As part of an independent study during my final year at ODU, I worked with Dr. Elizabeth Vincelette in designing a course curriculum with two objectives: 1) to encourage humanities students to pursue careers in medicine and 2) to instill empathy in all students considering a medical career by challenging their concept of the patient-physician relationship. Below are my journal entries in chronological order (newest to oldest) that I kept while I was creating the course. The syllabus is now complete and can be viewed here.
As part of my proposal for this course, I wrote an article “The Case for Bringing the Medical Humanities to ODU,” which was accepted for publication in the Fall edition of the Honors College Undergraduate Research Journal (not yet published). The final draft can be viewed here.
The course was since accepted by the Honors College and we are hopeful that the first class will begin in the Spring of 2018. I would like to thank everyone who has supported me throughout this project; but more specifically, I would like to thank Dr. V for her continued help, support, and guidance; and I would also like to thank Dean Metzger who has helped tremendously in making this course a reality.
If you have any questions, feedback, or advice on my course proposal or article, please feel free to comment below or email directly at firstname.lastname@example.org
I’ve definitely ruined my batting average given this recent, almost month-long hiatus; but considering that the end of my undergraduate career is fast-approaching, I trust you can understand why I have been away. These past few weeks have not been completely unproductive, however, in terms of this course. I have struggled these past few weeks in deciding how to end the course. Originally, I had planned to include either The Doctor’s Stories chronicling the life of Dr. William Carlos Williams or Hospital Sketches by Louisa May Alcott discussing her experiences as a nurse during the Civil War. Yet, as I began both of these novels, neither touched on the heart of the subject that I had been pursuing throughout the creation of this syllabus. Instead, I began anew and found one of Dr. Verghese’s novels. I have long admired Dr. Verghese, who now works as an infectious disease specialist, ever since I heard his TEDTalk on the importance of the doctor’s touch. Dr. Verghese’s novel My Own Country, is a fist-hand account of his experiences during the start of the AIDS crisis. He gives his accounts first-hand while he was serving a rural community that spanned across Eastern Tennessee and Western Virginia. In my eyes, Dr. Verghese is the ideal physician. He is kind, patient, and compassionate in his approach with his patients, and he sees his patients as people. To end this course, which works to instill empathy and compassion into its participants, by viewing the patient-physician relationship through his eyes then seems like the best possible way to conclude.
With that said, it is with great joy and pride that I finally present the completed syllabus for this course: Coming to Terms with Our Mortality: A Lesson on Empathy
Paul Kalanithi’s When Breath Becomes Air is a book that everyone should read. A neurosurgeon in the middle of his seven year residency is confronted with the prospect of death and chooses to face it head on. The physician becomes the patient. And in confronting his death, he echoes many of the sentiments that we have been exploring throughout the course of this syllabus, especially those of EKR and Dr. Gawande. Given the personal nature and biography of this book, I don’t want to speak to too much of the content but I was incredibly excited to find the Dr. Kalanithi’s novel masterfully blends and codifies the lessons on death we’ve learned previously.
Over the course of this semester as I’ve worked to piece together this course and test the novels against what I hope future students will learn as well as what I hope to teach myself along the way, I have been consistently reminded of this lesson’s importance as I’ve continued to work throughout the emergency departments in my area. I have witnessed patients not fully understanding their physician’s treatment plan for them and not knowing what questions to ask as their physicians is busily preparing to leave their room. I have seen the lucid elderly patient present to the ED after having his first fall at home, knowing that Dr. Gawande marked this as the beginning of the eventual decline. Or the patient who often chokes on her food in her old age, which I’ve learned is due to the change in the curvature of the upper digestive tract. I have seen physicians discuss their patients with the nurse in front of their patient as if the patient were not even there–just a pile of meat with an illness–commenting on the smell in the room, the hilarity of the picture on the patient’s chart, the possibility of death of the patient alert and struggling to breath. How many times I’ve wanted to scream, “they’re still alive, they’re right here, they’re a person, they hear you!” but yet could not due to the nature of my position. I am here to observe, to learn how to document charts, to learn how to problem solve and “treat” patients, to learn how to become a doctor. I have learned many things throughout the course of my employment here and now more than ever, this course has become my escape, my release. Through this course, I can somehow attempt to instill the humanity and empathy back into the practice of medicine.
This callousness towards the patient is not the ultimately fault of the physician. In conversations with these physicians outside of the exam room, many of them are extremely brilliant, pleasant, and often funny, yet their approach seems callous, I assume, as a mechanism developed over years of practice to survive the harshness of their positions. These are physicians who deal with death on a regular basis–it becomes easier to be hardened to it–to treat the numbers on the screen rather than the patient right in front of you; but this cannot be the norm.
My hope for this program is for future students to not only learn empathy, but to become more compassionate overall, and to learn about and approach death and dying in a meaningful way. Dr. Kalanithi often looked at his place in the world as a man who fights against the grasp of death yet in the end, he realized death’s place and that death, regardless of its timing, was a call for meaningful interaction–a call to action, to decide what you want to do in the time you have left.
I would like to think that in another life, Dr. Kalanithi would have taken this course. As he described his work before his diagnosis, it was clear that he was one of the good ones. He treated his patients like people.
“Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end.” (Kalanithi, 98)
Briefly, I also wanted to discuss Emma, Dr. Kalanithi’s lung cancer oncologist and her treatment of Dr. K throughout his illness. I cannot adequately express the amount of admiration I have for this woman in the way she is described. She is fiercely intelligent, admired in her field, and known for telling her patients when to push as well as when they need to reprioritize goals. She refused to give Dr. K what he wanted by estimating the amount of time he had left. Instead, she focused on meeting what his goals were. She ensured that his life before his illness was preserved so that he would be able to go back to it once his symptoms were under control. She became his confidant, the captain of his ship. At one point, Dr. K was admitted into the ICU and recalled how all of the specialists that were assigned to his care were bickering about the appropriate way to proceed. He wasn’t well enough to serve as his own advocate and he prayed for a captain to enter and direct his course, and in comes Emma who completely takes control of his care, aligns his specialists and rights the ship. Emma followed him throughout. At another moment Dr. K had decided to quit his residency program and Emma supported him as long as he was doing so because he wanted to and not because of his illness. Emma is everything I hope to emulate as a physician. She pushes until she knows when to stop. She is the embodiment of the physician Dr. Gawande described–not a Custer but a Robert E. Lee.
I’ve just finished reading On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families by Dr. Elisabeth Kübler-Ross and I cannot speak more highly of it. EKR was a psychiatrist by trade who completely shattered the norms of hospice and end-of-life care after she married and moved to the States in 1958. She observed that when patients were diagnosed with terminal illnesses, physicians and medical staff would often begin to alienate themselves from the patient in an attempt to escape the prospects of their own mortality. EKR quickly discovered that patients were often rapidly declining in their illnesses and were unable to communicate their final thoughts, hopes, and wishes because no one ever thought to ask them what they were. In an attempt to shield them from the pain and anguish of a terminal illness, it was the default response of the physician and family to often not disclose to the patient the details of their condition out of fear that the patient would be unable to confront the reality of their own demise. The result was a patient in rapid decline, seen as hopeless by the medical staff, whose only inkling that something is wrong is through the hushed tones, muted voices, and pitiful tones directed towards them. The patient knew they were dying but they more often than not continued the charade because they were never given the opportunity to broach the subject with their family or their physician.
Enter EKR who organized a multidisciplinary seminar of physicians, medical students, chaplains, seminary students, and nurses who interviewed patients facing terminal illnesses. In doing so, these patients were placed on the center stage and allowed to express their ideas, their emotions, and become part of something bigger. They were allowed to make their wishes known and vent their frustrations; and more often than not, at the conclusion of each seminar, the patient would generally be much happier and more at peace with their situation than they were previously. These seminars continued with a very simple mission–to learn as much as possible about end-of-life care from those directly living it. What can we as physicians do better, what is something you wish we had done better, what do you want people to know that you think they don’t, etc?
Throughout her book, EKR includes dozens of transcripts of these conversations and describes what she’s learned from these patients as well as how this program seemed to affect them and the staff directly. What was more amazing was the amount of push-back EKR got from the attending physicians–calling EKR a buzzard for hovering around those approaching death–until they were given the opportunity to hear what their patients had said in the recorded interviews, a portion of which can be found here , and these were things that the patient felt that they were unable to express to their physician because their physician had never before taken the time to discuss what was happening to them.
EKR was the first. She completely challenged the medical community in their care of terminally ill patients and she breathed a new life and a new sense of purpose into life’s final act by giving these patients a voice and purpose again. For as importance as EKR’s work has been and for as much time and effort she has dedicated to the medical field, EKR fell victim to many of the same practices she railed so strongly against–the indifference of the medical practitioner. In an interview given following a stroke in her final years, she discussed how dissatisfied she had been with her care and treatment while in the hospital and that she was treated not as a person but as an illness, a woman without a voice or purpose. EKR died in complete disbelief that she had fallen victim to that which she had fought her entire life against.
As unfortunate as EKR’s story is, her work lives beyond her. It’s a simple idea, really–talk to your patients. In the film To Live Until You Die, EKR discusses how what she has done is nothing new. “I didn’t invent anything new” she said, rather she simply listened. When she was a medical resident in Switzerland she was in charge of the health of several villages. And while she had never received a formal education in dealing with the terminally ill, she was quickly confronted with several of these patients as a new physician in her practice. She would do her rounds throughout the day and then save the rest of her day to care for these patients. In this way, she allowed them to become her teacher, which made all the difference.
Her concept is simple but extraordinarily powerful; and her work is at the very heart of what Dr.V and I are attempting to instill in the students taking our course and eventually our program: compassion, empathy, love. To be stoic is not human. It is important that the physician remain grounded in her humanity because without that grounding, we retain no other way to connect with our patients without slipping into complacency. EKR taught us that both throughout her life and in her death.
For this reason, I have decided to rearrange our syllabus. I will now begin the semester with EKR’s book and continue on into Tolstoy and then Gawande. I find it interesting how much of what EKR was writing about in the ’60s and ’70s was repeated almost verbatim by Gawande decades later, which serves as a bitter explanation as to why EKR was treated the way she was in her final years. The medical community has yet to learn; and it is my hope that this course will begin to teach future physicians from the very beginning so that no one, no patient, ever feels useless, out of place, or without their voice.
I’ve diverted from our syllabus to read Tolstoy’s The Death of Ivan Ilyich, which Tolstoy wrote following a nine year writing hiatus after Anna Karenina was published. The novella was mentioned in Gawande’s novel, which I read previously, and I thought that this would be an appropriate diversion. The hundred page novel follows the life of Ivan, an accomplished lawyer, who finds his health in rapid decline. While his physicians assure him that it is a mere illness, Ivan correctly assumes that this hope for his recovery is nothing more than a facade carried out by his family under the direction of his doctors. Because of this uncertainty, Ivan is never given the opportunity to come to terms with his death. He begins to view his decline as a punishment rather than a function of an unknown illness, and also begins to to view himself as more of a burden on his family over time. Ivan eventually prays for death to come quickly because he cannot stand to live in the shadow of the life he once had, and it’s a prayer that is eventually answered. Tolstoy’s novella takes us through the end-of-life experience from the perspective of the patient. He highlights the importance of end-of-life discussion between the physician and their patient by showing what happens when that conversation never occurs. We leave Ivan on his deathbed with a greater understanding that what we fear most in this world is not death but rather the act of dying. We fear the sensation that we have become a burden to those we love. We fear the conscious loss of our independence and the diminishment from the person we once were. No one should ever feel this way, and physicians are in a prime position to prevent the patient from ever feeling this way.
I’ve just finished reading Being Mortal by Dr. Atul Gawande, and let me tell you that I have never cried/teared up so much because of a book in my life. Not only is Gawande’s writing direct in its narrative approach; but Gawande tackles an issue that cuts at the very heart of what it means to be human– our mortality. Gawande is a surgeon by trade and found that as he was preparing this novel, he was guilty of some of the same approaches as other physicians in approaching end-of-life discussions with his terminal patients. In a “Dr. Informative” approach, Gawande describes that many physicians, when faced with difficult discussions, find themselves receding from the former patriarchal doctor to the physician who removes himself from the conversation and becomes a translator instead by laying out several options for treatment and allowing the patient to decide the direction to take. While this seems acceptable, empirically, very often the patient is coerced into pursuing an aggressive treatment in order to appease their family members or because they have inadequate expectations of the likely outcomes. The patient is rarely confronted with the necessary end-of-life questions. When addressing their treatment outcomes, they’re thinking in terms of 10-20 years when their physician is thinking in terms of 2-3. Gawande learned through the decline and death of his father, whose experience he follows towards the end of his narrative, the importance in asking these questions early on in the diagnosis and to ask four critical questions when deciding to move forward: 1) What is your understanding of the situation and its potential outcomes? 2) What are your fears and what are your hopes? 3) What are the trade-offs you are willing to make and not willing to make? and 4) What is the course of action that best serves this understanding? In learning from palliative care medicine to ask his patients these four questions when approaching an end-of-life discussion, he was able to put the patient back in control of his/her own narrative. And that’s essentially what anyone wants in their lives in the end–control, autonomy; but for so long, this has not been our approach to medical treatment. Very often, the option to do nothing is rarely put on the table by physicians when listing possible treatments.
“Our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives” (243).
Dr. Gawande taught me that for as powerful the capabilities of medicine have become, there is power in doing nothing; but it requires that we continuously listen to our patient and work for the patient to help them achieve realistic goals rather those that are lofty and unattainable. Gawande paints a picture of the physician-as-general. “The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end” (187). Ultimately, as Gawande describes, there is beauty in letting go.
“The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end” (187).
Ultimately, as Gawande describes, there is beauty in letting go.
Gawande also discusses the tremendous benefits of Palliative care and echoes many similar notes as Dr. BJ Miller of the Zen Hospice Project during his TEDTalk.
“[in discussing a study] those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives–and they live 25% longer. In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality. If end-of-life discussions were an experimental drug, the FDA would approve it” (177-178).
In closing, Dr. Gawande discussed the role of dying, the role of the patient to allow themselves to watch their lives play out. In this discussion, I repeatedly heard Dr. Miller reverberate in my mind,”Let death be what takes us in the end, not a lack of imagination.” Dr. Gawande previously described how nursing homes were originally designed as a continuum of care to handle the overflow of chronically-ill patients from the hospital they worked with. Nursing homes were designed after hospitals, but people with chronic illness were never intended to die in hospitals, they were meant to die at home, surrounded by those they loved, and empowered to finish their narrative with the punctuation mark that they placed as their last breath escapes them. Instead, so often now those moments are stolen from the patients we serve. In working in medical transport, I can’t tell you how many patients I’ve transported to/from nursing homes who have all but lost the will to live. They are surrounded by bare walls, fluorescent lighting, and can’t get through the hallway without encountering a sea of wheel bound patients tethered to their wheelchairs with a cord and an alarm. They were sent there to die, forgotten. Of course, no one with good intentions ever plans to place a family member there out of spite–it’s often out of love–they do it for their safety of their loved one in mind; but as Gawande describes, people need more than just safety, they need a purpose. In allowing death to play all the way out with comfort and support, we are often able to allow the patient more time than they would have previously been afforded with aggressive treatment. They are allowed the dying role.
“Technological society has forgotten what scholars call the “dying role” and its importance to people as life approaches its end. People want to share memories, pass on wisdoms, and keepsakes, settle relationships, establish their legacies, make peace with God, and ensure that those who are left behind will be okay. They want to end their story on their own terms. This role is, observers argue, among life’s most important, for both the dying and those left behind. And if it is, the way we deny people this role, out of obtuseness and neglect, is cause for everlasting shame. Over and over, we in medicine inflict deep gouges at the end of people’s lives and then stand oblivious to the harm done” (149).
In reading this novel, my outlook on medicine has changed entirely. Not only am I more empowered to pursue a career in medicine in which I am able to better follow my patients throughout their continuity of care, but I am also reminded of the importance to ask the hard questions. It’s a sentiment that I’ve repeated countless times as I’ve stressed the importance of treating the patient as a person and not an illness–it’s almost become a platitude; but Dr. Gawande has helped me make better sense of what this practice looks like in the day-to-day interactions that physicians have with their patients. As I go forward, I hope to make better sense of it still.
Create a series of thought-provoking questions that get students thinking about hard issues that can then be discussed during the lecture portions of the course.
I know I’ve included this in my main blog, but I want to write a note to myself to include this in the curriculum:
My initial concerns about The Plague being too much of a literary text have been abated by the ending of the novel. Without giving too much away, it absolutely tackles the main messages of our course and focuses mainly on death as well as the humanization of the physician; and even addresses the walls and various emotional barriers that Dr. Rieux put up and subsequently tore down towards the end of the novel. I am struggling with the syllabus, however–mainly with whether or not to keep Man’s Search For Meaning. On the one hand, it connects with many of the main points of Camus’ novel, but on the other, I’m concerned that it is too far removed from the point of the physician; but then again it isn’t, it’s just from the point of a psychiatrist, which has value. I’ve skipped the Emperor of All Maladies, which I’ve already read, and have moved on to Being Mortal by Atul Gawande. In the first few pages, Gawande alludes to the novella The Death of Ivan Ilyich and discusses how he read the novella during his first year of medical school and how it was an excellent way to address the shortfalls of the modern physician–they don’t accept death, which is one of the cruxes of our arguments in this course: that the physician treats the patients more than he addresses the goals of the patient as a person, which is a vital element. With the empowerment of the patient in the decision-making process, and the ease with which patients can affect the physician’s bottom-end through the power of the online review, physicians have become de facto customer service representatives who are expected to do as they are asked rather than administer the proper care; but I would argue that the physician should buck this trend by having the skill to get to the heart of the patient’s problem, explain to them why it is reasonable for them to request the specific drug or treatment, explain to them why it is advisable that they not receive it, and then explain to them your reasoning in order to win them over.
I’ve worked with a physician recently who went to see a patient in her room with the understanding that the patient was a frequent flyer and was with her daughter who was known for making a scene so he went into the room brusquely and commanded a strong presence. The consensus was that there was not much that could be done for the woman in the ED and that her care would be better managed as an outpatient because she would need a course of testing and assessment that was not available in the ED. The daughter was defensive and was annoyed at this because she felt that since her mother’s condition was worsening and they were already in the hospital that it wouldn’t be difficult for the physician to order the tests on the machines that were already in the hospital. The scene escalated from there and it ended with the daughter questioning the capabilities of the physician because he was younger and she asked to see another doctor, which escalated things further. Ultimately, this situation could have been solved with compassion and empathy rather than brute force or a power play. The woman’s condition is worsening, the daughter is obviously concerned and wants the best for her mother. She sees the physician as a gatekeeper for her mother’s health and is understandably demanding that she receive it. However, there was a clear break down in communication on the part of both parties because the daughter’s expectations of care were not consistent with what should have been expected. This was not the fault of the daughter, but rather the fault of her provider. The daughter has picked up the gauntlet in defense of her mother. She’s a good daughter, she’s a good person, but she was scared and didn’t have an adequate understanding or hasn’t come to terms with the fact that her mother will never be the same because no one seems to have thought to have that conversation with her. They ultimately left feeling hopeless, confused, angry, and again, without answers. They interpreted their care as a failure of the healthcare system, and really they weren’t wrong; but all of this could have been corrected immediately with, “I understand your concern. I understand that you want to do right by your mother and that you want the best care for her; but this is not the right place for her. Your mother needs a series of tests that I am not able to perform because as an ER doc, I am limited to what I can order. I’m not trying to waste your time, and I want you to know that you and I both want the same thing, but this is not the right place. Instead, let me help you get on the right track. Let me have my secretary contact your mother’s PCP to see if we can get her scheduled for a sooner follow-up appointment. I would also like to ask if you and your mother have ever discussed her wishes in the event that she can’t be treated. I know these conversations are difficult, but they’re important because they help guide her care plan to ensure that your mother’s wishes and your families needs are met and that your mother lives as long as possible in the way that she wants. As with anything, there is no guarantee that your mother will improve, and I’m sorry for that. But I can tell you that I will do everything that I can to ensure that you leave here today with your questions answered and with a plan going forward.”
Patients don’t ask for a lot–only to be treated as people. Gawande cited an interesting statistic early in his book that stated that the concept of dying in a hospital was practically unheard of prior to 1945. As of 1980, only 17% of the population dies at home. With the help of hospice care, this number has ticked back up to 45% as of 2010; but hospice remains stigmatized as we continue to fear death. Instead, we perform tests, we order biopsies, we perform surgeries all to extend and extract every bit of life possible, but we rarely consider the quality of life that it will give us in the end. There’s a reason why physicians often elect to withhold extensive treatment when faced with a terminal illness. They typically die at home and are typically better off because of it. They die with family and friends by their side in their bed, on their terms, and they often live longer and in a higher capacity when compared to those who pursue extensive treatment in the hospital. If more physicians took the time to discuss the end-of-life with their patients, I wonder how these numbers would change. I wonder by what margin the quality of the patient’s life in their final days would be improved. It asks so little of us as providers–that we just listen.
Those of whom I’m close with know that I have been on a new podcast kick, more specifically, I’ve been recently obsessed with Freakonomics radio. The show tackles a litany of topics ranging from Uber’s economic business model, to the application of psychology and sociology to nudge political decision-making, to medicine. Steven Dubner, the host, guides the listener throughout these landscapes and tackles some incredibly interesting topics. In a three-part series titled “Bad Medicine” Dubner interviews physicians to get a handle on the state of medicine today as well as how medicine has progressed over time. Most notably, Dubner’s guests discuss the relatively recent switch in medical ideology from eminence-based decision-making to evidence-based decision-making. They describe that physicians have typically made their medical decision-making (MDM) based primarily on their experience and expertise but had very little, if any, physical evidence to support their treatment. In an evidence-based approach, however, the physician would base their MDM on the available literature and clinical trials that can support the proper treatment of the time. This switch from eminence to evidence-based medicine has resulted in many medical reversals–areas of medicine where the professional impression of an illness has been completely flipped on its head. Most recently, the American Academy of Pediatrics has reversed its long-held belief that parents should prevent their children from early exposure to potential food allergens and now recommends that children should be exposed as soon as possible because new medical evidence and medical trials have shown that early exposure decreases the risk of allergy development later in childhood. This decision went directly against the commonly-held beliefs in the medical community, but it did so because the AAP made their decision based on evidence rather than eminence. In addition, the special also discussed how physicians have been found to be generally less-effective after 15 years outside of residency because their exposure is less and they become more complacent in comparison to newer physicians entering the field. This same data, however, found that the older physicians who were protected from this atrophy were those who saw a lot of patients on a regular basis. Interestingly, this showed that experience, as we generally measure it in terms of years practicing, has very little to do with a physician’s efficacy unless that physician practices regularly. It’s important to note that this atrophy was not found to be true in surgeons who often become better with time, and that this study was pointed more towards physicians in clinical practice. These findings suggest that the best physicians are those who not only remain up-to-date with medical literature but also those who continue to see a regular and frequent amount of patients.
There are several other episodes of Freakonomics that touch on applicable medical topics that address burnout as well as end-of-life care that I would like to incorporate into the course in some way or add as supplemental material to those students who wish to learn more. There are several books that address end-of-life care that we read over the course of the semester so I believe that the addition of these podcasts as supplemental material would be beneficial to the student’s overall education.
While I admit that I am a little behind in blogging (and reading), I wanted to briefly share some of my thoughts as I continue to read Camus’ novel. My main concern as of right now is that while this novel is eloquently written and pleasurable to read, it might not capture the attention of an audience who are basing their pursuit of medicine on backgrounds filled with theorems and enzyme reactions. To combat this, I think that it will be important for the instructor to frame the discussion of the novel as a focus on the human response to death as well as how man’s outlook on life can change when faced with a terminal illness. To make the novel more relatable (and to encourage compliance with the assigned reading) I recommend that the students be encouraged to approach this novel, which addresses the fate of plague, in a similar context as one reads about a diagnosis of cancer (which the students will read about in further detail in the next assigned reading, The Emperor of All Maladies).
I will submit a more substantive post on Friday. To remind myself,
- I want to incorporate additional supplemental resources that include the Bad Medicine Freakonomics Podcast
- I also want to consider including the Life’s Third Act TEDTalk by Jane Fonda that addresses how we can deal and make the most of a longer lifespan thanks to recent medical advances.
- Personal reminder to reach out to Dr. A P-S at EVMS to schedule time to meet in order to run the syllabus by her and to get her feedback. I want to know what it would take to get this course approved of by the faculty at EVMS.
- I need to start preparing a presentation and proposal for the course that I wish to present to the Dean of the College of Arts and the Honors College by the end of the semester.
In accordance with our updated syllabus, I have since started reading Camus’s The Plague, which so far follows a small town physician as he directly encounters The Plague as it ravages through the town in which he lives and works. While so far an excellent novel, it also does well to highlight the life and responsibilities of the physician for himself, his family, as well as the community he serves. Physicians are often revered as pillars of their respective communities and Camus’s novel does well in highlighting some of the less thought of roles that a physician can play, especially in terms of local/federal government policy as it pertains to health. In my own life, I have thought immensely about becoming more involved in the politics of climate change and how it pertains to human health and what’s more exciting is that I remain qualified to speak on these grounds because healthcare is so heavily interwoven throughout other aspects of our society. While Camus’s novel is set in a pre-modern era (at least in the terms of how we currently view modern living) it would be interesting to contrast the role of the physician then versus the role of the physician now. I would argue that the current role of the physician seems to have receded behind the curtain. Very rarely do you hear of physicians speaking out against matters of public policy, which is interesting to me because there seems to be so much to talk about, especially today. Rather than live up to the call to vocally serve their community, physicians now seem more cloistered, locked away in their ivory tower. I hope as students read this novel and go through their education that they take up the call and voice their opinion. There is a reason why physicians were once revered–they cared for the communities they serve more than the lifestyle they were able to build because of it. In an age where science is threatened, where climate change stands to challenge every fabric of our lives (including health), where growing poverty and civil unrest leads to shorter lifespans and higher rates of hypertension, diabetes, and high cholesterol in underserved communities, physicians need to come down from the mountain and raise their communities up. It’s time for them to get more involved in their local, state, and federal governments. It’s time for them to speak out. We cannot let Ben Carson lead the charge, we need more physicians who care about the communities they serve rather than those who care more about serving themselves.
Dr. Vincelette and I have decided to include a service-learning component that will require students to complete a minimum of 10 hours of community service in the medical field and to write/document/discuss their experiences given the new perspectives they will learn in class. The ultimate goal of this course is to instill in these students a greater sense of empathy and the ability to place themselves in the position of their patient in order to see beyond their illness and to acknowledge that they are an individual. By incorporating an opportunity to directly apply these goals throughout the course of the semester, it is my hope to further instill these values into our students before their semester has ended. I want this course to be a defining moment in their decision to become a physician. I want them to understand the true capacity and limits of what they can do. I want them to identify a weakness in the healthcare system, and I want them to leave their mark by changing it.
“Sometimes it is the people no one can imagine anything of who do the things no one can imagine.” -Alan Turing
Victor Frankl’s Man’s Search for Meaning indirectly outlines several key features that physicians can utilize when addressing patients suffering from a terminal illness or battling an addiction. While taking the approach of a psychoanalyst and by using his experiences as a prisoner in Auschwitz to validate his observations, Frankl tackles several of the more frequent issues that patients face due to the relative stigmas of their illness. By teaching the medical practitioner to embrace the patient as a complex individual rather than an illness with an attitude, Frankl states that treatment outcomes and success will be far higher when compared with the traditional medical approach that treats the objective data rather than the story. Throughout my work as a Medical Scribe, I’ve seen many patients who have come into the ED looking for reassurance that the rash or the slight chest pain that they’ve had for weeks isn’t serious but are met with hostility and indifference by the physician because the physician inaccurately assumes that the patient is there solely to waste the physician’s time. The patient wasn’t looking for medication or treatment, they were looking for reassurance, a human connection, an affirmation that they will be okay and that their rash doesn’t signify something much more serious.
There are many quotables throughout this book in which the meat of it lies in the analysis towards the end. Some of the more notable selections:
“I observed that procreation is not the only meaning of life, for then life in itself would become meaningless, and something which in itself is meaningless cannot be rendered meaningful merely by its perpetuation.” (119)
“as a professor in two fields, neurology and psychiatry, I am fully aware of the extent to which a man is subject to biological, psychological and sociological conditions. But in addition to being a professor in two fields I am a survivor of four camps–concentration camps, that is–and as such I also bear witness to the unexpected extent to which man is capable of defining and braving even the worst conditions conceivable.” (130)
“Logotherapy ‘may help counteract certain unhealthy trends in the present day culture of United States, where the incurable sufferer is given very little opportunity to be proud of his suffering into consider it ennobling and rather than degrading’ so that ‘he is not only unhappy, but also ashamed of being unhappy.'” (146)
There is also some fantastic dialogue that contains arguments that could be applied to the present-day discussion of physician-assisted suicide. In some areas, Frankl even seems to contradict himself:
“if it [suffering] is avoidable, The meaningful thing to do is to remove its colors, for unnecessary suffering is masochistic rather than heroic.” (147)
“doesn’t the final meaning of life, too, reveal itself, if at all, only at its end, on the verge of death? And doesn’t this final meaning, too, depend on whether or not the potential meaning of each single situation has been actualized to the best of the respective individual’s knowledge and belief?” (144)
Life has meaning and can only be understood as the sum of its parts, and suffering also has a place; but if suffering is only occurring for the sake of suffering, then it deserves to be put to an end as suffering is not heroic. A class discussion on PAS would be very interesting in this context. Ultimately, it boils down to patient choice. It should be accessible (like birth control and RU-486) and administered by the patient after full and complete consultation with the physician regardless of the physician’s personal beliefs. Should physicians retain the right to abstain? If they do, are they acting in their patient’s best interests or their own?
As I prepare to graduate from ODU in May, it’s important to me that I leave behind something to encourage other students like me who are majoring in the humanities with aspirations to become physicians. While it might not seem so at first, the humanities play a tremendous role in the patient-physician relationship and work to educate the physician on how to become more empathetic and understanding with her patients. Studies performed by researchers Kelly Zolnierek and M. Robin DiMatteo found that the education of physicians in communication increases the likelihood of patient compliance in their treatment by 1.62x higher than those patients whose physicians were not trained in communication.
While this study was referencing to the effectiveness of a specific course for physicians on improving their communication, an influx in medical school applicants who already have an education in the humanities can only help to improve the physician-patient outcome due to their extensive experience in communication, empathy, and understanding.
In my final months at the University, I will be working with Dr. Elizabeth Vincelette in creating a course to be taught at ODU directed towards humanities students considering careers in the medical fields. It is my ultimate goal to further diversify the applicant pool of students at ODU applying to medical school by encouraging students from all backgrounds to pursue their dreams.
By 2025, the AAMC states that there will be a shortfall of between 14,900 and 35,600 medical providers in primary care fields alone, and a much larger shortfall in non-primary care facilities. By encouraging applicants from “non-traditional” backgrounds to consider professional careers in medicine, we would not only be taking steps to lessen the shortfall, but will be taking advantage of the situation by improving upon the system from the bottom up.
Below is our proposal that is waiting to be approved. It is my hope to use this section of my website to catalog my journey throughout this process and to journal my efforts and realizations along the way.