Hoofprints - Stanford Medicine and Horses

The Doctor from Hell at EAGALA - by B Kane, MD

What is everyone's nightmare about the worst possible doctor-patient encounter? Sharon and I just got back from...

]]> ...the Equine-Assisted Growth and Learning Association Annual Conference in Ogden, Utah. Most of the attendees were psychotherapist, with a third being equine specialists the conduct equine assisted psychotherapy with a therapist.
In our M&H presentation, we performed a skit called "The Doctor From Hell." Sharon was the patient and I was the DFH. It went like this--see if you can detect the obvious examples of the DFH's cluelessness:

(Patient is in the middle of putting on ridiculous purple plastic johnny. DFH barges into the room without knocking, attention fixed on the patient's chart.)

Without any preliminaries, and without looking up, the DFH says: "It says here you have a cough."

Patient: "Yes it started when I was working in my barn with..."

DFH: "Well, you horse people get some stupid things."

DFH takes her stethoscope out of an ice bucket overflowing with ice and slaps it on the patient's chest. The patient jumps and flinches, but the DFH just says, "Breathe."

DFH: {gravely} Hmmm. [Louder and more gravely...} HMMMM! I have to do a procedure. (Takes out huge syringe which becomes filled with red fluid. [OK--as an aide--Special Feauture from The Making of "Doctor from Hell," the red stuff was this vile Hawaiian punch-type liquid they served us at lunch 2 days previous.]
DFH (looking at fluid): Ewwwww! Awful!

Pt. What?!?! What is it?

DFH: Seems like a case of fulminant interstitial necrotizing pneumo-anaplasmosis!

Pt. What?!? What does that mean.

DFH (scribbles on Rx pad, tears off sheet and drops in pt's lap). Here, take this medicine.
[DFH walks out}

Pt: Whaaa...? Am I done? Is she coming back?
-----
Well, maybe you had to be there. We kind of hammed it up.

We also showed the NBC video and a PowerPoint with lots of great pictures of our classes and the horses, overlaid with clinic and hospital scenes with doctors and patients.

We sold out of the stash of Manuals of Medicine and Horsemanship we brought! (Not only was I happy to have new owners for them, I was -really- happy not to have had to schlep the box back on the plane.) Several people expressed interest in starting M&H programs at med centers near them. It will be so exciting when the first/next one takes off and has its first class!

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.

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

My balancing ride

It was out last meeting for M&H, and it was our turn to experience "therapeutic riding". Divided in two teams of five, we worked together to guide and take care of the one of us who was riding bareback on one of our horses. I enjoyed being a 'sidewalker' (to make sure that our rider feels, and is safe on the horse), and I most definitely enjoyed the riding experience. First and foremost, I felt safe when I was riding, so much that I felt comfortable letting go my sidewalkers and even closing my eyes. While we were not trotting, riding bareback allowed me to fully feel the horse's body moving, and my own. I felt my leg moving within my hip joint (acetabulum, for those of us) as if I was walking!!! When we had time to do one more round, I wanted to ride backwards (with my back facing the front of the horse), and this was a relaxing and balance-testing experience. I feel fortunate to having experienced first-hand what horse therapy can do to the spirit and body. Thanks to all whom with I shared this 5 week experience with!!
MA

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.

My -un-informed consent

Hi all!! I hope you are all having a good week. I would like to reflect on M&H experience from last week (10/24). Besides the fact that I got to get away from the Stanford campus, I got to participate in the 'informed consent' exercise with the horses. This exercise is an analogy to having a patient sign an informed consent form for a medical procedure. The exercise consists of having a horse walk over a reflective, crinkly blanket. I was the first one to go, and selected Mocha, a small horse who seemed youthful and therefore -I figured- would be curious to participate in this. As I approached and guided Mocha towards the 'procedure' we seemed to be on the same page. I took a detour inside the horse pen, to give us some time to bond. As soon as we came to the edge of the blanket Mocha stopped, looked at the shiny surface and started making sounds I have never heard horses make (a grunt of some sort)... I patiently reassured Mocha, with what I assumed would be 'comforting' rubs along Mocha's neck and body, and speaking to Mocha sotfly. As I was growing slowly more anxious about 'getting the signed consent' I also made sure to not let Mocha back out too much. I could tell Mocha was curious about what lay ahead, but the curiosity did not overcome the fear. Anticipating that Mocha would be reluctant to 'sign the consent' I did not want to be forceful with Mocha, and therefore waited and reassured some more. Almost at the end of my exercise I 'called for an attending' figuring that I needed experienced help (which is allowed in a clinical setting).
Overall, this was an enlightening experience and the rest of our day was wonderful.
MA

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

A projection experience

Mounting research suggests that much of our decision making is made well before we are aware of it, leaving some to wonder what exactly our consciousness is for beyond our own amusement and/or torment. I would posit that, among other things, our conscious experience is used (for better or worse) in long term planning, where our awareness gives our "old brain" the stimulus for which to make a decision. Novel experiences, moments where our bodies' associations are lacking, are the moments where our awareness is not much help and our "old brain" gives its best guess. Seeing an old friend give you a look of annoyance isn't projection, that is knowing your friend. Seeing a new friend not laugh at your joke and thinking he doesn't like you/is sad/is not funny is projection. That being said, horses are more or less novel experiences to me, and I found myself projecting a mood onto Dream yesterday. As she stood still while we struggled to put her saddle on, I thought I saw a resignation, the type of general malaise that would come with the territory were I to be subjected to a master/subject environment. The moment was fleeting as I quickly reminded myself that I have no earthly idea what a horse expression for resignation might look like...but my associations were just giving it their best shot. And as we sat for our debriefing , I happened to look over someone's shoulder only to see Dream, standing there, in the same stance she had while she waited for someone's left brain to tell someone's left side to do something. Same stance as before, same ears, same angle of the neck, same look on her face...different projection. I thought to myself, "ha, what a silly assumption, well, then again, that is projection, and now I have something to blog about."

-Alex

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.

My First Day

Ok, this is my first time writing a blog, so we'll see how this goes. Its been almost two weeks since my first session in the M&H 'course'. To me it has been more like an experience rather than a course. Eve though some time has passed since the first time I got my boots muddy in the horse ranch, I can still remember the crispness of the air (it has just rained the night before), the greenness of the trees in the hills, and the stampede of horses coming into the enclosure where we were to observe them. It took me some minutes to overcome the 'distraction' that the beauty of the horses had on me accomplishing the observation of communication between horses. Besides learning a great deal about how horses communicate through the position of their ears, movement of their tails, and body 'driving'. One of the horses came really close to the fence where we were all observing and curiously observed us in his majestic elegance. Another of the most vivid memories of that first day was the analogy of horses as patients, and when I was placed in a scenario of introducing myself to a 'patient' while another one wanted to take over the 'introduction'. To me, this was an analogy of trying to establish a relationship with a patient while another one in the room wanted to have all the attention. I am glad that I finally have the opportunity to participate in this experience and look forward to the more experiences to come.
--MA

Hello from Liz

While I am well-versed in the language of horses, I am a neophyte in the language of Blogs. I did successfully log-on and read the two entries (SaraJane and Anna). Wonderful! Thank you for sharing.

Thirty years ago, when I was an terrified and insecure Stanford freshman, I used to get on my bicycle and ride north from campus on Alameda delas Pulgas and up Alpine Road into the mountains, screaming my anxieties to the blue jays and looking for redwood trees to hug. God, I wish that I had known to turn right on the road in to Webb Ranch! What I needed then (and now) was horses and mud and green grass to touch and smell and taste in my soul.

I realize that Horses and Medicine is a med school class whose purpose is to help the students become better doctors in the future. But it seems clear that in the present time (Wednesday afternoons from 12:30 to 3) that the equally important purpose is -- or at least can be -- to help the students acquire a new paradigm for seeing lots of things in the world differently, not just horses and patients. If nothing else, this is 3 hours of fresh air and "down time" that you might not allow yourself when the clamour of other responsibilites becomes too strong. ENJOY!
As many a cowboy philosopher has been creditied with saying,
"The outside of a horse is good for the inside of a man."

Liz Carey (princessbasia@yahoo.com My horse's name is Basia.)

Visual Learning

The four types of wisdom exercise today was a powerful one for me. In my "real" life, I am generally the logical, systematic person of a group. This has served me well in many years of school and especially science and medical classes. Remembering that indeed I have other aspects to my personality including sensory and intuitive ones was a great way to start off today. During several of the exercises today I found myself being more present in the physical aspect of grooming and a leading a horse. Somehow this made it possible to shut off the logical, judgemental, inner-monologue that can drown out the more subtle sensations. I felt like I did a better job of reacting to my classmates and to the horses because I was paying more attention and being a little less conscious of what I was supposed to be doing. Also just being around the horses was very relaxing for me and reminded me that I'm going to need to keep things in my life balanced to survive medical school and become a good doctor.

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.