Category: Submissions

By: Carlos Chan (c2020)

At McMaster University, we prize the ability to engage in self-reflection and learn from our experiences so that we can become better physicians. We dedicate an entire morning to it every week in pre-clerkship (professional competencies), we have required writing assignments centered around the idea (our reflective physician portfolio), and it’s been touted as a tool to guard against burnout in medical practice. As someone who tends to live in his own head a lot of the time, I personally think that self-reflection is a great practice as well. But I got some very interesting and unorthodox advice from my preceptor during my first week of clerkship, which sort of turns that idea on its head.

This surgeon mentioned that he often sees that clerks get into their own heads too much and become neurotic about things that ultimately don’t really matter. In the grand scheme of things, it really shouldn’t matter if we slipped up on terminology in front of a patient, unintentionally slighted a colleague, or made any other mistakes that are easily repairable. But it often is difficult to keep our eyes on the big picture when we’re all tunneling towards the goal of matching to our preferred residency. Indeed, it is almost impossible not to go insane as predominantly type A personalities obsessing over every little detail and then retreating into our own heads when doing so. Despite all of that my preceptor’s point was that it does a disservice to the team you are a part of to retreat in this fashion. You have to remember that while you are there, you are present to care for your patients, to learn from the team and to assist them in the goal of creating the best possible outcome for the patient.

I found myself slipping into my own head one night on call when the surgical team had to tell a patient in the emergency room that he had metastatic colon cancer and that there was not much they could do for him from a curative point of view. In that moment, I found myself thinking how horrible I was feeling about the entire situation and how it felt rotten just to be there in that room, even though I wasn’t even the one breaking the news. I was only a spectator.  The patient didn’t even seem to see the rest of the team in the room, his eyes remained fixed on the senior resident talking him through the news.

However, beyond that I cannot remember all of the details. Maybe I was too tired or perhaps it was because I avoided looking at him due to my own discomfort about the entire situation. But my feelings regarding that event still linger, like formalin that stays in your nose long after you’ve left the anatomy lab. And I do remember one other thing, the only thing he said in response to the resident’s monologue detailing the news which he must have been dreading.

“Shit.” Repeatedly.

Truthfully, I don’t remember much else about that consult. The night was still young and there were other surgeries to participate in and many other consults to attend to. But as I reflected on that experience, I felt badly about the fact that I had made that entire experience about me in that room. I was predominantly centered on how bad I felt about the situation, and how much I wanted to leave. My preceptor’s advice about getting out of my own head lazily wandered back into my mind, and I realized that I had disengaged from that moment, and I was not centered on the needs of the patient. I realized in that moment I had done exactly the opposite of what he had said that I should do. As I thought more on that situation though I realize now that perhaps it would have been unreasonable for me to not focus on myself and what I was thinking in that moment since it was my first time witnessing such a situation and I’m not sure I would have been capable of attending to the needs of both the patient and myself . But now that I’ve had this patient encounter and worked through my feelings on the matter, I know that I will be better equipped to engage with this type of situation in the future.

I’m sharing this because it has been useful for me at the start of clerkship. I’ve since told myself to get out of my own head repeatedly whenever I encounter something new and scary or when I make a minor mistake that really does not deserve a second thought. Although this advice has been useful, I still think that there is a role for reflective practice. However, as with most things in life, balance is the key. It does not pay to stay in your head forever burning a circular track in your own mind. Stay in your head to figure it out but don’t stay too long. Your team and your patients need you. Get out of your own head and engage.

The first delivery I ever saw was on YouTube. I was reclined on my bed—cup of tea in hand, and the familiar ‘ding’ of Facebook chats ringing from another Internet tab. I didn’t pay too much attention to the video, because I only meant to prime myself for the next day’s horizontal elective in Obstetrics & Gynecology. Many of my friends had already embarked on Labor & Delivery shifts, claiming the “magic” of delivery, explaining it was something that you simply must see to understand. I clicked back and forth to the YouTube tab throughout the video, making sure to catch the important parts—appearance of the head, clamping of the cord, delivery of the placenta. A few quick minutes later, I shut my laptop and went to bed, feeling a bit apprehensive about how I may react physically to the real thing in hospital (…maybe I should bring a paper bag).

Fresh in my scrubs the next morning, I eagerly awaited what the day had in store. My preceptor had one impending delivery: Nicole, a healthy woman pregnant with baby number 4, accompanied by her husband, and anticipating a quick and uncomplicated delivery. I was tasked with keeping tabs on mom and baby—I quickly learned how to read the printout of the fetal heart/uterine contraction monitor, and my preceptor patiently taught me about the basics of labor. To my delight, he took extra time to introduce me to “Fiona,” a plastic pelvic model used to demonstrate childbirth maneuvers, and “unnamed creepy black suitcase,” a large case full of rubber vaginas (yes, seriously) used to learn manual cervical examination.

After spending some time with my preceptor, Fiona, and the suitcase, I was surprised and excited to be given the opportunity to manually palpate Nicole’s cervix. It was a quick exam, and afterwards, I felt grateful to have earned the trust of both my preceptor and our patient—after all, it was a very invasive and sensitive exam. The afternoon continued with more teaching, observation, and exposure to new and interesting obstetrical cases. Eventually, during a brief break between patients, I found myself shooting the breeze with my preceptor and the team of nurses. It was casual conversation that ended with what felt like a bombshell: “Okay, Sarah, let’s go check in on Nicole. She’s almost ready, and you’ll be delivering the baby.”

I kept my cool, trying my best to exude professionalism, gratitude, and excitement. Internally, I looked and felt quite the opposite: my stomach churned anxiously as I mentally cycled through the delivery procedure that I had learned merely an hour before. Internal rotation, flexion, external rotation… was I missing something? Was flexion first? I didn’t have much time to think, because before I knew it, I was standing at the foot of Nicole’s bed, hands outstretched, eyes locked on the tiny human being who was making his first appearance into the world. My preceptor guided my hands as he talked through the birth, and in just a few minutes, Nicole’s son was calm, swaddled, and resting on her chest.

I could spend hundreds of words describing those few minutes: my sense of gratitude, the sharp awareness that I was the first human to touch Nicole’s son, the unexplainable reverence of witnessing the first moments of a new life. I felt an overwhelming and awe-inspiring sense of connection—I’m still not exactly sure to what, but I was completely present and aware of the moment’s intensity. Having the privilege of participating in this profound experience sparked a reflection on the intense trust that physicians receive from their patients. I realized that yesterday’s assessment of the ‘important parts’ of labor failed to take into account the patient’s whole story: the YouTube video didn’t capture dad’s teary smile and sense of relief, or Nicole’s admirable fortitude, or even the more ‘real’ components—smells, fluids, blood.

I want to be a physician who doesn’t forget about the whole story: the patient’s narrative. I’m coming to realize that these profound moments—a delivery, a death, a diagnosis—do not and cannot exist in a vacuum outside of real emotions and experiences. Physicians are somewhat akin to mechanics in that a job must be done, and they are under pressure to do it well: fix something, stitch something, put together pieces of a puzzle. Excellence in these skills contributes to the excellence of a physician, but I think that part of the ‘magic’ of medicine comes from the ability to remain mindful of what I’m doing, respect the immensely personal and intimate nature of the patient-physician relationship, and constantly reflect on my gratitude for the privilege of becoming part of this profession.

*Names have been changed for confidentiality purposes.

Jack* did not come into the shelter quietly. He blew in angry, yelling, slamming doors, and pointing fingers. His ongoing monologue was heard by everyone within 10 feet — sometimes it formed logical sentences, and sometimes it did not. From what I could gather, he was annoyed with a man named Ernest* – it wasn’t his fault, he would like everyone to shut the **** up, and he didn’t need any of this ****ing ****. To describe him medically, he seemed to be responding to internal stimuli, and his drooping red eyes, lack of coordinated movement and slurred speech pointed to some level of intoxication.

When asked by the staff if he wanted to come in to chat, he responded with an emphatic “no” and stormed off into the main lobby. Something was atypical about Jack’s presentation. Off to the left of the room, standing with her arms folded around herself, was his mother. Her eyes were heavy with the look of someone who had been through this with her son several times before. Yet, her eyebrows were knitted together with genuine concern over her son’s current condition. In order to try and de-escalate the situation, we took Jack’s distraught mother into the clinic room while a social worker went to talk to Jack one-on-one, and we let them know Jack was welcome to come and join the conversation at any time.

In the room, the staff I was with introduced us to Jack’s mother, and let her know that Jack was a client that was familiar to her, as he was a frequent visitor to the clinic building. The staff let her know that while we weren’t at particular liberty to disclose any information we had about Jack, she was welcome to share with us whatever she was comfortable with sharing, even if only for the therapeutic effect of talking about it. Jack’s mom proceeded to give us a full picture of how Jack’s life had played out up until the point where we had seen him today, yelling and angry in the shelter. She described a lifetime of mental health struggles, learning difficulties and neurocognitive concerns about Jack — a myriad of ways Jack’s brain had struggled throughout the years to help him take care of himself. On top of this, Jack had experienced several traumatic events throughout his lifetime that his mother said had caused him to spiral further away from a place where she felt she could help him. He had been abused by a family member at a very young age, and had started purposely hitting his head off of any surface he could find from the age of 18 months. From then on, his mother had watched as he struggled through school, struggled to cope with self harm, depression and social interactions, and then eventually struggle to cope with substance abuse.

All of these things had led him to where he was, in the shelter today, describing vivid hallucinations and bizarre thoughts, confused, and running out of options. He had been kicked out of his previous shelter for this behaviour. Jack’s mother  had seen him in plenty different states before, but never like this, she said. She was becoming increasingly worried about him, and didn’t know how to help him. If you were merely walking past Jack in his current state, you might have cast him as a classic young man living on the streets — seemingly intoxicated, aggressive, accusatory and destructive.

It is a rare opportunity to hear such a thorough life history, from birth to present moment, to give you a complete picture of how someone has ended up experiencing homelessness. It is a good reminder that everyone you meet is somebody’s baby.

The next thing we knew, Jack came knocking on the door of the clinic room. When we opened the door, a totally different Jack was standing there, social worker behind him. Jack looked meek and walked in quietly and then sat down next to his mom and held her hand. He apologized quietly and sat there on the examination table, head down, feet dangling off the edge of the table. Suddenly, it felt as if he had shrunk five sizes. After calming down with the social worker, he agreed to come chat. He admitted that the reason why he was so distraught today was that what he thought was weed last night had turned out to be peyote — something he only found out after consumption. He had been seeing and hearing all kinds of things ever since and seemed genuinely scared, ashamed, and unsure what to do. His eyes locked in on his mom like she was the only thing in his life not spinning wildly out of his control.

As a student observer in this situation, I became acutely aware that to anyone without the privileged view that I had at that moment, Jack was still that intoxicated, accusatory and destructive street youth — no evidence of anything otherwise.

He eventually agreed to stay at the shelter that night, and to come to the clinic the next morning to check in on how he was feeling. Agreeing to do that did not untangle Jack’s complicated situation, nor did it resolve any of the larger issues contributing to where he was that day. But for Jack — his mother held his hands and said, “Remember what we talked about about making one good decision a day? You just did that. And I’m so proud of you”.

In medicine, we are privileged to see people in significantly more detail than the rest of the world does. At the same time, we don’t always get the whole picture, and we often get to see people at their worst. My time on this elective, and this appointment in particular, taught me a lot about compassion, and the importance of always remembering that patients come into the office with a whole story behind them. We are just seeing today’s page.

Loneliness and Artificial Intelligence: A Looming Crisis in Mental Health

Modern society is enraptured by the prospect of technological progress. We focus on the increased convenience, connectivity, and sheer shininess of the new, even to the point of disparaging critics as luddites. Today, we are on the cusp of a revolution in artificial intelligence and automation (Frey & Osborne, 2017, 255); this transformation will have implications for human relations and may exacerbate one of today’s most pressing problems—loneliness. Loneliness is a key risk factor for mental health disorders and a prognostic factor in determining mental health outcomes; rates of which have been cited as one in five in Canada (Star Editorial Board, 2018).

There are many instances in human history where societal transformations have impacted psychological wellbeing. Drawing on the missteps of the past will help us avoid errors in the future. I’ll begin this paper by briefly highlighting how mental health management in the 20th century suffered because major social changes over the centuries prior were not adequately managed. I will then discuss future technological changes and their possible implications for mental health; finally, I will suggest some measures physicians can take to approach the challenges of tomorrow.

Modernity, Urbanization, and Mental Health

Western modernity has changed the nature of relationships. Communitarian structures of indigenous North American societies and medieval Europe, inculcated a sacred culture of shared responsibility that insulated individuals from bearing psychological distress and life’s hardships alone (Muir & Bohr, 2014, 67) (Hovden et al., 99). The extended family—not the individual or the nuclear family was considered to be society’s building block.  Over the past three centuries, the modern nation state upended medieval social structures in Europe and appropriated North American lands previously inhabited by indigenous peoples. These modern states became heavily influenced by a business elite made rich in part through the early industrial revolution of the mid 1700s (Polanyi, 1957, 135). Economic productivity necessitated the centralization of human beings which resulted in mass urbanization, and thus a move away from rural communities. In place of the community, mental health concerns had to be managed by the nuclear family and nation state. The nuclear family, overwhelmed by the responsibility of mental health challenges looked to the nation state which resorted to mass incarceration, heralding the ignominious phase of “psychiatric institutionalism”. Individuals suffering with mental illness were held in confinement en masse often without the hope of re-integrating into society (Chow & Priebe, 2013, 1). Mental health struggles were stigmatized. Over the last five decades, tremendous efforts have been made to create mental health support groups, train mental health counsellors, and open up space for mental health to be discussed within various public and private institutions. This effort has unfortunately come too late for many. Clinicians of today should proactively consider how future societal changes will impact mental health if the blunders of the past are to be avoided.

Future Technological Changes and Mental Health

In the last two decades, the internet, social media, and smart phones have changed relationships once more. We know more people, but have fewer deep ties—bonding through “likes”, texts, and tweets over substantive conversation. We connect online not to nuanced human beings but to shallow, airbrushed profiles that portray exciting lives seemingly bursting with joy. Even in person relationships have been impeded quite literally, as we stare into our smart phones enamoured by the superfluous happenings of social media, and unwittingly alienate ourselves from those immediately around us. We are now witnessing the rise of a new technological era that will likely accentuate loneliness in contemporary life. This includes more automation, robotics, and artificial intelligence in driving, delivery services, internet based education/courses, restaurants, household cleaning services, and even intimate relationships.

The implications of these changes in the realm of social interaction may be that human relationships that emerge as a by-product of essential or nearly essential human action—such as commerce, education, and leisure will be eroded. Despite the added convenience, there could be substantive alterations to social ties. For example, will social isolation become exacerbated when the elderly can go about their day with less reliance on sentient human beings? How will intimate relationships be impacted if romantic human interaction can be achieved through artificial intelligence? What will it mean for mental health if there is less engagement with peers at higher education campuses because of online courses/degrees? What will be the impact of drastic changes in workplaces leading to layoffs and fewer interactions in physical spaces?

As technology mediates changes in relationships, the long term mental health implications remain to be seen. Nevertheless, it is important to have a pragmatic picture of how social relationships will be altered by technology so that clinicians can mitigate and harness its effects. Public awareness campaigns can elucidate the mental health risks of loneliness as well as identify periods of vulnerability such as after child birth, loss of employment, or the passing of loved ones. Physicians can begin to screen for loneliness, especially as one gets older, and a greater emphasis can be put on in person group interaction for individuals who may not suffer from mental illness but need social support. While human beings tend to have an innate drive to be social, we also have competing drives to be “un-social”—to avoid embarrassment, to save time, to skirt the efforts of making face to face connections with strangers. Disorders of mood, anxiety, and more can thrive on loneliness and making deliberate efforts to bring people together might just be an antidote.

References

Chow, W. S., & Priebe, S. (2013). Understanding Psychiatric Institutionalization: A Conceptual Review. BMC Psychiatry,13(1), 1-14. doi:10.1186/1471-244x-13-169

Frey, C. B., & Osborne, M. A. (2017). The future of employment: How susceptible are jobs to computerisation? Technological Forecasting and Social Change,114(C), 254-280. doi:10.1016/j.techfore.2016.08.019

Hovden, E., Lutter, C., & Pohl, W. (Eds.). (2016). Meanings of Community across Medieval Eurasia: Comparative Approaches. LEIDEN; BOSTON: Brill. Retrieved from http://www.jstor.org/stable/10.1163/j.ctt1w76w6c

Muir, N., & Bohr, Y. (2014). Contemporary Practice of Traditional Aboriginal Child Rearing: A Review. First People’s Child and Family Review,9(1), 66-79. Retrieved May 19, 2018.

Polyani, K. (1957). The Great Transformation: The Political and Economic Origins of Our Time. Boston: Beacon Press.

Star Editorial Board. (2018, January 21). Governments Should Tackle Growing Problem of Loneliness. Retrieved from https://www.thestar.com/opinion/editorials/2018/01/21/governments-should-tackle-growing-problem-of-loneliness.html