Daily Blogs

Image at the Last Day of Class

When Beverley asked us at our last class, what image comes to mind when you think of this class--many impressions came to light. The rolling hills behind Webb ranch. Our first silent walk up to the corral on the hill. The four of us attached in a silly way as limbs and brains. But what came to mind most was something not visible. Or rather, not physically visible, and that is the community and bond our class formed during the five short weeks we were together. Perhaps one of the most valuable lessons of Horses and Medicine is the bond that can form between different human beings when they are genuine, honest and open to learning and getting to know others. It has been an honor to spend time in such an unusual and unique setting with fellow medical students and community members. Thank you for all that I have learned about horses, horsemanship and patients!

Anna

Therapy and Horses

This week we went and watched some therapy involving horses. There were some inspiring stories of how this type of therapy had really helped people. I think there is a real opportunity for physicians to know more about physical therapy and different options for severly disabled children. I'm not sure what will be covered in the official cirriculum but I'm glad to be aware of an option that might help some of my patients in the future.

Left limb, Left brain-Right brain, Right limb

Today we worked as a team--by taking about the body. Luckily, not our own body, nor that of our patient or horse. But rather we virtually "created" a body, by four of us coming together. Each person played one role: left limb, left brain, right brain or right limb. I was lucky enough to start as the left brain. As an undergraduate neuroscience major, I had a hard time unlateralizing (if that's a word) brain function and activity. I kept thinking that the left brain was going to move the right limb and vice-versa. However, physical proximity to our respective limb helped (as left brain I was immediately adjacent to the limb I was to move, the left).

The first decision I helped to make with my fellow brain was to have the four part of the body disconnect. After all, it was getting a bit awkward to have the four of us stand with arms linked, especially when anticipating that we would have to move like that to harness and saddle a horse. Indeed--keeping in mind a rule of the game that we had to "stay connected"--we argued that we would be "mentally connected." Seemed good to my right brain, but soon after unlinking arms, a violation was immediately called. Somewhat dazzled, especially as this was the first round of the game, we were surprised and somewhat embarrassed that we had misunderstood the rules of the game, and that "mentally connected" was a weak substitute for "physically connected" (tell any psychologist/psychiatrist that!).

It was not until the wrap up at the end of our day, that the right brain and I realized that in fact the violation that had been called earlier was because the right brain had pointed (NOT because we had dropped arms and stayed "mentally connected"). I think there is value to be found in this game on many levels--but the one that this example more clearly demonstrates is the need for effective communication at all parts of a process. At the beginning the group thought that they had understood the rules of the game, but when the violation was called we realized we weren't exactly sure. Could we drop our arms and mentally stay connected? What was the actual violation? These were doubts that remained all the way until the end of the day of class. In a medical environment effective communication is at the heart of the best care possible. Through this exercise, we were working to try to understand what that means and how we can better achieve that.

Thanks to all the limbs and brains I worked with Wednesday!
Anna

Confidence in your actions

It was an honest challenge to try and convince a horse to cross the spaceblanket today. Thinking through how to convince anyone to do something that they are truely scared of was an interesting aspect of the exercise. Techniquesthat we generally use for getting someone to do something include bribing them or trying to coerce them. It takes a specific kind of patience and dedication to get someone to agree to do something that they are initially uncomfortable with. I also realized that when I'm stressed, I am less clear with my leadership. Though I would generally say I can give clear direction, I found in several exercises today, I backed off when I was unclear about what I was supposed to do or not sure that I was doing it correctly. This made the horses (and me!) nervous. It is good to know that your manner and confidence can be so clearly mirrored in your patient. I'm hoping that these next two weeks will give me some more good insights into pitfalls for doctors in training.

The Language of Horses

Thumping of horses, twitching of ears, the tha-bump of a horse heartbeat--these are all impressions of the first day of the wonderful Horses and Medicine Class. Somehow, within minutes, we transformed from Stanford Medical Students learning embryology from slides and handouts to Rancheros surrounded by 350 horses and corrals. We had to take a leap of faith, not just in crossing a mile long dirt road, but in accepting the underlying assumption of the class: That the horses were our patients.

It may appear odd that a few hundred pound, four-legged, hairy and somewhat smelly creature would be associated with the vulnerable patient who walks in to the doctor's office, but there is much to be said for the association. What was most striking to me was the window I saw into the world of the horses and, in particular, to their language. Our first assignment was to observe the horses as they came galloping down from the hill to the corral. Through their "language" they paired up and slowly reestablished their hierarchy--recreating their community in a new location. They used a wide toolbox of nonverbal signals including ear placement, nudging and distance to guide, for instance, Dream to a specific place. Just through orientation of the ears, they could describe to their fellow horses whether they were fearful, calm and inquisitive, or angry and aggressive.

To me, this communication was curious and opened up a pandora's box of questions regarding horse communication. I also realized that to be their true health advocate--as I would be as their physician--I would need to understand this language and, ideally, learn to speak it. While I was not about to start twitching my ears in hopes that Dream would realize that I was "calm and inquisitive" (but not fearful, or worse yet, angry), I did begin to learn how Dream communicated with her fellow horses.

With this, I look forward to my continued excursions to the satellite campus at Webb Ranch.

Anna

Medicine & Horses Rides Again!--Fall 2007

The Webb lesson horses are on notice that herds of med students are about to stampede onto the ranch again.

Well, in truth, the lesson horses are looking forward to it--especially since we try to employ ones that aren't leased or even ridden. There are some cuuuuuute new horses to work with, as well as our good old horse network of Dream, Madison, and Dollar.

I am personally thrilled to be teaching again. Yippee ki O ki AY! This will be our best course yet--a full complement of students, a new EAGALA-trained assistant who is also an endurance and ride&tie athlete, and a nurse from Webb. And Lucia, our horse vet who teaches the most popular part of the course, seems poised to come to all the classes! Someday she can tell the r-r-r-rest of the story of how she wr-wr-wr-wrested this time away from the lab, but that's her tale to tell. Or you can wait for the movie version.

Over the summer I had several inquiries from equine assisted psychotherapy and equine experiential learning practitioners who want to start M&H programs in their areas--British Columbia, Texas, George Washington U. The "Manual of Medicine & Horsemanship" is almost done--at least to the throw-it-over-the-wall-to-the-copyeditor stage, and I the woman from BC is buying an advance copy. So the M&H Appleseed program is getting planted, starting to germinate.

The students will be required to blog again once IT gets the accounts set up, so watch this space for weekly stories.

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

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!