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What is the Fine Art of Healthcare?

picture of me in FAOH wkshpI have developed an innovative and interdisciplinary program at the University of Miami that uses art to hone observation and communication skills in the service of clinical diagnosis. Working in partnership the Lowe Art Museum, Miller School of Medicine, School of Nursing and Department of Psychology have filled a gap in medical education to strengthen healthcare.

Over the last five years I have read over 100s of publications, watched a number of videos, and listened to webinars that explore ideas, challenges and solutions for healthcare in the 21st century. Through weekly blog posts I look forward to dialogue on these issues.

 

Cardiologist Speaks from the Heart about America’s Medical System

Norman Rockwell

Saying Grace, Norman Rockwell

The honesty of this interview was a sober awakening to some of the issues that effect physicians on a daily basis.  In the interview on NPR, by Terry Gross, here, Dr. Sandeep Jauhar speaks candidly about doctors who face challenges, both financially and ethically, because they are mired down with paper work and malpractice insurance costs and he believes that a large part of the problem with our medical system is that doctors send their patients for too many tests; and there are multiple doctors, for one patient, and they are “not communicating with one-another”, so there is no coordinated patient-care.  Another point is that doctors are dealing with “defensive medicine” which ends of costing billions of dollars.

Dr. Jauhar goes on to say that as a salaried doctor he isn’t so concerned with reimbursement fees so one of the incentives to send out for more tests isn’t as great; that doctors who have their own medical practices, and are worried about overhead fees and liability insurance have more of “need” to send patients for expensive tests.

Can it be that one way to help the situation may start with communication and reimbursing for “care coordination”.  This is one positive part of the ACA; medicare will now start reimbursing for care coordination.

When Patients Read what Their Doctors Write, by Leana Wen

opennotesfinal7_wide-87daf1eba6d6f1f1ebea18692a6d855db1b39f89-s40-c85There’s a movement happening: some doctors are letting their patients read their notes.  What does this mean for the medical field? ” After the first year, the results were striking: 80 percent of patients who saw their records reported better understanding of their medical condition and said they were in better control of their health. Two-thirds reported that they were better at sticking with their prescriptions. Ninety-nine percent of the patients wanted OpenNotes to continue, and no doctor withdrew from the pilot. Instead, they shared anecdotes like mine. When patients see their records, there’s more trust and more accuracy.”

Read article here:

 

The Experts: How to Improve Doctor-Patient Communication

The DoctorAs a follow-up article to the WSJ’s April 8th article:  The Talking Cure for Health Care, an article called:  The Experts:  How to Improve Doctor-Patient Communication (see article here)   A group of medical and health care policy experts discussed what they believed to be important skills for future doctors and good communication, active listening and team work ranked high on all of their lists.

 

The Talking Cure for Health Care: Improving the ways doctors communicate with their patients can lead to better care—and lower costs

WX_Talking_Cure

The Talking Cure

Where was this article years ago?!  It seems so simple, yet according the IOM more people die everyday because of miscommunication.  The article: The Talking Cure for Health Care, in the Wall Street Journal, dated April, 2013 (read article here) explains that “Doctors need to work on their people skills. It’s something patients have grumbled about for a long time.  Doctors are rude.  Doctors don’t listen. Doctors have no time.  Doctors don’t explain things in terms patients can understand.”  Easy for the Wall Street Journal to say but how can doctors or future doctors get around the complicated medical system, in which they are mandated to see a patient in only 15 minutes.  It hardly gives anyone enough time to ask questions and get the informed responses needed to find a solution.

Apparently medical schools, health systems, malpractice insurers and hospitals are trying to help doctors improve their bedside manner.

The Structures of Growth: Learning is no Easy Task, by David Brooks

One might ask themselves what does a NYT’s op-ed column have to do with medicine?  In today’s NYTs (June 17, 2014), David Brooks comments on getting better at something and how really difficult it is to reach the pinnacle (or as he says, “the tipy-top”).  Because for those who have accomplished tipy-top growth has not been linear but has evolved through time.  And that people who are striving to the best reach plateaus (see article here).

Growth in any field requires repetition until it’s ingrained and it is only just that rote memory. I started taking sailing classes and our teacher told us to do knots “over and over and over again until it’s muscle memory”.  I played tennis for years and all we did were drills (until we played a match).  It wasn’t until we were out on the court did we realize that those drills really were worthwhile.

What medical students need to understand, in my opinion, is that a knowledge base is a must, and until they really understand a disease and all of its moving parts can they begin to make differential diagnoses (and then throw out those diagnoses and start over) and get ‘creative’.  When I say creative I don’t mean experiment around with someone’s life but they must be able to connect with their patients; to listen actively, ask questions, probe, fill in the gaps, in order to really

The Call of Stories, by Robert Coles

Man with head

The Call of Stories

After reading a post, submitted by a professor of literature, on the importance of infusing the humanities into medical education, and discussing a book, by Robert Coles (who was a medical professor/doctor, at Harvard Medical School) I decided to buy the book.  It’s filled with all sorts of wonderful recommendations for books, that can be helpful to medical students, in understanding stories and their importance.  Coles discusses authors like William Carlos Williams (who was a medical doctor), Walker Percy, George Eliot, George Orwell, Tolstoy and James Agee.  These are just a few, out of many, that he discusses.  Coles (who was a psychiatrist) believed that by delving into great works of literature, to try and understand what motivated important characters, in said works, would help him in his own practice.

I highly recommend The Call of Stories for anyone interested in great works of literature!

The Physical Exam as Refuge by Danielle Ofri

Physical exam

‘Have a Medical Examination: keep sickness away

That’s it put down the computer and your cell phone and spend 15 quality minutes looking at and listening to your patient.  In the Well blog of the NYT’s a piece was written by Danielle Ofri that points out what a physician can learn by touching the patient.  Maybe the term touching has a deeper meaning?  (Read article here)

Removing the “me” from “MD”

workshop 085

One of our FAOH facilitators

Anyone who practices medicine understands the pitfalls of communication (or lack of).  In the JAMA article dated November 13, 2013 (see here) a medical student states that, “Interprofessional communication can be challenging, and medical students should thus learn it throughout medical school. As medicine moves toward team-based models of care, more meaningful interprofessional education consisting of shared patient interactions is necessary.”

Working in a museum and running a series of inter-professional workshops for graduate students in: nursing, medicine, physical therapy and psychology the importance of listening to and respecting one another and their opinions is highlighted.  Students must take turns practicing facilitating discussions about works of art.  Students from all disciplines come at the discussion with similar background knowledge and experience in looking at art. So the playing field is leveled.

Toward the clinical humanities: How literature and the arts can help shape humanism and professionalism in medical education

Save the Humanities-From Themselves

Save the Humanities-From Themselves, by Michael Todd

 

There really is no need to continue trying to make a case for insertion of humanities into medical education after reading the blog of the Arnold P. Gold Foundation titled:  Medical Humanities:  How Literature and the arts can help shape humanism and professionalism in medical education, by Johanna Shapiro, PhD (see article:)

The qualities which make health care practitioners successful; compassion and empathy, are always evolving, and humanities helps this process develop.  Inserting the humanities into medical education also allows ‘space’ for students to reflect upon the reasons for wanting to become part of the complex system that calls itself ‘health care’.

The Process of Care for a Narrative Diagnostic Dilemma

Teaching medical listening through oral histories

The Story of Bhagvadgita, c. 1820-40, From: Bhagvadgitegianu folio 129 verso wellcome Library, London

In trying to sort out how to make connections between what we do and the recent Advanced Workshop, at Columbia University, in Narrative Medicine, I found the document, The Process of Care for a Narrative Diagnostic Dilemma to be very helpful.

Not to put a fine point on it but every patient should be allowed the opportunity to communicate their own narrative about their disease.  And health care workers, in my opinion, need to understand the importance of co-constructed narrative; the ability of health care practitioner and patient, to work inter-dependently on a narrative of a patient’s illness.  It’s the job of a health care worker to be able to interpret, metabolize, analyze and create a story that helps to create a diagnosis and treatment plan.  I believe this requires great skill (editor’s personal perspective here) to “actively listen” and fill in gaps and deal with ambiguities and takes a lot of practice.  So my belief is that Narrative Medicine, as a practice, can be achieved through a number of modalities and looking at, and interpreting works of art, is one way to do it.

See document here