[1/2] Finding someone (or something) to blame.

When things don't go well, we often look for someone (or something) to blame.  You could say it's almost human to do so.  But that doesn't mean it's the right thing to do, nor does it excuse the finger pointing.

As with most things I blog about, I started thinking about finger pointing and blaming people when I made the mistake of finger pointing and blaming people.

We were in our endocrinology block and our lecturer was pointing out the strong correlation between obesity and type 2 diabetes. Absentmindedly (not an excuse), I remarked "hmm, well it's the patient's fault isn't it?  We suggest lifestyle changes and nutrition changes when we catch them in the prediabetic stage, but they don't do anything about it, and end up with full blown [type 2] diabetes".  

Harking back to an older post, this is when having good friends who will call you out is very important.  One of my close friends got on my case for having such a "blame the patient mentality" (which I don't, but I still deserved to be called out for my comment), and I got to thinking about the "blame the patient" mentality.  

I guess two things need to be clarified:

1. Blaming is just plain silly:
It doesn't do anything about the situation.  It just makes people feel bad and it causes resentment.  All of which are barriers to improvement - which is what we should all be struggling towards.

2. Blaming implies judgement.

No one is ever in a position to judge anyone else.  

2 (addendum): As doctors, our job isn't to judge: it's to heal and maybe even prevent.

But all of those have to be separated from the concept of a root cause.  You always need to search for the root cause.  But it has to be done without blame.

It's analogous to working very hard on something, but being detached from the outcome (as the buddhists and hindus say).  It isn't easy to do, since the work itself (eg. studying for an exam) tends to attach you to the outcome because the outcome tents to be a big driving force (eg. doing well and getting an A).  It is very easy to forget you are working hard because you want to, or because that's what the task deserves.  In the case of medical school exams - it's the idea that some patient in the future may need you to know that tiny detail that could change everything about his diagnosis and/or treatment.

It's similar in root cause analyses.  You work hard to find the root case, and when you get to the "end", it's very easy to try and blame the cause on something.  But it's almost always better to focus on how to deal with the cause.  Dealing with the cause doesn't mean you blame the cause.  In this situation, there's a tiny detail that might make it easier to not blame - to not get attached to the outcome.  The reason you started looking for and analyzing the root cause is to help a patient.

Blaming the patient does not help the patient.

Here's an example: obesity is highly correlated with T2db (type 2 diabetes).  One of the major reasons we have an obesity epidemic is because of the amount of junk food that's (cheaply) available coupled with low physical activity.  Blaming people doesn't do much.  But pointing out that it is something that can be controlled by each and every American is important - we need to empower people to do something about it.  But we have to do it without blaming them.

It is very important to tell our patients that controlling T2DB progression is in their hands.  Weight and exercise will prevent / prolong the onset of T2DB damage.  Contrast that to something like Huntington's disease: the patient has little to nothing they can do to halt it's progress.  So we need to present them with the information, urge them to follow it, but not blame.

I guess my point is it's a very thin line between falling into blaming the patient for something and pointing out these points to improve the patient's life.

I guess it's the difference between

"You have t2db because you are fat.  It's your fault, and you should change how you live"

and

"Your t2db is probably caused by your obesity.  I can give you some medications for this, but the best way to control and reverse this disease is by lifestyle changes.  But to do that, I'll need your help and your commitment to these changes. I am here to help you through this, so let's talk about what we can do to get you to a healthier lifestyle."

Not judging?  Check
Actually trying to help the patient? Check.

[2/2] Finding someone (or something) to blame.

In my other post, I talked about blame and finger pointing and why they are bad ideas on a philosophical level.  But does that mean fingers shouldn't be pointed?  Am I saying that people who make mistakes should get off without any repercussions?  No.  But I think it needs to be done in a productive way - I like to focus more on the end goal.

As doctors - you need to be hyper-aware of your mistakes.  The best way to describe it is "For everyone to whom much is given, of him shall much be required." -- Luke 12:48.  (Before people get confused, no I'm not Christian).  The "popular" way to interpret this is "to those whom much is given, much is expected".

Much is given to doctors: in many cases it is people's lives.  Thus (understandably) much is expected.  The only way doctors can hope to live up to these expectation is by being very aware of any mistakes that happen, realizing the root cause, fixing it, and making sure it doesn't happen again.  This is very important in the medical field because the question of mistakes happening is not an 'if', but a "when'.  I am not an idealist, so I understand that the steps I mentioned aren't always possible in every case.  For that to be possible, we'd need to understand how everything works... and we are far from that.  Medicine is called an art for a reason.

But this doesn't mean you don't try.

You don't point fingers at the doctor.  You talk to them - about what happened and about how to prevent it in the future.  As part of this process, the doctor has to own his/her mistake.  It's the only way they can improve.

As a side note - here's a good article about why mistakes are a very important part of the learning process. The only issue is that in medicine, mistakes are usually very, very costly.

Bottom line: the doctor, nurse, any healthcare worker (really anyone) who "points" at the doctor to blame him/her should do it in the spirit of trying to improve healthcare.  Not in the spirit of trying to find incompetence.  I'd like to think that most healthcare workers are pretty competent.  Or maybe that's just my naivety?

As patients - (this will be from the perspective of a healthcare worker more so than as a patient) as much as doctors try to help patients with health issues, at the end of the day it is up to the patient to meet us half way (usually it's more like 75% of the way).  Doctors cannot help patients who don't want to help themselves.

So ask yourself what you are trying to accomplish.  Blaming the patient is bad for quite a few reasons (the focus of my other post).  In my view, the main reason it's bad is because it doesn't encourage them to fix the situation.  If your job is to help people (and if you missed that in the job description, let me clarify: that is your job), healthcare workers need to find a better way.

Step 1 of that better way is to have an open and honest conversation about repercussions.  "I'm concerned about your LDL levels and triglycerides being so high because it really increases your chances of having major heart problems.  And there's a good chances they'll occur earlier rather than later in life".

Step 2 is working with the patient to figure out how they can fix the issue.  I'd love to have a one-size-fits-all approach to patients.  Take the issue of healthy nutrition / lifestyle for example: if we could just hand them a card that says "do xyz and abc, and you'll do great!" - that really would be great.  Problem is: it won't work for everyone.  As time consuming as it is, we have to work with patients - ask them how their lifestyle / diet is right now and what they would be willing to change (which usually means what causes the least inconvenience).  No one is going to massively change their lives.  This is especially true for preventative measures - few healthy people will take warnings seriously because... well.. they think they are healthy now so they'll be fine forever!

Bottom line: don't blame.
(1) Tell them you are concerned and what the consequences are
(2) ask them what their current situation is
(3) suggest (or refer to someone who can suggest) changes that wouldn't perturb their current situation too much.

Repeat as necessary.

These are just my opinions - a doe eyed first year med student.  I'm sure people have more advise on the matter (especially the more seasoned veterans - aka real doctors) - and if you do, leave a comment or two!

Remembering

This Wednesday, Penn hosted the Humanity Gifts Registry's annual Celebration of Remembrance ceremony.

This is a ceremony "for the individuals who have provided their bodies for one final service to their fellowmen - the contribution to Medical Education and Research".  Anatomy isn't something you can learn from a textbook or a professor.  I mentioned this in my blog post after our last anatomy class too.  My class (and other medical school classes from around the city) was happy we had the chance to show the family of these brave donors how much we appreciated our donor's selflessness.

I was lucky enough to be one of the eulogizers during the ceremony.  I was also the first eulogizer (no pressure!) Fortunately, I had an awesome set of friends who helped me craft a great eulogy - thanks Asmi, Jon, Anna, Paul and Eric!  I couldn't have done with without you guys.  I can't think of a better way to express my gratitude to our donors than the speech, so here it is:

In my culture, we have an old Sanskrit adage: “Matha, Pitha, Guru, Dheivum.”  Translated, it means “Mother, Father, Teacher, God.”  Like any saying that has deep religious and spiritual roots, the literal meaning of this phrase has been argued for a very long time.  To me, it emphasizes the importance of teachers in our lives: like our mothers who teach us to play nicely with our siblings; our fathers who teach us never to start a fight; or our friends who teach us to love and share with one another. In the classroom, we may learn from a professor, or from scripture.  We also learn from our classmates, like a friend who reminds you that the hip bone’s connected to the leg bone might not be the most accurate way to describe a leg joint. We all have many teachers, and they all share common traits: they shape and form us; they guide our conscience and learning; and they ensure that we stay true to our values. In short, they help us grow: intellectually; professionally; and personally. At the core, these are all examples of paying it forward: by educating us, they show us how to make a positive impact on the world.  Maybe this ripple effect on the student’s life, as well as all other people with whom the student comes into contact, is why my culture associates teachers with divinity. 

To say that each of the donors that we honor today is a teacher is an understatement.  In my medical school alone, each donor has, in one way or another, helped instruct 168 students. I don't think I'll ever have another class as amazing as Anatomy.  I'm extremely humbled and touched that people have donated their bodies to science so we can train to become the best doctors we can be.  I would like to take a moment to thank the people and their families who make Anatomy possible.  Thank you all, so very much.  Be assured that our class (and medical school classes around the world) has learned an immense amount from our donors, lessons we could not have learned any other way.  Know that our ability to improve or save lives in the future stems from the willingness and commitment of these selfless people, and their families, to our continued education.

What I didn’t realize then was how our donors stay with us long after our Anatomy class.  Even in our classes now – where we are learning about renal artery blockages, vericoceles, or cerebral vasculature with the circle of Willis, I stop and think back to my anatomy lab and recall what the relevant structure looks like.  The anatomy experience allows me to visualize the pathological process that is happening and how it fits into a patient’s illness and treatment.  This exercise cannot be effectively learned from a professor’s lecture, a classmate’s explanation, or a textbook; it would be impossible without the contribution from our donors. Every patient we meet teaches us something. We consider our donors to be our first patients: their impact on us will, without a doubt, stay with us for life.

At the same time, I do not know who these donors were in life.  But you do.  They were fathers and mothers, brothers and sisters, sons and daughters.  They were friends.  As Pericles said many millennia ago: “What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others.”   I am sure every one of these donors had an impact on your lives.  But only a select few can make a substantive impact even after they’ve left this world.  We will soon read aloud the names of each donor, and every single person on that list is part of that select few.  Their nobility will not be forgotten, and their selflessness will continue to be greatly appreciated by us, and by our future patients.

Thank you.

Random thoughts

This has been an interesting week and weekend.  A lot of stuff happened (some good, some bad) - you'd think I'd have things to write about after it... but oddly I don't.  I'm not sure if my brain is just shutting down, but the whole week just seems like a haze.  I know stuff happened - but I'm not quite sure what they were.  Hopefully this happens to everyone at some point.  If not I'm either (a) getting really old or (b) need to seek medical help.

On a side note: one important thing we learned this week is never say a patient died "because they are old".  If your boss asks you "why does the patient have these issues", don't answer "because they are old!" That pearl of wisdom had us cracking up for a while.

We learned about the physiology of coitus (yes, seriously).  This was a nice capstone to our earlier lectures on how to build strong, positive relationships.  That earlier lecture on building good relationships was amazing - I feel like those were 2 lectures everyone should watch.  It can, quite literally, change your life.

Have I mentioned I love medical school?

Two more things:

1. Happy mother's day!  More than that, I want to say thanks to all the mothers out there.  We wouldn't be here if it wasn't for you, and we wouldn't be the people we are if you weren't "lovingly encouraging" us to reach our potential.  Keep it up!  We may not be able to thank you as young kiddies, but we will once we are old / mature enough.  Even if we don't say it, we appreciate you being there for us - don't ever stop.

2. We've got a remembrance ceremony coming up.  This is for all those great souls who donated their bodies to science so the medical students can learn anatomy and human physiology.  I'm humbled and honored to be a participant in the ceremony.  I feel like anything we do to thank them will pale in comparison to what they've done for us (and for all of our future patients), but we are going to try anyway.  Hopefully things will go well on Wednesday, and their families will see how much we appreciate what our donors have given us.

Ok, I'm running on 4.5 hours of sleep (not because I was studying) - time to catch up !

- Karthik

How to not rust

Whenever we learn about an illness in medical school, we also talk about the etiology - the origin of the disease.  The etiology almost always includes a combination of: genetics, environmental factors, drugs, and sometimes, nurture.  What we don't talk about as much is how these things interplay in curing illnesses as well.  Maybe we'll talk about it a bit more later on, but for now it's usually "Drugs X, Y, and Z; get lots of exercise, eat well; and have a supportive family".  


Over the last few weeks I was thinking about how environmental factors continue to shape us as people.  Specifically, the friends, colleagues and classmates we have around us.  I don't know about you, but for me, where I went to school played a huge role in selecting the friends I had growing up.  And it continues to do so.  Coming to an amazing institution like Penn Med means the friends I have around me are equally amazing.  


One of the reasons it matters so much to have good people around you is because they are there to set you straight when you make a mistake.  It's never really about the mistakes you make, it's more about how you deal with the mistake and handle its repercussions.  That part's hard, sure - but the hardest part is knowing that you made a mistake in the first place.  This is where good friends come in: they care about you enough to call you out on your mistake and then stand by you and help you handle the fallout.  


The reason I've been going over this in my head is because of the field I'm entering.  A field where (a) mistakes happen (although we really wish they wouldn't) and (b) handling those mistakes are so crucial (because lives hang in the balance - sometimes literally).  Often in our ethics class we are asked "If gold rusts, what will iron do?"  As doctors, we'll be held up to very high standards and it's important to practice not-rusting as early as possible.


Obviously, you don't keep good friends around you just so they can call you out on your mistakes.  They are good friends because they do it without you asking or expecting them to do it.  This is why it's important to surround yourselves with wise people that you can also call your friends.  The environment always matters, and it'll continue to matter.


Now of course, you are probably asking yourself "wait, then why do people keep you around?"  Well, wise people need to laugh too.  And I'm one hell of a comic relief.


P.S.: New rule - new blog post every Sunday!  Let's see how long I can keep this up :)

Letter to mother nature

Dear Mother Nature,

Snow in late march (25th) is now how I picture the 5th day of spring!  Please review your calculations, wind direction, precipitation and temperature values and recalibrate!  I want sun!!

Thanks in advance!

Sincerely,

Me.


The response:

Dear inconsequential little person taking up otherwise useful Carbon,

No.  You pollute my planet, just drop your Carbon emissions when you come in the door and don't bother to clean up after yourself?  You can deal with the effects yourself.

You know I love you, but sometimes, you and all your siblings just need to learn to clean up after yourselves!

With tough love,

- Mother Nature

P.S. I hope you are prepping for that crazy party in 2012!  With the way you guys are handling things - that party is definitely happening.  Just sayin!





Spring's here?  Lies.

Fast forward a month

How do you know Brain & Behaviour (the first part) is one of the most painful 4 (ish) weeks at Penn Med?  Because I haven't written a new blog post in a whole month.

I usually use my blog and Facebook (mostly Facebook) as my procrastination tools against studying. I had so little time that I could only terrorize people on Facebook and not here.  Ah, good times.

But hey - that part of B&B is over.  And even my Spring Break is over now!  It's one of the few times I'm sad that a weekend has rolled around - because that means my fun times of sitting on my butt doing absolutely nothing for a whole week are over.  But such is life - just as the really painful and challenging parts of life pass with time, so do the good times.  Would be nice if you got to pick which pass and which don't though.

So what's happened in the last 4 weeks?

- Spring break just ended.  I decided to take it really easy and do nothing.  At. All.  Fyi - best decision ever. 

- In ~3.5 weeks, we learned almost everything (anatomical) about the brain and spinal cord.  That means all the tracts in your spinal cord and brain that carries info up and down.  We learned about what most of the little bumps, lumps, and fissures in the brain represent.  

- If there is a lesion in your brain / S.Cord that's causing symptoms, I should be able to tell you exactly where it is (like down to a 1x1x1 cm^3 region!)  

- When I look at MRIs / CT scans.  I can actually identify stuff now!  I can't tell you what's WRONG or what's causing the issue per say (like what kind of tumor it is etc.), but I can say when something's not right!

So I basically went from this:

This is an MRI of a person's brain right?  Is that white stuff supposed to be in the middle?

To:

Being able to pick out each and every one of those structures.  And knowing what they all do and how they all connect.

And if I remember correctly, this was one of the easier MRI labeling pictures.  So when I say we learned a massive amount of information in those 3.5 weeks - I'm not kidding.

(Both images are from our Nolte's The Human Brain book - a really great resource for a class like this.  It was a required book, and it was highly recommended that everyone actually buy the required text book this time.  Because of some bad luck, I ended up not getting my hands on this book.  But that's a story for another day.  If I do well in B&B, it'll be a miracle)

Also, side note - you'd think that different people have "unique" brain structures right?  Apparently not.  Most people's brains are very, very similar in which parts do what (and their relative sizes!)  Actually - if your brain isn't like the "normal" brain, it usually means there's something wrong (and not in a good way).  But usually your brain can compensate for a few of the issues.  Really amazing stuff.

I did write up outlines for a couple of blog posts that are not related to academics.  I'll flesh them out and post them up as soon as I get to it!