Monday, June 3, 2019

Thoughts on Indigenous Spirituality June 2019

Recently I took a class at the University of Maine on Gender and Religion, which helped me to better understand why women are so angry about the past. I learned that the women born into the “religions of the books (the Bible, the Q’uran, the Torah) have clearly suffered more over the years as a consequence of religion than have the indigenous women of North America.  This was certainly the case in China and India, as well.  Pre-Christian North American indigenous society was more flexible in gender relations than these other cultures.  Women had more choices.  There was not necessarily only one right way to do things. 

Contemporary aboriginal women are remembering the power and knowledge of their maternal ancestors.  For example, the words of a song, “Okisikôwak,” written and performed by the indigenous women’s music trio, Asani, enunciates these memories:

Those very same hands stroke the face of a child
Warrior within, not meek or mild
Every step that she takes is clearing the way
Inspiring a change, for generations today.

Women were seen as warriors, every bit as much as men.  During the worst periods of government oppression of aboriginal people, Shalin Jobin tells how the women kept their knowledge and power alive through the stories they carried and passed to future generations (see Chapter 2, written about her Cree ancestors in Kermoal, N., Altamirano-Jiménez, I., & Altamirano-Jimenez, I. (2016). Living on the land: Indigenous women's understanding of place. Edmonton, CA: Athabasca University Press).  Jobin writes how the residential school system aimed to create a “double consciousness” in which the indigenous person could not help but look at himself or herself through the eyes of the colonizers and that her ancestors resisted this double consciousness through their commitment to the stories.

Raymond Bucko's book, The Lakota Sweat Lodge was his Ph.D. dissertation at the University of Nebraska, where he currently (unless he has recently moved) teaches (Lincoln, NE: University of Nebraska Press, 2004).  Bucko’s book also speaks to the flexibility and lack of a hierarchy of North American indigenous spirituality. Each family does things differently and it’s always correct for those who do it that way in the place where it’s done.  However, were he to write this book today, he would need a new title.  Elders tell us that we should not refer to this ceremony as a “sweat lodge.”  The word in Lakota is inipikaga, which is best translated as “revitalization ceremony.”  We hear that the Jesuits called this ceremony a “sweat lodge” because they saw sweat.  For the Lakota, this was not sweat, but was toxins exiting the body in its process of revitalization. In Bucko’s book, he discovered that no right way to do a sweat lodge exists.  He discovered that no central authority existed to say what should be done and that each family does things a little differently, though some basic similarities are present.  He similarly writes that no central authority exists for deciding what Native American spirituality is.  Felix Cohen is correct, I believe, in saying that Native Americans in the United States are at the bottom of the pecking order.  What happens to Native Americans will happen to other minorities eventually.  Bucko makes the point that this insanity of the governmental imposition of Christianity began at least as early as the time of Thomas Jefferson's presidency.  It actually began much earlier.  An infamous community in Massachusetts began to hang Indians who weren't Christians around 1640.

Bucko made another point that hit home -- that the contemporary pan-Indian identity arose as a shared opposition to the European invasion.  The shared reality of the oppression eventually led to a shared response, though not until the 20th century.  In the 19th century, tribes were still working against each other with one tribe serving as scouts or helpers to the U.S. Army in attacking their traditional enemies.

Before the Blood Quantum Act of 1904, no concept of being half-Indian existed.  One was either a member of the Nation or not.  During the time of the forced march of the Cherokee to Oklahoma (The Trail of Tears and Death), the head chief of the Cherokee, John Ross, would have been only 1/8 Cherokee by today's standards.  By the standards of that time, he was 100% Cherokee.  In 1904, the U.S. Congress invented Native Americans as a separate breed in the same way that horses or dogs are considered as half this or half that.  The goal of the blood quantum system was to eventually eliminate the Bureau of Indian Affairs.  Here's how it works.  If a Lakota person marries a Cree person, then their children are only half Lakota.  They are also half Cree, but that doesn't make them 100% Indian.  It leaves them half-Indian.  Then if the child marries a Crow person, their children are only 25% Lakota.  One more marriage to a non-Lakota and this person is removed from the BIA roles, even though they have only married other Native Americans.  It actually doesn't matter if they marry a non-Indian; anyone outside the tribe counts toward diluting the percent Indian.  What is amazing is that the numbers of Native Americans are growing anyway.  This is because of young women having multiple children.  Bucko quotes Marshall Sahlin as describing the extended kinship Native American family, which is inclusive of everyone.  That seemed entirely accurate to me, though he left out the dogs. 

O'Brien calls attention to the tremendous abuses of the Franciscans, which virtually destroyed the tribes of California.  Schooled by the Spanish Inquisition, the methods of the Franciscans were brutal.  The Jesuits were more subtle, but ultimately equally destructive, for they engaged in epistemological genocide, the destruction of people's ways of seeing the world. The New England Protestants created towns for indigenous people to shed all of their culture and religion and completely embrace the ways of the colonizers.

However, indigenous North Americans had difficulty relating to the religious ideas of Europeans.  The idea of a collection of rules that determined one's afterlife seemed absurd. In all the traditions I know, everyone goes to the spirit world and no punishment is inflicted there.  Whatever evil one accumulates in this life is left behind.  We are all so much better in the Spirit World.  The conflicts and disharmonies of this world are left behind.  The emphasis on eternal punishment would not fit within the Native American world view.  I can remember my grandmother telling me, if there were a hell, it would be here on earth.  The Creator wouldn't make such a thing, she said.  The idea of a limited number of spirits seemed strange as well.  Everything has a spirit.  The Visibles have spirits and the Invisibles are spirits.  The idea of limiting eligibility to Father, Son, and Holy Ghost seemed bizarre.  Also, the idea that one needed a priestly intercessor to speak to the spirits for one would have seemed equally bizarre.  However, many people converted out of necessity and continued their indigenous spirituality while tolerating the religion of the colonizers.  Others were so hopeless and distraught that they accepted the beliefs of the conquerors entirely.

The Indian Civilization Fund Act of 1819 provided money for Christian clergy to proselytize indigenous people and to create boarding schools to teach Native children English, the Christian faith, and European methods of farming. Here was the government violating its own principals of keeping church and state separate.  O'Brien describes Major John Chivington of the U.S. Army, who orchestrated the Sand Hill Massacre, in which he killed almost 400 Cheyenne, mostly women, and children, and then mutilated their sexual organs and scalped them to display to cheering crowds in Denver.  He was chided by the Army but not punished.  The Chief of the Cheyenne was in favor of peace and was flying an American flag at the time he was killed.

The Cherokee had tried to emulate the Europeans in every way but giving up their sovereignty, even to the point of changing their gender relationships and becoming patriarchal, though this strategy did not succeed in preventing the forced relocation to Oklahoma. 

The Fort Laramie Treaty of 1868 established a large reservation for the Lakota, which was progressively whittled down, especially with the discovery of gold in the Black Hills.  Gold was the worst-case scenario for indigenous people in North America.  Once discovered, the rest is downhill.

In the indigenous cultures of North America with which I am familiar, Creator is genderless.  Gender only enters later in the process of elaboration of creation.  Some versions of the Maine creation stories have a male creator, but these have clearly been shown to be revisionist stories influenced by Christianity.  Some people think that the Lakota have a male creator, because of the use of the word tunkashila, which means grandfather.  However, elders have explained to us that the elders of the time of first contacts were trying to explain their concepts to the Europeans and actually said, "your creator loves you as a grandfather would love his grandchildren," which is a powerful concept in Lakota kinship systems.  They didn't mean to say that the creator was a grandfather.  They abandoned this attempt at an explanation when the Europeans misinterpreted them.  Now the word Dakuskanskan is used, which is the proper term.  Literally, it means that (plural) which is the whitest.  The best interpretation of this is the spirit which is higher than the highest of the sky spirits. Similar, some people misstate rocks as grandfathers.  We hear people talking about bringing the grandfathers into the inipi ceremony (the hot stones).  They are not actually grandfathers, either, for the proper word is inyan, which means stone.  Stones are considered to be masculine and are the oldest inhabitants of our world, which is why perhaps the ancients thought to explain to the Europeans that they were like grandfathers. The Europeans didn’t understand that the Lakota were using metaphors, perhaps because they couldn’t step away from their assumption that indigenous people were primitive and stupid.

While rocks are male, the earth is considered feminine.  However, in Lakota, Dakuskanskan, has a male messenger Tate, or the wind, and a female messenger, Wohpe, or the White Buffalo Calf Woman.  In a famous story about the creation of the four directions and time itself, Wohpe is sent to the earth to tell Tate that it is time to create the four directions because people are coming, and they will need time and direction.  

There is a famous women's song associated contemporarily with Sissy Goodheart of Yates, North Dakota, that tells how women are sacred for they give birth to the Nation through their hearts, minds, bodies, and souls.  The song says that they are the heart of the Nation and are asked, therefore, to bring their highest selves to their task of being the heart and soul of the people. 

Paula Gunn has written about the respect which women received and the sacredness of menstruation and of the power of menstrual blood.  In the Lakota language, one word is used to refer to things of power and mystery, which is wakan.  This word can be translated as holy, sacred, or mysterious.  There really isn't a word that corresponds to the usage of the English word "taboo."  The word wogluze refers to something sacred or forbidden, a spiritual taboo or ceremonial restriction (as a certain animal or animal part that cannot be eaten because of a vision one has received or things that are forbidden to do during a pipe ceremony).  The other word is wahtani, which means to fail to perform a vow or to violate a tribal law.  However, in my experience wogluze is never absolute, but always subject to exceptions and alterations.

Problems are rampant in European translations of indigenous languages as in North Dakota, where a word that meant "lake of the spirits," was translated as "Devil's Lake," which is the current name of that town and that lake.  The general understanding is that one doesn't mess with things or beings that are wakan, unless one has a full understanding of how to use that medicine or power.  The word for power and the word for medicine are the same also.  I know women elders who have the power to work with menstrual blood and women with menstrual disorders, and I know male elders who stand in awe of that power.

Monday, April 3, 2017

Medicine for Ceremony Session 5 Sundance

Tuesday, September 8, 2015

Narrative Concepts

The idea of narrative is becoming recognized as basic to understanding humans and culture.   Philosopher Alisdair MacIntyre writes, "[W]e all live out narratives in our lives" and "we understand our own lives in terms of the narratives that we live out."   (MacIntyre, 1981) . The default mode of the brain according to Washington University neuroscientist Raichle is to make up stories.   It is what we do easiest.   It is what burns the least amount of glucose.   It is, according to neuroscientists and artificial intelligence experts Shank and Abelson, the template for human memory.   We humans actually think more in terms of verbs than in nouns.   When we see something, we want a story about it.   We want to know what it does or what it can be used for.

What is narrative?   The shortest narrative consists of two action clauses and an orienting clause.   I like to tell a short story that one of our clients told.   She said, "One time I killed my boyfriend, but then he came back to live and tried to kill me.   That was when we were living in Georgia and I was dealing coke."   This short story tells so much.   It conveys the essence of a character, of a human being positioning herself to be seen in a certain light.   It contains values and emotions.   It conveys a richness of understanding far beyond its mere words.   It is a work of social art, complexly rich and detailed.

University of Auckland Professor Brian Boyd argues that our big brains arose to do story.   Brain evolved to do story because story worked.   Story worked because it is the most efficient way to store massive social information as illustrated above.    Each of us can, apparently, know about 500 other people.   The amount of information we need to negotiate relationships with these others is massive.   We retain it in the form of stories.  

Thus, narrative medicine means an understanding of health and disease for humans, that is grounded in the stories humans live out in their lives and the stories that we understand about our lives which give our lives meaning and purpose.   Whatever we do only makes sense in the context of being grounded in a story or two.   When you recognize that I have a belief, that belief only makes sense if I tell about the experiences that led me to form that belief.   This belief rests upon experiences that led to certain conclusions that are stored in a narrative template.

Probably you wonder why this excites me so much!   I would answer, "because it bridges my indigenous parts with my non-indigenous parts.   In growing up, I learned that everything that mattered was a story.   If my grandparents had something important to tell me, they would tell me a story.   I was expected to interpret the story, to make sense of the story and to grasp what they wanted me to know.   I learned that "all there is, is story".   In Lakota, our personhood is the synthesis or integration of a swarm of stories that surround us called the nagy.   These stories consist of all the stories that form us or that we have told or are enacting as we move about in the world.   This nagy also consists of all the tellers of those stories.   We are forever embedded in each other's nagy's.  
To bring that into the practice of medicine, it means that illness is embedded in the stories we are performing and that are performing us.   There is a biological story about how we are organisms who are born, live, wear out, and die.   Our lives are finite.   Within that finitude, however, are multiple social stories which interact with the "how long do I have to live story".   Another story tells us that some events within our lives appear to be random, meaning that I can't make sense of them.   I can't place them within a story.   However, if I find the stories that people are telling and that are told about them, often their illnesses are illuminated in some way.   The illnesses make more sense.  
David B. Morris of the University of Virginia, writes that narrative is above all a form of knowledge (Morris, 2005) .   In this view, narrative knowledge complements and differs from traditional "logicoscientific" knowledge (Charon, 2001) .   For Charon, narrative knowledge is less of a product than a tool.   It is "what one uses to understand the meaning and significance of stories through cognitive, symbolic, and affective means."   Its identifiable properties -- beginnings, middles, endings, characters, conflicts, and turning points -- for Morris are more descriptive than definitive.
Narrative comes from the Latin word, narrare, which means "to tell" and refers to various forms of telling.   Philosopher Richard Kearney writes that, "[N]o matter how distinct in style, voice, or plot, every story shares the common function of someone telling something to someone about something" (Kearney, 2002) .   For Morris, these tellings include the gamut from fragments of discourse to ancient formulaic epic poems like the Iliad or The Odyssey to cryptic post-modern novels.   Other scholars go further than Charon to argue that all knowledge, even the conventional declarative knowledge of modern medicine is narrative because all knowledge is embedded in theory which is a story about how the world is supposed to work.   These stories have characters in the form of biological entities or molecules, they have plot in the sense of operations that take place upon these entities (enzymatic reactions, flows of ions, passage of molecules across membranes).   They have implicit values such as preserving the life of the organism.   Even mathematical proofs can be seen as narratives.   Some neuroscientists see human identity and the operation of human consciousness as narrative (Fireman, McVay, & Flanigan, 2003) .

Narrative is not strictly verbal.   It is visual, bodily, kinetic, musical, and mixtures of all these.   Choreographed dances are stories, such as American Spring as are musicals like Oklahoma.   For Morris, stories also hold the negative, what cannot be told, the gaps, silences, and what cannot be said.   Stories always contain a matrix of choices -- what is valued, what is marginalized, and what is excluded.   Within medicine, narrative reminds us that illness is always caught up in stories involving families, jobs, cultures, and meanings and is not limited to the simply biological rendering, which we call "the natural history of the disease".   Indeed, I suggest that illness is without natural history because it is always affected by human affairs -- by people's search for meaning and happiness, by the relationships in which they find themselves, and by the broader stories of culture.   Biology is not an island unaffected by the sea in which it swins.


Charon, R. (2001). Narrative Medicine: a model for empathy, reflection, profession, trust. JAMA, 286, 1897-1902.
Fireman, G. D., McVay, T. D., & Flanigan, O. J. (2003). Narrative and Consciousness: Literature, Psychology, and the Brain. Oxford: Oxford University Press.
Kearney, R. (2002). On Stories. New York City: Routledge.
MacIntyre, A. (1981). After Virtue: A Study in Moral Theory. South Bend, Indiana, U.S.A.: University of Notre Dame Press.
Morris, D. B. (2005). Success Stories: Narrative, Pain, and the Limits of Storylessness. In D. B. Carr, J. B. Loeser, & D. B. Morris, Narrative, Pain, and Suffering (Vol. 34, pp. 269-285). Seattle, Wash8ington, USA: Intertnational Association for the Study of Pain Press.

Single Payer Health

People's stories about health and disease determine their health behaviors.  I begin with an example of a patient whom I told 25 years ago that he had to take better care of himself and who just dropped dead of a heart attack in his 50's.  I wonder about how we help people change the story that they are living.  How do we help them change health destructive behaviors in a respectful way that honors the story they have brought?

Who should pay for health care?   If health care is a right and not a privilege and we should all contribute to each other's wellbeing, then how do we do that?   Taxation is the main means for governments to raise money, though I suspect that the current profits being generated in our capitalistic health care could go far to reducing the actual cost of health care if we no longer had shareholders and owners to please and CEO's of hospitals and health systems were public servants instead of capitalists.   The last time I checked the CEO of Health Care America was making an annual salary of 150 million dollars plus stock options and other perks.   We wouldn't tolerate salaries like that in the private sector.

I received enough comments related to single payer health systems on my last blog to make me want to write another essay on this topic (rather than respond to each comment one-by-one).
U.S. health care is the most expensive in the world by a factor of four and results in ratings that average about 27th in the developed world, all factors considered.

I think we should subsidize each other's health care because none of us are willing to sit and watch someone die in the waiting room because they haven't bought health insurance.   The Republicans argue that it is their right to eschew health insurance, but I'm sure few people would renounce health insurance if they could afford it.   Their argument is specious because few of them would stand by and let people die in the waiting room, either.   I'm quite sure some would, however, as they would see it as the will of God.   Like the Catholic Church in the Middle Ages, they would not want to interfere between God and man by helping a person to recover from God's punishment in the form of illness.   Once most of us agree that people can't just be allowed to die, then we have to pay for their care and some people's care is more expensive than others.   How are we to answer the question of people's own behavioral contributions to their ill health?   Should smokers pay a higher tax than non-smokers or is that factored into the tax on cigarettes?   Should people who regularly exercise pay a lower tax than sedentary people?   Should vegetarians be taxed at a lower rate than fast food aficionados?   The list is endless.   Figuring out the nuances of human behavior and how they affect health occupies the lives of endless epidemiology departments in public health schools around the world.   

The surprising downside (though maybe it's not) from some of single-payer health is that your health and your health related behaviors become my business.   I have an interest (because I pay for your illness) in controlling your behavior because "bad" behavior costs me money.   Therefore, matters that we have considered private are now public.   We must debate the cost of providing contraceptive care to which some Republicans object.   From a cost perspective, birth control is much less costly than children.   Only poor people could not afford birth control and the costs of not using it are then borne by all of us in the form of paying for the cost of their raising their children or our raising their children.   One Republican answer would be that many childless families (mostly white) are available to adopt children and should do so.

In the International Journal of Health Care Finance and Economics from 2009 (Volume 9, pages 1--24), in a paper on "Why U.S. health care expenditure and ranking on health care indicators are so different from Canada's", A. H. G. M. Spithoven writes about how the U.S. spends most of all developed countries on health care. Nonetheless, the U.S. ranks relatively low on health care indicators. This paradox has been known for decades. The turning point comparing the U.S. and Canada was in 1972. Health expenditure as a percentage of GDP was higher in Canada than in the USA from 1960 until 1972. Since 1972 expenditure on health care has been higher in the U.S. than in Canada.   The U.S. and Canada are two countries that are sufficiently similar to make comparisons useful. The comparison of factors influencing health care expenditure in the U.S. and Canada in 2002 revealed that health care expenditure in the U.S. is higher than in Canada mainly due to administration costs, Baumol's cost disease and pharmaceutical prices. It was not inefficiency in providing health.

What is Baumol's cost disease?   Assuming that wages in low productivity sectors must keep up with wages in high productivity sectors, prices for labor intensive goods or services will rise relatively to prices of goods and services produced by the high productivity sectors (McPake et al. 2003).
Productivity in health care is difficult to improve because health care relies for a large part on a direct face to face relation between the health care worker and the patient.   For example, washing a patient needs time that cannot be reduced beyond a certain point. Health care, where a large part of cost comes from staff looking after patients, is a low productivity sector. Baumol's costs disease may be overstated because the "output" used in measuring productivity in health care fails to capture major improvements in quality or results. So, while the cost of medical spending shot up from 1960 to 2000, largely as a result of the development and wide-spread use of new medical techniques, the cost per quality-adjusted life year decreased.   Health indicators for both males and females, such as life expectancy at birth and infant mortality rates, reveal that the quality of health care did not improve in the U.S. in comparison to Canada in the 1960--2000 period (United Nations 2005 data).

Administration costs prove to be a significant variable to explain the difference in health care expenditure between the U.S. and Canada. America's health care is characterized by a fragmented payer system, while Canada has a single-payer system. The first has less economies of scale in administration than the latter because competition among providers of health care, on the one hand, and competition among insurers of health care on the other, result, among other things, in extra expenses in billing and administrative operations of health care providers who have to deal with 100s of payers and different rules and prices.

Overhead costs in Canada's single payer system are much lower than in the U.S. with 72 US$ health care administration expenditure per capita in Canada in 2002 and 367 US$ per capita in the U.S. For 1999: "In the United States, health care administration cost $294.3 billion, or $1,059 per capita [. . .] In Canada, health care administration cost $9.4 billion, or $307 per capita [. . .] After exclusions, administration accounted for 31.0% of health care expenditures in the United States, as compared with 16.7% of health care expenditures in Canada". Using the same broad definition, this big difference is also reported by Himmelstein et al. (2003): "The U.S. wastes more on health care bureaucracy than it would cost to provide health care to all of the uninsured. Administrative expenses will consume at least $399.4 billion out of total health care expenditure of $1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately $286.0 billion in 2003, $6,940 for each of the 41.2million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage."

Another surprising public debate becomes for what should we pay?   In Canada, the National health system does not pay for dental care.   Apparently, teeth are superfluous.   In Holland, from where I am today returning, the government is about to decide that psychiatrists will no longer be paid for psychotherapy, only for prescribing medications for depression because medication is more cost-effective than psychotherapy and people can get cheaper psychotherapy from others.    I learned this at a Dutch hypnosis conference attended by a number of psychiatrists and family physicians.   Actually, the evidence in the literature does not support this contention.   A number of studies have shown that psychotherapy is more effective than medication or medication plus psychotherapy at 16 weeks.   For depression, a 2010 meta-analysis using the Freedom of Information Act to obtain all the clinical trials ever done on antidepressants (all must be reported to the FDA but not necessarily published) found no difference between medication and placebo.   A 2010 study compared behavioral activation (prescribing behaviors that cause the person to become more active) to cognitive-behavior therapy and to medication over 16 weeks.   Most antidepressant studies last 6 weeks, not long enough for psychotherapy to show its full effect.   

However, how much control should the payer have over how we physicians choose to treat people?   Typically, there are many equally good ways to treat a problem, though bureaucrats are not apt to notice this.   They wish the best way.   They wish a quick and easy answer.   And a bias exists!   Therapies that involve human interaction are always less trusted than technology.   We live in a world in which the bias is toward technology solving problems.   Payers for health care have an interest in what is provided just as do recipients of health care.   Where do the two intersect?   Her again, I would prefer Bernie Sanders (Senator, Vermont) solution of giving control of health care to local governmental units.   I think I would have a better chance of arguing my methods and why they should be compensated to a local board than to a faceless, nameless government agency.
Thus, in thinking about a single payer system, we must consider the politics of power.   Who decides what will be covered.   Who decides what we physicians are allowed to do and what we are not allowed to do.

Even as we consider who pays for health care, we must consider the kind of health care that we wish to have and how to insure that we get it. Today's health care relies extensively on technology which often fails to achieve its desired goals.   Some of us at the margin of health care want more human-oriented care.   We believe that health improves in the context of relationship and that physicians need to take the time to develop relationships with patients.   We need to have the time to develop the relationships to help people change the way they live and to change the way they see the world.   We need ways to provide care that allows us to spend time with patients and provide care that we and the patients believe will help.   The downside of single payer systems that are far removed from the doctor-patient relationship is that the control lies far from the relationship.   Bureaucrats don't necessarily even make evidence-based decisions, and evidence changes constantly.   Doctors and patients need some autonomy over what they decide to do to improve health.

Himmelstein, D. U., et al. (2003). Administrative waste in the U.S. health care system in 2003: The cost to the nation, the states and the district of Columbia, with state-specific estimates of potential savings. Cambridge MA: The Division of Social and Community Medicine, Department of Medicine, The Cambridge Hospital and Harvard Medical School; Washington, DC: The Public Citizen Health Research Group.

Sunday, February 22, 2015

Post Election Thoughts on ObamaCare

I haven't yet taken the opportunity this year to render my thoughts on U.S. health care and how it should be funded and implemented.    President Obama's plan for health care has come before the U.S. Supreme Court and its fate has already been decided.   We are waiting for the clerks of the Justices to write their opinions.   The Republicans maintain, in a strange twist of logic, that people demand the right not to buy health insurance.   With some exceptions of extremists, who would actually choose not to have health insurance if they could afford it?   The Republicans will next argue that people have the right to be poor and that we shouldn't take that right away from them!
My mother was leaning toward the Republican argument until I asked her what she would have me do if someone entered the emergency room in the midst of a potentially lethal heart attack without health insurance.   Should I save his life even if he doesn't have insurance? I asked.   Of course, she answered.   

"There's the rub," I responded.   "Once you believe that we as a society have the duty to save people's lives when they are having health crises for which they cannot pay, then we need a way to pay for it.   That's what we have now.   The nation's hospitals provide a somewhat dysfunctional local health insurance by virtue of laws preventing them from turning people away at the emergency room door.   Hospitals in New Hampshire have sued their state government because they are going broke from this policy arising from laws forcing them to provide care without any means of remuneration.   It's also important to remember that when those who have not had health insurance come to the emergency department, their bills are usually larger than those who have had care, because more has gone wrong.  
I found the interstate commerce debate confusing.   It seemed simple to me that we must care for whoever comes to our door regardless of where they live.   For example, our hospital in Brattleboro is the closest hospital for people who live in Hinsdale, New Hampshire.   If they have an emergency, the ambulance is going to bring them to Vermont regardless of any other concerns.   Our hospital is three minutes from downtown Hinsdale, while the closest New Hampshire hospital is 35 minutes away in Keene.   I'm not sure how well New Hampshire insurance pays our hospital, but I know that we do not accept New Hampshire Medicaid for psychiatric services since it pays $23 per hour visit (less for shorter visits).   That compares to Vermont Medicaid which pays $87 for a one hour visit.   State lines don't appear to exist when it comes to medical emergencies and hospitalizations; only for routine visits.   The New Hampshire to Vermont transfer works in reverse when we have really sick people in our hospital.   The closest major medical center is at Dartmouth University, which is in Lebanon, New Hampshire.   They send a helicopter to pick up our really sick people and bring them to the academic medical center for the advanced technology they have there.   Apparently state lines don't matter there either, for we don't send people the 260 km to Burlington, Vermont, to the University of Vermont medical center just because it's in-state.

The proposal which makes the most sense to me is that of Senator Bernie Sanders of Vermont, who believes that local regions should control their own health care budget.   I think this could work in Vermont because we could decide where the money is best used in accordance with our local values and practices.   We might choose to cover supplements and fish oil and not the most expensive drugs in the pharmacopeia.   We might add massage therapy for people with chronic pain and perhaps stop paying for anesthesia blocks since these do not appear to be better than placebo.   We might change every six months as data and preferences change, but we could do that.

I do think everyone needs health care coverage.   We need to know that we are covered in the event of illness or accident.   Someone must pay for this coverage.   It must come from health care insurance premiums paid by people or from tax funds also paid by people.   Either way, people must pay for health care, either through taxes or through premiums.   I would prefer taxes over premiums, but that is my personal feeling.   I would prefer a decentralized system in which each locality has a health authority which is populated by a community board of directors who determines how our portion of the health care tax is going to be spent in our community.   We could struggle together to make the hard decisions about allocation.   We could engage in the dialogic process as we do that.   It wouldn't be perfect, but no perfect decision making system exists.   Plus if we had the money locally, we would be forced to think locally about our neighbors and friends and not abstract concepts.
In my experience, what no one wants to address is the escalating costs of health care and why they are not going to stop rising.   Health care is only getting more expensive and will continue to become progressively, even exponentially, more expensive as time progresses.   New technology costs money and everyone wants more technology (seemingly).   New drugs cost more than old drugs, and everyone seemingly wants new drugs (though few new drugs work much better than old drugs).   When we invent a new test, we rarely stop performing the old test that the new test was meant to supplant.   Usually we do both tests.

The medicalization of life has generated tremendous costs for health care.   Ordinary misery has been elevated to a pathological condition.   Every ache or pain demands a label and a diagnosis.   In my role as family doctor, people bring to me a myriad of symptoms in search of diagnosis.   Most of these symptoms will defy diagnosis unless I can convince them that their symptoms are part of life.   Life involves aches and pains.   Life involves some element of suffering.   We get tense.   We get uncomfortable.   We forget how to relax.   We get anxious and experience the somatic symptoms of anxiety.   Our lifestyle leads us to pro-inflammatory conditions.   This irritates our joints, causes our immune system to produce pro-inflammatory cytokines which makes us feel flu-like, makes us feel depressed and more anxious, and promotes the development of other chronic medical conditions.   This pro-inflammatory syndrome is just being recognized and has no real pharmaceutical treatment.   Its solution is to sleep more, to exercise more, to eat an anti-inflammatory diet, to have more fun with other people, to stretch more, and the like.   So much of family medicine is about moving people in common sense directions to reduce inflammation which will improve their symptoms.   Laboratory studies don't really help me to do that, but are what patients often want.

Chronic pain represents another example from my area of practice.   Countless thousands of dollars are spent on X-rays, MRI's, and CT scans of the areas of pain.   They are really revealing.   Studies have shown that the findings of these studies rarely correlate with levels of pain.   They "hypnotize" an entire population of patients to believe that they are hopelessly immured in chronic pain with no hope of recovery, when that is not necessarily the case.   Often, the same simple measures will work wonders with chronic pain and cost very little.   Similarly, coaching people to lose weight and to exercise costs relatively little compared to the costs of being obese and not exercising, yet current health insurance does not cover these costs.   If we had local control over our health care dollars, we could make decisions about these types of matters on the local level and spend our money as we believe would benefit us best.   That's my recommendation for health care -- use tax dollars, cover everyone, give the money to the smallest local entity possible (village, township, shire, etc.), let the local entity decide how to spend it, and struggle with our unrealistic expectations of contemporary health care.

Friday, October 10, 2014

Problem-Based Learning

This week's blog is about teaching -- about my interest in problem-based learning (PBL) and interactive teaching.   My interaction with two students who do not like problem-based learning prompted me to write about this topic. 

First, everyone interested in this question, should, I think, view this resource:
Under 'audio of the program' you can click on 'listen' and hear the whole program. 
Professor Tan of the Nanyang Technological University in Singapore [O. S. Tan, Problem-based learning innovation: Using problems to power learning in the 21st century. Singapore: Thomson Learning. 2003.] describes PBL as a learner-centered approach that positions students as central to the process. He lists some common characteristics of PBL approach:
We begin the learning process with a problem to be solved. 

The problem is similar to those that professionals or practitioners in the field encounter in the world and therefore has an unstructured feel to it. If it is a simulated problem, it is meant to be as authentic as possible. 

The problem calls for multiple perspectives. The use of multi-disciplinary knowledge is a key feature in many PBL curricula. PBL encourages solutions that take into consideration knowledge from various subjects and topics. 

Self-directed learning is primary. Thus, students assume the major responsibility for acquisition of information and knowledge. The tutor's role is as facilitator, consultant, resource person, and mentor.
Harnessing of a variety of knowledge sources are essential PBL processes. 

Learning is collaborative, communicative, and cooperative. Learners work together in small groups with high levels of interaction. 

The development of skills for how to ask questions and solve problems within the discipline is as important (if not more) than acquiring content knowledge needed for the solution of the problem.
Closure in the PBL process includes synthesis and integration of learning. 

PBL also concludes with an evaluation and review of learner's experience and learning process.
Besides the characteristics mentioned above, the PBL approach highlights the importance of the transfer of skills [Oon-Seng Tan, Problem-based Learning Approach to Human Computer Interaction, World Academy of Science, Engineering, and Technology 76: 462-465, 2011]. Learners are expected to transfer concepts learned previously to new problems although spontaneous transfer can be hard without practice or expertise. Transfer often fails because problem solvers fail to retrieve relevant information or skills that they need. Since in PBL the knowledge is encoded in real-life problems, students are more likely to retrieve the knowledge when faced with future problems. For example, during each unit in my class we consider a DSM diagnosis or clinical condition and the brain areas that might contribute to maintaining that condition.   There are too many diagnoses to fit into the seven units of the course.   The goal is to teach a method of approaching learning how the brain fits into behavior so that students can tackle any diagnosis using the methods and resources they learned and find the information they need to come to an understanding.   Of course, this works better, since the information will substantially change each year.   Memorizing facts from this year will not prepare students for next year. 

In medical education, we try to teach students a systematic way to approach new problems.   Given a disease you have never encountered before, what do you do?   We hope the student will know how to access the literature on that disease, will look for the theories of causation, transmission, risk factors, resiliency, treatments, and interactive effects.   Students will have practice in understanding that diseases that are categorized in any one specialty or organ system affect all organ systems and require knowledge from all disciplines.   The body is full inter-connected.   Similarly, our understanding of diseases changes daily and yesterday's facts are out of date already.

Can we teach classes that are not about memorization?  Can we bring problem-based, interactive learning to an online course? Problem-based learning because is evidence-based and performs so much better than more conventional methods.

The problem with problem-based, interactive learning is that the students have to participate and to interact with the teacher.  The argument for problem based learning is that the students learn up to 60% more material.  Plus, for students who engage in it, after the first shock of realizing that the class won't be memorization based, they report having a much better time and learning more.  Some students resist at first.  The American Radio Works program says, don't try this if you still need tenure(!).  But that is because it feels different.  A Harvard physicist in the program makes the point that it used to be that we couldn't easily get to the library to get information, so we needed to memorize.  Now there are endless online resources at the drop of a thumb, so we need to teach people how to find, translate, and use information. 

Interactive, problem-based learning formats do seem disorganized to students who are used to conventional education .  Conventional educational practice lays out of body of material to be mastered (learned, memorized, etc.) and then tests the students on their temporary retention of that material through quizzes and exams.  These newer approaches to teaching attempt to engage the student in a discipline through interacting with it and learning its questions and challenges and where to find the relevant information.  There's not necessarily a body of knowledge to retain but rather a sense for how to orient oneself and find the information when needed again.  I can see how that could seem disorganized to someone who is used to conventional practices.  However, the literature suggests that the kinds of students who do best with these newer methods are just the ones who flounder at conventional education .  Many of the students who sail through college and graduate school without interruption are found to do well regardless of method used.

I'd like to see us change the culture of education .  The culture seems to resist frequent contact and interactive learning in favor of a kind of hierarchical isolation from the instructor.   This can become especially true in the on-line environment, which doesn't have to necessarily mean low contact with faculty.  I'd like to see students involved from the beginning in shaping the course the way they'd like it to go.  Interactive PBL requires student presence.  The University of Minnesota, Rochester, which is a health sciences campus that feeds the Mayo Clinic, entirely uses this approach and doesn't even have a lecture podium.

I have a way to go to get to where I'd like to be for the online environment.  For example, in one of my on-line classes, I still did two fairly conventional lectures each week with powerpoints though I encourage discussion.  Because I don't know who (if anyone) will attend, I need material upon which to fall back.  I also make my slides available as study guides/resources.  I'm still not generating the level of discussion I would like, so I have to be prepared to lecture.  I usually lecture for one hour and then have a half hour of discussion. 

Here is a summary of what students don't like about this style of education (the full article from McMaster's University is available at

Students' Readiness for Problem-based learning:
In PBL, students are not passive information receivers any more. They are expected to more actively engage in their learning process. Therefore, you should take into accounts of students' motivation, background and learning habits before you think about employing PBL into the classroom. Since the PBL approach put the responsibility of learning into the hands of students, students who are used to the structured and sequenced information presentation from the instructor may fail to make progress in learning and resent the self-learning challenge. 

Research on students' perception of PBL has reported that students' concerns about PBL include the unfamiliarity of PBL formats, dramatic differences between competitive and collaborative learning, demands on time and self learning, and ambiguous learning situations with direct instruction. Kingsland (1996), in his evaluative study of the architecture program at the University of Newcastle, reports students' reactions to the time issue in the problem-based learning: 

"Architecture 1 students maintain Reflective Design Journals to aid in the development of design and critical analysis skills. Comments in these journals highlight times of high stress due either to the accumulation of assignment or to time management problems." 

MacPherson-Coy, Sullivan and Story (2000) listed students' response to the question " What did you like least about the PBL program?"; stress over lack of time to complete everything and stress over getting familiarized with the PBL format are on the top of the list. 

In order to resolve students' resistance to PBL, enhancing students understanding of and positive attitude toward PBL process can help prepare students to face the challenges of PBL. If instructors perceive that students will have difficulties in self-directed learning, they may either provide more support during the process or accommodate students' different learning styles by balancing the learning activities via lectures, group discussions, and self-directed inquiry. 

Also, PBL relies on collaboration between students to bring in different perspectives and knowledge bases on problem solving. However, students' prior experience and skills in teamwork may either facilitate or impede students' learning in PBL. Therefore, the instructor should be open to any questions and concerns about the collaborative process. Nelson (1999) suggested to give an overview of the basic ideas and ideas about the collaborative problem solving process helping students understand what they will be engaged in and why.


Tuesday, May 27, 2014

Youth need to be heroes now more than ever!

Today, I had to arise at 5 am in order to run and be on time to Mission Australia's Youth Forum.   We had a long taxi ride across Sydney to a beautiful, green-grassed, lake present, conference center, with crazy birds with long thin beaks, who made shrieks from time to time.   The atmosphere was absolutely bucolic and the conference center modern and lovely.

Norma Ingram gave the welcome to country.   We learned that she had earned her Master's degree In Education at Harvard University and had visited Vermont during her year in the USA.   Norma formally welcomed everyone to her ancestral lands after which Rocky and I sang a song for her as the opening to our presentation.   Rocky gracefully allowed me to give the initial 45 minute talk and then we split the room into two groups for an hour break-out session.   I showed my usual slides to introduce my mother's people and land and then my father's people and land.   I began with the idea that youth appear to need to be heroic, now more than ever.   In a 1959 paper entitled The Adolescent Hero: A Trend by James William Johnson In Modern Fiction Twentieth Century Literature: A Scholarly And Critical Journal (Volume 5, Number 1 April, 1959), we learn that the literature of adolescent heroes began to dramatically increase in 1929 and continued to grow through 1959, and, I believe has continued ever since.   Adolescents, especially males, appear to need to feel heroic in some way.   They are saturated with stories extolling heroes and demanding that they be one.   Sometimes they choose pathways to heroism that adults find objectionable.   For example, joining a gang is a pathway to heroism, though often lethal.   I talked about how traditional cultures have historically had procedures for declaring a young person to be an adult and ways for them to be heroic.   I talked about using culture to create other opportunities for heroism, including the challenge of the sweat lodge, of sun dance, of vision quest, and the opportunities to feel heroic.   I talked about a pediatrician I know who prepares Lakota children for a swim from Alcatraz to San Francisco across the Bay -- the journey that was believed impossible when Alcatraz was founded.   We talked about the horseback rides across the reservation that Patrick Chief Eagle provides on the Pine Ridge Reservation.   A man in the audience mentioned that he was working with Maori youth to make and sail canoes in the traditional way.   I mentioned the programs for Native Hawai'ian youth to make and sail canoes between islands.   We just have to find ways to make what we adults consider to be wholesome and healthy seem more desirable and heroic than their alternatives like gang membership or the culture of drugs.   I argued that much of dysfunctional adolescent behavior can be understood as an attempt to save face when the attempt to be heroic or become a hero has gone awry.   I defined narrative units as I did on Day 3 for the Hearing Voices Conference and talked about the importance of creating positive story.   My slides are available to anyone who wants to email me at Email address removed .

After lunch, we heard Leonie Green, the Director of New South Wales Community Services talk about the recently launched Mental Health Strategies for Mission Australia.   She said that their previous strategy did not fully identify the need they had.   She talked about their biggest barrier being how to refer clients into clinical mental health services.   When people rang the mental health outreach services, they didn't get responses because they didn't have the language down that mental health used.   They don't actually see themselves as a provider of mental health support services in the broadest sense, though the majority of their clients presented with mental health issues.   She said, if you look at the social determinants of mental health, they are homelessness, poverty, unemployment, family breakdown, and the like, so it should be quite natural that their clients should present with mental distress.   She said that mental health should be everyone's business.   When people stop being homeless, poor, and unemployed, often their mental health improves.

Six months ago, they started drug and alcohol services which have been rapidly expanding. They call this a community of practice for youth services.   Everyone involved with youth in that area comes to the table to interact around managing these youth with drug and alcohol problems.

Here are some of the highlights of their current strategy:
1)       Replace the term mental illness with the terms "mental distress" and/or "loss of mental wellbeing", as these terms were less stigmatizing and recognize the diversity of experience that bring people into contact with mental health services.
2)       Services should transition from inpatient hospital to integrated community services.
3)       Social determinants of mental health need to be more widely recognized and addressed.
4)       Adopt a Recovery Approach to underpin service delivery.
5)       Establish a Consumer and Carer Reference Group to include the voices of people of lived experience of mental distress and loss of wellbeing and their carers in the planning, design, delivery, and evaluation of services.

We learned that aboriginal people have high rates of mental illness and loss of mental wellbeing in their communities.   Rates of suicide and self-harm are 2 to 5 times higher for aboriginal people than other Australians (   The New South Wales Social and Emotional Wellbeing Policy (2006-2010) states that the tragic state of Aboriginal mental health is due to a "" complex inter-relationship of individual, historical, social, cultural, economic, and environmental factors (and that) collective distress and trauma exist as underlying stressors to aboriginal life." (New South Wales Department of Health, 2007.

We learned that Mission Australia is at the forefront of responding to the social and emotional wellbeing needs of aboriginal people, especially in rural and remote portions of NSW.   At their Mac River Youth Drug and Alcohol Rehabilitation Service in Dubbo (where Sally made her documentary on elders sharing stories with youth) every referral except one had been an aboriginal youth.   They anticipate providing increasing services to aboriginal persons released from prisons due to their high levels of mental distress.

Next we heard about the Recovery Model, which was also prominent at the Hearing Voices conference from Day 3 and Day 4 of this journey.   It emerged from the consumer/survivor movement following the de-institutionalization era of the 1970's and 1980's.   They define recovery "as a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills, and/or roles.   It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness.   Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness." (Anthony, W.A. (1993). Recovering from mental illness: The guiding vision of the mental health service system in the 1990's. Psychosocial Rehabilitation Journal, 24(2), 159-168.).   The U.S. does not subscribe to the Recovery Model so much but is steeped in the biomedical model.   My sense of Australia is that its physicians are also steeped in the biomedical model with a large disconnect between psychiatrists and other mental health professionals.

Mission Australia (NSW Mental Health Strategy 2012) wrote that "Recovery is not dependent on professional intervention and can and does occur without it. Recovery does not mean an absence of symptoms. Rather when achieved, it allows people to live meaningful lives regardless of any unremitting symptoms and periods of relapses". [R]ecovery is not a linear process"."

Next Dr. Ramesh Manocha, Senior Lecturer at the Sydney University Psychiatry Department and Founder of Generation Next (you can google him) spoke about meditation -- what it is and what it's not.   He's planning a study with Mission Australia to teach kids at risk how to meditate.   He presented a study of 40 minutes of meditation instruction twice weekly for one term who experienced improved benefits in grades and study habits.   He found that the people who were experiencing mental silence several times per day or more had the highest mental health scores.   People who experience mental stillness less than once per month had the lowest mental health scores.   He reported taking 14 women with hot flashes who were perimenopausal for 8 weeks twice weekly meditation instruction.   They were to meditate twice per day.   They found a 70 to 80% improvement in symptoms using meditation at the end of 8 weeks.   The majority of women maintained a benefit at 16 weeks except for one woman who stopped meditating.

At this point we had to leave the conference for our trip back to Melbourne and the final day of our Australian Cultural Exchange Adventure.