The Paradox of Positive Thinking

Since I have been spending a fair amount of time in my first semester of med school combing the medical literature, my wife asked me to dig up some information on positive thinking in coping with illness. I was happy to oblige. Like most med students with a $30,000/year subscription to PubMed, I looked there first. I tried the keywords, "positive thinking cancer," thinking that might yield a large initial result. Nothing. Next, I tried "positive psychology." Still nothing. I checked my internet connection at that point, because not five minutes earlier I had entered the keyword "pigeon," and had 346 hits. My connection was fine, and so I tried every trick I knew to navigate the unimaginable hugeness of medical peer-reviewed literature. Finding nothing, I switched over to PsychInfo, the go-to database for peer-reviewed journals during my music therapy graduate studies. There I found a few articles, none of which demonstrated any clinically significant benefit to positive thinking. I found it interesting that no one had thought to include these on the PubMed database, where plenty of other non-biomedical topics are well-represented. Then I came across this article on my Twitter feed by Dr. Kevin Pho, MD (@KevinMD):

http://www.kevinmd.com/blog/2011/06/positive-thinking-affects-patients-illnesses.html

I always thought that my own grouchiness in the face of adversity was a flaw, but according to the scientific literature, perhaps not. Each person is uniquely equipped to cope with difficulties, and there is no reason to deem one coping strategy better than another.




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Trust

In a professional environment now teeming with litigious parasites and Starbucks-wielding pharmaceutical reps, it is hard to imagine that a modern physician can trust anyone. Yet, as I barely wrap up my first block of my first year of med school I already deeply trust my classmates and teachers. Having been burned more than a few times in the past I am not a particularly trusting person, but somehow in the short time we've been together we have a camaraderie that I can see lasting throughout the rest of my career. How does this happen so quickly, I wonder? Is it the fact that as a group we all face so much adversity and hostility in the general public, or is it something intrinsic to the profession of medicine? I don't know the answer to that question yet, but I think it's important that we stand together on what common ground we can find to take on the enormous challenges of health care in this contentious time.

Humanism in Medical School

One of the reasons that I chose my med school over some other very attractive options was the genuine concern they expressed for students, even during the application process. There has been a strong emphasis on life balance in every stage of recruitment during this last year, and our first official week has proven to be in line with this priority. I know there are physicians out there who see the toughness of their own experiences as med students as having been formative in their becoming professionals, and I think there's probably some truth to that. However, I also know many physicians are unhappy with their work, feel underappreciated and even sometimes undercompensated for what they have endured. The approach at my school seems to be less one of "enduring" training to claim one's reward at the top and more one of enjoying the journey. We are actively encouraged to explore non-medical interests, maintain commitments to family and be social as a class. This is all with the understanding that we must meet our academic and clinical responsibilities unequivocally, but with a pass/fail basic sciences curriculum we only have to hit 70% to be undifferentiated "successful" students in the first two years. Even without internal competition and rankings our three-year old campus has had 100% pass rates on USMLE Step 1 (the first and most critical licensing exam for MDs applying for residency) for the life of the school and above average scores for the last two years. Our match list (the list of residency assignments for new graduates) for the first graduating class (2011) included placements at Massachusetts General (Harvard), Cleveland Clinic, Mayo Clinic and many other highly competitive sites. It seems clear to me that any benefit that comes from a more humanistic medical school curriculum does not come at the expense of lower performance on the more academics-driven residency matching process.

So what is the point of expanding a medical student's focus from raw quantitative science into the ethereal realms of self-care, emotional intelligence and qualitative understanding of illness and experience? Well, first and foremost I would never dream of entering a service profession (which medicine certainly is) that didn't at least make an obligatory nod to the existence and importance of these factors to health, not to mention the greater human experience of which health is but one piece. A patient is not a problem to be solved, if only because their own awareness of that problem innately entangles their own emotions, spiritual resources and sociocultural influences, all factors that are virtually impossible to differentiate on a digital printout. Even a non-communicative (e.g. comatose) patient has an internal world that is both influential upon and influenced by these factors, whether or not there is any feasible way to assess them. I can't think of a scenario in which this information would be completely accessible, even to a very skilled interviewing physician with an extensive support team, nor is that a realistic objective. Rather, I see it as more of a critical part of the history and physical (H&P) process to help determine the best course of treatment for each patient.

To those of you with a social sciences background this may seem like common knowledge, but the "typical" medical student (a term that is getting more difficult to define with each application cycle) med school is an extension of years of rigorous scientific study, often accompanied by even more extensive lab work. There is a standard requirement of volunteer work in a medical setting, but that 1-2 hour commitment per week pales in comparison to the 20-40 hours of study and research they are logging in order to pump up their application enough to be competitive. Luckily my class, although very impressive academically also has a diverse array of backgrounds and academic interests, having both chosen to apply to this humanistic program and having been chosen by it in return. I admit a strong bias in favor of my own school as well as some ignorance about other programs that I will not likely ever be deeply involved with as a student. However, I can say after in-depth research of many, many allopathic (MD) schools across the US during my own application cycle, as well as interviews at nine of those programs, our situation here is unique and the care for the student is equal to or greater than any other school at which I personally interviewed. I feel cared for, but I also feel personally responsible for thoroughly understanding and applying vast amounts of information and techniques that may someday save a patient's life. This is perhaps the greatest argument for a humanistic approach to medical education. I am not just mastering this material because I should try to be the best in the field for my own benefit. I am doing so because I should care deeply and want to do the best I can for my patients, a principle that so far has been central in the curriculum and modeled daily by our staff and instructors.

Social Media (Epilogue)

One final note about the usefulness of social media: mobile applications make this all so much easier and more practical. I am currently blogging from an iPhone on the free app "Blogpress Lite," and 99% of my social media use is mobile via the free eponymous apps for each service. I'm finding social media can streamline mass communication much more efficiently than clunky email, but for secure communications, email is still a must. Most cell phone providers have low minute plans to reduce cost, and even huge data plans are pretty affordable. If you still have doubts about how useful social media can be to you, consider turning off your computer and going mobile. It will make your days more productive and your free time even more free.

- Posted using BlogPress from my iPhone

How to Use Social Media (The Big 4)

There are almost as many social media "experts" out there in the virtual world as there are social media users. I do not consider myself one of them, not even remotely so. However, as a former skeptic about the usefulness of social media, I have come to appreciate just how much we all can benefit from the thoughtful and effective use of this nearly infinite, and if you have an internet connection, free resource.

I've limited my own use of social media to the "Big 4," Facebook, Twitter, LinkedIn, and blogging, in the order that I began regularly participating in each. There are many more services, such as Digg, Tumblr, Foursquare, Yahoo! Groups, and the brand new Google+ network, all of which serve a niche group of users, but for various reasons beyond my own expertise they have not (yet) reached a critical mass that makes them worthwhile for casual online iPeople like myself. Here is a brief description of how I use each:

Facebook: Only trusted friends, family, and colleagues who I either know in real life (IRL) or have met online through other trusted people. Because of Facebook's constant privacy breaches and back-door shenanigans to harvest personal info, I am very careful to check privacy settings monthly (My account is private, so only people I've "friended" can see my information and posts), and I don't put any info on this site that would damage me personally if it got leaked to the public. I use Facebook as a tool to keep in touch with people I know who I wouldn't otherwise be able to see or talk to. It's also a good place to have in depth conversations (more than 140 characters) with people in your inner social circle. WARNING: If you "friend" family members or colleagues with different political or religious views, steer clear of these topics unless you want to invite aggressive posts and potentially damaged real-life relationships! I've experienced this first-hand and am not sure the consequences were worth taking a firm stand in this type of forum.

Twitter: This is by far my favorite social media site right now. Unlike Facebook, you don't have to wait for someone to "Accept" or offer of "friendship." Instead, you just "Follow" whomever you are interested in, and they may or (more likely) may not follow you. I follow the Dalai Lama, Smokey Robinson, and President Obama, but only one has followed me back...so far! I also follow hundreds of fascinating scientists, community leaders, and artists from around the world, as well as my wife, and the handful of friends and family who have Twitter accounts. This is an amazing way to connect with people in all walks of life, and because of the limit on post length (140 typed characters), it's easy to shoot back a quick reply to someone of interest without sounding curt. I've had replies, and even repeated exchanges with many interesting people way outside of my immediate social circle because of Twitter. Finally, Twitter doesn't yet have the amount of advertiser intrusion and extraneous nonsense that Facebook does, and Twitter users are almost uniformly resolved to abandon ship if things ever go that way on a large scale.

LinkedIn: LinkedIn is fairly new to me, and initially I ignored requests to join because I couldn't see the point of posting your virtual resume online unless you were actively seeking employment. I finally caved a month ago, and am glad I did. LinkedIn is geared towards professionals and is not the place to make "lulz" grade posts about cats, hipsters, and Michelle Bachmann. I think of it as a very politically correct virtual business card that includes all of the contacts that you consider to be influential in your professional/academic life. It's your 21st century human capital bling. Before you go out and "Connect" (I'm not using sarcastic quotation marks; each site has it's own vocabulary) with industry icons and celebrities, be aware that many accounts don't allow you to connect unless you are already connected to them by some degree (think Kevin Bacon). For example, I can connect to a colleague's colleague in Denmark because they are a 2nd degree contact, but I can't connect to my own sister, because we are in completely different career fields with few shared contacts. I'm still figuring this out for myself, but that is a marked difference between LinkedIn and the others. I'm sure there are more elements to this service that I am missing, but LinkedIn, like all social media, has a steep learning curve and a constantly evolving interface that reflects the needs of the huge base of users.

Blogging: This is the final frontier for me as a social media joiner. I am known for being verbose in person, but online it's taken me a long time to find a writing voice that feels authentic. I am now on my 4th attempt at regular blogging, and each time I read something from a previous post I am so horrified that I shut it down. I also find pictures and videos distracting from the point in other blogs, so I'm not inclined to pepper my own with photos, links, counters, and other multimedia candy, despite the insistence of the 100 million internet gurus that I must include some flashy stuff, superfluous or not. I'm still working on that piece, and if you're reading this now, then it's probably despite my lack of blog finesse. Here I am, however, and because Google Blogger wouldn't erase the final two posts of my last deleted blog, I brought them over here. I hope you enjoy reading, and that you'll feel free to comment as I go along, including any constructive criticism that might help me make this a resource for other denizens of social media. I have a lot of fun online, but I've also learned a lot, and I'd love to share that knowledge, as well as things that I've gleaned from my life in the analog world.

Die and let die

Here's the thing, you're going to die. Your grandparents are going to die, your parents are going to die, and you are going to die, hopefully in that order. Perhaps this comes as no surprise to you, but if you were born and raised in the U.S. it is possible that you have not yet had to confront death up close and personal. Americans rarely die in the arms of loved ones or even in their own homes. It is much more likely that we will die attached to a latex octopus of tubes, bags and noisy machines. This, in my opinion, is the greatest casualty of American health care. Why can't we just die?

Most people would never wish such a painful and prolonged demise upon their loved ones if they knew what it was really like. Some people do know, sign DNR (do not resucitate) orders, and are still subjected to expensive and invasive "heroic" medicine because of fear of litigation. So what can we do to give our loved ones and our selves the "good death" that has become more myth than reality in modern society?

The experts on palliative care, the clinical term for non-curative management of symptoms at the end of life, are hospice providers. Some of the richest experiences of my music therapy career have been providing care at the end of life through hospice. Rather than the intense and often experimental treatments in mainstream medicine, hospice focuses on pain management, spiritual and emotional care, and preparation for death in a peaceful and warm environment, often the patient's home. Also, every adult needs to prepare a living will so that loved ones can honor that person's wishes without agonizing over what they would have wanted. Finally, anyone who cares about a loved one's right to die should petition their lawmakers to pass legislation similar to what is currently on the books in Oregon. Yes, this is controversial, and unfairly used to charicature the liberal tendencies of that part of the country. This is not a partisan matter however. Oregon may be the only state that admits it, but "assisted suicide" is practiced in every part of the country. Every day, physicians and nurses nationwide make clinical decisions that may aid in reducing pain while accelerating the death of patients already at the end of life, often through continued use of large doses of opiates like morphine. The use of legal methods like those in Oregon would likely lead to less risk of abuse and increased opportunity for patients to have their wishes for end of life care honored.

The threat of evidence-based practice

A lot has been said about the benefits of evidence-based practice in recent months, especially as it relates to improving the effectiveness of medical care under health care reform. One model in particular, Intermountain Health Care in Utah and Idaho (http://intermountainhealthcare.org/Pages/home.aspx), has drawn national attention for low-cost care with significantly improved outcomes. President Obama has gone so far as to suggest that all medical facilities should rely on strict metrics and "care by committee" to lower health care costs nationwide. As a music therapist and an aspiring physician, this idea is unsettling to me. I'm not bothered by protocols clearly supported by data, washing hands for example, or following a checklist to prepare a patient for surgery. Unfortunately, data hungry as we may be, the vast majority of medical maladies are not so clearly understood and even less clearly described by what quantitative means we have available.

This lack of statistical significance is even more evident in quantitative anayisis of behavioral health issues and complex disorders such as autism. That's not to say that quantitative studies can't provide helpful guidelines for treatment of all sorts of clinical issues, but there is a dangerous trend of setting protocols for virtually every clinical presentation, and much of it is based on financial and legal motivations in the insurance industry. Saddest of all is the seeping of this medical groupthink into music therapy. The allure of labeling one's approach as "evidence-based" is difficult to resist when most people in the general public wouldn't know how to begin to take a closer look at that evidence. The fact is, much of the evidence out there is from music therapy studies with very small groups, which makes them fairly insignificant statistically, but compelling trends just the same. One of my goals as I struggle through the quagmire of American medical education is to figure out how to respect the lessons of our vast, quantitative medical knowledge about the human body without forgetting the singularity of the human being.