I 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.
Everyone is going to die but some are going to die sooner than others. Isn’t it part of a physician’s job to have that conversation with terminally ill patients and their families? I understand that the creed of physicians is to “do no harm” but why should a patient be hooked up to machines, only to prolong the agony, or to appease the family? As hard as it might be to say ‘goodbye’ don’t we owe it to people to explain the options? Instead of being hooked up to a ventilator patients, according to studies, would rather die at home home surrounded by their things and the comfort of their families, and loved ones? Hard questions but ones that Atul Gawande explores in this Frontline piece,
EVERYONE SHOULD WATCH THIS VIDEO! (Warning: this is not an easy thing to watch but it is reaffirming)
author: Dhruv Khullar
Doctors are constantly negotiating; with their patients, with other doctors, with nurses and the article in the New York Times highlights that part of learning how to do this centers around communication skills, and learning communication skills is becoming de riguer in medical schools around the country. The following paragraph is particularly relevant to me:
“Negotiation, in this context, is not about winning or losing, or haggling over price or scare resources. It’s about exploring underlying interests and positions to bring parties together in a constructive way. It’s about creative, innovative thinking to create lasting value and forge strong professional relationships. It’s about investigating what is behind positions that may seem irrational at first to understand the problem behind the problem.”
Negotiating is building upon relationships and developing trust with colleagues as well as patients. see article here:
The sooner medical faculty learn the importance of building that trust within the structure of health care the faster medical students will learn the art of negotiation.
Most of us who do any investigation into medicine now realize that medicine is not a science; there are too many unknowns, too many questions, too many rare diseases, that haven’t been researched and written about. So why not use all the tools available to become more adept at finding the answers to medical mysteries? And maybe using art to hone diagnostic skills is not a bad idea. According to an article in the Wall Street Journal called, Doctors Enlist Paintings to Hone Skills, “More physicians are offering a different perspective on paintings by ‘diagnosing pieces of art.” (see article here)
Funny title but not so funny if you are sitting in your doctor’s office and he/she isn’t listening to you! Apparently this happens more often than not; doctors interrupt patients every “18 seconds”, often they don’t let their patients know what their final diagnosis is before they leave the hospital, and often they are rude, when they are in a hurry. We all know that there are huge restrictions on doctors these days: insurance companies, CEOs, etc.. but that doesn’t preclude being compassionate and opening one’s eyes and ears when sitting in front of a patient. (see article here)
Mallory Raymond, a fourth year medical student, at the University of Miami, has been an active participant in our Fine Art of Healthcare workshops. She wrote a great piece in the most current issue of Academic Medicine, “Part of what went wrong was a system’s failure—a long wait, an exhausted resident—but part lies deeper, resting on the roles of health care providers as humans, communicators, relators, and reflectors. Although we may notalways pay attention to the subtleties of language and emotion, the gravity of what medicine stands for should hold us to higher standards, for the sake ofour patient’s safety, comfort, and health.
Medicine demands that we not only understand and apply science to our treatments but also teach and care for our patients, through a deeper understanding of their socioeconomic status, culture, and capabilities. Medicine demands that we pay attention, analyze, and observe.”
see article here
Technology can be a very very useful tool but it can also be a distraction, especially in the world of medicine. Electronic Medical Records (EMR) are the way of the future. But can EMRs replace the old-fashioned taking of a patient’s history? I think not! The NYT’s had a article in the Health section called, With Electronic Medical Records Doctors Read, When they Should Talk. (read article here)
There is something to be said for a doctor sitting down with a patient and asking and re-asking, if necessary, about the patient’s history. In my opinion there is no replacing that direct contact and communication with the patient. EMR’s can only do so much but they cannot replace the relationship that needs cultivation between doctors/nurses and their patients.
So my husband went into the hospital on September 26 for a blocked colon; painful, but not serious, and he was released on Tuesday, October 1st. He told the docs that he was “good”. But the next night we were back in the ER because he was vomiting and miserable. So they gave him some painkillers, did an x-ray, and he was feeling no pain. So they let him go. We were back 24 hours later; again with vomiting, nausea, and this time they did a CT scan and “discovered” the block had grown. On Friday, October 3 they did surgery to remove the blockage. He felt better when they inserted the tube to remove a lot of bile that had collected. And in spite of the surgery he was feeling a lot better. On Tuesday, October 7th they did an x-ray and a ct scan and discovered he had pneumonia. So now he has pain from the surgery and on top of it a hard time breathing. On my way to the hospital the doctor calls and said, “there is a mass on his lung”. I asked, “is it cancer?” Doctor: “we can’t rule that out”. So here we are. A pulmonologist was called in and he asked a lot of questions and listened to my husband’s lungs. He concurred that there was fluid in his lungs. However, he told us “no procedures until my husband is better”. When I spoke to his infectious disease doctor, the next day, he said, “I don’t think it’s a tumor because it is large and it just appeared. But we can’t do anything until he’s better.”
So here we are in limbo-land, again, and we will wait, and hope that it isn’t a tumor and that it was a “mass” or “shadow” that was because of his pneumonia. But the back and forth and not knowing is the most difficult part of it all!
Atul Gawande; author, doctor, Harvard Medical professor, has written another book, Being Mortal. Although I have not read it to date I know the premise deals with the patient’s ability to have a conversation with their doctor about end-of-life decisions. Nobody wants to die in a hospital or assisted living facility and the majority want to die at home, with dignity.
See interview here
It’s almost unheard of: a doctor who pushes for less aggressive measures in order for the patient to die with dignity. But that’s what Dr. Atul Gawande suggests in his New York Times Op-Ed piece, The Best Possible Day.
He speaks from first-hand experience about his daughter’s piano teacher who is dying of a rare pelvic cancer. And when asked what she wished for she said, and I’m paraphrasing here, to die at home, with dignity, and to be able to teach piano for as long as possible.
Physicians take note: this is really the wish of almost everyone!
Many articles, panels and presentations have focused on questions regarding the relationships (if any) among the humanities, humanism, and professionalism. These questions may never be definitively answered (nor, perhaps should they be). Nevertheless, below I share some of my own in-progress thoughts that I hope add light not heat to this ongoing debate.
Professionalism itself is a contentious subject, with many competing definitions. However, to be meaningful, professionalism must, as Robert Coles knew, engage the moral imagination (ref 1). To me, the most important meta-questions a future physician can engage with (preferably every day of her life) are fundamentally moral ones :
- What kind of doctor do I want to be?
- Who am I and who can I become within the practice of medicine?
- How do dominant discourses in medicine and society influence me, my patients, and our community in negative or positive ways?
- What is my commitment/responsibility/ to my patients and my community and how can I best serve them?
The questions above should be asked by anyone and everyone who enters the health care world. As a matter of fact the questions can be used to guide all professions.