musings...

New England Journal of Medicine - Day 1

2011-09-26T21:31:00.000-07:00

It is always a turn-on when a doctor quotes Karl Popper. Our first lecturer today paraphrased Popper’s stress on the importance of reproducibility in research: science does not rest on it’s infallibility, but on it’s reproducibility. The project of medical journals, he offered, is to provide a forum for rigororoulsy reviewing science, and making sure it is reproducible. To take a step back, our first question was “what is the point of medical journals?” The follow up question was naturally, “and why not just cut out the middle-man, and let basic researchers communicate directly with the public?” Numerous scientists take the latter question seriously, and through online databases, provide forum for rapid dissemination of scientific work, prior to the laborious peer-reviewed paper journal process.

One of the prominent groups that is advocating increased access to scientific findings is a website Panton Principles, named after a UK watering hole (seen above). Their argument is given below:

- Science is based on building on, reusing and openly criticising the published body of scientific knowledge.
- For science to effectively function, and for society to reap the full benefits from scientific endeavours, it is crucial that science data be made open.
- By open data in science we mean that it is freely available on the public internet permitting any user to download, copy, analyse, re-process, pass them to software or use them for any other purpose without financial, legal, or technical barriers other than those inseparable from gaining access to the internet itself. To this end data related to published science should be explicitly placed in the public domain. (http://pantonprinciples.org/)

Note that these priniciples do not distinguish between scientific specialty – presumably, physics is on the same footing as geology, medicine, or astronomy. There are a number of issues with this:

1) What are the stakes? The stakes of research in the physical sciences (and mathematics) are different from those in medicine. If an online mathematical journal publishing a spurious proof prematurely, this is a small price to pay for this reasoning being out there. In contrast, in medicine such a mis-step in information could have downstream effects for other researchers, clinicians, and ultimately patients.

2) What is the quality of the review board? In certain online scientific databases, journals are reviewed via large editorial boards. In contrast, large medical journals are reviewed via editorial boards and outsource to academic specialists. If there is a hot paper in cardiology, the editor will collaborate with an independent expert cardiologist in the field. The latter model may take longer but ultimately tailors reviews to speciality with greater precision.

3) Who are you accountable to? While laborious, the peer-review process offers a high standard of scientific accountabilty that is not yet built into less traditional forms of publishing. What if you pre-publish online, and then subsequently make radical changes and get your publication submitted elsewhere. Do you have an obligation to re-post your new research? If you do not, are there mechanisms in place to find this out?

4) Who decides what is the “best information” for the public? One of the advantages of open-source forum is the democratic ideal that the consumers of information will determine what constitutes important science. As someone who perceives a bias toward invasive, sub-specialized care in academic medicine, this reasoning appeals to me. This is known as subject bias – to preferentially publish in certain areas at the exclusion of others. One rebuttal to this is: well, the duty of a journal is to accurately represent what people are choosing to investigate, as well as what is possible to investigate. In some ways, investigating the finer points of glucose metabolism is easier to capture than accurately testing a large-scale societal strategy for diabetes.

Will the open-source activism that is taking hold in the physical sciences take hold in the medical arena? Perhaps, but the stakes are invariably higher.

To Stanley Fish: A Lesson in Scientific Reasoning

2011-04-26T14:20:00.000-07:00

A Response to Fish's Article "Dorothy and the Tree: A Lesson in Epistemology" (NY Times, April 25th, 2011)

A few years ago, I happened upon a talk in a St. Louis Barnes and Nobles by Frans De Wall – the famous primatologist. After the talk, I got up the gumption to ask him one of my favorite philosophical questions: did he think that animals had consciousness? He looked at me like I had ten heads and summarily dismissed my question. He said, “I don’t know what you are talking about. If you give me a way to measure it, I might be able to approach your question.” Ever since then, I have tried to be more careful about letting my philosophical brain run wild. Stanley Fish does not seem to have this mechanism – as he routinely eschews practicality in favor of ideas. But like a lot of philosophy, I think he could use a little bit more scientific rigor in his definitions.

His definition of thought is as non-explantory as they come: “Thought is a structure that at once enables perception — it is within and by virtue of thought’s finite categories that items emerge and can be pointed to — and limits perception; no structure of thought can enable the seeing of all items, a capacity reserved for God.” In other words, we think about specific subjects, not everything. If only the mind were that simple! He then makes a bridge to dismiss all forms of “consciousness-elevation,” which he equates with various forms of deconstructionism and critical theory. To equate an undefined concept of consciosness with other loosely defined entities leads him into no-man’s land. I think what he is trying to get at is simple – if the way in which we think is programmed by our culture, is there any way to step outside of this, to truly experience otherness. The ethnographers ask the question as “can the researcher ever truly participate in the studied culture?”

We are doomed to write about these questions for eons until we become more empirical with terminology. So, back to his question:

Say we have been persuaded to the thesis that the things we see and the categories we place them in and the value judgments that come along with those categories are functions of ways of thinking that have their source in culture rather than nature, what follows?

I am not persuaded, as I believe the culture/nature dichotomy is a false one. What does it mean to say that a way of thinking is “natural?” If our thought is determined by culture, surely this is along a continuum, for example, from community-oriented versus individualistic, monochronic to polychronic (i.e. time as rigid versus fluid), rational to emotional, or experiential versus narrative. To move across culture is not to enter an alternate universe, as Dorothy does in Kansas, but to shift our commitments along multiple spectra. Perhaps that means trying harder, as Richard Rorty wrote, to “keep trying to expand our sense of ‘us’ as far as we can” by becoming more community-oriented, looking at our watch less, acknowledging and naming our emotional reactions, or choosing to see ourselves as part of a larger life-narrative.

Science fits in by defining some parameters around “ways of thought.” In the mindfulness literature, this involves looking at some rather cool experiments. A recent study took a group of seasoned meditators and a group of novices and asked them to adopt either experiential self-focus or narrative self-focus while reading the following personality trait adjectives: nervous, cowardly, indecisive (negative, and powerful, energetic, hopeful (positive). By experiential versus narrative, I imagine they mean the difference between “I feel cowardly” versus “I am a cowardly person.” In any case, when they put these people in an MRI, they found certain brain regions lighting up more strongly depending on the type of self-focus. The shocker is that for novices, certain brain regions were coupled together, which were separate for the experienced meditators. In the words of the study, “this suggests a fundamental neural dissociation between two distinct forms of self-awareness that are habitually integrated but can be dissociated through attentional training: the self across time and in the present moment.” (Farb et al, Attending to the present: mindfulness meditation reveals distinct modes of self-reference) In other words, experienced meditators process the world differently on biological level. To relate this back to Stanley Fish, we know it is possible to shift our awareness to different “ways of thought” through specific training.

As for the claims against the Everything-is-socially-constructed-thesis, I again would object to such a blanket thesis. Ian Hacking does a great job with this argument in his book “The Social Construction of What?” where he outlines what constructivism means in different contexts: i.e. what is means to say that mathematics is socially constructed versus a particular religious practice. In one sense, to say that something is constructed means that it could be otherwise. Under this definition, a mathematical proof is not constructed, whereas one’s preference for ripped jeans is – the proof is self-contained, while you could just as well preffered stone-washed jeans. This leads to epistemology, which Fish correctly points out, is wholly distinct from politics. I am skeptical about the utility of epistemology because it seems immune to empirical study. How can one measure the difference between epistemological claims? For what does it make a difference? At least if we carve up the world in terms of experiential versus narrative, selfish versus altruistic, group-oriented versus individual, at the end of the day we have something to measure. Fish finishes with,

The every-thing-is-socially-constructed thesis, however exciting and powerful (or dreadful) it might seem as a revolution in epistemology, cannot itself initiate a revolution in any other realm; it has no political implications whatsoever. And I say this even though each movement on the intellectual left — feminism, postmodernism, critical race theory, critical legal studies — believes that the thesis generates a politics of liberation.

I’m curious about the following:
1) What are other ways in which scientific study demonstrates distinctions in modes of thought (i.e. experiential versus narrative)?
2) If scientists create and define our experiences, what role is their for epistemologists?
3) If epistemology has nothing to do with the politics of liberation, what is it that grounds these politics?

Winifred

2011-04-25T14:48:00.000-07:00

My friend Cari aptly boils down every medical student writing piece to the following platitude: “and in the end, I realized that [insert patient’s name] was more than the sum of her symptoms.” Q.E.D. High Honors. Residency here I come. I wager that the majority of residency essays are some permutation on this theme. May the universal appeal to this small amount of humanism lay claim to its deficiency elsewhere in the medical profession?

I have one patient here in Uganda, by accident. Her name is Winifred. In the medical dichotomy of sick versus not-sick, Winifred is sick. She made it through the five days of Village Health Worker training while taking “short-calls” (latrine breaks) a couple of times an hour. She still scored nearly perfect on the post-assessment. At the end of the training, we urged her to go to the health center and request a fasting blood sugar. With transport, this costs about $4, which she, as a farmer with five children, does not have. Thankfully, I had a medical resident from Tufts by my side who backed up my mutterings about Winifred having hyperglycemic hyperosmolar syndrome versus frank diabetes, and she pitched in to help her get a fasting blood glucose test.

Last week I visited Winifred in her village as part of a pilot program we are doing to deliver “prompts” – two-sided laminated sheets of paper with basic health information, to households in their community. We picked Winifred as one of the superstar VHT’s to go house to house with us and explain the prompt, elicit questions from the houses, and see her suggestions for improving it. She lived up to her status. On her advice, the first household installed a “tippy-tap” – two sticks supporting a can of water, with a lever on the bottom, so you can wash both hands at the same time. At the next household, eight children danced around as we approached, dirt lining their bare feet. Two were vigorously scrubbing pots and pans, caked with mud. Two days ago, Winifred told the head of the household she needed to make a latrine, and two days later, I peered down into a 10 foot hole and saw for myself. The cement would be arriving in 1-2 days from town. I asked Edward, my Ugandan counterpart/boss what makes some VHT’s persuasive and other’s not. He said that she had “great counseling skills.” I probed further but couldn’t get anything else out of him. Some things you just have to see, I suppose. The writer in me wants to go off – she possessed a quiet tenacity, an uncompromising will, an unflinching moral compass. Or, to put it simply, Winifred is one of those people who gets shit done.

In truth, she does have a quiet tenacity. She called me yesterday to explain that she had the results from her testing, and wanted to discuss them with me. I invited her to the OmniMed office, where I read the physician’s inscrutable and sparse differential: rule out cardiac disease. I then took my own history, which lasted at least 45 minutes. With no access to laboratory testing, she is a medical puzzle to me – status post diagnosed malaria 3 weeks ago, treated with Coartem, normal fasting blood sugar, 3 years of general weakness and fatigue, 4 years of intermittent, non-radiating, reproducible and non-reproducible chest pain, sometimes associated with eating, difficulty swallowing liquids and solids for one year, polyuria for three years, and painless vaginal bleeding for three weeks.

Every time I tried to summarize the case, a new symptom seemed to pop up, with no single diagnosis tying everything together. In the US, I would have had twenty minutes for the history, which I most likely would have performed with the luxury of first skimming the notes of an ER doctor and nurse, and seeing what immediate labs had been ordered. I then would have spent the day tracking down specialists and lab results. Fortunately, the head of OmniMed is coming tomorrow, who is an emergency room attending, and he will hopefully encourage her to find the funds to get to Kampala for more testing. But what quality of care does one get in a city hospital of 3,000 beds, in a country with a life-expectancy of under sixty years old? To see Winifred’s sickness as injustice is to me both inevitable and non-explanatory. On the first point, through what other lens than justice can one view saving money month after month for piecemeal test after test? On the second point, the fact of injustice in and of itself does nothing to identify the multitude of causes. And here’s the kicker, identifying a multitude of causes does nothing to help Winifred get the money to go to Kampala tomorrow.

I will take my own bait – Winifred is more than sum of her symptoms, but not in the way of the cliché above. Winifred’s case illustrates the uncertain medical fate of those who are not sick enough, or have enough money to be on the hospital wards. In epidemiology, it is called lead-time bias when the discovery of a screening tool markedly increases the lifespan of those with the disease – not in virtue of any life-saving properties of the screening test; rather, the test enables people to be screened sooner in than they normally would, and thus, live longer after the test. For every ten Winifred’s, only a handful show up in hospital or clinic data, thereby skewing this data. So now this is a case about epidemiology, lack of health care infrastructure, economics, injustice and yes, pathology. I end with this multiplicity because bringing it back to the human is scary – that I can look up all the pathology I want, but this does not guarantee she will have access to any tests, let alone treatments she needs.

But maybe my organization can employ a few more people, who gather data from the VHT superstar’s, volunteer at the health center, become nurses, get elected to local office, find better ways to access basic medical care, get support from US medical students, and so on. For sociopolitical problem, sociopolitical solutions, right? What are incremental steps to building health care infrastructure in developing countries? Is it possible to provide specialty-driven Western medical care through technology and partnership? We know that economic inequity is inversely correlated with health outcomes. But, will building the economic ladder spur health care gain more quickly than health care investment alone? What do you think? What are your personal, academic, professional experiences? What have you, would you read?

Kisoga

2011-04-13T02:00:00.000-07:00

We arrive in Kisoga, sky clear and sun blazing. Twenty people gather under the shade of the church tin roof. Some prefer benches, made of bare-bones supplies – thin slabs of wood, a few nails, and penned graffiti on the back, Other benches bear the mark of charitable organizations – “this was donated by xyz foundation.” One hears that time moves slowly in Africa, as if this is a statement of incontrovertible fact to everyone in the country. This is not true for Isiah. A fisherman and farmer from Tererre parish, Isiah awoke at 6am to take a boda-boda (motorcycle) – “just to wait here!” The training was slated to begin at 8am, and it is now approaching 10am. Isiah’s shoulders fall at right angles from his enormous upper frame, his smile wide and infectious. He walks with a dance-like movement, as if he uses his immense arm strength to impel him forward. A physician may say it is choreoiform or antalgic, and then upon examination notice the etiology – born with club feet that have never been corrected. While sitting, one notices that the soles of his feet face upward, toes pointing in.

Today we are observing the training for drug distribution of malaria by the Ministry of Health. The program formally began in 2009 but has only begun to have funds. The idea is simple: give a two-day training course to existing village health workers to give Coartem (an anti-malarial drug) to people with symptoms of malaria, prior to referral to the health center. There is scientific rationale for this strategy – a study in Egypt showed that teaching village health workers to give ORS (oral rehydration solution) for diarrhea reduced infant mortality by 50%. The organization I am working for uses the nomenclature VHT, which technically stands for Village Health Team, in reference to community mobilization of a village. The trainees, however, refer to themselves as VHT’s. Our model closely parallels those of CHW’s (community health workers). Uganda has trained over 80,000 VHT’s since 2002, with variable success, depending of course, on how you define success. On the epidemiologic level, there is little data that the comprehensive program has produced significant reduction in malaria, infant mortality, life expectancy. On the local level, there are pockets of trained villages which have shown incredible gains in water sanitation. On a human level, the programs have allowed people with minimal education and income the opportunity to be elected by fellow villagers and to serve their communities.

In the literature, researchers denote the difference between tangibles and intangibles. For health workers, they have found, much to the chagrin of the epidemiologists, that the intangibles win out. Health workers are motivated by extrinsic, tangible factors such as monetary incentives or bicycles, but even more than this, by rigorous, structured trainings, and feeling a responsibility for their community. I am reminded of the work of James Landes, a historian who laments the absence of considering “culture” as a decisive force in economic history (The Wealth and Poverty of Nations). I am working for an organization called OmniMed that has trained over 400 VHT’s, and is in the process of systematizing how we follow –up and support them. One of our tasks in the next year is to develop an incentive system to encourage VHT’s to visit all the homes in their village, deliver health reports, and volunteer at their health centers. I often coerce myself into thinking this should be easy – after all, I know what the science says. Incentives work best when tangible and intangible rewards are coupled, financial incentives work in the short term but lose out if funding runs out. Why can’t we just write a check, buy some bicycles for the village with the best record keeping, and then run some more follow-up meetings and see what happens? My educational background has primed me for such trial and error methods. Perform poorly on a test – radically change your study plan and see what happens. I am also primed to think “strategically,” which oftentimes means to fall into the fallacy of premature closure. One of my professors in medical school often told me, with authority, to write these two words on my palm prior to examining a patient – the premise being, do not fit all of the patients symptoms into one disease, thereby excluding other disease categories from your thought process.

Here, it is enticing to read a few papers on community health, and then try a solution. I believe this has been tried in other places, and contributes to the unintended consequences such as people selling malaria nets for food, or developing malnutrition due to over-reliance on foreign food subsidies and lack of local agricultural development. So, back to the bicycles. What do the villages think about being in competition with one another? Would giving certain individuals bicycles create a hierarchy between villagers? These are questions that can only be approached with trust, over time, and with commitment to the same goals.

Yesterday I visited the local health center to try to forge connections between our program of US volunteers, VHT’s, and health center staff. We created some preliminary plans, for US volunteers to give talks at the health center, for the VHT’s to have monthly meetings at the health center, and for the health center to use data from VHT’s (i.e. on number of cases of malaria in household, or the number of unprotected water sources). Of everyone in the room, I was the most transitory – I was accompanied by Edward, who is from this village, and has been working as a drug distributor and VHT trainer for many years, as well as a Peace Corps Volunteer, who will be working here for another year. I am amazed by each of them - Edward for his big brain and dedication and the Peace Corps volunteer for her commitment to understand before acting, and to ask questions of everyone she comes across.

Right now, over 40 VHT’s have gathered and are intently listening to the presenter talk about malaria. They take notes in little blue books like the ones from high school. Edward is next to me and helping translate. He knows this backward and forward, but continues to take detailed notes. He writes “3 places where mosquitos bread,” and I tell him the difference between “breed” and “bread.” He is one of those people who do not laugh, but chuckles ---with a light “kee-kee-kee” from the back of his throat. We are going over myths about the causes of malaria, a topic the VHT’s know very well. The most common myths are “eating mangoes, maize, witchcraft, and sleeping in the sunshine.” In an hour, lunch, and then another four hours of presentations, which will drag but be punctuated by bouts of unexpected hilarity. Time moves the same here, but people understand that change is made “empola empola” – slowly by slowly.

Off to Uganda

2011-03-21T14:25:00.000-07:00

I'm going away for seven weeks to do work with a great organization called OmniMed (www.omnimed.org) I will be helping to train Village Health Workers and strengthen educational programming. My aunt gave me this quote which I thought was perfect before leaving.

My love is my weight.
By it I am carried.
wherever I am carried.

St. Augustine

Book Review: Absence of Mind (by Marilynne Robinson)

2011-03-17T16:00:00.000-07:00

If there ever was a book to break the stale, polarized, and argumentative debate over science and religion, this is it. Marilynne Robinson writes primarily from the standpoint of a humanist, well-versed in the history of scientitic thought, Western philosophy, and the recent proliferation of books either uniting or fractioning science from religion. Although “Absence of Mind” could fit easily in ones’ back pocket, each page packs a seminar’s worth of weighty ideas. Robinson’s project is to provide an account of the origins of Western conception of science, and to dismantle any attempt to take science beyond its’ appropriate referents. In other words (watch out… spolier alert), Robinson’s project is not to assert a fundamental incompatibility of science and religion, but more to rein in scientists who uncautiously tread in religious territory.

Her title could be construed as a tongue-in-cheek chide on the Daniel Dennet’s of the world – but it makes more sense within the work as a totality. She ascribes to William James’s conception of religion as internal experince, and firmly believes “religion is indisputably a central factor in any account of the character and workings of the human mind.” (12) Tracing scientific thought from the 19th century to present, she details how scientific thinkers have evaded treating the mind to the same scientific rigor as the physical universe. Perhaps more profoundly, she cites our modern complicity in this interpretation, noting our adulation of theories that are ahistorical and explain the self as understandable via universals, whether class struggle (Marx), Oedipal complex (Freud), or evolution (Darwin).

Robinson’s tight, graceful, and witty prose works like a scalpel on conventional attacks on religion by new-age science writers. Ever wondered whether religion can be explained as a social phenomenon that evolved by virtue of close-kinship and ceremony? Whether contemporary knowledge of brain chemistry excludes the possibility of a mind/soul? Or, whether our ability to ask questions about imponderables such as truth, meaning, and reality is an evolutionary by-product, or an intrinsic part of being human? Time and again, Robinson answers such questions by deconstruction, paying close attention to unstated assumptions of scientisists. If she can be described as pushing an agenda, it is to force us to indulge, if briefly, in ambiguity. She often offers two interpretations, a scientific and humanist account, and leaves us to fend for ourselves. In response to Steven Pinker’s materialist view of the brain, she writes,

What is man? One answer on offer is, An organism whose haunting questions perhaps ought not to be meaningful to the organ that generates them, lacking as it is in any means of ‘solving them.’ Another answer might be, It is still too soon to tell. We might be the creature who brings life on this planet to an end, and we might be the creature who awakens to the privileges that inhere in our nature – selfhood, consciousness, even our biologically anomalous craving for ‘the truth’ – and enjoys and enhances them. (130)

Her point could be boiled down to: scientists should stick to doing science, instead of asnwering philosophy questions with worn scientific assumptions. And the rest of us could do well to honor our inner experiences, affirming a humanity science has yet to fully explain.

Some of my favorite quotes below...

On accident versus intentionality:
“Why is the human brain the most complex object known to exist in the universe? Because the elaborations of the mammalian brain that promoted the survival of the organism overshot the mark in our case. Or because it is intrinsic to our role in the universe as thinkers and perceivers, participants in a singular capacity for wonder as well as comprehension.” (72)

On Freud:
“Notably, he [Freud] attempted to redefine the unconsious, a concept then broadly associated with primitive racial and national identity, making it instead a force in a universal yet radically interior dynamic of self.” (107)

University Park School, Worcester MA

2011-03-14T16:10:00.000-07:00

Today I visited University Park School in Worcester (http://www.upcsinstitute.org/), a unique and innovative model of a high-achieving public school. The school began in 1997 as a neighborhood school in the area of Clark University, a lower class area flanked by Main Street. The school is grades 7-12, has approximately 40 students per grade, and receives funding as a public school of Worcester. All 11th and 12th graders who have access to the full course cataogue at Clark, and those accepted to Clark receive four-year free tuition. Since opening, 95% all graduates have attended college.

In first period, I sat in on an anatomy and physiology class for seniors. I gave a short presentation on requirements of medical school, and then mingled among groups. Toward the end of class, I came to a group of four boys, each of a different nationality, working on an assignment of respiratory physiology. I asked them what they enjoyed about the school. They responded in unison that they loved the partnering with outside agencies (such as a job creation program) that landed them high-paying summer internships. We moved on to discuss the partnership with Clark – a wiry, athletic student commented “We had a professor who taught us all about sociology, a class called Understanding Poverty. I don’t think he knew what he was talking about.” On further questioning, this student outlined the academic argument that to get out of poverty one needs one of the following factors: a god-given talent, to marry into more money, more education. The student became agitated even broaching this subject: “what does he know about poverty? He has never lived it. Maybe this is the conservative in me, but I think that what it takes is hard work.” I wondered aloud how much of his conservatism was experiential versus political.” With his classmates working silently beside him, the student outlined his family’s move out of generational poverty. In telling this narrative, he prioritized hard work and determination.

I am inspired that this eighteen year-old, with no access to higher education in his family, had the opportunity to be exposed to academic literature on poverty in America. I am inspired that he felt confident to openly challenge a professor, and offer his story to his peers. I am also inspired by the partnership itself. In my work with students in St. Louis, I described the path to college primarily within the narrative of socioeconomic opportunity. Hard work = college = success. Ironically, I think that for this student, exposure to the theory of academia forced him to challenge this narrative, and to begin to ask more nuanced questions. What does it mean to study poverty without physically stepping foot in one’s community? On an educational level, how can one teach students both self-determination and the socio-economic determinants of poverty and health?

I am sure of the following after my visit today: I have no desire to teach middle school students, I am inspired by the possibility of teaching high school again, as a vocation or as a collaborater with medical schools and undergraduate schools.

Humility in Medicine

2011-03-13T14:17:00.000-07:00

I recently read an article entitled “On Humility” on one of my favorite medical dork websites www.kevinmd.com. The author contends that humility involves three things: unflinching self-awareness; empathic openness to others; and a keen appreciation of, and gratitude for, the privilege of caring for sick persons. I am torn by such codifications: on the one hand, I think they are important for our work, but part of me scoffs at their “unscientific” nature. After all, what we are defining is not a scientific entity, but the borders of a theory.

The more pragmatic question that the author brings up is “How do we teach concepts of virtue and character, in collaboration with a competency-based approach to education?” I love this characterization. I love it because I saw this both in the education and medical fields: the drive to define bigger principles within competency – whether cultural awareness, personhood, teacher-as-leader, etc… I use the word collaboration above because I think that competency is important, but not the whole story.

Let me give an example. In medical school, we are asked to reflect on one experience during our internal medicine clerkship and write a one-page paper about it. We are not assessed on this formally, though I imagine in some strategic document it meets requirements set by a larger organization claiming students to be “competent” in reflective inquiry. We are simultaneously evaluated on our capacity of “physician as person” throughout our entire clinical rotations, without this being formally defined for us. To put it personally, no evaluation I have ever received has detailed how they evaluated my ability to be a “person.”

One solution to this would be to create a rubric outlining qualities of physicians (caring, empathy, self-inquiry) and define these behaviorally. I would propose the following conceptual shift: instead of discussing competency, and physician’s attributes as static, inherent qualities, to structure clinical education giving explicit focus to virtues. What would it be like for a nephrologist to give a talk on hope in the context of renal disease? Or, for a surgeon to give a well researched talk on human error both in the context of the operating room, and outside of it?

Aristotle defines virtue in terms of our habits. The next question is “what would it take to educate medical students to develop such habits?” I believe this involves giving concrete exposure to physicians who have lived this experience, and then having honest discussions about the process of developing virtue, in a similar way in which we discuss the process of developing a good lung examination. Perhaps when I return from Uganda, I can organize such a speaker series.

The Science of Mindfulness

2011-03-07T11:07:00.000-08:00

I am doing a month long elective on mindfulness in medicine. As part of this, I am taking an 8 week course called Mindfulness-Based Stress Reduction (MBSR), a program developed at UMASS Medical school and now offerred in wordwide. For 2 ½ hours of Wednesday nights, I sit in a room and do meditation exercises, yoga, body scanning, guided imagery, and participate in discussions about the nature of the mind. When I tell people this, they often expect one of two things: for me to offer sage-like wisdom, or to defend this study as something more than a new fad in health care. I will do both. My sage-like wisdom is that the techniques I have learned over the last few months are exactly this – techniques and tools. I am reminded of a quotation by one of my favorite psychologists, who I refer to as “feelings doctor Bob.” One day a patient angrily came up to him and said “I’m only talking to you people because I have to. I don’t believe in psychiatry.” He responded calmly, “neither do I. It’s not a religion. It works for some people and not for others.” I feel the same about mindfulness. Although I believe people are drawn to this for the same reasons people are drawn to religion, the practice of mindfulness that I am studying is a thoroughly secular practice. I believe it is religious in James’ sense of religion as: “feelings, acts, and experiences of individual men in their solitude, so far as they apprehend themselves to stand in relation to whatever they consider divine.” To practice mindfulness involves solitude and compassionate awareness to one’s feelings, thought patterns and experiences. Jon Kabat-Zinn’s definition is widely used:

“Mindfulness means paying attention in a particular way; on purpose, in the present moment, and  non-judgmentally.”

There is a burgeoning literature on mindfulness as it related to health care, medical education, nursing, addictions treatment, and physician burn-out. As a way to elicit feedback on my research questions, I am posting my daily writings here. Here are the questions I am currently bouncing around in my head:

Is it possible to be scientific about mindfulness? In a systematic review, the literature is inconclusive about the use of specifically “mindfulness” based therapy due to operational and methodological problems. Another way of putting this is that in order to do science, we need to have a definition of mindfulness, or in science jargon, to “operationalize it.” Yes, there have been studies showing that mindfulness-based interventions result in better subjective well-being, less anxiety, lower rates of physician burn-out. But the question becomes, is this due to something specific about “mindfulness” or is it due to subjects’ expectations of treatment, social support, or participation in groups. This is the classic problem of confounding variables. Let’s compare this to the way we think about statins for high cholesterol. We know the construct for how these act, namely, they inhibit an enzyme called HMG co-A reductase, and we can measure the cholesterol before and after. For mindfulness, we do not yet have a mechanism of action, nor validated standards of measurement to show that are distinct to this specific meditative practice.

Too few randomized control studies have been done in this area to determine how mindfulness meditation is different from transcendental meditation, or from prayer. Another more conceptual issue is how you measure what mindful practice is actually doing on a psychological and neurological level. On the psychology model, there are highly developed techniques to measure cognitive performance of students before and after classes. For instance, if we think that being mindful makes one more attentive, we can measure attention vigilance by having people press buttons in response to stimuli. If we hypothesize that people become more able to switch attention to different tasks, we can measure this as well. On a neurobiological level, recent studies have shown increased activity in the pre-frontal cortex for meditators versus non-meditators on MRI. The idea here is to associate mindfulness practice with external psychological markers or even through imaging techniques. From a phenomenological perspective (i.e. at the level of the individual conscious experience of the practitioner), there are numerous metrics to assess a students’ openness, subjective stress, and attentiveness.

To answer the original question, I believe that it is possible to be scientific about mindfulness, but to stress that science itself is a potpourri of tools to look for reproducible trends. While I think it is fascinating to see that our brain structure changes based on mindful interventions, I think this research, no matter how far advanced, will not capture the full human experience of the mind. I realize that my bias as a social scientist comes out here, and I think Rita Charon put it best, when she writes “The primary choice of an outcome to study is a philosophical and political choice, hardly a quantitatively derived position.” (Charon, Multi-dimensional interaction analysis: A collaborative approach to the study of medical discourse) Should we choose to study mindfulness through the lens of human stories, MRI scans, randomized control studies or complex psychological tests? I would say “all of the above.” However, I am primarily interested in the science insofar as it is useful for medical students, patients, and health professionals. (Coming soon).

Aging and the Limits of Mortality

2011-01-25T16:45:00.000-08:00

Today my resident gave an ad hoc lecture on the limits of the human lifespan. Advances in public health, hygiene and antibiotics have lifted the average lifespan over the last century. The upper limit of the human lifespan has held asymptotically stable at 120. Given our Western obsession with immortality, it is no surprise that many scientists have taken up the question: what, on a cellular level, leads to aging, and how can we reverse this?

There are two scientific schools of thought on this: first, aging is a result of cellular damage, and second, that aging is preprogrammed into our genetic code. On the cellular level, our corneas are damaged over time by UV radiation, which causes collagen molecules to cross-link. This, in time, invariably leads to decreased vision. In certain diseases, such as xeroderma pigmentosa, DNA mutations lead to cellular damage and aging. On the pre-programmed side of the debate, scientists point to the role of telomeres, small bits of DNA at the end of each strand. Each time our DNA replicates, we lose a little bit of our telomeres. When the telomeres length becomes small enough, our DNA sends a message to itself to stop reproducing, in a process called apoptosis. The limit of how many times a normal cell population will divide is called the Hayflick limit. This is important biologically because the smaller our strands of DNA, the greater chance of mutations, and cancer.

But are telomeres the whole story? We know that mice have longer telomeres, yet still age. We also know that a host of other signaling pathways effect aging, with names like sir2, IGF-1, and FOX3A. The fascinating thing about these pathways is they are riddled with biological paradoxes. For instance, the tumor suppression gene p53 (familiar to fellow medical students) helps to inhibit the growth of tumor cells, yet in doing so, also hastens the aging process.

Perhaps maybe one day we will decipher the genome, as well as the complex interplay of our biochemistry, only to have most of us die of atherosclerosis, the effects of obesity, or smoking too much. If we accept the premise of our bodies as an engineering problem, then we can convince ourselves to be optimistic about emerging science. In experiments with mice, researchers induced reversible ischemia (lack of blood flow) to their heart cells (cardiac myoctyes). Then, they dyed bone marrow cells and found that stem cells originating from their bone traveling through the blood stream to replace the heart cells! Of note, these stem cells are also subject to the Hayflick limit, but the example indicates that basic research opens up doors for new treatment.

I remain torn about the underlying premise of aging as deficiency, and health defined in terms of number of years of life. I prefer to think of health more holistically, and of aging as beautifully tragic, yet beautiful nonetheless. What do you think?

Below is a Ted Talk I found by a computer scientist addressing some of these questions. It’s worth it to watch, even if you just skim his slides. Enjoy: http://www.ted.com/talks/lang/eng/aubrey_de_grey_says_we_can_avoid_aging.html

Bloom’s Taxonomy and Medical Education

2011-01-24T19:03:00.000-08:00

... or, how to actually teach a one-hour morning report!

I am finally appalled enough with pedagogy in medicine that I am prepared to dig deep and throw out some potential solutions. Here goes. I have spent the last week working on a medicine service in an academic hospital. For those not in the medical work, this means I am on a team taking care of 10-12 patients, and carrying a patient load of 3-4 patients myself. I coordinate my patients’ care: organize family meetings, call consultants, write for medications, talk to nurses, and essentially run around the hospital all day.

As my learning experience for the day, we have two conferences: morning report, where we passively listen to a case for 20 minutes, offer up our differential diagnoses, tests we want to order, and then debrief what actually transpired. Then comes noon report – a staid Powerpoint presentation where a presenter reads off of slides on a topic chosen essentially out of the ether. The range of topics include an hour long foray into the treatment of flatus, and the public health outcry over indoor tanning booths. During these classes, I wonder how we got to this point in medical education. More specifically, I wonder whether anyone else has thought “Is it permissible for medical students and residents to spend two hours in a learning environment without ever measuring their understanding?”

Here are the common questions I hear during these reports:

1) “What labs would you order?” In general, this is a rather low-level question, as the answer is invariably “CBC, BMP, Mg/Phos, liver function tests if the problem is anything abdominal, CT scan if the patient has come from the emergency department”

So how could you improve this? Ask, What are you hoping to find from this particular lab test? Predict what the results would look like for acute on chronic COPD.

2) “Any questions about the case?” No one ever has questions with this prompt. A better prompt would be “Ok. Everyone go around and say one thing they are wondering about the case.” Audience participation solved.

Using Bloom’s taxonomy as a framework, here are some leading questions:

Knowledge – Define the common findings in pancreatitis
Comprehension – Summarize the mainstay of therapy for acute pancreatitis. Compare this with the treatment for chronic pancreatitis.
Application – Make a chart of the findings unique to both disease processes
Analysis – Examine the evidence for and against a particular therapy (actually have people get off their PDA’s to do this)
Synthesis – Hypothesize about “what else it could be”
Evaluation – Justify the use of a CT scan

The health professionals out there may be groaning at this point – “Why do we need to have new fancy learning techniques? I got to medical school by hearing didactic lectures and I was able to ace my boards.”

Interestingly, the non-health professionals (I hope) will be aghast that our training involves the highest level of scientific acumen in regards to patient treatment strategy, yet incorporates very few pedagogical princples operating in most middle schools in the United States.

I believe it is important to both break down the system and offer strategies for one simple reason: I have no idea what I have learned from 11am-1pm for the last three weeks. And, even if I could give you five main points about flatus, or tell you why indoor tanning is dangerous, there was no measurement tool documenting my understanding. As a ¾ MD, this is scary to me.

On pleasure

2010-07-08T22:39:00.000-07:00

I have spent the last week on summer vacation for the first time in two years. I've been biking the sweltering streets of Worcester, reading novels in my air-conditioned apartment, meditating, cooking regularly, and behaving like a real person again. I've also been thinking quite a bit about where I see myself in medicine (public health, family medicine, psychiatry) versus back in the classroom as an educator.

I have been embracing a culture for the last three years that defines pleasure in part as "that in which other people are unable to do." Of course, there are inherent elements in medicine and health care that give us satisfaction, and yet there is a certain pride in waking at 5am, eating quickly, and studying until your eyes fall out of your head. When I had difficulty in my medicine rotation this Spring, one of my professor's attempted to encourage me with this principle. She said, "99% of the world could not do what we do." I have unpacked this statement in countless ways. First of all, I was not displeased with what 99% of the world had been doing, only justifiably searching for my role in the 1%. Thus, as a counseling tool, I did not find this incredibly useful or reassuring. As for the statement itself, there is a hidden value-laden quality to it - we (as medical people and doctors) are more worthy, deserving, and should give ourselves credit for this.

My professor's comment speaks to a principle I am consciously trying to avoid right now - that adding difficulty to a task makes it more virtuous. I feel my medical education has been conceived in order for me to live out this ethos. There is never quite enough time for complete mastery of material. When I do feel I have a grasp on a certain subset of knowledge, I became nervous - what next? After three years of dogged memorization, what do I read now? JAMA? The New England Journal just for fun? For the last three years, I have told myself that dedication = virtue. The harder I study, the more good I will be able to do in the world. This simplistic narrative has helped me through the most arduous of tasks (remembering which viruses have negative versus positive stranded DNA). And yet, at baseline, this is not a healthy way for me to live. I am easily consumed by competition, indoctrinated by a meritocratic dullness that equates achievement with self-worth, conflates mastery with goodness, and challenge with virtue.

I worry that as medical students we become overtaken by this narrative at the expense of thinking critically about building community, public health, and care for ourselves. We are taught to plan the discharge paperwork when the patient comes in, but not encouraged to think about what keeps bringing them back. We are encouraged to be good to ourselves, yet receive approving nods when we discuss our epic nights on call. We are instructed to be nice to nurses at all costs because "you don't want them on your bad side," but don't investigate what makes a health-care team efficient in the long-term. As I spent more time in the hospital, I realized I had been asking questions few others did. Lest I give the impression that my colleagues perceived me to be brilliant, I found it challenging to come up with the questions I should have been asking (Why Vancomycin when some other antibiotic could give adequate gram-positive coverage?) And yet, I felt confined by a culture that dressed self-sacrifice as virtue.

I am finally taking a step back to re-think this narrative both personally and professionally, and to find pleasure not in what is most challenging and inaccessible, but in what is in front of me - relationships, books, music, family, and air-conditioning. Today was my first day at Community Health Link, working with the homeless population of Worcester. I felt refreshed to be in a community of social workers, case managers, nurses and doctors who actively cultivate community within themselves and the people they serve. These are more my people. I'm excited to bike to work, be present with people, write again, and have a summer.

The ten best things in my life right now...

2010-04-12T17:00:00.000-07:00

1) Walking home from work at 6pm, with the sun piercing the sky orange
2) Watching 60 minutes with my parents on Sundays as I did 20 years ago
3) Learning to really take care of patients in the hospital
4) Having the freedom to read about the sociology of medicine, Foucault, and the Civil Right’s movement after work
5) Being in love!
6) Waking up to do yoga in my living room every morning
7) Lost on Tuesday nights with Naomi, Rachel and Nick
8) My friends in Boston
9) Late night car rides with Liz from Boston to the Woo
10) Running along Lake Quinsigamond at sunset

Thoughts on Freud and love

2010-03-29T17:20:00.000-07:00

I am finally settling into spring break: sleeping ten hours a night, eating regular meals, and pressuring myself to do nothing at all. I took this picture on my kitchen table this afternoon, a rainy Worcester day with no chance of letting up until Wednesday. The picture in the background is of me playing with my sister in a stroller. Her eyes are wide, hair askew and cheeks lumpy and adorable. Once I start scanning my pictures, I will enlarge it much to her embarrassment. I've decided to upload a picture a day as a way to pay closer attention to what is going on around me, and to give me an excuse to use my camera again. So, this is day 1 of the project.

Amidst moments of inaction this break, I am surprised how much I miss college for the ability to wake up and write philosophy all day, to delve into age-old questions, weave between theorists, and at the end of the day come out exhausted yet feeling sharp. My methods of writing would be to isolate as many controversial passages as possible, dog-ear them, and later painstakingly tear through each one of them, analyzing them in relation to a single question. I read now without the pressure of a term paper in sight, but continue with my dog-earing, waiting the day when I will collect my thoughts into words.

I just finished “The Philosophy of Love” by Irving Singer, an analytic philosopher at MIT. This work is a condensation of a three-part series he has written over the last few decades, dedicated to a philosophical exploration of intimacy and the varieties of romantic love. The feminist in me prefers bell hooks book “on love” for it’s inclusively and exploration of love along less traditionally gendered lines. What both authors do share is the concept of love as a verb; an action, orientation, embodiment, rather than as a possession or destination.

My latest project has been the reread Freud’s “Civilization and It’s Discontents,” a book that has been baiting me nightly for the last couple of months. After reading it, to my surprise, I picked it up to find “University of Michigan bookstore” on the back, indicating that this was not mine, but my good friend Eric Shieh’s copy. I should have realized this by the chicken-scratch marginalia and vicious comments such as “boo-hiss, ?!?!!, and reflection without action!” The book is now marred with both Eric and my comments, harkening back to the days in which we read “The Purpose Driven Life” together. Eric would tackle a chapter in the morning, mark it up, and then I would respond equally vociferously in the evening. I think we must have made it only thirteen of the forty days it required to mold us into saved, purposeful beings. Instead of writing a treatise-like pedantic post, I thought I would instead comment on some interesting quotes.

- “A love that does not discriminate seems to me to forfeit part of its value, by doing an injustice to its object; and secondly, not all men are worthy of love.” (Freud, C &D). This is part of Freud’s larger argument that wholesale loving of everything is not desirable. This is a question that seems to come up a lot – what ought to be the bounds of one’s influence/capacities/love, and does one to a disservice to himself or humanity by restricting/expanding these boundaries too far in one direction.

- “It is that we are never so defenseless against suffering as when we love, never so helplessly unhappy as when we have lost our loved object or its love. But this does not dispose of the technique of living based on the value of love as means to happiness.” (Freud, C&D). Singer touches on this issue as well in his treatment of Sartre; the idea that as actors/lovers/individuals we are autonomous yet inextricably bound to others as members of society/spouses/etc… It seems that everyone discusses romance within the subject/object dichotomy: an individual loves by giving over one’s self and attaching it to an object (i.e. another person). I believe this conceptualization oversimplifies what happens in human relationships, that there is something more going on that purely a loss of self and gain of vague unity.

- “When philosophers and theologians offer me some transcendental conception of the spirit, I shrug my shoulders. I know nothing about that. Like the world itself, love is an emanation grounded in matter, and comparable to its parental origin.” (Singer, Philosophy of Love). This is one of my favorite quotes from both books. Ironically, the author goes on to discuss these philosophers and theologians’ ad nausea, but his pragmatism here is great.

- “I have always considered love a projection of what people do, or are trying to do all the time, and that only if we accept the reality of this kind of projection can we construct an adequate theory of human love.” (Singer, Philosophy of Love). Again, I appreciate Singer’s approach here, especially after reading about Freud’s account of male versus female micturation on fire as an explanation of instinctual desires.

My surgery rotation - 7 weeks in

2010-02-23T16:46:00.000-08:00

It is 12:10 on a Monday. I am making soup and watching the sun glisten off of Lake Quinsigamound. I am listening to poppy-folk music. It feels strange to be calm, to have some semblance of control over my time, even if for a few hours. My books lie open in front of me and I’m tempted – do I study the general surgery behemoth, finish Dreams of my Father or that history of medicine book?

Everyone is going to tell me what to do in the short-term, yet no one seemingly can help me figure out the bigger questions. In the words of my friend Matt, this is a time of hazing. I feel like I am working at McDonald’s sometimes – taking orders and serving up fries, crispy, but never quite right. I will not be a 3rd year student for the rest of my life – I know this. I have committed to graduating medical school. I also know this. I have an amazing capacity for social change, critical thought, creativity, love, and passion for education, theory, politics, policy, philosophy, ethics, and literature all of which lay latent to following orders and asking basic anatomical questions. I feel beaten down by a system that tells me that I need to “appreciate” 4 hour surgeries with no clear learning objectives, make copies and fill out charts without explanation or praise… all in the service of taking care of the ill, a notion I have come to question.

I have always taken the fundamental precepts of medicine to be self-evident – to altruistically reduce suffering, and save lives. Recently, taking care of the sick has taken on a new dimension for me. You quickly realize that the timescale and scope of “saving one’s life” is not what pop-culture tells you. The spontaneous pneumothorax is a singular, perhaps bi-weekly event that an integrated team responds to. If you are not here, someone else will save this patient. And what about that man in the ICU who looks yellow as the sun - that man with portal hypertension secondary to cirrhosis secondary to alcoholism? After you consult anesthesia to intubate him, GI to work-up his lower gastrointestinal bleed, pulmonary to analyze his lung function, then what? He remains; big yellow belly protruded at you, asking, baiting you “what can you do for me now?” What of your pulmonary function tests, your renowned ICU faculty, you million dollar MRI’s and CAT scans? I am on this earth but for a few moments longer… I’m still alcoholic so you won’t transfer a liver to me. I’m decompensating. I can’t eat. What can you do for me?

Practicing medicine is like reading thousands of plays, and then performing random scenes on a given day. In your first year, you learn about pulmonary function testing, then you really learn it the next year, then you are asked to be “familiar with the consultation note about pulmonary function” and then, when you are a doc four years later, you take this laboratory test along with five others and say, “yes, you have respiratory distress syndrome,” and follow the algorithm for treating it. Or, perhaps one day, in fifteen years, you will pick up a chart and say, “wait, the FEV1 is too low --- this person probably has COPD.” Amazingly, this is but an iteration of one of thousands of disease processes you learn. Either way, you wait on this time, when everything will come together – when your immense amount of book knowledge may in fact have an effect upon the world.

But you are not there and have to trust that those around you will take you, push you, and believe in you enough to ask you difficult, clinically relevant questions. Some of them will, but most of them won’t – after all, they came through the same system. You have to believe that underneath the surgeon’s insecurity, the pulmonologist’s sheer mastery and dedication to the lung, there is a deep-seated reason they show up to work everyday – that there is something more than finding biology interesting or “helping people.” Is it the gaze of a patient’s uncle when he tells them how deeply he appreciates their care, the definitiveness and certainly that their patient will never have gallbladder problems again, that they helped someone stay alive for one more day? I have not experienced this yet. I don’t know if I am ready to. But perhaps I am looking for a different type of transformation - psychological, existential, educational. When I change vacuum dressings at 5am I think it might as well be someone else.

I feel guilty for not finding this experience more interesting – for not wanting to make small talk about laparoscopic surgery, suturing wounds, or taking a medical history at 4am. I feel like a sham. Even if uninteresting at times, shouldn’t I place more value the ability to take care of the sick? Shouldn’t the sheer weight of my profession drive to me study all night, crack the next case, and eagerly devote myself to my daily tasks? My ideal educational experience is so far removed from my experience now that I question my ability to work within such a system in the future. What I find theoretically interesting – analyzing ICU data, pathophysiology of disease, end-of-life care all seem diametrically opposed to the day-to-day workings of the hospital – taking out dressings, taking vitals, figuring out IV fluids. But this is not about me. In three years, the yellow man in the ICU will have passed away, perhaps with no knowledge at all that I worked sleeplessly on his chart, trying to figure out his acid-base disturbance. The lady with gallbladder surgery will remember coming out of anesthesia and gratefully recognize that her pain has subsided, but she will not remember me. In the words of my friend Matt, I am being hazed – to sacrifice much of myself, my ego, my interests, my fixation on being remembered, in the pursuit of one day giving my patients a few more years, months, or breaths. And is this trade-off worth it for me? I am still holding this in my mind, twisting it, heaving it to and from my awareness, waiting to be moved.

A post for Mardi

2010-02-07T09:24:00.000-08:00

A few months back my friend proposed that I write a post about community. I had just finished teaching a Saturday math class at the ACE (African Community Education) program in Worcester, invigorated by the possibilty of my students. After six classes, Joseline had finally started to pay attention. When I asked her “what percentage of class were you focused” she emphatically responded with 75%, up from the self-admission rate of 10% on her first day. As my usual routine, I wildly dialed anyone who would listen to my ranting on the car ride home. I began telling her about my afternoon teaching and applying it to the idea of “zones of intention” and “zones of influence.” I am admittedly a sucker for business-leadership jargon, and have a shelf-full of books on leadership habits and styles. But this one feels more authentic. The premise is that in order to effectively engage in our work, we must first articulate the interlocking web of relations that constitutes our community.

During my studying for the Boards, I confined my web to the triad of my couch, refridgerator and bed. On the occasional day, I would walk outside to get my mail, or to the yoga studio down the road. I would talk with my neighbor, half-deaf at 79 and ranting about the times where there was no hospital, or Jen, the yoga instructor down the street who could weave an inspirational opening class sequence about anything from dirty laundry to Avatar. It is not a novel idea that our tiniest connections are the ones that bind us. They hold us together at the seams. We fail to notice them until we move to a new city or go on vacation, and feel frayed, tattered, incomplete.

In the last few months I have been trying to patch my seams… to make a new coat. I have been thinking about the need for an academic community – a community focused not purely on scientific findings, but on ideologies of power, influence and social change. And yet I also crave an environment where I am pushed to my emotional and physical limits – where I am up against the world and in contact with those suffering around me. I crave the urgency of teaching, where a ninety-minute lecture demands hours of prepation and focus, or the surgical floor at 5am, when ten patients vitals need to be taken, and we need to know whether to operate. I conceptuatlize academia (and often writing) at odds with this sense of urgency, as if to slow down and reflect, analyze data, and theorize is selling out. After all, for whom does it matter that I can dissect Foucault’s analysis of psychiatric diagnosis, or explore the ambiguities of Cartesian dualism? My schizophrenic on the floor is no less pained nor better for it.

Similarly, I feel that much of my medical education prioritizes facts over problem solving; memorization over inquiry. On Friday, I spent over six hours in a darkened conference room where I was told of the primary objective to “appreciate the field of radiology” and that “no on excepts you to remember much from this.” During these classes, my mind wanders away from MRI’s, CT scans, and retaining my new fifteen basic facts about transplant surgery. I wonder to myself “is this the community I want to be a part of for my career?” Do I want to plan seminars for medical students, tell jokes about radiologists screwing in light bulbs, and reminise about my days back on the floor? Is there a way to feel creatively and intellectually driven as a hospitialist, as an internal medicine doctor? My mind wanders to my friend Stu’s clinic in Rwanda, where she asks a different set of questions: “how do I create a pediatric ICU from scratch” or “how do we respond to the unyielding rates of TB in the community?” I want to teach and practice medicine where I create curricula, train students, nurses and doctors based on the urgency of sickness and suffering, where there is no time to socratically debate which chromosome carries HLA haplotype information (it is 6, if you are wondering) or which interleukin regulates hyperacute rejection (it is IL-2).

My friends’ original question was to describe my ideal community. Short of detailing my peculiar web of friendships around the States, my community consists of those fifteen-ish people who I bear all to during car-rides and walks home from school, Jen, my ACE students, and the hundreds of people I know in the hospital. I value these connections deeply and feel that I am pushing my limits of influence. And yet I crave more: a global community dedicated to medicine, social justice, teaching, and urgency of action. But craving only goes so far. To borrow an idea from Richard Rorty, belief (in this case in the power of medicine for social change) is significant insofar as it manifests itself in action. Just now, I realize that such a community does not statically exist, awaiting my membership; rather, I need to be the force for action, a thought both liberating and frightening.

Babies

2009-12-12T20:48:00.000-08:00

Suiting up to give labor is like preparing to go to the moon, but with more blood. I have waited for this day for two months now. I break the silence of the room when I enter, as a cacophony of greeting comes from every corner. “We’ve heard so much about you Tom!” I redden and raise a hand in appreciation. It comes off awkwardly as part wave, part salute. But they get the point. My patient gushes with an enthusiasm I rarely see in her. The last time I saw such raw enthusiasm was when she jokingly threatened to blow up the clinic. This time her smile veers away from maniacal and more toward true joy. This is her day: packed in a room with four family members and a boyfriend, she is the center of it all. The family speaks of the upcoming baby lovingly, yet as a novelty item. “I hope it doesn’t have thunder-thighs like its aunt…. I wonder what color hair she will have… Will she be a gymnast or a dancer…” I wonder to myself what other possibilities there are – journalist, schoolteacher, biologist, engineer. These options are not entertained. I wonder what will happen when the baby gets home, what her first birthday will be like, what her favorite book will be.

I am both thrust into her life and distant from it. My professional boundary allows me free access to the in’s and out’s of her life in fifteen minute spurts. I am written into her history, as a page in the baby’s scrapbook, tucked in a shoe-box under the couch until holidays and anniversaries. Then I will be unearthed for discussion – “remember Tom the medical student… how he told the boys that the baby’s butt looked big on ultrasound… remember how he skipped out on work to visit after the delivery.” I wonder if she will remember that I believe in her goodness, that she is smart, that she can and will be a great mom. I want to convince her to go back to school, to go to psychotherapy, to treat her boyfriend better, to actively fight against the desire to read her history into the baby’s life. Oddly enough, everything I want for her has very little to do with her medical care. Yes, I want her to be healthy, but this is the easy part. I wonder whether I have helped her at all – whether hours of listening, friendship and consolation can be measured. I realize that I ask this question scientifically, in search of empirical evidence. Even now, I cannot escape my training – in the last three years I have been measured on everything from my ability to show empathy to calculating neuronal cell potentials. And now, in the words of a wise friend, “this becomes part of my consciousness.” I want to measure her A1C, the babies Apgar’s, her level of patient satisfaction. Yet all of this measurement doesn’t encompass the breadth of my influence.

When I think about what I hope to accomplish as a physician, I think about a few levels of change: biologic/medical change, personal growth/behavioral change and societal change. As I discuss this loosely with a child psychiatrist, he expresses to me that the heart of medicine is in the second level – it is one thing to know what to do for a patient, yet another to actually have them do it. While I agree with this sentiment, I am most fascinated by the last level. How does my patient’s underlying socio-economic conditions effect her health? More importantly, what is my role as a physician to address the underlying societal conditions that lead to her welfare, smoking, uncontrolled diabetes?

At 3am this Tuesday morning, I hold her beautiful daughter as she, her boyfriend and I watch the end of an episode on Adult Swim. For one of the first times in medical school, after memorizing tens of thousands of slides, taking hundreds of exams, and feeling like I never knew enough, I feel an arresting sense of satisfaction. In contrast to most nights of piercing anxiety, I drive home, curl up into bed, and sleep soundly.

what if?

2009-10-06T21:39:00.000-07:00

I have been reading Erich Fromm recently and am struck by his simple and elegant depiction of humanism. I agree with him that in our age we have transferred our focus from who we want to be to what we want to do, to produce, to make. I am also struck by his conception of choice – that the best way of approaching creating a free society is to allow conditions to flourish that maximize human choice and agency.

In regards to my medical training, I am still somewhat at a loss of whether I want to do this with my life. In medicine, we ask a whole lot of questions regarding specificity and localization of pain. And yet, we never ask “what if?” When people do research in the basic sciences, they ask this question periodically to use to guide their research protocols. And then comes the hard-core scientific questioning and experimental design. As a medical student, I am never in a position to ask this question and have the time or agency to pursue an answer to it – there are just too many knowledge-based questions that get in the way of this. What if the clinic was structured to counsel patients in groups and bring in families with similar concerns? What if we followed up with patient’s in another context than a 1-year outpatient visit to ensure that they were following our recommendations? These questions interest me, but perhaps not as much as more societal questions that I feel office-based medicine fails to address. Among these are, what if we placed all of our intellectual resources into transforming not just a patient’s symptoms, but the social conditions that reinforce their poverty and pain?

I just don’t know if my participation in primary care medicine goes far enough in addressing these concerns. I am skeptical and optimistic; I feel that I am behind in thinking about my life. I am anxious that I have stopped thinking critically and creatively – that now in thinking like a doctor I will stop wondering about the potential underlying strings vibrating through a patient’s lymphoma, or whether I will look forward to lunch everyday, as opposed to desire to work through it, because it is work that sustains me. I sympathize with Fromm when he says “I believe that these men of good intention should not only arrive at a human interpretation of the world, but must point the way and work for a possible transformation. An interpretation without wish for change is useless; a change without preliminary interpretation is blind.” Right now, I am charged with the task of interpreting the world as I examine neonates, take histories from children in the emergency room, and make plans for treating kids with cerebral palsy. My ability to change their lives and the scope of the community I work with is limited in my role as a medical student. Insofar as I can teach kids on the weekends, plan after-school programs in my free time, and engage in self-dialogue about social change, I venture into the land of broad-based change. In virtue of thinking in these terms, I fall prey to conceiving of myself in terms of my consumption and production, rather than in terms of my convictions, sense of wonder, and ability to love. So, what if I focus on my convictions, wonder, curiosity, and love and see where it takes me?

Getting lost in the woods...

2009-09-30T20:59:00.000-07:00

The clouds hang like hot dogs above the treeline: horizontal, bursting with yellows and oranges. As dusk sets the yellow faded to pinks, then deep purples. We walk with no direction or timeline. I try my hand at navigating the woods, and orient my mental compass at every divergence. Yet the woods are too impenetrable and windy. So we focus on the basketball sized fungus protruding up at us, glimpses of the hiding sun, and plastic deer sculptures. What if I walked like this everyday? My abstract freedom comes at the cost of geographic certainty. The sun is truly setting. It is cold.

We reach an outlet to a New England suburban street: through the window of a two-story family house, the silouette of a father setting the table with his two children. We are still directionless, yet bound by the time of the night. Treehouses, barns, and mangy dogs greet us, and point us toward streetlights of civilization. And then, a highway – Mack’s truckhouse, and cars blazing at 60 with no shoulder to walk on. I want to keep walking until my feet hurt so much they blaze. I want to explode my narrowness, like when I read Kerouac and dreamed only of mountain sunsets and driving fast.

I sink awkardly into a cool metal fench, as I watch the traffic on Route 20. We are close enough to the road for motorcyles mufflers to pierce our ears, but far enough away to be unnoticable for the common passerby. This is good, we decide, as were anyone to see us here – two future medical professionals, we might lose what little reputation we have. She meditates with seamless ease. I try, but as usual, am bombarded by an overactive mind. What if I walked like this everyday?

thoughts on medicine and social justice...

2009-05-12T22:35:00.000-07:00

I’m burned out with school, but damn I need to start studying for the boards. Today was my equivalent of Sunday – I went to the Teach for America Boston event, talked to Aaron and then Cari for a few hours, while getting a modicum of work done. Life is going to become much more interesting very soon. I’m excited! As for where I am at with the doctor-teacher crisis, I feel in as good a place as ever. I’m convinced that what I’m doing now, if authentic and heartfelt, can only help what I want to do in the future. The future is a big place, which is very unpredicable, including what I may end up doing. I love the idea of spearheading an educational program somewhere – at a high school, community college, medical school, and then to take these skills and apply them to an urban school system context. And yet here I am studying medicine.

A few things that I’ve been pondering:
-How are we to define systemic change that closes the acheivment gap? We (Teach for America) say we are doing this in fields like medicine and law, but how to we quantify this? Should this be quantified?
-How do issues of nutrition, physical activity, access to health care impact our students? What is the physican’s role in this? Where is an acceptable sphere of influence beyond the scope of the office visit?
-If the key lever to fighting poverty is education, how do we prioritize access to health care? I realize that these are both human rights, but how are they intertwined?
-What is the role of medical professionals as advocates in schools?

What is unique about the role of a physician is the ability to be a source of scientific knowledge and emotional support through times of great vulnerability. To do this authentically, you have to believe in the inherent value of all lives, be comfortable with assisting patients in learning how to cope with illness, and to know that much of your impact on their lives will be on their emotional landscape and how they conceptualize illness, suffering, and their physical condition. After hearing the speaker at the Teach for America event tonight, I realized that for me, while I value these ethics, I feel called/compelled/drawn to the transformative capacity of education as a means of social change. The speaker spoke dramatically about the role of his teachers in his future successes, and argued that we have the ability to change the world tomorrow, not in five years, or ten years down the line. While I believe strongly in health as a human right and working with suffering, I feel personally drawn to the stories of my students – to Tony, Juan, Shakina, and Travis, who approach the world differently after being in my classroom. I’m curious to see what transformative process is possible in medicine. At the same time, I am aware that its aims are different: to minimize suffering, affirm humanity, rather than to invite dialogue, create knowledge, figure out one’s direction and change the course of one’s life.

Where's waldo?

2009-01-11T19:59:00.000-08:00

I found myself at the gathering of the 8th annual Pantless Subway Ride in New York this weekend. This is among one of my favorite photos from the event. For those who haven't witnessed my impeccable, polished fashion sense, I am wearing a blue/white scarf and a striped winter hat. As I hope to one day have a job and practice medicine someday, please note this picture neither confirms nor denies the visibility of my undergarments.

What You Don’t Know Won’t Hurt You

2009-01-11T19:56:00.000-08:00

This is one of the final pieces I wrote for my Creative Writing elective. The assignment was to write a piece from the perspective of a patient.

What You Don’t Know Won’t Hurt You

John Kerry and Edward Kennedy are looking out for me. I wrote them a letter about my condition, and they will – I mean, will help me out. I know you don’t believe me doctor. I may be mad, but I know that looks in your eyes, how you move your shoulders down like that when you try to listen to me but can’t. And how you roll your chair back. Yeah, like that.

And why is this medical student in here – he’s a waste of my time. I told him everything for thirty mintues when I could have been talking to you. My head rages and you still do nothing for me. Fine. Fine. I know I let him interview me, okay. But my head has been raging for minutes, hours. I have fibromalagia you tell me, but I really don’t. I DON”T. I still have Lyme in me, and maybe you don’t believe me doc, but I do. They can’t see it in my system. It lurks like mist on gravestones. It’s there. I’m going next week to Connecticut and the specialist will find it – he has a test for it, you know. And Kennedy, he got my letter. He’s out of the hospital now and is on my side.

And when the specialist tells me, finally, the truth, at least I will know. I may not feel better, but at least I’ll know it was Lyme from the start, and the other docs will stop fucking me around anymore. And if I’m wrong? How dare you ask me that? I think, but can’t say. You’re lucky you’re my Doc, to be able to say stuff like that to me. I’ll go on my way. If this test comes back negative, I’m done. I’ll do whatever you say after this. But I have a feeling about this guy. It’s been two years you know. My bones ache, my migraines pound my head in every day. And still they don’t believe us.

You think – ah, I see, you think this is like last time. That this is just another one of my “crusades?” I remember that. No. Last time, it should have worked out. I knew it could. My partner just screwed it all up. I had the equipment sent to my home – but he never did shit. I had to do it all. 40 grand. And what do I have now?

Yeah, you did? You read the article I gave you. You should have because it’s the truth. I see your head nodding but it still does nothing for me. I’m still going to Connecticut. What’s that? You will support anything I do that I think will make me better? Well, okay. And my meds – I’m taking them allright but they’re not working. My diabetes – fine. My hand is shaking, Doc. I think I need a drink, but can’t tell you this. I need my home back.

Edward Kennedy knows about me. I called his office. My letter is seven pages – I typed it out last night. I sent him the article. And this doctor, he’s not like the rest. He’s a Harvard doc, he knows. So you’re happy for me? You think this might be it for me? It might help bring things together? You know too. I need my meds. And my cab – is it here yet?

I patient gruffly shakes my hand, and is off. Back in the office, I exchange looks with my preceptor – a mutual look simulaneously confirming our ignorance and intrigue. I muddle through the 5-minute consult book on the etiology of fibromyalgia. Meanwhile, my preceptor starts dictating the visit. She begins, “This was a thirty-minute consult, more than 50% of which was spent counseling the patient.” If only this told us anything about our patient.

do I ever muse about anything funny?

2009-01-11T19:53:00.000-08:00

My good friend Cari informed me that whenever she reads my blog, she feels like jumping off a very tall building. In an effort to address this somewhat sobering criticism, I considered incoporating more bodily humor into my posts. I am still working on a post offering fart jokes, but this will have to do for now.

Twenty Things I hope Never To Do In My Medical Career

1) After getting back blood work from a patient, exclaim to them “That’s the most fascinating case of [insert obscure idiopathic disease here] I have ever seen.”
2) Say “Oops”
3) After describing a patient in an editorialized story, lament “I then realized that [insert tragic name here concealing identity of real patient – Willie, Cletus, Sallie Jane, Alfonzo] was more than his symptoms.”
4) While cleaning out someone’s ear canal for the 100th time, think to myself “this is why I went into medicine” – and actually mean it
5) Practice exclusively in the United States
6) To my patient with chronic illnesses, instruct “If you had been compliant with your medications, none of this would have ever happenned.”
7) Ever use the expression, “Care to go out for a drink later?” or “Sorry, I wasn’t listening”
8) On Memorial Day, tell my last patient “You’ll have to come back tomorrow, I need to get on the Pike to beat beach traffic to get to my 2nd home”
9) To a jaded medical student, tell him “I can’t do anything about that sebaceous cyst of yours, until you scratch it out of your face in the next mindnumbingly boring pathology lecture. Then, I may be able to refer you to a plastic surgeon… but we’ll have to talk.”
10) To a 30 year-old woman on a routine visit, say “Congratulations, when are you expecting?” Followed by a few seconds of akward silence, and subsequent menacing glare of said patient
11) Cut corners
12) While giving a lecture to medical students, use more than one cartoon from the Farside to inject humor into my lecture
13) While talking to anyone, under any circumstances, muse “back when I was in medical school…” and continue talking uninteruppted for more than thirty seconds
14) Wear tan khakis, a blue blazer from Brooks Brothers, mocassions, and a “wacky tie” that really shows my creative personality
15) Become interested in yachts, sailboats, hunting, or Republicans
16) Enter private practice to make more money
17) During a bimanual vaginal/rectal exam, engage in a discussion with my patient about “how I can practice this with my girlfriend.”
18) Write a book about how my anatomy lab dissection changed my life
19) Tell my patients how to grieve
20) Lose my sense of humor

To begin again...

2009-01-11T19:49:00.000-08:00

Last semester, I took a class on medical creative writing through UMASS. We spent afternoons eating cheese and crackers (the prepacked little squares, nothing fancy or goat-like) and discussing our attempts at coming to terms with being medical students. Here is the first of a few pieces I wrote for the class.

To begin again

“I am not in charge of you.”
“But, sir, she be messing with me.”
“I’m here to get to know you, not to be your police officer.”
“But he keeps playing with me.”

I spent three years listening to this kind of dialogue as a middle-school teacher. I thought I had moved on, yet something indefinable pulled me back. I sit at a table with five “troubled teens” in front of me. At least that is what everyone tells me they are. They lean back in leather chairs, making noise, making noises, hollering at kids out of the window. They are part of a group – project intervention – prevention intervention - intervention prevention – I can never remember the name.

We watch life in Great Brook Valley unfold outside the window. Kids play ball with sticks, couples argue in Spanish on the stoop, and kids walk by with no shoes on. I know enough not to try to take charge of a group of six teenagers. I walk up to each, extend my hand, and ask their names. “I’m Tom, nice to meet you.” Jerrell limply extends his hand from burly frame. He gets back to his chair as quickly as possible. I am new, suspicious, too old to be a peer - too young for an authority figure. Faith opens up to me with a huge smile. I ask her if she likes to write. Her eyes widen and she inhales deeply before screeching. “I am writing my own book.” I listen to her read from it, a pseudo-autobiography about her and her boyfriend from Atlanta.

Jerrell starts talking trash to Ciara behind us, and I turn to give them the “teacher stare.” I am no longer a teacher, but they get it. I make my way over to Jasmine and Ciara, who just want to tell me stories about school. “You look like Mr. Davis, you know?” I tell them I’m a medical student at UMASS. They don’t seem to care.

I search for the mysterious fifth child, who darts in and out of the room at will. Jarred sustains attention long enough to assure me he has no interest in writing – anything. “So, I’m interested in running a writing group here,” I exclaim, finally addressing myself to everyone in the room. “I’ll be back next week at 4pm if anyone is interested.” Jerrell makes sure to grab me after this comment. He tells me his father writes plays, and pulls me aside to show me his rendition of his father’s work. Jerrell writes in bold chicken-scratchy letters that trail off to the right, as if they have been italicized and magnified to 150%. I read the fragment on his lined paper, and realize I have no idea what he’s talking about. “It’s about Tupac, George Washington and zombies,” he tells me. “So does Tupac travel back in time, or do the zombies come out of the netherworld?” I am hooked. Before Jerrell speaks, he awkwardly shifts in his chair, twirling his pencil underneath the desk. He lives in his body like its an oversized raincoat, uncomfortable and sweaty. His ideas share a similar fate - their vibrant originality suffocated in scattered sentence fragments.

The Intervention Prevention kids are part of a program targeting “at-risk” youth. They are caught-up in the social service agencies due to truancy, violence, or other issues at school. Through this program, they get tutoring services and supervision from a mentor-parole officer who runs the small classroom we occupy.

After talking horror movies with Jerrell, I get up to leave. Faith wears a parental look of disdain as she continues to write admits the playfulness around her. Jarred runs back into the room from the basketball court, panting, and demands his seat back from Ciara. “But I just starting sitting here” she shouts. “Quit playing with me, and give me my seat back,” he counters. “I’m not in charge of you,” I think to myself, with a faint grin.

MOMA in NYC w/Stephanie

2008-11-08T21:56:00.000-08:00

the westernized "self" - join the dialogue!

2008-10-08T15:17:00.000-07:00

(Jodut) I just finished reading a paper for my proseminar class, and came to this quote at the very end that the author started to draft. It woke me up a bit about how little responsibility andcare I take for those around me. Obviously, I am here to do so, to learn how to do so effectively in the long run, but how little I do in my every day experiences to comfort or assist. What a lonely, selfish, and ill-invested life I lead...

"In the United States it is now possible for a youth, female as well as male, to graduate from high school, or university, without evercaring for a baby; without ever looking after someone who was ill, old, or lonely; or without comforting or assisting another human being who really needed help. The developmental consequences of such a deprivation of human experience have not yet been scientifically researched. But the possible social implications are obvious,for--sooner or later, and usually sooner--all of us suffer illness, loneliness, and the need for help, comfort, and companionship. No society can long sustain itself unless its members have learned the sensitivities, motivations, and skills involved in assisting and caring for other human beings." Urie Bronfenbrenner, “The Bioecological Theory of Human Development” (2001)

(Stephanie) I had been thinking about this. So much of our lives, in the "contemporary West" are around self. Therapy, grades, "self-help," finding "one's way"...

Of course, I'm in theology, and to me, when I think about being attuned to God, or caring for those around me as all being graceful and worthy---this seems to run counter to the way I'm encouraged to actually live: ambitious, self-focused and motivated, articulating my goals.

Interesting. Are these Western norms, or contemporary?

(Eric) Really provocative quote, jodut, and I'm wondering whether the author offers any recommendations. i just read Jhumpa Lahiri's Unaccustomed Earth, and the title story draws that out in the way a daughter and father find themselves unable to touch/move in each other's lives anymore (Lahiri would answer steph's question as a difference of western norms vs. eastern ones, though that distinction is becoming more and more confused in globalization). It also reminds me of the research studies done on the degree to which we don't talk, or physically touch, each other anymore.

I think we might blame, in part, our understandings of freedom, right?--that phallic thrust of the american dream that we often take as a striking forward, hitting the road, discovering the frontier. We seldom find the maturity to see freedom as the kind of responsibility to each other that, in the end, we need and want so much.

But nor, I think, are things as bleak as the quote suggests, nor as naively sentimental. Though familial obligations have shifted, we do care profoundly about what we do for people we love, people who are marginalized, neglected, handicapped, a world that is being wrung out. Only the ways we do it aren't so clearly personal anymore (if they ever were).

(Tom) Eric is right. We are afraid to get close to each other – physically, emotionally, and spiritually. Perhaps this is because there is no model for this in our westernized culture – what we do not learn from our fathers or from television goes unlearned. Or perhaps we just don’t know where to look. I felt acutely aware of this in yoga the other day. Interpresed between intricate “eastern postures,” and sit-ups to “attack those abs” the group broke out into a collective moaning session. For most, it seemed to be gutteral. For others, forced inauthentically through pursed lips. The overwhelming sign rippled off sweaty mats - more cathartic than orgiastic, yet laden with sexual undertones. Maybe people just weren’t getting laid enough.

The yoga studio sits across the street from the Episcopal Church my family attended for 15 years of my childhood. In class, we twist, contort and confront the limits of our self-discipline. We perform – not individually, but collectively. We yearn for grounding in a tradition “wiser” than our own. Maybe “they” know more than we do about the human condition. If only we “ohm-ed” more we could create a better world, right?

What, if anything does this moan teach us about the above quotation? Does this mean that secularization is taking over more traditional religious forms? Does it mean yogic practitioners are among these developmentally disabled – in virtue of seeking comfort and companionship outside of the traditional family structure? Or, does it express an untapped public yearning for intimacy and community?

Hannah Arendt wrote extensively about the privatization of the individual – we structure societies to retain a priveledged place for individual reflection, sin, joy, and pleasure. This is most acute in the United States, where the wealthy raise children in separate wings of the house and send them to day care at the youngest age possible. American collective wisdom ties freedom to our ability to be self-sustaining, financially independent, and mobile. Our churches, yoga studios, and sections in bookstores tell us to privately strive for self-actualization. This somehow shook out after the Enlightenment when people realized that there were rational, moral agents, and codified the concept of “self.”

The author correctly observes that people can now move through the world without significant experiences that shatter the prominence of the self. Our societal struggles become subsumed under the moniker of “personal struggles.” If skeptical, consider unquestioned truth of the platitudes: “In order to help others, you need to help yourself” or “change first begins with yourself.” Imagine saying this to a single mother working three jobs, or a 13 year-old who can’t do their homework because they take care of their ailing grandparent. Why does this feel inauthentic? Perhaps because Westernized notions of self-actualization assume the luxury of a private life removed from class, race, and gender issues.

Pre-enlightment religion focused on the role of the church as the locus of transformation, as a place to confess, mourn, and baptize. In the modern west we are moving toward a more personal God (what can Jesus do for you?), and further toward new age practices and self-actualization. We are privatizing. Like Reagonomics, we believe that our personal salvation will “trickle down” to others publicly. Sometimes it does; sometimes it doesn’t. What we lose in all of this is a public community focused on justice, relationships, and companionship. We lose the closeness to mourn, grieve, and live in solidarity with people who are stuggling.

The question remains – what, then do we do? I think it begins with a willingness to critically examine how we privatize love, compassion, and grief. What do you think?

Kids, health and social change

2008-09-24T21:43:00.000-07:00

"Be discontented. Be dissatisfied...be restless as the tempestuous billows on the boundless seas. Let your dissatisfaction break mountain-high against the walls of prejudice and swamp it to the very foundation."
John Hope

Today was a tiring but satisfying day. At times I almost felt like I was living the life of a teacher again – an endless amount of work, human interaction, and the sense that I am on the cusp of doing something great… if only. I tutored four girls at the Center for Healthy Kids on math, playing games, making jokes and getting them excited about academic acheivement. The predominant thought running through my mind was “could I have done this for years longer?” In retrospect, I realize that I became somewhat discouraged by the monotony of what I was teaching – though never of the students themselves. I also realized that I could do this – medicine and some teaching, and possibly even get my fix of it. That is after all, if I confined myself to teaching middle-school math once again.

After working at the Center, I drove across the city and through the gates of privledge into Worcester Academy. I showed up to talk about the Center, and possibly collaborate with some other community organizers. We meet in a band room flanked by semi-circular windows. In the adjacent hall lies a placard of donations for the building we occupy – the minimun is $1,000 and some reach up into the millions. I think of Great Brook Valley, and what their schools look like. Do they have placards with donor names? Do they have access to golf teams, chess clubs, and adults who devote their afternoons to extracurricular activities? These questions are intentionally rhetorical – but not for the reason you are thinking. That is, the answer is yes to last question. The kids have Erica, who works for a little above minimum wage to run the HW center, the librarian, and an over-worked bi-lingual educator who tutors kids in Spanish. And yes, there is me and a few other volunteers, reading to kids and teaching math to get our minds on/off medicine.

Very smart and succesful people tell me that health inequities are rampant and affect the school-lives of these children. When I came into medicine, I expected these inequities to look like those in education. Within 5 minutes of meeting a student, you can roughly tell their reading level, math skills, and ability to communicate. Within 10 minutes, you can usually tell where they have been placed in the social hierarchy. These facts are jarring and demand immediate action. How can we wait when we know what is at stake?

When I thought about entering medicine, I had only a vague grasp of how my students’ health (physical, mental, psycho-social) affected their lives. Yes, many were absent frequently from school with “sickness.” I expected, however, that this was just as much due to environmental conditions as slyness of the teenagers themselves. My reading students had cognitive and behavioral disorders that psychiatrists could spend months studying – yet few had work-ups past the run-of-the-mill outmoded intelligence testing. Nonetheless, I perceived a mystical component to caring for the ill – somehow through sheer will and solidarity with patients, treating the sick could produce transformative social change. I expected the health disparities to be visually jarring and understandable in all its complexity only to the medical elite (that is, after all, why I needed to be a doctor – without this knowledge, what could I do?). Moreover, I expected to slide into a large and transformative mission to eradicate these inequities.

I confront this naiveity on a daily basis. Visually jarring? The children I work with every day have sugar water and cookies for “healthy snack,” have higher rates of asthma, visit doctor’s less frequently, and stastically will die at a younger age. Do you need to know the foundations of epigenetics to realize that generational poverty and poor maternal health set kids up to be more obese, prone to diabetes, and sicker? Do you need a medical degree to explain the correlation between access to nutritious food and performance in school? What does it take to confront this? What do you do with 30 medical student volunteers, a reasonable budget, and the backing of a reputable medical institution?

A few weeks ago, I met with a pediatrician in Boston about my work at the Center. I explained that while volunteers loved playing with the children, some didn’t see the point of documenting their progress with kids. I understand this sentiment – behavioral changes are difficult to track, kids can be unpredictable. On top of this, kids rarely enjoy “tests,” or euphemistically “learning activities” to show what they know. What is the point of working for justice, if we don’t know how far we have come to achieving anything? We need to teach our volunteers how to plan effectively and actually see if the kids retain anything we teach.

In many ways, I see my work this year at the Center as a microcosm of what I may end up doing as a physician – community advocacy, teaching children, spending time outside of a clinic, creating programs to teach social justice through action, reflection, and more action. Do I need a medical degree to do this? Will I love “doctoring” enough for this to be worth it? Will I become as dedicated to my patients as I did to my students? Will I be disappointed by the time differences in this relationship? Will I say to myself – if only I was their teacher and not their primary care physician? Or, will I declare the opposite – I am so glad that I am their primary care physician? Will I be able to get involved in education purposefully and productively? Will I be able to be intellectually stimulated in all of my pursuits?

Last year I struggled to define and come to terms with these questions. They are difficult for me to ask myself, as they call into question my very motives for a career I have thought about my entire life. I’m tired of feeling listless, unchallenged intellecutally, and disconnected from social justice in medical school. I’m ready to move… purposefully.

Ecuador... everything and more

2008-08-10T21:09:00.000-07:00

The paradox of the vignette is that it expresses the essence of an experience while leaving out the background that makes it feel real. In my studies in Ecuador I can describe a few vignettes that encapsulate my doubts, successes, revelations, and struggles here. The details that form my life - that is, the smell of dusk on a Cuencan night, the nights alone with my Spanish dictionary, the impromptu cooking lessons from my host mother, are interwoven around these ¨top moments.¨ It is these routines that give weight to the vignettes. In this journal, I will dare to capture both the highlights and the everyday realities that made these possible.

“The Title of Volunteer is a fluid one…”

I enter the Fundacion Humanitaria in a typical Cuencan morning – the gray sky obscuring the elusive sun, and streets packed with workers bustling to start the day. I first enter the physical rehabilitation room. The walls speak for the whole room – light blue paint chips hang from the wall, scattered among anatomy posters in Spanish of the various organ systems. An illuminating clock of Jesus with arms spread separates two exam tables. I am first surprised at this, as the Fundacion has no religious affiliation. Yet as I learn more about Cuencan culture, I find that this far from extraordinary – Cuenca prides itself on its colonial roots – its architecture, conservatism and ardent Catholicism. When I bring up separation of church and state, I receive a bemused look from most Ecuadorians.

In the rehabilitation room, I turn my gaze downward to the arsenal of tools – two electronic massagers, a heating pad, a hair dryer, a hair curler, and a tiny bottle of hand sanitizer. I soon become intimately aware with all of these instruments. The physical therapist Pedro immediately puts me to work on the first patient. An indigenous woman of 60 years enters, who has had arthritis in her knees for two years. Pedro models the massage technique for me, and I try my best to imitate. The patient grunts as I put my hands on her knees. While I don’t understand much of her invective speech, I gather that my hands are too cold and uncoordinated.

Eduardo Jorge Sosa established the Fundacion Humanitaria in 2004. Since, it has provided services for thousands of patients in Cuenca. They function similar to an NGO (or ONG as they call it in Ecuador) and house the offices of three lawyers, a laboratory for medical tests, and a rehabilitation room for physical therapy. Volunteering doctors staff the medical part of the Fundacion. Most of the doctors work concurrently either in private practice or in the public system. Each consult costs three dollars, and can last anywhere from five to fifty minutes. This price is much less than the thirty that it costs for a private appointment. In addition, the clinic provides financial support for X-Rays. As I tour the city, I am surprised to find countless buildings advertising X-Rays. Some businesses have the distinction of advertising the supervision of and “M.D,” though most do not. Patients bring a doctor’s note indicating what they need, pay out of pocket for the tests, and then return to the clinic with results in hand. The Fundacion is armed with a small medical cabinet, and the doctors with the bare bones of medical instruments – stethoscope, scale, and blood pressure cuff.

Two thin doors separate the doctor’s office from the waiting room. They may as well not exist. Thin rectangular windows line each vertically. They clatter when a patient enters. My job is to stand behind the doctor and watch. In my residency application, I may write that I am a ¨assistant¨ or ¨preceptor¨ but in reality my primary job is to be as transparent as the window. Dr. Sosax greets each patient with a calm smile and cautious energy. He wears the hair he has slicked back. At times, droplets of liquid creep down his face. It is difficult to discern where perspiration and gel meet. In the office, we have a bookshelf of medications, a bed, and a screen to shield patients’ privacy.

The health clinic is a room in the back of the old colonial building. In the centre of the three-story complex you can look up through the plastic skylight, and if lucky, catch a glimpse of the ever-elusive sun. The health clinic consists of a desk, padlocked medicine cabinet, exam table, privacy screen and aging tape player in the corner. It is staffed by three rotating doctor’s from surrounding clinics in Cuenca, as well as one from Quito. The diversity of clinicians is striking. Mercedes is a soft-spoken Cuencanen, who approaches patients with a collected, confident ease. Eduardo Sosax is an internal medicine doctor from Quito, who is currently doing epidemiological research on osteoporosis. His burly frame and brusque voice belie his inner compassion and dedication to his patients. On one of my first days in the clinic, between patients Eduardo took the time to speak converse with me in kindergarten Spanish. In contrast, Jose greets patients with a brutish handshake. As patients describe their symptoms, he meticulously transcribes their history into his laptop. To date, Jose has 238 patients at the clinic – they know that he works on Wednesday, and they come in to see him without fail. José’s work is amazing in light of the tomes that have been written about the difficulty of achieving continuity of care in developing countries. With a laptop, clinical judgement and compassion, Jose provides the backbone to a developing health care system.

Every morning, I make a thirty-minute trek to the center of Cuenca for my volunteer “job.” The quotation marks around “job” are more than necessary, as my role changes by the day. Friday of last week marked the last day of classes for many of the middle schools and high schools in the area. Consequently, many families went out of town, or sent their children off the “La Colonial” – the Ecuadorian equivalent of summer camp. Due to this bustle in the city, our clinic remained vacant for the morning, save for one patient. This was a mixed blessing – fewer patients, more time to practice Spanish with the staff. Most days around 11am I wander up to the law offices and have tea with the lawyers, lab technician, and the other American volunteer. Despite my inner desire to speak English, I decide only to speak Spanish with the other volunteer, much to her chagrin. She will begin to speak in English, pause, and then exclaim “you hate me for speaking English, don’t you.” I just smile.

I shadow the doctor in the health clinic, weigh patients, take blood pressures, and try not to get in the way too much. This Wednesday, I spend my morning shadowing Jose. Our first patient knocks on the door with trepidation, quietly comes in, and gives an in depth account of his loss of vision in one eye. We do not have the capacity to perform vision testing. Thus, after a brief neurological exam (touch your finger to your nose type of exercises), we refer him to a specialist. Before the second patient can enter, an immaculately dressed man smiled his way into the office. He is a pharmaceutical representative from Pfizer, peddling a new hypertension drug. He speaks with the ease and speed of an American salesman, drops off a few samples and pamphlets, and leaves promptly. At first, he thought that I was an American doctor, and took great interest in maintaining eye contact and professionalism. When Jose informs him that I am a mere student, I become dispensable and his gaze reverts back to Jose.

The second part of the Fundacion is a laboratory for blood and urine tests. Rosie, a short-statured, fast-talking Ecuadorian runs the tests for the clinic. The lawyers on the third floor describe her as the “mother” of the floor, and with good reason. Not only does she work tirelessly in the lab; she also uses her hot plate to boil coffee for us every morning at 11:30. On a slow Tuesday morning, Rosie explains how to calibrate the spectrometric guage on the antiquated spectrometer. Our conversation quickly turns from science to math, and I feel at home in the comfort of the language of mathematics. She then explains that each test takes about twenty minutes to complete – a life-time in the US. She wants to garner enough funds to upgrade the technology. However, the three dollar fee per visit does not make this possible.

Next to the doctor’s office lies the physical therapists office. I spend most of my first week here, underneath the religious clock and aging anatomical illustrations. I massage arthritic knees, apply heating pads to aging ankles, practice my basic Spanish skills, and vigoroulsy rub my hands together to make them warm enough for patients. Meanwhile, the “real” physical therapist Pedro studies for his engineering exams behind the canvas partition. Pedro’s age remains illusory to me – he trained in Cuba as a physical therapist, reads X-rays with clinical ease, has a one-year old son, yet has a youthful smile and immature sense of humor. Like many Ecuadorians, he foresees a more promising future in technology, and more specifically, in applied engineering. The physical theraphy room remains packed throughout the morning. In interviewing the patients, I learn that many have received treatement here for at least six months, and with self-reported excellent results. As my Spanish begins to improve, I begin to assume more responsible jobs. I grill Pedro on the exact technique for loosening muscles, implore him to use hand sanitizer before and after each patient, and gradually pull him away from his books. I learn that the title of “volunteer” is fluid, and entails different responsibilities with each health care worker . For Pedro, I need to draw the line more firmly – I am not yet a medical professional, and not ready for the responisilibty of patients’ physical recovery. I tell him I need more supervision and support in treating patients. Pedro gracefully accepts my self-demotion. In the rare instances where there are no patients, we do calculus together, checking the results of our integrals on his TI-87 calculator.

The third floor houses three law offices and a clinical psychologist. Since I only volunteer in the morning, I do not have the pleasure of working with the psychologist. The lawyers – two Joanne’s and one Monica, work for the same salary of three dollars per client. In addition, they help with community outreach projects – organizing summer camps in rural farms, and art, music and nutrition classes in the city. The mother of one of the Joanne’s directs the Fundacion. One day, I ask what has been on my mind for weeks – how on earth does the Fundacion stay alive? She replies that it is through “autogestation.” The literal translation is “auto-financing,” but this misses the point. The government provides the physical space, electricity, furniture and lab equipment. The salaries come solely from clients and patients. Again, I ask “how on earth do the staff make a living?” It turns out that most of the lawyers are young, and this job is an excellent starting point for their careers, the equivalent of a minimun-wage internship in the States. As for private or international support, this does not yet exist.

On my last day at the clinic, I pose for pictures with the staff and try to hold back my emotions. I leave with a renewed sense of possibility – in community-based medicine and in myself. Jose taught me the importance of rigorous, data-driven medical care. Pedro taught me the ins and outs of physical therapy, and pushed me to speak Spanish all the time. The three lawyers taught to smile constantly, read widely, and discuss health care in Spanish. Rosie was a mother to me and taught me the importance of care-taking. As I leave I tell them I will return – and I mean it. We joke that it will be with five children, three adopted from Ecuador. I remain excited for this day.

“Let the Interviews Begin”

WHAT?

As I begin to learn more Spanish, I interview patients more extensively in Spanish. In a moment of brilliance or stupidity, I decide to give a talk in Spanish based on my experiences. I have a book of medical spanish, a collection of essays on health care from a Latin American perspective, and a list of ten open-ended questions for patients. First, I ask “What experiences has your family had with the health care system here?” and “What do you do when you get sick?” Then I ask more specific questions about insurance, patient confidentiality, and politics. The more open-ended the question, the more detailed a response I get. For two weeks, I ask, listen, rephrase, paraphrase, and listen even more.

When you get sick in Latin America, a medical doctor occupies a long-list of potential people to contact. The first option is to access alternative or natural medicine. Although I have not undertaken epidemiological research in this area, my observations bear out that Ecuadorians of lower socio-economic status utilize this option heavily. Many of the indigenous woman I help treate for arthritis remark that they came to the Fundacion after years of having little success with natural remedies. Nonetheless, it is important to point out that natural and western medicine are not practiced with distinct boundaries – patients undergoing physical therapy and taking medicine for high blood pressure may also routinely visit a healer, or drink traditionally prepared herbal drinks for pain. In addition, the title “Alternative and Natural Medicine” encompasses a wide-variety of treatments, including curanderas (natural healers), shamans, homeopathic healers, and auto-prescription of natural concoctions of herbs sold in the markets. In the “10th of August” market I witness a curandera perform a cleansing ritual for a young boy with a fever.

The curandera sits perched on a stout wooden stool. In the distance, a row of dozens like her extend towards infinitiy, like two parallel mirrors in a barber shop. A scaffolding of plants and roses rise behind her, dwarfing her even more. She brings the boy close to her, retreives a single egg and proceeds to touch his whole body with the egg. With small circles, she quickly massages over every bone and muscle. She cracks the egg in a cup and watches the elegant cylindrical dance of yolk and water. Carefully, she selects just the right plants and forcefully pats his body with them. Finally, she takes a small sip from a pinkish liquid in a gatorade bottle, and spits a stream of liquid in the boy’s face. He winces as the liquid spreads across his face, then opens his eyes and falls into his mother’s arm. The price – one dollar. The next week I watch a similar ritual by a Shaman. Interestingly, he dismisses the curanderas in the market as fradulent. As an indigineous Ecuadorian, he learned to communicate with plants and nature through his ancestors, and refuses to charge for his services. In contrast, he explains that the curanderas seek money for their services, which sours the energy they try to channel.

The Shaman lectures frequently at my international school. I attend his talk on a quiet Tuesday at sundown, along with a few of the Spanish language teachers, and fellow spanish students. He speaks with a refreshing air of calmness about acheiving communion with nature, the lifestyle of indigineous Ecuadorians, and natural health remedies. I get up the courage to ask him about the process of educating future Shamans. He replies somewhat cryptically that he learns from the plants and nature, and has no formal teacher. He then goes on to explain the duality of masculanity and femininity in nature – how each plant and object in the world embodies either a masculine or feminine form. I think back to the transgender talk at UMASS, my intense conversations in college dismantling the gender binary, and try to think of a way to present this in Spanish. After brief deliberation, I decide this project must wait until I return with more language skills. At the end of the lecture, he invites everyone to embrace one another in thanks for sharing our time and energy. I hug every person in the audience and feel a sense of community and love I haven’t felt in years.

Another popular option for medical care is to directly visit the Pharmacy. The pharmacists can pin-point common symptoms, and in absence of a physical exam provide a cheap alternative to a doctor. The down-sides to this treatment are obvious – such expedient, unrigorous medical diagnosing can result in unintended complications due to drug interactions and misdiagnostics.

For those seeking the treatment of a doctor, three major options exist: a non-profit foundation, the social security system, or a public hospital. The Ecuadorian social security system functions similar to the system in the United States – it covers goverment employees and those who elect to pay into the system. For example, a public school teacher may pay $30 into the system a month (which is roughly 10% of an average salary), and this money accumulates until the time she needs it.

If you seek medical treatment, you must choose from the services of affiliated hospitals, where quality and consistency vary considerably. At least two patients describe it as follows – “If you need to see a doctor, you need to get ready to spend the night in the hospital to wait for an entrance ticket. After this, be prepared to pay considerably for your own medications.” Other doctor’s bemoan the lack of medical supervision – residents provide much of the medical care, and doctor’s acutely feel the lack of medical technology. On the other hand, certain patients describe receiving excellent care. An elderly woman with Addison’s, arthritis, and hypertension insists that Social Security is the only thing keeping her alive – without it, her Cortisol medication alone would cost more than $300 a month. Public hospitals battle similar problems of long-waits, inadequate staffing, and cheap medications for patients. Generally, the priority of health care remains low on the list of priorities of the patients in Cuenca. Aside from well-child visits, patients do not make regular check-up appointments.

Lastly, private hospitals remain the domain of those with money. In the clinic I visit, I observe an office with over ten specialities (in contrast to the one in the Fundacion). The doctor I meet with graciously takes his time to explain the tripartite system of health care here – he elaborates on the dearth of specialists, and the imminent need for reform. For example, Cuenca, a city of nearly a half-million residents, has only two registered Geriatricians.

SO WHAT?

Today is a week before my talk, and I am beginning to become petrified. Thankfully, I have three years of teaching experience to boost my confidence. One heuristic that I am committed to using is entitled “What, So what, Now What.” Outdoor education leaders typically utilize this technique as a processing activity for campers and staff. In the previous section, I discussed the “What” of the health care system in Ecuador – the differences between foundations, public hospitals, social security, and private care. The question “so what” poses these facts as a problem – why should we care about this?

Health care workers, governing officials and patients all answer this question differently. Unsurpisingly, I will offer my own unique take as a foreign medical student. However, I hope to ground my commentary in the realities of the patients I have served and interviewed. I will rephrase the question again - So What? What is the significance of the structure of the health care system?

First, as Americans, we have a lot to learn from the successes of the Fundacion and similar free-clinics. As Jose has shown, it is possible to practive evidence-based medicine at a community-based level – and with results. This is not to say that the Fundacion does not need more financial support, medicines, and laboratory equipment. Rather, it is to note that infrastructure to practive preventative medicine exists, and can be improved. Secondly, the current system jeapordizes the right to health care of millions of Ecuadorians on a daily basis. We have a lot to do to confront this reality. I offer six solutions in the upcoming section.

NOW WHAT?

While I greatly value my experience in the clinic, observation is not enough. Fundacion Humanitaria is part of a larger network of health practices, beliefs and norms. To fully understand our patients, we must understand the structural conditions that caused them to walk in the door. In his essay Alternative Health Report: A Tool for the People, Jaime Breilh makes this point within his critique of Western epidemiological studies of third world health. He writes, “From a positivist paradigm, they [International health reports, such as those of the WHO] obscure the health situation, since they magnify insignificant average health outcomes of national programs, while concealing major problems, or presenting these problems in a manner impossible to determine from their structural origins.” The scientist in me craves to dismiss Breilh´s commentary. After all, without some method of evaluation, how are we to know if our interventions are successful? Upon further reading, it becomes obvious that Breilh´s larger critique is not of health studies themselves, but of the failure of policy makers, NGO´s, clinicians, and scientists to critically engage in the social, historical, political, religious antecedents to health. In my brief few weeks of observation, I took this approach to the system of health care in Ecuador, learning from the doctor’s in the clinic, and most of all learning from the patients themselves.

Thus, I propose six solutions for improving the health care system in Ecuador. The first stimulus for change is always personal. As health care workers, patients and policy makers, we need to believe that real change is possible. Secondly, we need to boost health education considerably. In the clinic I observe countless patients daily with diabetes, hypertension, scoliosis, arthritis and scoliosis, all conditions that we can tackle effectively from a preventative standpoint. The Fundacion currently runs nutrition and health education programs in schools throughout Cuenca. This is an excellent start and needs to expand to include common conditions identified on a community-based level. For conditions highly prevalent in older populations, we need to think more creatively and collaboratively about educational forums to teach about high consumption of sugar, salt, smoking, and vitamins.

On a bus ride from Latacunga to Quito, I observed first-hand the lack of health information available. On a frequent stop, a young boy of fifteen enters the bus. He stands erect in the front of the shaking bus, and through his toothless grin describes the miraculous benefits of an Echinacea pill. He has a lamitated folder with images of each organ system, along with taped articles about the amazing effects on Echinachae for nearly every infirmity. Over half of the bus listens attentively, and I can’t help but wonder where else they hear medical advice. The boy passes each row solemnly, disseminating bottles of pills and collecting two dollars for each. As quickly as he enters, he leaves the bus. I retell this story to highlight the lack of awareness about proven medical treatments. In addition, the story reveals that the desire for health care knowledge exists – we just need to figure out how to fill this niche.

In addition to personal reform, we need increased support on the community and governmental level. As of July 2008, under populist president Rafael Correa, the Ecuadorian government has completed the first draft of one of the most progressive constitutions in the world. Within this constitution and political infrastructure, there is room for far-reaching public-health intitiatives and changes to the current health care system. In Cuenca, there is a pressing need to create specialized public health initiatives to address problems of obesity, scoliosis, diabetes, and hypertension. Unfortunately, the current health care system doesn’t prioritize community health. Finally, there is room for collaboration with the private sector as well as with other countries to garner funding for medications, train residents, and educate excellent physicians. As I reacclimate to life and culture in the United States, I am excited to learn more about how health care for Ecuadorians here.

Lingering Questions

I finish my interviews, practice for days to present my talk, and finally it comes. Over thirty students, teachers, and adminstrators from my school show up to hear me speak. On each seat I place a small chocolate and the handouts for the talk, which gets the audience in a cheerful mood. Then, for an hour and a half we discuss health care, poverty, and our role in the world. My favorite moment comes when I observe a group of college students listening intently and asking questions to my Spanish professor, who speaks eloquently about her options for health insurance. This is experential learning at its best, and it saves me the embarrasment of lecturing more in Spanish. After I finish the talk, I realize that I have posed more questions than answers. Among these are the following:
- When you travel to a country with limited resources, whose standard of care do we accept?
- How can you collaborate with people whose expectations of health care differ radically from your own?
- Where is my obligation as a person, America citizen, and physician?
- Do we have an ethical imperative to engage in international health efforts?

To conquer or communicate – learning Spanish from scratch

I leave the states with a pocket dictionary, intermediate Spanish book, and a basic vocabulary from a decade ago in high school. The dominant phrase that describes my experience is ¨utter fear. ¨ I am a thoroughbred ¨type A¨ and naturally apply this worldview to the study of Spanish. I immediately ask: ¨What will it take to conquer this language? What is the shortest amount of time that I could acquire fluency? ¨ My questions reveal more than their elusive answers; both focus on needs, my abilities, and me. In my capacity as a true medical student, I had memorized Spanish phrases with dedication on the six-hour plane flight. In my first taxi ride, this paid off. I had a ten-minute conversation with the driver about his likes and dislikes, and the great taste of ice cream. This all changed with my host family.

My host brother picks me up at the airport, immediately senses my discomfort, and starts speaking in broken English. Minutes later, we arrive at his house. Enormous mirrors hang from every angle in the trapezoidal living room, and mini-chandeliers with broken lights. I give my host mother a gift bag with a note in Spanish. She reads it out-loud and thankfully understands the central message – I like chocolates, I bought some for you, I want to learn Spanish. We eat chocolates. They try to find the easiest questions in the world to ask me. I respond with either grunts or mutterings. They try again. By the end of six weeks, I learn a great deal from my family about loyalty, dedication, and culture. Here are some of my revelations.

Everyone told me that food is important in Latin America, and I should have listened. In Cuenca, lunch is the central meal of the day. Businesses, schools, law offices and clinics all close between one and three o’clock. For me, this means a thirty-minute walk home for lunch with my host brother and mother. On Thursdays, the family circle expands to include cousins, aunts and uncles. Unlike my family lunches of ten or fifteen minutes in The States, Cuencan lunches last hours. We sit, talk, eat, and exhaust every angle of a conversation before moving onto the next one. This means that my host brother knows nearly everything about his mother’s life, and visa versa. I initially balked at this level of intimacy with one’s parents, as this is completely foreign to me. In time I come to appreciate this.

I slowly came to realize that even more important than food is the family. For most of the summer, our house is under construction for a new kitchen. In all parts of this process, my host brother Omar makes this run smoothly. He strips the old walls, paints vigorously, and negotiates prices with contractors, all at the age of twenty. Still, one’s family responsibility extends deeper than business negotiations. On the weekends, the entire extended family (around twelve in total) travel to our house for the day. We watch movies, babysit the children and eat for hours. When I ask my teachers about this tradition, they remark that this is extremely common in Ecuador, and explain this in terms of the geography of the region. Ecuador splits geographically into three regions – the coast, mountains, and selva (forest), each with a distinct culture and significant economic differences. The low average salary throughout the country, combined with these cultural and economic barriers make it difficult for children to move to other parts of the country. As a result families generally live and die and in the same place. My host-family is no exception. Save for a small stint in Argentina, they have lived in Cuenca for three generations. On a personal level, the strength of my host-family made me re-evaluate my obligations to my family here in Massachusetts, and realize the importance of spending more quality time with them.

On a typical Friday night, my family invites me to the birthday party for the uncle of my host brother. We drive through bumpy dirt roads to get to his house in the suburbs of Cuenca. I learn that the characteristics of a suburb are opposed to those in the States. In general, Ecuadorian suburbs are less safe, have worse schools and less access to health and social services. At the same time, the suburbs provide cheap ground for constuction projects. Everyone I travel outside of Cuenca shows signs of intermittent construction – half-hatched roofs, unfinished elegant stairways, and countless empty houses on each block. The financers of these houses are workers who have emigrated to the United States. This is a story of grand proporition – nearly 5 million Ecuadorians have emigrated to other countries (primarly Spain and the United States). With increased wages, they send money back to families in Ecuador, invest in real estate, and promise to return one day. Few keep this promise, as evidenced by countrysides of abandoned houses and never-opened businesses.

Omar’s uncle sells jewelery in New York City. On the car ride to his surprise party, each family member describes him with nearly God-like status. We arrive at 7pm, to a room of thirty family members of all ages. In typical Ecaudorian fashion, everyone greets everyone, which takes nearly half an hour. I firmly shake hands with each man. With woman, we hug gently, touch right cheeks and blow a kiss into the air. Much to my and Omar’s surprise, the chefs take until 10pm to prepare the food. I begin to feel antsy. Admist my hunger, I realize the stratification of genders – the men drink whisky out of plastic cups and converse while four women work tirelessly on the feast. The house is lavish by Ecuadorian standards – there are mirrors everywhere, large contemparary paintings, and an over-size staircase. Similar to most housing in Ecuador, there is no central heating or cooling system. This explains the rampant consumption of whisky on this cold night. Tonight, I opt for Coke, which turns out to be a good choice, because my host-mother comes by periodicially to inspect the contents of my cup. She is of the Ba’hai religion, and does not permit drinking in her house. I am interested if she believes that this extends to her host-son at family gatherings, but choose not to press the issue. I pass the time talking with Omar about video games. Upstairs six children crowd around the computer for fun. In the corner, the older guests segregrate and talk about family issues. The highlight of the party commences with the entrance of two musicians, hired by the entire family. They sing old Ecuadorian folk songs into the night – some soothing and romantic, others misoginistic and outdated. I tap my foot to keep warm and follow along with the beat. Meanwhile, the elderly women sing along, make requests, and have the time of their lives. I marvel at the closeness of their family – that at 1am three generations celebrate together with love.

We return home at 2am to our house in the center of Cuenca. I have come to love this house – with its constant construction, changing business owners downstairs, and influx of people. My family lives modestly by American standards – they own a few comfortable couches, lots of cheap DVD’s, a radio, television, and durable wooden cabinetry. I sleep on an ostensibly sturdy bed, which I sink into every night – my weight bends the plywood and cardboard under the thin matrress. Still, I learn to love it and by the end of six weeks, the contours fit my body perfectly. After many weeks of no heat or air conditioning, I finally become accustomed to sleeping with more blankets. In addition, I realize that the scalding hot water of the States is probably too hot, and does damange to my skin. Thus, I also accustom myself to the lukewarm temperature of the showers.

Time revolves around meals here, and arriving within fifteen minutes of an appointment constitutes “being on time.” In the evenings I run with my host-brother through the park. As runners, we feel out-numbered by the countless people playing soccer, volleyball, and doing aerobics to early 90’s rap music. Although Cuenca prides itself on its Catholocism, many families separate religion from their home life. My host mother rarely brings up religion, and my host-brother only infrequently brings up his Catholic upbringing. Still, my mother sharply points out the perils of secular society in modern music and culture – most sharply when she inveighs against the merits “The Simpsons” and “Futurama.” Families in the suburbs of Cuenca live without the presence of family member who migrate to the States. The cost of a coyote to help cross the Mexican border can cost upwards of $10,000, a sum payable even if the person perishes in the process. As a result, families in the suburbs (and in larger cities of Ecuador) can struggle economically for many years in the absence of a family member. In addition, recent reports show the incidence of suicide on the rise, a putative result of increased numbers of single-parent homes. In contrast, those who can afford to live in the city do so with more economic and familial stability.

My last day in Cuenca

Today is my last day in Cuenca. I eat my last hard-boiled egg for breakast and make simple conversation with my host mother. I still have not bought presents for everyone and inform her that I may not be home for lunch. She rolls her eyes, and then raises her voice at me. In a lighhtening quick description, she describes how my choice of running times makes it difficult for her to cook for the family. I sit in utter silence, afraid to respond. While I feel completely justified in my personal schedule (I keep a very regular schedule and inform her where I am at all times), I also feel uncomfortable engaging in a heated conversation with an older person, especially in a foreign language. I sit in silence for the rest of my meal. For the rest of the morning, I say my goodbyes at the clinic with great emotion. I decide to come back home for lunch after all, and pretend nothing happened. In the afternoon, I buy presents for my teachers – Spanish books and flowers from the local market. My shopping experience with Marie Elena. Tania buys me a bracelet. I give a ¨Deepak Chopra¨ book to my host-mother. She tears up at the dedication. I give a few excellent DVD´s to Omar, wrap the gift in pink wrapping paper, with the inscription ¨for my favorite machista. ¨ Omar gently unfolds the wrapping paper, puts it in a frame, and then on his wall for posterity. I tell him that when I return to Ecuador, this artwork must be on the wall. He accepts. For my final meeting with my language teacher Faviola, I take her out to coffee. We talk about the importance of family, cultural differences, and express mutual joy at having the opportunity to learn from each other. I almost cry as we say goodbye.

I spend my last week in Ecuador travelling and practicing my Spanish with everyone I meet. Much to my surprise, nearly every Ecuadorian I meet embodies the openness and kindness of my friends in Cuenca. On a bus to Quito, I begin to talk to my seat-mate, a teacher travelling from a rural town to the central bank. We quickly bond over teaching and books. I show her the Spanish book I am reading, and she immediately insists on reading me her favorite excerpt. At first, I am skeptical – it has been nearly twenty years since anyone has read to me. She begins with the calm composure of a third grade teacher, and reads me an eloquent story about conquering disabilities. I try to imagine this interaction in the States – a middle aged woman reading to a medical student on a public bus. I then laugh to myself and realize that some moments are too unique to generalize. I now realize that language is not to grasp, conquer, or acquire. Language is a vehicle for opening yourself to the world and creating community. In my journal I attempted to express this more poetically – can the study of language be separate from a study of oneself, ones own culture and of another culture? Due to my experience in Ecuador, I respond with a resounding “no.” I am now poised to begin my second-year of medical school. As I gaze forward into this year, I carry with me the wisdom of my patients, host-family, and teachers. I resolve to live more simply, strenghten relationships with my family, and to live for others rather than myself.

Ecuador Journal 7.5.08

2008-07-05T15:26:00.000-07:00

“Our elders taught us that the celebration of memory is also a celebration of the future. They told us that memory is not turning our faces and heart to the past, its not sterile remembrance of our tears and happiness. Making memory, they told us, is one of the seven guiding inspirations the human heart can apply in his life long journey. The other six being: truth; shame; loyalty; honesty; self respect and respect to others; and love. That is why, it is said that memory is always facing tomorrow and that paradox is what makes it possible to avoid the same nightmares and that to recreate happiness.”
Subcommander Marcos, Marzo, 2001

Today nearly marks the midpoint of my adventures in South America. I report with minor linguistic accomplishments (I can successfully navigate the present tense), a bit of cultural competency (I can successfully do what my host mother asks at all times, even if it means having no acceptable time to exercise), and medical prowess (I can perform physical therapy for patients with problems to their sciatic nerve). I am devoting the majority of journaling to health policy, care and my experience here. I decided on Thursday that I would give a talk at my University here about my experience in Fundacion Humanitaria, the free clinic where I volunteer.

The health clinic is part of a larger NGO (or ONG as they call it here) which houses the offices of three lawyers, a laboratory for medical tests, and a rehabilitation room for physical therapy. The health clinic is a room in the back of the old colonial building. In the center of the three-story complex you can look up through the plastic skylight, and if lucky, catch a glimpse of the ever-elusive sun. The health clinic consists of a desk, padlocked medicine cabinet, exam table, privacy screen and aging tape player in the corner. It is staffed by three rotating doctor´s from surrounding clinics in Cuenca, as well as one from Quito. The diversity of clinicians is striking. Mercedes is a soft-spoken Cuencanen, who approaches patients with a collected, confident ease. Eduardo is an internal medicine doctor from Quito, who is currently doing epidemiological research on osteoporosis. His burly frame and brusque voice belie his inner compassion and dedication to his patients. On one of my first days in the clinic, between patients Eduardo took the time to speak converse with me in kindergarten Spanish. Jose greets patients with a brutish handshake. As patients describe their symptoms, he meticulously transcribes their history into his laptop. To date, Jose has 238 patients at the clinic – they know that he works on Wednesday, and they come in to see him without fail. Jose´s work is amazing in light of the tomes that have been written about the difficulty of achieving continuity of care in developing countries. With a laptop, clinical judgement and compassion, Jose provides the backbone to a developing health care system.

Every morning, I make a thirty minute trek to the center of Cuenca for my volunteer “job.” The quotation marks around “job” are more than necessary, as my role changes by the day. Friday of last week marked the last day of classes for many of the middle-schools and high schools in the area. Consequently, many families went out of town, or sent their children off the “La Colonia” – the Ecuadorian equivalent of summer camp. Due to this bustle in the city, our clinic remained vacant for the morning, save for one patient. This was a mixed blessing – fewer patients, more time to practice Spanish with the staff. Most days around 11am I wander up to the law offices and have tea with the lawyers, lab technician, and the other American volunteer. Despite my inner desire to speak English, I decided only to speak Spanish with the other volunteer, much to her chagrin. She will begin to speak in English, pause, and then exclaim “you hate me for speaking English, don´t you.” I just smile.

When patients do arrive, I undertake one of two jobs. First, I assist with physical therapy, interview patients, and practice my Spanish with the physical therapist. Second, I shadow the doctor in the health clinic, weigh patients, take blood pressures, and try not to get in the way too much. Last Wednesday, I spent my morning shadowing Jose. Our first patient knocked on the door with trepidation, quietly came in, and gave an in depth account of his loss of vision in one eye. We do not have the capacity to perform vision testing. Thus, after a brief neurological exam (touch your finger to your nose type of exercises), referred him to a specific. Before the second patient could enter, an immaculately dressed man smiled his way into the office.

While I greatly value my experience in the clinic, observation is not enough. Fundacion Humanitaria is part of a larger network of health practices, beliefs and norms. To fully understand our patients, we must understand the structural conditions that caused them to walk in the door. In his essay Alternative Health Report: A Tool for the People, Jaime Breilh makes this point within his critique of Western epidemiological studies of third world health. He writes, “From a positivist paradigm, they [International health reports, such as those of the WHO] obscure the health situation, since they magnify insignificant average health outcomes of national programs, while concealing major problems, or presenting these problems in a manner impossible to determine from their structural origins.” The scientist in me craves to dismiss Breilh´s commentary. After all, without some method of evaluation, how are we to know if our interventions are successful? Upon further reading, it becomes obvious that Breilh´s larger critique is not of health studies themselves, but of the failure of policy makers, NGO´s, clinicians, and scientists to critically engage in the social, historical, political, religious antecedents to health. In the next month, I am interested in researching the system of health care in Ecuador, learning from the doctor´s in the clinic, and most of all learning from the patients themselves.

Career angst - take 1

2008-04-02T23:01:00.000-07:00

I have been very unmotivated with school recently. The memorization has got the best of me and I am constantly in the hunt for more interesting projects – teaching PPS class, juvenile health, Great Brook Valley, taking Spanish, writing more often, and seeing friends. Through all of this, I do not feel a common bond with the majority of people here. I feel that some days I am learning medicine on the side while I really figure out what I am doing with my life. Perhaps others are thinking this as well – I should find out. Nonetheless, I think my psychological distance from school makes it hard for me to engage with other students sometimes. We are in “this together” – but the “this” – medical education, means different things for each of us. With teaching, I felt united with everyone in Teach for America by a common vision for what is possible in education. I do not feel the same common drive in medicine.

Today we saw a number of Marlborough patients with the usual set of disorders – mental health issues, substance abuse problems, and obesity. I question our role as physicians in responding to patients with these symptoms over and over. Is it to come to the best clinical understanding of their disorder and to provide the best medical treatment? Or, can we be doing something to confront the more systemic issues? Tony is a boisterous man in his late fourties with chronic emphysema, a long history of substance abuse, and a brief incarceration. But he is more than his symptoms – as he rigourously chews his gum, his eyes radiate hope. His words follow. He tells me about how he is overcoming his addiction problems by speaking to large audiences – he says “In order to keep it in you, you have to give it away to others.” I puzzle over this statement, and ask him to repeat it. And again. On the third time, I realize he is talking about hope.

Tony does not have COPD (chronic obstructive pulmonary disease), morbid obesity, and a smoking addition in a vacuum. Tony is part of a struggling community of hard-nosed workers with little access to education, nutritional choices, and support systems. Part of what Tony deserves is the best medical care possible. But this is not enough. When Tony leaves, he may be denied by his insurance for his nicotine patches. He may not be able to find enough work, become stressed, begin smoking again, and wind up in the hospital with emphysema. Tony deserves more than this. The causes of generational poverty are too numerous to name, yet I still believe that education is the most impactful tool against this.

I have an intuition that I will end up as an educator. While I love spending time with patients, and the potential of clinical problem solving, I want to be around more. I want to be engaging with classes, schools, and communities on issues of access, social injustice and equality. As a physician, I will start with patients, families, and communities. But I have a feeling that I will creep back into schools.

Here are the 3 main questions I’m struggling with now:
1. Is it worth pursuing a medical education, if I know I want to be involved with students and in education?
2. If I go back into education after four years of medical school, will it be worth it?
3. If I continue in medicine, will I find a calling in education and social justice? Where will this be? What will it look like?

For Alex

2008-03-27T20:46:00.000-07:00

“Today we will be removing the brain.” The professor’s thick Romanian accent booms off the tightly enclosed walls. Most students stare passively ahead, awaiting the next verbal gem. My partners at the table quietly cackle to one another. This has been a long awaited moment for many reasons. Aaron is obsessed with neurons, and can’t wait to get his hands on more of them. ML has read five chapters ahead and has been previewing the cranial nerves for us. And Genevieve loves to cut things. For our project, we have a chisel, hammer and powered cast saw – like the one that removed my wrist cast in 7th grade. Genevieve immediately grabs it, and rears her head toward the ceiling in glee. She loves the power, the novelty - the raw human body. I feign excitement and lean in. An air of formaldehyde oozes from our cadaver’s scalp and into my nostrils.

I named her Victoria, but after my group vetoed this name, she became “our cadaver” in public. Her body lies before us in finely dissected segments – her lungs in a bag beneath our table, her heart preserved in a jar, and chest cavity exposed with sporadically broken ribs. When ML removed her heart, she let out a gasp of pain. Within this sigh she realized conclusively that Victoria wasn’t coming back. Up until now, Victoria’s pliant skin and peaceful expression belied this reality. Aaron and Genevieve acknowledged her gasp and gazed solemnly at the red mass. Meanwhile, I stood back in denial. She could come back. She could.

In 7th grade, my best friend decided that we needed to get rich in order to become cryogenically frozen when we die. As budding atheists, we reasoned that souls did not exist, and even if they did, they would not be us. They could not include our facial expressions, our pains, joys or laughter. Most of all, they would exclude what makes us us – our brains. My later obsession with physics only confirmed this teenage fact – we are determined by our neural connections, and the equations governing these connections. With no matter, no connections, and no prospect of eternal life.

The smell of formaldehyde gives way to burning bone. I am reminded of the dentist’s office and pulled teeth. Our cadaver is not cooperating on our circumferential cranial cut. Her dura matter is too thickly adhered to the skull. Genevieve continues to try in vain. I replace her with impatience. Instead of tapping lightly on the chisel, I insert it into a groove and bash it, hoping to pry open the skull. I fail to open the scalp but succeed in damaging her brain. Now I gasp. I glance around the room to see how many people notice. None. There is just a sea of destruction, rearing saws and sawdust embers. For the only time all semester, I leave the anatomy lab.

I return to the enamored faces of my group huddled around her brain. As they examine the nerves, sulci and fissures, I stare at the gaping hold that once held her brain – that once held her. Whatever neural connection dormantly waited excitation are now gone. She could not come back. I felt like emailing Alex and telling him our plan will fail. But what could I say – “Dear Alex, Both of us will not live forever. We were wrong. Our claims to cryogenic freedom were as illusory as the religious superstition we ridiculed.”

I could tell him “beware, death is real,” but we both know this painfully well from our past. We have mourned the death of his mother and stepfather together. We have fought and cried together. I could tell him “My cadaver challenged me to live life more fully” but that would be untruthful. In fleeting moments, contemplating nothingness is too much. It is as if my subconscious takes the reigns and says to my conscious self - “don’t give away the secret yet.” At these moments, I am acutely aware of life – my heartbeat, the poor circulation to my fingers, and my ability to think. Maybe I’ll tell him this.

Moments of Grace

2008-02-01T14:30:00.000-08:00

This is an essay I recently submitted to the Pharos Student Essay Contest.
Any thoughts would be appreciated, although save grammatical concerns for another day, as the essay has already been submitted. I hope you enjoy!

Moments of Grace
By Thomas J. Peteet (MSI)

“Hey, Tom. How are you Tom?”
Sue is slightly graying, hunched over shyly, and doesn’t make eye contact. The porch of Sue’s home overlooks a dusty construction site. It is near dusk, and the crew has gone home for the day. Further down the road the high school football team practices, and sounds of whistles, banging and grunting fill the air. Sue excludes all of these stimuli. Head down, hands clenched together, she continues. “That’s great Tom. That’s great that you’re well,” she says softly.

Alex and I ask Sue to give us a tour of the house – a group home for adults with intellectual disabilities – or as most say, mental retardation. Sue methodically paces through the house. In every room she pauses, as if waiting for our prompt: “What room are we in now, Sue?” She answers dutifully and moves on to the next place.
When we come to the window, she becomes giddy.

“Is that your car, Tom? Where is your car, Alex?” Not much changes here day to day, and she clearly picks up on the disrupted pattern of parked cars. There are no large white vans today, just Alex’s mini-van. As we walk up the stairs, Sue’s breath increases, and she lets out little gasps. At the top she collects herself. “Alexandra, I have to ask you something.” She presents this as a secret, despite my presence standing next to both of them.

“Alex, I have to tell you something,” she whispers even more softly. “I have never been in your van before, Alex.” Her tone has a raspy urgency to it – as if Sue has left her life in Alexandra’s car – and must get to it immediately. Over the next hour we attempt to be passive observers. Most of the residents recline on the sofa watching SpongeBob. At commercials, agitation sets in. An older man starts pacing in front of the television, a woman hollers at him from the corner, and all hell breaks loose. Within seconds, the house coordinator comes in to install order. Sue stays clear, cradling her arthritic fingers beneath her hands. If in clear sight of Sue, she sucks us back into her world, and asks us her same questions again and again. I imagine how easily it could be for someone to take advantage of Sue – a stranger, boss, or even doctor. I am glad that she is well taken care of here.

This is the formal introduction to my community clerkship through UMASS Medical School. Over the next two weeks, I travel across Massachusetts with a fellow nursing student researching health challenges for adults with mental retardation. My coordinator packs my schedule with human rights advocates, lawyers, psychologists, politicians and obesity researchers. My mind cannot yet process these issues. Sue is my only expert now, and my mind keeps coming back to her. What does she think about all day? Who is important to her? What are her dreams in life?

When we jump in the mini-van, Alex (my nursing student colleague) and I don’t discuss these questions. We want to help Sue, and help her immediately. We also want to locate her within a larger puzzle of health care for the disabled. How does Sue get health insurance? Did she choose her doctor? What does her doctor say to Sue when she comes to her office? Does she talk to Sue, or only to her aide? How does the doctor redirect her focused curiosity? Is Sue she smiling when she leaves? For the next two weeks we attempt to answer these questions as we tour across Massachusetts.
Day two.
I watch through the front window as some older men trickle into an expansive, factory-like room. Once there, they sit down calmly – some assemble boxes while others stare off into space. We must be in the right place. We meander to the “executive suite” – a green-tinted office building behind the concrete, muted workplace. Seven Hills is a private agency contracted by the Department of Mental Retardation (DMR) to provide services for individuals with mental retardation – the agency that set up Sue’s home. I do not yet understand the politics involved in the designation of “mentally retarded.” What I do know is that DMR is well funded, to the tune of 1.4 billion dollars per year in Massachusetts. The green-tinted office building, pristine entranceway and slate staircase confirm this fact.

Our first meeting begins with an introduction by one of the Seven Hills managing directors. Seven Hills is one of many private contractors of DMR, and the largest in the Worcester area. They provide day-facilities, home-care facilities, worker-training programs, counseling programs, and community-integration programs for individuals with mental retardation. Thirty years ago, she explains, nearly all of the individuals that Seven Hills serves would have been institutionalized. Some quick figures:

10,000 The number of individuals institutionalized thirty years ago in Massachusetts
1,067 The number institutionalized today in Massachusetts
200 The approximate number of residents still living at the Fernald Center in Waltham (formerly known as the Massachusetts School for the Feeble Minded)
1 Number of American films banned from release for reasons other than obscenity or national security (Titicut Follies)

The director presses play. For fifteen minutes we watch, eyes glued to one of the most horrific parts of the film. Titicut Follies was filmed inside the Bridgewater Correctional Institution, a prison hospital for the criminally insane. After the Commonwealth of Massachusetts sued the filmmakers, the Massachusetts Supreme Judicial Court ruled that the film constituted was an invasion of inmate privacy and ordered the withdrawal of the film from circulation. Now, the film can only be shown in restricted educational contexts. This is progress but not enough, as the film captures the legacy of pain and suffering of the mentally ill. Luckily, a written description of the atrocities of Titicut Follies has not yet been judicially banned.

The scene begins: a steel door in a hospital ward. Nurses and doctors scurry around performing their daily routines. The camera zooms in. Within this door is a peephole, the size of a small paperback, reinforced by a glass window. The doctor approaches the hole methodically, “You gonna eat anything?” he shouts into the enclosed room. Again, the camera zooms to a man, curled up with his legs, withered and exhausted. He chooses not to respond. The black and white film reel adds a historical distance to the film. There is no life here, no green of trees or brightness of sweaters. There are only contrasting shades of gray: the steel door against the doctor’s white coat, the tiled floor against the man’s pale skin. “So you’re not going to eat, are you?” he shouts again, raising his voice. “We gonna have to feed ya then.” A slew of large gentlemen emerges from the corner of the camera. The next set of events transpires as a continuous scene that my memory fails to synthesize. They become discrete, searing, seared into my consciousness.

The bolt unlocks. The withered man stands naked. Four guards stand by his side like a diamond. The withered man lies on a gray operating table. The doctor’s cigarette ember burns, dangling over the table. As an afterthought, the doctor tosses a towel to cover the man’s front. The doctor looks embarrassed. He knows the camera is watching. A four-foot plastic feeding tube enters the picture. Now he applies Vasoline to lubricate the feeding tube down the esophagus. No eye contact. Coughing. Swallow. Swallow. Esophagus and tube meet. It’s in. No eye contact. The doctor attaches a funnel at the top to insert the protein powder. The doctor’s cigarette ember burns. The ash is one inch long. The funnel waits below. It can’t fall in. It can’t.

To the viewer, there is no color in this film – just shades of gray. As for the “actors,” there is no moral reasoning, just black and white. “We didn’t know we should treat them any differently,” says a nurse who worked at Bridgewater. She wipes tears from her eyes as she speaks. I imagine the doctor would say the same. They live simultaneously within our anachronistic judgment and well-intentioned sympathies. I think to myself, “These are human beings! They are not to be treated like this.” I like to believe I would have acted differently. At the same time, I realize that my judgment is retroactive, based on my liberal upbringing and positive experiences working with the disabled. How is the doctor supposed to know better? The doctor may not know the perils of smoking, and has never experienced a patient at Bridgewater treated with the dignity we demand. Perhaps my sympathy should lie with him as well as his patient.

I learn three lessons from this film. First, we have come a long way in treating the disabled with the humanity they deserve. The fact that it is banned at all reflects a discomfort with the past. Second, we have still a long way to go. While doctors’ are not in danger of feeding patients cigarette embers, individuals with disabilities are still vulnerable to poor quality care. Finally, I learned that history matters. I imagine the ripple effect of broadcasting Titicut Follies, and the dialogue it would generate. I imagine people of all ages reflecting on how treatment of the disabled has changed, how it has stayed the same, and where it should go. Most of all, I imagine people in dialogue about an issue that most of us tuck away.

Day seven.
We meet with one of the major self-advocacy groups from Seven Hills. Initially, I am uncertain what self-advocacy would mean for a population with mental retardation. After all, the ability they need most to advocate (reasoning and communication) is diminished by their condition. There are three members in the self-advocacy group. Marie is boisterous, talkative, and on first appearance, looks as if she has high cognitive functioning. As she talks, she has trouble focusing her thoughts, pacing her speech, and relating to the group. Caroline has cerebral palsy, but has average cognitive functioning. It is both heartbreaking and inspirational to watch her speak. The facilitator asks her what the group does for advocacy – Caroline twists, turns, and sputters while she talks, and explains that they write letters to their legislatures. I am heartbroken because I imagine how difficult it must be for Caroline to communicate – to show people that she is intelligent, thoughtful and active. I am heartbroken that most people will not take the time to be patient with her. At the same time I am inspired by the patience of the group facilitator, and by Caroline’s resilience despite all odds.

Day ten
Today begins on a brisk windy road in Holden for a “day in the life of” a patient. Jim lives in a residential home along with several other individuals with disabilities. The ambulance is here, and Jim needs to be transported to his appointment to get his feeding tube replaced. I follow the director into Jim’s room, where his walls bear scattered paintings – an artistically rendered American flag, a Van Gogh replica couched within a faded wooden frame, and a Patriots team flag. The pictures hang amidst the 19th inch Panasonic – blaring “classic” music videos from the 70’s. The EMT arrives just in time to read my thoughts and express them. “What is this supposed to be? I’ve never even heard it before?” The EMT exclaims. I agree, thinking it must be a mutant artist crossed from Kevin Bolton and Barbara Streisand DNA. I’m glad I just missed the 70’s I think, but keep this to myself.

Within old paintings, music videos, and medics lies Jim. Unlike the EMT and myself, Jim did experience the 70’s and clearly appears calmed by the television. He wears a blue rugby shirt, unbuttoned at the top, with the number 88 stitched on the chest. Jim has the look of a rugger – strong build, thick jaw, and burly. I do not yet know that he is paralyzed on his left side and cannot walk. Jim’s eyes belie his physicality – their blueness radiates upon the yellowish-white walls. He is so peaceful, I think. I do not yet make the connection that this is the Jim who gags himself frequently and tries to pull out his feeding tube.
My eyes now wander to his right hand, which passively sits, tied to the rod of his bed. I remember speaking with his doctor about this “restraint” – without it Jim will claw himself into pain. This does not please the guardian advocating for Jim, and he wants the restraint removed. Politics aside, I am surprised how pleasant his hand looks. I am expecting handcuffs or a painful contraption, like the cage in my parents basement used to trap squirrels. Instead, Jim’s wrist rests supported by a light-green towel – his hand strapped carefully by a sling fabric from an old tee shirt. The director cautiously removes the sling, and slips her hand into his. As I admire her care, I notice the EMT has moved out of the room to get the stretcher. From the far end of the house, I hear “can you find me that meds list?” She offers to me, “can you hold his hand for just a moment?” I accept. I slip my hand beneath his. His hand weighs a heavy pressure on mine, his fingers curled within mine. Jim’s thumb sticks out above my hand, its girth twice the size of mine, and nail twice as long.

Now it is just Jim and I. I tell him softly “I like your rugby shirt, Jim.” He shows no response. I hold his hand more tightly, kneading my fingers into his palm. I perceive his dull grunt as acceptance of companionship, but cannot be sure. I want to give Jim love and support, and this is all I know how to do for him. In return, I will accept any utterance as validation of my presence. I wonder what it is like to work with Jim, day in and day out. I wonder what it is like to know his grunts and gurgles, twists and turns, head rocks and bobs. I wonder at what point he and his nurse solidified this physical language – at what point his caregiver reacts unconsciously, mirroring Jim’s need with compassion. Now we are placing Jim on the stretcher. His body weight thumps into our forearms as we pull his sheet, lift, and let him down. Meanwhile, his hand clenches more tightly. He knows I’m here for him, I think.

We arrive at the hospital to the familiar experience of waiting. I had thought that door-to-door ambulance service would exempt us from this charade, but I’m wrong. In a cramped office I wait with the residential director and two dueling EMT’s. Jim lies placidly on the stretcher as the common bond between us all. Our voices carry over his herniated stomach, shrill enough to keep him eyes fluttering open every few seconds. The crowded atmosphere brings out our worst experiences. We go in rounds: “Being dispatched to MGH is the worst.” “I was watching this craniotomy, where they take part of your brain and store it in your abdomen for six months.” “These are the issues we deal with for this population.”

The doctor comes in quickly, followed in tow by a resident. We exchange pleasantries and then get down to business. The hospital has not ordered the 24-g-tube replacement for Jim, and they only have the 18 in the room. Jim’s needs have fallen through the cracks, and we wait further for them to scavenge a 22 from the hospital downstairs. The doctor and resident leave to take care of this. “They knew he was coming for weeks,” the residential director says calmly. She is not surprised, just disappointed. I imagine what she is thinking, but too polite to say. I then look over at the EMTs’ blank looks. “Aha. This is what my high school English teacher meant by the expression ‘elephant in the room.’” The elephant in this case is the pressing question, “If Jim were not mentally retarded, would this g-tube foul up have ever happened?”

The doctor returns and treats Jim with the utmost dignity. She lifts his rugby shirt to find a herniated stomach, and half-inch hole leading to his feeding tube. I have not eaten enough breakfast. She lubricates the new 22-tube and places it to the side. With swiftness, she pulls out the current tube to the sound of a small fart. Now for the hard part. She struggles to place the larger tube, as Jim writhes in pain. His director holds his hand tightly, and he rests his head upon her shoulder. The EMTs’ and I stand by and watch with curiosity and encouragement. The crisis moment brings out the best in all of us – Jim winces with pain, and we know how to help him.

Day fourteen
Today is the last day of our clerkship, and my thoughts come back to Sue. I am still no closer to knowing the inner workings of her mind, her doctor’s bedside manner, or her satisfaction with her medical care. If she is lucky, she will continue to qualify for services under DMR, her physician will lean into her slouching posture to make eye contact, and she will be treated with dignity. Sue is not part of just a puzzle. She is part of a troubling history of neglect and mistreatment. Titicut Follies shook this into me. My observations at the hospital confirmed the current challenges disabled patients face.

While there is room for improvement, the resources provided in Massachusetts are impressive – individuals in the day programs explore the state on daily field trips, learn from an inspirational horticulture therapists, follow behavior plans created by highly competent psychologists, and are treated with dignity by staff members. Yet while these individuals receive first-rate care, others barely miss the stringent requirements that would qualify them for DMR services. Meanwhile, public school teachers pay for their own copy paper, social workers are barely paid a living wage, and individuals slightly above the poverty line cannot afford health care.

Part of the explanation of the current allocation of resources is political. The Shriver Center started in Massachusetts in large part due to the advocacy of the Kennedy’s (President Kennedy’s sister was mentally challenged). Nonetheless, Massachusetts continues to support programs for those with developmental disabilities. Throughout my clerkship the following question has jiggled in the back of my mind. Since certain programs are under-funded, and every dollar committed to DMR is a dollar that could be spent elsewhere, where is the taxpayer’s dollar best spent? The question itself presupposes a utilitarian framework. It assumes that we can quantify the greater good based on the allocation of money in one place over another. More specifically, it asks us to make a value judgment on the worth of relative programs – is one more dollar for horticulture therapy worth as much as a dollar raise for a city school teacher? On reflection, I have concluded that such a quantitative measure does not exist. Observe Caroline’s beaming smile from planting seeds for next spring, her increase in dexterity, and ability to communicate with adults. Now observe the city-school teacher, whose raise provides a more relaxing respite from a tumultuous workday, increased respect, and the ability to go to school the next day. There is no algorithm to decide what to do. Unfortunately, there is just politics.

In the current political climate, we ask our politicians to make these decisions for us. Politicians may be tempted still to use a utilitarian model. I would argue that this is neither moral nor instructive. A better outlook would seem to come from facing, and being present with those experiencing needs. Massachusetts is ideologically committed to providing the best care to those with developmental disabilities - and (for the most part) finds the funding to do this. Having made this commitment , the relevant question is “What can we do to give other priorities (i.e. funding for public schools, welfare programs, minimum wage) the same ideological weight?” Culturally, we have begun to embrace the notion that it is our duty to support individuals with disabilities. This ideology is most striking in health care – we consider the disabled, elderly, and very poor deserving of federal funds. If you happen to fall outside of these boundaries – if you are working class, a poor child, or a not poor enough adult, the United States expects you to pull yourself up. Our notion of duty has not yet expanded to embrace everyone. The work done in the last thirty years in the field of mental retardation proves that this task is difficult, but possible.

We have come a long way from throwing the developmentally delayed into schools for “idiots, imbeciles, and the feeble-minded.” Now we see individuals with disabilities as holding rights, personal goals, and aspirations. Our work is not done. This is clear from my experience working with caregivers, psychologists, social workers, and the disabled themselves. We need to do a better job educating caregivers, the public, and local communities about the experiences of individuals with developmental disabilities, including within the medical world. The encouraging advocacy that has come from facing, and being with individuals such as Sue, Marie, Caroline and Jim offers me some hope that entering the experience of other disadvantaged members of our society will lead to similar social and political progress in meeting their needs.

Peteet-Hughes religious dialogue - take one

2008-01-13T21:23:00.000-08:00

A skeptics response to the book "Presence" - From Boulder, 2006

In Boulder, I have had fewer opportunities to transform other lives (I no longer teach a hundred children daily, have you, Eric, and Jodut to debate with), and am trying to turn inward and work towards self-transformation. This is difficult, as I firmly believe that true change comes from activism and service, not from just thinking. Then again, I am forgetting that the bridge that ties action to thought is reflection. Basically, this is a long way of justifying reading philosophy, theology, and pseudo-scientific pop psychology (of which Presence is an example).

Thought/knowledge → Action → Reflection

First off, this book was engaging for me not because I bought into it entirely, but because it bore further religious questions and connections. It drives me crazy when books oversimplify scientific experiments, and assume that no one is informed enough to notice. The authors talk excessively about this physicist David Bohm, who yes, is creative and brilliant, yet also outside the radar of the majority of the physics community. This, in and of itself, is not necessarily a bad thing. When they start talking about his interpretation of Bell’s theorem as displaying non-locality at work, this is highly debatable, and in my opinion, the wrong interpretation (this is, if you remember, what my entire thesis was on). Aside from selective references to scientific studies, the book did highlight some important theological questions. I have created a new word document for our discussion of these questions, knowing full well that without organization, the Hughes-Peteet correspondence will be lost on my desktop, never to be uncovered.

First, some quotations to reflect on:
1. Once you see what’s needed of you, you act spontaneously (91)
2. Two central questions: Who is my self? What is my work? (101)
3. If you form and hold your intent strongly enough, it becomes you (134)
4. You cannot do great things. You can only do small things with great love. (139)

The central point of this book is true change happens through individual transformation. We transform when we discard our previous assumptions and commitments, and see how our individuality relates to the wholeness of which we are a part. The most tangible example of this is the man who sees his childhood farm burn down, and in doing so, feels liberated from his material connections. The diagrams they use show the relationship clearly.

Basically, self-growth involves confronting our deepest fears and anxieties – without judgment. Sound familiar? What is interesting is the fruits of this process. I find it easiest to relate this to teaching. “Operating from this larger intention brings into play forces one could never tap from just trying to impose our will on a situation (91).” I immediately recall that I am the most powerful, inspirational teacher when I “hold my intent strongly” and have a deep-seated reason for teaching. Otherwise, teaching becomes the imposition of wills – teacher vs. students, which is oppressive.
When I read this next piece, I thought immediately of your classroom. It is from an influential teacher of leadership, describing his own classroom: “Too many people’s lives were being too deeply touched for me to conceptualize what was happening in terms of resonances with my individual energy.” In other words, you are good, but not that good – some cosmic energy is behind you.
The end of the book talks very generally about the connection between self-discovery and science.

I think that one of the fundamental ideas of Buddhism is that the reality of the phenomenal world is emptiness. This connects directly to the physical science understanding that all manifest phenomena are in flux, including our bodies and physical selves. We reify these through our thought, which creates the appearance in our awareness of substance, but this appearance is illusory. (184)

This is a decidedly Eastern turn of explanation. Some scientists unquestioningly uphold a metaphysical external reality to themselves, and operate under the assumption that they are discovering inherent properties of this reality. In fact, to question this simple assumption results in immediate, often virulent charges of postmodernist or relativist thinking. The metaphysical question of whether our reified thoughts correspond to an uncovered objective or experienced subjective realm is not necessary. The truth conveyed by science is that of reproducible and predictable phenomenon, which involves the interaction between scientists with the world of which they occupy. The illusion is not the external world, but dualist perspective that we have inherited from Plato.
Despite dropping the ball on the scientific questions, Presence did powerfully describe where we as humans fall short, and where we need to go. Fundamentally, we see ourselves as fragments from an interconnected world. We view our conscious self as a disconnected part of nature – not something, dependent, organically tied, and devoted to nature. It is rare that we find ourselves under the control of nature – when we do it is frightening, as when we are at the whims of a rubber tube and rapids, screaming for help. Otherwise, we are in control – in cars, on laptops, etc… I guess my point is we should hug more trees.
Actually, my point is that our spiritual consciousness is re-directed (subverted) to technological and scientific pursuits. This reminds me of when I went on my Brookline tirade, about how no one is open to new dialogue or growth. At worst, we are like the narcissist in Peck’s A People of the Lie who infringes on the spiritual development of others. How, then, do we start to hug more trees? I have found very few non-preachy ways of expressing this. After all, how do you tell people their way of looking at the world is incomplete, without sounding a bit forward? Anyways, I think the book does a good job in describing what I see as the concept of charism – put simply and without religious overtones.

“The ultimate aim of the servant leader, the quest, is to find the resources of character to meet your destiny, and to find the wisdom and power to serve life that way.” (221)

Stick Jesus in there if you want, and the message stays. My question is this: where is our agency in this process? Is self-discovery a process of active process or searching, a passive process of revelation, or some combination of both? The book often notes that to experience the “bottom of the U” and find stillness within ourselves involves “bringing future potential into reality.” Dewey places activism within our capacity for becoming, moving, and projecting into the future. His pragmatism rejects traditional sources of inspiration (relying on religious metaphysical pictures), and thinks we are better off repositioning ourselves to act meaningfully for the future (Dewey must have roots in Nietzche – building off the idea that God is dead, and that man is in a position of re-creating himself. I’m sure there are a few books written on my oversimplified point. You can find them at Columbia, or have the scary-goth girl tell you all about them).
Now back to the original question: Does the “energy” or strength in our process of becoming derive from ourselves, an external source, or from a God that resides within us? Thus, the infamous Shieh/Hughes divide! Here, a brief conversational interlude:

Shieh – I am sustained by discovering and becoming the person I need to be to enact change in the future.
Hughes – [I’ll let you fill this one in]
Shieh – And turn off that damn night light.
Hughes – But look at Tom’s fan!
Shieh – That’s for a future family meeting. God will not save us from environmental destruction. I don’t believe in miracles. Thus, the night light needs to go off.

And it continues… Someday, our dear reader will find this either hilarious or pointless. Probably the latter.

Now that I’ve opened up the internal/external can of worms, I am going to close it. You have your room to respond. Onto a similar problem, for theists and atheists alkie: the paradox of freedom. Here it is – when people surrender (to God’s will or by abandoning their preconceived habits of thought) they experience it as an act of freedom. Just think of the person of faith who surrenders to God and feels liberated – free to act within the world. Or think of our environmentalist who hugs a tree and surrenders to it, and who feels clear-header, and renewed.
The experience of freedom seems more explicable in secular terms – we are no longer bound by our traditional habits of action, and therefore are free to entertain new forms of thought and love. For the theist, this sense of freedom becomes more complicated. Where does the agency of God enter, if at all? What is the relationship between our discovery/enacting of our charism, and God’s role in creating and sustaining this discovery? How do the religiously devote conceive of God’s purpose for them? Is the mere proposition “I exist for the glory of God” adequate, or would most subscribe to the teleology of Peck, who asserts that God’s goal is for humans to become “like him” through reaching higher levels of spiritual growth? The crux of these questions is how God interacts with/within us, and how She (ha ha ha) promotes or gives us our free will.

Here is one of the few places where the burden of explanation lies with the theist. I know, most atheists would say that religion always bears the burden of explanation – proving, justifying, and explaining the existence and working of God. This is one reason I think that conversations about belief are rarely fruitful – the atheist wants an explanation for everything, yet believes they have nothing to explain. To drive this point home, think about your conversations with Kim – she feels as if she has nothing at stake. After all, in her eyes, her world-view is impenetrable because it based completely on rationality. And, of course, she thinks, religion is under no circumstances rational. [Lewis’ essay on belief/non-belief applies directly here, and I will leave it for another time] If I learned anything from the Freud-Lewis video that we never finished, it is that an atheist world-view involves as much commitment to a set of beliefs as a theists’ worldview. In addition, it is necessary to investigate the origins of our own worldview, whether in the context of our relationship with our father, or our early experiences with church, death, and doubt. Personally, it is hard for me to honestly completely separate my atheism from my parents ardent Christianity. Then again, I am not opposed to other forms of spirituality, or even openly considering the nature of a non-monotheistic, non-intervening God. I guess my reaction against my familial history of Christianity manifests in my feeling that I don’t need church, not to mention that disbelief in central tenets of Christianity (i.e. that Jesus was God, for example).

I think it was Lewis who wrote that the existence of Good is far more puzzling than the existence of evil. This is something the atheist must explain, through evolution, consciousness, etc.. Lewis’s argument against an evolutionary account of the emergence of Goodness is powerful, yet Eric and I think we refuted it, late one weekday night over a nightly snack of hot water, celery and cookies (the cookies were for me, and ended up all over my face). So, there is much theology, (or negative theology as I might call it, ha ha) to be done, even for the atheist.

I want to end bridging theory with action and service. What is religion, after all, if it doesn’t address how we engage with others? The end of the book refers loosely to three part process of service:
(1) Practice – discipline for quieting the mind
(2) Study – theoretical knowledge
(3) Service

As I have said to you before, and as we discussed with Sister Carla Mae, I really believe that I need some practice to ground all of my spiritual questionings/yearnings. Right now, I am operating out of pure scholarship and service. It may sound scary, but you are a model of this three-part process for me. I can see how empowering/sustaining it is for you spiritually/practically to be involved in as strong of a community as Emmanuel. I am not writing this seeking an answer from you on this matter, or even corroboration that this is something good. Like my reflections on reacting to my parents’ religion, I am “letting free’ of this thought – and in doing so, have confidence that when it flies back to me, I will be glad for letting it go.

Letter to the St. Louis Post Dispatch - February 2007

2007-10-09T21:19:00.000-07:00

This is a letter I wrote to the Post-Dispatch as a teacher of L'Ouverture Middle School in St. Louis. Due to Union politics, this never made it into the edition. I think it captures the harrowing reality and enormous potential of the my students' future education.

Destiny Booker is the most gifted 7th grader I have ever worked with. She walks with zing, does math like a wizard, and wants to learn calculus this year. I believe she can. The magnet school application denied her request for admission based on “scores under 85.” Does this take into account that she has had 4 social studies substitutes this week? Or, that her English teacher doesn’t give grades higher than a B – lest the students “think too much of themselves early in the year?” No and no.
I’ve read Destiny poetry. One page is about boys, the next a rhyming couplet about school lunch. I’ve also read her math reflection where she says “I emailed my teachers from the county schools, and they are way passed us.”
Destiny future holds two options – remain in the public schools and barely make it to college, or go to McKinley and attend one of the most prestigious universities in America. Everyday I teach knowing this reality, and it hurts. It hurts because this is what available for the brightest minds in St. Louis. Tomorrow I will teach Destiny to derive the volume of a cylinder, then give her my calculus text book. I will wait with her after school, huddled on the concrete yard. Most likely, her bus will be late, and she will scurry along, with a single book in hand for the weekend.

Phillip has a cell in juvi waiting for him. His special education teacher stopped me to tell me this. Phillip apparently made a poor choice and stole candy from a teacher. This was familiar to me. In 3rd grade in my affluent public school, my friend Brian stole a Game-boy. They held a parent conference with all the teachers, developed a behavior plan for Brian and led a class discussion on respect for property.
Phillip is in my reading class this year – the lowest level class in the school. Every day he struts into class carrying an Animorps book, an unmistakable lisp, and a vivid imagination. When I asked him what he most wants to be in this world, he said “a power ranger.” In the hall, Phillip constantly plays, so much so that it is invective. He tries his new wrestling moves out on me, and then we talk about super-heroes. Tomorrow we will have a class raffle, and with it a discussion about respect. I guarantee he will be courteous, honest, and kind.

One of my biggest struggles as an educator is deciphering exactly what my students need. I can usually tackle this well on the instructional level by asking “What does Destiny need to get the instruction she deserves? How can I best help Phillip to read?” On a school-wide level, I am consistently stumped. Do my 7th graders need more positive attention? More love? More tough love? Or just more serious consequences for their actions? Everyday I play with a dangerous combination of all of these.
At L’Ouverture, it feels as if only I am self-critical. With a staff of over thirty, there are only a handful of staff members the students say hello to. As for the teachers, they have made up their minds. The students need discipline, and it is our job to give it to them. Ironically, the same teachers who advocate hard punishment are the ones who attain the least respect.

Today the social studies teacher was absent. The substitute must have heard “L’Ouveruture” and decided not to come. Instead, the special education teacher took over the class, which prevented her students from receiving their accommodations. This is not just unfortunate, but illegal. I received a note from the special education head that read “The special education teacher cannot be with you today. She has an urgent IEP to finish.” In other words, they want to expel at student, and must do it now. Meanwhile, my 7th grade student Chris struggles to read a passage at 3rd grade level. I am the only teacher able to help him. I thought about writing a note back that said “This teacher has a legal and moral obligation to teach Chris to read this instant. She must return immediately.”

Fifth period, I realized that there would be no one to watch the social studies class. As the team leader, I sought out any teacher to step up and watch twenty students for a class. I pleaded with four separate teachers, and was greeted with the same response – I can’t, I have too much paperwork today. Instead of jumping at the chance to laugh with Phillip, or philosophize with Destiny, these teachers will eat an extended lunch and do paperwork. After hours of work, Phillips’ IEP will contain ungrammatical sentences and frivolous goals such as “student will recognize the numbers 1-20 with 80% accuracy.” There will be no mention of power rangers, wrestling moves, science fiction, or Phillip’s moral growth.

Everyday I teach with three goals: love my students, be myself, and push them harder than I have ever imagined. I arrive at 6am with compassion and energy and leave at 7pm with exhaustion and outrage. The reality is that even if I petition to get Destiny into McKinley, there are fifty students who will not have this chance. The reality is that if Phillip makes one more mistake he will spend a significant portion of his adolescent in the criminal justice system. The reality is that every time we deny Chris his reading teacher to place her as a substitute, we are committing a crime. At some point during the day, this reality begins to hurt. It hurts because this is what available for the brightest minds in St. Louis. This is the reality of the Saint Louis Public Schools, and change is long overdue.

St. Louis Documentary - One-Up, take one

2007-10-09T21:17:00.001-07:00

In the next two and a half weeks, I will be filming the first part of a five year documentary on eight of my students from the St. Louis Public Schools. I am mixed with enthusiasm, curiousity, and dread over the magnitude of this project. Here are my thoughts and notes so far. I am interested in any/all comments, but am particularly interested in the following:

1) Do you know of anyone with tangible film experience I could talk with?
2) Do you have any probing questions about the essence/mission/outline of my project?
3) Are there any additional questions you feel I must ask students?

Inspiration #1 -
Last night I had the prototypical “educational inequity” conversation with a few friends where the familiar arguments of low-quality teachers and administrators surfaced. My friend Chris then shifted the subject from blame to me personally. He asked me what my most significant gain was as a teacher. I described my class goal for my students to master 2 years of math in just one, and their incredible dedication towards reaching it. I also described my joy at perusing their near perfect scores on the statewide math test. He then pushed me to quantify the number of students who “will be on a different life path” after having me as their teacher. I commented that the number was around twelve but had no idea.

This got me thinking about my project. What, exactly does it mean to be on a different “life-path?” Obviously, this will look different depending on the student. Some students will have the confidence to take advanced algebra in high school, others will be pushed to go on to college, while for some my nagging voice will hopefully linger with them throughout their academic careers – and push them to see the value in education.

Chris’s question also solidified that I have an obligation to my students to stay in their lives. The Tasha’s, Ariel’s and Destiny’s who are graduating from high school now are going on (at best) to mediocre St. Louis colleges and universities. Case in point – the saludatorian at Roosevelt High School – one of the largest public high schools in St. Louis, will be attending community college next year. Throughout high school our students are not challenged, inspired, or provided the resources necessary to reach their academic and personal goals outside of high school. One of my major goals through this project is to push my students to re-evaluate their own goals and ambitions. Another goal is to provide them with the knowledge and resources to achieve their goals – whether this means providing references, researching summer camps, or walking them through the college admissions process. Finally, my goal is critically engage in dialogue about social and education inequity. This last goal is two-fold:
I am interested in how students frame discussions of poverty, race, and inequity throughout their adolescence. This interest is not purely academic. It is only with an understanding of moral development can we engage with adolescents to produce positive action.

I strongly believe that the public policy debate on education needs voices – voices of our children – those who have enormous potential yet are consistently short-changed. There needs to be faces to the achievement gap. Instead of a sound bit that “low-income students are 3-4 years behind peers in suburban communities” we need a narrative of what this looks/feels like to these students. I hope this film provides this narrative.
Here are the broad questions I want to answer by making this film, along with the list of questions I plan to ask my students.

Broader questions for the film:
How do high expectations from a single teacher shift the life prospects of students in poverty?
What sustains the cycle of intergenerational poverty, and how must we respond to it?
How do teenagers perceive social inequity, and how does this perception change with age?
How do teenagers perceive their role/legacy in their families – how do they plan to act this out?
What resources are students getting/not getting through the public school system?
What are students’ goals and aspirations and how do they adapt through adolescence?
Documentary Questions for students (by topic)

Teachers
Describe the best teacher you have had. What about them inspired you? How did they treat you? What were their expectations of you?
Describe the worst teacher you have had. What about them inspired you? How did they treat you? What were their expectations of you?
Describe the principal of your school.
What would you do differently if you a school principal?
What would you do differently, if you were a classroom teacher?

School culture
Who is responsible for making schools better? Rate in order of responsibility – Students, parents, teachers, administrators (principals, district people)
Do you think it is important for students to fear their teachers/principal?
Which statement do you agree with more strongly – A) “In school, teachers should be feared and treated above students.” B) “In school, teachers should be given the same respect as students.”
Why did you chose that statement?

Social Inequity
Only 3% of L’Ouverture students scored on grade level last year on the MAP test. [Or, another telling statistic – Students who graduate from St. Louis Public Schools read and do math on an 8th grade level.] Why do you think this is?
In your opinion, what is the difference between the county (suburbs) and the city? (Open-ended – I will give the students the opportunity to define the difference in terms of racial make-up, schools, etc… Basically, I am trying to figure out how they approach this difference over time)
Do you think students in the city or the county get a better education? Why?
What does it mean for someone to be racist? Have you ever known anyone who was racist?

Family/Home life
1. Describe your family.
2. Who is the most important person in your life? Tell a story about this person.
3. How do you feel about where you live?
4. What should be the role of a father in someone’s life?
5. What should be the role of a mother in someone’s life?

Short-term goals
Did you have any personal/academic goals in the past year? Did you achieve them?
What are your goals for this summer?
How do you define success? (For students to falter, I will give the examples… to make money, have a good family, give back to your community, etc…)
Who is the most successful person you know? Describe this person.

Long-term goals
What are your dreams in life?
Have your dreams changed since you were younger? How?
What are three goals you have for the next year of your life?
Are you planning on going to college? Why? Why not?
What is your ideal job? What is your second choice? Why?

Friendship
1. Who is your best friend right now?
2. What qualities make a good friend? (trustworthiness, popularity, humor, etc…)
3. Tell a story about a time you had a conflict with a friend. What happened? How did you feel? Was it resolved? How?
4. How have your friendships changed over the course of middle school?
5. How do you think your friendships will change in high school?

Thanks for reading.

More to come tomorrow....

Tom

on dawkins, god and theology

2007-10-09T21:12:00.000-07:00

"God was invented to explain mystery. God is always invented to explain those things that you do not understand. Now, when you finally discover how something works, you get some laws which you're taking away from God; you don't need him anymore. But you need him for the other mysteries. So therefore you leave him to create the universe because we haven't figured that out yet; you need him for understanding those things which you don't believe the laws will explain, such as consciousness, or why you only live to a certain length of time--life and death -- stuff like that. God is always associated with those things that you do not understand.”
- Richard Feynman

This writing has been in the works for a long time now – bits and pieces written in China, St. Louis, and on an airplane. Someday I hope to write a more comprehensive, less invective and balanced view on spirituality. Alas, this is what I’ve got for now. I have found that whatever I happen to be reading at the moment somehow infiltrates anything philosophical I write. Here are my main sources up front:
Hannah Arendt’s The Human Condition, John Barr’s Modern Physics and Ancient Faith, Richard Dawkins The God Delusion, and an article in Christianity Today by Platinga in response to Dawkins (the link is below).

http://www.christianitytoday.com/bc/2007/002/1.21.html

Atheists see Richard Dawkins as a liberator, a secular-savior, whereas theists claim he is a hack. Can he be both at once? I would argue so. His major attraction and flaw is that he writes on the cusp of good theology – not quite there, but close enough that we follow him. He is trained as an evolutionary biologist and thus has no need for the principle of charity in his writing. His philosophical tools are also somewhat limited – save for the “straw man” argument and a few other rhetorical devices. In short, he does not give theology a chance, and suffers for it. In the same way, his theist critics do not give naturalism a chance – they are too quick to refute it with tired philosophical tricks. At the risk of sounding postmodern, I believe the truth lurks somewhere between Dawkins’ and Platinga’s rhetoric. Both have pushed their positions to the extremes for obvious reasons. Dawkins can only mobilize atheists and assuage his own apprehensions about spirituality if he is as ruthless as possible. Similarly, Platinga must present Christianity as providing a coherent philosophy that captures all the atheists concerns. The following quote by Platinga illustrates this nicely:

So if Dawkins proposes that God's existence is improbable, he owes us an argument for the conclusion that there is no necessary being with the attributes of God—an argument that doesn't just start from the premise that materialism is true. Neither he nor anyone else has provided even a decent argument along these lines; Dawkins doesn't even seem to be aware that he needs an argument of that sort. (Platinga)

I think that this analysis reveals the polarizing sides to the debate about a Creator – where does the burden of proof lie? Dawkins clearly takes the position that it is up the theist to “explain” (granted, an explanation that would satisfy a materialist) the origins and workings of a complex God. Given this starting point, I don’t think this gives the theist anywhere to get off of the ground. Clearly, no one could give a scientific account of how an omniscient being could read the thoughts of millions of people, perform miracles, let alone create the universe. This part of Dawkins, though simplistic, appeals to the hard-wired scientific side of me. The second part of his argument that appeals to me is the historical, social narrative about how religious belief positively enhances community and is somehow naturally selected for. I believe that Dennett gives a more rigorous account of this in his book.

On the other side of the spectrum is Platinga, who equally unfairly places the burden of proof on the materialist to “explain/prove” that there is no God. This is like “proving” that your dog is not thinking about Shakespeare all day. We all believe that is improbable that your dog thinks about anything but sleeping and yelping. Also, we can give an account of dog behavior throughout history that explains why they think this way. Nevertheless, we do not have the experience of what it is to be like a dog, and therefore will never know if the dog is thinking about Hamlet – or ham. Similarly, our scientific explanations that discount a creator can only go so far. There is always something on the edge of science that we do not know – and many people are tempted to neatly fit God here. Paul Davies is an excellent example here – he takes recent discoveries in quantum physics and cosmology to “fit” a divine creator into physics.

What is comes down to is this: both atheist and theist are playing hot potato with the burden of proof – and whoever is writing is usually throwing it of his back. So here we are left back in the middle. Now let’s get down to some of their arguments.

One of the theist’s best cosmological arguments for God is the fine-tuning principle. Basically, the universe has some set of constants – gravity, the strong-force, weak-force, etc… and if these constants were different by a very small amount (say, that gravity is 9.79999999) we would not be here. The molecules in the Big Bang would have behaved differently, and these imperceptible differences would propagate over millions of years to produce – well, not us. This leads many theists to say that it was God who punched 9.8, and other constants into his computer, and said GO! The common response to this argument is some version of the anthropic principle – the only reason we think it is significant that a world with g = 9.8 harbors life, is that we happen to be in it. In other words, there have been tons of other universes with different gravities, but none of these came to anything. We are lucky, yes, but that does not mean that God made us. Physicists get around this fact by positing that there are multiple universes, separated by trillions of light-years away, where these different constants exist. We just happen to live in the one that allows life. Here is Platinga’s response to this:

So if there are an enormous number of universes displaying different sets of values of the fundamental constants, it's not at all improbable that some of them should be "fine-tuned." We might wonder how likely it is that there are all these other universes, and whether there is any real reason (apart from wanting to blunt the fine-tuning arguments) for supposing there are any such things. (Platinga)

This argument is also put strongly in John Barr’s book Modern Physics and Ancient Faith, and I think it is very compelling. Basically, the book runs through countless other examples of physicists appealing to mysterious, unsubstantiated entities (vibrating strings of String theory, multiple universes, etc…) to get around the simple question of the existence of God. For this argument, I accept defeat on behalf of the physicists. But all is not lost! The physicist should have just said – we are lucky, yes, but that does not mean that God made us. Just because g = 9.8 here and now and we live just means that we are lucky. We endow this with significant because – well, we are wired to do so.

Here is a practical analogy. I was in the Beijing airport, and out of the corner of my eye see someone I haven’t seen for seven years. I immediately shout out “Lizzy” and much to my surprise, it is the Lizzy I knew from college. Clearly, this is extremely unlikely. I may call it coincidence or synronicity, and then create a narrative in which this meeting has deeper significance to my life. There are thousands of different “futures” that could have transpired. I could have met Vince, Kristin, or TJ in the airport or a different city. Instead, I am living in the “future” that includes Lizzy. Now, here is the tricky part. The only reason why I think that Lizzy’s meeting was a coincidence is because I do not consider the thousands of meetings that did not transpire. Our brains are hard-wired to gloss over absence (see examples in Daniel Gilbert’s new book Stumbling on Happiness). It is true that meeting Lizzy is improbable, unexpected and even meaningful to my life (in fact, I learned a great deal about the Chinese economy from her). Nevertheless, this does not give the experience cosmic significance, or mean our meeting was somehow designed or orchestrated.

My meeting with Lizzy represents one possible future – analogous to where g = 9.8. My meeting with Vince in Wuhan represents another possible future – analogous to where g = 9.7. My meeting my death on the taxi cab to the airport another future – where g = 9.9. The point is I endow meeting Lizzy with significant because: it happened, I am hard-wired to create a personal narrative including this, and it is fun. If I had met Vince, I would have lived in a different future – but this event would be equally improbable, and I would have constructed a similar narrative of its significance.

How depressing! Aren’t we just back to Dawkins and thinking of ourselves as products of a random interaction of particles? Yes and no. The rationalist in me is persuaded that the fine-tuning of gravity, meeting Lizzy in the airport, and hundreds of other events are indeed, random. But there is no need for random to be a dirty word. We are lucky, yes, and this is a great source of joy and inspiration in my life. I am in awe of the precision of our universe, our ability to formulate physical laws, contemplate black holes and represent reality in pages of mathematical notations. I am inspired by seeing an old friend’s smile in the airport, meeting her father, and discussing social justice. There are places in The God Delusion where Dawkins hints that he feels the same way, though he is so driven to criticize religion he fails to expand on it. Plantinga, on the other hand, strives overbearingly hard to prove God’s plan in everything from fine-tuning to coincidence. I believe that the truth lurks somewhere in between. In the words of my favorite author Richard Feynman, “I can live with doubt and uncertainty and not knowing. I think it is much more interesting to live not knowing than to have answers that might be wrong.”

the most humane week of my life...

2007-10-09T20:55:00.000-07:00

Some background:

In the middle of this semester, UMASS gives us two weeks to devote to a "community health clerkship" to explore medical issues in the community. My clerkship is on adult mental retardation - a subject near and dear to my heart. For three years, I taught a reading class of children with disabilities. I wondered what happenned to them after public school - did they become the "crazy aunt" in the neighborhood - go into a group home - get decent medical care - or end up on the streets. Here is what I've found so far. I hope you enjoy. Comments are much appreciated as I have to turn this into a formal journal assignment in the next weeks.

“Hey, Tom. How are you Tom?”
Sue is slightly graying, hunched over shyly, and doesn’t like to make eye contact. The porch Sue’s home overlooks a dusty construction site. It is near dusk, and the crew has gone home for the day. Further down the road the high school football team practices, and sound of whistles, banging and grunting fill the air. Sue excludes all of these stimuli. Head down, hands clenched together, she continues.
“That’s great Tom. That’s great that you’re well,” She says softly.
Alexandra and I ask Sue to give us a tour of the house. She methodically paces through the house. In every room she pauses, as if waiting for our prompt: “What room are we in now, Sue?” She answers dutifully and moves on to the next place.
When we come to the window, she becomes giddy.
“Is that your car, Tom? Where is your car, Alexandra?” She clearly sees a disruption in the parking lot pattern of cars. There are no large white vans today, just my gray Volvo and Alexandra’s mini-van.
As we walk up the stairs, Sue’s breath increases, and she lets out little gasps. At the top she collects herself.
“Alexandra, I have to ask you something” She presents this as a secret, despite my presence standing next to both of them.
“Alexandra, I have to tell you something.” She whispers even more softly. “I have never been in your van before, Alexandra.” Her tone has a raspy urgency to it – as if Sue has left her life in Alexandra’s car – and must get to it immediately.
Over the next hour we tour the house with other members. If in clear sight of Sue, she sucks us back into her world, to ask us her same questions again and again.

During the first week of clerkship I have discussed health policy, human rights, self-advocacy, obesity and countless other issues with experts. Still, my mind keeps coming back to Sue. What does she think about all day? Who is important to her? What are her dreams in life?

When I leave the home, Alexandra and I don’t discuss these questions. We want to help Sue, and help her immediately. We also want to fit her into a larger puzzle – of health prevention, access, and care.

How does Sue get health insurance? How did she choose her doctor? What does she say to Sue when she comes to her office? Does she even talk to her, or just the aid present? Is Sue her own legal guardian? How does the doctor redirect her questions? Does Sue leave satisfied? Is she smiling when she leaves?

There is an essential humaneness to working with the developmentally disabled. Sue cares about my smile, how I like UMASS, and really means it – every time she asks it. Bob is eager for me to say hi and shake his hand – every time I walk by. Trust builds with repetition - humanity with acknowledgement of our basic need to communicate. I think of the educated environment of medical school, where undisclosed social dictums govern whom we greet and whom we tactfully ignore. As medical students we intellectually understand this – our social psychology courses in college enlightened us – and we have a term paper in the depths of our laptops to prove it. Nonetheless, everyday I selectively ignore people. As I step onto the front porch of Seven Hills, I actively ignore my pretentiousness. I am unburdened now by social restraint. In an atonal voice, I can recite the Brady Bunch theme song, and will be joined by a number of residents. Or, I can freely greet everyone, and have no fear of judgment. Sue will not unconsciously/consciously determine my social class based on my tattered Air Force sneakers, wrinkled J-Crew shirt and slouching posture.

10.9.07

Today began on a brisk windy road in Holden. I arrived to meet with the residential advisor for a four-person home care site. She greeted me kindly at the door and immediately offered me access to a brick of files that made up her patients’ histories. I sat down, coffee-less at her desk, feeling a little out of my element. I had no idea where to start. In front of me, lay a tome of information about medications, behavioral plans, podiatry appointments, and even bowel movement logs. I decided to start with history. For Jim, the doctor was excellent to point out his abilities first – he favorite activities were playing with string, being outside, and going out with staff members. Next, came his laundry list of medical diagnoses, the material that thickened his blue binder to overflow capacity. I have begun a habit of skimming material backwards to forwards – perhaps for unpredictability or just to avoid the hyper-clinical prose. As I searched forward, I came to his yellow tag labeled “psychiatry.” Yes, I thought, this is where the action is going to be! I was wrong. Every page bore the illegible script of the doctor’s symptoms and prescriptions. Every shortened “r” or absent “e” signaled hurriedness, fastidiousness, and annoyance at the specific form provided via DMR. “Patient shows no signs of scratching or self-injurious behavior – refill current meds…”

As I flip through the thirtieth of these scripts, I feel jaded. Is this really what I want to do for a living, I ask myself? Fortunately, I do not have time to indulge my career phobias. The ambulance is here, and Jim needs to be moved for his appointment to get his feeding tube replaced. I follow the director into Jim’s room – while walls bear scattered paintings – an artistically rendered American flag, a Van Gogh replica couched within a faded wooden frame, and a Patriots team flag. The pictures hang amidst the 19th inch Panasonic –blaring “classic” music videos from the 70’s. The EMT arrives just in time to read my thoughts and express them. “What is this supposed to be? I’ve never even heard it before?” I agree, thinking it must be a mutant artist crossed from Kevin Bolton and Barbara Streisand DNA. I’m glad I just missed the 70’s I think, but keep this to myself. Within old paintings, music videos, and medics lies Jim. Unlike the EMT, and myself Jim did experience the 70’s and clearly appears calmed by the television. He wears a blue rugby shirt, unbuttoned at the top, with the number 88 stitched on the chest. Jim has the look of a rugger – strong build, thick jaw, and burly. I do not yet know that he is paralyzed on his left side and cannot walk. Jim’s eyes belie his physicality – their blueness radiates upon the yellowish-white walls. He is so peaceful, I think. I do not yet make the connection that this is the Jim – who gags himself frequently and tries to pull out his feeding tube.

My eyes now wander to his right hand, which passively sits, tied to the rod of his bed. I remember speaking with his doctor about this “restraint” – without it Jim will claw himself into pain. This does not please the guardian advocating for Jim, and he wants the restraint removed. Politics aside, I am surprised how pleasant his hand looks. I was expecting handcuffs or a painful contraption, like the cage in my parents basement used to trap squirrels. Instead, Jim’s wrist rests supported by a light-green towel – his hand strapped carefully by a sling fabric from an old tee shirt. The director cautiously removes the sling, and slips her hand into his. As I admire her care, I notice the EMT has moved out of the room to get the stretcher. From the far end of the house, I hear “Can you find me that meds list?” She offers to me “can you hold his hand for just a moment?” I accept. I slip my hand beneath his. His hand weighs a heavy pressure on mine, his fingers curled within mine. Jim’s thumb sticks out above my hand, its girth twice the size of mine, and nail twice as long.

Now it is just Jim and I. I tell him softly “I like your rugby shirt, Jim” he shows no response. I hold his hand more tightly, kneading my fingers into his palm. I perceive his dull grunt as acceptance of companionship, but cannot be sure. I want to give Jim love and support, and this is all I know how to do for him. In return, I will accept any utterance as validation of my presence. I wonder what it is like to work with Jim, day in and day out. I wonder what it is like to know his grunts and gurgles, twists and turns, head rocks and bobs. I wonder at what point he and his nurse solidified this physical language – at what point his caregiver reacts unconsciously, mirroring Jim’s need with compassion. Now we are placing Jim on the stretcher. His body weight thumps into our forearms as we pull his sheet, lift, and let him down. Meanwhile, his hand clenches more tightly. He knows I’m here for him, I think.
All of us pile into the ambulance for the ride to the hospital. As the two EMT’s load up Jim, one of them stumbles with the stretcher. “Pull up the back, will you?”
“We didn’t have these stretchers in New York,” replies the other. I learn that he is a “newbie” – a fact that becomes painfully obvious as the day continues. The newbie fumbles with the exhaust in the back of the ambulance – the driver scolds him and lets out a frustrating sigh. The newbie then takes Jim’s vitals. He estimates the blood pressure by the ticking method – with no stethoscope. Not only this, but he does so on Jim’s paralyzed side. I learn that they probably see at least one person die a day, work up to 24 hour shifts, and cars frequently don’t pull out of their way.

We arrive at the hospital to the familiar experience of waiting. I had thought that door-to-door ambulance service would preclude us from this charade, but I’m wrong. In a cramped office I wait with the residential director and two dueling EMT’s. Jim lies placidly on the stretcher as the common bond between us all. Our voices carry over his herniated stomach, shrill enough to keep him eyes fluttering open every few seconds. The crowded atmosphere brings out our worst experiences. We go in rounds: “Being dispatched to MGH is the worst.” “I was watching this craniotomy, where they take part of your brain and store it in your abdomen for six months.” “These are the issues we deal with for this population.”

The doctor comes in quickly, followed in tow by a resident. We exchange pleasantries and then get down to business. The hospital has not ordered the 24-g-tube replacement for Jim, and they only have the 18 in the room. Jim’s need have fallen through the cracks, and we wait further for them to scavenge a 22 from the hospital downstairs. The doctor and resident leave to take care of this. “They knew he was coming for weeks,” the residential director says calmly. She is not surprised, just disappointed. I imagine what she is thinking, but too polite to say. I then look over at the EMT’s blank looks. “Aha. This is what my high school English teacher meant by the expression ‘elephant in the room.’” The elephant in this case is the pressing question, “If Jim were not mentally retarded, would this g-tube foul up have ever happened?”

The doctor returns and treats Jim with the utmost dignity. She lifts his rugby shirt to find a herniated stomach, and half-inch hole leading to his feeding tube. I have not eaten enough breakfast. She lubricates the new 22-tube and places it to the side. With swiftness, she pulls out the current tube to the sound of a small fart. Now for the hard part. She struggles to place the larger tube, as Jim writhes in pain. His director holds his hand tightly, and he rests his head upon her shoulder. The EMT’s and I stand-by and watch with curiosity and encouragement. The crisis moment brings out the best in all of us – Jim winces with pain, and we know how to help him.