McGovern Center for Humanities AND Ethics 15 Year Anniversary
John P. McGovern Foundation
from the FAculty Editor
“We physicians are a privileged lot — privileged to serve, to share the human drama of our patients, and to contribute to their health and well-being. To be properly educated to practice his or her art, it is essential that a knowledge of science be supplemented by familiarity with the humanities.” John P. McGovern, M.D.
Table of Contents
Page 4 Student Desk Page 5 A Song for My Patient - Mindy Wang Page 6 The Shared Table - Sheena John, Miranda Tiang, Zoya Mohammad Page 10 Graduate Perspective - Gabe Sandoval Page 12 Student Perspective - Niki Khandheria Page 13 Student Perspective - Fatema Shipchandler Page 15 Graduate Perspective - Erin Harvey Page 16 Graduate Perspective - Jai Gandhi Page 18 White Coat Reflections - Chip Routt Page 19 Center News Page 21 Human Ties Message Board
Danielle Ofri writes in the NY times that professionalism of doctors and nurses is often viewed as an infinite and free resource contributing to burnout and poor job satisfaction. But how does one keep the heart and art in healthcare? Are they different or one in the same? The McGovern Center for Humanities and Ethics celebrates its 15th anniversary supporting a humanistic approach to medical education and healthcare. Through visionary leadership, alongside generous support from the John P. McGovern Foundation, the Center remains focused on its founding mission. Dedicated students, trainees, staff, faculty, supporters and collaborators have spent a remarkable 15 years fostering meaningful growth and resilience in a constantly evolving and challenging health care environment. In recognition of the McGovern Center's anniversary, this edition of the Human Ties digest calls upon medical students, residents, dental students and faculty to reflect and share their unique perspectives and creativity. Alumni of McGovern Medical School and the scholarly concentration in medical humanities were asked to share how the humanities and the center shaped the way they practice the art of medicine. Anson Koshy Assistant Professor, Department of Pediatrics Faculty, McGovern Center for Humanities and Ethics
studenT desk
Munir Buhaya and Maggie O'Brien Student Editors MSIII, McGovern Medical School
We are celebrating the McGovern Center for Humanities and Ethics' 15th anniversary, and we want to invite you, on this special occasion, to reflect upon your humanity, that very intimate quality that makes you a beautiful being. Many of us, challenged by the demands of medical training, inadvertently ignore our emotions, avoiding distractions to continue excelling academically. Our medical training should be more than studying at the LRC or seeking to honor rotations. Instead, it should be a time to learn how to become a caring and compassionate doctor. Yet by neglecting the essence of our human nature, we do a disservice to our future patients and ourselves. As co-editors we have witnessed other ways to reflect, as sometimes it is mind-exhausting to process emotionally charged events. The artwork presented in Student Desk inspires us to continue exploring how to nurture ourselves, because contrary to test questions, there are many right answers. Thank you to the artists highlighted here. We can foster our humanity by composing a song for a patient, designing a cookbook of delicious and culturally rich dishes to enjoy among friends, reflecting upon the role of medical humanities during training, drawing and painting colorful metaphors and symbolism to convey emotions, or writing about a sorrowful experience to welcome transformative growth. Student Desk offers a safe space for trainees and others to freely express themselves, and as a result of their boldness and vulnerability they provide us with a welcoming invitation to reconcile our own experiences. With a celebratory spirit, we invite you to stop for a moment and reflect. Be sensitive to what you need to allow yourself to feel and grow whlie learning how to be a caring and compassionate doctor.
During my Internal Medicine rotation, I had the privilege of taking care of a veteran who was, unfortunately, declining rapidly from his stage 4 lung cancer. Our team informed him and his wife of his poor prognosis and that this may be his last hospital admission. While he was with us, I got to know him and found that he was an avid piano player. Because of this shared passion in music, I felt that I had a deep connection with him. Over the next few days, he declined very rapidly - he stopped talking, was less interactive, and did not eat. On a Sunday afternoon, I reflected over the week and thought of him. As I sat at my keyboard, I started playing a melody and then my left hand accompanied the melody...eventually, I composed a piece for my patient. I recorded this piece and played it at bedside the next morning during rounds. I remember very well that his face brightened up and his wife shed tears. That afternoon, he was transferred to the Palliative Care Unit. I followed him there and, to my surprise, found an upright piano in the middle of the unit. I gathered his entire family by the piano and played his song for them. Instead of a standing ovation many performers expect to end with, the piece ended with tears mixed with sadness and joy. The following day, he passed away. I spoke with his wife afterwards and learned that his funeral would be held the following Friday. She invited me to the funeral and said that the music that I wrote for him will be played then. To be able to play a part in this intimate time in one's life is very meaningful to me. This was one of the most honorable acts I have ever done in my life. I hope to continue delivering compassionate patient care. Mindy Wang , MD PGY-1 McGovern Medical School Department of Radiology
A song for my patient
"Let the food be thy medicine and medicine thy food" - Hippocrates
McGovern Medical School Class of 2019 Final Project Scholarly Conentration in Medical Humanities
Welcome WHY DID WE DO THIS? When we began our medical school journey, far from home, in the diverse metroplex of Houston, the rigors of medical school were the common obstacle that helped us develop a strong friendship. Soon our conversations about medical school and the challenges of being the first females in our respective families to pursue our professions blended to include more important conversations, meaningful conversations about our families, challenges and joys of our cultures, ruminations of our colorful experiences that blended into the make-up of our lives. Where better to have these conversations than a shared table with delicious food? We would like to introduce this cook- book to you as a glimpse into our kitchens and our shared table. We hope you enjoy!
THE SHARED TABLE an anatomy of our cultures S H E E N A J O H N M I R A N D A T A I N G Z O Y A M O H A M M A D
Eating Together
F A M I L Y S T Y L E M E A L S I N P A K I S T A N I CU L T U R E The Shared Table Food is the bridge between friends and family in Pakistani and Indian cultures. Each meal at home is an ode to the Thanksgiving buffet. Substituting the turkey and mashed potatoes each dish is an intensive concoction of spices and seasonings - adding unique flavor, texture and body to each plate of curry, meat, and rice. These dishes, prepared and placed in large family-style servings, are meant to bring family and friends together. Perhaps this can be taken back to the history of large families and poorer socioeconomic conditions, where sharing gossip, sports, and news over a meal connected people through laughter and food. This idea may also stem from how Islamic and Hindu based cultures previously looked down upon public drinking. Instead of meeting for a quick drink, people would meet for a meal with longer, thoughtful conversations. Each person would take turns breaking naan bread from the same basket, scooping up pieces of tandoori chicken from the communal hotpot, and savoring the conversation to be had. Family is the nuclear foundation of Pakistani and Indian cultures, where keeping multi-generational households together is fundamental and the love for feeding guests has been weaved into everyday life.
Art by: Resa Magill, MSI McGovern Medical School
My decision to concentrate in the Humanities while in medical school was one of the best decisions I have made. I sincerely believe that my education at the McGovern Center for Humanities and Ethics made me a more grounded, more caring, more understanding, and an overall better physician. Throughout our time in medical school we’re continually bombarded with the science of medicine. We had to study pharmacology, human anatomy, physiology, pathology, microbiology, immunology, and then we were released to start our practical training on the wards armed with the knowledge gleaned from textbooks and lecture halls. However, we received very little education on the art of medicine. We had no semester-long courses that covered topics such as how to be a caring physician, how to communicate with the dying and desperate, how to console the families of the dead, or how to connect with our patients on a more personal level. Because of this, it was incredibly easy, and I would argue even encouraged, by the much of the current medical establishment and culture to think of patients as a set of diseases or problems that we must solve, instead of what they really are people, friends, neighbors, fathers, mothers, and children with diseases. The Center for Humanities and Ethics helped me to rebuke that sort of thinking and bring the focus of my medical practice back to what really matters: the patient. While in the Humanities concentration, we read medical literature that highlighted the relationship between the physician and the patient and we took time to always consider things from the prospective of the patient. The amazing professors at the Center helped guide us to think critically of the way medicine was delivered to patients and the culture of medicine. They helped us complete projects that reminded us of the reasons we came to medical school in the first place – to help the least among us. With their guidance I was able to stay grounded during my training and protect my internal code of ethics while practicing in a medical environment that seems to challenge your tightly-held beliefs on an almost daily basis. The amazing staff at the Center were always there to build us up when we were at our lowest, celebrate with us when we accomplished our goals, and always reminded us that we were more than doctor-in-training; we were people with families, friends, lovers, and that our self-worth should not be based solely on our medical abilities. I reflect back on my time in the McGovern Center for Humanities and Ethics and I have a deep sense of gratitude towards the great educators, and more importantly great overall people, that work there. I do not know if I could have made it through medical school in one piece without their help and I know for a fact that I would be a less physician if I had never been a part of their training program. I highly recommend any physician-in-training to consider joining the program!
Art by: Samantha Hentosh, MSII McGovern Medical School
Gabe Sandoval, MD
PGY-2, Internal Medicine Vanderbilt University Medical Center McGovern Medical School Class of 2018
Fatema Shipchandler
Niki Khandheria
MSI McGovern Medical School
The Blessing and Burden of Death Our goal in medical school is to learn how to preserve quality of life. Yet in order to better understand human life, we are immediately faced with death by means of anatomy lab. From week one, we are tasked with removing the skin and fat from a cadaver’s thorax—desensitizing ourselves to death enough so we may cope with dissecting someone’s beloved mother or adored husband. It’s difficult not to contemplate what the same body was like when it brimmed with life. It’s difficult not to think how the absence of an electric current is the only thing keeping our loved ones, and ourselves, from that same absolute stillness. To get through each lab, I learned to avoid this ‘death’ rabbit-hole and strictly focused on identifying the assigned anatomical structures. I got by with dodging ‘death’ until the week of Block 2 exams. I spent the morning of October 28th preparing for a marathon of review sessions, when my mom called with news that Nani had passed away in India. My maternal grandmother, whom I called Nani, had been suffering from osteoporosis and advancing dementia. Despite anticipating this day for the past few years, I was paralyzed with pain. My mom, through her own unbearable pain, explained how Nani had died in little distress. She remained mobile till her last day and had not spent any time in the hospital. Nani lived her final moments laying peacefully in her bed, in the company of family. The third of ten siblings, Nani was nothing short of an icon. In the 1960s, she studied microbiology and graduated at the top of her class at St. Xavier’s College in Mumbai, India. Her professors encouraged her to apply to medical school and, when offered admission, she made the difficult decision to turn it down. At the time, Nani was leading an infectious disease research team at Glaxo Laboratories and was teaching introductory science courses at an esteemed local college. She felt these positions better suited the impending pressures to settle down and start a family. As anticipated, Nani soon got married and gave up her career to raise her family. Nani’s devotion to her faith and family was unshakable and became central to her new venture—beginning a ‘rida’ business. While designing the colorful head-to-toe dresses worn by women in my religious community, the ‘rida’ became Nani’s agar plate. She applied techniques to the dress that she had cultivated during her grade-school years, like cross-stitching and cloth painting. Her trailblazing trends drew clientele from around Mumbai, then across the globe. While processing Nani’s death and simultaneously trying to prepare for exams, I was nervous to take part in the anatomy practical later that week. It’s not ideal to be tested in a room filled with dead bodies immediately after the death of a loved one. I had to find meaning in Nani’s death in order to carry on. For the past nine years, I have proudly displayed the work of my microbiologist turned- fashion-designer grandmother daily. I realized my rida serves as a reminder that Nani lived fully, and that she helped thousands of other women express their identity through their attire as well. Similarly, the cadavers’ bodies serve as reminders that human lives were lived. Now in their death, we as medical students are afforded the priceless opportunity to learn from them. (continued on next page) A month after I was born, my maternal grandfather died unexpectedly and Nani became our family’s matriarch out of necessity. Even while grieving the loss of her husband, she remained unrelentingly optimistic. Nani continued growing her business in Mumbai and, throughout my childhood, she spent a few months each year with my family in Katy, Texas. Among countless other life-hacks and lessons, I learned Nani’s trusty home remedies. My favorite was a yoga pose for bloating called ‘pavanamuktasana’ (literally translating to ‘wind relieving pose’—look it up, you’ll thank me later). Another leveraged our Indian roots (pun-intended), where Nani emphasized using turmeric and ginger instead of Sudafed and TUMS. Nani instilled in me a curiosity for holistic health and well-being, a curiosity that led me to medical school. I tried, and still try, my best to emulate her no-nonsense attitude, her eye for detail, and her unyielding optimism. Understanding death is focal to understanding the art of healing. Though unfortunately, we don’t approach death head on. We try to escape it at all costs, using terms like “end of life” and “poor prognosis”. That knee-jerk reaction to avoid death even translates into medical treatment, with clinical goals so often prioritizing the forceful extension of life rather than accepting a life well-lived. As a first-year medical student dealing with the blessing and burden of death, I am trying to channel my inner-Nani and find pragmatic, positive ways to make meaning of it. Slowly, I am becoming more comfortable falling down that ‘death’ rabbit-hole.
MSIII, McGovern Medical School and School of Public Health
Some days of clinical rotations I feel energized, inspired, and grateful and think to myself, "Wow, I can't believe I get to do this every day!" Other days I feel utterly incompetent, discouraged, and exhausted and think to myself, "What did I get myself into, and how can it possibly be worth it?" On one of those particularly difficult days I was overwhelmed by my patient's suffering within our broken and unjust health care system. My oncology attending at LBJ advised me to "anchor myself to the patient's story and everything else will follow." I loved that metaphor and find comfort in it often, so I decided to explore it with art. The waves represent the burdensome aspects of medicine (demoralization, powerlessness, feeling like a cog in a machine), and the anchor represents what makes it worth it: the humanity of the patient whose deep and colorful story we are privileged to be a part of. The anchor keeps me grounded so I don't get swept away by the unforgiving waves. Medical training is a journey full of complex emotions, and learning how to maintain grace and light within a broken system is challenging. For now, I am grateful for the opportunity to connect with the patient in front of me, to learn and practice the art of medicine, and to keep health care human.
Art Work by Kiran Makhnejia DDS2 School of Dentistry
PGY-1 Family Medicine Aurora St. Luke's Medical Center McGovern Medical School Class of 2018
Participating in the book groups, lunch lecture series, and 3rd year journaling hosted by the McGovern Center helped me get through medical school. I found many mentors among the faculty at the Center and hold their guidance close to my heart. As I make my way through Family Medicine residency, I frequently think back to the lessons I learned – resiliency, close listening, and embracing the socioeconomic determinants of health to provide stronger care. When I went unmatched my graduating year, my mentors at the McGovern Center were there with kind words of encouragement and support. I was able to participate in a night of creative non-fiction readings and share my story. I shared the story of anger, doubt, and hope that I felt during my failed Match Week to a room full of strangers from all parts of the Medical Center. The experience was incredibly cathartic, and I felt welcomed back into the medical fold which I had felt exiled from just weeks before. For my Capstone project as a 4th year student, I researched Narrative Medicine and produced a collection of flash fiction pieces based on the patients I met during my Hospice elective. I still carry forward the lessons in “close reading” of my patients when I sit with patients in my own clinic. I am surprised every day by how much healing simply listening provides. As an intern, I have the luxury of longer clinic visits with my patients, but as I hone my medical knowledge and master the workflow of my clinic, I aim to continue to make space for close listening during my patient visits. In one of the most memorable book clubs I participated in (though I could mention any of the book clubs here!), we read Mama Might be Better Off Dead by Laurie Kaye Abraham. Abraham, a white journalist, follows the Banes family, an African American family living in one of Chicago’s poorest neighborhoods, as they stumble through the obtuse and barely navigable public medical system. Today, I work in Milwaukee, America’s most segregated city, and the patients I see every day mirror the Banes family. Merely reading a book or devouring statistics cannot create perfect understanding of the struggles of these families, but I hope that every new piece of information makes my practice more effective for the urban under-served. Every lunch lecture series, book club, ethics Team-Based Learning, creative journaling session, and 4th-year elective adds to the depth of education available at McGovern Medical School. Simply, participating in any programming by the McGovern Center for Humanities and Ethics provides knowledge that the standard medical curriculum misses. Without the Center, my medical education looks flat.
Erin Harvey, MD
Photo by: Emma Villamaria, MSI McGovern Medical School
I held the crumpled paper in my hand, shaking slightly, although I was confident in my decision to share. My third year in medical school had not come without its emotional toll, and I knew this was an important piece to verbalize. Dr. Carlin had organized an “open mic” event for the medical students, an opportunity for students to share from the myriad of beautiful, stimulating, and trying experiences that medical training foists upon its unexpecting enrollees. The moment of catharsis, while sufficient in that moment, was a part of a string of exercises, opportunities, and lectures offered through the Medical Humanities Scholarly Concentration. Through the rigor of medical school, I often made little time for my own well being, and the requirements of the medical humanities scholarly concentration might have been seen as an added burden to the strains of medical school. Yet, the tasks often served a protective function, pushing my peers and myself to spend time on ourselves as individuals, our patients as persons, and the sequelae of a healthcare system we had a superficial understanding of at best. As I reconciled my identities as an individual and a professional through the culture shock of the third year of medical school, where I was exposed to patient suffering on a daily basis, the required journals of the medical humanities program ensured I was able to witness this reconciliation in real time. From the journal entries through my third year, a course on the nature of suffering during my second year, and a stream of lectures that challenged the bounds of traditional biomedical education, the medical humanities scholarly concentration indelibly shaped the physician I became. As I entered my training as a resident in psychiatry, I held an incredible gratitude for the opportunities for reflection on personal growth, and I simultaneously found myself exploring the effects of race on the delivery of health care. As the variety of egregious healthcare disparities fueled solely by differences in race became more apparent to me, I found myself motivated to educate the students and peers around me about these horrors. In a field often driven by data, I leveraged the science to facilitate reflections on the suffering of persons, an approach to education directly motivated by my education in the medical humanities program. My desire to learn and subsequently teach on issues that impacted psychiatry and psychiatric care deepened. I found myself single-handedly developing an undergraduate course to examine the meaning of mental illness, the impact of culture, and the influence of industry on the biomedical approach to understanding and treatment. An exploration of the manner through which racism directly impacted, and continued to impact, psychiatric care led to the invitation of Jonathan Metzl, MD, PhD, a speaker I first met through the medical humanities program. The influence of industries on psychiatric care drew me to a book titled “White Coat, Black Hat” by Carl Elliott, MD, PhD, which allowed me to discuss the undue influence of the pharmaceutical industry and funding on medical and psychiatric treatment with my students, peers, and my attendings. The medical humanities scholarly concentration provided a constant reminder that the practice of medicine is about the individual suffering in front of us, and the importance of our approach as providers. As an educator, these reminders remain at the center of my goal in my work with residents, students, and my fellow attendings. Our patients are beholden to a bewildering system with a variety of influences beyond their control; our task is to alleviate their suffering through the means we can, and being cognizant of the factors that might prevent our patients’ improvement, as well as our own.
Inpatient Psychiatrist Assistant Professor North Texas VA Healthcare System/UT Southwestern McGovern Medical School Class of 2013
Jai Gandhi, MD
Keisha Ray, Assistant Professor with the McGovern Center was interviewed by Elemental by Medium and discussed science fiction and racial bias as part of her "Science Fiction and Topics in Bioethics" sub-elective for fourth-year medical students in the Humanistic Elements of Medicine course. Click below to read the interview: How Sci-Fi Creates Better Doctors Dr. Ray was also interviewed by The Exchange, New Hampshire Public Radio discussing lower quality healthcare and outcomes for women and people of color. Click below to for the interview: Lower Quality Healthcare and Healthcare Outcomes
Milton Chip Routt, MD
Rebecca Lunstroth, Associate Director of the McGovern Center gave the James Lecture at Baylor Scott & White titled, "What to do about the 80%: Healthcare's obligation to address the social determinants of health- Experiences with a poverty simulation". The James Lecture is annual program designed to create dialogue between medical professionals and clergy.
Center NEWS
Gene Boisaubin, Professor of Internal Medicine and faculty for the McGovern Center was elected President of the Houston Civil War Roundtable. Dr. Boisaubin also presented "What if the Placebo Effect is not a Placebo?", to the Regional Association of Clinical Research Professionals.
White Coat Reflections
Nate Carlin, Associate Professor and Director of the Medical Humanities Scholarly Concentration interviewed Dr. Keith Meador from Vanderbilt University for the second installment of Life and Work, an audio interview series. Click image above for link to audio recording
The first white coat that I put on didn’t come close to fitting me - it was my maternal grandfather’s, and it was just hanging right there in his closet. I was 12 years old and had heard stories about Waldo A. Knolle, M.D. since I could remember. His passion for medicine and devotion to the Brenham, Texas, community for nearly four decades was legendary. People always had some favorite memory to share about him from delivering generations of babies, to making house calls on horseback, to saving their life in some manner. He even died while seeing clinic patients. My interest in being a doctor sprang from their stories. I would spend hours thumbing through the pages of his “Cyclopedias of Medicine”, playing with his medicinal scales and microscope, and listening to my heartbeats with his well-worn stethoscope. Wearing his white coat that first time made me want to be like him even more and it set my career dreams into action. I remember it like it was yesterday. Waldo’s brother-in-law, Henry A. Holle, M.D. was also a physician and he guided me as I worked through high school and college. He aimed me straight for Galveston and that’s where I finally got my own white coat. There was no ceremony. There was no ritual. I still vividly remember my excitement going to the UTMB student bookstore and buying mine. It was perfect – roomy and sturdy with sleeves that I could roll up. The two lower-side pockets were huge, and I packed them initially with a notebook to document everything. Those big pockets were then slowly filled with supplies that were critical to my function. Dressing supplies, tape, IV catheters, tourniquets, blood tubes, a stethoscope, reflex hammer, and sturdy scissors stuffed those pockets to the point where I couldn’t even sit in some chairs. I didn’t fit those chairs, but my white coat fit me perfectly. My white coat became my passcode to incredible experiences. It allowed me interact with patients who taught me trust while revealing the depth and breadth of the medical field. My white coat gave me easy access to educational conferences and bedside teaching that broadened my understanding. These experiences and skill development pulled me deeper into each illness, symptom, diagnosis, and subspecialty detail. My white coat helped me develop meaningful and lasting relationships with my attendings, resident physicians, students, and all of the other professionals devoted to caring for patients. My white coat even gave me access to out-of-state medical centers where my learning experiences expanded. On one away clinical rotation at Vanderbilt, the program director noticed that I had sewn extra pockets on the inside of my white coat in order to keep more supplies readily available. He noticed me because of my white coat, and I am convinced that moment helped me get my residency there. My white coat symbolized the responsibility of caring for the well-being of other humans. That responsibility quickly matured me. It motivated me to learn everything that I could as fast as possible. The white coat caused complete strangers in need to tell me their stories and histories so I could help them, or get them the help that they needed. That taught me trust, confidentiality, and integrity. It took about five nanoseconds in my white coat to realize that excuses, lies, and half-truths were clearly not tolerated. And even today nearly 40 years later, my white coat constantly reminds me how to behave and treat others - my Golden Rule. Dr. Waldo’s white coat didn’t fit me, but mine always has and always will. .
Professor, Department of Orthopedic Surgery McGovern Medical School
The McGovern Center has temporarily moved! Find us on the 3rd flor of the JJL (JJL351). Take the elevators at the front of the JJL to the 3rd floor and we are located through the first doorway across from the elevators.
Link to UTCommunications article on Old Man Country
Pedro Mancias, Professor of Pediatrics, Assistant Dean of Diversity and Inclusion, and Associate faculty for the McGovern Center presented an "ED Talk" through the Academy of Master Educators titled, "The Wondrous Excitement of Discovery." Dr. Mancias is featured in the Time Capsule video series celebrating 50 years of McGovern Medical School . Click below for a link to the video: McGovern Time Capsules - Pedro Mancias
Special thanks to Angela Polczynski, Senior Coordinator, Special Programs at the McGovern Center for her keen eye and support of this publication!
Cover art by: Maneera Chopra MSIV McGovern Medical School
Link to Houston Chronicle article on Old Man Country
Calling all artists, photographers, and writers If you have content to be considered for the next edition of Human Ties email submissions to: anson.j.koshy@uth.tmc.edu
Welcome Ange Finn Program Manager Sacred Vocation Program Ange Finn is the program manager and a facilitator of the Center’s Sacred Vocation Program. Ms. Finn is also a private life coach in the wellness sector, teaching and coaching clients in stress management, emotional self-regulation skills, and resilience. She is a senior fellow of the American Leadership Forum.
The latest book by Tom Cole, Professor and Director of the McGovern Center , titled Old Man Country: My Search For Meaning Among the Elders was released in December of 2019. The book was featured in various news outlets including The Wall Street Journal and Houston Chronicle.
www.website.com
Thanks to the artists sharing their work for this edition of Human Ties: Samantha Hentosh Resa Magill Kiran Makhnejia Niki Khandheria Emma Villamaria