The Importance of Being Human(ities)

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Restroom sign at the University of Washington’s Intellectual House. Photo credit: Josephine Ensign/2015

All of our current ‘wicked problems’ such as racism, homelessness, environmental issues, human gene editing, violence against women, mass murders, and terrorism, cannot be addressed constructively by science or technology. As the late Donald Schon wrote:

“In the varied topography of professional practice, there is a high, hard ground overlooking a swamp.  On the high ground, manageable problems lend themselves to solution through the use of research-based theory and technique.  In the swampy lowlands, problems are messy and confusing and incapable of technical solution.  The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern.” (Schon, D.A. “Knowing-in-action: The new scholarship requires a new epistemology,” 1995, Change, November/December, 27-34.)

In order to muck through the swampy wicked problem areas, we need–more than ever–the humanities. Before we continue down the path of denigrating the humanities (Rubio wanting more welders/less philosophers) and decimating university programs in the humanities, we need to ask ourselves if this is who we want to be–both individually and collectively. Where would we be without grounding in history, language, literature, comparative religion, philosophy, ethics, archeology, the theory/philosophy of law, and the criticism/theory of art? The excellent short (7 minute/ June 2013) video “The Heart of the Matter” by the American Academy of Arts and Sciences explores this question. “No humanities? No Soul,” George Lucas states. 

William ‘Bro’ Adams, Chairman of the National Endowment for the Humanities (NEH), gave a speech this past week at the University of Washington’s newly opened (and gorgeous) Native American center, called the Intellectual House. Adams reminded us that both the NEH and its sister organization, the National Endowment for the Arts, are 50 years old this year. In 1965, President Johnson signed the act designating both the NEH and the NEA, and he made them a central part of the Great Society.

Adams was, of course, ‘preaching to the choir’ in that most of the audience consisted of academic-types from the different disciplines traditionally considered the humanities. I didn’t recognize anyone else from the health sciences, and none of the audience members asking questions identified themselves as being from science or technology fields. This was disappointing, although not surprising. After all, even physically the UW’s Intellectual House is surrounded by buildings that house the humanities and is a far trek from health sciences or any of the science and technology buildings. But as Adams emphasized towards the end of his talk, there’s a great need to increase the intersection of the humanities with science/technology/medicine (health sciences more broadly). The humanities bring the important tools of reflection. Reflection on what it means to be human. Reflection of what it means to be a citizen.

Carrying Stories: Beyond Self Care

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Girl with Balloon, street art by Banksy. This one found at intersection of K-Road and Queen Street in Auckland, New Zealand. Photo credit: Josephine Ensign/2015.

What to do with difficult stories? Stories of refugees, victims of mass shootings, of hate crimes, of rape, of torture victims, of people dying alone and unnoticed ?  It all gets overwhelming and depressing to hear or read these sorts of difficult stories, to carry them in our hearts, to bear witness to so much suffering in the world.

Of course, for many fortunate (perhaps unfortunate?) people, there is the option of tuning out these stories, turning off the news, unplugging from any non-vacuous form of social media. Taking a break from difficult stories.

But what about all the other people who cannot or choose not to disconnect? What about people whose work involves listening to these stories on a daily basis? Frontline health care providers who work with people experiencing trauma (physical, emotional, sexual). First responders. Counselors, mental health therapists, lawyers. Human rights activists. Researchers working on social justice issues. What can they do to, if not prevent, at least deal effectively with, vicarious or secondary trauma? And for those of us who teach/train/mentor students in these roles, how do we prepare students to be able to carry difficult stories while maintaining well-being?

In a previous blog post, “Burnout and Crazy Cat Ladies,” I explored the issue of ‘too much empathy’ and of pathological altruism, linking to some of the (then/2011) current research. After writing that post and some related essays, I began incorporating a new set of in-class reflective writing prompts for soon-to-be nurses in my community/public health course. I used these in a class session I titled “Public Health Ethics, Boundaries, and Burnout.”

The first writing prompt: ‘What draws you to work in health care? What motivates or compels you to do this work?’ And then later in the class session– after discussing professional boundaries (how fuzzy they can be), individual and systems-level risk factors for burnout, and asking them to reflect on how they know when they are getting too close to a patient, a community, or an issue–I gave them the follow-up writing prompt: ‘Referring back to what you wrote about what draws you to work in health care, what do you think are the biggest potential sources of burnout for you? And what might you be able to do about them?’

Feedback from students about this in-class reflective writing exercise and the accompanying class content on boundaries and burnout, was invariably positive. Many of them said it was the first time in their almost two years of nursing education that anyone had addressed these issues. I understand that patient care, electrolyte balances, wound care and all the rest of basic nursing education takes priority, but it makes me sad that we don’t include this, to me what is fundamental and essential, content.

“…people who really don’t care are rarely vulnerable to burnout. Psychopaths don’t burn out. There are no burned-out tyrants or dictators. Only people who do care can get to this level of numbness,” Rachel Naomi Remen, MD reminds us in her book, Kitchen Table Wisdom: Stories That Heal (Riverhead Books, 1996). Something to remember when we are feeling overwhelmed by difficult stories.

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Here are some excellent resources:

 

Hospital Healing Gardens

Sheltering Arms Hospital labyrinth and park. Richmond, Virginia. Photo credit: Josephine Ensign/2014

Our hospitals are bustling, intimidating, drama-filled, miraculous, expensive, technology-driven, antiseptic, and confusing places. Anything that can make them more ‘grounded’ and healing should be a welcome thing.

The first photo here is of the walking meditation outdoor labyrinth and wheelchair accessible park/paracourse that was associated with the (now closed) Sheltering Arms Hospital in Richmond, Virginia. This is where I would go for stress-reduction and perspective-seeking when I worked as a rehab nurse at the hospital (1980s), and then much later when my father was in home hospice nearby.

Paul Farmer, physician, anthropologist, global health activist, and founder of the Harvard-based Partners in Health, says that he has two main markers of quality of health care in a hospital that he visits anywhere in the world. His are not the usual quality of health care indicators those of us who work in health care and health services research think of. For hospitals, these include such things as: 1) timely and effective health care for conditions such as heart attack, 2) lower complications (and deaths) from surgeries, 3) lower hospital-acquired infections, and 4) patient report of good communication with doctors and nurses (see the very useful and consumer-friendly online tool based on national Medicare data, Hospital Compare). No, for Dr. Paul Farmer a hospital’s restrooms and gardens are what reveal its overall quality of care.

The fascinating topic of restrooms I will leave for another time, but hospital gardens are something I want to focus on here.

Modern hospitals trace their roots to the cloistered buildings of religious monastic orders that took in those too poor or disabled to be taken care of in their own homes by family members. These early hospitals were often built around a courtyard with a medicinal/herb garden, fruit trees, and a kitchen garden.

Garden of the Hospital in Arles 1, by Vincent Van Gogh. Public Domain license Wikimedia Commons.

The hospital healing garden shown here was an inner courtyard garden of the psychiatric hospital in southern France where Vincent Van Gogh was a patient. The view is from his hospital room. He also painted his famous series of blue irises from the hospital’s gardens. In letters he wrote to his family, he relayed how these gardens were an important part of his tenuous hold on mental and physical health.

Florence Nightingale knew the importance of nature in hospital reform and redesign. She emphasized the role of fresh air, sunlight, flowers, and of patients being able to see out of the window instead of looking at a wall. “She wrote, ‘I shall never forget the rapture of fever patients over a bunch of bright-coloured flowers’ she noted, adding ‘people say the effect is only on the mind. It is no such thing. The effect is on the body too'”(quote from the Wellcome Trust blog post ‘Why every hospital should have a garden,‘ 11-8-13). I wonder what Nightingale would say about our ‘modern’ hospitals banning the delivery of fresh flowers or plants to patients for fear of allergies or mold or whatever it is they fear.

Yesterday I went in search of the healing garden at the University of Washington Medical Center (UWMC) where I work (and where I have been a patient–for a bit more on that see my Medical Maze photo description in Pulse: Voices From the Heart of Medicine 1-23-15 ). I remembered it as an almost shockingly calming and contemplative space near the coffee shop adjacent to the main surgery wing. The UWMC healing garden was a rooftop garden designed by local UW landscape architect Daniel Winterbottom who specializes in healing/restorative gardens. I sought the healing garden in vain, as it was torn down several years ago to make room for yet another wing to this already massive hospital and medical center (at over 6 million square feet of mostly concrete, the UWMC/Health Sciences complex is the world’s largest single university building). The very helpful UWMC information desk staff directed me to this spot (see photo below) as the ‘backup’ healing garden. It appears to be a series of mud puddles with a no smoking sign and smokers happily puffing away. Clearly, there’s much work to be done.

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UWMC mud puddle ‘healing garden.’ Photo credit: Josephine Ensign/2015

Resources:

The Therapeutic Landscape Network has a searchable index ‘Gardens in Healthcare and Related Facilities.’

An excellent (and expensive! see if your local library has/can get a copy) book on the topic is Therapeutic Landscapes: An Evidence-based Approach to Designing Healing Gardens and Restorative Outdoor Spaces, by Clare Cooper Marcus and Naomi Sachs (Wiley: 2013). It includes an extensive collection of case studies of different types of healing and therapeutic gardens associated with hospitals, rehabilitative facilities, nursing homes, and hospices.

The Travelator of Racism

indexA few blog posts ago I wrote about the use of metaphor in health policy, focusing on the Cliff of Health analogy developed by Dr. Camara Jones. (See “Falling off the Funding Cliff of Good Health”). Dr. Jones is a family physician and epidemiologist who until recently was Research Director on Social Determinants of Health and Equity at the CDC in Atlanta. She resigned from that position in December to become President Elect of the American Public Health Association. She also IMG_3541teaches at the Morehouse School of Medicine. This photograph, which I took on Friday this week, shows Dr. Jones on the right with my colleague and epidemiologist Dr. Wendy Barrington.

Dr. Camara Jones was in Seattle to consult with the University of Washington School of Medicine on diversity issues. She gave a riveting (and standing room only) Grand Rounds talk “Achieving Health Equity: Naming, Measuring, and Addressing Racism and Other Systems of Structured Inequity.” And on Friday she talked with School of Nursing students, faculty, and staff about these same issues. In person she is warm, engaging, funny, and a gifted storyteller. As she says, she uses stories–allegories (which are really extended metaphors with a ‘lesson’)–to distill and clarify complex public health concepts and ‘difficult to discuss’ topics like racism. I highly recommend watching her recent (July 10, 2014) TEDxEmory videotaped talk “Allegories on Race and Racism,” in which she tells four stories: 1) Japanese Lanterns: Colored Perceptions, 2) Dual Reality: A Restaurant Sign, 3) Levels of Racism: A Gardner’s Tale, and 4) Life on a Conveyor Belt: Moving to Action. Conveyor belt, or moving walkway, is also called ‘travelator’ by those clever Brits.

The conveyor belt allegory is one of her most recent, and as far as I can tell she has not yet included it in any of her published articles. Dr. Jones said she has extended the ‘conveyor belt of racism’ analogy from the work of Beverly Daniel Tatum, author of Why are all the Black Kids Sitting Together in the Cafeteria? And Other Conversations About Race, Beverly Tatum (1997). Tatum writes about what it means to be antiracist:

“I sometimes visualize the ongoing cycle of racism as a moving walkway at the airport. Active racist behavior is equivalent to walking fast on the conveyor belt. The person engaged in active racist behavior has identified with the ideology of White supremacy and is moving with it. Passive racist behavior is equivalent to standing still on the walkway. No overt effort is being made, but the conveyor belt moves the bystanders along to the same destination as those who are actively walking. Some of the bystanders may feel the motion of the conveyor belt, see the active racists ahead of them, and choose to turn around, unwilling to go to the same destination as the White supremacists. But unless they are walking actively in the opposite direction at a speed faster than the conveyor belt- unless they are actively antiracist- they will find themselves carried along with the others” (pp 11-12).

It is highly telling that many of the online quotes of this passage from Tatum’s book conveniently delete both sentences that include ‘White supremacist,’ as if  it is ‘that which cannot be spoken.’ Camara Jones extends the conveyor belt/travelator of racism allegory by pointing out there are three stages of anti-racist action: 1) name it–look for and point out the racism inherent in the conveyor belt; 2) ask ‘how is racism operating here?’–not only walk backwards on the conveyor belt, but seek out the mechanisms and the history behind the building of the conveyor belt; and 3) organize and strategize to act with others who are trying to dismantle the mechanism behind the conveyor belt–to stop it. In her Grand Rounds speech, Dr. Jones pointed out that we have to talk about and understand history, we have to ask ‘how did this problem get to be this way?’ “Often knowing and uncovering the history behind how we got this problem can give us ideas of how to address it.”

I continually struggle to find ways to include meaningful course content and discussions about racism and health in the community health nursing and health politics and policy courses I teach, as well as in my narrative medicine/health humanities courses. Using the allegories on racism developed by Dr. Camara Jones has been among the most effective teaching tools.

If you haven’t done this already, try taking the Implicit Association test on race, available online through Harvard University. Make sure you are well-rested and feeling both left-right hand coordinated and willing to have your world rocked before taking this test!

 

Complicating Forgiveness

IMG_2754Forgiveness sounds so warm and fuzzy and facile. And religious: Forgive us our debts (or trespasses) as we forgive our debtors (or trespassers)…. Like a joyous sunflower turning its laughing seedy face toward the warmth and the light.

But wait. That sunflower looks decidedly sinister. Could there be a dark, prickly underbelly to forgiveness? Is forgiveness always a good thing?

These are questions I’ve been asking myself as well as ‘asking’ various experts through an extensive search of the academic literature related to forgiveness (mainly within the fields of philosophy, psychology, and counseling). These questions have led to more questions: Can you forgive someone or something like an institution–a hospital system for instance–for wrongdoing in the absence of an admission of guilt and a sincere apology? What constitutes a sincere apology? What constitutes sincere forgiveness versus a too-quick-to-give (or forced into) ‘cheap grace’ forgiveness? Do you have to forget to forgive? What is self-forgiveness and why is it important? What are the power dynamics, including gender dynamics, embedded in forgiveness? Who has the ‘right’ to forgive? Are there some instances of wrongdoing (like the atrocities of the Holocaust and of various genocides around the world, or like severe child abuse) that are of such great magnitude that they are unforgivable? Can there be reconciliation without forgiveness?

Forgiveness and its close relations of shame, guilt, righteous indignation, anger, revenge, restitution, reconciliation, and restorative justice are highly relevant to health care, to public/community health, and to all health care providers. There are the all too frequent medical errors leading to patient injuries and deaths. There are the ‘second victim’ casualties to health care providers involved in medical errors. There are the just and unjust cultures of hospitals, medical systems, and health regulatory boards. There are the U.S. Public Health Services’ infamous Tuskegee Syphilis Study and its lingering effects. There are worsening environmental justice issues, racism, gender-based violence, police brutality, and global health inequities.

Within health care provider education in the U.S. we now include course content and interprofessional mock trainings on ‘error disclosure.’ We try to identify and intervene with incompetent or ‘bad apple’ students. We have student counseling services for students struggling with emotional issues. We have (or rather we should have) faculty development trainings on how to provide clear, constructive student performance feedback in a supportive, non-shaming way. But we don’t really have a place for open discussion of forgiveness, shame, vulnerability, and uncertainty. We’re all about measuring and having students attain ‘competencies.’

The closest I ever come to teaching about forgiveness, vulnerability, and shame is when I touch on the concept and practice of cultural humility in my community health course (the best description of cultural humility is the short video Cultural Humility: People, Principles and Practice by Vivian Chavez). As social worker, therapist, and researcher Brene Brown points out, we can’t have constructive conversations about race, class, power, and privilege without addressing shame. If you haven’t already seen it, I encourage you to watch her 20 minute TED talk “Listening to Shame.” It reminds me of how much I love the profession of social work.

Out of the thirty or so scholarly books and articles I have read on the topic of forgiveness, here are the ones I found most helpful, provocative, and powerful:

  • The Sunflower: On the Possibilities and Limits of Forgiveness, by Simon Wiesenthal (Shocken Books, 1976, 1997). The first part of this book is Wiesenthal telling the story of his experience as a Jewish prisoner in a Nazi concentration work camp in Poland. He was picked at random by a Nazi nurse to visit a young, dying SS officer who wanted to ‘confess his sins’ to a Jewish person and ask for forgiveness. Wiesenthal sat for hours by the patient’s beside listening to him–at one point he brushed a fly away from the patient’s bandaged head–but he stayed silent and did not forgive him. The episode bothers him and he asks people what they would have done in the same or similar situation. The remainder of the book is comprised of responses from various theologians (Jewish, Christian, Buddhist, and Muslim) and philosophers. This is a book that will haunt you long after you’ve finished reading it.
  • Before Forgiving: Cautionary Views on Forgiveness in Psychotherapy, edited by Sharon Lamb and Jeffrie G. Murphy (Oxford University Press, 2002)–and especially Sharon Lamb’s chapter “The Good, the Bad, and the Ugly: Psychoanalytic and Cultural Perspectives on Forgiveness.” She writes about power dynamics and gender politics vis-a-vis forgiveness. “Gender conformity then is ‘met’ when a woman forgives her wrongdoer and lets go of resentment, even at the cost of self-respect.” (or safety as she add in the case of abuse and intimate-partner violence).
  • “Shame, guilt, and the medical learner: ignored connections and why we should care,” by William Bynum and Jeffrey Goodies, Medical Education, 2014, 48:1045-1054.)
  • For an amazingly rich sci-fi take on the topic of forgiveness, there is Ursula Le Guin’s book Four Ways to Forgiveness, the first part of which is titled “Betrayals.”
  • In the realm of fiction, Naseem Rakha’s novel The Crying Tree (Broadway, 2009) is carefully researched and beautifully written. It’s a fictionalized account of the complicated grief process of the mother of a murdered teenage son who forgives and befriends her son’s murderer while he awaits his execution on death row. This novel is based on Rakha’s work as a journalist covering the death penalty in Oregon.

Of God and Toilets

Public_VIP_latrine_(photo_taken_in_2011)_(5529288428)As I finish grading student papers for an undergraduate  community health course, I am reminded of the two most influential courses in all of my undergraduate and graduate education: 1) Comparative World Religions taught by Clyde Holbrook, Oberlin College in 1980; and, 2) Water and Sanitation taught by Clive Shiff at Johns Hopkins School of Public Health in 1992 (in which we applied a problem-based learning/case study approach to a Zimbabwe village water and sanitation project in a team-based approach with health care providers from mostly resource-poor countries). These two courses on seemingly disparate topics were the most personally transformative for me in terms of expanding my worldview and enhancing my critical thinking skills. Those, in turn, are two of the most important educational outcomes or standards that I aim to teach to in my work educating future nurses and other health care professionals.

As a society, as a world, what do we most want and need in health care providers? Yes, of course, we want and need intelligent, highly competent providers who are up-to-date on all of the latest scientific, evidence-based practice guidelines. But robots can do that. What we really want and need are flesh-and-blood, compassionate, grounded, and questioning humans who understand at a visceral level what it means to face existential questions of life and death; what it means to face complex personal and community-level ethical issues; and what it means to wrestle with the visceral, practical questions such as how to best to take care of basic bodily functions (like pooping and peeing) and how a community can obtain safe, clean drinking water (and the complex political, cultural, social, and historical issues related to that access).

In order to have more health care providers capable of such things, in order to ‘humanize health care,’ we need to have better support of the humanities within basic primary education, undergraduate education, graduate education, and continuing education…. Ah yes, and we need to have more health care (especially nursing) educators who have meaningful exposure to, education in, and orientation towards the humanities. By humanities I mean “the study of how people process and document the human experience” (source: Stanford Humanities), which typically includes the academic disciplines of: philosophy, literature, religion, art, music, history, and language/linguistics. Humanities and a ‘liberal arts’ education are foundational to our country and to democracy; they are also currently being undermined by a focus on ‘practical’ jobs-based education in STEM (non-humanities) subjects: Science, Technology, Engineering, and Math. As an important counterpoint to that trend, I encourage you to view the brief (7 minute) video “The Heart of the Matter” by the American Academy of Arts and Sciences (to accompany their 2013 report of the same name).

Remember to ask the important questions: who are we? where did we come from? why are we here? where are we possibly going? and where is a safe place to poop?

Narrative Medicine Collection

product_thumbnail.phpHere are a few of my current favorite narrative medicine/medical humanities things:

  • Heart Murmurs: What Patients Teach Their Doctors (UC Medical Humanities Press, 2014). This new collection of personal narratives by physicians, edited by my colleague Sharon Dobie, MD, a family medicine doctor who teaches and practices relationship centered care. In these essays Dr. Dobie and thirty-five other physicians explore lessons they’ve learned from patients.
  • Those whacky and wonderful Brits have a much better health care system than we do, and they have this wonderful new (creative) collection (is it a book? is it a collage?) on medical humanities. Published by the Wellcome Collection, Where Does It Hurt? The New World of the Medical Humanities is both entertaining and thought-provoking. (While you’re at it, spend some time browsing their website for fun quizzes, interactive educational games, videos, and more). Here’s what they say abut the book:
    “What does it mean to be well? Or ill? And who, apart from you, really knows which is which? Contemporary definitions of medicine and clinical practice occupy just one small corner of a vast field of beliefs, superstitions, cultures and practices across which human beings have always roamed in the search to keep themselves, and others, feeling well.The label ‘medical humanities’ is the best effort we’ve made so far to define the fence that encloses that very large field; recognising that it’s a space in which artists, poets, historians, film-makers, comedians and cartoonists – in fact every one of us – has as much right to explore as any humanities-schooled or clinically trained professional. This book is a walk through that field, a celebration of its rich diversity, a dip into some of the conversations that are going on within it, an attempt to get it in perspective – and an invitation to you to join the conversation yourself.”
  • The always friendly folks in the middle of cornfields in Iowa (University of Iowa) put on a terrific annual narrative medicine conference: The Examined Life Conference. They just announced that a keynote speaker for their upcoming conference (April 16-18, 2015) is poet Jimmy Santiago Baca. His memoir A Place To Stand (Grove Press, 2002) was made into a documentary released last month.