Spring 2019 Digest
Table of Contents
Anson Koshy, MD, MBE Assistant Professor, Pediatrics and McGovern Center for Humanities and Ethics
From the Faculty Editor
3 Faculty Editor Message 4 Student Desk - Student Co-Editors Message 6 MS III Journal Entries 15 Resident Reflections 16 Physician's Writing Group 18 Faculty White Coat Reflections 20 Center News 23 Human Ties Message Board
ne of the most formative and rewarding periods in medical school are those first clinical experiences. It is remarkable how those first moments participating in the care of patients can remain with you for a lifetime. The loss of a patient, the challenging preceptor, to the small gesture of gratitude from a favorite patient — these are the moments that gradually shape the path forward for students and trainees. For this edition of the McGovern Center Human Ties Digest our dedicated student editors and center faculty and staff shine a light on our collective stories. A selected group of third year medical students in the scholarly concentration in the medical humanities have graciously allowed us all into their most personal writings as they navigate their first year of clinical clerkships. Residents and faculty demonstrate how easily creativity flows from the prescription pad to the writing pad. Dr. Jenn Swails shares her own white coat reflections to remind us of the importance of those early patient experiences. As we wish the McGovern class of 2019 well and prepare to welcome a new cohort of physicians in training, let us hope that although time moves us all forward, we remain close to those first teaching or patient experiences to serve as a human connection — a critical human tie.
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Artwork by Kaleigh Olmsted MSI
-Hippocrates
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Student Co-editors: Margaret O'Brien & Munir H. Buhaya
n our second issue of the digest, we wanted to embrace the overarching theme in the majority of our submissions: personal narrative. There's so much we can learn from each other when we share our different experiences and perspectives. It is this fundamental need to share stories and be heard that is the backbone of the patient- physician relationship. The experiences, pain, and healing of our patients expand our own knowledge and advance our training. So what do we as physicians and future physicians do with our stories? We believe the pages of this digest you'll find one answer to this question. Included in this issue is a piece by a pediatric resident, Kevin Tien, PGY2, written from the perspective of an autistic child as part of the rotation in Developmental and Behavioral Pediatrics. There are also several journal entries from third- year medical students in the scholarly concentration in the medical humanities from their experiences during clinical rotations. In their writings, we live the joy, frustration, fatigue, and wonder that comes with putting down the books and putting on a white coat. On a personal note, we are both about to begin our third year, and in reviewing these submissions, we were both filled with anticipation and excitement for what is about to come as we start our clinical rotations. Included in Student Desk is a combination of photographs and paintings from our fellow medical students and residents. We hope you will be as moved and intrigued in reading and viewing these pieces as we were. C.S. Lewis once said "We read to know we are not alone." It is our hope that in these narratives, we each might find something kindred, a likeness we can hold up against our own experiences. As always, we will be looking for new creations to include in the next issue. So please, find inspiration, create, and submit to our next issue coming Fall 2019.
“Wherever the art of Medicine is loved, there is also a love of Humanity.”
Student Desk
In my words: Selected MS III Journal Entries
In the second half of my IM rotation, my first patient was a man recovering from hepatic encephalopathy. The patients’ demographics reflected those of a man my parents would often advise me to be cautious of. He was Caucasian, in his 60s and spoke with a Southern accent. I treated him like I did every patient before him while expecting the question “were you born here?” a gateway question that could either lead to a positive or negative outcome. He inevitably began the dreaded conversation by asking “where are you from?” I answered Dallas in which he replied, “where are you really from?” I told him my parents were from Ethiopia and that I was born and raised in Texas, a tidbit he was surprised by. Based on his reaction, I assumed the conversation would become negative so I quickly finished my history and physical and told him I’d return with the team for rounds later in the day. The next day, I pre-rounded on my patient and he insisted on restarting the conversation. He learned that my family immigrated in the 1980s, that I am a Muslim as indicated by my scarf and that my name is Nadia. I learned that he was afraid I wouldn’t like him. My patient told me he worked with many people and that in his company, there were a few Ethiopians that never seemed to speak to him. He thought they didn’t like him, that their opinions reflected those of all Ethiopians and that I would probably have the same ones. In his perspective, however, I seemed genuinely interested in his care, asked about his complaints to address them and didn’t seem to discredit his words. I thought I was doing my job but to him I was slowly chipping away at a generalization. I was surprised by his story and initially felt guilty for applying my fears onto a man I did not truly know. As I continued to round on him the next few days, he seemed to open up with every encounter. He revealed stories about his family and his ex-wife while often shedding tears about their life together. He became a bright light during my prerounds and would end each morning with many thanks. He was grateful that I treated him like every other patient and grateful for everything I addressed. But honestly, I think I’m more grateful that I started my rotation with this patient.
Author : Laura Moore McGovern Medical School Class of 2020
Life has been crazy. I have been having such a hard time getting out of this funk. It feels like God has been challenging me over and over and over for the past 10 months or so. I’m in situations I don’t want to be in. Situations I never even imagined I would be in. I look around me and I see everyone thriving. No one seems to be struggling. Everyone moving on to the next step (oh the irony) and I am stuck. Stuck. STUCK. I am discouraged and saddened. I feel like every time I think things are starting to look up, something else gets thrown directly in my path. Typical. I just can’t win. BUT. Today I woke up. I took breaths continuously through the night. And I’m trying to feel my feet on the ground when things seem to get out of my control. I think it’s okay to not be okay sometimes.
"Submerged", artwork by Vida Chitsazzadeh MD, PGY-3, Dermatology
Author : Nadia Gidia McGovern Medical School Class of 2020
My post church grocery store trip is a ritual as hallowed as the service itself. Every Sunday, I break bread with the congregation and then later fight them for a parking spot at my HEB. My HEB has greenery growing up the walls and potted plants lining the entrance. My HEB always has free samples of freshly squeezed juice or recently made sushi. My HEB always had enough berries that I could always find a box that didn’t have any blemished fruit. When I moved, I was resigned to find an HEB closer to my new home. We had an early end to one of our post call days at LBJ and decided to check out the new location. I drove to my new apartment in Student Housing, picked up my reusable bags (a leftover habit from living in Austin and their plastic bag ban) and followed Google Maps to this new HEB that I might call home. Hm. Scott Street. I had driven this path when I dropped my sister off at UH but rarely came on this side of town. I crossed the highway and realized that this community was far different than my old neighborhood in the museum district. This HEB has chipped paint on its walls and security lining the entrance. This HEB had two (maybe three?) aisles of produce and had zero samples of any foods (which really goes a long way in fighting post church hunger). This HEB barely had any produce that I didn’t have much choice of which box berries I’d take home. I looked around and realized that the people at this HEB looked more like me (blacker and browner than the HEB I frequented), but this store was entirely different from what I knew. I looked closer at the people around me and realized that some of the patrons were patients. I recognized the arm band that people received at hospitals. These were people that I could have easily walked by during rounds or offered directions to in the clinic. I couldn’t stay there. I left and drove back to the HEB I knew. I told myself that it was because the HEB off Scott didn’t have what I needed (although I’m sure I could have found a loaf of bread or apples). I told myself that the old HEB was too familiar to leave. But I left because I was uncomfortable. It is easy for me to talk about the food deserts and social inequalities that impact the communities I serve. It is easy for me to call into question privilege in the classroom and ask that someone check their bias. It is hard for me to shop in a HEB that doesn’t carry the bread from a certain brand (a brand that does have fair hiring practices and employs those who were once imprisoned). It is hard for me to walk around an area that has quick cash loans and pawn stores. It is hard for me to walk into a community and break bread in a community that isn’t as affluent as I am used to. I felt a lot of anger. I thought I could call it righteous anger. An anger that would move me to make some change or speak up. I think I was just really feeling a lot of shame. Shame for not being better than I was. Shame for not being able to walk the talk. I still feel some shame and still want to excuse it away. You don’t have to shop where your patients shop. You aren’t obligated to be poor to serve the poor. As someone who talks about community-based care, I still have a lot to learn about being part of the community I want to serve.
Author : Christle Nwora McGovern Medical School Class of 2020
Author : Tiffany Robles McGovern Medical SchoolClass of 2020
I want to help you. You came in with a lot of pain. I want to help you. You were so agitated you fought and then ran away from a cop. I want to help you. You came in yesterday with pain. You left because the ER was taking too long to see you. You went back home and did a measurable ton of PCP because that was the next logical conclusion. You passed out. You fought the nurses trying to help you. It wasn’t you; it was the PCP. I want to help you. Your body is screaming at you, so you are screaming at us. We’ve sedated you to nullify the war raging inside of you. We are flushing you with so many fluids to wash out the little soldiers marching up to take war on your organs. We are scared and concerned. You are in so much pain. I started when my mom died three years ago. I cry everyday ever since. I went to the streets because only the streets wanted me. I sell for my brothers. They need a man. I need to be a man. You continue to complain of pain. You want better drugs. I want to help you. I don’t trust you. ___________________________________________________________________________________________________________________ As a Hispanic woman, I feel a natural connection to my Hispanic patients. Each time I walk into a patient room and introduce myself, I feel a sense of familiarity and comfort. It’s strange to say, I see my family in a lot of these patients. I feel more relaxed in this sense and as I am taking a history, I imagine myself talking to my mom or my aunt or my grandpa. I conduct the exam in a way I think they would be the most comfortable and make sure to tell them what I am doing each step of the way. I understand why patients are not compliant with their medications because I hear many of my family members grumble on saying things like, “I don’t need to take these blood pressure meds, I feel perfectly fine”. I realize the type of food we’ve been raised on our whole lives is not the healthiest and what an obstacle to change the sweet bread we eat at each family gathering (which happens quite often). There are so many factors that interfere with Hispanic patients and their health and having a physician who is understanding of it all makes the visit smoother and the patient feel understood. That is not always possible however, and sometimes physicians are not the most empathetic with their patients. I’ve witnessed situations in which the communication between the patient and physician was inadequate and nonconstructive. “No mas tacos, no mas tortillas” I’ve heard being said to Hispanic patients countless times, some confused because they don’t even eat that. It’s frustrating to see patients getting little to no guidance with few people willing to listen to the root of their problems, mostly being things outside the doctor’s office. I hear students and physicians say, “Hispanic patients are so non-compliant” when many patients are unaware of the importance of taking their medications, “even if they feel good” (this has happened to my mom). There is miscommunication on both ends leading to poor quality of care and patients are left with impossible instructions to follow such as exercising 30 minutes a day 5 times a week, when they’ve never exercised before. It is difficult to feel obligated to educate patients, when you have a bias towards a patient and their culture. As I grow as a student it is interesting to see how some physicians handle the cultural barrier, but I also feel like I am much more aware of it because of who I am.
Author : Katherine McElroy McGovern Medical SchoolClass of 2020
Today is Yom Kippur, the Jewish Day of Atonement. It’s not only a fast day (I write as I take a swig of my caffeine intake of the day), but a day traditionally spent in shul reflecting on the past year, making amends for sins, and turning over a new leaf to try and do better in the future. I had wanted to go to synagogue last night for the Kol Nidrei service where one asks for all their vows to be annulled, releases any personal grudges they have held dear in the past year, and beginning the annual self- cleansing process. I really had wanted to go. The service had started at 7:00 pm which in my mind gave me enough time to finish my notes from the day, study a bit, go home, shower, dress in traditional white, and catch a ride with my brother to the synagogue. Unfortunately, my residents were swamped with work which meant I was swamped with work. I got home at 6:00, not having eaten since 11:00 that morning, dirty and still in my scrubs, I went to fix a small snack, and fell asleep with my frozen dinner still in the microwave. I didn’t even get to call my Bubbe before the holiday to wish her G’mar Chatimah Tovah, a sentiment wishing that she would be written in the book of life with only good things to come of the new year. On the metro ride home from the hospital I hastily group texted my family “wishing yall an easy fast and im sorry if Ive hurt yall this past yr. I hope to do better in the future.xoxo” not sure if they’d even see it before services began. So much for deep soul searching. While it’s easy to blame medical school, the truth of the matter is that I chose to be here at my computer right now. I could have gone to student affairs and requested time off. I could have made a bigger deal about going to synagogue and prioritized it over my patients, my studies. But the simple truth is - I didn’t. I think the hardest part for me to come to terms with right now is that aside from getting an earful from my Bubbe if she finds out I wasn’t in shul all day davening, I don’t really feel like talking to G-d right now. I am very fortunate that I am surrounded with 239 classmates all going through the same medical school experience with me. Together we scream at our alarm clocks when they go off too early in the morning, fall asleep during the same lectures, pump our veins full of caffeine, cry when we have to stay late, cram right before a test, and celebrate once the test is over. I have a community of friends working towards the exact same goal as me- becoming a doctor. Our shared goals, obstacles, celebrations- we are a community. *This is a portion of a longer journal entry
-Quote Author
Author : Amanda Actor McGovern Medical SchoolClass of 2020
Author : Amber Darr McGovern Medical School Class of 2020
“You got this. You can do it. Think of puppies! And Cupcakes! Ahhhhh here it comes. No, no, no, don’t you do it.” This was my attempted pep talk as I stood in a patient’s room, one slight breeze away from crying. It was my very first day of third year with internal medicine as my first rotation. We were just thirty minutes into morning rounds and were having our third end-of-life conversation of the day. Let me tell you, no one prepared me for this and my pep talk did not work. No amount of puppies could keep these tears in as our patient’s wife looked at me, yearning for even the slightest bit of hope, hope I couldn’t give her. I silently slipped out of the room and let the tears fall in the hallway. I wasn’t embarrassed or ashamed, but completely okay with myself while I slightly wept there in 3C, hurting for this man and his family. That was, until my upper level resident came out to answer a page and laughed at me. Actually laughed that I was tearful after telling three separate patients they were dying. I couldn’t help but to start judging myself. “Wow I must be weak, no one else is visibly upset. And he just laughed at me, he must never see this from students. Oh no, I’m not cut out for this. I’m not strong enough, or tough enough. Maybe I care too much? Should I care less? But that’s not the physician I want be.” The rest of the day my thoughts raced wondering, am I good enough to be here? Later in the day, the situation was mentioned again, and I wanted to crawl in a hole as that resident teases, “Yeah, and she was in the hallway crying!” with a thumb pointed my direction. “That’s it I’m out of here.” But much to my surprise the attending immediately spoke up and shut him down, put him in his place, made HIM feel unworthy to speak. “It is perfectly okay for someone to feel emotions for our patients. I’m appalled that you don’t…” the attending began. He continued to chastise the resident for such a heartless comment, disrespecting both me and the patient. He affirmed me that my feelings were normal and human and would make me a great doctor someday. I’m not one much for accepting affirmation, but this time I did. You’re dang right my tears are okay. YOU should be embarrassed Mr. resident, that you’re not hurt by your patients’ deaths. But as I continued through the rotation I realized, nearly everyone in that hospital is detached from their patients. It’s as if all the medical staff are simply working in medicine, not being physicians, or residents, or nurses. Because those roles require patient care, require emotion and empathy and care beyond what today’s potassium level is. So that day I made one big conclusion: I never want to stop crying for my patients.
Photograph by Travis Smith MSI
The patient had flown in from out of state to see Dr. F because of a bowel obstruction. He had an appointment at the clinic that Thursday, but instead he was admitted to the hospital, so we visited him during rounding. Dr. F had operated on his metastatic cancer the year before and the new tumors were very likely causing the bowel obstruction. He had been in the hospital for three days already and the NG tube had helped to decompress the bowel and allow some return of bowel function. Dr. F reviewed the patient’s new CT scan with him to show him the tumors in his abdomen, as he does with all patients. The patient was grateful, but then expressed concern about the Hilton hotel room that he had prepaid for until the following day. He was hooked up to IV fluids and would not be able to return to his room to pack up his suitcase and retrieve his work laptop before the hotel did that for him. Dr. F paused, mentioned the possibility of getting social work involved, and then asked if the patient would mind if he entered his hotel room to pack up his things for him that evening. I offered as the medical student to please allow me, but Dr. F dismissed me and his PA drove him to the Hilton where he packed up this patient’s suitcase and returned it to the hospital that evening at about 7 pm. Dr. F hardly eats, hardly sleeps, and never takes a vacation without his pager. He covers for the other colorectal surgeons when they go on vacation, but Dr. F can’t seem to trust that anyone would provide the same care he would. And I bet that’s true.
"Aura", artwork by Vida Chitsazzadeh MD PGY-3, Dermatology
Author: Kristine McAndrews McGovern Medical SchoolClass of 2020
I stand in the OR, the scissors trembling in my hand. It’s my first rotation, my first time scrubbing into a surgery, my first C-section. I’m just a medical student, but I am responsible for three things— dabbing/ suctioning the blood between deep incisions and snipping the thread whenever the resident finishes a suture. Simple enough--I catch the suture string and squeeze my scissors. “The string’s too long” the resident complains. Crap, I didn’t know there was a specific length. I nod my head and ask: “Do you want me to trim it?” “No, it’s fine. Just cut 1 cm next time”, she replies. I nod again and take a mental measurement. The resident sutures the stitch, pulling the thread up for my second cut. I carefully approximate and snip my scissors again. “Careful” she warns. “Just use the tip and make sure not to angle the blades too close to the bladder. You might puncture something.” Third time’s the charm, I reassure myself. The resident pulls the thread up and again, I cut, but this time, the thread doesn’t shorten. I struggle repeatedly, but the string slips hopelessly between my scissor blades. “Screw side up, turn the scissors to 45 degrees” the resident chuckles. “I bet you didn’t know there was a wrong way to cut a thread before medical school, huh?” "Third time is the charm, I assured myself." I don’t look up, but I can feel the nurses and residents watching. In my mind, they’re laughing at me. The rest of the surgery proceeds with the dull scissors, and repeatedly, it takes several attempts to cut the string. My face burns in embarrassment and at each failed attempt, and a tiny voice nags in the back of my head: “You have the most trivial job, and you’re so useless. Why are you even here?” I drown out the voice and power through each failed snip. The week proceeds in the same manner. First, I don’t get my gown and gloves on fast enough to catch my first baby. Second, I lose sterile field while adjusting the drape. Third, my subsequent C-section strings are still too long or too short, and at one point, I’m even revoked of my blood suctioning privileges. At each mistake, the tiny voice haunts me: “Sloppy...Incompetent...Why can’t you get anything right?” I try to remind myself it’s my first rotation. I try to remind myself, next time, I’ll get it right. Next time, I’ll be useful. I’m embarrassed at my neuroticism. I know it’s unhealthy to beat myself up when others don’t seem to care. I know that at the end of the day, I’m just a medical student, and my role in the grand scheme is to learn--But no matter how simple the task, I seem to do it wrong. No matter how hard I try to help, I can’t seem to do anything but get in the way. The residents have worked much longer hours and even overnight shifts, and I feel that I have no reason to complain. "I try to remind myself next time, I'll get it right. Next time, I'll be useful." I admire the strong women on my team. I admire their work ethic, their stamina, their resilience in the face of tough patients and tougher attendings. I’m impressed whenever they deal with an acute hemorrhage or whenever they make snap decisions save the lives of both mom and baby. I want so badly to contribute to the team. I want to excel in my role and to impress them. Nobody has scolded me or been mean to me—in fact, they’ve all been incredibly encouraging. The nicer they are to me, the more incompetent I feel. Day by day, the voice harasses me, “You’re nothing like them...How are you going to a doctor some day?... How are you going to be held responsible for a life?” I take a deep breath and exhale my mantra. I am a student. I am learning. I have purpose and strength in growing. These experiences will shape me to become a more compassionate and a better doctor. I sigh. It’s futile. As hard as I try, I don’t yet believe in myself.
A blur of sounds and colors. The familiar bars around me when I open my eyes. Shrieks, yells, squeals coming from the halls and rooms that are so far away. As I stir I begin to fumble around the space around me. Where’s mommy? But she’s never failed to show up. So I lay there, still, my eyes continuing to wander around the comfortable and colorful space I see. Maybe I’ll just slip back into sleep… And then I’m in a different room, this one bright and white but noisy, shiny tiles on the floor and the various smells of everyone’s food wafting up to me. I sit atop my familiar throne, high above the ground, like a pedestal. My own food doesn’t really smell that great but I consume it vociferously – it had been far too long since I had last eaten. Around me small children – my older brother, with glasses and large almost protuberant eyes, finishing his juice (can I have juice??) and eager to get back to his wooden blocks that he was stacking. Far away my older sister sits in a corner, quiet as is her typical, playing carefully, independently and meticulously. And then everyone is moving quickly around me. Mommy and big bro fighting to put his jacket on correctly, him campaigning that he “doesn’t need it” but mommy staying strong and forcing it on him and zipping it up. And all the while my sister unwilling to put down her favorite fuzzy toy while attempting to pull a sweater over her head. Mommy gently redirects her attention from the toy towards the jacket, in between short yells and shrieks and giggles, she finishes the task and goes back to inspecting her toy. I, on the other hand, remain seated and disciplined, high atop the fray, with one hand in a bowl and the other holding tight to my food. I wonder what happens if I tip this bowl over. And then we’re off again, again I’m seated and quiet, to my right I see my brother facing the opposite direction. We’re racing along at an uncomfortably fast speed and I can’t see where we’re going, but mommy had mentioned earlier about an appointment we had to all go to for my sister, so here we go. The hum of the spaceship we’re in is very soothing. And then we arrive at a truly impeccably designed office, my siblings walking alongside mommy while I’m wheeled in like a king in the smoothest ride. Mommy sits and separates my siblings as they fight over a toy that he brought from home, telling my sister “that’s mine!” while my sister says little besides squawks and short bursts of protest. We’re ushered into a back room and a strange pair of men are there waiting for us. There’s a lot of “hi!”s and “welcome!”s. My siblings sit down on chairs for approximately 10 seconds before they’re up again, reaching for the various toys and dolls in a container near the wall. I remain seated in my mobile throne. Mommy introduces my brother to the strange men, and then my sister who they spend a bit longer on, and then when one of the men points to me, mommy says something about being“the youngest” and that I’m “10 months”. Whatever it means I’m sure it was a compliment. One of the men begins: “So mom, what do you know about autism?"
Author : Anonymous McGovern Medical School Class of 2020
Resident Reflection By Dr. Kevin Tien PGY-2 Department of Pediatrics A fictionalized piece based on a patient encounter
"feeling like a spiritual emissary ... I am changed forever"
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I can’t wrap my head around this. Just a couple of days ago Hasan* was at work and now I am told that a hospice facility will be best for him? I understand he had a stroke and a heart attack. I understand he is deathly ill, but I still can’t wrap my head around it. We have four young kids. We have a business together. How do I go on? The doctor promised he’d be comfortable but last night was anything but comfortable. He was agitated and it sounded like he was drowning. Why did the nurses not do anything? It is all a blur. So many people to call. So many things to do. I am not even sure what to do. He is only 54. We hadn’t talked about death rituals. He is Muslim and I am not and his brother is helping me through this, but his brother-in-law wants to call the shots. Hopefully the Imam will get here soon. I feel so alone despite being surrounded by people but they are all his family and they know what the expectations are. The medical team this morning seems to care and they are patient, but how do I make heads and tails of this? Will he really be fine? Will he ever be comfortable even for just a bit? I wanted to take him home, but I am scared to do it, if the nurses couldn’t care for him last night, how can I presume to do it by myself? Now what? How do I raise the kids? How do I go on? *** I hear tragic stories all the time but sometimes they hit a little closer to home. I could have been this patient’s wife three years ago when my own husband needed emergency bypass surgery. Today my heart aches. My patient’s wife has made the right decision, the decision that hurts her soul the most in the here and now but honors his wishes and is best for both of them in the long run. The most selfless act one can perform is to allow death to occur naturally when all modern medicine can do is delay death at great emotional, physical, and financial cost. Ensuring his comfort and providing his family with support are the best treatments we can offer at this time, and yet sometimes we don’t do that well. I watch him struggling to breathe and I can hear the phlegm in the back of this throat rattling, yet the overnight nurse did not think he was in distress. Breathing 42 times a minute cannot possibly be comfortable! I am angry that I didn’t foresee this better and angry that the clinical care team let this happen. I spew out a litany of orders to try to mitigate his suffering and relieve her distress. I don’t know how much longer he will live and I hope and pray that I can make him comfortable before he dies. The bedside nurse called to have one of us come pronounce his death that afternoon. I came to the bedside and intruded in this sacred space and personal time. I desperately want to make his death less dreadful for this family, so I ask how to help as his new widow is clearly distressed and his family is pre-occupied. I wrap his jaw tightly to ensure his mouth stays closed and I bind his feet together in accordance with the Imam’s request; in so doing I learn about their faith tradition feeling like a spiritual emissary or rather an inadequate stand-in and I am changed forever by this experience. I carry a little piece of Hasan and his family with me to the next time I am invited to witness the end of someone’s life. I hope that I have done enough to ease his pain and her distress. Dr. Ana L. Leech is an Assistant Professor of Geriatric and Palliative Medicine and the Director of the Palliative Support Team at MMH-TMC
"..healing cultivates new professional relationships and growth"
Physician's Writing Group: Resilience Through Reflection
We created a physician-writing group at McGovern Medical School in an attempt to enhance our scholarly productivity, and we discovered an unexpected outcome. Using a mix of reflective and impromptu writing exercises, we discovered personal and professional insight to our day-to-day experiences and situations. Through openness and revealing, we explored issues of grief and loss, as well as compassion and care giving. Our group writing is a haven for processing demands of daily life and stressors related to caring for patients. For instance, our patients allow us into their most difficult life’s stages of illness and dying, and these encounters change us even if it may not be readily apparent. We have found that creating this safe space for expressing our most intimate thoughts and feelings promotes further group discussion. A common theme amongst our group was the inter-personal similarities in career paths and provider benevolence as motivation when experiencing emotional fatigue and burnout. Writing down and sharing these writings with the group conveyed validation and closure to deep wounds that were unbeknownst. This healing cultivates new professional relationships and growth. Ultimately, while honing our writing skills we stimulated our colleagues’ kindheartedness and revealed valuable personal resilience. Dr. Renee J. Flores , Assistant Professor and Associate Program Director Internal Medicine & Geriatric Fellowship Program Department of Internal Medicine A selected piece from one of the physician writing group members is shared on the next page. *The patient's name was changed to ensure confidentiality.
How? What? Why? Dr. Ana L. Leech
Artwork by Kaisu Koski
I don’t remember many specifics about my white coat ceremony at the beginning of medical school. I was wearing the same brightly flowered skirt and turquoise top that I had worn at college graduation a few months prior. It felt like a miracle that I had made it in to medical school with all these incredible people. Four at a time, we filed to the front of the room and beamed as the faculty slipped short white coats over our shoulders, covering the bright colors we had chosen to wear. We walked back to our seats, the stiff coats barely moving as we walked. All the starch practically held us up in our chairs, making us feel secure and strong. With this ceremony, medical school began. During one of our first lectures, we giggled as the course director specified how often to shower, to wear simple makeup and hair, to wear skirts to our knees and closed-toed shoes. The week before third year started, we all walked downtown to buy matching clunky black clogs. During clinical rotations, we joked about putting on “the uniform.” Black clogs, low ponytails, minimal makeup, and the white coat. The uniform homogenized, identified, and protected us. Beneath the white coat, I was deeply affected by life inside the hospital. I saw my first patient die—a woman with pulmonary fibrosis who had missed her son’s wedding the week before. I had met her son and new daughter-in-law when they had visited in their wedding attire. After she died, we completed rounds. I became used to ignoring the way my heart broke as I held screaming babies still for their IV placement. I developed a calm neutral face during times of disaster. Eventually, everything had become “uniform”, from presenting patients to breaking bad news. One night close to the end of residency, my pager went off with a new admission. I pulled up the note template and started filling in details from the chart. A young man with metastatic cancer, presenting with shortness of breath and found to have a pulmonary embolism. CT brain showed a hemorrhagic metastasis. The case was sad, but straightforward. I moved to the checklist at the bottom of my note. Regular diet, Activity as tolerated, next of kin… and as I pulled up his emergency contact information, my heart sank as I saw the name of a co-resident, a colleague, a casual friend. I had known her husband was sick, but he had been doing really well. As I walked into the ER, his wife gave me a big hug. It felt strange to hug someone while I was wearing the white coat. Although we knew each other before, that night the questions went much deeper than they had previously. When it came time to discuss the plan, we talked about an echo, IVC filter and brain radiation. At the end, I stood up to leave and reverted to my script, “ok, sounds good!” My friend turned to me and said “no! It does not sound good. I hate everything about this. But it is the best we can do.” I walked out in tears, wiping my face with my coat sleeve. She displayed her deep sorrow, cutting through my script to activate the sorrow that pulsed deep inside my chest. It was an authentic moment that wouldn’t have happened in our typical interactions, but was made possible because I was the person with the white coat in the room that night. At the beginning, we need our starched white coats to protect and mold us as we learn our professional role. But over time the starch slowly wears out; the white becomes spotted with pen marks and undisclosed body fluid stains. As we grow into our coats, they mold to us just as we molded into them. We stop hiding our humanity. Instead, we wear them to invite patients into safe and authentic connection. I can imagine no greater privilege. Dr. Jennifer Swails is an assistant professor of Internal Medicine and program director of the Internal Medicine residency program at McGovern Medical School. She is also co-director of Interpofessional Education.
"As we grow into our coats, they mold us just as we molded into them."
"..everything became 'uniform', from presenting patients to breaking bad news."
"I was deeply affected by life inside the hospital"
White Coat Reflections Dr. Jennifer Swails
"Lorem sit ipsum dolor sit amet at vero eos et."
Artwork by Mathew Forrester McGovern Medical School Class of 2019 amet consetetur sadipscing elitr.
Life & Work Audio Interviews Nathan Carlin, Ph.D.
In this inaugural interview for Life and Work, Dr. Carlin talks with Dr. Jones about, among other things, the health humanities movement and her role in founding and shaping the field. Dr. Carlin holds the Samuel Karff Chair and is Associate Professor at McGovern Medical School.
Artwork by Anson Koshy MD
I am very excited to return to the McGovern Center for Humanities and Ethics as a faculty member! After completing my Ph.D. in philosophy (with a specialty in bioethics) at the University of Utah, and completing a bioethics post-doc at University of South Carolina I first came to the McGovern Center as a post-doctoral fellow in 2016. As a post-doc I led a blue book about the effects of race and class on access to adequate health care and led multiple ethics, humanities, and professionalism courses. I then left to be an assistant professor of bioethics in the philosophy department at Texas State University in San Marcos, Texas teaching bioethics and contemporary ethics courses. In my new role at McGovern I have already taught a cultural bioethics course in which MS IV students and I examined the ways in which race and gender determine who is allowed to have privacy, specifically focusing on African Americans and women of all races. I plan to continue to teach courses that use narratives, case-studies, and examples from popular culture to examine the intersection of race, gender, and medicine. My research interests include racial disparities in health care and health outcomes and how we can equip physicians with the tools to end racial disparities. I also have an interest in biomedical enhancement and the concepts we use to determine what interventions are treatment and what interventions are enhancement. "Intersectionality and Power Imbalances Clinicians of Color Face When Patients Request White Clinicians” is my latest published work. My current project focuses on racial disparities in sleep sufficiency. I am fortunate that I get to exercise my creative muscle and blog for American Journal of Bioethics’ online site at bioethics.net where I write on topics such as marijuana use in the NFL, vaccinations for children, race, end of life issues, and other hot topics. I am originally from San Antonio. When I’m not working you can catch me running at Hermann Park, sampling the diverse cuisine of Houston, or reading and watching sci-fi book and films. I am excited to be back at the McGovern Center. Feel free to stop by for a chat even if it’s just to give me a great restaurant recommendation! -Quote Dr. Ray is an assistant professor at the McGovern Center.
Center News
McGovern Center New Faculty Keisha Ray, Ph.D.
Life and Work is a podcast-like series where Nathan Carlin talks with intellectuals and writers about the relationship between their personal lives and their public scholarship. Life and Work is supported by the McGovern Center for Humanities and Ethics.
Therese (Tess) Jones is Associate Director of the Center for Bioethics and Humanities and Director of the Arts and Humanities in Healthcare Program at the University of Colorado Anschutz Medical Campus. She serves as editor of the Journal of Medical Humanities and lead editor for the Health Humanities Reader, Rutgers University Press (2014). She teaches health humanities and disability studies in the Schools of Medicine and Pharmacy and the Physical Therapy and Physician Assistants Programs.
Timothy Houk, Ph.D.
CALLING ALL ARTISTS, WRITERS and PHOTOGRAPHERS Do you have work you would like to submit for future editions of Human Ties Digest? email: anson.j.koshy@uth.tmc.edu
I earned my Ph.D. in Philosophy (specializing in ethics) from the University of California, Davis. Shortly after I finished the degree, Lucy, my 4-year-old daughter, overheard someone call me “Dr. Houk.” She was incredulous. “You’re not really a doctor, are you?” she asked. Silas, my 6-year-old, was quick to reply. “He’s a doctor. But he’s not, like, a real doctor—not like the kind of doctor that helps people.” I won’t argue here why I think my son was wrong. (Although he was, in fact, wrong!) But that story highlights one of the great things about my time as a postdoc fellow with the McGovern Center. I’m not that kind of doctor. However, during my time here I have had the privilege of being surrounded by those kinds of doctors. I have experienced the inner workings of the largest medical complex in the world and learned to better see through the physician’s eyes. And this experience has been invaluable to me and to my research. Working with physicians has provided me with important perspectives that I might not otherwise have been exposed to. Philosophers don’t work in a lab. If we do any experiments, we do “thought experiments.” Much of our work is done “in the armchair.” So as a philosopher working on medical ethics, I spend a great deal of time thinking about the practice of medicine and the ethical issues involved. But, if done in isolation, this process can become detached from reality. So this is where my interactions with physician doctors is essential. I had been thinking about the role of hope in medicine. What, exactly, is hope? What role does it play? What role should it play? These are important questions. Many people seem to regard hope as an unqualified good; it’s important to never lose hope. But as I discussed these issues with various physicians, I heard another side of the story. One doctor who worked in hospice care explained to me that she often had work against false hope—or, at least, help her patients reorient their hopes toward more achievable goals, so that they weren’t basing serious medical decisions on their wishful thinking. This doctor was witness to many cases where patients did not truly understand the nature of their prognosis. And since “informed consent” is the bedrock of modern medical ethics. A lack of understanding (i.e. not truly being informed) can be a serious ethical issue. Modern medicine has developed rapidly. New “miraculous” treatments are constantly being discovered. Our medical institutions will often advertise themselves by touting such innovations. It gives us hope. And that is not always a bad thing. But neither is it always a good thing. It is too easy for those of us outside of medicine—including myself—to view medicine as a place of miracles. Our hope leads us to believe that by signing up for the next clinical trial, we will be the one who gets miraculous cured. But medicine is not about miracles. It is about health and healing when possible. It is about caring for the patient—even if that does not mean curing the patient. And my time with the McGovern Center and UT Health has helped me understand that better than ever. Dr. Houk is currently a post doctoral fellow with the McGovern Center. From the Fall 2019 he will be Associate Professor of Philosophy at the College of the Sequoias in Visalia, CA.
Artwork Page 13 Deconstructing Dementia: Mitigating Memory Loss with Art Toward the tail end of my third year rotations, I noticed that medical students often only interact with people living with memory loss in a hospital or a clinic. As a result, we mainly see them at their most vulnerable and focus on their deficits. After spending a day volunteering at Sheltering Arms Senior Services, I saw how creative and spritely people with dementia can be. I came up with my course to make medical students better clinicians by exposing them to people living with memory loss outside of a clinical context. It's vital for us to recognize that people are more than their diagnoses. Interacting with this population shows us how vibrant they still are, instead of merely focusing on their losses. This course consists of students utilizing art to engage with individuals with dementia. The students lead an interactive discussion about a series of art pieces, and then host a creative activity based off the discussion. This semester, the classes revolved around Post-Impressionism paintings. The very last class was held at the MFAH to view the Vincent van Gogh exhibit with the day center members. Brina Bui McGovern Medical School Class of 2019
Not That Kind of Doctor: A Philosopher Amongst Physicians
Cover Art by: Mathew Forster, McGovern Class of 2019 "The Descent", "Rock Bottom", "The Ascent" A series of three paintings depicting the evolution of Major Depressive Disorder with psychosis in a pregnant patient and its resolution after electro-convulsive therapy.
Special thanks to McGovern students and medical resident artists who shared their work: Kaleigh Olmstead MS I Travis Smith MS I Vida Chitsazzedeh MD, PGY-3, Dermatology
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