more compassionate than breaking the news of his death once again? What happens when reality and compassion clash?
Or consider this headline from BBC Health this week:
Virtual reality could help stroke patients recover by “tricking” them into thinking their affected limb is more accurate than it really is, researchers find.” In this case, an illusion is central to the therapeutic process . . .
Stroke Arm

The virtual reality arm appears to move faster and more accurately than the real arm. Courtesy of BBC Health

Perhaps the guiding principle is that we should be more interested in meeting people where they are, than where they should be. This does not mean abandoning timeless ideals of truth and justice, but it does ask for a certain nuance and compassion in how we apply these lasting principles.