Monday, July 23, 2018

Forest Bathing

For years I've enjoyed taking long walks in the woods. But it's only from reading a recent New York Times article that I learned I've been following the Japanese practice of shinrin yoku - "forest bathing."

There's nothing new about walking in the woods. Our ancestors spent their lives in forests. I assume many forest-dwelling genes are buried in our DNA. But as our species has become progressively more urbanized we spend most of our time indoors. A 2001 EPA survey reported that we Americans spend 87% of our waking time indoors, and another 6% in an enclosed vehicle!

In 1982 the Japanese Ministry of Agriculture, Forestry and Fisheries coined the term translated as "forest bathing" to describe the effort to imbibe what it saw as the healing power of nature by going into green areas with a mindful attitude. Since then, in the U.S., an "Association of Nature Forest Therapy" has trained and certified multiple cohorts of forest guides. A Google search shows that forest bathing is catching on as a commercial "back to nature" trend.

As an adolescent, Walden and Henry Beston's The Outermost House were among my favorite books. It seemed obvious that there was something very "natural" about being in "nature."

Three days ago the Journal of the American Medical Association published an important study demonstrating that creating green spaces of grass and trees on what had been garbage-strewn abandoned lots has a positive mental health effect on the neighborhood. This was a methodologically rigorous, randomized study that is likely to convince skeptics that there's more than sentimental anecdote behind the endorsement of time in the woods as a promoter of health and well-being.

In an aggressively capitalist society, it only takes a few nanoseconds for good ideas to become "monetized" and the focus for snake oil style hype. On the web I found vendors hinting that walking in the forest will combat cancer. But despite the hype surrounding the forest bathing concept, if I were still in clinical practice I would add spending time in "nature" as a recommendation to many of my patients.

Saturday, July 21, 2018

Medications and Religious Rituals

This morning as I put the pills I take into the pill container I fill each week, I thought about religious ritual.

On average, Americans over 65 take between 4-5 different medications each day. (See here and here for more information on pill-taking.) I noticed my feeling of pleasure as I put each of the 4 pills I take into the slots of the days of the week. I was carrying out an instrumental task, but the emotion I felt came from an entirely different realm.

I understood the rationale for each of the medications and found myself thinking of them as friendly presences, whose aim was to minister to my well-being. These thoughts led me to recall all the families I'd visited at home in my years of practice who showed me the Saints (Catholic) or Gods (Hindu) they prayed to and who they saw as crucial contributors to their health.

Although in theological terms I define myself as a "secular humanist," I respond to the pill-container filling with the same underlying emotions that my religiously observant patients felt about their Saints and Gods. It's important that I understand the medical rationale for the medications and their potential side effects, but I'm sure that a component of their efficacy comes from my attributing to them a benevolent intention to heal.

In the early 1970s I chose to work on the Jewish High Holidays, based on my lack of theological acceptance of the dogmas the holidays were based on. On Rosh Hashanah I was making a home visit to a Catholic family whose treatment I was involved with. They proudly showed me the little alter they used for prayer. It occurred to me that they might not have any more theological conviction about the Saints they prayed to than I did for Jewish theology. But unlike me, they were respecting the traditions and values they'd been brought up with.

From that day on, whether or not I was attending religious services, I didn't work on the High Holidays. I'm grateful to the family that taught me to distinguish between ritual, symbolic action, and literal theological beliefs.

In similar fashion, I'm grateful for the caretaking attitudes I associate with the medications I put into the pill container this morning.

(For a previous post on why religious language can be so valuable in clinical practice, see here, and for a discussion of physicians as "Counsellors," see here.)

Thursday, July 12, 2018

Ethics education and democratic values in high school and middle school

Every summer since 2012 I've taught at least one workshop on "making ethics part of high school and middle school English class" at the Bread Loaf School of English, a Middlebury College program in which the students, mostly teachers, can get a Masters degree in English in the course of 4-5 summers. I've written a series of posts on what I've learned in the workshops (see here, here, here, here and here if you're interested.)

I build the workshops around the issues the teacher-students bring to it. This year several teachers brought up the question of how best to deal with students who assert views the teachers regard as morally repugnant. They don't want to let the repugnant views go unchallenged but at the same time they don't want to put down the student. To squelch the student goes against the goal of fostering a classroom atmosphere of respectful deliberation, but to let the repugnant view stand can be seen as enabling.

The National Conference of Teachers of English (NCTE) statement on Academic Freedom urges teachers to cultivate democratic values in the classroom as a central objective:
NCTE maintains that students have the right to materials and educational experiences that promote open inquiry, critical thinking, diversity in thought and expression, and respect for others.
At the same time, the NCTE directs teachers not to proselytize or preach to their students:   

Educators and educational institutions must not require or coerce students to modify their beliefs or values. Efforts to convince students to modify their beliefs or values must be academically justifiable.
The teachers are in a difficult bind. They want to encourage  "diversity of thought," but human nature (and adolescence) being what it is, diversity can include prejudice, bias, and hate - the opposite of the "respect for others" NCTE calls for!

The teachers asked each other - "how can we best deal with this dilemma?" Three examples illustrate the kinds of strategies they suggested:
  •  After a hurricane, a  student said "why should we spend money helping people from XYZ?" This touched a very personal nerve - XYZ was where the teacher came from. The teacher kept anger in check and asked the class "does anyone have ideas about why we might want to spend money helping XYZ?" The question led to a thoughtful discussion. 
  • A student called a classmate "you bitch." The teacher used a jiu jitsu-like approach: "thank you for bringing that up - it lets us discuss the implications of the language we use..."
  • Another teacher described how she used "kindness" in dealing with cruel comments: "that might be hurtful...let's put it aside."
In medical practice and medical education we pay tremendous attention to the doctor/patient relationship. For teachers, "classroom management" has the same prominence. But the challenges I've faced over the years in relating to patients strike me as much easier than the challenges the teachers I've come to know at Bread Loaf have to deal with. 

As physicians, we're largely in 1:1 interactions, except for pediatricians, who deal with parents as well as the child, and geriatricians, who often deal with their patient's caretakers as well as the patient. Our field of action is less complex than a classroom that could have as many as 30 youngsters. And teachers typically must consider the expectations of principals and other administrators, parents and the school board in addition to dealing with a classroom full of bumptious students.

At the end of the workshop, I asked if the participants could help me pull together the wide-ranging discussion. The final comment, coming from an ex-teacher, was especially useful. He pointed out how much students learn from the way we comport ourselves and relate to them. Whatever the problematic situation we're dealing with, fairness, thoughtfulness and compassion will always convey "good lessons."

Recalling his comments put me in mind of Francis Peabody's 1927 address to Harvard Medical Students on "The Care of the Patient" that was given to us in a thin red booklet on our first day of medical school in 1960. Peabody's unforgettable final line rings true 91 years later. I expect the same will be said in 2118 and 2218: "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."

Tuesday, July 3, 2018

Transmission of Values within a Profession

Last night I had the pleasure and privilege of having an extended conversation about medical ethics with Laurie Patton, president of Middlebury College. I was surprised when Laurie expressed great interest in my experience teaching medical ethics. Was she just being polite? It turned out to be much more than that.

Laurie explained that two months ago she’d invoked the Hippocratic oath and the influence of her surgeon father in an essay titled “Our Moral Directive,” in which she argued that “a Middlebury education should be accessible to all, regardless of financial means.” Here’s the opening paragraph:

My father is a retired cardiovascular thoracic surgeon. My childhood memories are punctuated with instances of him being called away from home for emergency surgeries. On those days, and many others over his long career, he never questioned whether the patients whose lives he was trying to save were able to pay for his services. He had taken the [Hippocratic] oath to heal to the best of his ability all those who presented themselves—and he spent his career doing so…In higher education, we don’t—yet—have our own official version of the Hippocratic oath. But at Middlebury, we do have a mission that serves as our moral directive… 

Our conversation and her essay conveyed a crucial insight into what it means to be part of a profession. As professionals we profess values imbibed from our teachers. Laurie invokes two - her father and Hippocrates. She treasures stories her father told about nurses in the operating room who saved him from making mistakes. From those stories she took lessons about respect for competent women, humility about one’s own expertise, and teamwork to serve patients.

Out of curiosity I Googled “Dr Patton cardiovascular surgeon.” What I found reinforced the lesson about transmission of values within a profession. In college Dr. Patton broke his collar bone playing hockey. Two of his moral influences were the surgeons who took care of him – their empathy, competence, positive attitude and the pleasure they took in their work. And in an essay of his own, Dr. Patton tells the story of Dr. Daniel Fiske Jones, a noted surgeon who graduated from Harvard Medical School 62 years before Dr. Patton did. The subtext of the story is that Dr. Patton is guided by the same values that guided Dr. Jones.

In my first year of medical school I experienced the process of value transmission directly. I was in a tutorial group that met with Dr. William Castle, a distinguished hematologist. Dr. Castle, who was 63 at the time, described the following dialogue from when he interned at the Massachusetts General Hospital in the early 1920s:
Teacher: Dr. Castle, if you had a patient with pneumonia, and you did ABCD, but the patient died, how would you feel?
Dr. Castle: I would feel terrible!
Teacher: Dr. Castle - if you persist in feeling that way, you will have to leave medicine. You would have done everything that we are able to do at this time. You will have to learn to govern your emotions! (reconstructed from my memory)

Dr. Castle was a gentle, compassionate man who I admired. Over the years his story has led me to reflect on the challenge of how to be close enough to our patients to feel love for them, and at the same time to have enough internal "insulation" to maintain our own stability when our patients do not do well.

Laurie Patton is applying the values professed by her surgeon father. I reflect with my own students about the values Dr. Castle's teachers tried to pass on to him almost 100 years ago. 

That's a large element of what professions are all about!