Archive for the ‘Medicine’ Category

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.

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?
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.