Parisa Selseleh is a medical student in the Class of 2022 at the University of Manitoba

 

 


Dear you,

I must be honest, I was not looking forward to seeing you in the gloomy October day that coincided with my birthday. Despite my eagerness to learn about human illnesses, I was not ready to shatter my ignorance of human mortality and the hearts that give up. I slowly walked the long hallways leading to your current resting place, the Gross Anatomy Laboratory. Then, I saw you covered by an orange body bag, and in the blink of an eye, I became a medical student.

I had a vague understanding of what it meant to be in the business of mending bodies and minds, but I felt the gravity of my role the moment I saw how. I did not have much medical knowledge when I first met you but slowly, you taught me. How lucky I was. ...continue reading

Kacper Niburski is a medical student in the Class of 2021 at McGill University. He is also the CMAJ student humanities blog editor. Follow his writing : .

 


 

ventricular septal defect

you would not understand

what it means to fall in love

with the blue

to come to pour it

to read it in the cracks of light under heavy spines

to see it in green marseille waters ...continue reading

 Austin Lam is a medical student at the University of Toronto.

 

 

 


 

In a session on narrative medicine in medical school, a clip from the film (2001) was shown in which Vivian Bearing (portrayed by Emma Thompson), an English literature professor, was told that she has Stage IV cancer by Dr. Harvey Kelekian (portrayed by Christopher Lloyd). In this scene, he was, to put it mildly, less than considerate of the gravity that the discussion had for Vivian. He was Efficient. Domineering. Self-interested.

As Dr. Kelekian lectured her on the experimental treatment regime, he emphasized how she would be contributing to “our knowledge." In response, she repeated the word knowledge in a state of disorientation, seemingly to both him and herself.

What struck me the most was a question that came to mind: even if he had communicated in a gentler and more compassionate manner, even if he had mastered the art of breaking bad news, why would I still be left with a visceral feeling of discomfort?

At first glance, a fulsome sense of niceness would seem to be the answer — the answer to the power imbalance between patient and physician, amongst other problems, demonstrated in this movie scene. In fact, has been emphasized as an integral factor in treating patients.

The problem is that even if Dr. Kelekian, or his non-fictional ilk, were nice — maybe even counting amongst the nicest people in one’s life — there remains an ostensibly irreconcilable gulf between his stance of epistemic objectivity (“our knowledge”), , and that of so-called subjectivity in Vivian’s phenomenological reality, grounded in her experiences. The divide is not a Manichean duality. It is not that there is an inherent ‘rightness’ or ‘wrongness’ in one or the other.

The trouble lies in how the manner of approaching the patient’s concern(s) is framed: to explore that which is objective, and to this, adding considerations of the subjective (or the reverse in some cases). The conceptual divide between objective and subjective is not and cannot be solved by niceness. A change in attitude hardly substitutes for what is needed, namely, conceptual/philosophical sensibility, and corresponding epistemic humility.

One can imagine a hypothetically transformed nice Dr. Kelekian who nevertheless works under the guiding principle that his set of meanings, those belonging to “our knowledge,” are the ones that are objectively correct — and that when his patient’s meanings align, then all is well; but when they do not, then something has to give. An area not only of mis-understanding, but of non-understanding emerges between the ostensibly nice physician and the patient.

The patient may have a differing position that is judged to be ultimately misguided. It may be seen as a tolerable position or maybe even one with which the physician sympathizes but nonetheless sees as wrong — possibly accompanied by perceptibly nice phrases such as “I hear you, this is what I think…”. The physician may ultimately be ‘right,’ but in what sense? And so, here lies my discomfort: the . Equally, however, this discomfort does not necessarily translate into an espousal of untethered subjectivity.

What follows is not the demand that medicine requires expertise in academic philosophy. Rather, there ought to be a recognition that meanings can have truth, and that this does not require the meanings to be processed, subsumed, or translated into one objective account, the one taken-up and assumed by medicine. This kind of singular account has been as the following position: “the condition of my understanding you as you think and act in your terms is that I construe you as making sense in my terms most of the time.”

The underlying stance is that of ‘observer to object’ — the medical gaze — a notion introduced by philosopher Michel Foucault in . The medical gaze has been “how doctors modify the patient’s story, fitting it into a biomedical paradigm, filtering out non-biomedical material.” Despite many criticisms of Foucault’s ideas, his notion of medical gaze galvanizes further refinement in conceptualizing the constitutive forces in the patient-physician relationship.

The objectifying medical gaze necessitates a correction. However, this cannot be one of plastering ‘subjective’ elements onto ‘objective’ elements nor one of unbridled relativism for fear of losing grasp with reality and ending up with an impoverished category of ‘inner appearances.’ An account of understanding that transcends objective and subjective is needed. Philosopher Hans-Georg Gadamer provided this in his book .

Summarized by , Gadamer’s argument is “ontologically based: human beings are in contact with the real … Gadamer makes central the paradigm of a ‘conversation,’ in his understanding of human science, rather than that of an inquiring subject studying an object. Success comes, not with an adequate theory of the object, but with the ‘fusion of horizons.’” In essence, he challenged the subject-object dichotomy with his ‘conversation’ paradigm.

Again, elegantly wrote:

“If understanding the other is to be construed as fusion of horizons and not as possessing a science of the object, then the slogan might be: no understanding the other without a changed understanding of self … Real understanding always has an identity cost.”

The necessary identity cost cannot be paid for by niceness per se, it demands something more: an authentic conversation, where authenticity involves heeding the call of in a Heideggerian sense.

5 Comments

Ally Istl is a senior General Surgery resident at Western University

 


 

The concept of Wellness in the professional medical arena has become a contemporary Gargantua that we are perpetually seeking to satisfy, but never able to sate. As other disciplines seek to make their trainees ‘Well’, wellness has also become a growing subject of exploration in surgical disciplines.

Wellness means different things to different people and formal definitions provide no clarity in the context of the medical profession: ‘the state of being in good health, especially as an actively pursued goal’ only provokes more ...continue reading

Tharshika Thangaraa is a fourth year medical student at the University of Ottawa.

 

 


The sound of her alarm pulsated through her room. Startled, she awoke. It was just another day. As the fog of nighttime cleared, she felt the weight of everyday resurface. Gradually, they claimed their spot, perched atop her shoulders. She sunk deeper into her bed.

What would she wear?

How would it flatter her figure?

What would they think?

She managed to pry off the covers and make her way downstairs for breakfast. She poured herself a bowel of cereal and set the coffee to brew. She barely noticed the happy chirps of the morning songbirds or the vibrant petals of the summer flowers starting to bloom.

...continue reading

In this next "Med Life with Dr. Horton" podcast, Dr. Jillian Horton chats with Dr. Allan Peterkin about creative arts and playfulness as related to medicine and as tools to help balance out a stressful life.

Dr. Horton and Dr. Peterkin talk about:
- music, writing, theatre, improv groups
- the time Dr. Peterkin was on The Tonight Show with Jimmy Fallon because of one of his books about beards
- how learning to interpret a painting is related to diagnostic skills
- how a practice in creative arts can influence the way doctors approach patients and can help prevent burnout
- finding a balance between pleasure and purpose in life
- the absence of play in medicine
- practical tips for picking up that long forgotten creative practice again
- and much more

...continue reading

 is an Internal Medicine Resident (R1) at the University of Toronto. Check back the last Thursday of each month for a new featured piece as part of his series (Doc Talks: Reflections to Reality)!

 


 

No S1Q3T3

on the waveforms of her ECG,

but nobody turned to check

for signs of right heart strain in me.

 

Alarm beeping cuts through cold silence

only to leave the same void behind on cue;

my mother, ‘the patient’, is fading away,

and I, ‘the bystander’, am too.

...continue reading

1 Comment

is a General Practitioner, and Founder and Principal Investigator at PrimeHealth Clinical Research in Toronto, Ontario.

 

On July 10, 2018 Health Canada issued a recall of several products containing the blood pressure lowering drug, valsartan. This came in response to a disclosure from its Chinese manufacturer that the drug had been contaminated with a known carcinogen. A massive effort to contact patients to stop the affected drug lots, and to replace it with an alternative, ensued. Few clinicians had been even remotely aware that ...continue reading

The new season of "Dear Dr. Horton” is here! Send the anonymous questions that keep you up at night to a real former Associate Dean of Medical Student Affairs, Dr. Jillian Horton, and get the perspective you need with no fear of judgment. Submit your questions anonymously through , and if your question is appropriate for the column, expect an answer within a few weeks!



Dear Dr. Horton,

How do you address concerns with friends over questionable coping methods, when they are highly educated nearly-doctors too? My roommate has always had body image issues, but I did not know how deep they were rooted. In fact, after a recent psych block, I am pretty sure she has an eating disorder. I'm just not sure how to address it.  Nothing seems to be falling apart in her life.  Any tips on how to address uncomfortable suspicions that are unconfirmed?  Without offending my friend?

Signed,

Tip Toeing

*

Dear Tip Toeing,

Have you ever heard of the invisible gorilla?

In a famous psychology experiment, participants are asked to watch a video clip of two basketball teams and count the number of successful passes. (1)  Most people get the right number of passes.  But they miss the person in the Gorilla suit who literally moonwalks through the game.  Why?  Because they’re not looking for a gorilla.  And we have a hard time seeing what we are not expecting.

My colleague Ron Epstein uses this concept to help physicians go off autopilot and become more observant (2).  It’s a helpful construct for understanding cognitive error as well.  But I think it has another, more personal application.  When it comes to physician suffering, I think there are a lot of invisible gorillas in the room.

The first thing I want to commend you for is noticing.  Too often in medicine, we’re blind to the suffering of our peers. Sometimes this is because we are struggling to contain or manage our own suffering.  Sometimes it’s because we assume that nobody struggles the way we struggle.  And sometimes we assume our colleagues are “smart” enough to be able to identify when they are in over their heads, and we share the fallacy until things have spiralled totally out of control, or worse, until it’s too late.

This is a fundamental paradox of life in medicine...that being a doctor means you always have insight into your own health.  It’s true that being a doctor can be helpful if you are trying to decide if you have a virus.  But there’s no reason to think it’s particularly helpful if you are trying to decide if you have an illness that is characterized by cognitive distortion.  Meanwhile, the people around you may mistake your intellect for insight…words that are not synonyms.  And before you know it, the invisible gorilla has pulled a Godzilla and torn up not just the basketball court but pretty much everything else in your life.

I had some very hard times in my residency, times when a gorilla followed me into every room.  For years afterwards I used to wonder: didn’t my friends know I was in over my head?  Didn’t they see my suffering?  Wasn’t I worth the discomfort of saying something?  I grieved this abandonment; it was a sadness that stayed with me for at least a decade.  But then, in the years that followed, I missed these same signs in my own friends, and sometimes in my residents and students, and I wondered how I could have been so blind.

Life has taught me that my friends didn’t abandon me.  In fact, they were often watching me closely…closely enough to know I never missed a pass, that I always kept catching the ball.  They thought performance was the metric that would measure whether I was alright.   That’s how they missed the gorilla.

It doesn’t absolve them, or me, or any of us of the responsibility for taking better care of each other.  But it helps give us a framework for how we have failed so miserably as a profession when it comes to judging the wellbeing of people around us.  We have to start looking for gorillas.

Tip toeing, you’ve noticed something amiss.  There’s a moonwalking gorilla in your rented apartment.  Maybe you’ve talked to it a few times and it laughs and tells you it’s not a gorilla, it’s a seahorse.  Or maybe it’s barked like a dog, in the hopes of throwing you off its trail.

You have a choice.  You can pretend it is a seahorse, or a chihuahua, and you can become party to the cognitive distortion.

Or you can sit your roommate down.  You can show her this post.  You can tell her you wrote this letter, because you’re worried sick about her.

Be prepared for anything.  Gorillas are unpredictable.  Enlist the help of friends, family, trusted faculty, and school resources, to help get through to her.   Will that make the gorilla angry?  It might.  But my experience is that in processes that don’t preclude a degree of insight, most people welcome true expressions of caring and concern.  Some people have been wrestling the gorilla on their own for so long that it is a relief to know that backup has finally arrived.

Even if things go the other way, would you rather have an angry friend or a dead friend?  And what would any of us want or expect our friends, family and teachers to do if we had an illness that could impair our judgment, insight, willingness, and ability to seek help?

I think we would want them to be brave, to step up, to help us send that gorilla packing, so we could get on with our lives.

Yours,

Dr. Horton

 

References:

  1. http://www.theinvisiblegorilla.com/gorilla_experiment.html
  2. Epstein, R.M. Attending. Scribner, 2017.  P 17

Dr. Jillian Horton is a general internist in Winnipeg, Manitoba. She was the Associate Dean of Undergraduate Student Affairs at the University of Manitoba from 2014–2018 and now directs programs in wellness and medical humanities at the Max Rady College of Medicine.

She writes a column for CMAJ Blogs called Dear Dr. Horton: 

 Grace Dao  is a second year medical student at Dalhousie University.

 

 


From the beginning of medical school, we are taught about balance --the balance between each individual’s autonomy and the public well-being, the balance between focusing on the present and always being asked to plan for the future, and the balance between investing our time and energy into becoming skilled practitioners and the famously important, ever elusive “work-life balance”. Yet despite the mentioned importance, each lesson often ends with the thought that “well, you just have to find the balance…”. ...continue reading