Clinical Relevance

Advise (, Pet,) and (No) Consent

Love makes the world go around but will it help a horse do a very scary thing?

The horse we named Orion or Beau, a large flashy paint, is the horse Sherrie referred to in the previous entry. The youngest of our three "patients," he was completely stopped in his tracks by our laying on the ground a shiny, crinkly space blanket festooned with a hot pink feather boa, several traffic cones, and the always-intimidating white lab coat.

Once Beau expressed his fear, the students made many attempts to get him to walk through the Little Shop of Horrors. Efforts included pulling repeatedly on the lead rope, playing follower-the-leader by walking on the space blanket one's self ("See, nothing to it!"), and the universal (for these exercises) tactic of stroking and petting.

With regard to the latter, almost everyone tries the "I'm your friend, so love me and do what I ask" technique. But what does stroking and petting mean to a horse? As we explained--and observed during round up--when push literally comes to shove, horses don't respond to making nicey-nice. As prey animals, they respond to the strong leader who is going to ensure survival of the herd. Horses push each other around quite aggressively and usually from the rear. The lead horse flicks her ears and says "Move! NOW!" and the submissive horse responds, by moving off, "Yas, MA'AM!"

To a horse being asked to perform a task, petting means "Goo' boy! Do just what you're doing." Petting is a form of positive reinforcement in the technical sense of operative conditioning: positive (adding a stimulus) reinforcement (increasing the behavior).

After half an hour of being petted every time he refused to walk on the space blanket, Beau just figured he was being rewarded for standing in place. In the end, he didn't even seem afraid. He just seemed stubborn and enjoying being petted in exchange for standing still.

What kind of patient does Beau represent? Well, certainly he is typical of patients to whom we physicians give a mixed message: "We think you ought to make changes to improve your health, but it's OK--in fact, we'll reward you--if you don't change." We are unconsciously saying to them, "I'd like you to be healthier, but more than that, I'd like you to like me." We are unintentionally teaching them that there are no consequences to not making healthy choices. These are the patients to whom we keep giving medications to substitute for healthy behaviors--cholesterol lowering drugs for the obese person who refuses to exercise or change his or her diet, pain killers and sleeping pills for those who do not want to face their addictions or get psychological help for their stress. We are, in effect, petting with pills. Do we want to be liked so much that we are unable to provide Tough Love where warranted? (My previous posts on Michael Jackson's doctors also illustrate the professional dilemmas involved.) As we progress from being med students to practicing physicians, we tend to feel more comfortable with our role as leaders. We have enough self confidence and self esteem to not sacrifice our patient's well-being for our need to be liked as a buddy.

At these times we should remember Beau and realize that if crossing the space blanket represents something he needs to do for his own good (and it is to the horse's benefit and our safety to get him over his fears and trusting of human leadership), we are not doing him any favors by being people...er...horse...pleasers.

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.