October 2008

Motivational interviewing and the tarp

Today, while reflecting on the moments we will most remember from this incredibly memorable class, I spoke of the poignant connection I saw between the tarp exercise and the technique of motivational interviewing. What I found most interesting about this linkage was the way it was formed: my first experience with motivational interviewing came not with a lecture or a course reading but rather came in watching Joslyn lead a horse over a tarp, an unfamiliar and scary object for such a creature to cross. In fact, I was not even aware of the theory of motivational interviewing that day on the ranch-- I was only aware of the experience I had. So, what exactly is motivational interviewing?

Motivational interviewing, quite broadly construed, is the idea that the role of the physician is not to coerce their patient into making a beneficial change, but to act as an advocate and guide them through a process of self-discovery in which the patient, when ready, makes the decision to change (or engage in a procedure) on their own terms. Why is this important? Because just as when we tried to push the horse to cross the tarp and it pushed back harder, our patients will do do the same and with increased resistance, any hope of establishing commitment to change might be lost. Long story short: a physical push is not that different from a verbal push and pushing patients to change when they are not ready, (whether they speak or not) is counter productive in a setting where we ought to embrace patient autonomy.

Reflections

Today is our last class, and I find myself thinking about the beginning. On the first day, Beverley asked us to simply watch the horses. I did this- there were about 40 or so in the corral, some actively moving about, others more sedentary. We were then asked to "pick a horse that is you." How was I supposed to do this? I watched for some time and my eyes fell upon a relatively calm chestnut that had made its way to the fence to see who these strangers were. I liked this horse. He seemed "curious." But why did I pick this horse and not a different one? I believe that I have other qualities besides curiosity- placidity, playfulness, courage... What was so special about the curious one?

We talked about the idea of projecting, how we frequently look at someone else and selectively see qualities in them that we either see in ourself or have prior experience with (ie stereotyping). We strongly project these qualities on people- often in an exaggerated or unfair way- even if we only have a brief exposure to them. I was doing this to the "curious" horse. Of all the qualities that I felt in myself (I was inclined to look at the good rather than the bad), curiosity was figuring most prominently in my life at the time. The transition to medical school has inspired in me newfound interest in learning and exploration. I felt as though this horse could identify with that.

In the context of a doctor-patient relationship, however, it is important that we be wary of projections that we impose on a patient. In many cases, doctors need to learn to separate out their personal emotions and deal with this situations objectively. When talking about horses in class that day, we were repeatedly told to distinguish between our interpretations (projection) and our observations (objective). This is a lesson that I will not soon forget. Medical practice can be highly demanding and emotionally taxing for both the doctor and patient. When life or death decisions are being made, one needs to know what is objective and what is personal.

Looking forward to the last class

This coming Wednesday will be our last class. While I am looking forward to the components of this last class, the "mysterious" extended appendages exercise and the therapeutic ride, I am a bit sad that this will be our last day on the ranch.
Looking back, I feel that I will take away many lessons from Horses in Medicine. I have learned to take time to observe, to read the subtle cues that horses (and people) exhibit. From the horse leading exercise, I gained a little bit of insight about myself. I learned that I tend to be gentle and "nice," a fault when the occasion calls for a more assertive approach to accomplish a task. From the tarp exercise, I have learned to place take into account the patient's perspective and their fears, to take into account that what may seem normal to me may be extremely scary to a patient. Lastly, from last week's hippotherapy session, I saw first-hand the clinical applications of using animals in therapy and convincing me to be open and curious about these alternative treatments.
I feel that I am taking out a renewed sense of sensitivity that I can apply to my future clinical practice, as well as insights into my own stregths and weaknesses. I hope that I can use this last class and the rest of my medical school education to build on these initial skills to become a better physician.

Hippotherapy

Our fourth class was spent at NCEFT Ranch in Woodside. It was a wonderful opportunity observing patients, their physical therapy horses, a team of medical experts and volunteers working together.

Tears welled in my eyes as a tiny little girl was assisted onto her therapy horse. I found myself comparing her disabilites to my freedom of movement. At first it was hard to watch wondering what life must be like for her with limited vision and use of her extremeties?

A few moments later she, her horse and therapy team stopped nearby in order for her to ring a bell. As the horse slowly passed by I observed a bright smile on her face. Accomplishment!

I believe the lesson for me was realizing my thinking and interpretation had limited my observation? It is my hope to continue applying what our class Medicine and Horsemanship teaches. Observation first, paying attention to the non-verbal communication.

Crossing the Tarp

My standardized patient encounter went well this week. She was a middle-aged woman with a persistent pain in her right ear. Her mother had gone deaf shortly after having similar symptoms, and she feared that her newfound irritation was no coincidence. After a few minutes of interrogation, I still didn't have much clinical sense of what was going on. But I imagined that a licensed MD would. All I knew was that she looked scared, and all I could think about were horses.

Only a few days earlier we were charged with the task of getting a horse to cross a piece of tarp that was laid out over the ground. Simply enough, right? Not quite. To the horses, this innocuous tarp was altogether unfamiliar. It was shiny, reflective, crinkly, and flapped slightly in the wind- nothing like the ground they were used to walking on. My horse was terrified. He stopped a foot before the tarp and refused to budge. I tried to show him that it wasn't dangerous by stepping on it with my own feet, but he wasn't convinced. Out of impatience, I gave him a tug and he stubbornly reared back.

Only after several more tries did the horse cross the tarp. He required guidance, ample time, and lots of encouragement. It isn't so different with patients. The one in front of me, with a hand over her ear to sooth the pain, was afraid and looked to me for direction. And it was easy for me to divorce myself from her perspective. Even though I didn't know the clinical obstacles that lay ahead of her, I wasn't in her situation, and that was enough to make it difficult to understand. A doctor needs to be sensitive to the fact that the patient's perspective may involve strong uncertainty and fear. Because of the horses, I was that much more aware, and I carried on my interview with nothing but the patient's perspective in mind, as best as I could.

Stress

As the end of last week progressed I caught myself paying special attention to Beverley's quote, "Stress is held above the waist." While I am very aware that my back and shoulders are often tight, that choas in my life tends to migranes, and that my right hand looses feeling when I prioritize activities over food.... I've never taken it upon myself to move my stress to a different part of my body. My general attitude is that I must calm down and find a way to expunge it completely. This often takes much longer than I desire and in turn, has an affect on my being until it is accomplished. I spent Friday attempting to "Push my stress down. Make your feet like lead." On Friday we had a session in clinical skills and I was much more focused than I had been in the session two weeks prior. I was able to communicate with the standardized patient effectively, listen well, and organize my thoughts in a linear fashion. My standardized patient responded that I was a calming presence to his hysteria. Reminded me of Shah's active horse. In addition, I left the session feeling I had accomplished something; more positive vibes to balance out the negative ones.

It worked for the day-- by Saturday I forgot about it again. Now if only I can internalize it into my everyday mode of operation. Hope the rest of you are having better luck grounding yourself as it seems like many of us are going through trying times.

Observation

During our second class and waiting my turn to exam our horse patient I found myself observing the observer (other students in their exam approach). As each classmate approached the horse I was struck by their tenderness, compassion, and willingness to gently move across the horse's body while ensuring their patient was comfortable.

Throughout the week I found myself reflecting on those observations and how deeply impressed I was with all of the pre-med students. "Our future generation of bright, intelligent, compassionate people that will graduate as doctors making changes in other's lives."

I feel extremely grateful having the opportunity to be in the presence of such wonderful people in our class. Medicine-Horsemanship is teaching me whether or not someone is a patient, physician or observer, fundamentally our approach through observation can depict a positive outcome in the end.

Kudos to Dr. Kane and the horses for opening the door and our classes willingness to go through it.

External Apprehension

When others outside of the Stanford community ask about the classes you are taking, how do they often respond to your explanation of "Medicine & Horses"?

Last week I asked Beverley if she experienced negative pushback when "pitching" the idea to various parties because I notice a negative pushback in my own life when I express my excitement about this class. Personally, the ingenuity of such a simple concept is staggering. Animals do not communicate in words. They communicate through action. Each species has a different "languange" by which other species could learn through observation. Equally, people communicate through actions, often moreso, even though we have words. So to the primary question I was asked about this class....I made a statement of: "Through their ears, breathing, foot stomping, head position, etc, the horses feelings and intentions are translucent. By honing my skills of observation on their actions or responses to my actions, it enables me to acutely observe the actions my patients-- or anyone for that matter-- and change my own actions accordingly. I mean, with a horse it could lead to danger if I dont pay attention. With a patient, it could lead to danger if they won't allow me to do my job". From one friend I received a rather true and interesting response: "Yet its our ability to change our words despite our true feelings or true intentions that makes human communication different." I paused for a minute and said, "Exactly! That's why it's important that horses don't speak! It's our natural tendancy to listen to what people say and not watch what people are doing." Anyone else had experiences like this?

First Impressions and then some

I decided to take the Medicine and Horses class mostly out of sheer curiosity. I have always been interested in alternate or unique ways of learning different concepts, and I am intrigued by alternative therapies and approaches in and to medicine.

From the first day, I found this course so strikingly distinct from all my other classes. While I can go on and describe in minute detail all the facets and differences between this course and the traditional "medical curriculum," I feel that I will just constrain this entry to the topics of serenity and subtlety.

One of the most remarkable features of this class is the serenity of the setting. We are placed away from the campus, surrounded by rolling hills and fresh air. The setting is quite calming. However, the most important feature is the encouragement to "leave it at the gate," to leave all our issues, our worries, our fears, and all our little preoccupations at the gate and to just focus on the task at hand. When we enter to work with the horses, we just focus on them and on the current moment. I used to do this before competition, but was surprised how applicable this cleansing and refocusing is to real life and to work. It allows more to be taken from the task and it allows better relations with those we work with (both people and horses). I will now focus more on being able to apply this mentality of "being in the moment" for my patients, my schoolwork, and my interpersonal communications.

The second striking feature of the class was the subtleties in communication. I had no idea how much can be said through ear movement in horses. I thought it was interesting to observe the horses interact in the ring and really pay attention to body language. I think that often we tend to overlook the subtlties in communication in favor of "speed" or "efficiency." I know that when I have seen horses in the past, I never notices thier communication. It is only now after really slowing myself down and really paying attention to them that I can "see" their social cues. I suppose this is a lesson for real life: it is important to slow down, take a moment and really listen to whoever is talking/interacting with us. It is important to be aware of subtle cues and react appropriately to them.

So those are my impressions. I hope that more lessons will follow in the coming course sessions

The Physical Exam

This week we were asked to perform a physical exam of sorts on a well-behaved but skeptical horse. I was handed my stethoscope and, draping it around my neck so as not to appear too single-minded, I approached my patient. He allowed me to place my hands along his neck, and I began to stroke gently in an effort to build rapport with my patient. I was intently focused on his ears, looking for a sign that he was relaxed and comfortable with me. But after nearly a minute, his ears remained pinned back- a sign of wariness. I did not know what more I could do, so I slipped on my stethoscope and placed the diaphragm behind the elbow of his left forearm. What struck me most was how uncomfortable I was listening for a heartbeat while knowing that my patient was not at ease. Herein was a valuable if subtle lesson. Establishing a good rapport is remarkably important, as it puts both the patient and doctor at ease. However, one way or another, a doctor needs to get the necessary information from the patient. This may entail a certain level of discomfort on the part of the patient, physician, or both.