The Art of Reflection

I was listening to our national radio broadcaster (CBC) interview a botanist, Lyn Baldwin, at one of our BC universities and she was describing what she used to do when she'd go out on a field walk. She always took her handy notebook to jot down what she observed, however she realised this use of text lacked sufficient description to what she was seeing. Thus, she decided to take art lessons so that she would be able to do more with her journalling by adding her impression of what she saw through drawings. These are on display at the Kamloops Art Gallery "Not Just a Snapshot" (Jan9-Feb1).

She found that her artwork enhanced her ability to do better reflections. This makes sense. Words can only go so far to describing something one is thinking about or is reflecting on based on something they have seen, smelled, touched or heard. I spend a lot of time reading student reflections and sometimes, although for most part what I read is very thoughtful, they still lack something that had they had the opportunity to draw what they saw or felt, maybe it would allow them to express themselves better.

At this point, the method of entering the reflections is through a web interface where they simply type in their reflection. I log in as a faculty member, and can read them. We have become incredibly text oriented in our modern age of technology. I communicate almost exclusively via text in some form or another to my health mentor students. Yes, they have all met me once or twice but after that it is all online. Am I missing something from them? Students feel so comfortable with this approach since most of them communicate the majority of their time to their own friends, via text. Yes, they do take photos like crazy and post "selfies" on Facebook but does that really communicate everything?

Should we expect something different in their reflections? When I read how excited they are to see an accessible home for the first time and discover how homey it feels, wouldn't it be neat to see a drawing of what they saw or a photograph (as long as they get consent if a person is in the photo)? I know that many of our students are incredibly gifted artists with one form or another but when do they have an opportunity to use these talents outside of the Medical School Spring Gala or the "Do Bugs need drugs" video project. I would love to see more creative ways for students to express themselves in a reflection. The question is whether our online learning modules allow for this to happen easily. Guess I better start figuring this out! Love any suggestions if any other school is already ahead of us.

The joy of teaching

The first question people ask me when I say I am a prof at UBC is, "what do you teach?" As someone who does primarily research but still has a teaching portfolio I find that it is a difficult question to still answer. My main job is to teach graduate students how to do research in the field of biomechanics. I have to say it gives me great joy to do what I do because I mainly get the creme de la creme of students. My students want to study with me and often travel to work with me. I have had students from BC, Ontario, Nova Scotia, Iran, Amsterdam, Germany, Australia, Mexico, US, and of course, Vancouver. Typically one does not get too many poor students this way, but even so I do find it stressful meeting a new student the first time.

It doesn't take too long until we've found an understanding of how my lab works and the expectations are. For many, it is their first exposure to working with people with spinal cord injuries so that is very new. I love watching them learn and discover for themselves what research question they want to tackle. After that it is a struggle to see them develop their projects, work with equipment that can be so finicky and with a population that has many health challenges. However once they get through it and data is collected, analysed and synthesised, it's fun to see them get through their thesis successfully. I'm amazed at how much they can learn and accomplish in such a relatively short time.

They are amazing people who not only are highly intelligent but often artistic or athletic or both! They have a passion for learning and often go on to work in research labs, clinics or do professional training like medicine, physiotherapy or occupational therapy. Why wouldn't I like my job.

As mentioned in previous blogs I teach within a special program called the Health Mentors Program. My role is to supervise the 51 medical students who are in small groups of health students along with a mentor over a 16 mo block. Students write what they learn after each session and I read those and write back to them, responding to what they've learned and give guiding concepts or questions for next time. Reading what they learn in their groups is fantastic. They discover the human element of medicine, meeting the person with a disability or chronic illness. So many things make sense to the students once they have met with their mentors. Again I feel so privileged to teach and dialogue with these young adults as they prepare to become physicians. 

Maybe my job isn't what people think when they ask, "what do you teach?" However my role of teaching young adults in  the university system is a total joy and for many faculty I am sure their favourite thing is seeing the pieces connected in someone's mind. It is a gift to do what I do and I hope my enthusiasm comes through to the students. I have learned so much from these individuals as well. I hope that I maintain my passion for teaching well up to when I retire, but hope I recognise it when my time is finished to let another young faculty member inspire the next generation. 

The in"spiration" of health care.

It was much longer than I had hoped to write more in this blog. I am now out on the other side of the health care system again and gearing up for another year of new grad students (and old ones) and new medical students. I have to say, going through the surgery of bilateral TMJ replacements was probably one of the hardest things I have done in a very long time. Post operative care didn't quite go as smoothly as I had hoped, particularly with pain management but now that I am 9 weeks post op, all is pretty good. Nice to be pain free for the first time in 21 yrs. Quite the freedom!

I do believe I still got pretty optimal care. Knowing I wasn't going to be broke after this surgery is pretty amazing considering the challenges we are facing in providing a publicly funded health care system. Sure, they get you out as soon as possible but I still believe nothing beats your own bed anyhow. I also had amazing care at home through loving family and awesome friends. This is pretty critical in one's ability to go home and recover. However not everyone has a supportive spouse or great friends who can make time out of their day to visit or go shopping for something. In this day and age, this type of support may be the critical factor in how patients manage at home with sometimes quite complicated post operative care plans. Sure, we have nurses who do home visits. These can be quite superficial and short depending upon the demand on the nurse to make it to all her patients. 

What are other resources in the community that patients can tap into during these challenging post operative periods when they might not have other personal support? Some might say that the health care system is already stretched enough and social workers are running off  their feet. People need to help themselves. Maybe this is true but many patients don't have the emotional reserve to seek out help. Pain and disability from illness or diseases zap the energy from people to a point that reaching out for help is exhausting. 

Health care in the form of hospitals originated in temples in Ancient Egypt. In ancient Greece, temples dedicated to the healer-god Asclepius, known as Asclepieia, functioned as centres of medical advice, prognosis, and healing, where procedures were often done under an induced sleep known as enkoimesis not unlike anesthesia(1). 

The declaration of Christianity as accepted religion in the Roman Empire drove an expansion of the provision of care. Following First Council of Nicaea in 325 A.D. construction of a hospital in every  cathedral town was begun. In Turkey, the "Basilias", resembled a city and included housing for doctors and nurses and separate buildings for various classes of patients (2). There was a separate section for lepers (3). Some hospitals maintained libraries and training programs, and doctors compiled their medical and pharmacological studies in manuscripts. Thus in-patient medical care in the sense of what we today consider a hospital, was an invention driven by Christian mercy and Byzantine innovation (4). 

Other religious groups have also taken care of the sick such as Jews, Muslims and Buddhists. This idea of taking care of the sick world wide stems from a "God-inspired" notion that we need to take care of our community around  us. We have a moral and ethical obligation to provide care. Although our Canadian health care system is no longer tied to any religious affiliation, many faith groups still work to provide support to the physically and mentally unwell, alongside the government system. As our system becomes more secularized and funded through governments rather than churches or temples do we miss an element of care that was once there? Where is the role of spiritual care? How does this link in with physical care? 

We teach that physicians need to consider the whole person: physical, mental, emotion and  spiritual. Health care originally was inspired by a spiritual call to care but what do our students learn about spiritual care in our secular, politically correct system? Not really sure. Should we be teaching more or just rely on the few spiritual care staff in hospitals. 

I believe my vastly improved health comes from all the aspects that make me whole. I got great physical care in the hospital and at home, was mentally and emotionally supported over and over, and spiritually encouraged by those friends have a similar faith. If any one of these was not provided, I don't believe my healing would be so dramatic. 




1. Risse, G.B. Mending bodies, saving souls: a history of hospitals. Oxford University Press,  1990. p. 56 
2. Catholic Encyclopedia  (2009) www.catholic.org/encyclopedia
3. Roderick E. McGrew, Encyclopedia of Medical History (1985), p. 135.
4. James Edward McClellan and Harold Dorn, Science and Technology in World History: An Introduction (The Johns Hopkins University Press, 2006), p.99,101.

Being patient.....

Well after almost 5 years of surgery free life myself, I am facing now the biggest surgery of my life...bilateral total TMJ replacement with custom prostheses just for me! I'm only the fourth patient in BC to have this procedure but I trust my surgeon to do it well. My angst isn't about his ability as much as it is the health care system to support his work. He does not do it alone. As patients we rely on doctors, nurses, technicians, pharmacists, therapists, dieticians, clerks, and cleaning staff just for this one procedure, all be it quite complicated, but these are also required for an appendectomy. Our system relies on many folk to get it right and do their best. Do I trust them?
In some ways, I would say, yes. But then there is a part of me that feels that it only takes one miscommunication to get it terribly wrong. If the pharmacist or tech make an error, the wrong medicine can make me sick. If a clerk makes a mistake I might get an extra xray I don't need. If the dietician makes an error I might get food I cannot tolerate. If cleaning staff inadequately clean the O.R. I could get infected. These are examples that could make my stay good or bad, smoothly or seriously go wrong.
In medical school we teach our doctors that they are part of a team and cannot deliver good health care on their own. We emphasise communication skills as a necessity to being a good doctor. Not only must they be able to talk well with their patients but also other members of the team. However, do we teach this latter skill well?  I'm not really sure. Until we incorporate something like the Inter-professional Health Mentors Program (see my last blog) into the whole of the medical school class, many will still not get this training (formally) in our medical school.
Where else can students learn this skill if not for a specific inter-professional program? I do believe students learn this through modelling of some excellent faculty and preceptors that we have associated with our school. Compared to the old fashioned hierarchical approach to health care whereby doctors were at the top and cleaning staff were more or less treated as servants, we now see doctors on a team talking pleasantly to staff rather than barking orders. However, we do see a bark occur at times under stressful situations. Nurses can now give their opinion to a physician without fear of being fired for insubordination. However, we seldom see a true equality of  team members occur just yet. Physicians are now modelling an acceptance of the other members to the team for students to see and hopefully practice in their own clinical practice or on the hospital wards.
With more and more inter-disciplinary clinics popping up for all various types of health conditions from neuromuscular disorders, to cardio-vascular diseases to paediatric asthma  patients, trainees are seeing how doctors can get along with their various allied health professionals. It's encouraging to see these develop. Some have been going on for decades. It's not particularly new but has not been prevalent until the increasing need to provide quality, "patient-centred",  health care with less and less resources has pushed for this model.
So... as I face another complex surgery I do feel like I am safe and will get some of the best health care in the world. I am so fortunate to not only teach in a fantastic medical school but also experience the benefits of that training first hand as a patient.
Am I nervous about this upcoming surgery? I'd be a fool to say, no. However, I am optimistic it will all go well. Not only do I need a good surgeon and a good health care team, I need to be a good patient. I need to be cooperative; I need to adhere to post-operative health plan; I need to have a good sense of humour; I need to have friends and family to take care of me; I need to have hope! Without hope, all these other things are not worth the effort.

Education through reflections:

It's been quite a while since I last posted a blog about my work and thoughts related to the disability field. Sometimes I wonder what I am thinking about my work as I just often react to the work coming my way with out always wondering why or how I am doing it. I'm sure many of us are like that in this fast paced and driven society. How many people reflect on what they do?

I actually feel a bit hypocritical in my work since one of my favourite things I do is supervise medical students who are part of a special program that we've initiated at UBC to increase collaboration across disciplines in health education, called the Inter-professional Health Mentors Program. This means that occupational therapy, physical therapy, nursing, dentistry, medicine, and speech pathology all are in this together as part of their first year training. It's optional still for most but some programs have made it mandatory. Students meet about once every 6 weeks in a multi-disciplinary group of 3-5 students along with a health mentor. The health mentor is someone who has a chronic illness or disability. Our mentors include those who are HIV positive, have bi-polar disorders, a spinal cord injury, born with cerebral palsy, etc. We have 51 groups of students. During each session they are guided through a variety of questions to keep the conversations going but it doesn't take long for these groups to "click", taking off on various tangents that are meaningful to them. I do most of my "supervision" through emails and I read their reflections that they are expected to write after each session. Although they take time, I am fascinated from what they learn that we fail to teach them during class or bedside teachings in medical school.

What they learn through this program is the contextualisation of medicine. Where in the patient's life does that visit with a family doctor or a specialist fall and what impact does it make? It's surprising how much the issue of a patient feeling "listened" to is one of the biggest differences to a successful approach. Even if the treatment is not overly successful the patient feels the doctor tried. The med students also learn the value of their team players from other disciplines.

Besides the obvious of teaching students about learning to work with other professionals and listening to their patients, they are learning to self reflect on what they are learning. At first there is often resistance to this part of learning but it does not take long before they are learning to use it to process difficult things. Unfortunately one of our mentors died during the program leaving the group to grieve their first "patient" so to speak. How do doctors and health care providers grieve in the midst of a busy clinic or hospital ward? We constantly talk about patient centred care but where are the health providers in this model? Who is taking care of them? We do teach them to take care of themselves, get rest and exercise, pace themselves, but is mostly talk and little reality when you see the pace that physicians and others professionals keep.

Using the practice of reflection is valuable. I once kept a journal before I was married but now fail to make the time. Talking one's day through with a spouse or friend is good but by the mere relatively slowness of writing something down, I believe we think differently. I do hope I can be better at this blogging thing for my own sake as a reflection of what I do professionally. I get so excited when I read the student's reflections because it does give me hope that we are creating doctors who will strive to listen to patients, considering their whole life and not just the limb or organ affected. We are complex beings and not simply a pathological specimen needing another drug.

How can I help mould these students as I reflect back to them in their journaling, challenging their assumptions and encouraging them to open their eyes and ears more as they learn. I feel incredibly privileged  to be able to read their personal  thoughts on how the program affects them. I can say that the students are amazing individuals who honestly want a better health care system for patients. Yes, they have ideals but that's where it begins.

Advocacy or Education?

This week an older gentleman from my church died. He was 85. He contracted polio when he was a child and lived in a wheelchair most of his life. For a small man living from an old style wheelchair (probably heavier than him), he did pretty good. When I met him many years ago he was still living on his own in my condominium building, with occasional help from friends and neighbours. He moved here from Montreal when he was 40 to try life on his own. His mom told him he could never do it and needed to be with her. He was never going to amount to much according to his mother's generation. He proved them wrong. He worked and lived like anyone else.....well maybe not like anyone else. He had tenacity. He was always pushing for better access. He wanted his life made a bit easier but also for the lives of others. Apparently he regularly showed up at City Council meetings to voice his concerns over the unsafe nature of curb dips at corners. He always had some issue he was advocating for and at times it was a bit tiresome for people around him. Was it ever going to be good enough for him? Would he ever be  content with how things were? Probably not. Now he's at peace.
I think too of my life and it was quite the opposite. I was told I could do all sorts of things and basically told to lead a normal life - including chores at home like my sisters! I went to school, had summer jobs during university, moved out on my own, got a job...in some ways, I desperately tried to be "normal". I didn't want to ruffle feathers around me because it was so important that people liked me. However as I learned more and more in university I did start to take a stand. For example while studying biomechanics it seemed that all the examples given to us were from elite sport. Can we figure out  a way to get this triple jumper to jump 2 cm further? Can we change the free style swimming stroke to shave off 1/10 sec? Did I really want to spend my career doing these things? I wanted to figure out ways to make kids with cerebral palsy or spina bifida walk a block instead of 2 metres. I wanted to see a child in a wheelchair be able to propel without getting shoulder pain. I'd love to know if new ergonomic crutches really can make a difference to those with amputees. The more I work in this area the more passionate I get but I am not attending city council meetings for better access. I don't nag when barriers are in my way, because I am not the only person.
Maybe I am too  quiet at times and don't speak up for those less fortunate. I'm not always the best advocate for disability issues but  I do believe quiet subtle education can make a difference in the long run. Educating our future doctors about patients who live with chronic illnesses and disabilities through our Health Mentors Program at UBC, will hopefully help change the attitude towards disabled patients struggling to manage their disease day after day. Educating future engineers, kinesiologists, physiotherapists, occupational therapists and professors about how to address people with disabilities and include them in research and other decisions about their lives will build up this community instead of continuing to oppress them, labeling them as unfortunate patients or just research subjects to study.
I admired my friend who passed away this week - his zest for life and quest for justice. He did what he knew how to do. I hope that I have that same zest and tenacity to slowly work for change so that folks with mobility impairments or other disabilities know they matter and their lives are of value. I know my life matters.

Are we making a difference?

I’ve just spent the last two weeks traveling in the U.K. and Europe for meetings, conferences and visiting friends. It was exciting to see the research that people are doing in other countries pertaining to mobility and improving function for people with spinal cord injuries. However once I got outside  the sheltered world of the research centre, hospital or conference centre the environment that people must negotiate is still challenging. There are many considerations being made such as more lifts (elevators), slopes to curbs, and automatic doors that make life easier but because it is still inconsistent whether an accessible route is available it is always a guessing game how we might get somewhere. Also because the cities are historically old, they keep the old cobblestone look even though they are the most difficult surface to negotiate and are actually painful. It’s painful to be the one in the chair and painful for my husband pushing, if he’s available.

The dichotomy between the precise research that we do both in my lab and in the labs in Europe and the real world leave me to think are we really doing the right research. Yes, I am a biomechanist and forces and angles are what I like to measure, but can I really make a difference when the lab does not reflect the true world? I am so fortunate to have a relatively easy life in Vancouver where accessibility is pretty much expected in almost every public venue so maybe I am only reflecting my work to what I see at home. But, when I travel it is so much different. Even Europe has developed standards for accessibility that have come a long ways. I was able to see a lot compared to what I might have seen 20 years ago, but the developing world has even more barriers  for people with disabilities, not just physical barriers but social and attitudinal barriers. Are we making a difference?