Monday, September 15, 2014

The Spirit Catches You and You Fall Down by Anne Fadiman

I'm re-reading this book for my social and behavioral determinants of health course as part of my MPH coursework this year.

This story has innumerable examples of how culture affects the psychology and behavior of the parents and community of one sick Hmong child.

  • beliefs about what causes sickness
    • epilepsy is when the soul flees the body, or is stolen.
      • causes concern but also pride
    • medication was causing sickness
    • can't give medicine forever
  • beliefs about what cures sickness
    • treat the soul and the body
      • ceremonies
      • rituals
    • Western medicine seen as disrespectful
      • finite amount of blood (but repeated blood tests)
      • can't take out organs without messing up next life
    • misconceptions about what the doctors were trying to do lead to fear
  • the rituals required for being and then for un-being (living and dying)
    • attaching the soul to the body
    • burying the placenta under the home



The behaviors and beliefs of the US medical community are painfully illuminated by this collision

  • Epilepsy has a natural cause just as other diseases have
    • not asking the family what they thought was causing the seizures
  • The shamanistic rituals might be harmful
    • not allowing Hmong mothers to take home their placentas
    • cutting off spirit strings for fear that they were fomites
  • Westerners hold all of the medical knowledge
    • medicine not as exchange, but as gift
  • Communication is not as important as are objective laboratory results
    • little effort to secure translators
    • 5-month delay between medical presentation and diagnosis of epilepsy
    • translating just language instead of having a "cultural broker" (95)
  • Failure to understand why dilantin was not being given at home, and resorting to CPS to intervene.
  • Viewed taboos against blood tests, spinal taps, surgery, anesthesia and autopsies as "self-defeating ignorance" (61).
  • Episiostomies one decade but not the next
  • Inability to compromise, to give up the "medically optimal" treatment in exchange for one that was more acceptable to the family (257).
  • Not a single word in Lia's entire medical chart "dealt with the Lees' perception of their daughter's illness" (259).



The political, social, and economic determinants of this Hmong family's situation include:

  • The long history of genocide attempts by the Chinese and other groups.
    • "they would rather flee, fight, or die than surrender"
  • The Hmong fight against French colonialism in 
  • The Hmong alignment with US interests against the socialist Pathet Lao party throughout the Laotian civil war, and then when the US and Hmong were defeated and the Vientiane government fell in 1975, yet another attempted genocide of the Hmong.
  • The Lees' time in a Thailand refugee camp Ban Vinai.
  • Immigration and placement in Merced, CA.
  • Racism, misunderstanding
  • Each side expected the other to be grateful.
  • US success measured in economic terms

The medical system of the US
  • No payment for cognitive work or time spent with interpreters
  • Practice is responsible for paying for interpreter
  • "Evidence based"
  • Little training in cultural medicine
  • little training in cognitive errors. "If it had been a brand-new kid walking off the street, I guarantee you Neil would have done a septic workup and he would have caught it. But this was Lia. No one at MCMC woul have noticed anything but her seiaure. Lia was her seizures" (256). 
  • The idea of "compliance" (261) "implies moral hegemony". 
What have I learned from this book? What questions remain?
  • Arther Kleinman's cross-cultural medicine questions (260).
    • What do you call the problem?
    • What do you think caused the problem?
    • Why do you think it started when it did?
    • What do you think the sickness does? How does it work?
    • How severe is the sickness? Will it have a short or long course?
    • What kind of treatment do you think the patient should receive? What are the most important results you hope she receives from this treatment?
    • What are the chief problems that this sickness has caused?
    • What do you fear most about the sickness?
  • Model of mediation instead of coercion. Negotiate with another Hmong or a medical anthropologist. Compromise must come from both sides.
  • "If you can't see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else's culture?" (261)
  • Mindfulness of my own emotions and reactions can improve my ability to be a healer. 
  • Which is more important? Life or Soul? (277)

Tuesday, August 19, 2014

Thinking Fast and Slow by Daniel Kahneman

Two selves
  • remembering self constructed by system 2 but still have duration neglect and peak-end rule following. This was demonstrated with the cold hand test.
  • experiencing self is in the moment, used to create the U-index of unpleasantness.
Econs and Humans
  • Econs act rationally always, they read small print, and calculate the value of two bets.
  • Humans are not well described by the rational agent model. Noto to say they are irrational, but they often need help to make more accurate judgments and decisions especially considering that they have system 1 and system 2 thinking giving them conflicting answers.
  • The failure of humans to act rationally leads to libertarian paternalism which is based on the idea that "freedom has a cost, which is borne by individuals who make bad choices, and by a society that feels obligated to help them." Protecting individuals against their mistakes is not controversial if you realize that humans do not follow the laws of economics.
Two systems
  • System 1 is prone to heuristics, meaning it generates answers to related questions to the one actually asked. System 1 does not realize when the information it is using to make decisions is unreliable or sparse. What you see is all there is, intensity matching, associative coherence, anchoring, nonregressive predictions, overconfidence, and many others.
  • System 2 is who we think we are, articulating judgments, making choices, but it often endorses or rationalizes ideas and feelings that were generated by system 1. System 2 is prone to narrow framing. You can get system 2 to kick in by getting outside observers to introduce doubt into your decisions. Checklists, reference-class forecasting, and premortems. 

Monday, June 16, 2014

The Stranger by Albert Camus

Something connects these books written once WWII had begun, all within the context of WWI, pure dystopia.
Camus here paints a picture of a man who may be autistic or perhaps just disillusioned. There is excruciating detail of the protagonist's downfall reminiscent of Crime and Punishment.  

Sunday, March 30, 2014

The Diving Bell and the Butterfly by Jean-Dominique Bauby

able to move only his left eye
he writes this entire book
and records for us some of his thoughts and experiences
then we sit
with our catered lunch
and try to put ourselves in his shoes
would we want to go on living?
better to be happy demented than fully with it yet locked in?
hard questions without clear answers


Thursday, March 27, 2014

A Fortunate Man: The Stories of a Country Doctor by John Berger

"It is generally assumed that doctors take a professional view of suffering"
"Doctors use a technical, entirely unemotional language".
"Increasing specialization encourages an increasingly scientific view of illness". 

"He never separates an illness from the total personality of the patient- in this sense, he is the opposite of a specialist."

"Most important of all, he considers that it is his duty to try and treat at least certain forms of unhappiness". 

"He can try to extend the meaning of sex for them. But the more he thinks of educating them - according to the demands of their very own minds and bodies before they have become resigned, before they accept life as they find it - the more he has to ask himself: by what right do I do this? It is not certain that it will make them socially happier. It is not what is expected or wanted of me. In the end he compromises - as the limitations of his energy would anyway force him to do; he helps in an individual problem , he suggests an answer here and an answer there, he tries to remove a fear without destroying the whole edifice of the morality of which it is part, he introduces the possibility of a hitherto unseen pleasure or satisfaction without extrapolating to the idea of a fundamentally different way of life."

"If the man can begin to feel recognized - and such recognition may well include aspects of his character which he has not yet recognized himself - the hopeless nature of his unhappiness will have been changed: he may even have the chance of being happy."

"How is it that Sassall is acknowledged as a good doctor?"
"He is acknowledged as a good doctor because he meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognizes them. Sometimes he fails - often because he has missed a critical opportunity and the patient's suppressed resentment becomes too hard to break through - but there is about him the constant will of a man trying to recognize."

"It is as though when he talks or listens to a patient, he is also touching them with his hands so as to be less likely to misunderstand: and it is as though, when he is physically examining a patient, they were also conversing."

"Previously the sense of mastery which Sassell gained was the result of the skill with which he dealt with emergencies. The possible complications would all appear to develop within his own field: they were medical complications. He remained the central character. 
Now the patient is the central character. He tries to recognize each patient and, having recognized him, he tries to set an example for him - not a morally improving example, but an example wherein the patient can recognize himself... he 'becomes' each patient in order to 'improve' that patient. He 'becomes' the patient by offering him hi own example back. He 'improves' him by curing or at least alleviating his suffering. Yet patient succeeds patient whilst he remains the same person, and so the effect is cumulative. His sense of mastery is fed by the ideal of striving toward the universal."

There is so much more in this essay, so much I cannot yet understand. In that way, I mark this as something that I must come back to, maybe repeatedly, in an attempt to build off of, and not just repeat Sassell's journey.

Interestingly, Sassell committed suicide, though many have suspected that he suffered from bipolar disorder, and never received cognitive behavioral therapy.






Wednesday, March 19, 2014

Alchemist by Paulo Coelho

"When someone sees the same people every day, they wind up becoming part of that person's life. And then they want the person to change. If someone isn't what others want them to be, the others become angry. Everyone seems to have a clear idea of how other people should lead their lives, but non about his or her own."


I really enjoy reading books like this, just told like a story, with some morals but often just telling of things that happen, without too much interpretation, letting you make of it what you will.

Two books finished and only on the second day of basic science!
So strange how medical school ebbs and flows...


Tuesday, March 18, 2014

A Short Guide to a Happy Life by Anna Quindlen

"Don't ever confuse the two, your life and your work"

"remember that love is not leisure, it is work"

I'm trying to decide exactly how those two statements fit together...

Monday, March 17, 2014

Silence: Lectures and Writings by John Cage

Didn't actually finish this one. Seems like John was quite a character. Lots of his notes and letters remind me of my dad. Statements that are heavy on facts and observations and descriptions.

One of my mentors encouraged me to read some of this since I have set out to study how silence is used in medical conversations, and John Cage explored silence in music.

Anyway, I could only renew it twice, and now I'm in between shelf exams and should really keep reviewing my flashcards for neurology, so I'm just going to go check this book back in to the library and get back to remembering what mesial temporal sclerosis looks like on MRI images.

Thursday, February 6, 2014

ACLS H's and T's of PEA

Hypo/Hyper Kalemia
Hypothermia
Hypovolemia
Hypoxia
H+ acidosis
Hypoglycemia

Tamponade
Tension pneumothorax
Thrombosis
Toxins
Trauma

Wednesday, January 22, 2014

Born to Run by Christopher McDougal

Absolutely fascinating chapter on the anthropology of running, explaining how our species adapted to running after we split from chimps, giving up speed and strength in exchange for endurance. The best answer he has for this is persistence hunting, though the evidence for this is rather slim.

I wish I had run barefoot my entire life, but now, with my achilles tendinitis, I don't really know where to go. My achilles have to stretch over large bone spurs on my heals, themselves probably a result of shoe wearing. At least I won't feel the need to buy new running shoes so often.


Still Life with Woodpecker by Tom Robbins

Author reminds me of my dad, saying so many things that just don't make sense yet with some really profound wisdom interspersed.

The most important subject that this book stirred in me was "how to make love last", and taking about what that exciting mystery is in new romances and what happens to it later on. Romance in solitude, romance in mystery, romance in new things and forgotten things. Overall hopeful, but with plenty of realism. Reminds us that the mystery will tempt us in "the next pair of eyes that smile at us". But in the end, as in real life, there is no single answer for how to make love stay.