Recognizing Healing

Surgical Procedure Board - Tenwek, Kenya

It was a day like many others at Tenwek Hospital(2/2012) when during rounds it was announced that two term pregnant patients arrived with seizures.  Both patients were diagnosed with eclampsia, both delivered.  The first patient’s baby was an early neonatal death, the other patient’s (JR) baby was small but survived.   The first mother improved quickly, but JR had evidence of renal failure, liver changes and the most obvious was her altered level of consciousness and subsequent hallucinations.   These symptoms required treatment with anti-psychotic medication.   Two weeks after presentation, JR suddenly became engaged with her baby, smiled and interacted appropriately with her family and providers.  Her renal failure and liver failure resolved. She remained in the hospital to continue to care for her baby.  


The reasons for resolution of this life threatening complication of pregnancy are only partially explained by her care.  What is most amazing is the long list of possible etiologies and mechanisms of injuries.  The patient and her family believe that she was healed.   Physicians and nurses use longer explanations about mechanisms and the sources of the dramatic change.   


These cases are a source of encouragement for those who work in very difficult settings with limited resources.   I believe that this case is a wonderful lesson in ”Let the living, teach the living” and another example of the “mystery of healing”!

Marvin

See previous blogs:

The Awe of Healing - January 15, 2012 

A Right Mind - September 5, 2011

The Mystery of Healing - April 17, 2011

Thackeray EM.  Tielborg MC. Posterior reversible encephalopathy syndrome in a patient with severe preeclampsia. Anesthesia & Analgesia.  105(1):184-6, 2007 Jul.

Belogolovkin V.  Levine SR.  Fields MC.  Stone JL. Postpartum eclampsia complicated by reversible cerebral herniation. Obstetrics & Gynecology.  107(2 Pt 2):442-5, 2006 Feb.

Fear, Freedom and Reconciliation

God has given us the task of telling everyone what he is doing. We're Christ's representatives. God uses us to persuade men and women to drop their differences and enter into God's work of making things right between them. We're speaking for Christ himself now: Become friends with God; he's already a friend with you.  

2 Corinthians 5:18-20 (The Message)

Visiting Robben Island is not just a lesson in history but a reflection of who we are!  There were three categories of prisoners; criminals, lepers and political prisoners.   The common element shared by all categories is fear.   The lesson we learned was the struggle for freedom from a former prisoner.   He was age 20 when he was imprisoned for being a member of the ANC.   He is now 49!   His work is telling the story of Robben Island as part of the larger story of reconciliation.  

That same day we attended a outdoor concert.  The group “Freshlyground” appeals to all ages looking not to the past, but to the future.   It is not unlike what we have seen in other parts of Africa and in the U.S.   What or who will continue the “healing”?   Will it be within and through the arts, economic policies, altruism or some religious response?   

For me, the answer is found in the reconciliation model that we see in the life and ministry of Christ.  It may find expression in the hopes and dreams of the youth, in the words of the music or art, but it’s Source is what gives me Hope!

Marvin

in Capetown, SA

Reference: The End of Words: The Language of Reconciliation in a Culture of Violence by Richard Lischer is a wonderful statement of the message of reconciliation.

Local Knowledge

"Africa to Anchorage"

Love never fails. But where there are prophecies, they will cease; where there are tongues, they will be stilled; where there is knowledge, it will pass away.  

1 Corinthians 13:8( NIV)

This last three and a half years have taught me the essential nature of local knowledge in providing health care.   This is not a rejection of evidenced based medicine or new scientific discoveries.   The reality is that as clinicians we have the task of translation of evidence and new knowledge in response to changing demands.  Underneath that reality is a passion to make a difference!

When asked “Are you retired?” I respond that “I still practice part time anywhere between Africa and Anchorage.”   This changes the conversation from my age to “Wow, that must be interesting!”.  Well it is “interesting” but more importantly, I have come to appreciate the local realities of the delivery of care.

What I have seen are very dedicated healing agents who are willing to share their knowledge and responses to challenges.   I see people looking for more efficient and safe transport of patients.   I see nurses and physicians separated from family and their homes working diligently to learn and improve care.  I see frustrations with systems of care that interfere with the care they want to provide.  

What has also been wonderful for me is the great diversity of the patients and having a chance to sometimes, if only briefly, to be invited into their lives with its celebrations and losses.  In addition, I have been able to see education at its most basic as well as it’s most advanced.  But what excites me most is the passion and dedication at the bedside.  It is true that there is “burnout” and “frustration”, but there is another reality of local strengths and knowledge making a positive difference in the care of patients in many global locations!

Marvin
in Kenya

p.s.  Here are some references that you may find interesting.

Henry SG.  A piece of my mind. The tyranny of reality. JAMA.  305(4):338-9, 2011 Jan 26.

Smith DG. Viewpoint: envisioning the successful integration of EBM and humanism in the clinical encounter: fantasy or fallacy?.  Academic Medicine.  83(3):268-73, 2008 Mar.

Shaughnessy AF.  Slawson DC.  Becker L. Clinical jazz: harmonizing clinical experience and evidence-based medicine. [Review] [16 refs]  Journal of Family Practice.  47(6):425-8, 1998 Dec.

“Standing Firm” and Pilgrimages

World Medical Mission "Chariot"

"It is always instructive to observe the life cycle of the First World aid worker.  A wary enthusiasm blooms into an almost messianic sense of what might be possible.  Then, as they bump up against the local cultural limits of acceptable change, comes the inevitable disappointment which can harden into cynicism and even racism...”  from When a Crocodile Eats the Sun by Peter Godwin. 2006 Little, Brown and Co. Publishers

“Therefore, my dear brothers and sisters, stand firm. Let nothing move you. Always give yourselves fully to the work of the Lord, because you know that your labor in the Lord is not in vain.”   1 Corinthians 15:58 (NIV)

Later God's angel spoke to Philip: "At noon today I want you to walk over to that desolate road that goes from Jerusalem down to Gaza." He got up and went. He met an Ethiopian eunuch coming down the road. The eunuch had been on a pilgrimage to Jerusalem and was returning to Ethiopia, where he was minister in charge of all the finances of Candace, queen of the Ethiopians. He was riding in a chariot and reading the prophet Isaiah.  Acts:8:26-28 (The Message).

One of the benefits of “getting away” is the reassessment of the direction and purposes of your life.  Being in Africa is a long distance from many of the assumptions that we hold about who we are and what we are doing in the world.   The dislocation takes time as you are confronted with people, places and beliefs that you may or may not share.

Pilgrimages and Lent share the common goal of reflection that prepare us for rededication and resurrection.   The tension is how we “stand firm” and yet “move”.   Will we see new opportunities, have new courage or just keep doing the same thing?  There is also the reality described by Peter Godwin that we could become cynical and discouraged.   

It seems to me that during these “trips” both are happening.  The foundation is rediscovered as well as new opportunities.  Not just doing the same thing, but finding those new people and truths that give us direction for the rest of the pilgrimage.  The larger context is we see the Isaiah story of faith that gives us courage and sends us on our way!

Marvin 

Tenwek in Kenya, Aftrica

See Posts:  Oct 31, 2010 - An International Healing Parable

                    Feb 27, 2011 - Pilgrimage and Healing

Kingdom Learning

He told them another parable: “The kingdom of heaven is like a mustard seed, which a man took and planted in his field. Though it is the smallest of all seeds, yet when it grows, it is the largest of garden plants and becomes a tree, so that the birds come and perch in its branches.”  Matthew 10:31-32 (The Message)

One day children were brought to Jesus in the hope that he would lay hands on them and pray over them. The disciples shooed them off. But Jesus intervened: "Let the children alone, don't prevent them from coming to me. God's kingdom is made up of people like these." After laying hands on them, he left. 

Matthew 19:13-15 (The Message)

We visited Disney World this last year and were again impressed with the pilgrimage from around the world.  We had fun seeing the excitement in the eyes of our grandchildren as well as the memories of this place.   What was a favorite in the Magic Kingdom was the “It’s a Small World” ride that celebrates children and their cultures. 

The learning issues that confront us are similar to what we experienced in the Magic Kingdom.  We have been challenged by the expansion of information and information technology and we are like children learning how to explore this big world of ideas and information.   The question is how to approach this “big” problem?  Will we approach it from the “bottom” or the “top”.  The answer in the past has generally been, top/down with assigned educational goals and objectives.  

Microlearning starts at the bottom with small learning groups confronted with a care challenge.  Beside the learners there is a guide who asks  the questions and facilitates getting the answers and applying them.  It is much like the “mustard seed” approach.  It starts small and then grows!  The other similarity is, it is how we learn when we are children.  Small, simple steps that can have a “kingdom” impact on the lives around us.

Marvin

from Tenwek Hospital, Kenya

Conscience Check

The recent announcement by Katherine Sibelius of HHS created a dilemma for faith-based organizations and providers.   The context of the dilemma is the provision of contraceptive services to women as a part preventive services without additional charges or co-pay.  This final rule provides for a grace period of one year to “allow these organizations more time and flexibility to adapt to this new rule.”  This rule is a response to the Institute of Medicine’s report,  Clinical Preventive Services for Women: Closing the Gaps.

There is no question that the administration is aware of tension between religious liberty and the scientific basis of the recommendation.  The last sentence of the release is particularly revealing...”And this final rule will have no impact on the protections that existing conscience laws and regulations give to health care providers.”

There are a multitude of state rules/regulations as well as a long history of federal rules that support the idea of not forcing health care providers to participate in any procedure or service that they find morally objectionable.  The concern is that these protections are  “slipping away” given the demands of “access” and “control of health care costs”.

This issue is an opportunity to revisit prior “posts” addressing the purpose and nature of why and what we do.(1)   What seems likely to happen is that this will be seen in political terms particularly at this time in our history and ultimately as a legal question.  So what should be our conscientious response?

We can say that there is “a significant minority” of physicians who object to participation in procedures or recommendations that are morally objectionable.(2)  The other data is the impact of oaths and professional codes.  One example has been the refusal of physicians to participate in capital punishment.(3)  The anesthesiology board prohibits participation and sights a “Hippocratic” reason and support of the AMA.   Their policy is informative in that it does not argue the laws but addresses their professional response. It is a clear response that physicians are not agents of the state.

In summary, rules and regulations are important to consider in our actions as individuals and organizations but are not the definition of our mission either as a profession or as a vocation.  We have been confused in the past and should try and avoid this error as we are confronted with changes in the framework or context of our practice.

Marvin

(1) 12/24/2010 - The "Telos" for Christian Healing Agents

07/23/2011 - Power, Politics and Healing

01/6/2012 - Burdens and Benefits

(2) Lawrence RE, Curlin FA. Physicians' beliefs about conscience in medicine: a national survey.  Acad Med. 2009 Sep;84(9):1276-82.

(3)  http://www.theaba.org/pdf/CapitalPunishmentCommentary.pdf


(4)  Genuis SJ. (2006). Dismembering the ethical physician.  Postgraduate Medical Journal, 82(966), 233-8

Techniques and Transformation

These are the things you are to do: Speak the truth to each other, and render true and sound judgment in your courts;  Zechariah 8:16 (NIV)

“Blessed are the peacemakers” or “Blessed are those who struggle for justice.” Greater precision in translation would say, “You’re in the right place if … you are single-hearted or work for peace.”

Boyle, Gregory (2010-02-14). Tattoos on the Heart (p. 75). Simon & Schuster, Inc.. Kindle Edition. 

For healthcare education, the most difficult task has not been the cognitive or the procedural tasks; it has been the transformative educational task.  In a CNN report on medical certification exams getting the right answers apparently took precedence over doing the right thing.  

In his memoir, Tattoos on the Heart, by Father Greg Boyle we get some insight into the sociology of education of very difficult students.   What we see is a passion for the more difficult educational task of transformation.    He is not a teacher in an identified school.  His life, loves and actions are all predicated on a deep worth of his “students” that to him become “kin”.   He is one of them and at the same time a trusted mentor and critic who suffers and celebrates.

One tactical educational response has been the use of blogs as a tool for self-reflection in undergraduate medical education*.   There are concerns**but one obvious advantage is that these tools are not limited to a specific place***.   What we must keep in mind that with these new tools, we need faculty like the example of Father Boyle who was in the “right place” and committed to those he saw as “kin”.

Marvin

*Chretien K.  Goldman E.  Faselis C.  The reflective writing class blog: using technology to promote reflection and professional development.  Journal of General Internal Medicine.  23(12):2066-70, 2008 Dec.

Gewin V. Social media: self-reflection, online.  Nature.  471(7340):667-9, 2011 Mar 31.

**Shore R.  Halsey J.  Shah K.  Crigger BJ.  Douglas SP.  AMA Council on Ethical and Judicial Affairs (CEJA).  Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media.  Journal of Clinical Ethics.  22(2):165-72, 2011.

***Ali FR.  Finlayson AE.  Tweet to collaborate with poorer nations.  Nature.  475(7357):455, 2011 Jul 28.