Healthcare Quality Improvement Instruction in Undergraduate Medical Education: A Call for Formal Training Curricula

By L. Blake Rivas, MHA – SKMC Class of 2024

Most physicians spend between seven to fifteen years in training before they begin practicing in their chosen specialty.1 Despite such rigorous training, more than 10% of patients will suffer some degree of harm while receiving medical care.2 Studies suggest that at least half of these incidents are ultimately due to preventable medical errors.2 While these adverse events are usually manageable, about 12% ultimately result in permanent disability or even death.2 In 2021 alone, more than 251,000 people in the United States died due to preventable medical errors3, which one of the highest rates in the world4 and five times more deaths than all car accidents combined in the United States in 20215. These incidents are not only tragic, but also increase healthcare spending by tens of billions of dollars6 and contribute significantly to burnout among healthcare workers12.

Our best tool to decrease the rate at which these medical errors occur is with healthcare quality & safety (HQS) evidence-based practices. According to the World Health Organization (WHO), HQS aims to “prevent and reduce risks, errors and harm that occur to patients during provision of health care,” by “learning from errors and adverse events” as they occur.7 One of the earliest examples of HQS in action was Florence Nightingale’s review of patient records in 1854 to identify potential sources of infection in the hospital where she worked.8 Nightingale’s efforts lead to improved hospital ventilation and cleanliness and made their mortality rate plummet from 42.7% to 2.2%.8 HQS has been a fundamental element of any functioning healthcare system ever since, having significant positive impacts on patient outcomes for more than 100 years. 

While early on most HQS innovations focused on covering basic needs, more recently HQS has begun to borrow ideas from other highly complex, but reliable industries, like the construction industry. One of the most famous examples of this is the use of checklists to ensure crucial process steps are not forgotten or overlooked. In 2018, one hospital introduced a checklist of proper central line insertion techniques and sanitary practices and found that patients who were managed with this checklist had a 36% reduction in central line associated bloodstream infections compared to a control group.9

Despite the startling frequency of patient injury and the demonstrated success of HQS practices, in 2012 fewer than 50% of undergraduate medical education programs reported having any kind of patient safety curriculum.10 Worse still, only 20% of all programs reported being satisfied with their students’ level of competency in healthcare quality and safety practices (HQS).9 These programs cited several reasons for their lack of HQS programming: a lack of faculty time (78%), a lack of faculty training (65%), and no mandate for HQS programming from the program’s dean’s office (38%).10 More recently, the number of HQS graduate programs has begun to grow significantly. Across all health professions, the number of HQS graduate programs doubled from 2017 to 2021 due to a growing demand for formal training.11 Still the number of programs remains relatively small: only 25 programs exist in the United Sates, which is not nearly enough programs to be able to offer formal training to every training physician.

Even though there is a disappointing number of formal training programs, many medical students and resident physicians opt to pursue training in HQS independently because they recognize the immense value it brings to patient care. One of the most accessible options for most is research. Many academic institutions have at least a handful of faculty members who conduct HQS research or likely would be interested in these projects if students and/or residents demonstrated interest and agreed to lead them. A more expensive and time-consuming alternative would be pursuing a formal Master of Science degree in HQS. While there are few M.S. programs, many of them offer an online option, which increases accessibility, especially for those training in rural locations. Some programs offer graduate certificates programs for their students and residents. These programs are similar to the M.S. in terms of structure, but mostly stick to the basics and do not offer the same level of depth and credibility that comes with a formal graduate degree. Finally, students may choose to seek out free training online through the Institute for Healthcare Improvement. All these options allow trainees to develop a critical skill set that will help to keep patients safe for generations to come.

Any one of these independent learning options offer valuable experiences for students to improve their clinical skills and enhance their careers. Pursing these opportunities allow students to better identify and correct the numerous systemic processes that facilitate medical errors that directly harm patients. What’s more, students who reduce their number of medical errors will also reduce their risk of burnout. While HQS programs are largely still in their infancy and not yet well studied, I anticipate that soon studies will increasingly show the dramatic and wide-ranging benefits of physician trainees receiving a formal HQS education. Moving forward, it’s my hope that undergraduate medical colleges and universities will create formal HQS curricula to increase students’ access to this powerful and much needed programming.

References:

[1] https://www.aamc.org/system/files/2020-11/aamc-road-to-becoming-doctor-2020.pdf

[2] https://www.nbcnews.com/health/health-news/medical-mistakes-harm-more-1-10-patients-many-are-preventable-n1030996

[3] Anderson JG, Abrahamson K. Your Health Care May Kill You: Medical Errors. Stud Health Technol Inform. 2017;234:13-17. PMID: 28186008.

[4] https://www.healthsystemtracker.org/indicator/quality/rate-medical-errors/

[5] Newly Released Estimates Show Traffic Fatalities Reached a 16-Year High in 2021. National Highway Traffic Safety Administration. Washington, D.C. https://www.nhtsa.gov/press-releases/early-estimate-2021-traffic-fatalities

[6] Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. 2, Errors in Health Care: A Leading Cause of Death and Injury. Available from: https://www.ncbi.nlm.nih.gov/books/NBK225187/

[7] https://www.who.int/news-room/fact-sheets/detail/patient-safety

[8] Brenda Helen Sheingold, Joyce A. Hahn. The history of healthcare quality: The first 100 years 1860–1960, International Journal of Africa Nursing Sciences, Volume 1, 2014, Pages 18-22, ISSN 2214-1391, https://doi.org/10.1016/j.ijans.2014.05.002. 

[9] Wichmann, D., Belmar Campos, C.E., Ehrhardt, S. et al. Efficacy of introducing a checklist to reduce central venous line associated bloodstream infections in the ICU caring for adult patients. BMC Infect Dis 18, 267 (2018). https://doi.org/10.1186/s12879-018-3178-6

[10] Jain CC, Aiyer MK, Murphy E, Alper EA, Durning S, Aldag J, Torre D. A National Assessment on Patient Safety Curricula in Undergraduate Medical Education: Results From the 2012 Clerkship Directors in Internal Medicine Survey. J Patient Saf. 2020 Mar;16(1):14-18. doi: 10.1097/PTS.0000000000000229. PMID: 26558648.

[11] Oglesby, Willie H. PhD, MBA, MSPH, FACHE1; Hall, Allyson G. PhD2,3; Valenta, Annette L. DrPH, FACMI4; Harwood, Kenneth J. PT, PhD, FAPTA5; McCaughey, Deidre PhD, MBA6; Feldman, Sue RN, MEd, PhD7,8,9; Stanowski, Anthony C. DHA, FACHE10; Chrapah, Sandra MHA11; Chenot, Teri Ed.D., MS, M.Ed., MSN, RN, CCE(ACBE), FNAP, FAAN12; Brichto, Eric Esq.10; Nash, David B. MD, MBA1 Accrediting Graduate Programs in Healthcare Quality and Safety, American Journal of Medical Quality: November/December 2021 - Volume 36 - Issue 6 - p 441-448. doi: 10.1097/JMQ.0000000000000021

[12] Martin A. Koyle. Musing on leadership, quality and safety, and burnout: what goes up must come down. Journal of Pediatric Urology. 2020; 16(5): 530-534, ISSN 1477-5131, https://doi.org/10.1016/j.jpurol.2020.01.017.

Experience and Evidence-Based Benefits of Dog Therapy in the Hospital Setting

By L. Blake Rivas, MHA - SKMC Class of 2024

Dogs were first domesticated more than 20,000 years ago.[1] At first, dogs and humans simply coexisted peacefully, but soon humans started selectively breeding dogs for nearly every purpose imaginable – everything from hunting, guarding, herding, and more. This already versatile skillset among canines expanded even further in 1947 when dogs entered yet another field: healthcare.[2]

Today, dogs serve a wide range of purposes in healthcare and have a growing body of evidence supporting their use. Studies show that even a single interaction with a dog has substantial physiologic benefits, such as lowering blood pressure[3], relieving anxiety[4], reducing perceived pain[5], and, of course, improving mood[6]. In hospitals, patients and staff most commonly experience these benefits during therapy dog visits.

Animal therapy visits consist of a human handler bringing a certified therapy dog to staff spaces, patient rooms, or waiting areas for short visits with anyone who is interested. Generally, these visits are relatively casual and do not have a formal therapeutic or clinical endpoint that is anticipated or tracked in any way; the only intended outcome of the visits is mutual enjoyment of the patient and the therapy dog.  

I first became involved in animal therapy in ten years ago when I started making visits to my local hospital’s hematology and oncology infusion center with my Cavalier King Charles Spaniel named Scooter. Since then, I have visited hundreds of patients, begun evaluating and guiding other therapy dog teams, helped write our hospital’s animal therapy policies, and have personally trained and certified two more dogs in therapy work. These experiences have been incredibly rewarding, because therapy visits make such a difference for patients and staff.

In animal therapy, I found that there are generally two types of patients: (1) patients who like dogs, but are lonely and primarily want to talk to the dog’s handler for company and (2) patients who only want to interact with the dog and have no interest in interacting with the dog’s handler. Both types of patients experience the quantifiable benefits mentioned earlier, but I’ve also observed many intangible benefits to patients, particularly for the second type of patient who engage solely with the dog.  

Over the ten years I’ve been involved with therapy work, I have seen many instances where patients and therapy dogs have had interactions that could only be described as magical. Some patients are so overcome with joy at seeing the therapy dogs that they are brought to tears and will sit with a therapy dog for an hour or more. Other patients have come out of their shell and wanted to talk for the first time in days or even weeks during our visits. In some cases, I’ve even seen patients make their first efforts to speak or move since suffering a debilitating accident or medical condition. Formal empirical evidence and personal experience have convinced me that dog therapy is as legitimate a tool as traditional medical therapies for managing patients’ anxiety and improving their overall wellbeing.[1] 

Despite the supporting formal research and anecdotal evidence, however, there are not nearly enough therapy dogs working in the United States. Currently there are only about 50,000 therapy dogs[7] available to take care of the 36.2 million hospital admissions in 2019.[8] This number is thankfully on the rise because of growing awareness of therapy dogs’ value and improved access to high-quality training resources. I hope that therapy dog visits will become much more widely available to patients over the course of my career because of the many benefits they have in a clinical setting.

If you are interested in becoming involved with animal therapy, a great first place to start would be looking into the certification process. There are dozens organizations that certify therapy animals in the United States – some of the most reputable include: Pet Partners, Alliance of Therapy Dogs, and Therapy Dogs International. Pursuing a certification is essentially a universal requirement for becoming a therapy team at hospitals because they typically involve a formal background check, veterinary wellness check, and provide teams with thousands to millions of dollars of liability coverage.

Sources

[1] Botigué, L., Song, S., Scheu, A., et al. (2017). Ancient European dog genomes reveal continuity since the Early Neolithic. Nat Commun 8, 16082. https://doi.org/10.1038/ncomms16082

[2] Frankel, R. (2014). Dogs at war: Smoky, a healing presence for wounded WWII soldiers. National Geographic. Available from https://www.nationalgeographic.com/history/article/140520-dogs-war-canines-soldiers-military-healing-yorkshire-terrier-smoky

[3] Katcher et al. (1983). New perspectives on our lives with companion animals. Pp.352-62. Philadelphia: University of Pennsylvania Press.

[4] Cole at al. (2007) Animal-assisted therapy in patients hospitalized with heart failure. Am J Crit Care. 16:575-85. Available from https://doi.org/10.4037/ajcc2007.16.6.575

[5] Calcaterra et. Al (2015). Post-operative Benefits of Animal-Assisted Therapy in Pediatric Surgery: A Randomized Study. PLoS ONE 10(6): e0125813. Available from https://doi.org/10.1371/journal.pone.0125813

[6] Marcus, D. (2013). The Science Behind Animal-Assisted Therapy. Curr Pain Headache Rep 17:322. Doi: 10.1007/s11916-013-0322-2.

[7] Lombardi, L. (2018). Therapy dogs work miracles. But do they like their jobs? National Geographic. Available from: https://www.nationalgeographic.com/animals/article/animals-dogs-therapy-health-pets

[8] Total number of hospital admissions in the U.S. from 1946 to 2019. Available from https://www.statista.com/statistics/459718/total-hospital-admission-number-in-the-us/#:~:text=In%202019%2C%20there%20were%20over,admissions%20in%20the%20United%20States.

Single-Use Devices (SUDs) and Lack of Recycling in the OR

By Michael Velez

While operating rooms generate the highest revenue for hospital administrators, it turns out they also generate the most waste and supply costs in any given hospital. I began looking into this issue after my Anesthesia and Surgery rotations at Thomas Jefferson University Hospital Einstein Hospital respectively, in Philadelphia. During my time in the operating room (OR), I noticed that the amount of trash accumulated and seemingly recyclable plastic materials thrown away each day is outrageous. Every day, the environmentalist in me would cringe at the sight of each operating room’s waste bins as the abundance of plastic and cardboard wrappers for the various sterile supplies required for each procedure overflowed. 

As an innovator at heart, I was compelled to investigate further to better understand the harmful potential of the issue. My suspicions were confirmed when I learned that 20 to 30 percent of hospital waste comes directly from the OR.3 

As it currently stands in many hospitals, these products are instead discarded in the OR together with materials that do come into contact with bodily fluids. While I understand that there needs to be proper disposal for single-use devices (SUDs) and equipment that get contaminated with patient fluids that can serve as infectious sources, I feel strongly that recycling the packaging materials and supplies that don’t touch bodily fluids is easily possible, while those that do come into contact with patients should undergo some sort of cleansing or sterilization process that allows them to be recycled rather than adding to waste landfills.

If packaging and uncontaminated products were properly discarded separately from their contaminated counterparts, they could be recycled by NGOs into other products like aprons, tote bags, or other byproducts or even into new wrapping for future single-use devices. 

Though the trash buildup associated with the packaging of these products is one thing, the waste generated from the SUDs themselves are a whole other problem altogether. This problem is so rampant that it is finally leading hospital administrators to take notice. Consequently, over the last decade, hospitals and private companies alike are starting to realize the potential financial and environmental benefits that come from reprocessing SUDs. I found that only a few companies exist that reprocess SUDs with Stryker Solutions, a subsidiary of Stryker, dominating the market. Nevertheless, only a small fraction of existing hospitals use services like these. Even as the market leader, Stryker Solutions only serves 3,000 hospitals (Jefferson NOT included) meaning there is plenty of opportunity to make an even bigger impact across the nation. In 2016 alone, Stryker helped health systems save over $300 million and eliminate 12.9 million pounds of medical waste from landfills.2  If we could compound this effect by increasing hospital participation, the impact could be enormous.

Though the numbers speak for themselves, sustainability in practice is not limited to just demonstrating the benefits of waste reduction, recycling materials, and eliminating infection for patient safety. It requires active implementation and training for all staff in the operating room. This includes physicians, anesthesiologists, nurses, medical technicians and maintenance staff who need to be informed of the financial and environmental aspects of sustainable practices and programs and then trained in their respective roles to uphold them.3 With the COVID-19 global pandemic currently active, I can only imagine that the PPE and SUD usage, and consequently the generation of plastic waste, has exponentially increased further worsening the issue. Now more than ever, all large organizations need to be doing their part and hospitals are no exception.

Sources:

1. http://sustainability.stryker.com/

2. https://www.beckersspine.com/orthopedic-a-spine-device-a-implant-news/item/35547-stryker-s-sustainability-solutions-bill-scott-talks-reprocessed-medical-devices.html

3. http://tinehealth.com/2017/09/04/how-to-reduce-operating-room-waste/

4. https://practicegreenhealth.org/topics/greening-operating-room/greening-or

Alarm Fatigue

By Michael Velez

This is my call to action. Do your part to combat the safety risks alarm fatigue poses to our patients! Alarm fatigue is the sensory overload experienced when clinicians and health providers are exposed to an excessive number of alarms in the hospital, which can result in desensitization to alarms and consequently missed alarms. During my IM rotation, just at the start of my 3rd year of clerkships, I remember the constant sound of alarms and monitors beeping as I strolled the floors of the hospital. Though I may have still been acclimating to the new environment, it felt as though no one around me was responding to them. For the first few weeks, I remember being in a state of hyperawareness. Any time I heard an alarm go off (which felt like it was happening every 20 seconds!) I would look around and assess the scene as I tried to identify the source of the alarm, anxiously worried if I was responsible for responding to it. My heart rate would quickly rise, my palms would get cold and clammy, and sometimes I would even start to feel little beads of sweat build up at the top of my brow and forehead. It was as if each alarm sent my sympathetic nervous system into overdrive; fight or flight. In this context, it meant I had to fight the gut feeling telling me to run from my daunting clinical duties in the hospital and instead hold my ground to figure out how things worked around here. I’m sure to all the nurses and hospital staff around me, I looked like a deer in headlights, standing in the middle of the hallway, looking around like I was lost, except I happened to be in a white coat. Though I don’t think I’m particularly more sensitive to alarms than anyone else, I definitely felt as though I was the only person caught up in trying to figure out what each alarm signified, who was responsible for attending to them, and which required immediate attention. When I asked my residents and attendings how they manage to appear unphased by the constant cacophony of beeping that filled the hospital wards, they told me they’ve managed to tune it out. After a few weeks seeing patients and rounding the same floors day after day with my team, I finally started to better understand the ebb and flow of the hospital. Though it is mainly each patient’s nurses that is responsible for most alarms we hear, the reality is that they aren’t always around or available to respond because they are balancing their time managing their other patients. When that occurs, other team members, nurses and physicians alike, must often step up to address the blaring alarm as they walk by.

Another way to conceptualize this phenomenon is to look at the numbers. One UCSF study1 found that there were 187 audible alarms PER bed per day in the ICU, with a false-positive rate of over 88%  for arrhythmia alarms. In other words, this means that not only is there an excessive number of alarms going off, but also that the large majority are FALSE alarms. The mere frequency of alarms for each patient is disturbing for both patients and providers alike. It makes getting rest nearly impossible, causes excess worry and anxiety, and is a constant distraction to guests and hospital staff. With so much to do, ignoring alarms almost becomes a necessity to be productive. Nevertheless, the issue of alarm fatigue has become so significant that the Joint Commission named it a National Patient Safety Goal. As the number of ways we monitor our patients continues to increase, it is more evident than ever that we need a better system for managing alarms to ensure we avoid missing real emergencies and prevent deaths from happening as a result.

As the intelligence of technological devices used in the hospital increases exponentially over time, devices have already become more reliable than humans. A significant opportunity exists to improve physiologic monitoring and reduce alarm fatigue and this should be a priority in hospitals across the nation. To start combatting this often-overlooked issue in healthcare, all active alarms in each patients’ room should be limited to only what is necessary based on the patient’s individual needs (i.e. those lacking cardiac conditions or significant risk factors for cardiac events shouldn’t be hooked up to telemetry monitors). Additionally, there should be a platform in place that stratifies alarms based on a hierarchy of importance. This may involve developing systems that help triage alarms by priority, like the emergency department (ED) does with the Emergency Severity Index (ESI), a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 to 5 on the basis of acuity and resource needs. There could also be extra nurses/hospital techs, in addition to charge nurses on each floor that solely focus on managing and triaging alarms in their unit. Lastly, a final redesign alternative could involve strategically creating unique sounds to replace standard alarms and monitor beeps. Implementing this solution could reduce both the confusion of junior hospital staff adapting to their new work environment and the alarm fatigue in more veteran nurses and physicians simultaneously, allowing the whole team to instantly distinguish alarms by type and urgency, in order to facilitate faster responses.

As my IM rotation came to an end, I found myself feeling guilty as I realized that I was beginning to tune out the alarms as well. Whether it’s the bystander phenomenon in full effect, and my subconscious had learned over time to tune out the alarms as a result of never being the person responsible for responding to them, or I’ve just become desensitized and more comfortable in the hospital setting as my rotations went on. I experienced alarm fatigue firsthand within just a few weeks. Moving forward, I plan to do my part in staying mindful of each patient’s needs, responding to alarms when appropriate and helping my colleagues do the same. 

Sources:

1. https://www.ucsf.edu/news/2014/10/119601/hospital-logs-staggering-25-million-alarms-just-month

2. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0110274

3. https://www.vocera.com/au/industry-solution/manage-alarm-fatigue

Plausible News and Its Impact on Healthcare

By Dylan Selbst – Class of 2023

As medical students, we have extensive experience in assessing the legitimacy of our information sources. We spend the better part of our adult lives engaging with the scientific method through countless hours of research and prerequisite courses. Nevertheless, navigating the onslaught of novel research and health policy changes related to the COVID-19 pandemic remains daunting and cumbersome. 

Our understanding of the current pandemic is rapidly evolving on a microbiological, epidemiological, and political scale. Now, more than ever, it is crucial to be able to separate the facts from the falsehoods. The distortion of information by online media compounds this complicated situation. Unlike traditional forms of journalism, in online media, the burden of proof is no longer bestowed upon the claimant; with virtually infinite ways to consume information, it has become the consumer’s duty to determine what bits of information are reliable.

This struggle to determine the reliability of information has spawned an increased awareness and debate about “fake” news. Despite all the media attention that it gets, real “fake” news is often reasonably easy to spot. For example, when reading a proclamation from a “friend” on Facebook that “Bill Gates released the coronavirus and wants to inject us all with microchipped vaccines,” I felt it was an absurd conspiracy theory and wrote it off as fake news. However, when I encountered a somewhat plausible yet politically fueled claim referring to the intricacies of Medicare reimbursements for patients with COVID-19, the onus was then on me to assess its validity. 

The claim was in the form of a Facebook post from a website with a seemingly politically biased URL linked at the bottom. The post and attached headline said something along the lines of “The government is paying doctors to say their patients have COVID-19”. To me, this was an inflammatory headline designed to sow distrust in the healthcare system and downplay the health effects of the current pandemic. However, I couldn’t help but try to understand if this claim had any legitimacy.

After all, claims like these may erode public trust in healthcare and the authority of organizations designed to protect our national public health interests. Trust between patients and the healthcare system is integral to building a positive patient-physician relationship. The potential loss or damage to this relationship can lead to nonadherence, decreased tendency to seek out care, and adverse outcomes (Ozawa & Sripad, 2013).

Intrigued by the backstory behind this claim, and admittedly naive to the intricacies of  reimbursement for patients with COVID-19, I decided to pursue more background research on its source and legitimacy.

The true story behind the post begins with the signing of the Coronavirus Aid, Relief, and Economic Security (CARES) Act on March 27th, 2020. One of many provisions included in this bill granted the Centers for Medicare and Medicaid Services a 20% increased compensation for patients with Medicare diagnosed with COVID-19 to deal with complications associated with treating and managing their condition (Centers for Medicare & Medicaid Services, 2020).

Two weeks after the act’s signing, on April 9th, 2020, Republican Senator (and physician) from Minnesota Dr. Scott Jensen claimed, “Right now Medicare has determined that if you have a COVID-19 admission to the hospital, you’ll get paid $13,000. If that COVID-19 patient goes on a ventilator, you get $39,000, three times as much” (Palma, 2020).

These statements were not outright lies; in fact, they are reasonably close to the truth; the Kaiser Family Foundation estimated the average Medicare reimbursement for non-COVID-19 patients with respiratory infections with comorbidities and complications to be $13,297 and the reimbursement for 96+ hour ventilation support for that patient to be $40,218 (Levitt, Schwartz, & Lopez, 2020). With no knowledge of the situation, Senator Jensen’s claims seem to indicate corruption and conspiracy within our government and healthcare system. However, with relevant context, the reimbursement for COVID patients seems to fall right in line with expected values, even before the 20% increase from the CARES act.

Despite the very relevant context behind what Dr. Jensen said, his statement gained tremendous attention, especially on social media. Over the following weeks, memes, posts, and even conspiracy theory videos claiming “the government is paying doctors to say their patients have COVID” pervaded the internet. 

The root cause of this issue lies in the sad reality that a headline claiming “The government is paying doctors to say their patients have COVID-19” captivates considerably more attention than one that says “There is a 20 percent increased weighting factor of the assigned Diagnosis-Related Group for patients diagnosed with COVID-19”. Unfortunately, factual, non-inflammatory headlines seldom get the social media traction they desperately deserve.

This example is but one of many displays of plausible news that I have encountered recently. The uncertain nature of a global pandemic combined with the power of social media and a thirst for conspiracy sparked the spread of many conspiracy theories, not only limited to health policy.

The world of journalism is not as dichotomous as reputable stories and abhorrent fake news. In between these two extremes lies a pervasive and murky middle ground of misleading and sensationalized journalism. This misleading of the uninformed public is eroding the healthcare system and has the potential to affect us as future physicians and our future patients.

This is not a call to political action, but rather a plea for awareness. Misleading headlines are pervasive throughout journalism today, but they can be especially detrimental when they work to undermine public trust in our healthcare system. As medical students, we should feel free to open a dialogue with others about healthcare issues and always be sure to come to any argument armed with reputable sources. Shortly, we will be physicians ‒ leaders in the hospital and within our communities ‒ and we will be trusted to be pillars of truth and honesty in a sea of misinformation.

References

Ozawa, S., & Sripad, P. (2013). How do you measure trust in the health system? A systematic review of the literature. Social Science & Medicine, 91, 10–14. doi: 10.1016/j.socscimed.2013.05.005

Centers for Medicare & Medicaid Services. (2020, April 27). New Waivers for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) due to Provisions of the CARES Act. Retrieved May 21, 2020, from https://www.cms.gov/files/document/se20015.pdf

Palma, B. (2020, April 17). Is Medicare Paying Hospitals $13K for Patients Diagnosed with COVID-19, $39K for Those on Ventilators? Retrieved from https://www.snopes.com/fact-check/medicare-hospitals-covid-patients/

Levitt, L., Schwartz, K., & Lopez, E. (2020, April 7). Estimated Cost of Treating the Uninsured Hospitalized with COVID-19. Retrieved from https://www.kff.org/uninsured/issue-brief/estimated-cost-of-treating-the-uninsured-hospitalized-with-covid-19/

The Family Meeting

By Michael Velez, SKMC Class of 2021

More than halfway into my third year of medical school, I still found it difficult to shake the feelings that came with the inevitable daily identity crisis resulting from the expectation that we are to constantly adapt to each resident and attendings’ unique preferences for student performance. This is just one of many layers of pressure put on us; we also have the expectations we set for ourselves to be top performers, to always go above and beyond for our teams, all while trying to learn and deliver quality patient care. Rotating through clerkships with constantly changing expectations keeps us on our toes and out of our comfort zones to make sure that we are always prepared. But for all of us, there are moments that make us feel unprepared, those moments that grab hold of us and remind us what being a physician is at its most bare and stripped-down core: being a human who cares for others.

For me, one of these moments occurred during my Neurology clerkship, a week into working in the Neuro ICU (NICU). I took part in a meeting with my team to update a family on the status of their loved one. It was my first time in this type of meeting, especially for a patient that I was directly involved in caring for. To our team of medical professionals, he is our 51-year-old male patient with a 45-pack-year smoking history but to his family, he’s a son, a husband and a father. All they understood about his condition up to this point was that Mr. R had a heart attack that led to some swelling in his brain. We were tasked with conveying that Mr. R suffered from an episode of cardiac arrest that lasted long enough for his heart to fail at pumping blood to his brain, causing an anoxic brain injury with poor prognosis. What we needed to explain to his loved ones was that the state of his brain injury from a temporary lack of oxygen and nutrients was so severe that Mr. R would remain comatose and most likely never wake up. Choosing to keep him alive would mean keeping him in a special care facility on a ventilator that breathes for him, with a full-time staff that feeds him through a feeding tube and manages his other basic needs to sustain his life indefinitely. 

For Neuro Critical Care physicians in the NICU, this is a common outcome for patients with severe anoxic brain injuries. These physicians are unfortunately well versed in meetings like these, breaking bad news to families, whose family member they often have known for less than a day, in the most respectful and empathetic way possible. Though it usually takes just 30 minutes to 1 hour of their time, for a patient’s family, hearing this news is one of the most devastating and traumatic moments of their lives and can feel as though it lasted a lifetime. 

To Mr. R’s 3 kids, it means they will never get to talk to their father again. It means they will never have their dad at another birthday party or have him walk them down the aisle at their wedding. To Mr. R’s wife, it means she lost her best friend, her lover, her partner in crime and the father of her children. To his parents, it means they had to live to see their child pass away before his time; every parent’s worst nightmare. 

As our team walked to the conference room with the family, I found myself experiencing an overwhelming mix of emotions. I was anxious, nervous and distraught all at once. My heart was pounding, my body stiff and my palms were clammy. As we trickled into the cold and dimly lit conference room, I could see a similar mix of emotions on different family members’ faces. Some tried to make eye contact and read into our expressions to get a hint of what was to come. As I entered the room, I remember wondering how to conduct myself. What kind of facial expressions would be compassionate, respectful and comforting all at once? What was the right balance between acting professional and acting human? Though we learned strategies for delivering bad news in medical school and practiced role-playing scenarios during small group sessions, nothing truly prepared me for what it would be like in real-life. Emotions are predominantly beyond the scope of our control. There is no recipe for how to process and manage their physical and mental manifestations when they hit you. After a few minutes of trying to micromanage my own expectations and uncomfortable feelings of vulnerability, I allowed myself to be present – not just as a medical student, but as a human being watching a family fall apart. I let go of my self-imposed insistence to appear prepared and opened myself up to act and process the experience in whatever way came naturally. I listened, I cried, I gave head nods, I passed around tissues and I touched his father’s shoulder on our way out. At first, I felt badly because I wasn’t perfectly prepared and my emotions showed through. But I later came to realize that I would never be prepared for this the way I thought I should be and that’s perfectly ok. That’s perfectly human.

While practicing medicine involves both algorithms and altruism where in an ideal world both calculated decisions and compassion are balanced and operate in sync, the truth is that life is messy and the practice of medicine is no exception. As a medical student integrated into the clinical environment, it quickly became apparent that the reality of being a doctor was far more difficult and complicated than the ‘butterflies and rainbows’ many of us thought it would be like while growing up. Even as students, it is easy to get overwhelmed managing our clinical duties to the point that we get so caught up in following treatment protocols that we lose sight of the fact that being present and empathetic is just as, if not more, important for patient healing. With so much at stake and so little time to process, we tell ourselves that if we do the right things and act in accordance with the guidelines, our patients will be fine. But it is these moments that help us to realize that there is no such thing as perfection in the practice of medicine. It is these moments that serve to remind us that quality patient care isn’t based on sticking to the SPIKES protocol script for delivering bad news. It is these moments that remind us that fundamentally, we are human caretakers. I understood why we are always kept on our toes, trying to anticipate the unexpected – but sometimes being prepared isn’t possible or even beneficial. Sometimes altruism should take precedent over the algorithm. Being a doctor means being human first and foremost; perfectly imperfect.

A Holistic Approach to Mental Health

By Marty Morris, SKMC Class of 2021

The other day, I came across a Venn diagram depicting access to mental health services. In one circle was “Sorry, you’re not mad enough”, in the other “sorry, you’re too mad”. What struck me the most was what was in the middle: “You are the correct amount of mad. Here, we will put you on an 18 month waiting list.” (1) While the drawing pokes fun at how mental health is currently treated in our healthcare system, it brought an important question to mind – how can we get help with our mental health if and when we need it?

At the heart of the discussion is the prevalence of mental health problems and the subsequent cost to our healthcare system. (2,3) From stricter gun laws to treating neurological disorders, politicians and medical professionals alike have proposed methods to improve how mental health is handled in our current healthcare system. An article in Scientific American even recently proposed changing the title “Psychiatrist” to “Mental Health Physician” to help reduce the stigma around mental illness, based on studies of the effects of such a name change. (4) Yet, most of these arguments are centered around changing the stigma of mental illness to subsequently improve early psychiatric diagnosis and treatment. This, in turn, is hoped to decrease long-term costs to the healthcare system.

But, what if we instead approach mental health care reform from the opposite side? Rather than working to change the stigma, we should first work to make psychiatric services available to anyone and everyone who desires it. The reasons behind this approach are evident. In 2010, 89.3 million Americans were living in federally-designated Mental Health Professional Shortage Areas. (5) Even for those with services available, federal researchers found that cost acted as a significant barrier for 45 percent of people not receiving care. If we make efforts to improve access for therapy and treatment services – whether it be for a minor social stress or a major depressive episode – could this change our outlook on mental health?

Now, as someone raised by two physicians, I can understand the dichotomy of the diagram. As a child, it was often difficult to get my parents to listen to my health concerns. My worries were often met with “You’re fine. Take some ibuprofen.” With mental health, these concerns were even easier to brush aside. Individuals are often told by friends and family: “Just relax - tomorrow is a new day”. Yet, mental health is different from the rest of medicine because of this very point, when individuals no longer know when and how to discuss their real concerns. While an untreated physical illness may lead to debilitating symptoms and eventual medical intervention, the same severity of mental health illness often ends at debilitation. To prevent these downward spirals, we must reach a point where any mental health concern is a valid mental health concern.

The good news is that this movement has already started. For example, employers and universities have increasingly recognized the importance of mental health, and some even adopted approaches like “mental health days”. This has allowed individuals to take responsibility for their own mental health while increasing productivity and decreasing lost days of work in the long-term. In addition, the growing attention of the press has increased laypersons’ awareness and understanding of mental health issues. Even the sports world, an arena where mental illness has been highly stigmatized, has recently brought mental health awareness to the public eye. Players and coaches have taken ownership of their mental health and are calling for mental healthcare reform. (6)

However, even with social progress, we need the healthcare system to adapt with us. Over 5 million people end up in emergency rooms every year due to mental illness (7), costing our healthcare system approximately 456 million dollars. So my original question expands – how can we get help if and when we need it, before an emergency room?

To start, increasing access to mental health services is a step we can take. Of course, opening more therapy and counseling centers will burden the healthcare system in the short-term. However, this can also be done within pre-existing institutions, such as mental health screening in high schools and universities. Especially with the inclusion of community health centers, individuals of all demographics and socioeconomic status would gain access to mental health services. This is a risk we ought to take if we want to change how mental health is approached in this country.

Simply put, both our societal norms and healthcare have to change for reform to be effective. Efforts toward individual education, prevention of early symptoms, and an openness to listen to others will only suffice so long as there is legislation supporting funding for early therapies and prevention centers. Likewise, without introspective individual attention, legislation is likely to hold no value. I understand that this is no small undertaking, but mental health can and ought to be thought of on equal terms with physical illness. By increasing individual access and decreasing waiting list times, our notion of mental illness will slowly start to shift. Only then will the two circles of the Venn diagram become one, and anyone who wants help from mental health services will hear: “Come on in - how can we help?” It’s time we each play a part to make sure that happens.

Works Cited:

1. Ruby. "Instagram Photo." Instagram. Rubyetc, Web. 27 Nov. 2016.
2. "Mental Health Myths and Facts." MentalHealth.gov. MentalHealth, Web. 27 Nov. 2016.
3. "America's Highest Healthcare Cost in 2016? Mental Health." HealthCare Recruiters International. 10 Oct. 2016. Web. 27 Nov. 2016.
4. Morris, Nathaniel P. "Maybe We Should Call Psychiatry Something Else." Scientific American Blog Network. 20 Oct. 2016. Web. 27 Nov. 2016.
5. Kliff, Sarah. "Seven Facts about America’s Mental Health-care System." Washington Post. The Washington Post, Web. 27 Nov. 2016.
6. Love, Kevin. “Everyone is going through something.” The Players Tribune. Web. 6 Mar. 2018. https://www.theplayerstribune.com/kevin-love-everyone-is-going-through-something/
7. Szabo, Liz. "Cost of Not Caring: Nowhere to Go." USA Today. Gannett, 12 Jan. 2015. Web. 27 Nov. 2016.

Medical Innovation and the Silicon Valley

By Matthew Carr, SKMC Class of 2019

Healthcare is amid an unprecedented paradigm shift. Rapid advances in technology, new legislation, and a myriad of other factors are constantly remodeling the healthcare landscape. However, for medicine to successfully transition into this new future it will require some restructuring of the fundamentals of its culture, a shift in mindset of both patients and healthcare professionals, and changes to medical education. To ensure the professional and emotional viability of the next generation of physicians, there must also be a resolution to the present system’s ineffectiveness in providing quality, affordable care to everyone. This will require disruption of the status quo of medical practice and improved allocation of our healthcare assets. Unfortunately, medical institutions and the government have well-earned reputations for conservative policies and a long history of resistance to change.

In contrast to this “Old Guard,” Silicon Valley has been synonymous with creativity and innovation for the past generation. Before this area became the technology hub that it is today, it was a sleepy agrarian community of scenic orchards on the outskirts of bustling San Francisco. The birth of the silicon semiconductor forever altered the face of this land. Massive companies such as Hewlett-Packard were created in the garages of suburbia, springing from brilliant minds which were powered by their spirit of invention, regardless of their shoestring budget. This burgeoning electronics industry became a powerful economic force and gave the area its famous moniker. The farmland and tract houses evolved into a mecca for modern technology and innovative business ventures. The capabilities of the computer chip and the software industry exploded and spawned the familiar behemoths we know today as Intel, Apple, and Google. These companies embrace the shared purpose cited by Timothy J. Sturgeon that "the strongest thread that runs through the Valley's past and present is the drive to 'play' with novel technology." In another contrasting intellectual discipline, northern California is also home to several of the most prestigious medical institutions in the country. This poses an interesting question regarding whether the proximity to a hotbed of innovation is intellectually contagious?

Healthcare has always taken a more cautious and measured approach to change. Any deviation from the norm usually requires a groundbreaking scientific discovery or the proven efficacy of a lengthy clinical trial. However, the outcome from the intermingling of the 'playful' tech culture and the conservative bastion of the healthcare institutions has yielded some interesting results. For example, medical students in proximity to the Silicon Valley, such as those attending Stanford or the University of California San Francisco, are diverging from the standard practice of clinical medicine. In 2011 only 68% of Stanford graduates sought medical residency positions. Many students are instead opting to found startup ventures, create new medical devices, or seek employment in financial or pharmaceutical companies. Many of the most qualified young physicians are being drawn from direct patient care to positions with greater financial, personal, and professional autonomy.

These graduates can be found as employees of newly founded companies, such as Vida Health, founded by UCSF graduate Connie Chen. Her business connects chronically ill persons with physicians, nurses, nutritionists, and therapists. This healthcare team assists each patient in meeting their individual medical needs. Another entrepreneur, Pelu Tran, chose not to pursue a residency tract after graduating from Stanford Medical School. He instead formed Augmedix, a company that markets the use of Google Glass which is an eyeglass mounted camera and display. This device enables a remote connection between a physician and a scribe that allows the completion of the EMR during the visit. This frees the doctor to devote uninterrupted time to focus on the care of the patient. To further capitalize on its location and history of collaboration, Stanford Medical School recently announced the creation of the Center for Digital Health. This entity aims to facilitate intellectual camaraderie and interface in a collaborative business relationship with their technology neighbors, both startups and corporate giants alike.

But the question remains: how can this type of thinking be cultivated from the start of medical school and make the greatest impact on the life of each student? The opportunity to embrace the spirit of innovation and change is of paramount importance, especially if the stature and desirability of pursuing clinical medicine is to continue. Medical schools should emulate the success reaped by those inhabiting the Silicon Valley who adopted the changes as they appeared on their doorsteps. In fact, some schools far from Silicon Valley have embraced the inevitability of this evolution and acted accordingly. At Jefferson University, Sidney Kimmel Medical College recently adopted a unique extracurricular JeffDESIGN program. This provides the opportunity for students to attend workshops and lectures to learn how design skills can be utilized within the arena of healthcare. Other medical institutions have also chosen to expand their traditional educational tenets. Students attending the Donald and Barbara Zucker School of Medicine at Hofstra-Northwell spend their first educational block training to become certified EMT's. Matriculants at the Duke University School of Medicine complete a compressed core curriculum in two years which allows almost one third of students to complete an additional advanced degree.

Although there has been a significant learning curve to adopt of these innovative ideas, it should be clear to all medical schools that the medical education and the practice of healthcare is in the midst of inexorable change. Institutions must accept and then contribute to the progress of this inevitable evolution. This will assist the current generation of students and future physicians to succeed in this competitive and innovative world. We must all be believers in Charles Kettering who wrote, "If you have always done it that way, it is probably wrong." 

References

1. Beck, Melinda. “Innovation Is Sweeping Through U.S. Medical Schools.” Wall Street Journal, February 17, 2015, sec. Life. http://www.wsj.com/articles/innovation-is-sweeping-through-u-s-medical-schools-1424145650.

2. Dzau, Victor J., Ziggy Yoediono, William F. ElLaissi, and Alex H. Cho. “Fostering Innovation in Medicine and Health Care: What Must Academic Health Centers Do?” Academic Medicine 88, no. 10 (October 2013): 1424–29. https://doi.org/10.1097/ACM.0b013e3182a32fc2.

3. Farr, Christina. “Bay Area Doctors Quit Medicine to Work for Digital Health Startups.” KQED Future of You (blog). Accessed November 20, 2017. https://appserver-2b362ed1.c.pantheon-dmz.internal/futureofyou/2015/07/17/increasingly-young-bay-area-doctors-leave-medicine-for-digital-health/.

4. “JeffDESIGN - Philadelphia University + Thomas Jefferson University.” Accessed November 26, 2017. http://www.jefferson.edu/university/skmc/programs/cwic/tracks/design.html.

5. Kenney, Martin. Understanding Silicon Valley: The Anatomy of an Entrepreneurial Region. Stanford University Press, 2000.

6. “Med School Grads Go to Work for Hedge Funds.” Bloomberg.Com, September 5, 2017. https://www.bloomberg.com/news/articles/2017-09-05/med-school-grads-go-to-work-for-hedge-funds.

7. “Ostrovsky_hjdsi_2014.Pdf.” Accessed November 21, 2017. http://scholar.harvard.edu/files/mbarnett/files/ostrovsky_hjdsi_2014.pdf.

8. “Siren Song Of Tech Lures New Doctors Away From Medicine.” NPR.org. Accessed November 20, 2017. https://www.npr.org/sections/health-shots/2015/07/19/423882899/siren-song-of-tech-lures-new-doctors-away-from-medicine.

9.  “Medical Student’s Startup Uses Google Glass to Improve Patient-Physician Relationship.” News Center. Accessed November 26, 2017. http://med.stanford.edu/news/all-news/2015/02/medical-students-startup-uses-google-glass.html

10.  “Stanford Launches Digital Health Center to Connect Faculty with Tech Companies.” News Center. Accessed November 26, 2017. http://med.stanford.edu/news/all-news/2017/01/stanford-launches-digital-health-center.html.

A Medical EMRgency!: A Discussion of the Incorporation of Electronic Medical Records (EMR) into the Healthcare System

By: Alisha Maity, SKMC Class of 2020

I sat on a stool in the corner of a small office, silently grimacing. In another corner, an anxious, middle-aged woman sat as she stared down her doctor who had been occupied for the last 30 seconds searching the woman’s electronic medical record (EMR) for her latest CT scan. When the doctor finally looked up from the screen, he delivered the news about the presence of new nodules that would require biopsy, words that overwhelmed the woman. Throughout my afternoon of shadowing, I witnessed every complaint that I had heard doctors and nurses mention about the EMR, in action. The doctor had to click on box after box to establish diagnoses in the EMR, tests had to be reordered multiple times because the system kept crashing, and patient after patient waited with bated breath while their doctor struggled to cut through the “note bloat” of the EMR to unearth critical information.

As someone who cherishes the organization and capabilities of Google Calendar and makes detailed to-do lists, the EMR seems exciting and essential. But as the daughter of two health care professionals, I’ve heard the full gamut of complaints ranging from the costly implementation of EMR into private practices to the idea of doctors getting “dinged” for not filling out electronic forms properly. While EMRs have been around for a while, a mandate to adopt the EMR was put in place in 2014 through the American Recovery and Reinvestment Act (ARRA). In an effort to improve healthcare, engage patients, improve care coordination, and maintain patient privacy, hospitals that demonstrated “meaningful use” of the EMR were eligible for various financial incentives and, as of 2015, hospitals that failed to comply faced penalties. (1)

However, studies on EMR effects on doctors and patients have demonstrated mixed results. For example, numerous studies detail low physician satisfaction and increased physician burnout associated with the EMR. (2, 3, 4) Furthermore, one recent study found that a sample of Family Medicine doctors spent 6 of their 11-hour work days and 1.5 hours after clinic working on the EMR, with nearly half of this time spent on electronic clerical and administrative tasks. (5) Yet, numerous other studies have demonstrated an improvement in patient care with the advent of the EMR; in fact, according to the National Physician Survey, over 75% of physicians use EMR and, of these, 65% believe patient care has improved. (6, 7) From the information in these studies, it appears that EMR has improved healthcare at a cost. While EMRs are capable of improving patient care through the consolidation of information, doctors forced to undertake time-sucking administrative tasks and their patients can be affected negatively because of this technology.

One possible solution to this problem is the use of scribes. Pooja Selvan (MS2 at SKMC), a former scribe with ScribeAmerica, describes a scribe’s role as “removing the clerical aspects of a patient’s care from a doctor’s workflow.” Although provided with several training sessions on medical terminology, SOAP notes, and some basic instruction on the EMR, much of scribes’ training occurs on the job. In the doctor’s office, a good scribe should “be invisible” and record all aspects of a patient’s visit, allowing the doctor to maximize patient contact. While scribes can be beneficial, some argue that they serve as a quick-and-dirty fix that obfuscates larger problems that need to be solved like better workflow designs. (8) If scribes are not the final solution, what is the future of doctors’ interactions with the EMR?

Dr. Kent Berg is an Associate Professor in the Department of Anesthesiology at TJU. He also holds the title of Vice Chair of Information Systems & Technology and has been working on adapting Epic in an Anesthesia-specific setting and remains positive about the benefits of EMR. “[Although] it was a very steep learning curve, I am confident that most of our Anesthesia colleagues now would find the EMR very hard to live without.” Dr. Berg has recently been working on improving Status Boards, large-screen monitors in pre-op and post-op areas. These boards serve as communication tools amongst staff and reduce the need for constantly checking in on computer terminals. Because the EMR can often be filled with so much extraneous information, changes that are specific to a department or specific workflow seem to be the best kind of mechanism of improving EMR use.

Dr. Berg’s advice to physicians struggling with balancing patient interactions and utilizing the EMR is to “practice the workflows in the training environment and reach out to a ‘SuperUser’ (someone who has been identified as someone who excels using the system), as mentor-mentee relationships can be extremely valuable, especially for improving your EMR skills.” At a place like Jefferson, where the EMR has been in place for over a year and has specific workflows in place, this advice is exactly what experts suggest in the implementation of EMR.

The advent of EMR has scared some physicians and won over others. Future physicians, such as ourselves, have the advantage of letting technology work out its kinks before engaging with it fully. And by the time we do engage with it, EMR will be the norm. From the diverse range of opinions expressed in research over EMRs, it is clear that the best way to approach EMR is to embrace it as a tool that can enhance patient interactions and outcomes. Over-reliance and under-reliance on such a tool both pose their own problems. Disregarding the EMR as an instrument for collaboration of care, a way to reduce medical errors, and a solution to physicians’ terrible handwriting is impractical. On the other hand, relying on an electronic device without also maintaining a strong doctor-patient relationship interferes with the tenets of good clinical practice.

In researching the EMR, I found one message from a breast cancer patient who found her experience with her oncologist negatively impacted by the introduction of the EMR, particularly memorable: “It’s very hard to…learn to trust somebody with our well-being and our lives when all we see and hear is the back of a white coat and the click of a mouse.” (9) As future physicians, the EMR is a tool that will continue to evolve and improve but throughout this process we must remember that it is the patient and not their medical record that represents the true consolidation of medicine. 

References

1 https://www.usfhealthonline.com/resources/healthcare/electronic-medical-records-mandate/

2 http://www.mayoclinicproceedings.org/article/S0025-6196(16)30215-4/abstract

3 https://www-healthaffairs-org.proxy1.lib.tju.edu/doi/full/10.1377/hlthaff.2016.0811

4 https://www.ncbi.nlm.nih.gov/pubmed/24005796

5 http://www.annfammed.org/content/15/5/419.long

6 http://www.bmj.com/content/354/bmj.i3835.full?sid=f4a035af-758f-4be0-b265-2d9c680bbd4b

7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607324/

8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978695/

9 https://www.kevinmd.com/blog/2011/03/emr-patients-perspective.html

A Personal Account of Resilience and Coping

By: Vivek Bilolikar, SKMC Class of 2021

Midway through my second year of university, my childhood friend, EE, called me around 1 AM on Sunday and woke me up from what I could only assume was a perfectly good dream. 

“I hope I didn’t wake you,” she ironically stated.

“No,” I sleepily replied, “I was up anyway. What’s up?” 

She told me that she was having trouble sleeping. Initially, I thought that she had broken up with her most recent boyfriend, or something along those lines, but there was something different in the sound of her voice. We made small talk for a little while and just as I was about to end the conversation and hang up she was ready to talk. 

“I’m going into surgery tomorrow,” she blurted out. 

Stunned, the only words I could manage were, “For what?”

She explained that she was going to have a lumpectomy for breast cancer. A week earlier, she was diagnosed when the doctor found a lump during a routine exam. The doctors were hopeful that the lumpectomy would cure her cancer. I didn’t know what to say. I just lay in bed and listened. I tried to console her and tell her that everything will work out but what did I know? I was just a college sophomore over 1000 miles away. We talked for an hour and then hung up. I didn’t sleep the rest of the night. 

A week later, when I called to follow up on her surgery she picked up the phone sniffling. 

“The doc said that I have to start chemo because it spread to the lymph nodes,” she revealed. 

That moment lasted for an eternity, my phone slowly slid out of my hand and bounced around on the floor. The only thought I had was that I might have to go to my best friend’s funeral. 

“Are you still there?” she asked.

“I’m here, when is your first session?” I asked, coming back to reality. 

“Tomorrow,” she replied.  

“I can’t be there tomorrow, but I’ll be there for the second session and every single one after that,” I promised without hesitation. 

Once I got home I accompanied her every other week to her chemotherapy sessions. 

“Don’t go and shave your head and eyebrows. You’ll look like an alien, and there don’t need to be two of them!” She exclaimed out of the blue during her third session.

In the moment, I laughed. I realized that I would look ridiculous with no hair or eyebrows. Reflecting back on the moment, however, I realize she was looking for stability, not trying to make fun of the shape of my head, even if it was just my appearance. I think that she was acutely aware that a lot was going to change and wanted some things to stay the same. She insisted that we do things that we had done before her diagnosis, even as kids. We played P-I-G in the hospital parking lot before her chemo sessions to get rid of her anxious energy. We played cards during her sessions to pass the time. We enjoyed each other’s company without letting the circumstances define it

Unfortunately, the first combination of chemo did not work. I was frustrated and heart broken. I can only imagine EE felt the same, but she did not even seem phased by the news. 

“The first round did not work, so I’ll be expecting you next week! I need to beat you at cards so that I can take your money and pay for this next round of chemo,” she declared with a smile on her face. 

I could not believe her courage in the face of such devastating news. I’m sure that cancer changed her outlook on life but you wouldn’t know it by looking at her; she was still the same sharp, witty, funny girl she had always been.

Before she was diagnosed with breast cancer, EE was studying to go to law school. She tried to keep up with school but it proved harder than she expected. She took a leave of absence but she did not stop studying when we weren’t playing cards or complaining about the terrible hospital TV.  She refused to become a slave to her situation. To me, it appeared as if her diagnosis had increased her zeal to thrive. After six months of chemotherapy, EE's cancer went into remission and she immediately went back to law school; she did not skip a beat. 

After watching EE and being a part of her treatment, I have come to realize and appreciate that in a time of crisis having the opportunity to continue with one’s normal life is key. EE and I did not dwell on her diagnosis. I treated her as if she was still nineteen and did not have cancer. That stability, I think, gave her the chance to process the monumental changes in her life at her own pace.

Great stories about resilience and coping center on the fact that in the face of great adversity people want to continue, even excel, with their regular lives and routines. The normalcy allows them to concentrate on something else that is not connected to their crisis situation. Their subconscious has the time to process the crisis situation and begin adjusting to the adversity. Yet, often that stability is elusive because of the monumental changes that are occurring.

 As future physicians, all of us at some point will have to interact with patients who have terminal illnesses. In fact, many of us will have to give patients a life-altering diagnosis. We must consider that patients and those around them deal will deal with this crisis in different ways. Dr. Shastri Swaminathan, a psychiatrist with Advocate Illinois Masonic Medical Center in Chicago, said, “In the face of a major medical illness, everything we know shows that patients go through the same five stages: denial, anger, bargaining, depression and, eventually, acceptance. Any intervention by a medical professional should be pertinent to the stage the patient is in”. It is imperative that we are able to identify the mental states of our patients so that we can offer pertinent advice when it is most effective; discussing treatment options with patients in denial will not result in a beneficial exchange and effective decision making. 

Furthermore, patients who are facing adversity need to be able to develop coping mechanisms on their own terms and we, as health care providers, need to be involved. We cannot utilize a one-size-fits-all approach when it comes helping patients with facing their diagnosis because each patient is different and will require different support. The best coping mechanism is for patients to actively face their illness head on. In that same vein, physicians should encourage their patients to become an active member of their treatment team. Active involvement will help patients to maintain a sense of control and stability as they are empowered to control the elements of their life that they can. That way they are no longer a passive recipient of their treatment course, but the agent of their own destiny.

1. A shorter version of the basketball game H-O-R-S-E

2. http://www.ahchealthenews.com/2014/09/08/coping-with-a-life-threatening-medical-diagnosis/

3. http://www.apa.org/helpcenter/chronic-illness.aspx

Doctors Should Embrace the Ocean

By: John (Teddy) Nohren, SKMC Class of 2018

“We are not students of some subject matter but students of problems. And problems may cut right across the borders of any subject matter or discipline.” –Karl Popper (1`).

Every day the mountain of knowledge and innovative ideas in various scientific fields grows with increasing speed and complexity. Much like organisms in the ocean, new devices and groundbreaking treatments are discovered every day. This rate of constant expansion demands interdisciplinary individuals to facilitate incorporative innovation. Overlap between fields has no limits. In fact, seemingly unconventional combinations have provided a multitude of discoveries that have changed the modern world as we know it! Two such fields are medicine and marine biology.

Marine life has provided many clues, tools, and unique compounds to medical research with the promise of more waiting to be discovered. Porifera (sponges), for instance, have been a resource of several chemicals undergoing various clinical investigations. Two examples, crambescidins and batzelladines, are organic compounds that have shown antiviral properties, the latter of which has the ability to inhibit HIV-1 envelope-mediated cell-cell fusion (2). Discodermalide, derived from a deep-sea sponge, has shown the ability to stabilize microtubules and is being developed for cancer treatments (3). Porifera aren’t the only marine life providing chemicals that could dramatically alter current treatment standards. A little higher up the food chain, sharks have been an animal of extensive research regarding potential therapeutics. For a while there was a belief that shark cartilage held a secret to cancer treatment. However, this ultimately has been disputed after drugs, such as Neovastat, showed no significant improvements during phase III clinical trials (4). Presently, sharks are able to provide models for cancers such as melanoma (5) and their immunoglobulins & T cell receptors are promising in the field of immunotherapeutics (6).

This brief foray into a handful of instances where sponges and sharks can play a role in medicine illustrates that there is a potential treasure trove of discoveries to advance the medical field in the vast, open sea. Physicians and other medical researchers who also have a personal passion for marine biology, as well as other natural sciences, may be in a unique position to be on the forefront of innovation by existing where two fields overlap.

References:

1.     Popper, K. (1962). Conjectures and refutations; the growth of scientific knowledge, (p. 88). New York, NY: Basic Books.

2.     Bewley, C., Ray, S., Cohen, F., Collins, S., & Overman, L. (2004). Inhibition of HIV-1 Envelope-Mediated Fusion by Synthetic Batzelladine Analogues. Journal of Natural Products, 67(8), 1319-1324.

3.     Kijjoa, A., & Sawangwong, P. (2004). Drugs and Cosmetics from the Sea. Marine Drugs, 2(2), 73-82.

4.     Falardeau, P., Champagne, P., Poyet, P., Hariton, C., & Dupont, [. (2001). Neovastat, a naturally occurring multifunctional antiangiogenic drug, in phase III clinical trials. Seminars in Oncology, 28(6), 620-625.

5.     Waldoch, J., Burke, S., Ramer, J., & Garner, M. (2010). Melanoma in the Skin of a Nurse Shark (Ginglymostoma cirratum). Journal of Zoo and Wildlife Medicine, 41(4), 729-731.

6.     Criscitiello, M. (2014). What the shark immune system can and cannot provide for the expanding design landscape of immunotherapy. Expert Opinion on Drug Discovery, 9(7), 725-739.

Adding Value Wisely: The Case for Economics as a Medical School Prerequisite

By: Nishant Pandya, SKMC Class of 2019

The health care system steadily faces increasing costs. Under its current trajectory, healthcare spending is projected to account for nearly 20% (approximately $5.5 Trillion) of the US GDP. $700 billion of this money is considered avoidable and unnecessary, including $325 billion of unwarranted use, $100 billion of provider inefficiency, and $50 billion of poor care coordination (1).  While unfortunately there is no silver bullet for this challenge, the health care system must attempt to reduce costs without compromising the quality of patient care. Without an unexpected new revenue source on the horizon, many healthcare leaders have started prioritizing high value care to address this issue (2). The concept is straightforward: for each dollar spent, healthcare teams are to focus on achieving the greatest health outcome. However, the challenge lies in developing this mindset in practicing health care professionals and medical students (2,3).

Before implementing its High Value Care Training, the UNC Pediatrics Department Needs Assessment found that majority of the teaching faculty and residents did not feel confident in their abilities to deliver high value care and few had received any relevant instruction in the past. In hopes to bring change, the department used case base learning and guided lectures in a 5 part series to teach high value care through understanding benefits and harms, decreasing low benefit interventions, choosing high benefit interventions, customizing care according to patient values, and identifying system level opportunities to improve outcomes (5).

In one case study, the participants considered how to create a workup including tests for a patient with suspected pulmonary embolism. The group collectively ordered nine different tests, notably CT angiography, which costs $294.40 and D-Dimer assay which cost $65.88. A follow-up study analyzed the 22 CT angiograms that were ordered to “rule-out” pulmonary embolism (PE). For each patient, health records were provided to calculate their Wells’ Score, a probability scoring criteria used to diagnose likeliness of PE due to deep vein thrombosis. The calculated score indicates whether a patient is at high, moderate, or low likelihood for PE. The diagnostic algorithm advises high probability patients should have CT angiography performed while low probability patients should have a D-dimer assay performed (1).

Of the 22 CT angiograms that had been ordered, only 2 patients had PE. From the 20 other patients, 18 of those patients scored low likelihood on the Wells Score. Higher cost CT Angiography was unwisely ordered for patients whose risk for PE could have been equally measured by a lower cost D-Dimer assay. This case study hoped to highlight the overuse of imagining without initially checking pre-test probability and alternate low cost ways to rule out pulmonary embolism in patients (1).

While the training guided physicians through numerous “real-life” scenarios, participants admitted there would be challenges towards clinical implementation. They most frequently expressed difficulty changing habits, unawareness of every cost, and lack of support and instruction from administration (5). Even after the training, structural barriers exist that present challenges to changing the way practicing physicians approach their decision making by encouraging change at this stage in their career.

With this feedback in mind, the evidence points to the importance of introducing value based health care training early on in medical education. In 2012, the AAMC adopted the Do No Harm Project created at the University of Colorado. This initiative sought to develop clinical vignettes written by physicians to humanize concepts of medical overuse, over diagnosis, downstream harms and challenge the “more healthcare is better” culture (6).  Two anesthesiologists from Beth Israel Deaconess Medical Center studied over 73,000 low-risk surgeries and focused on pre-operative tests ordered to look for potential imaging overuse. The study found chest x-rays (CXR) were regularly ordered to assess risk for pulmonary complications. However, they found pre-operative CXRs rarely contained unexpected findings that would not be available in the patient’s medical history and physical exam. Furthermore, despite 20% of CXRs being abnormal, the imaging only influenced operative management in 3% of cases (6). This unnecessary imagining order added roughly $200-400 to the health care cost and rarely improved the patient outcome quality. This study stressed the importance to use all available sources of information and order tests wisely.

The conversation, however, is not one-sided. There is concern towards the increased focus medical students receive towards high value care. Johns Hopkins Medical Ethics Department believes that the welfare of the patient must remain the primary focus of the medical profession and overemphasizing cost saving burdens the risk of unintended consequences for the patient (7). For example, screening is an early detection tool that may allow for earlier treatment and potentially significantly reduced medical costs. All screening tests however are not equal. When a patient comes to a doctor with symptoms, a screening test offers a possibility of relief and explanation of an ailment. Screening asymptomatic healthy patients, however, is different. In 2012, the Clinical Journal of American Society of Nephrology faced this issue when exploring the merits of screening regularly for chronic kidney disease by regularly testing urine protein levels. At the core was the struggle between marginal cost and marginal benefit. By testing asymptotic patients, there is an opportunity to improve long term outcomes and prevent further progression of disease. However, there is also risk of false-positive screening that would unduly cause the patient anxiety or the risk of false-negative screening that would wrongly reassure the patient of their health. As of 2014, the National Kidney Foundation suggested a compromise in recommending healthcare professionals test asymptomatic patients who are at considered high risk (8). Debate still surrounds the merits of asymptomatic screening. It holds the potential to reduce healthcare costs and improve outcomes, but the screening itself may ignore hidden costs that burden the patient without full guarantee of benefit.

The Johns Hopkins Ethics Department does not argue against the movement towards high value care nor is it complacent with where healthcare stands today. There is clear need to reduce costs, but the approach towards accomplishing this without harming patient care is its priority.  Ideally, Hopkins Ethics Department suggests putting greater emphasis towards teaching students to communicate costs of healthcare initially while introducing more complex concepts of value much later in training. This hopefully ensures a distinction that high value care is not synonymous with low cost care.

I understand the long term benefit of introducing students to high value care early in training, but I share the ethical concerns mentioned above. Ultimately, physicians are asked to uphold the Hippocratic Oath and care for patients. Medical education is fast paced and voluminous with the goal to ensure students meet a set of academic competencies. In its current structure, medical education often leaves insufficient time to properly introduce and teach important concepts, such as high value care. While vignettes and seminars can teach high value care in theory, it is a greater challenge to expect students to seamlessly integrate potentially new concepts into a clinical mindset without long term exposure and comfort with high value care.

Considering the challenges and shortcomings associated with a condensed curriculum of high value care, I suggest a two part method to introduce students to this style of thinking in a meaningful and efficacious manner earlier in their medical careers. The end goal is to expose students to the financial aspect of medicine through a longitudinal curriculum during their preclinical years. Specifically, showing how each step of a hospitalization including tests, orders, and medications sum towards the final cost of healthcare. Peeling back the curtain and showing how the conversion of healthcare services into healthcare costs allows students to incorporate the concept of cost into their clinical mindsets before they hold direct patient care responsibilities. While the primary part of this idea requires greater structural change, an immediate option for medical schools to consider is requiring Introductory Economics as a prerequisite for admission. If high value care is one of the primary initiatives in medicine, then requiring incoming students to be familiar with cursory economics may be just as efficacious towards accomplishing this goal as the basic and social sciences medical schools already require.

With healthcare spending becoming an increasingly important topic, medical schools will have to find a way to integrate the fundamentals behind high value care earlier in the curriculum. Students should be introduced to economics topics like cost vs. benefit analyses and how they apply to healthcare before they are treating patients. However, the updated curriculum should not ignore the patient’s well-being at the risk of these economic principles. Schools must find a way to incorporate and balance these overlapping values and they must do so quickly. 

Works Cited

1. Swaroop, Bindu. “Introduction to High Value Care: Eliminating Healthcare Waste” Department of Medicine. University of California. 2016
2. Rice, Lauren. "Health Care On a Budget: The Rise of Economic Dominance in Health Care Reform." (2012).
3. Hillary, Wilson, et al. "Value based Healthcare." Advances in Management 9.1 (2016): 1.
4. Porter, Michael E. "Value-based health care delivery." Annals of surgery 248.4 (2008): 503-509.
5. Warthrop , Richard. "High Value Care In Practice and Education." The University of North Carolina. Pediatrics Department , 2014. Web. 28 Mar. 2017.
6. Smetana, Gerald W. "The conundrum of unnecessary preoperative testing." JAMA internal medicine 175.8 (2015): 1359-1361.
7. "Medical Ethicists Urge Caution in Teaching High-Value Care." Department of Ethics . Johns Hopkins University , 13 Dec. 2016. Web. 28 Mar. 2017.
8. Kliger, Alan S. "Screening for CKD: A Pro and Con Debate." Clinical Journal of the American Society of Nephrology 9.11 (2014): 1987-1987.

Medical Aid in Dying: What My Dog Taught Me

He was sick, but it wasn’t like he was going to die anytime soon. A year ago, my dog Sierra sustained a neurological insult that left him delirious, unable to walk straight and almost entirely blind and deaf. Still, he enjoyed our loving touch, snuggling against my thigh as I watched a movie or falling asleep in my arms while being held. I struggled with these thoughts as the vet pushed the pink, fluid-filled syringe into his vein. He collapsed into my arms and let out a groan, as he had many times before. But this time, he did not get up.

I said goodbye and left him to join my parents standing in the waiting room. My father looked up at me, “Is it done?” I nodded, and suddenly, we all broke into tears. We embraced each other and talked about what a good dog he was. We told each other it was the right thing to do, that it was time. But was it? Why now?

I couldn’t help but think we were being selfish. Objectively, nothing much had changed since his suspected stroke, albeit he was undoubtedly more of a burden. We were constantly cleaning up after him, redirecting him when he got caught in a corner and paying for vet visits and medications. But the bottom line was that he still found enjoyment in life. Was the choice to put him down for our wellbeing or for his?

Health professionals and loved ones struggle with these same questions when caring for those nearing the end of life. Sierra’s decline came at a poignant time, one in which many are fighting for the right to choose death in the face of terminal illness or suffering. Currently, five states allow those with a terminal illness and a prognosis of less than six months to end their life with the help of a physician, also known as “medical aid in dying.” Canada legalized physician-assisted death in 2016, joining a small number of countries that have laws enabling this practice.

The principle behind these laws is relatively simple. People want to die with dignity, and in the process of fighting for the right to do so, they’ve ironically improved end-of-life care. As a free nation that claims to be a leader in health care, why have we not adopted this practice? While poking fun at “the land of the free,” Jim Jeffries, an Australian comedian known for his outsider political commentary, pointed out that “assisted suicide for the sick … is the biggest freedom of them all.”

Opposition to physician-assisted death comes from both the public and from within the medical profession itself. Deeply rooted societal ideals, values and norms fuel the debate. From day one, physicians take an oath to “do no harm.” Common sense tells us that healthcare professionals are supposed to help heal the sick, not to “help” them die. Furthermore, for some patients, taking one’s life goes against their religious values and/or our fundamental values as human beings. Also, many families find that loved ones nearing the end of life are often incapable of making well informed decisions due to fear, depression or the effects of disease on their mind. And so we choose life, even when death seems so near.

Despite the moral controversy, attempts have been made at giving patients the right to take control of their own death in the United States. Numerous court cases have brought the legality of this practice into light culminating in the 2006 Supreme Court case Gonzales v. Oregon. Under this ruling, the federal government failed to prohibit physicians in Oregon from prescribing drugs to help patients die, opening the door for states to legalize medical aid in dying. Organizations such as the Death with Dignity National Center have taken it upon themselves to both educate the public on end-of-life options and to advocate for physician-assisted death. Even so, there has been little done to legalize this practice in federal law.

Lawmakers took a step in the right direction during discussions about health care reform and the implementation of the Affordable Care Act (ACA). The misleadingly-termed “death panels” were a way to incentivize physicians to have discussions about end-of-life care with their patients. Unfortunately, this section of the ACA was thrown out due to political controversy. Finally, in 2015, the Centers for Medicare and Medicaid services approved regulations that allow qualified healthcare professionals to be reimbursed for providing advance care planning to patients. Still, moral and legal barriers persist, preventing patients from making the decision that is right for them.

Looking back, I am grateful that Sierra left us when he did. Choosing to put him down was not easy, but afterwards, I came to an important realization. By choosing death at that moment, we determined when, where and how he died. We chose a period when our family was home together so that we could spend quality time with each other in his last moments. This pronounced the end of our living relationship, giving us a sense of completion. We made sure that he died with us, in a peaceful environment, around those he loved instead of alone on the kitchen floor. He was able to leave the world peacefully and quietly without the suffering of a drawn out painful death that would taint our memory of his long and happy life. Sometimes, I wonder if the groan he let out at the end was a sigh of relief, a goodbye or even a thank you.

This article was written by Jeffrey Henstenburg, SKMC Class of 2018

Recognizing Historical Trauma’s Role in Cross-Cultural Psychiatry

As a first-generation Singaporean American, I sometimes think about the stark contrast in richness between the age-old historical narratives of Asian countries and of acculturated Asian Americans. Identifying more with the latter, I realize how the absence of an inspiring historical narrative among us has left some of my second and third-generation peers susceptible to internalized prejudice and reduced self-esteem. My parents, even as immigrants, may have an unconscious boost to resilience from feeling tied to a Chinese historical-cultural tradition with millennia of achievement. Yet, many of my Asian American peers, who only remember life in the states, are unaware of positive role models and absorb their own stereotyped misrepresentations in media and literature. Collective historical identity obviously need not define a person; however, it can subtly erode at one’s mental wellbeing. 

Stress resulting from historical consciousness is by no means isolated to Asian Americans. In Black Skin, White Masks (1952), Frantz Fanon described psychiatric stresses specific to citizens of African ancestry in the West at the time. He noted how collective memory of African culture and achievement had long disappeared, but historical trauma and cruel portrayal by media within the “mother country” insidiously ravaged one’s self-esteem. Even today, even ignoring ongoing injustices that cause stress, it should surprise none that repeatedly hearing, starting from elementary school, about the horrific enslavement of and discrimination towards one’s ancestors could contribute to mental trauma. 

Joy DeGruy proposed a term for the results of such historical trauma: “post-traumatic slave syndrome” (PTSS). According to DeGruy, and which may seem intuitive, a collective memory of centuries of slavery, Jim Crow laws, and unwarranted mass incarceration aggravates maladaptive behaviors among many African Americans. Acute racism against African Americans has subsided markedly since the last century, but widespread sentiments of being victimized persist despite this reduced context of racism. Older generations, who experienced and vividly remember acute racism, may indoctrinate their children into anti-authority cynicism and aggression. Despite policy and sociology’s roles in perpetuating PTSS, there exists an enormous opportunity for psychiatrists to help patients identify and defuse their maladaptive mechanisms. 

At times, psychological impacts of historical consciousness are so strong that cultures have well-established terms for them. Such terms abound today for Korea, which historically had little power to resist brutal interference from militaristic giants. Connecting all this to psychiatry, palja denotes a sort of fatalistic, helpless attitude: an acceptance of lack of control over one’s life’s course that stems from folk memory of both those invasions and the historical caste system that dictated individual Korean status. Even more prominent, han describes an unresolved, distress-inducing—often strong enough to elicit somatic pain—and collective feeling of unjust victimization among Koreans, to this day. A lifelong internalization of memories of unavenged foreign humiliation no doubt contributes immensely. 

All of these examples relate to Arthur Kleinman’s term “cross-cultural psychiatry,” which first described a tendency towards somatization of depression among patients of native Chinese cultural background. Fanon’s observations, PTSS, and han could be categorized into a new 

“collective history-bound” subfield within cross-cultural psychiatry. Much of psychiatry and, especially, psychoanalysis tries to alleviate latent tension in part by bringing buried, uncontemplated stressors into conscious processing. These stressors arise not only from a person’s life events, or events involving their close friends and family, but also from their ethno-cultural community. Discussing historical traumas relevant to an entire culture could benefit certain patients. 

A more immediate priority, however, is public awareness of cross-cultural psychiatry. In 2016, some psychiatric morbidities allotted the greatest federal funding for research included acquired cognitive impairment ($1.132 billion) and depression ($410 million). Few would argue against such conditions receiving major attention in research, due to their conspicuousness and universality across demographic lines. Yet, mental stress arising from historical collective memory, even if a culture-specific source of burden, receives very little attention from American psychiatric research. 

The gap in research funding for cross-cultural psychology has two causes. First, the US is relatively young among civilizations. In turn, the dominant historical narrative we do have about our last 241 years almost close-mindedly emanates optimism. The national narrative is easily replete with heroic George Washingtons and Abraham Lincolns and achievements like our contribution towards an Allied victory in both world wars. However, it may not show a rounded picture with darker undertones, such as fairly recent, extensive de facto racism as depicted by Fanon. Thus, researchers may not perceive historical consciousness as a stressor. 

Second, there is a lack of diversity among academicians. Trends at any academic center will likely be influenced by issues its researchers feel most aware of. More ethno-cultural diversity among research psychiatrists would likely lead to increased academic interest in the impact of culture on mental health. Inadequate representation in academic psychiatry alienates ethnic groups that have unique culture-bound and minority status-related psychiatric stressors. Hence, advocates for psychiatry and other mental health care training programs should intensify thir current academic diversity initiatives. When demographic diversity among trainees may not be easily obtained, more psychiatry residency programs should adopt training initiatives surrounding culture-bound mental illness, such as those that at Yale and George Washington University. Furthermore, more programs could train all residents to show awareness of and sensitively screen for history-bound conditions such as PTSS and han, especially in and near large cities. 

Finally, cross-cultural psychiatry as a whole deserves stronger advertising among medical students and psychiatry residents. Long-term solutions include the addition of several pertinent lectures to medical school curricula and the creation of clinical rotations in cross-cultural psychiatry. Immediately, psychiatry clerkship preceptors could encourage trainees, when giving psychiatric evaluations among diverse patients, to ask about cross-cultural concerns. Advocates can also write and speak about cross-cultural psychiatry’s relevance not only to academic centers, but also to community practice. In turn, more attention can be paid by psychiatrists to distress specifically related to historical trauma. 

Identifying with one’s cultural history may enhance resilience but may also generate distress. A traumatic collective history can certainly aggravate the latter, justifying a greater awareness of historical narrative’s effect on mental health when evaluating diverse patients. Mental health advocates can promote awareness of and encourage research on culture-bound psychiatric stressors. In turn, by also acknowledging the limited attention thus far on historical trauma’s role as a stressor, we can promote a new “collective history-bound” field of discussion within psychiatry. Such a field would help psychotherapy patients transcend trauma from not only their individual pasts, but also from a far larger collective past. 

This article was written by Richard Zhang, Sidney Kimmel Medical College Class of 2020

The Case for Spirituality and Medicine

Effective medicine requires developing meaningful relationships with patients. As students, we are taught to start conversations with patients with open-ended questions. Without a simple "yes" or "no" for an answer, the patient shares their story and is able to decide what is important to tell the physician. Clinicians can then ask follow up questions to fill in any gaps in the patient's narrative. Not only is this efficient in terms of diagnosing and treating the patient, but it also facilitates an environment of trust. The patient’s concerns are easily conveyed to the physician and the physician can focus their therapy based on this conversation. Although this is an excellent technique, including spiritual histories could enhance the standard patient interview.

Readily focusing on patient values, spiritual histories allow patients and physicians to connect on a deeper level. They also facilitate planning of advance directives, end of life care, and other spiritually-sensitive medical treatments. By talking about spirituality, patients are able to share, in their own words and in a way that they can understand most, what gives their lives meaning and how this can be applied during difficult times. Physicians have a spiritual role in terms of caring for others and physicians could use this role to their advantage by acknowledging it and using it during patient care.

One method that can be used by residents and physicians to take a spiritual history includes the HOPE acronym:

H: Source of meaning, hope, strength, and connection

O: Organized religion

P: Personal spirituality and practices

E: End of life issues and how spirituality affects medical care

For example, in terms of “H: Source of meaning, hope, strength, and connection”, a physician could ask, “What are the sources of hope in your life?” Alternatively, one could ask, “I understand that religion and spirituality can help people find strength and meaning in their lives; is this true for you?” This step in the spiritual history opens the door to the rest of the questions. If the answer is yes, then the physician could ask about “O: organized religion.” When asking about organized religion, a physician should ask how important the patient’s spirituality is to him or her and what role it has in his or her life.

“P: personal spirituality and practices,” has two sides. One side focuses on the patient’s beliefs independent from an organized religion or the patient’s belief in God and what that relationship looks like. The other, and equally valuable, side looks at the patient’s spiritual practices, such as prayer, meditation, or other practices that helps the patient find motivation and comfort throughout the day. Finally, as it especially pertains to medical practice, a physician should address “E: end of life issues and how spirituality affects medical care.” For example, a physician can ask the patient if there are any spiritual restrictions health care professionals should know about, such as dietary restrictions, that could change the patient’s treatment plan.

So what can physicians do after they have received this information? There are many different options depending on the circumstances and patient’s desires. Firstly, the physician can take no further action with this information if that is what is desired. Even if no further action is taken, the patient will feel a connection with the physician after speaking about his or her spirituality and the physician will gain a better understanding of the patient’s values and what they find meaningful in life. On the other hand, if desired, the physician can incorporate the patient’s spirituality into the patient’s health care. For example, if a patient is dealing with anxiety related to his or her illness, the physician can try to encourage the patient to use spiritual practices such as prayer or meditation to get through difficult times. A physician could also help find resources that the patient could use to find motivation during an illness, such as speaking with a spiritual leader or spirituality-focused support groups.

Incorporating a spiritual history into patient care is important because not only does it open the dialogue, but it also creates a safe space for discussion. This helps to create a meaningful relationship between the physician and the patient that can facilitate trust. In addition, the spiritual history helps the physician to understand where the patient’s desires and values come from. This enables them to be advocates for their patients by making sure that the care that the patient is receiving is in line with his or her values and motivations in life. Considering these advantages, the argument can be made that a spiritual history can be a valuable add-on to a medical history that helps to create a trusting environment between the patient and the physician where open dialogue can be facilitated, patient concerns can be addressed, and care that aligns with the patient’s beliefs can be offered.

This article was written by Michelle Evans, Sidney Kimmel Medical College Class of 2019

References:

(1) http://www.aafp.org/afp/2001/0101/p81.html

(2) https://www.psychologytoday.com/sites/default/files/attachments/52072/apt-taking-spiritualhistory-may-07.pdf

(3) https://depts.washington.edu/bioethx/topics/spirit.html