Fall 2018 Digest
Photo Credit: Alma Rosas
Pg 3: From the McGovern Center Director Tom Cole Pg 4-12: Student Desk Munir Buhaya and Maggie O'Brien Pg 5: MS II Advocacy Writing Excerpts (Class of 2020) Pg 6-9: Narrative Medicine: The Hospice Experience Erin Harvey Pg. 10: Texas Health Experts Can Address Gun Violence Michael Bagg Pg. 11: The Chronicles of Medical School Ikenna Kingsley Emelogu Pg. 12: Art and the Operating Room Britt Boles Pg 13-15: Center News - Programs Pg 16-18: Center News - Teaching Pg 19-20 : Human Ties Message Board and Moment of Zen
Table of Contents
"...we also hope to establish a shared creative space to engage and support clinicians, administrators, staff, and trainees to foster their own creativity and resilience through the medical humanities."
From the Center Director Tom Cole
The mission of the Center is to address the dehumanization of health care and to focus on bioethics and social problems in medicine. We bring humanities and ethics to students in order to enhance their own humanity and equip them with tools for problem-solving and personal development. We publish scholarship in pursuit of these and other intellectual goals. The McGovern Center was founded in 2004, thanks to the generosity of Dr. John P. McGovern and the initiative of President James Willerson and the support of Dean Stanley Schultz. The Center built on the longstanding work of faculty members Dr. Stanley Reiser and Rabbi Sam Karff. Thanks to the ongoing support of the McGovern Foundation, the Center has grown and flourished and its future is secure. Over the last 14 years, the Center’s programs, teaching and scholarship have grown and evolved in unique and exciting ways. Center faculty play an important role in the medical school’s required curriculum. We offer a wide range of elective courses, including student-led courses in Medical Spanish, Humanities in Film, Gun Violence and Physicians, and Sacred Sites of Houston. Our Certificate Program in Humanities and Ethics is also the largest Scholarly Concentration in the school. The Sacred Vocation Program provides residents in several Departments with an opportunity to explore questions of personal meaning, healing, burnout, coping, and the meaning of medicine in their daily work. The Center has developed several other influential programs that contribute to the intellectual, clinical, and cultural life of the medical school and UTHealth. These include: a Campus-Wide Ethics and Humanities Program built on a successful QEP that works with faculty from all six professional schools; a postdoctoral program; Tibetan Meditation; an Arts and Resilience Program that presents monthly music and performance art for all faculty, students, residents, and staff. In 2016, Dr. Anson Koshy, Medical Director of the UT Physician’s Center for Autism and Related Conditions at the Children’s Learning Institute, joined the McGovern Center as part-time faculty. He lectures on ethics, professionalism, and perspectives on disability and also offers electives on visual arts and clinical medicine. Dr. Koshy is a special and gifted person. This inaugural issue of Human Ties Digest is the fruit of his effort alongside two MS II student co-editors Munir Buhuya and Margaret O’Brien to develop a creative space of interactive textual and visual communication through research, writing, photography, and graphics from students, trainees, and faculty. While one goal of this resource is to highlight work fostered by the McGovern Center, we also hope to establish a shared creative space to engage and support clinicians, administrators, staff, and trainees to foster their own creativity and resilience through the medical humanities. I am excited and proud to present Human Ties as a new and unique resource to share with the McGovern Medical School community.
Letter from the Editors… When Dr. Koshy approached us last spring with a vision to create a newsletter that would showcase the creativity and talents of McGovern medical students, we were both immediately on board. From the art hanging in the LRC to the friends we have who sing and dance and draw, there has never been a shortage of creativity at our school. We may all be going through the same classes and rotations, but no experience is alike and the chance to express our own perspective or appreciate that of another’s is vital. The student desk is a chance to be inspired by imagination and to reveal the humanity inside of all of us. On a personal note, it has been a privilege (and challenge!) to sort through the amazing work we were given to choose the pieces you read now. Some of the work featured comes from the final projects of our MS4 Medical Humanities scholarly concentration students, offered here as their parting gifts as they go on to residencies across the country. Others come from students spanning all classes. As this is the first issue, we hope that this newsletter inspires you to create your own content and submit it to us for future publication. There will be a call for pieces in the spring, so keep in touch for deadlines sometime this spring.
Student Desk
Photo Credit: Elisabeth Haberl "Resilience of Houston" Scholarly Concentration in Medical Humanities Final Project McGovern Medical School Class of 2018
Co-editors: Margaret O'Brien Munir Buhaya
In the Physician Charter Summary it states, “ To maintain the fidelity of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society.” To collectively improve the healthcare system, it is imperative that our medical student learn how to advocate. After receiving introductory lessons from Dr. Sandy MacKay, Assistant Professor in Pediatrics, students are assigned to write a letter or editorial on one of five topics during their ethics small group sessions. This is followed by a discussion on the challenges and value of being advocate.
"I think the attitude and conversation surrounding health care of immigrant children needs to be re-evaluated. No child (or any person for that matter) should be worried about seeking health care due to their immigration status. " ~Marina Petsalis McGovern Class of 2020
"If enough people vaccinate their children with the HPV vaccine, then it is possible that the cervical and oropharyngeal cancer caused by this virus can be erradicated from this country like polio and smallpox were erradicated. Parents have the opportunity to give their children the gift of improved future health." ~Kristine McAndrews McGovern Class of 2020
Advocacy
"When someone is afraid, you don’t make them more fearful. When someone needs something, you should help them. When someone is sick, you should heal them. Or at least not stand in the way. " ~ Helen Hoover McGovern Class of 2020
"Between 1999 and 2015, over 183,000 people have died as a result of an opioid overdose, enough to fill the Reliant NRG center two and a half times over. We need to find a solution; we need to make a change." ~Samuel Floren McGovern Class of 2020
"This world is new, but you are loved."- Mother
"I started smelling oranges everywhere, only there weren't any" - Oranges
The Hospice Experience and Narrative Medicine In October, I took the opportunity to rotate at Houston Hospice for one month. The rotation, unlike any I’d completed, allowed me to follow the nurses and social workers and chaplains as they visited their patient’s homes. The experience also inspired me to journal. As a result of this experience, I produced a flash fiction series about a hospice provider and her patients. Over the course of a month, I engaged in the observing, writing, and caring for patients described in narrative medicine, the particular theory of medicine developed by Rita Charon and her colleagues at Columbia University. Narrative medicine provides a powerful tool for improving patient care and physician resilience, especially in the face of end of life care as seen in palliative care and hospice medicine. Narrative medicine, as defined by Charon, is a “set of convictions and methods that fortify clinical practice with narrative skills to listen, to recognized, to witness, and to be moved to action on behalf of patients through close attention to their situations” (“Shock” 9). In this definition, narrative medicine is a way to practice medicine. It moves beyond just writing stories about one’s patients; however, Charon details in several articles how writing about, and sharing that writing with, her patients has become a crucial part of her narrative medicine practice (“Membranes,” “Form, Function,” and “Shock”). The goal of the movement, again, per Charon is to “enable the physician to practice medicine with empathy, reflection, professionalism...” (“Narrative Medicine” 1897). The intersection of medicine and literature has worked to mold the practice of medicine from paternalistic and cold to increasingly patient-centered and warm. Charon describes humble beginnings of this union - readings from Chekhov during a class discussion or a poem read during rounds. Charon, primary founder of the narrative medicine movement, began to write about her patients. Inspired by success in her own practice, she began publishing papers on the topic in the early 2000s. Amusingly, she carefully crafted the term “Narrative Medicine” to avoid alienating other physicians who found “humanities” indicated “‘soft stuff back then.” With her colleagues, she designed a program of workshops and courses from a framework of “attention,” “representation,” and “affiliation” as the steps toward embracing and wielding narrative in the practice of medicine (“Shock” 8). The goal? To provide “Rigorous training in close reading, attentive listening, reflective writing, and bearing witness to suffering,” thereby informing patient care (Charon, “What to do” 1265). Rita Charon’s article “The Shock of Attention” defines three steps to narrative medicine: perception, representation, and affiliation. Perception, or close listening, requires the receiver to be “wholly present.” The physician becomes akin to a literature student performing a close reading of a text. The programs that she developed to teach narrative medicine require attendants to practice close listening through close readings of texts. After perception, the narrative medicine practitioner must solidify the observations through representation. What is observed, Charon argues, cannot be fully realized until it is creatively represented. Finally, the physician is prepared to affiliate with the patient (or other physicians or themselves or the community) - they are ready for “bilateral engagement.” Both sides, patient and physician, can take stakes in the outcome of care (10-13). The primary goal of narrative medicine is to improve patient care. In her “Close Reading and Creative Writing in Medical Education,” Rita Charon writes, “Teaching reading, writing, reflection, or the humanities to clinicians and clinical trainees is done for one overarching reason: to improve the health care that they are able to provide to patients” (345). Narrative medicine streamlines care. When a physician engages in “diagnostic listening” the physician listens with their “inner resources - memories, associations, creativity….” The physician directs care more appropriately. Without the whole story, care is misled, insufficient (Charon, “Narrative Medicine” 1899). Narrative medicine tackles the dissatisfaction Arthur Frank describes in his memoir, At the Will of the Body. He writes about his muteness in the exam room. Physicians, he feels, are not interested in allowing him to “express the changes that illness has brought to my life” (8-15). Charon acknowledges this complaint, noting, “A scientifically competent medicine alone cannot help a patient grapple with the loss of health or find meaning in suffering” (Charon, “Narrative Medicine” 1897). In practice, narrative medicine begins the encounter with close listening. Narrative medicine is the natural course of the hospice visit. Unburdened by the need to “fix” patients and unfettered by the time constraints of a busy clinic, the hospice doctor and nurse can sit with the patient and listen. Goals of care vary with each patient so the hospice practitioner must listen closely. While not its primary goal, narrative medicine benefits physicians, too. The practice allows “authentic engagement” with patient. The “reflective practitioner,” Charon writes, is able to “identify and interpret their own emotional responses…, make sense of their own life journeys,” and because of this can engage in effective patient care from a sturdy emotional foundation (“Narrative Medicine” 1899). Rita Charon has published numerous essays and articles about creative writing and better patient care. In one essay, she notes that several eminent creative writers “claim that writing is simply how they come to know what they think” (“Close Reading” 346). Bluntly, I agree. In journaling, I tease out and reconstitute my thoughts on patient experiences. In fiction writing, I re-condense these thoughts into demonstrative nuggets. I aim to re-express moments of my time with the hospice team for an audience by starting with emotion and adding context for the differently-initiated reader. My hospice rotation asked very little of me - no overnight call, no fourteen hour days, no charting, no patient interviews or rounding or pimping. My job was to observe and learn: not necessarily about the details of morphine dosing for air hunger versus pain, or how to get around Houston, or about the physical signs of dying (though I did learn these things), but I was meant to learn about the patient experience on hospice, about what hospice offered patients and families, and about working with a team. The experience was moving, painful yet joyful, simultaneously very easy and very difficult. And it inspired me to write. I chose to showcase the hospice experience from the medical caregiver provider because that was the angle from which I experienced hospice medicine. Also importantly, I chose to write several flash fiction pieces rather than a longer single narrative because I wanted to capture a feeling of a day-in-the-life of home visits. My hospice experience allowed me to experience several different teams, but because of this the experience lacked long-term continuity. This affected my narrative; Michelle visits each character-patient only once in the writing, much like my real life experience in October. I wrote each piece with the goal of featuring a different aspect of my hospice experience or how I have come to imagine the end of life. “Oranges” reminds the reader of how our patients can become mental landmarks - Michelle will forever associate oranges with Mrs. Marvin. In “Mother,” the longest single narrative, I explore the socioemotional offerings of hospice care for families and patients as well as my own imagining of the death character as a mother-like guide. Finally, “Mask” describes the equalizing effect of death and dying. Medical practitioners have the privilege of meeting so many people in the extraordinary situation that is illness. In every way that we guide and teach our patients, they guide and teach as well. In the process of getting to know our patients, we too are shaped. “Oranges” reflects this shaping. Mrs. Marvin, pleasant, cheerful despite her cancer, becomes a cherished patient of Michelle’s, and Michelle is left raw following Mrs. Marvin’s passing. Our patients leave imprints on our minds. For Michelle, oranges will remind her of Mrs. Marvin. In “Mother,” I point out that, for my experience, hospice was less about medicine and more about personal connection. Michelle, like many hospice workers, became involved and invested in this family’s dynamic. She witnessed the growth of the daughter, Cindy. The chaplains, social workers, nurses, medical assistants, grief counselors, volunteer, and physicians of the hospice team effect change in families’ ability to cope every day. They accomplish these, often great, changes through purposeful relationships with family members. Hospice gave this fictional family an opportunity to tie up loose ends, say goodbyes, and prepare for the death of Martha. And hospice, with enough time, does this well. During my rotation, families invited my preceptor and me into their homes. We travelled across all parts of Houston and across the entire socioeconomic spectrum to meet patients in their own spaces. I detail the divergent lives of three patients then point out their convergence as they develop the “death mask.” Despite their variations in upbringing, apparent wealth, and family life, these patients all die. The story also touches at some of the physical changes that come with dying – a particular piece of my medical education that was neglected until the hospice rotation. Narrative medicine provides a framework for truly listening to patients, for internalizing their struggle, and for providing patient-centered care. By virtue of their field, hospice practitioners are particularly effective narrative medicine providers. In my quest to be the most effective physician I can be, I have found that journaling and writing creatively provide an outlet and a reflection source. Writing has provided growth in my practice, and I hope to continue to listen closely to my patients, reflect on their life experiences, and attend to their needs as well as I do my own.
In October, I took the opportunity to rotate at Houston Hospice for one month. The rotation, unlike any I’d completed, allowed me to follow the nurses and social workers and chaplains as they visited their patient’s homes. The experience also inspired me to journal. As a result of this experience, I produced a flash fiction series about a hospice provider and her patients. Over the course of a month, I engaged in the observing, writing, and caring for patients described in narrative medicine, the particular theory of medicine developed by Rita Charon and her colleagues at Columbia University. Narrative medicine provides a powerful tool for improving patient care and physician resilience, especially in the face of end of life care as seen in palliative care and hospice medicine. Narrative medicine, as defined by Charon, is a “set of convictions and methods that fortify clinical practice with narrative skills to listen, to recognized, to witness, and to be moved to action on behalf of patients through close attention to their situations” (“Shock” 9). In this definition, narrative medicine is a way to practice medicine. It moves beyond just writing stories about one’s patients; however, Charon details in several articles how writing about, and sharing that writing with, her patients has become a crucial part of her narrative medicine practice (“Membranes,” “Form, Function,” and “Shock”). The goal of the movement, again, per Charon is to “enable the physician to practice medicine with empathy, reflection, professionalism...” (“Narrative Medicine” 1897). The intersection of medicine and literature has worked to mold the practice of medicine from paternalistic and cold to increasingly patient-centered and warm. Charon describes humble beginnings of this union - readings from Chekhov during a class discussion or a poem read during rounds. Charon, primary founder of the narrative medicine movement, began to write about her patients. Inspired by success in her own practice, she began publishing papers on the topic in the early 2000s. Amusingly, she carefully crafted the term “Narrative Medicine” to avoid alienating other physicians who found “humanities” indicated “‘soft stuff back then.” With her colleagues, she designed a program of workshops and courses from a framework of “attention,” “representation,” and “affiliation” as the steps toward embracing and wielding narrative in the practice of medicine (“Shock” 8). The goal? To provide “Rigorous training in close reading, attentive listening, reflective writing, and bearing witness to suffering,” thereby informing patient care (Charon, “What to do” 1265). Rita Charon’s article “The Shock of Attention” defines three steps to narrative medicine: perception, representation, and affiliation. Perception, or close listening, requires the receiver to be “wholly present.” The physician becomes akin to a literature student performing a close reading of a text. The programs that she developed to teach narrative medicine require attendants to practice close listening through close readings of texts. After perception, the narrative medicine practitioner must solidify the observations through representation. What is observed, Charon argues, cannot be fully realized until it is creatively represented. Finally, the physician is prepared to affiliate with the patient (or other physicians or themselves or the community) - they are ready for “bilateral engagement.” Both sides, patient and physician, can take stakes in the outcome of care (10-13). The primary goal of narrative medicine is to improve patient care. In her “Close Reading and Creative Writing in Medical Education,” Rita Charon writes, “Teaching reading, writing, reflection, or the humanities to clinicians and clinical trainees is done for one overarching reason: to improve the health care that they are able to provide to patients” (345). Narrative medicine streamlines care. When a physician engages in “diagnostic listening” the physician listens with their “inner resources - memories, associations, creativity….” The physician directs care more appropriately. Without the whole story, care is misled, insufficient (Charon, “Narrative Medicine” 1899). Narrative medicine tackles the dissatisfaction Arthur Frank describes in his memoir, At the Will of the Body. He writes about his muteness in the exam room. Physicians, he feels, are not interested in allowing him to “express the changes that illness has brought to my life” (8-15). Charon acknowledges this complaint, noting, “A scientifically competent medicine alone cannot help a patient grapple with the loss of health or find meaning in suffering” (Charon, “Narrative Medicine” 1897). In practice, narrative medicine begins the encounter with close listening. Narrative medicine is the natural course of the hospice visit. Unburdened by the need to “fix” patients and unfettered by the time constraints of a busy clinic, the hospice doctor and nurse can sit with the patient and listen. Goals of care vary with each patient so the hospice practitioner must listen closely. While not its primary goal, narrative medicine benefits physicians, too. The practice allows “authentic engagement” with patient. The “reflective practitioner,” Charon writes, is able to “identify and interpret their own emotional responses…, make sense of their own life journeys,” and because of this can engage in effective patient care from a sturdy emotional foundation (“Narrative Medicine” 1899). Rita Charon has published numerous essays and articles about creative writing and better patient care. In one essay, she notes that several eminent creative writers “claim that writing is simply how they come to know what they think” (“Close Reading” 346). Bluntly, I agree. In journaling, I tease out and reconstitute my thoughts on patient experiences. In fiction writing, I re-condense these thoughts into demonstrative nuggets. I aim to re-express moments of my time with the hospice team for an audience by starting with emotion and adding context for the differently-initiated reader. My hospice rotation asked very little of me - no overnight call, no fourteen hour days, no charting, no patient interviews or rounding or pimping. My job was to observe and learn: not necessarily about the details of morphine dosing for air hunger versus pain, or how to get around Houston, or about the physical signs of dying (though I did learn these things), but I was meant to learn about the patient experience on hospice, about what hospice offered patients and families, and about working with a team. The experience was moving, painful yet joyful, simultaneously very easy and very difficult. And it inspired me to write. I chose to showcase the hospice experience from the medical caregiver provider because that was the angle from which I experienced hospice medicine. Also importantly, I chose to write several flash fiction pieces rather than a longer single narrative because I wanted to capture a feeling of a day-in-the-life of home visits. My hospice experience allowed me to experience several different teams, but because of this the experience lacked long-term continuity. This affected my narrative; Michelle visits each character-patient only once in the writing, much like my real life experience in October. I wrote each piece with the goal of featuring a different aspect of my hospice experience or how I have come to imagine the end of life. “Oranges” reminds the reader of how our patients can become mental landmarks - Michelle will forever associate oranges with Mrs. Marvin. In “Mother,” the longest single narrative, I explore the socioemotional offerings of hospice care for families and patients as well as my own imagining of the death character as a mother-like guide. Finally, “Mask” describes the equalizing effect of death and dying. Medical practitioners have the privilege of meeting so many people in the extraordinary situation that is illness. In every way that we guide and teach our patients, they guide and teach as well. In the process of getting to know our patients, we too are shaped. “Oranges” reflects this shaping. Mrs. Marvin, pleasant, cheerful despite her cancer, becomes a cherished patient of Michelle’s, and Michelle is left raw following Mrs. Marvin’s passing. Our patients leave imprints on our minds. For Michelle, oranges will remind her of Mrs. Marvin. In “Mother,” I point out that, for my experience, hospice was less about medicine and more about personal connection. Michelle, like many hospice workers, became involved and invested in this family’s dynamic. She witnessed the growth of the daughter, Cindy. The chaplains, social workers, nurses, medical assistants, grief counselors, volunteer, and physicians of the hospice team effect change in families’ ability to cope every day. They accomplish these, often great, changes through purposeful relationships with family members. Hospice gave this fictional family an opportunity to tie up loose ends, say goodbyes, and prepare for the death of Martha. And hospice, with enough time, does this well. During my rotation, families invited my preceptor and me into their homes. We travelled across all parts of Houston and across the entire socioeconomic spectrum to meet patients in their own spaces. I detail the divergent lives of three patients then point out their convergence as they develop the “death mask.” Despite their variations in upbringing, apparent wealth, and family life, these patients all die. The story also touches at some of the physical changes that come with dying – a particular piece of my medical education that was neglected until the hospice rotation. Narrative medicine provides a framework for truly listening to patients, for internalizing their struggle, and for providing patient-centered care. By virtue of their field, hospice practitioners are particularly effective narrative medicine providers. In my quest to be the most effective physician I can be, I have found that journaling and writing creatively provide an outlet and a reflection source. Writing has provided growth in my practice, and I hope to continue to listen closely to my patients, reflect on their life experiences, and attend to their needs as well as I do my own.
Erin Harvey, MD Scholarly Concentration in Medical Humanities Final Project McGovern Medical School Class of 2018
Narrative Medicine: The Hospice Experience
"For all the different paths they took, these patients all wore the same mask in the end."- Mask
Oranges
Chuck starts the team meeting with prayer. His words meander across the room, his voice appropriately subdued and still strong enough to breach the void. I feel his words evaporate above me. “Amen,” then the rustling of papers in chorus. Let us begin the weekly ritual of listing our team’s dead and dying. Across the table from me, Karen, bereavement counselor and prolific consumer of organic produce, peels an orange. I watch absently, my mind otherwise engaged, as she pulls the flesh back, exposing the pith and flesh. I watch a drop of juice slip down her finger and mingle with her wedding band. Then I smell it. Crisp citrus, the distinct scent of ORANGE. And I am transported…. She was eating an orange when I walked in. “I can smell the orange at the door, Mrs. Marvin.” I dropped my bag in the seat of a scuffed dining room chair and sank into my usual spot on the overstuffed, floral patterned ottoman. “Well it’s a good thing I’m actually eating an orange, or we’d know you have brain cancer too!” She laughed as she handed me a wedge. I reached out to take the treat and we laughed together when the juice ran down my fingers and onto my blouse. “What do you mean?” “Well that was my first symptom… Long before that seizure. I started smelling oranges everywhere, only there weren’t any.” I nodded, “That’s really interesting.” “So now I always tell folks,” she nodded toward her nephew sitting at the breakfast table in the kitchen, “What do I always tell you, Michael?” He looked up from his computer, and in his best bad approximation of his aunt’s voice he said, “If you smell an orange, find an orange!” “Yes!” Mrs. Marvin laughed. “I’m lucky! The neurosurgeon said a lot of times people smell dog shit or burned rubber. I’d take the orange any day!” Mrs. Marvin told me that story, weeks ago, at one of our early visits, before the stupor of transitioning had set in. Days ago, I’d gone to visit because Michael called the 24 hour line. Mrs. Marvin was transitioning. Her breathing, he told the nurse on the line, had become more labored overnight. They’d had to turn the oxygen up on the concentrator and opened the emergency kit to give atropine drops for her secretions. I pulled away her socks and saw that her feet were mottled. Her breathing had become agonal, just a jolting shadow of true breathing. Michael and his mother, Mrs. Marvin’s sister were gathered beside her on the couch, each holding one of her hands. I sat with them for a while, it would be soon, but not any of the moments I there with them that day. “Michelle?” Karen’s voice jolts me from my reverie. “Mrs. Lucy Marvin passed 10/05. Nephew and sister to receive mailings.” She’d passed in the night after I’d seen her. There was a full bowl of oranges on their kitchen table.
Death says these things: This world is new, but you are loved. Come, walk with me, I will guide you. Go, you are safe. I am beside you. You can. Don’t look back. Today, Martha says this: “I’m scared.” She’s dreadfully pale and I can tell that this conversation is a struggle for her. But she wants to talk, needs to say what’s on her mind. Now is not the time for a blood pressure measurement. I take her hand and lean closer to ease some of her effort. “Who will be here when it happens? Will I die alone?” Cindy, her daughter, sits beside us and stifles a sob. “I’ll be here, Momma. You know I will.” “I’m scared for my family. What will they do once I’m gone....” Her question is more than just about her family’s emotional health. Cindy, despite her tears, is unusually composed today. I can tell our chaplain and social workers have been working their usual magic. Unfortunately, it hasn’t spread to Martha’s husband, Bill. He greeted me at the door, pulled me a chair beside Martha’s place in the living room, pronounced that he had business to take care of, and disappeared into his office. His distance is conspicuous and telling. He’s struggling, building a wall out of funeral arrangements and business dealings, to avoid the specter in his living room. Martha has been the cornerstone of this family. Never the breadwinner, but always the glue. Cindy is what the social workers call an “increased grief risk.” She has two young boys - one with autism, the other is painfully quiet. They’re living across town from their dying grandmother but come to visit with their mom nearly every day. And until today, I’ve never seen Cindy sit at her mother’s side without the encounter ending with a tear-stained outburst of “I can’t, I just can’t do it!” before running out the door. As Martha grapples with what her death will mean, I notice that this issue is more pressing than ever. She’s pale, gaunt, and her eyes seem heavy. She’s close. I think this may be one of our last times speaking. One of the last times for her husband to hold her hand and hear her say, “I love you.” Suddenly, I’m angry. I want him in this room. I need to tell him the opportunity he’s about to lose. Shake him and scream, “You’re going to wish, desperately, that you were here. With her.” I do nothing like this. Instead, I hold her hand. We listen to her daughter talk about their day of sitting together on the couch. How they talked about nothing yet so much and how it felt like closure. Cindy is ready, Martha is ready. When I started this job, I didn’t believe in being ready to die. I imagined death just ripped people away, kicking and screaming. Some do go this way. Others, like Martha will soon do, walk with death, with child-like meekness: curious but reserved. They hide in his robes, unsure, but bolstered by death’s confidence, the confidence of a mother. As Martha’s mother once did, holding her screaming newborn in her warm arms, whispering, “Shh… This world is new, but you are loved.” As Martha did for Cindy, arms outstretched to her wobbling daughter, “Come, walk to me, I will catch you.” As Cindy did for her boys when they were little and scared of the tall slide at the park, pushing them toward the exhilaration of conquering fear, “Go, you are safe, I am near.” And as all mothers, with open hearts and experienced advice, “Yes, you can. Don’t look back.”
Mother
Mask
To meet Merrick Aberdeen was to dislike him. Born in rural East Texas to an alcohol abusing mother, he quickly fell out of school and into alcohol himself. Life dragged him through three incarcerations and dumped him on the doorstep of the welfare office. Quick to anger (though, perhaps rightfully so) and slow to change, he lived with a sort of uneasiness that made everyone around him uncomfortable. The stomach cancer striking him down at age fifty two was just the last inconvenience in the line of insurmountable bad luck that began with his “insipid mother” and ended with “those damned Mexicans.” Helen, just Helen like Cher, just Cher. Matriarch, fierce, quick-wit, strong shoulders and birthin’ hips. Dreamed of getting outta Edlow and moving to the city, but not because it was what all the girls from her small town dreamed of, but because that’s where university was and where her dreams of learning the stars would finally come true. Workin’ at the Clinique counter to pay for her first semester when her damned cowboy muscled his way into her perfect plans, when Jesus said, “Your plans are changin’.” Four babies, forty-nine Christmases, too many Democrat presidents, thirteen grandbabies, one house fire, seven funerals, not enough vacation cruises, and innumerable Sunday suppers later, she is surrounded by family, reminiscing. And Jesus sayin’, “Your plans are changin’.” Dr. Nelson Desma: university professor, published author of the unsurprisingly underselling book Capitalism and Derrida: Phenomenological Interpretation of Capitalism and Promotion of Unfettered Spheres of Thought, and founder of the most robust online community for aquarium owners. He loved to watch his mother make bread. Later, he loved watching his wife clipping flowers in the garden. In the end, when his mind had forgotten itself, he watched the fish in the nursing home’s cloudy tank. Helen’s daughters draped her in homemade quilts and butterfly scarves. Merrick’s hospice volunteer dabbed is lips with a dampened sponge on a stick and took care to comb his hair in the morning. Dr. Desma’s nephew kept his distance, let the nurses handle everything, but I’ve never seen someone keep closer vigil for the dying. For all the different paths they took, these patients all wore the same mask in the end. Somehow my patient’s always start to resemble each other. Temporal wasting, dehydration, decreased perfusion leave them drawn, gaunt, haunted. They wear the death mask.
Michael Bagg Texas Health Experts Can Address Gun Violence Opinion piece originally published in the Houston Chronicle May 25, 2018 Article originally published in the Houston Chronicle May 25, 2018
On Aug. 1, 1966, a gunman climbed The University of Texas at Austin clock tower and systematically shot 31 people before his life was ended by local authorities. Our modern history of Texans shooting Texans began at that clock tower, and it should have ended there. Instead, on May 18, 2018, we added another date to a growing list of Texas massacres. The events in Santa Fe should not be considered routine, yet this year alone we’ve seen 36 Texans die from mass shootings. We are not doing enough to abate this epidemic of gun violence. In Houston, we have a world-renowned medical center, and we are failing to use it as a resource to find solutions for our gun violence epidemic. We can do more to ensure that Santa Fe is the final page in this dark chapter in Texas’ history books. Our political leaders are quick to offer one of two solutions from the top of their bully pulpits; either for gun control or increasing access to firearms, but nobody really knows if their proposed interventions will work. Some tout what works in other countries, while ignoring the sheer quantity of privately owned guns in America: 300 million firearms in homes across the U.S. — well above any other nation in the world. Our situation is unprecedented, and we cannot simply extrapolate solutions used by other countries. Texans don’t need impulsive reactions to a deadly issue. We need solutions proposed by our local public health community. We should turn to the Texas Medical Center before we propose options for the Capitol.
Artwork Titled: "Murder Suicide" A husband, an ex-wife, and two gun shots bring this violent confrontation to its tragic conclusion. by Cihan Kadipasaoglu, MD Scholarly Concentration Medical Humanities Final Project McGovern Medical School Class of 2018
More from The Chronicles of Medical School in the next issue.
Ikenna Kinglsey Emelogu MD Scholarly Concentration in Medical Humanities Final Project McGovern Medical School Class of 2018
Cochlear Implant Sound was chosen for me before I knew it was missing. They said, "So you'll be normal." I'm not listening.
Spinal Fusion They said, "Grow a back bone." So I did. Enthusiastically. They said, "No. Not like that." And straightened me out.
Arteriovenus Graft They are talking like I'm not here. They are chatting like today isn't the start of a sentence. An arm and my freedom for life.
Total Aortic Arch Replacement I was split in two. My heart was ripped out. Broken But I survived. I'll love again.
Laparoscopic Gastric Banding They say, "Food is life." They yell, "Your eating will kill you." They chant, "Eat for fuel, not for pleasure." I just want to live my life.
Britt Boles, MD Scholarly Concentration in Medical Humanities Final Project McGovern Medical School Class of 2018 Art and the Operating Room
Center News N
Christine Wieseler, Ph.D. I earned my Ph.D. in philosophy at the University of South Florida in August of 2016 and joined the McGovern Center for Humanities and Ethics in September. Although philosophers are primarily concerned with conceptual issues, how theorists write about and discuss ethical problems in medicine has clinical implications. In particular, authors’ assumptions are inevitably reflected in the textbooks and articles we adopt in medical ethics courses, and they are passed on to students. Thus, I was eager to gain a better understanding of and be directly involved in medical education. Although I completed research during my tenure at the Center (see christinewieseler.com), I will focus on my teaching here. I saw my role as helping students to examine their assumptions and to consider how provision of health care can be made more just. This was my ways of enacting the mission of the Center, which is to address “the dehumanizing forces in healthcare today”. I developed and taught multiple sub-electives of Humanistic Elements of Medicine, an extracurricular elective (commonly referred to as a “Blue Book”), clerkship lectures, and the Summer Humanities Seminar. Several of the courses I taught centered on the experiences of patients with bodies that are marginalized in relation to ability status, gender, race, and size. I will discuss a couple of examples. Although faculty at many medical schools advocate for inclusion of critical discussion of disability and instruction on how to meet the needs of disabled patients, few have provided suggestions on how to incorporate these topics into the curriculum. Dr. Anson Koshy and I worked with Dr. Danielle Melton, Dr. Margaret Nosek, and Dr. Margaret Uthman in order to develop a lecture in the required medical school curriculum entitled “Perspectives on Disability: Barriers to Access and Appropriate Care.” We discussed models for thinking about disability as well as concrete ways to increase the quality healthcare for disabled patients by centering their perspectives and concerns, adopting universal design, and improving communication. In the subelective “Anti-fat Bias and Fear of Fat in the Age of the ‘Obesity Epidemic,’” students were asked to carefully examine stereotypes that are prevalent in our society regarding the characteristics associated with being thin or fat. We listened to a podcast in which Lindy West describes her experiences of struggling with and eventually learning accepting her body, including refusing to consider the term “fat” to be an insult. Students delved into the literature on obesity—including the rhetorical function of the phrase “obesity epidemic,” implications of classifying obesity as a disease, funding sources for research, and the Health at Every Size Movement. The course concluded with students reflecting on how to provide the best care for patients, regardless of size. I am grateful to have had the opportunity to work with a number of incredible students, faculty, and staff during my two years as a postdoctoral research fellow at the McGovern Center. Dr. Wieseler completed her post doctoral fellowship with the McGovern Center in August of 2018. She is currently an Assistant Professor (term) with the Department of Philosophy at the University of Louisville.
Post Doctoral Fellowship
Programs
Remembering Why
Residency is challenging in a myriad of ways. After the flush of accomplishment in completing the demanding curriculum of medical school, interns are propelled into the everyday practice of medicine minus some of those layers of supervision and protection. As one resident at Columbia University noted in a New York Times editorial a few years ago, once an “M.D.” is appended to our names, expectations ramp up exponentially. And while putting on a brave front, many interns experience grave self-doubt. From maladies like depression and burnout to the extreme of suicide, even new physicians are at risk, and too often, they suffer in silence. The McGovern Center’s Sacred Vocation Program (SVP) for UT Residents is conducted with an eye towards “nurturing the healers”. The program consists of five one-hour sessions, usually conducted over lunch in a quiet, confidential setting where residents can relax and take a mini ‘timeout’ from their demanding schedules. Facilitators encourage open dialogue and sharing, with the caveat that everyone listen respectfully and non-judgmentally. Groups focus on the non-biomedical aspects of medicine, reflecting on what called them to medicine, and how they can be healers’ of body, mind, and/or spirit. Other sessions include discussion about medical error and the need to address the blame and shame that can surround them. Residents put their heads together to tackle some of the barriers to doing their work as a sacred vocation as well as ways in which to care for themselves during residency. As SVP manager, I relish this opportunity to facilitate hundreds of residents in a number of residency programs. And the stories residents share about their interactions are the oxygen that brings fresh energy—and a renewed sense of the ‘WHY’ each one of them undertook the long and difficult process of becoming a physician. At our final session, they craft a group statement about the principles on which they choose to base their daily practice. All previous sharing and dialogue gets distilled into this unique statement and each member gets a laminated copy. The goal of helping residents process some of their growth during residency comes with the absolute privilege of hearing their stories. They describe times when they educate, advocate for, and are fully present for their patients. When they sit with dying patients and their families, offering attention, kindness and relief from suffering at the end of a person’s life. When they help new parents, who expected a healthy baby, to begin to understand and come to terms with the reality of a serious congenital problem. When they meet the anger and antagonism of patients in pain with compassion and skill and turn around a difficult situation to become allies in their ongoing care. As one resident observed in a post program evaluation, “Most of us have stories we are dying to tell – but no one ever asks us.” Sharing and reflecting on these stories helps new physicians remember that caring for people at their most vulnerable is a hard won privilege—and doing it wholeheartedly is its own reward.
Sylvia S. Villarreal Sacred Vocation Program Manager
"As one resident observed... 'Most of us have stories we are dying to tell - but no one ever asks us'."
"20 million US adults use meditation for health purposes and those numbers are increasing"
Tibetan Meditation Alejandro Chaoul Adjunct Faculty Meditation has been a wonderful tool for me in dealing with existential anxieties as well as bringing calmness and clarity to my personal and professional life. I was first introduced to the practice of meditation in high school. I continued with meditation and yoga in college, finding my way to India before pursing my graduate studiesafter college. This trip to India changed the course of my studies and career from communications and philosophy during my undergraduate years to religious studies, focusing on India and Tibet, while pursuing my Masters and PhD. While completing my PhD program at Rice University, a series of circumstances led me to volunteer at MD Anderson, starting a meditation class for patients and caregivers. That led to a collaboration with the Integrative Medicine Program, to research mind-body practices, as well as co-teaching a class that included medical students. One of the former McGovern Medical students, Marie Frando—now Dr. Frando, felt meditation could be a useful tool for students and asked me to lead a weekly guided meditation class. With the support of Dr. Tom Cole and the McGovern Center for Humanities and Ethics we began the class for medical students which has since expanded to faculty and staff. We have been running these classes for close to a decade! Over these years, we found interesting and positive results of meditation and other mind-body practices in patients and caregivers. Staff and faculty who attend the meditation classes, share how these practices help relieve stress and re-invigorate them for their daily work. Hearing this, and recognizing the high rates of burnout and suicide among healthcare professionals and trainees, I have decided to begin a new venture: a Mind Body Spirit Institute (MBSI)! This new institute to support health of body, mind, and spirit is within the Jung Center of Houston, which has been a resource for Houstonians for 60 years. I have been teaching at the Jung Center for over 15 years. Through MBSI, we offer programs both in situ, located in the Museum District, as well as in different locations, including medical centers. I often prefer to begin with addressing acute stress utilizing a program that I call ‘CPR’ or Compassionate Professional Renewal. This program includes simple practices to cope with stress and empowers professionals with tools that can be used at work and at home to thrive, flourish and promote a healthy work-life balance. It is interesting to look back nearly 20 years when I first started a meditation classes for patients and caregivers at MD Anderson and how meditation practices are seen today. As you can imagine, back then it was an awkward word that described an unknown practice with little to no scientific backing. Today, there is robust research, showing positive effects on many body systems (e.g., immune, endocrine, neurotransmitters [neuromodulators], and gene expression to name a few), demonstrating improved quality of life, reversal of the harmful effects of stress, and establishing a fundamental change in the way the brain functions. The 2007 National Health Interview Survey revealed that some 20 million U.S. adults use meditation for health purposes and those numbers have been increasing. Meditation has an excellent safety profile and is increasingly accepted and, in many cases, integral to patient care. There are many opportunities for patients, caregivers, staff and faculty to begin or enhance their own mindfulness practice. For opportunities to meditate in the TMC: UT: Mondays 12:15-12:45pm at McGovern Center 1st and 3rd Thurs. of the month at 7000 Fannin For more information contact: Anna.Racelis@uth.tmc.edu MDACC: Tues. 9:30-10:30 a.m. Wed 2:30-3:30pm. Contact: www.mdanderson.org/integrativemedcenter or 713-794-4700. Rice University School of Continuing Studies Meditation courses: www.glasscock.rice.edu JUNG CENTER’S MBSI. Meditation and CPR courses. www.Mbsihouston.org 713-524-8253 ext. 15 For more information on Alejandro Chaoul and his programs visit: www.alechaoul.com
Poverty Simulation
Rebecca Lunstroth Associate Director McGovern Center For years I facilitated a session with MSIIIs where they are asked to put themselves in the shoes of a patient and imagine this person’s illness experience. Those that raise good questions are read aloud and discussed. These were stimulating and frustrating discussions that frequently resulted in students assigning blame over their patient’s lack of compliance and health literacy. Yet, does anyone really want to be sick? No, but why weren’t patients following their doctor’s orders? For many patients, filling a prescription, scheduling and attending a follow-up appointment, or eating healthy foods is a luxury. How could we impress this upon students? This was the genesis of the Poverty Simulator.
Center News
Teaching
MS I Professionalism Team-Based Learning McGovern first year medical students participated in a TBL exercise on professionalism nearly one week after receiving their white coats as part of the White Coat Ceremony. Images from the TBL - highlighting qualities that constitute professionalism are shown below. For additional information on the TBL exercise click here.
As I prepare to start my day in clinic I make sure I have all I need. As a neurologist I have a charged ophthalmoscope, a Queen Square hammer, an OKN tape, and a tuning fork amongst other tools. Last but not least is my white coat as I head to clinic. I can’t recall the first time I experienced putting on a white coat as we did not have a white coat ceremony when I was in medical school. The mere gesture of putting it on is in many ways just as important as having all of my other tools. There should be no sense of superiority wearing it; rather a sense of duty to others. An unspoken agreement between you and patients interests in mind and their families: deliver the best possible care based on up to date medical knowledge and practice. All of this delivered with honesty, trust, empathy and with our patient’s best whether ordering a test, performing a procedure or reviewing results. This white coat appears at times to be magical. Things you say while you wear it may drastically change people’s lives, whether we realize it or not. We encourage our students, residents and faculty to share a few interesting experiences about “their” white coat encounters.
My White Coat Pedro Mancias Associate Faculty McGovern Center Ass
Or so Gawande thought. “We made a fast, deep slash down the middle of his abdomen,” and “we grabbed the retractors and pulled him open. And what we found was . . . nothing.” No internal bleeding. They checked the catheter again—no blood there either. They also could not find the bullet, despite searching for an hour. There was no trace of the bullet on the X-rays. They sewed him back up. A couple of days later Gawande’s team received another X-ray and this one did show that the bullet was still inside him. Gawande reflects, “We had no explanation for any of this—how a half-inch-long lead bullet had gotten from his buttock to his upper belly without injuring anything, why it hadn’t appeared on the previous X-rays, or where the blood we had seen had come from. Having already done more harm than the bullet had, however, we left it and the young man alone. We kept him in the hospital for a week. Except for our gash, he turned out fine.” This clinical vignette highlights the fact that medicine is human. Therefore it is messy; it is uncertain. At the McGovern Center for Humanities and Ethics, we explore this human side of medicine with you. In the coming weeks you will have more chances to hear about our program, the largest in our school, the largest of its kind in the country. But now I’d like to share with you a journal from one of our graduates, Genevieve Cruz. She’s training to be a pediatric neurologist. Here is Cruz: “I’ve seen pictures of miscarriages in sterile containers and babies that have died prematurely, but I’ve never seen a 19-week-old [fetus born to become a baby] . . . desperately trying to breath without lungs. She was a perfectly formed human, only 6-inches long, silently gasping for breath . . . . We couldn’t do anything but project our love and sorrow onto this tiny human [being] and be her only moment of . . . contact in this life. She was too young to have eyes that open but her mouth and chest flailed and her heart pounded visibly through her ribs. The charge nurse look[ed] me in the eye and [said], “I need you to stay here with her; the parents don’t want to see her or hold her, so I need you to.” Her parents were in too much horror and shock and denial to fathom watching their . . . daughter die—so I was going to. The blur of doctors and nurses across the hall working on mom faded and I stopped listening to what they were whispering . . . . I held her in my hands as her heart kept right on frantically beating, and for a feeble fleeting moment [I] tried to bargain . . . my way through her surviving. If her heart is still beating, she must be strong . . . . But then my brain quickly conceded to . . . the science I had been taught. There was nothing functional in her lungs . . . . She continued gasping against a solid organ that would not open. Her heart kept beating, heaving through her ribs. I kept my eyes on her because I didn’t want to miss a single beat of her short life. Her fingers and toes were perfectly . . . . She had no fat or hair on her body and her skin felt left like putty . . . . The incubator kept us warm as the minutes kept ticking . . . . It felt like hours were passing, yet it would never be enough time to hold her. I could see the flutter of her heart slowing. She had given up . . . . My eyes stayed on her long after her heart stopped beating.” You are going to go through so much these next four years. You will bear witness to the mysteries of life and death. I am reminded of how Frederick Buechner, a Presbyterian minister, once described the doctrine of grace, which, come to think of it, just as well could describe medical education. Buechner said: “Here is the world. Beautiful and terrible things will happen. Do not be afraid!” Do not be afraid, Class of 2022! There is bread for the journey. Come by and tell us how the road is for you. The above was shared by Dr. Carlin to the Class of 2022 during the Freshman retreat
On trauma duty a young man presented with a gunshot wound. All of his vital signs were fine, writes Atul Gawande in his book Complications: A Surgeon’s Notes on an Imperfect Science. And while the entrance wound was readily apparent, there did not appear to be an exit wound, meaning that the bullet was still inside of him. Also, when Gawande did the rectal exam, he found blood. He did again when he inserted a urinary catheter. All of this suggested internal bleeding; the patient would die without immediate surgery. When Gawande explained this to the patient, he reluctantly agreed, despite the fact that he felt fine. Surgery was necessary to save this young man’s life.
"..medicine is human. Therefore it is messy. It is uncertain."
Welcome Class of 2022 Nate Carlin Director, Medical Humanities Scholarly Concentration
MEET OUR NEW POST-DOCTORAL FELLOW TIM HOUK Tim Houk joins us as the new Postdoctoral Fellow with the McGovern Center for Humanities and Ethics. He completed his Ph.D. in Philosophy at the University of California, Davis and his M.A. in Philosophy of Religion and Ethics from Biola University. He specializes in ethical theory and bioethics—focusing especially on the ethics of influence and writing on topics such as manipulation, moral responsibility, advertising, and “nudging” (i.e. using people’s cognitive biases to help them make good choices). Tim, along with Kate (his wife) and their three children (Silas, Lucy, and Caroline) hail from northern California and are excited to experience life in Texas—especially the delicious food!
Calling all artists and writers.... Have a photograph, painting, short writing piece you would like to submit for future editions of Human Ties Digest? Click here to share your work or to request more info
Covert Art: Yayoi Kusama by Anson Koshy Faculty McGovern Center As a young unknown Japanese artist, Kusama sent some of her early art pieces to renowned American artist Georgia O'Keefe asking for career advice. Against O'Keefe's advice Kusama relocated to New York City and quickly found herself immersed within a male dominated post war abstract art movement. She participates in art shows alongside Andy Warhol, George Segal, and Robert Morris. Kusama's art draws clear parallels to disease including her own mental health issues. Kusama has shared that her characteristic 'polka dots' symbolize disease and that her art originates from her hallucinations. In an interview she once shared, "I translate the hallucinations and obsessional images that plague me into sculptures and paintings. All of my works ...are therefore inextricably connected to my disease." Art and medicine often intersect and one of my personal favorite voices at this crossroads is Yayoi Kusama. Currently Kusama resides in Japan in a mental health facility. She continues to paint in a private studio during the day and aims to "create art for the healing of all mankind." I painted this portrait of Kusama - acrylics on canvas - inspired by an original portrait by artist Beck Lane.
Reading is Fundamental Books we Love Bellevue by David Oshinsky “Enthralling book about one of the most storied hospitals in American medical history where decades of evolving diseases, immigration movements, scientific, social advances and potent politics all comingle. Also an excellent compilation of vivid stories of patients, physicians and groups such as nurses as they slowly gained authority in a facility that eternally has served the most needy and unwanted of New York.” - Gene Boisaubin Professor Internal Medicine McGovern Center Faculty Fahrenheit 451 by Ray Bradbury "This view of a dystopian society in which the rise of technology erodes thinking and books are burned is one I will always love. Bradbury reminds us to value individualism and knowledge, and to hold tight to our creativity and humanity. " - Angela Polczynski Senior Coordinator, Special Programs Postmortal by Drew Magary "This book was completely disturbing and yet extremely intriguing. It is about the unintended consequences that a cure for ageing has on society. What at first seems like a positive solution to the ageing dilemma quickly spirals into all sorts of personal and societal issues.” - Allison Ownby Assistant Dean for Faculty and Educational Development
zĕn; Noun A Japanese school of Mahayana Buddhism emphasizing the value of meditation and intuition rather than ritual worship or study of scriptures. Choose your own adventure below
Fight
Click here for more information regarding the 2018-2019 Arts and Resilience Lecture Series
International Voices Houston and Art Director Mark Vogel with
moment of zen
"Shark Breath" with Jane Weiner
Respond
Fly to the Moon with Alicia Gianni
Flight
713-500-5970
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The McGovern Center addresses the dehumanizing forces in health care today. We bring ethics and humanities to students, while evoking their humanity.
Student Desk Co-Editors: Munir Buhaya, Maggie O'Brien Faculty Editor: Anson Koshy MD, MBE For questions or to submit content: anson.j.koshy@uth.tmc.edu
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