Posts Tagged ‘Medicine’

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.

Design-thinking-stanfor´d

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.”

michelle-obama-tuskegee

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 . . .