Sidesaddle Sidebars - Musings

M&H, Boundaries, and Michael Jackson's Homicide

Today Michael Jackson's death was ruled a homicide. I would not be Conrad Murray today for all the buckles at Tevis. I, too, once had a super star as a patient--he shall be nameless for now, although he talks about it in his autobiography. The issues that come up are some of those we address in Medicine and Horsemanship--boundaries, people pleasing, professional integrity.

I have been thinking about this for a long time, certainly since June 25th. It takes amount of personal integrity to Just Say No to rock stars and other celebrities. They are powerful, rich, glamourous, and in the public eye. Who wants Michael Jackson to fire him or her as his $150,000/month private physician and tell Rolling Stone that we won't give him the one thing he needs to be happy? (It's the same in the Sports Medicine world where elite athletes beg, whine, and cajole to be shot up with performance enhancing drugs and pain killers.)
In Medicine and Horsemanship, an equine-assisted learning program, our activities with the horses portray doctor patient communication scenarios. They dramatize and reflect back to us where we stand on the spectrum of wanting to be liked vs. Tough Love in the best interest of our patient's health. Other activities reveal how comfortable we are being permissive vs. assertive. To what extent do we yield to patient pressure and prescribe the Purple Pill whether or not we think it's indicated? To what extent do we seek to avoid conflict and inch down the slippery slope of just one more prescription, just 6 more months to put off quitting smoking. (My Celebrity Patient wanted oral antibiotics for septicemia. I was doing a locum tenens for his primary care physician up in Marin County. I argued and argued that he needed to be admitted for IV antibiotics, but he refused. And in the end, I capitulated and wrote the scrip for Diclox.) To what extent do we as physicians take the more assertive, controlling, authoritarian role in the doctor-patient relationship?
Tonight the Michael Jackson homicide story will hit the public blogs and talk radio. I don't know if I can stand to listen to all the harsh recriminations on one hand and the harsh exonerations on the other. We will certainly be talking about these issues--and enacting them with the horses--in Medicine and Horsemanship this quarter.

Michael Jackson and Bright Shadow Projection

We are in L.A., where the whole city has throbbed with grief and buzz over the death of Michael Jackson on Thursday, 25 June. At the moment of his death,

my husband and I were half a mile from the UCLA Hospital where he lay lifeless on the ER gurney. (Ironically, we were getting our tickets for the blacxploitation spoof, Black Dynamite, our de rigueur token activity for the Netflix junket to the L.A. Film Festival). But it wasn't till we were sitting in the Ford Amphitheater, nestled in the Hollywood Cliffs, that we learned he had died. The moment is now as indelible as the memory of where I was when John Kennedy died in 1963, when the Shuttle exploded, when the Twin Towers were struck in 2001.

Since Thursday, the City's Angels and all its pundits have been laying flowers, holding candlelight vigils, crying, hawking T shirts, and pundificating. The L.A. Times in particular, reduced by online news and social networking to, effectively, a broadside, had its music critics and rock journalists on overtime and over-column-inch. Triple lattes were evident in their prose.

Channel surfing CNN x 2, E!, and FOX is an All Michael, All The Time experience.

So how does this all relate to Medicine and Horsemanship? This way: everything I have heard and read refers to Michael Jackson's art, his loneliness, his torment, his stress. It refers to the shock and sadness of his family, friends, and fans. The print and online journalists, in particular, have spun the death to be about Michael and about their connection with him ("yep, back in '03, when Jackson and I were just hanging out at Neverland...") as part memoir, part self-aggrandizement.

What strikes me, is the Bright Shadow projection evident in the memoirs and in the fan reactions. Bright Shadow is an archetype that lives in each person and gets projected outward. The Medicine and Horsemanship Projection monograph [link] says:

"Projection is the act, usually unconscious, of attributing or blaming one’s feelings, traits, circumstances, and attitudes to or on other individuals, racial or ethnic groups, or animals.

The Bright Shadow is the part of us that we project onto celebrities, heroes, role models, pets, and people toward whom we feel immediate affection. Those who are receptacles for our Bright Shadow projections personify the talents, gifts, and strengths that we are afraid to recognize in ourselves."

After John Lennon was murdered, at least two fans killed themselves. Due to the less grizzly circumstances of MJ's death, I do not expect that Bright Shadow projections will reach the level of extreme despair that leads to suicide.

The Projection monograph goes on to say:

"Internalizing Bright Shadow creates the problems so many depressed and drug-addled celebrities have in trying to live up to their impossibly inflated public images. Bright Shadow identification can also, however, allow us to see the good that others see in us."

In Medicine and Horsemanship, we deliberately elicit projections on the horses. Horses allow us to enact our Bright Shadow projections in a healthy, playful way. In the short space of a Medicine and Horsemanship activity, horses don't introject (see monograph) our projections. It is a safe, well-intentioned archetypal theater for all involved.

Let us take Michael Jackson's death as an opportunity to examine our own Bright Shadow forces and find the courage to express these gifts and talents in a way that is joyous and constructive.

If They Say -
Why, Why, Tell Em That Is Human Nature
--Michael Jackson "Human Nature"

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?

Impact

H&M's impact seems to be quite varied across our illustrious lot. For me, the impact was more subdued. I think this was partly because of my expectations of a skills training rather than an insight building program for lack of a better descriptor. But, I think that it was mostly due to being fortunate enough to have had very similar if not identical exercises in my youth and in different organizations in my past, sans horses of course. In attempting to think about the things we did from the perspective of someone who was never exposed to arm-brain type activities or delineating between perceptions and interpretations, I can see how these things could be very powerful. And, I can certainly appreciate the link between insight, self-awareness, and being in control of one's nonverbal communication. On the flip side, as someone who appreciates the subtle techniques of nonverbal communication with humans, I think that a horse's reliance and sensitivity to nonverbal communication gives a great opportunity to hone one's nonverbal skills. And I hope that future classes further use the horses' sensitivity more as a tool in that regard.

Feeling Inspiration

Sometimes it is hard to know what sticks with you, which memories will persist and which will fade away. So 2 months out is not a bad time to check in and see what's still bouncing around between the gyri. And I must say, the memory that seems to be the strongest was feeling the horse breathe beneath me during out bareback ride. Perhaps because it was unexpected, perhaps because it was something new, perhaps because it was a different kind of connection made. Not quite the same as feeling ribs expand with your hands, definitely not the same as listening through a stethoscope.

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.

Comfort

Though not a specific topic of today's exercise, I found myself reflecting on the cooperative versus authorative role we can have as a physician.

I have tended to be a very cooperative physician, unlike many cardiologists. This feels good to me because I feel respectful of the patient. And frankly, most of my patients love it MOST of the time. But there are times my patients want to be "told" what to do--and sometimes it feels a bit uncomfortable for me. Now comes the horse part...horses that are "bossy" are comforting to the other horses--it means that they will be taken care of. So I have recently been stretching my usual patterns and become more "bossy", especially as it regards lifestyle changes. It seems patients need to be able to say to others, something on the order of "MY doctor wants me to exercise every day", or "I'm on this diet plan because my doctor wants (demands) it this way"--in other words, it seems to be comforting to them to have me a be somewhat demanding or bossy in this regard. When I'm on the trail with one of my horses, they feel comforted when I sit tall and ready to help them through any unfamiliar obstacle. So while I still don't want "bossy" to become part of my dominant personality characteristics, I now see where some variant of this quality can be comforting to patients and effective in eliciting necessary change.

Madison, the PMU Rescue--or Why I Don't Use Premarin - by B Kane, MD

Madison lived much of her life penned up like a veal calf in the service of the pharmaceutical industry.

Madision is a HUGE bay horse--brown body, black mane, tail, and lower legs. We always use her on the first day of Medicine and Horses due to her big, pushy, possessive personality. She is one of the stars of the Emmy nominated NBC-TV Medicine and Horses News Video.

Madison is also a PMU rescue. PMU stands for PREgnant MAre urINe. Sound familiar? Premarin. Premarin is a hormone made from mares who are kept constantly pregnant, constantly confined in tiny quarters, like veal calves. "PMU foals," as they're known, (and eventually the mares) from this ghastly process are often simply disposed of if no one rescues them. Kudos and blessings to Webb Ranch for rescuing Madison!

Premarin is used for hormone replacement therapy (HRT) for, especially, post-menaopausal women. When I was in clinical practice, I virtually refused to prescribe Premarin due to the cruelty to horses.

In 2002, in an almost karmic adjustment, the results of the NIH Women's Health Initiative--15,000 women--showed that HRT actually -increased- heart disease and breast cancer. The study was even stopped due to early results. Premarin fell into disfavor as physicians and patients rethought risk factors and the physiology, psychology, and philosophy of normal aging and menopause.

It would have been a nice karmic readjustment if Wyeth, which makes Premarin and also some widely used and highly beneficial horse medicines, had approved our grant application for funding Medicine and Horses. But they declined. And anyway, Stanford now has a strict policy against pharma phunding.

Still, every time I see Madison, I hope that doctors and menopausal women will shun Premarin in favor of synthetic and "natural" alternatives.