It’s interesting to note that when I write, my inclinations are to use scientific principles and logic to make an argument. However, from my work with the Worcester Free Clinic Coalition, I’ve learned that this technique doesn’t always work. I’ve recognized the need to carefully understand your audience, who they are, what knowledge they will come with, and never write for the “general population.”
One piece of advice that I learned from my rhetoric classes is this: when you define your audience as the general public, your audience is actually you. There is no such thing as a true “general public” and so when we think this way, we are actually imagining others through our own lens. Rather, we should carefully consider the audience and stay away from thinking that a piece is written for the “general public.”
One of the most important considerations in writing is the emotional context. As humans, we are not nearly as rational as we would like to think.
I have a deeply ambivalent relationship with electronic medical records systems, or EMRs. Initially, like many young people, I was completely on board with the transition to paperless and the efficiencies that come with it. However, my stance has changed during the course of my work at the free clinics in Worcester.
A lot of the clerical volunteers are older folk—people who are quite skeptical of technology. The physicians, too, are hesitant to embrace EMRs in the free clinics because of their constant struggles with the systems in their day jobs. In his well thought out and in-depth article, Dr. Atul Gawande describes the dangers and pitfalls of EMRs. Specifically, he mentions how EMRs are in fact a big contributor to physician burnout as a result of excessive record keeping and administrative burden that falls on the shoulders of physicians.
The physicians at the free clinics explain that the biggest reason why they enjoy volunteering is that they can practice true medicine without being encumbered by the unnecessary complexity of EMRs. Instead of staring at their screen trying to document patient encounters writhing the 15-20 minute time slot allotted, physicians can be more present with the patient, carefully listening to their story. This personal touch is why many doctors decided to pursue medicine in the first place, and EMRs should not take that away.
This is one big benefit of the free clinics, that doctors can devote their full time to listening to patients, answering their questions, and understanding their situation. They have a piece of paper in front of them rather than a screen and keyboard. They enjoy the freedom of being unshackled from their computers and electronic medical records systems.
Yet, all of these physicians also recognize the immense benefits that EMRs provide. Being able to quickly look up past patient records, even from different providers is incredibly useful. Automatic prompts that remind physicians to ask questions if a patient is at-risk can catch some maladies that might easily go overlooked without such systems in place.
Communication in medicine is critical to patient care. In fact, one of my past projects was to design a mobile application, quite akin to a pared-down EMR, for the labor and delivery ward to make patient handoff between providers easier and less prone to user error. A big challenge that we faced was ensure in that the system does not get in the way of patient care. We knew that often, software causes more problems than it solves, even if well-intentioned. So we put a lot of effort in observing the workflow of physicians and nurses to see where we can make a difference and where we need to make adjustments once our software was put in place.
There are times when there is utility for EMRs, even at the free clinics. For example, EMRs can be used to collaborate between clinics where patients may not be able to return to the same location or time due to transportation issues or scheduling issues, allowing them to easily come in where is most convenient. This alone would be immensely beneficial to patients, especially when the patient population is prone to not following up. Even just pulling charts from the filing cabinets, because sometimes they get lost, or are filed in the wrong area, or a patient used a different name. Having an EMR would probably alleviate 99% of all of those problems and save countless hours of work. However, careful, diligent testing and making sure that the EMR actually is is solving the problem rather than creating more problems is absolutely necessary.
And so there’s this dichotomy of whether we should actually use any EMR system or not. I really don’t know what the right answer is. I think both have their pros and cons and I think there should be more debate. I love the fact that Epworth is doing a pilot study to figure out the best way to implement an EMR system.
My mother, a primary care physician, comes home every day with a multitude of notes left over to finish. She wants to spend more time with her patients, and I talked to her about this because user experience design and software development is an area that I’m interested in (particularly after my time working in the labor and delivery ward) and so I knew a bit about what goes into an EMR system. She told me how she doesn’t even bring her computer in, instead choosing to just bring a clipboard and some paper so that she can be fully present with the patient. There’s a computer in the room, but she only uses it if she needs to look up something that she didn’t jot down before entering.
And when I talk to the doctors and volunteers at the free clinics, where they still use paper, they consistently tell me how refreshing it is to go back to the original practice of medicine where EMRs aren’t getting in the way. I worked as a chart puller when I started volunteering, and still do when when the clinic is packed, and that’s when I think to myself, “maybe an EMR wouldn’t be so bad—I wouldn’t have to do all of this running around to find a specific chart.” But every time, I quickly realize that it would just cause even more problems with burnout and the volunteers likely wouldn’t want to come in. Patients would lose out on the personal connection with the physicians that the free clinics are able to provide.
This is ultimately why I think that EMRs, and specifically human computer interaction, is becoming a big problem in medicine. It’s contributing to physician burnout, worse patient outcomes. Importantly, though, it’s also a problem that we can reasonable work towards a solution and eventually solve. There are so many benefits to EMRs, but we should make them work for doctors, not the other way around.
To say that “the future belongs to generalists” betrays an unfortunate truth of modern technological development and scientific inquiry. We have reached a point of dichotomy where the frontiers of research have become the domain of super-specialists. Just publishing a paper now requires extensive understanding of very in-depth phenomena, rather than the type of brilliantly simple science of the superstars that we now look up to such as Maxwell, Bohr, Flemming, and Snow.
However, invention is beginning to slow. Society has matured, and some argue that American society is becoming decadent and repetitive. Marques Brownlee asks if we’ve reached “peak car” in his video. And ultimately, this article continues this discussion. While reaching the peak is not necessarily a bad thing, it does mean that the past few decades represent a transition to innovation.
Innovation is the domain of generalists, Mansharamani summarizes, in an insightful metaphor:
Breadth of perspective and the ability to connect the proverbial dots (the domain of generalists) is likely to be as important as depth of expertise and the ability to generate dots (the domain of specialists).
[. . .]
The skill of generating dots is losing value. The key skill of the future is, well, not quite a skill; it’s an approach, a philosophy, and way of thinking — and it’s critical you adopt it as soon as you’re able.
However, there is a lot of nuance involved that precludes a simple black and white understanding. Science will continue to require ever-increasing expertise to remain at the forefront. Even in medicine, healthcare of specific diagnoses is now relegated to specialists.
While the idea of specialization certainly exists in every field, it is especially evident in medicine with the drastic rise in specialists required to treat patients. In fact, I’ve written extensively about the topic. Unfortunately, I’m not sure that an adequate solution exists other than better collaboration and a renewed focus on primary care.
We may take a page from history and embrace the ideals of the “Renaissance Man.” Britannica explains that the “gifted men of the Renaissance sought to develop skills in all areas of knowledge, in physical development, in social accomplishments, and in the arts.” Perhaps this is the way forward.
Storytelling is something that is shared across the human experience. All of us have been inspired, or awed, or frightened, or intrigued by stories. There is one thing that storytellers have in common—an incredible imagination.
They allow their thoughts to wander, and importantly they are able to capture them for the future. This ability lets them develop them later, to dream and dream with such fidelity that they resonate across the human experience. These are the most powerful storytellers.
For me, the magic of cinema is a result of the balance between the artistic and the technical. You have to tell a powerful story, but breathe life into it the through actors and actresses, lights and cameras, sets and visual effects, music and sound. You have to use those tools to make something powerful to humans, and that requires and understanding of people. You need to be aware of how people think, how they make connections
When these things come together, cinema can be transformative. It allows us to wield the power of emotion.
We are often confronted with tragedies throughout the world that are challenging to comprehend. The abstraction of such adversity presents an often insurmountable obstacle to action. Elizabeth Dunn, a researcher studying the science of giving and happiness, asks, “if any of us had been asked to donate 15 hours a month to help out with the refugee crisis, we probably would have said no.” But, she explains, when people can “easily envision the difference they [are] making” and feel “a real sense of connection,” they are much more willing to help.
Cultivating a meaningful connection between members of society allows us to work together to address challenges that can sometimes feel overwhelming, such as the social determinants of health that affect the uninsured and underinsured patients coming in to the free medical programs. The volunteers are uniquely positioned to see the impact that their work has on the lives of patients. Part of their role is to listen to the stories of the patients that walk in. They engage with patients and are deeply embedded in the community.
However, this doesn’t translate particularly well to those on the outside. The hurdles that patients face are not easy to understand from a perspective of privilege. The vast majority of Americans will not be disenfranchised from the healthcare system. They will not face the difficult decision of forgoing medicine or treatment for food on the table, a roof over their heads, or books for their children. Yet, their contributions, whether through donations, volunteerism, or subsidized services for patients, are essential.
Often, we fall into the trap of thinking of charity as something that we have a moral obligation to do. But we should not forget the incredible joy that comes from helping others. This is especially true if we do it, as Dunn notes, by creating opportunities to “appreciate our shared humanity.” This appeal is reinforced through millions of years of evolutionary biology, as human society was built on foundations of collaboration and cooperation. We find happiness in helping one another and the human brain is highly attuned to the personal connection that comes as a result. Here, Canadian writer Marshall McLuhan’s suggestion is apt, our medium, volunteering and working to reduce the healthcare burden among the most vulnerable, truly is our message.
Medicine, and especially the work of free clinics, lies at the intersection of science and humanity. Science is built on logic and observation, which have proven to be powerful tools to improve our understanding of the world around us. However, to most people, data and statistics are nothing more than abstractions that are difficult to relate to. Recognizing our own humanity allows us to wield the incredible power of stories to move people to tackle complex and nuanced issues.
As medicine continues to evolve, a new philosophy that embraces stories is taking hold in opposition to the impersonal style of medicine that has become increasingly common throughout the United States. Narrative medicine, championed by Dr. Rita Charon at Columbia University and Dr. Lisa Sanders who writes regularly for the New York Times, invites physicians to think of listening to patient stories like reading a mystery novel. While this concept may sound strange at first, there are many parallels that solidify her argument. For example, Charon argues, “‘You have to be so present, so alert, with your curiosity so intact [and] you have to assume that the narrators are going to mislead you. When a patient tells you what happened, you’re going to hear the opposite story from their mother or neighbor.’ Doctors, like readers, have to take in all the different narratives and resist the urge to immediately say which is right with premature certainty.”
This approach requires time, something that can be hard to come by in modern primary care offices and emergency departments. Instead of spending time with patients, doctors often must deal with excessive administrative work, much to their chagrin. Dr. Atul Gawande argues that dealing with insurance, billing, and inputting patient records are a big cause of physician burnout. He backs his argument with a 2016 study that found physicians spend two hours on the computer for every hour with patients. The volunteers at each of the free medical programs take pride in the fact that they can take the time to listen deeply to patient stories and it’s an important part of their work.
Listening to these stories helps to hone awareness to a greater Truth, one that requires interpretation and careful judgement. The stories of patients help paint a picture of society where certain communities are disenfranchised and have disproportionate struggles to access quality healthcare. They highlight the importance of the work that the free medical programs do and are an incredibly powerful tool to bring people together to effect change.
The importance of stories is twofold: (1) listening to patient stories is a big part of the free medical programs and narrative medicine can improve patient care and (2) stories can be used to move people to take action in a way that data and statistics cannot.
Dunn points to an example where two charities in similar lines of work, UNICEF and Spread the Net, exhibited completely different responses when people donated the same amount. Most people might think, she argues, that UNICEF is so broad that a small donation probably won’t make a big difference. Spread the Net, however, offers “a concrete promise: for every 10 dollars donated, they provide one bed net to protect a child from malaria.” She found that people are happier when they give to organizations, like Spread the Net, where they can easily envision the difference that their contributions will make.
This subtle contrast makes a big impact for organizations. Based on her research, Dunn specifically advises organizations to reward donors and contributors with “the opportunity to see the specific impact that their generosity is having.” In this regard, the free medical programs have a powerful tool to wield: the stories of the community. This must be done carefully, of course, out of respect for patient privacy. But the stories of patients are consistently a big reason why the volunteers continue to do their work. The volunteers feel a real sense of connection with the community and with the individual patients that they speak to. When done well, stories can become a major driving factor of change.
We would love to hear your ideas and suggestions to demonstrate the impact of the free medical programs on our community. Please send any comments to firstname.lastname@example.org.
In this TED talk, Elizabeth Dunn discusses her research showing that personal connections when giving make a big impact on our happiness and discusses her own experiences with sponsoring a Syrian family in Canada.
Dr. Rita Charon is a pioneer of narrative medicine, an approach to medicine that likens seeing patients to reading novels. She emphasizes how listening to patient stories in this way can make medicine better for patients and physicians alike.
Note: this is a piece of fiction that I wrote for a project.
Every few days the brewery received complaints from the tenants next door. One day it was the ants all over the floor, seeping out from under the shared wall and disturbing the frightened third grade teachers and her squeamish students. As the evening wore on, a few fifth grade boys thought it would be funny to leave squashed ants all over the floor, hoping to hear the childish screams of the next class of sixth graders as they walked down the almost painfully bright hallway towards the packed waiting room.
Almost seven, it was just past rush hour. A line of cars backed out into the parking lot of the brewery next door, adding fuel to the daily battle between the two tenants. The setting sun streamed through the glass walls of the waiting room, and the students bustled about trying to get a good view out the windows to look for their parents’ cars.
One of the fifth graders opened the door to the waiting room and stood aside to let the others through. She looked outside, but the hard glare made it difficult to see easily. She glanced at her phone, hoping to see an unread notification from her mom who was supposed to pick her up. Alas, nothing. And so, her mind wandered, her gaze flitted about from face to face at her peers laughing at each other’s jokes, discussing their antics from the class. Two friends stood in the corner near the sign in window, intently discussing a problem that stumped them earlier in the day. She noticed a small ant, crawling near their feet. It wandered, looking for something to eat. A few others followed, making a distinct line.
Even more followed, and she noticed that they seemed to be coming from a small gap between the wall and the tiled linoleum floor. Amidst the commotion of the waiting room, she barely noticed the sweet smell from the brewery. It seemed that everyone had gotten used to it, but looking at the ants made her more aware of its particular odor. It seemed familiar to her, reminding her of the small gatherings her parents often held with friends, often late into the night.
Next door, the sweetness was far more pungent. The warm glow of the brewery lights spilled over onto the sidewalk right outside, complementing the rapidly waning sun and the deep purple sky. The glass walls overlooking the same parking lot were covered in condensation. A result of the brewery keeping their humidity and temperature just high enough for the yeast to be comfortable. The distilleries hummed in the background, so the employee giving the tour spoke loudly at the visitors. As the tour made their way towards the distilleries, a couple towards the back whispered to one another.
The husband seemed meek at first glance, his hands placed firmly in his pockets. His dress was odd, with well-worn jeans, but a collared shirt neatly tucked in. His appearance belied his deep expertise in the brewing process. As he joked with the others in the group, his wife smiled, and though quiet, she had an air of mischievousness about her. In the heat of the brewery, she unzipped her company jacket, clearly emblazoned with the logo of the pharmaceutical company with offices and labs just up the street. They both had just arrived after work, passing by the bridge and a Starbucks that had recently opened up.
Earlier that day, both were working in the lab on an experimental biologic that could degrade membrane-spanning receptors. It was accidentally discovered a few years ago in the adjacent building by a group of chemical engineers working on increasing production rates of the company’s bioreactors. The engineered yeast cells expressed a chimeric antigen on their surface, patented by the company. This was used to help degrade the yeast quickly and extract the biologic, but without adding surfactants or other contaminating chemicals. Their system used hijacked chimpanzee macrophages to quickly destroy the yeast cells by phagocytosis, but it seemed that it was working too well. . . .
One of my past projects was developing a more effective solution to live patient updates in the labor and delivery ward. During that process, we observed the flow of patient information from one provider to the next, all in two places: pieces of paper scrunched up in the pockets and labcoats of providers, or on Epic’s software.
What does the company behind it look like? Kate Kelly compares it to Willy Wonka’s chocolate factory:
In the farm country of southern Wisconsin, 12 miles from Madison, is one of the nation’s biggest tech companies — and almost certainly the quirkiest. The woman who controls it is a septuagenarian coding savant, its campus contains a human-size rabbit hole and an elevator to hell, and in all probability your personal medical records are on servers running its software.
[. . .]
Epic’s software is ubiquitous in doctors’ offices and operating rooms, and companies like Amazon, Microsoft and Alphabet regularly hoover up its young engineers. Yet most people outside of the Madison environs, I’d be confident to say, have never heard of the company.
I certainly hadn’t. I cover Wall Street, not health care or technology, and when I came across the privately held Epic this year I was consumed with questions. Who was this publicity-shy yet spectacle-loving C.E.O., and how did her theme-park sensibility coexist with the mundanity of health care billing protocols? Was Epic’s odd culture a magnet for talent and clients, or was it an indulgence that kept the company from growing even bigger? In August, I traveled to Wisconsin to see what this 1,100-acre Midwestern behemoth might be hiding.