Posts Tagged ‘Medicine’

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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 . . .

 

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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

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.

Doorknob

Door knobs can be annoying. They’re not all the same. It’s not always clear whether you should push or pull and nothing makes you look like an idiot faster than struggling with a door. There are people who spend their days determined to spare you this anguish and they are called designers. In the past week, I have been reintroduced to the possibilities of design to solve all kind of problems including the ones that seem most intractable. I am especially interested in how design can improve how we deliver health.

So how did this start?

A couple of years ago, I took part in the HULT Prize, a global student competition in which teams from around the world are challenged to come up with a social entrepreneurship solution to a pressing world problem. In our year, it was the growing problem on non-communicable diseases in urban slums. We reached the finals with an idea that combined microinsurance, theatre, and mobile technology to dynamically manage diabetes and hypertension. To come up with this solution, we used something called design thinking. Design usually conjures up the idea of decoration and aesthetics, but in reality the best design goes beyond making things pretty to actually improving how things work, something the heathcare system badly needs. Some of the principles of design thinking include observation, defining the problem, which is often not easy, then free-form brainstorming, prototyping and then testing the idea and starting the process again. The process is not linear or analytical but rather cognizant of the fact that complex problems cannot be solved with only one line of thinking but rather multiple iterations.

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Design Thinking

And so it was refreshing to come across the work of Dr. Joyce Lee at the University of Michigan who is a doctor with a strong interest in design and how it can transform healthcare delivery. Her work started with a simple observation, that her son’s school had an allergy action plan that was badly designed. She worked creatively with her son (who has severe food allergies) to create a simple, yet compelling YouTube video on how to respond to ingested food allergens that was so effective, it was adapted by the school and spread over the Internet.

One of the most powerful methods of design thinking is the process of observation, really taking the time to notice how things and people work around you. We miss so much. Interestingly, I used to give similar advice to my actors, to go out and really watch people (in a non-creepy way, preferably). It’s the tiny nuances that can make the biggest difference in presenting characters on stage. Take the simple act of convincing an audience that you are drinking a hot cup of coffee. The obvious part would be to gingerly pick up the cup and sip carefully showing that the coffee is indeed hot.  But if you watch someone carefully with a hot drink, there is one other detail, the tiniest of squints as the steam from the cup arrives at the eyes. The audience may not consciously register this detail, but the illusion is complete and effective. That kind of detail comes from observation. The actor needs it; so does the designer; so does the doctor.

My first goal in learning about health and design is to “see” better. How do things really work in everyday life? When challenged to think about what I really see, Bertolt Brecht came to mind. The famous German Theatre practitioner built his Theatre on the premise that we should always question the status quo, but that we could only do that if we had a way to reexamine what we have gotten used to, a process he called “making the familiar strange.” His motivations were primarily political but his principle is compelling. How much around us is really set in stone? What do we presume to be fixed and unchangeable? Do we ask “why” enough? So, yes, I’d like to see more. To help prompt this process, I will be reading the book Hidden in Plain Sight: How to Create Extraordinary Products for Tomorrow’s Customers by Jan Chipchase. Feel free to join me . . . let’s see what we’ve been missing.

Hidden In Plain Sight

Christian, in flight at the District Finals . . .

It took me a while, but I eventually noticed a pattern: It was the last of Christian’s track meets and I had just finished watching the closing races of the season. Long distance races have always intrigued me because they are lengthy enough for a narrative to develop, for a back and forth, for a test of stamina, for the dramatic come back win. But it wasn’t the dynamics of victory that caught my attention on Thursday. It was the reaction of the crowd to the various participants in the race. Predictably, the first few runners got the cheers of victory. But so did the very last runners, especially if they were way behind and struggling. We feel for the underdog, the determined “loser.” But what about those in between runners? What did they get? Wild cheers from their parents, perhaps (or sometimes suppressed disappointment). But from the crowd at large? Mild interest, half-hearted applause, if that. But mostly, they were invisible, extras to frame the exploits of the first runners and the determination of the last.

Invisibility has been on my mind since Michelle Obama mentioned the idea in her speech earlier this week at Tuskegee University. She spoke of the challenges of the African American experience this way:

“So there will be times, just like for those Airmen, when you feel like folks look right past you, or they see just a fraction of who you really are . . . the realization that no matter how far you rise in life, how hard you work to be a good person, a good parent, a good citizen — for some folks, it will never be enough.  And all of that is going to be a heavy burden to carry.  It can feel isolating.  It can make you feel like your life somehow doesn’t matter — that you’re like the invisible man that Tuskegee grad Ralph Ellison wrote about all those years ago.”

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Some of the kids at the middle school track meet worked really hard, gave it everything and still did not end up receiving honor for their work. They were invisible.

That made me consider my own experience with invisibility.

The truth is I don’t have a harrowing story to tell. I cannot say I have felt invisible on account of my race for example . . . well, that’s not quite true. Quick context: I grew up in Kenya, biracial with a Scottish mother and a Kenyan father. In Kenya, there is a defined racial category for mixed people. We are called “point-fives”; you cannot deny the mathematical accuracy of that term! Connotation? Not derogatory at all. If anything, the term is used positively. At least, that was how I experienced the word growing up. So, like many biracial African immigrants, I came to America, and became “black” for the first time (One of my favorite comedians, Trevor Noah, has a great bit on the same experience https://www.youtube.com/watch?v=QDXWUBIUi88!). The transition to “black” took some adjustment, but was ultimately fine, except in one area, casting.

I came to America to pursue a graduate degree in Theatre (Acting) and began to notice a trend. Directors would come up to me and say “I think you’d be great for this role” and I slowly began to notice that all the roles I’d be “great for” were black roles, that is explicitly written as black characters. Many of these roles were in fact good, but in those same plays I saw many other attractive roles that were not necessarily written as black characters. I was used to being selected for roles based on the depth and layers of the character, but now part of me was invisible. To some, I was black first, an actor second (quite the adjustment after being in an all Kenyan cast of Fiddler on the Roof many years ago. Yes, you read that right; 40 Kenyans playing Russian Jews without batting an eyelid!). That said, there have been many notable exceptions: I was cast as Jack in The Importance of Being Earnest and Pooh Bah in The Mikado by directors who recognized, but did not define, my acting by my color. I respected that.

But how did the limited view that some other directors took feel? It felt restrictive of course, but perhaps also put me in touch with certain parts of the minority experience in America in a more tangible way.

I must emphasize, though, that these challenges in no way compare to the very real, difficult and often daily experience of many in this country who are just not seen, either on account of their race, class, financial status, or position in all the races we run. But, I at least caught a glimpse of Ralph Ellison’s predicament in The Invisible Man:

“When they approach me they see only my surroundings, themselves or figments of their imagination, indeed, everything and anything except me.”

In medicine, there is an irony that it is possible to look at patients very closely, yet somehow manage not to see them. We pore over chest x-rays, dissect MRIs, scrutinize pathology slides, diligently save the finest image slices of their brains in a navigation program, yet somehow miss who they are.

So how then do we see the invisible?

There is a difference between the invisibility of an object and that of a person. A truly invisible object has some intrinsic quality that makes its presence unapparent. But an invisible person is not intrinsically invisible. That invisibility is conferred. That is what is so disheartening, that we as humans would ever choose to not see someone else. But perhaps, therein lies also the possibility for change. If we can confer invisibility, we can confer visibility. Each day can be an exercise in noticing the “middle runners.” Who is invisible to you? Who can you choose to see?

RalphEllison

Research Graphic

Quite unexpectedly, I have found myself taking a detour in my medical school journey. I will spend the next 2 years on a research leave of absence from medical school in which I will pursue a Masters in Clinical Research through the School of Public Health at the University of Michigan. I will then apply to residency in September 2016 and graduate in May 2017 to start residency in July 2017.

This Masters program, though, does not begin till September this year so I get to spend the summer with my whole family in Elk Grove (Sacramento) California. Anne just joined us from LA after completing a grueling first year in her Masters of Architecture program. I’m extremely proud of her.

I plan to take advantage of this summer to dig into Neurosurgery research. I am currently working on two projects: the first project is based on my research at Kijabe Hospital earlier this year, focusing on hidden costs to families in obtaining pediatric neurosurgical care in Kenya. The second project looks at a rare but significant complication of the treatment for SubArachnoid Hemorrhage (bleeding in the brain). This complication is called PRES (Posterior Reversible Encephalopathy Syndrome) and occurs when fluid and proteins escape the blood vessels and thus cross the blood brain barrier. This is apparently more likely to occur when the blood pressure is high, which is exactly what we want to raise to treat vasospasm (narrowing) of vessels following sub-arachnoid hemorrhage. So this represents a classic medical dilemma: What do you do when the treatment for one condition precipitates another?

I am enjoying this research, but I must admit I was initially wary about engaging in such a dedicated period of study. I was concerned about long hours in front of a computer screen and limited human contact. Unlike some of my other endeavors like medical globe-trotting and teaching Improv, protracted research seemed decidedly unsexy! I miss the clinical scene, but research is striking unexpected chords within me. There is something captivating about seeking unearthed knowledge and adding something new to the literature. Research allows you to share knowledge that can potentially affect the care of millions of patients. Research appeals to the big picture, the “why” of medicine and that is compelling. You see, I don’t think doctors should be let off the hook of being challenged to think big. Yes, medicine is noble and takes a lot of work and that should be acknowledged. But becoming a doctor is only the beginning. Are we thinking big enough? Empathetically enough? Or is it simply easier to hide self-interest under a white coat?

This surprising level of engagement in research led me to wonder what other things I underplay that may, in fact, be meaningful. We decide early on that certain pursuits are not for us and justify that saying “That’s not me” or “That doesn’t fit my personality” but this rationale presumes that we have a complete and accurate perception of who we are. It also ignores the fascinating contradictions that make us human. What happens, instead, if you only decide who you are after you pursue certain paths instead of pre-judging the path based on a potentially imperfect perception of yourself?

You might just surprise yourself . . .