Posts tagged “medicine”

Keeping the Humanity in our Technology Work

A few articles about the practice of medicine echo each other in significant ways, but I share them here as a reminder that all of our work that increasingly relies on technology (e.g., developing digital products) will suffer terribly if we fail to engage the human who thinks, talks, listens and tells stories.

With Electronic Medical Records, Doctors Read When They Should Talk

Even if all the redundant clinical information sitting on hospital servers everywhere were error-free, and even if excellent software made it all reasonably accessible, doctors and nurses still shouldn’t be spending their time reading. The first thing medical students learn is the value of a full history taken directly from the patient. The process takes them hours. Experience whittles that time down by a bit, but it always remains a substantial chunk that some feel is best devoted to more lucrative activities.

Enter various efficiency-promoting endeavors. One of the most durable has been the multipage health questionnaire for patients to complete on a clipboard before most outpatient visits. Why should the doctor expensively scribble down information when the patient can do a little free secretarial work instead? Alas, beware the doctor who does not review that questionnaire with you very carefully, taking an active interest in every little check mark. It turns out that the pathway into the medical brain, like most brains, is far more reliable when it runs from the hand than from the eye. Force the doctor to take notes, and the doctor will usually remember. Ask the doctor to read, and the doctor will scan, skip, elide, omit and often forget.

Like good police work, good medicine depends on deliberate, inefficient, plodding, expensive repetition. No system of data management will ever replace it.

Why Doctors Need Stories

I have long felt isolated in this position, embracing stories, which is why I warm to the possibility that the vignette is making a comeback. This summer, Oxford University Press began publishing a journal devoted to case reports. And this month, in an unusual move, the New England Journal of Medicine opened an issue with a case history involving a troubled mother, daughter and grandson. The contributors write: “Data are important, of course, but numbers sometimes imply an order to what is happening that can be misleading. Stories are better at capturing a different type of ‘big picture.’ ”

Beyond its roles as illustration, affirmation, hypothesis-builder and low-level guidance for practice, storytelling can act as a modest counterbalance to a straitened understanding of evidence. Thoughtful doctors consider data, accompanying narrative, plausibility and, yes, clinical anecdote in their decision making. To put the same matter differently, evidence-based medicine, properly enacted, is judgment-based medicine in which randomized trials, carefully assessed, are given their due.

I don’t think that psychiatry — or, again, medicine in general — need be apologetic about this state of affairs. Our substantial formal findings require integration. The danger is in pretending otherwise. It would be unfortunate if psychiatry moved fully — prematurely — to squeeze the art out of its science. And it would be unfortunate if we marginalized the case vignette. We need storytelling, to set us in the clinical moment, remind us of the variety of human experience and enrich our judgment.

From October 2003, Diagnosis Goes Low Tech

“This technology has become a religion within the medical community,” said Dr. Jerry Vannatta, former dean of the University of Oklahoma College of Medicine. “It is easy to lose sight of the fact that still, in the 21st century, it is believed that 80 to 85 percent of the diagnosis is in the patient’s story.”

Yet medical educators say that doctors are insufficiently trained to listen to those stories. After all, there is no reimbursement category on insurance forms for it. It is this lost art of listening to the patient that has been the inspiration behind a burgeoning movement in medical schools throughout the country: narrative medicine.

The idea that medical students need an academic discipline to teach them how to listen may strike some as farfetched. After all, what should be more natural — or uncomplicated — than having a conversation?

But the narrative medicine movement is part of an ongoing trend in exposing medical students to the humanities. It is needed, educators say, to teach aspiring doctors to pay close attention to what their patients are saying and to understand the way their own emotions affect their perceptions, and ultimately their clinical practice.

The basic teaching method is to have medical students read literary texts and then write about themselves and their patients in ordinary language, rather than in the technological lexicon of the traditional patient chart.

Venerable medical journals like The Journal of the American Medical Association and Annals of Internal Medicine are increasingly publishing reflective writing by doctors, their editors say. And now some medical schools even have their own literary journals. At Columbia University College of Physicians and Surgeons, there is Reflexions; Pennsylvania State University College of Medicine publishes Wild Onions; at the University of New Mexico’s Health Sciences Center, there is The Medical Muse.

Columbia also publishes a semiannual scholarly journal devoted solely to narrative medicine, titled Literature and Medicine, which is edited by Maura Spiegel, a literary scholar, and Dr. Rita Charon, a professor at the medical school and a founder of the narrative medicine movement.

ChittahChattah Quickies

Restaurants Turn Camera Shy [NYT] – While on one level this is a story about shifting norms, where an emerging behavior is deemed rude and disruptive. Where it is or not is another question, not really explored here. But there is at least one example of finding alternative ways to address the need rather than just banning what is considered wrong.

But rather than tell people they can’t shoot their food – the food they are so proud to eat that they need to share it immediately with everyone they know – he simply takes them back into his kitchen to shoot as the plates come out. “We’ll say, ‘That shot will look so much better on the marble table in our kitchen,’ ” Mr. Bouley said. “It’s like, here’s the sauce, here’s the plate. Snap it. We make it like an adventure for them instead of telling them no.” Mr. Bouley is setting up a computer system so that diners can get digital images of what they’ve eaten before they even get the check.

‘Friends’ Will Be There For You At Beijing’s Central Perk [NPR] – While in the west the show might be a somewhat-beloved artifact of a decade past, in another part of the world, the possibility for a different meaning is ripe. Perhaps, as the article suggests, this somehow embodies freedom that young Chinese are yearning for?

Tucked away on the sixth floor of a Beijing apartment block is a mini replica of the cafe, orange couch and all, whose owner Du Xin introduces himself by saying, “Everyone calls me ‘Gunther’ here.” Indeed, he is a Chinese version of cafe owner Gunther from the show, down to his giddy passion for Rachel (the character played by Jennifer Aniston). “I’m crazy about Friends,” Du says. “For me, it’s like a religion. It’s my life.” The extent of Du’s Friends obsession is clear on entry to Beijing’s Central Perk. The level of detail is scary: same window, same doorway. People sitting on the orange sofa are watching TV – reruns of Friends, naturally. The cafe only serves snacks mentioned in Friends, and the menus are even annotated.

The Role of Anecdotes in Science-Based Medicine – An imperfect but perhaps illustrative analogy to user research, about the relationship between stories and what some may call “proof.”

Here are two limiting factors in how anecdotes should be incorporated into medical evidence: The first is that anecdotes should be documented as carefully as possible. This is a common practice in scientific medicine, where anecdotes are called case reports (when reported individually) or a case series (when a few related anecdotes are reported). Case reports are anecdotal because they are retrospective and not controlled. But it can be helpful to relay a case where all the relevant information is carefully documented – the timeline of events, all treatments that were given, test results, exam findings, etc. This at least locks this information into place and prevents further distortion by memory. It also attempts to document as many confounding variables as possible. The second criterion for the proper use of anecdotes in scientific medicine is that they should be thought of as preliminary only – as a means of pointing the way to future research. They should never be considered as definitive or compelling by themselves. Any findings or conclusions suggested by anecdotal case reports need to be later verified by controlled prospective clinical studies.

ChittahChattah Quickies

Mice as Stand-Ins in the Fight Against Disease [New York Times] – Looks like this has been happening in some measure for a while, but some new methods are increasing the usage. The most science-fiction thing you’ll read all week.

In what could be the ultimate in personalized medicine, animals bearing your disease, or part of your anatomy, can serve as your personal guinea pig, so to speak. Some researchers call them avatars, like the virtual characters in movies and online games. “The mice allow you the opportunity to test drugs to find out which ones will be efficacious without exposing the patient to toxicity,” said Colin Collins, a professor at the University of British Columbia.

Australia 2012 [Flickr] – My complete set of pictures from Australia earlier this month.

Chinese families’ worldly goods in Huang Qingjun’s pictures [BBC] – We’ve seen other projects like this, but the focus on China captures a material culture in transition.

Amid China’s tumultuous dash to become rich, one man’s photographs of families posing with their worldly goods will soon seem like records from a distant era. Huang Qingjun has spent nearly a decade travelling to remote parts of China to persuade people who have sometimes never been photographed to carry outside all their household possessions and pose for him. The results offer glimpses of the utilitarian lives of millions of ordinary Chinese who, at first glance, appear not to have been swept up by the same modernisation that has seen hundreds of millions of others leave for the cities. But seen more closely, they also show the enormous social change that has come in a generation. So the photo of an elderly couple of farmers outside their mud house reveals a satellite dish, DVD player and phone.

Four Big Things, a phrase dating from 1950s for most sought-after goods for newly married couples: sewing machine, bicycle, watch, radio. It’s since come to refer to whatever is most fashionable at the time. By 1980s the four big things were: TV, washing machine, rice cooker, fridge. Now, consumer goods flood China’s cities, it tends to be used to describe people’s aspirations for the latest thing.

Must-See Video: How a Woman With No Arms Dresses Herself. What Assistance Can Design Provide? [Core 77] – I love the reaction; that excitement of discovering how current solutions could be improved. Designers are so great at bringing that creativity and know-how to bear to make change for the good. But let’s remember, we don’t need videos to be posted by users to uncover what things aren’t working for them. Are designers waiting for broken products to appear in front of them so they can spontaneously improve them, or are they out there looking at current behaviors and solutions in order to proactively find opportunities. Designers: you don’t need the disabled (or anyone) to post their own videos, go and shoot your own!

I hope that more folks with disabilities make videos like this, not just to share with others what their particular trials are, but to enable us designers to improve upon the objects they use.

FILMography – a Tumblr with an incredible series of images where a printout of a still from a film is held up in the actual location where that scene was shot. It’s a “trick” I’ve seen before but mostly as a one-off; the breadth here is fascinating.

FILM + photography = FILMography.

ChittahChattah Quickies

  • [from steve_portigal] Rent a White Guy [The Atlantic] – And so I became a fake businessman in China, an often lucrative gig for underworked expatriates here. One friend, an American who works in film, was paid to represent a Canadian company and give a speech espousing a low-carbon future. Another was flown to Shanghai to act as a seasonal-gifts buyer. Recruiting fake businessmen is one way to create the image—particularly, the image of connection—that Chinese companies crave. My Chinese-language tutor, at first aghast about how much we were getting paid, put it this way: “Having foreigners in nice suits gives the company face.” We were supposedly representing a California-based company that was building a facility in Dongying. Our responsibilities would include making daily trips to the construction site, attending a ribbon-cutting ceremony, and hobnobbing. During the ceremony, one of us would have to give a speech as the company’s director. That duty fell to my friend Ernie. His business cards had already been made. (via @Kottke)
  • [from julienorvaisas] Hey Facebook! Here’s your privacy redesign [Fortune.com] – [The community is now literally begging Facebook to fix this issue. Free design!] We asked several leading user experience designers how they'd overhaul the social network's obtuse privacy settings interface if given the chance. Here, in their own words, are their innovative solutions.
  • [from steve_portigal] For Forgetful, Cash Helps the Medicine Go Down [NYTimes.com] – [The challenge of marketing, design & other forms of corporate persuasion is revealed when you see that people need incentive/motivation to take medication] One-third to one-half of all patients do not take medication as prescribed, and up to one-quarter never fill prescriptions at all, experts say. Such lapses fuel more than $100 billion dollars in health costs annually because those patients often get sicker. Now, a controversial, and seemingly counterintuitive, effort to tackle the problem is gaining ground: paying people money to take medicine or to comply with prescribed treatment. The idea, which is being embraced by doctors, pharmacy companies, insurers and researchers, is that paying modest financial incentives up front can save much larger costs of hospitalization…Although “economically irrational,” Dr. Corrigan said, small sums might work better than bigger ones because otherwise patients might think, “ ‘I’m only doing this for the money,’ and it would undermine treatment.”
  • [from steve_portigal] Creativity thrives in Pixar’s animated workplace [SF Chronicle] – At another company, the employee in Payne's position might be a feared corporate rules-enforcer – the guy who tells you not to put tack holes in the plaster or forbids you from painting over the white walls next to your cubicle. But the architect and 14-year Pixar veteran embraces the madness. Among the more creative additions on the campus: One animator built a bookcase with a secret panel – which opens up into a speakeasy-style sitting area with a card table, bar and security monitor. Other employees work in modified Tuff Sheds, tricked out to look like little houses with front porches and chandeliers. "Sometimes I just have to let go," Payne says with an amused sigh, as he walks into a newer building with a high ceiling – where someone has interrupted the clean sightlines with a wooden loft. A couch and a mini-refrigerator are balanced 10 feet above the floor. [Did a mini-ethnography of Pixar a few years ago and the cultural factors around creativity and community were outstanding]

ChittahChattah Quickies

  • The process of converting books to Kindle format introduces errors in the text – The cost of a printed book covers some degree of proofing and checking—not enough, but some. The cost of a Kindle book does not support editorial quality control, and the multi-step conversion process, handled in bulk by third parties, chops out content and creates other errors that no one fixes because no one is there to do QA.

    As the economics of publishing continues to change, perhaps one day soon, a Kindle edition will contain the same text as the printed book. Until it does, Kindle is great for light reading. But if it’s critical that every word, comma, and code sample come through intact, for now, you’re better off with print.

  • The Social History of the MP3 – For Reading Ahead, we're looking at other transitions to digital: "So omnipresent have these discussions become, in fact, that it's possible the past 10 years could become the first decade of pop music to be remembered by history for its musical technology rather than the actual music itself. This is a chastening thought, but at the same time we have to be careful not to overlook how the technologies we invent to deliver music also work to shape our perception of it. When radio came along, its broadcasts created communities of music-listening strangers, physically distant from each other but connected through the knowledge that they were listening to the same song at the same time. Where radio brought listeners together as a listening public, the LP started splitting them apart. The LP and 45 rpm formats took the phonograph, which had been in existence for over half a century, to the masses, right as the American middle-class was going suburban and privatizing their lives."
  • Medical Students Experience Life as Nursing Home Patients – Students are given a “diagnosis” of an ailment and expected to live as someone with the condition does. They keep a daily journal chronicling their experiences and, in most cases, debunking their preconceived notions.

    To Dr. Gugliucci’s surprise, she found nursing homes in the region that were willing to participate and students who were willing to volunteer. No money is exchanged between the school and nursing homes, and the homes agree to treat students like regular patients.

    “My motivation is really to have somebody from the inside tell us what it’s like to be a resident,” said Rita Morgan, administrator of the Sarah Neuman Center for Healthcare and Rehabilitation here, one of the four campuses of Jewish Home Lifecare.

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