May 2007

Last class

First off I want to thank the fellow students and Beverley for the opportunity to be included in such a class! Even though I'm not a med student, I do plan to go into psychology and hopefully something to combine working with kids and horses...this course definitely applied to me too!

The last class was really fun for me because I got to see the other students - most of which hadn't really ever ridden before - experience (in my opinion) the BEST part of working with horses. There really isn't anything quite like being able to relax and move with another living being.

The tarp exercise was also really interesting. I believe it was Pearl that most of us worked with, and while generally compliant, she did not enjoy crossing the tarp, even though she did it once in the beginning without too much fuss. After that she just didn't want to cross it. So when it came to be my turn to lead her over the tarp, I didn't expect her to go over the first time, and I was prepared to try to push her from behind. However, I did go into it with the mindset of "we're going to do this no matter what" - much like the mindset I have when show jumping or going cross country. I think that mindset, whatever approach you feel in your mind, really communicates to the horses. Pearl ended up following me over the tarp no problem! That is, after I gave her some yanks and kept walking straight ahead, not looking behind, when she heisitated. This exercise proved to me again that sometimes I really can be the dominant leader. Of course, I think I act differently with horses then I do with people, in large part to my years of riding. It was a really cool experience to observe everyones different "leading" styles.

I think what I gained most from this class was seeing how simply working with a horse can bring out so many aspects of someones personality, their characteristics, and their approach to life. It really makes me interested in Equine Assisted Psychotherapy. On a personal level, it was cool to see how I approach certain situations, people (in this case horses), and what I use in decision making.

It was a pleasure having class with you all and I hope everyone learned as much as I did!

~ Kaitlin

Closing Comments

Looking back, it's amazing how much was accomplished in such a short amount of time.

This class was eye-opening in many ways and I really appreciated how much I learned about myself.

4 weeks gone by

Wow- those 4 weeks did go by quickly! There were some eye openers for me-

What got me thinking a lot was the notion that (at least for horses) “dominance” isn’t necessarily a bad thing. In a herd, I learned, a dominant horse will “take care” of a weaker one. I caught myself thinking that maybe that’s a thing humans have forgotten somewhere along the way.

Basically the idea that a good “leader” takes care of his/her “followers” still exists- for example in the military, in families, and of course, in “traditional” doctor-patient relationships. But in many places, that concept has gone completely out of the window- I’m thinking academic work environment, for example (see references to “pimping” in previous blogs). So while I agree that every physician needs to find the place where they personally are comfortable on the scale of directive vs. non-directive, I found it very reassuring that there is a concept that it’s ok to lead others, as long as you keep your end of the bargain- loyalty works both ways.

I think this may be especially interesting for women. Culturally, women leaders are often perceived in a negative way (as being “bossy”, rather than “assertive”). Since women generally also like to avoid things that antagonize those around them, that often leads to women not leading, even though they may be suited for it. So it’s just a nice thought that this concept exists for us, and it will benefit everyone, leaders and followers. I LOVE win-win situations...

On the last day, when we were trying to lead the horses over the “scary” blanket, I had to think about one of my patients again. He had been with us for a long time and gone through a long and excruciating treatment plan to successfully reject his cancer. At the end, he was completely sick of anything related to healthcare. At his request, we would enter his room only after taking off our white coats. When he finally got to go home, he didn’t go in for his scheduled follow-up, a “simple” blood-draw. As a result, a complication wasn’t discovered in time, and he died of it. After all the pain, and after having beaten his cancer, he still died of something that could have easily been corrected-

While ultimately, one has to respect every person’s informed decisions, even if it kills them, I was wondering whether he might still be alive if someone had taken the pain to accommodate his “irrationality”, and sent out a mobile nurse to him?
Which drives home another point of this class: always pay attention to your patients, and to what they don’t tell you. It may not kill you if you don’t, as a horse might. But it might kill them.

Overall, I am still astonished at how much I learned. My initial motivation for the class was just to hang around horses. It was amazing to see how well an animal can model a relationship between humans. We constantly project and transfer on a horse- my emotional reaction to a “noncompliant” horse may actually be not that much different from my emotional reaction to a noncompliant patient. It’s one thing to be taught about the dangers of projection in a lecture and another thing to be “caught in the act”! Guess which one you remember 

Lastly, I’d like to give a big hand to my fellow students, and to Bev! You’ve made this class fun, and a real growth experience. Thanks!

Wrap Up...Third and Fourth Classes & NCEFT

The four weeks went by too quickly! What have I learned about myself...

Last week we had a small class, but this did not detract from the great learning experience. We started out with Lucia who explained and demonstrated a physical exam of a horse. We thought this horse would be tempted to resist the exam but she was very cooperative. The most troublesome thing for the horse was all of the flies! Lucia explained that examining horses is different from examining humans because horses will let you know if they are uncomfortable with the exam and this signal may be life-threatening! The main teaching points that I got from Lucia were (1) Take your time to make sure the patient is comfortable with what you are doing and if he/she is not, then step back and go to where it is comfortable for them, and (2) Make sure that you, as a physician, are appropriately prepared for the exam/procedure and that you feel comfortable with what you are doing. For me, this second teaching point was important because there are many times when I don't properly prepare (ie: for a biopsy) and I believe this leads to inconsistencies. It also made me remember that I have to look at my patient for non-verbal cues as insight to how they are feeling/reacting to what I am doing. It was also a lesson in how to get something done when you have a resistant patient... We ended this class doing an exercise being one unit of 3 people playing roles of "the brain" or "an appendage." This was a communication and team-work exercise in putting on a bareback saddle onto a horse. My biggest take home message was that I am not comfortable taking the leadership role if I do not know what I am doing. We need to remember to ask for help in these situations.
The fourth and last class was a perfect way to end. We did an exercise called "informed consent." The exercise was to lead a horse over a shiny reflective surface that is otherwise scary for the horse. As humans we know that the surface was harmless but the horse does not know this, especially if this is new to them. Medical things and procedures that are apparent and second nature to us are not necessarily the same for our patients. This reminds me of a patient that I had who refused to take any oral medication for a serious illness. As physicians, these medications seem benign and it doesn't make sense to us that a person would refuse these "harmless" medications. We finally asked "Why?" and the answer was apparent. In the country where she was from, these medications were considered dangerous with a lot of side effects. The therapeutic riding session was heavenly. I enjoy taking time out for myself to relax - I just don't do it often enough. I enjoy being with the horses and I finally feel more comfortable with them. I would like to find a way to spend more time with these creatures who have so much to teach us, both about ourselves and about relationships and interactions with others.
And NCEFT, was an uplifting experience. I brought a co-worker who was just amazed at the possibilites for those with neuromuscular difficulties. I commend those who do these treatments and I find it amazing that we have hippotherapy and therapeutic riding as options for our patients and loved ones.
Thank you to all of my classmates and especially to Beverly for this wonderful opportunity.

Class #4 - Informed Consent -Therapeutic Riding - B Kane, MD

I am suffering from empty nest syndrome now that the Medicine and Horses class of 2007 has graduated.

Blinked and I missed it. This course seemed way too short. I will not again try to squish 24 hours of Medicine and Horses into 8.

That said, let me look back on what I learned in these 4 short classes. We teach that which we most need to learn and we attract those who need to learn from/teach us. We had a great group, and for the first time, mixed med students with a resident, a fellow, and a practicing physician. I really like how that worked out. I could look at each one and see myself in a different phase of my own development.

Now I am learning to stay out of the way more and let the experiential learning process be one of the person's own discovery. It's so tempting to think you know what's up with someone--including, or especially, your patients. It's so easy to get into a thinly-veiled directive of "fixing" people or trying to get them to see what you see in them. Fergeddabout it!

My gem from yesterday, and from the Oklahoma experience, was: all that pimping on rounds, all that Socratic methodology--it's all aimed at making the person wrong. One person pointed out that some attendings will pimp until they get the resident to come up with a wrong answer. Our way of using the Socratic method in M&H is to ask questions from a genuine place of curiosity about the person.

As usual, the horses brought out different things in different people. Amazing how differently they react! In our first exercise, "Informed Consent," students tried to get the horses to cross a crinkly, shiny, flapping space blanket--very scary for a horse! It's probably the horsey equivalent, in fear, of open heart surgery or a kidney transplant. Some students wanted to pet the horse into compliance, some took a more directive, get-over-it approach. There ensued an interesting discussion of where everyone was on the assertiveness scale. Not that one place on the scale is better than another--some patients will respond better to kindness than coercion. Some patients want the doctor to take charge. It's up to each physician to know w/here she is comfortable on that scale.

And don't tell risk management, but we -did- get the students up on horseback in a therapeutic riding model with sidewalkers. Extremely safe and instructive! That's the technique we use with TR patients--people with MS, autism spectrum, status post CVA, CFIDs.

I'm looking forward to Fall. We already have a couple of people waiting to take the class!

O-O-O-OKlahoma! See One, Do One, Teach One - B Kane, MD

Oklahoma, where the wind comes sweepin' down the plain
And the wavin' wheat can sure smell sweet
When the wind comes right behind the rain.

...and where Medicine & Horses starts its outward journey

About 6 months ago Dr. Carlos Garcia, University of Oklahoma Derm Surgery, called me at 7 AM on a Saturday. It seems an 80 year-old patient of his, who boards her horses with his, told him about Medicine & Horses, saying he -had- to do the program. (The rrrrrrrest of the story, infra vide.)

Lo and behold, Dr. Garcia followed through on this plan at every step and this weekend I had the pleasure of going out to OU to teach M&H. The idea is that they will establish an ongoing course there, a good start for my "M&H Appleseed" vision of having M&H programs at 100s of med centers.

On the plane out there, I was reminded of Forrest Gump's homily, "Life is lahk a box o' chocklits. You never know waht yer gonna find." We had made fairly detailed preparations--I sent the syllabus and advised on details of water, snacks, etc. But I allowed for the possibility that the venue would be highly unsuitable, that we wouldn't have enough appropriate horses, that the students wouldn't get the point (that they were just coming to please Dr. Garcia, in whose hands their residency match rests to some extent, so I imagined.) I also fretted and fretted about whether and how to include Dr. Garcia in the proceedings--whether as a particpant or as a leader. The latter was going to be hard to do, with his never having even seen the exercises before. But I only had the one day for him to see one, do one, teach one.

Long story short--will post more later, we had a fantastic day! Eight med students, a derm resident, a derm attending, 2 TV stations, 2 local newspapers, and the University press.

Exhilarating and exhausting. More later, as I have to go to Webb to teach our last M&H class of the quarter.

Finally, a chance to participate! - by L Mokres, DVM

I finally got to join up the Medicine and Horses students today. Due to a rigorous lab schedule, I am only able to attend one of the four sessions this spring, which is frustrating as I put so much work into the course behind the scenes. The most rewarding part of this course is seeing students grasp a new concept or discover something about themselves that they did not know before, and I miss that when I can not attend.

Ah, well, I at least made it out today, albeit a bit late. I teach a portion of the course based on doing a physical exam, though the exam is a metaphor for any situation that involves patient contact and/or patient communication—it could be a physical exam, a procedure such as a spinal tap or skin biopsy, breaking the news to someone that they have cancer or a loved one is in intensive care--you name it. What I try to lay bare is the fact that physicians can get away with some pretty bad bedside manner. Whether their patient is comfortable or not, in a physical or emotional sense, should be a top concern. However, the fundamental pathology that underlies poor bedside manner is that they simply don’t care—they just want to get in, get out, and get on with it, and the patient’s impression of them is disregarded. Veterinarians DO NOT HAVE that luxury, in particular large animal veterinarians. If we disregard the signals that a horse is sending when she is not comfortable with how she is being approached, handled, etc, we could very easily get ourselves critically injured and even killed. We have absolutely *no* leeway in equine practice for ignoring the feedback that our patients provide us, in particular because it is nonverbal. Horses are big and fast and they will let us know when they are unhappy.

As such, horses provide a wonderful tool to provide feedback to the students, as they learn to pay attention to the signals that a patient sends while being worked with. Some patients, out of fear or respect for the physician, will not speak up when they are uncomfortable, and those physicians with good bedside manner will be able to pick up on this discomfort, without having it spelled out or spoon fed to them, and respond accordingly. *That* is good bedside manner, and *that* is what I want to teach in this section. Despite the fact that I actually had an overly cooperative mare, who was not about to kick or bite at anything but flies, it seemed that the students really got the message, and I was so happy to be able to open their eyes to this aspect of medical practice!

--posted for Lucia Mokres, DVM by B Kane

Class #3 - Projection, The Magic Mirror - by B Kane, MD

"You spot, you got it." That's projection.

When I learned about projection, transference, and countertransference in med school, I was in some post-prandial slump of a class. I barely remember it. Now the horses teach it better than I learned--or can teach--it.

This is the hardest class to teach. It the deepest didactic we do in what is otherwise a course that tries to counterbalance the extreme intellecutalizing that the rest of the med school curriculum requires. But if I had understood projection when I was a med student, and especially as an intern and resident, I would have been spared a lot of grief and self-loathing. All that pimping of me on rounds, all those times either feeling myself or feeling someone else was being stupid, or careless, or incompetent! All projections.

Projection is when we put our 'stuff' on other people. This comes out both as irrational hatred and as irrational adoration. The strong, destructive emotions are the key to the projection. Other people mirror our good and bad qualities and we go ballistic. (Introjection is when we internalize other people's projections of us. We get into self-loathing or self-aggrandization. The latter, believe it or not, is harder to live with. That's why Britney Spears went a bit nutso and cut off all her hair. Celebrities have a hard time living up to--introjecting--other people's adulation of them.) Introjection is also when you allow yourself to feel stupid when you get pimped on rounds and you don't know the answer.

We also project onto the horses--"That horse doesn't like me." "That horse is dominant." "That horse is sad (or bored, or old, or...)" I always ask, "What behavior of the horse makes you say that?" Like yesterday, Class #3, Mocha walked forward a few steps. M. interpreted that action as a sign that Mocha didn't like her. M. was projecting onto Mocha feelings of dislike. I projected that Mocha was not moving away from M. but moving into the circle, as I've seen horses do in these workshops. They seem to be attracted to the energy of the herd. The fact was that K., unseen by M. or me, had held her hand out to Mocha and Mocha was merely walking toward K.'s hand to see if there was a treat! So many projections, so little time.

Now the big question is, should I try to teach projection at the University of OKlahoma on Saturday? Or will that seem too Californiated to them?

class 2 & 3 - by Kaitlin Medeiros

So I didn't get a chance to write last week's blog till now, so we'll have two for the price of one : ) . Last week's exercises were really touching close to home for me. When we were picking up hooves and waiting for the horse to release, it hit me that I have never once in the ten years that I've been riding allowed a horse to do that.

I also did not recognize that they do have that kind of reflex that allows them to "give" their hoof to you on their own. At the same time though, I usually tend to hurry when tacking up or picking a horses hooves. If I can't give a horse the time to connect with me, and I'm always hurrying, that must translate as some kind of stress to the horse.

Another amazing thing about last week was the progress with "Lantern". I had the experience of catching him, leading him out of the catch corral, and tying him up before the others started to work with him. He was fidgety, mildly excited, and just didn't seem to be the type of horse that would be willing to stand still and be useful for us. Basically, I kind of wrote him off from the start. I was surprised to see how well Mika (sorry if I didn't get the spelling right!) did with him. Her concept of letting him get away with the movements or antsy-ness that didn't really matter, that wasn't dangerous, just more annoying than anything else, was different. I'm used to telling a horse to "quit it" and giving them a slap on the shoulder if they are incessantly pawing, or tying them tighter if they continue to pull away and be fidgety at the tie rack. I've had these "horse sense" skills engrained in me for so long that it's really hard to turn that part of my brain off! So it was interesting to see how someone could do really well with a horse by being more permissive with them. The one thing that surprised me the most was at the very end, when Lantern followed his team without the use of a halter and lead rope. In my experience, it's very hard to get most horses to follow without some kind of aid, unless you've had a major connection with that horse for some time. The fact that Lantern followed showed that the use of non-verbal communication was really working and that he had in fact made a connection!

Yesterdays class continued to be really exciting for me. I met Lucia, who I've heard much about, and we got to work with Mocha (one of my favorite ponies!). The thing that was hardest for me in the class yesterday was again working against my brain, and telling it to shut up. This isn't to sound know-it-all-ish at all. When we did the exercise with the brain and the appendages, it was so HARD to be an appendage. I couldn't talk, even think, even though my brain was telling me to just do things. I had to follow the instructions of someone else. When I was "the brain" I was definitely more in my comfort zone, and felt confident that we could accomplish the task. I think a lot of it had to do with the fact that in this particular surrounding, I did have a lot of knowledge. If i was in the ER assisting, I would have no clue what to do. At the same time though, I think it brought up some minor trust issues. It's hard to follow someone's direction sometimes, especially if you feel like you're the one with the right idea! It was a really good exercise to show us how we work with others and when we're more comfortable being leaders or followers.

Another cool thing about yesterday was learning about the awareness of a patients comfort level, and the surroundings. Also, I realized that one day when I am (hopefully) a psychotherapist, I need to be aware of what's going on with me when I step into the office. A lot of projections can take place in psychology, and it's not always something that the doctor is doing, or not doing, that is causing the patient discomfort.

So far I have really enjoyed this experience! It's teaching me about horses from a whole new angle. It is a bit like retraining, or untraining the way I relate to horses, and people too.

THE SECOND TIME AROUND....

Although several issues were brought up during last Monday's class, the one that impacted me most was the one that came out of our last exercise "Am I Being Herd?"

As two separate teams we were tasked to lead respective horses around an arena; the last few revolutions without harnesses. Dream, my team's horse, was extremely food driven and distracted by the food pans outskirting the arena. It was difficult getting her started and initially we had to constantly guide and redirect her in the right direction otherwise we'd lose her attention and cooperation. The other team had a very independent-minded horse who required a lot of cajoling and resisted being lead. Naturally, analogies to the patient population were made. Our horse made me think of the overly dependent patient, the patient who wants an extreme form of guidance or the distracted patient, the patient who never keeps regular visits to treat a chronic problem because of lack of time or sidetracking life events. The other team's horse evoked what I personally feel is the most frustrating type of patient, the non-compliant patient. As a clinician, how hard do you push a resistant patient? At what point do we need to let go and still feel at peace with our own efficacy as doctors? For me, because my father was a non-compliant patient until the day he passed away, it was a question framed at a personal level and it asked, when do I GIVE UP? And viscerally it's hard to not frame it as "giving up"-- as a surrender or failure of sorts. But having learned how fighting the tide just exhausts one needlessly, I now consider the doctor-noncompliant patient interaction less as giving UP, and more as giving IN, and respecting our patients and their autonomy. It's a lesson I learned on a personal level and I think will serve me well professionally.

Oh, I saw "28 Days" this Friday after our preceptor mentioned it in class. Equine Therapy! In fact, one of the exercises we did in class on Monday was featured ("Hind Real-ease"). From coaching struggling alcoholics and addicts to future clinicians...is there no end to what these creatures do?