Visual Rhetoric

The modern world hinges on the ability to create better user experience through carefully crafted design.

Inane

Running every day, in naught but vain,
Visceral desires and futile pursuits,
Love, unrequited, is blissful pain.

What Storytellers Have in Common

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.

A Saccharine Explanation of Chirality

How Stories in Medicine Connect Us

Note: This article was originally published as part of the Q4 2019 issue of the WFCC Newsletter and is reproduced here with permission. See original: http://www.sahilnawab.com/wfcc/q2_2020.pdf

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 worcesterfreeclinics@gmail.com.

Dossier

“Helping Others Makes Us Happier — But It Matters How We Do It,” by Elizabeth Dunn, April 2019. https://www.ted.com/talks/elizabeth_dunn_helping_others_makes_us_happier_but_it_matters_how_we_do_it

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.

“This Doctor is Taking Aim at Our Broken Medical System, One Story at a Time,” by Sigal Samual, March 5, 2020. https://www.vox.com/the-highlight/2020/2/27/21152916/rita-charon-narrative-medicine-health-care

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.

“Why Doctors Hate Their Computers,” by Atul Gawande, November 5, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers

This article examines how, despite their utility, electronic medical records can often be a hindrance to patient care and contribute to physician burnout.

Classroom Ants

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. . . .

Whimsical Software

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.

Kate Kelly

Dossier

“Willy Wonka and the Medical Software Factory,” by Kate Kelly, December 20, 2018. https://www.nytimes.com/2018/12/20/business/epic-systems-campus-verona-wisconsin.html

Is it Time for FaceTime?

On the heels of the tenth anniversary of the introduction of FaceTime by Steve Jobs, most people rarely video call, argues Ali Drucker. Despite a recent surge due to the pandemic, “Zoom fatigue” often sets in after only a half hour of continuous video calls. It’s surprisingly exhausting. Why?

Perhaps it takes much more mental effort, creating a space and a neat background, touching up appearances to make sure we’re presentable, adjusting lighting, and constantly paying attention. But now during the pandemic, there is renewed interest in video calling, connecting with others digitally when we can’t do so physically.

Somehow, even though I rarely saw my New York friends in the Before Times, I’ve been missing their faces more. Their wisecracks and constant, clever one-upmanship. All the while, I could have just asked for this — a modest video call to catch up — whenever I wanted to. But I didn’t. And if you’re a bit like me, you probably didn’t either.

[. . .]

So why, actually, are so many of us only just now making video calling a habit? Did I really not see my parents’ faces for months on end, even over a screen, simply because I had the option of socializing with my partner and nearby friends instead? Was I actually “just super busy” or did I want to avoid confronting how much I missed them? How I was quietly nursing the loneliness of feeling like I might not truly know the people I can’t see in person anymore.

Amid the continuing carnage in this country, I can’t bring myself to make a rhetorical turn toward a silver lining. The pleasant paradox of families and friends like mine getting in more quality time in the age of social distancing feels moot when there’s a national reckoning on racism and the scourge of police violence against black people; when every day thousands of people are still contracting a disease that could kill them — that has already killed more Americans than several wars did. There is no public plea here to boldly carry this newfound sense of connectedness with us into the new normal, whatever that is.

For me, that kind of optimism would be a sleek betrayal, albeit a convenient one: Focusing on the good in all of this would be much easier than admitting the truth — that I could have reached out to my loved ones at any moment, but didn’t until this pandemic made me feel as though I was hanging on by a bare thread.

Ali Drucker

Dossier

“Why Weren’t We Video Calling All Along?” by Ali Drucker, June 15, 2020. https://www.nytimes.com/2020/06/15/opinion/covid-video-calls-zoom-facetime.html

“Why Zoom Meetings Can Exhaust Us,” by Jeremy Bailenson, April 3, 2020. https://www.wsj.com/articles/why-zoom-meetings-can-exhaust-us-11585953336

“Why Does Zoom Exhaust You? Science Has an Answer,” by Betsy Morris, May 27, 2020. https://www.wsj.com/articles/why-does-zoom-exhaust-you-science-has-an-answer-11590600269

From the Helicopter to the Hospital

One of my aviation friends discussed with me the incredible advances in night vision technology in recent years. Only a few days later, we visited the LifeFlight program at UMass and were treated to an amazing demo of the helicopter and a conversation with the pilots, mechanics, nurses, and paramedics that make the whole program run.

The pilot explained that, without night vision technology, they would not be able to land in adverse conditions, pointing out that they don’t have runway approach lights in the fields and roads that they land on to bring patients in.

I imagined one of my own flights. The setting sun peeking behind the wispy clouds; the turn onto final as the approach lights flit towards the runway; slowly gliding down towards the ground; winding down with friends after a fun evening flight.

Then I pictured the harrowing image of rain beating down while the rhythmic thump of helicopter blades overshadow the blaring siren of an ambulance; three paramedics stand soaking wet protecting the stretcher from the downdraft as the patient is loaded in. (See the Prologue of Jurassic Park, the book) The stark contrast between the two images reminded me of the stakes.

Image: Sam Aldon, New York Times

The same scene unfolds half an hour later at the entrance of the hospital:

My office overlooked the street in front of the hospital. After half an hour, I looked down to see the surface of coffee in my mug rippling like in the scene in “Jurassic Park” where the approaching T. rex’s footsteps are detected in puddles of water. Within seconds, there were rhythmic pulsations all around, then a strong thump-thump-thump-thump as the air beat against my window. Outside in the midst of the downpour, trash cans tumbled down the street and pickup trucks were forced down on their shocks. I gazed up to see an Army Blackhawk helicopter, giant in comparison to our standard medical helicopters, hovering steadily over the children’s hospital helipad, rain and fog swirling in all directions. Every part of the office thumped, the heartbeat in my own chest now overpowered.

[. . .]

The operating room team was ready for the girl, the sterile instruments laid out on the back tables, blue drapes applied after a quick clipping of her hair and lightning-fast wash of her head with sterilizing prep solution. Knife. Retractor. Drill. Scissors to open the dura, the thin leathery covering of the brain, bulging and tight from the underlying blood. Once the brain is exposed it does the work for us, extruding most of the coagulated clot in a matter of seconds. We clean out what is left at the edges and I see the offending vein, torn away from the brain during the accident. We coagulate it and begin to make our way out, step by step, gently repairing all that we had to take apart to get there.

[. . .]

A decade and a half after her injury I received one such letter. No longer the hand-drawn cards of childhood or newspaper clippings from her proud parents, this was a handwritten note on elegant stationery inviting me to her wedding. Her wedding. I could still see her in the bed of the pediatric I.C.U. after surgery, a 9-year-old child with abrasions on the side of her face from the accident and a clean white head wrap around her head. The nurses methodically connecting her to the monitors, line by line, tube by tube. Me urging her to squeeze my hand, for a sign, any sign, that she was better. Now, years later, I was reading how thankful she was to have been given this chance. Grateful for those soldiers in that helicopter, the two hospital teams, and for me. She promised to always have us in mind as she began her new married life and hopefully one day raise her own family.

As I read the letter sitting in a different office in a different city, thinking back over those events, I found myself realizing how deeply grateful I was to her, for her evolving story over the years — all the cards, each barrier broken, every milestone — and for what that experience taught me. So many other critically ill children in the subsequent years benefited from this early experience, when I was learning how hard to push, where to draw the line and how much to expect of others.

My father’s lessons in the air, that industrious emergency room doctor, those brave soldiers soaked to the bone standing there as we rolled away — so many people and events came together for this one child to grow into her life, to find happiness, to find love. All of us need a living, breathing reminder to just keep pushing on. There may be a life there to be beautifully and fully lived, a person who just needs someone, anyone, to work the problem, to make the hard call, and to fly in a storm.

Jay Wellons

From this, I am reminded of the incredible cooperation that we are lucky to have here.

Dossier

“From Blackhawk to Brain Surgery to Bride,” by Jay Wellons, February 29, 2020. https://www.nytimes.com/2020/02/29/opinion/sunday/doctors-medicine-military-emergency.html

The Humble Mask

Moving Away from Nosology

Medicine is a privileged field. Every day, patients place their trust and lives in the hands of physicians. As a result, physicians have a responsibility to society, and that includes being aware of their own biases and mitigating their effects.

Nosology: the branch of medicine that deals with the classification of diseases

Despite this, disparities exist. For example, black women are much more likely to suffer from complications during childbirth. Even more troubling, is that they are also less likely to be listened to by doctors.

On Sept. 2, the day after giving birth to her daughter via cesarean section, Ms. Williams was having trouble breathing and “immediately assumed she was having another pulmonary embolism,” the article says.

She alerted a nurse to what she felt was happening in her body and asked for a CT scan and a blood thinner, but the nurse suggested that pain medication had perhaps left Ms. Williams confused, according to Vogue. Ms. Williams insisted, but a doctor instead performed an ultrasound of her legs.

“I was like, a Doppler? I told you, I need a CT scan and a heparin drip,” Ms. Williams, 36, said she told the medical team.

When the ultrasound revealed nothing, she underwent a CT scan, which showed several small blood clots in her lungs. She was immediately put on the heparin drip. “I was like, listen to Dr. Williams!” she told the doctors.

Maya Salam

Athletes like Serena Williams are particularly tuned in and aware of their bodies. Of anyone, they would be most likely to understand when things feel wrong or abnormal.

There is a movement to move medicine and the role of the physician away from the age-old idea of the nosologist. Medicine in the past was about the heroic physician-scientist; the idea that doctors are there to solve puzzles, make diagnoses, classify diseases, rather than treat patients. That job is supposedly for nurses and other healthcare professionals. That philosophy of medicine is slowly going away, as medicine as a whole is becoming more humanistic and empathetic.

There is still a long way to go. However, I think we are on the right path and are continuing to move forward. Ultimately, it is important to recognize that it is our human experience that brings us together. While physicians are certainly not immune from bias, they take pride in being able to recognize that patients come in with complex and nuanced issues, including the social determinants of health.

Hospitals are one of the very few places left where you encounter the whole span of society. Walking the halls, you begin to understand that the average American is someone who has a high-school education and thirty thousand dollars a year in per-capita earnings, out of which thirty per cent goes to taxes and another thirty per cent to housing and health-care costs. [. . .]

Most people don’t have this broad vantage. We all occupy our own bubbles. Trust in others, even our neighbors, is at an historic low. Much of society has become like an airplane boarding line, with different rights and privileges for zones one to ninety-seven, depending on your wealth, frequent-flier miles, credit rating, and S.A.T. scores; and many of those in line think—though no one likes to admit it—that they deserve what they have more than the others behind them. Then the boarding agent catches some people from zone eighty-four jumping ahead of the people in zone fifty-seven, and all hell breaks loose.

Insisting that people are equally worthy of respect is an especially challenging idea today. In medicine, you see people who are troublesome in every way: the complainer, the person with the unfriendly tone, the unwitting bigot, the guy who, as they say, makes “poor life choices.” People can be untrustworthy, even scary. When they’re an actual threat—as the inmate was for my chief resident—you have to walk away. But you will also see lots of people whom you might have written off prove generous, caring, resourceful, brilliant. You don’t have to like or trust everyone to believe their lives are worth preserving.

[. . .]

I didn’t understand him or like him. But all it took to see his humanity—to be able to treat him—was to supply that tiny bit of openness and curiosity.

Atul Gawande

Dossier

“Curiosity and What Equality Really Means,” by Atul Gawande, June 2, 2018. https://www.newyorker.com/news/news-desk/curiosity-and-the-prisoner

“For Serena Williams, Childbirth Was a Harrowing Ordeal. She’s Not Alone,” by Maya Salam, January 11, 2018. https://www.nytimes.com/2018/01/11/sports/tennis/serena-williams-baby-vogue.html

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