“Something Happened…”

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Sometimes things happen that we can’t fully explain!

That’s the point of an excellent recent commentary by Ray Waddle, one of the sharpest religion commentators in secular media today: In keeping with the season, Waddle is referencing the inexplicable, world-changing events of the Passover and Easter narratives. But a recent episode at Siloam highlighted this point as well.

The following anecdote about a seemingly inexplicable healing of a patient is shared by retired local endocrinologist, Vanderbilt faculty member and regular Siloam volunteer, Dr. Alan Graber. Whatever happens with this patient–and whatever you make of his story–it undoubtedly represents a fascinating interplay of faith, health, and culture!

Dr. Graber writes:

Today I witnessed a miraculous event.

One of my patients at the Siloam clinic this morning was a young Egyptian Coptic Christian man. The Coptic Christians are a minority in Egypt and are persecuted there. From what I understand, their religion is more similar to the Eastern Orthodox than to Roman Catholicism. Many live in a tight community in Nashville, they are an educated, hard-working group, and many who are uninsured receive their health care at Siloam.

My patient had the abrupt onset of severe, symptomatic diabetes last summer, and rapidly lost about 30 pounds. He was hospitalized at Vanderbilt, and when discharged he was taking 3 injections of insulin daily. I first saw him at Siloam in October. He had stopped his insulin and was doing fine without it. In fact, his blood sugar was normal. A few weeks later he stopped his pills for both diabetes and hypertension, and both of those conditions have remained normal for the past 3 months. He feels and looks fine.

Today he asked me if I had time to hear what happened to him. When I said I was definitely interested, he told me. After he left Vanderbilt Hospital but before he first saw me, he had a dream about Baba Kyrillos. Kyrillos is apparently a frequent name among his people, in fact, his son is named Kyrillos.

Baba Kyrillos was the Pope and patriarch of the Coptic Orthodox Church. His real name was Pope Cyril VI of Alexandria. He died about fifty years ago. Countless miracles were felt to have occurred both during and after his lifetime, attributed to his intercessions. My patient’s dream of Pope Kyrillos was that Kyrillos pinched his pancreas and told him that his diabetes would be cured when he awakened. Sure enough, it was. The next day he stopped his insulin shots without ill effects. He did not mention the dream to me at our first visit. He believes fervently that he has been cured.

Sometimes children who develop severe diabetes develop a spontaneous remission and are able to stop taking insulin for a few months. Medical people call this a “honeymoon” because, like all honeymoons, it doesn’t last long, and the diabetes always recurs. During the honeymoon period the islet cells in the pancreas recover the ability to secrete insulin temporarily. I have seen thousands of adult patients with diabetes over the past 52 years and have never witnessed or heard of a honeymoon or a remission like this. I told the Evangelist chief doctor and chaplain at Siloam about this, and they smiled knowingly, as though they weren’t surprised at all. We’ll see what happens…!

Turn or Burn…!

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No, this is not a blog featuring a scraggly preacher delivering a “Hellfire and brimstone” sermon. But it’s close…:)

Do you have any idea what an “Escape Fire” is? I didn’t until last week. Apparently it is a radical technique used by firemen caught in a rapidly encroaching forest fire. When they sense they have no chance of outrunning the flames they light a small, controlled fire around themselves to burn up the nearby tinder. When the huge fire engulfs their area, the resultant bare spot becomes a safe haven which can save their lives.

This Saturday evening at 7 and 11pm (CST) CNN will be showing an award-winning documentary entitled “Escape Fire.” The film is about a different type of disaster that is rapidly engulfing our nation–the healthcare spending crisis. The point is that the crisis is so out of control that we need to start lighting metaphorical “escape fires” to avoid getting consumed!

Siloam Family Health Center has been one such “escape fire” for thousands of uninsured–and desperate–Nashvillians. The Siloam Institute seeks to provide a similar kind of oasis for potentially jaded health care professionals in training. We offer transformational learning experiences which help them to step out side the “Matrix” of consumeristic, industrialized medicine and to reengage the practice of health care for whole persons.

Although the film has its limitations, it is a provocative, engaging, and even-handed examination of the issues, and I would highly encourage you to check it out–either in a viewing on CNN this weekend or by streaming the video on your personal computer.

If you get a chance to see it, we’d love to hear you thoughts. Perhaps if enough “escape fires” are lit, we may one day put an end to this mess…

Unlearning “Bobble Head Medicine”

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By Morgan Wills

The case revolved around an experience I had caring for a patient late one night in the emergency room at the VA hospital several years ago. A young man with a history of a brain tumor (a “frequent flyer,” according to the nursing staff) had come in yet again complaining of vague symptoms and demanding an MRI to rule out a recurrence of his tumor. There was no clinical evidence from the workup to do so, and I was tempted to just send him on his way. But a gnawing sense of conviction led me to stay up late and pursue the patient on a personal level in a way which transformed the experience for both of us—and helped the VA team care for him better (and more cost-effectively) in the future.his past Monday I had the chance to share at the first of a series of lunchtime presentations at Vanderbilt Medical School about the joys and challenges of Whole-Person health care (WPHC) Although we write and speak about this concept a lot at Siloam, it was good to have the opportunity to articulate some of this approach in the academic setting as well.

Below are a couple of highlighted principles from what we covered.

1. Most clinicians (including myself) are trained in a way that prioritizes cognitive knowledge and technical competence over human interpersonal skills. This results in doctors who are a lot like “bobble-heads.” You know: the little dashboard toys that bobble from side to side with the movement of your car because of the weight of their disproportionately huge heads? Too often, that’s us! So, like our patients working through the 12 steps, the first step in WPHC is to admit we have a problem!

2. A second, and related, point is that WPHC begins with tending to our own personhood. Mindfulness, or the practice of fostering deliberate awareness of what’s happening inside ourselves, is a key first step. For good and ill, we bring desires, moods, and agendas (some might say, baggage!) to the clinical encounter that inevitably frames what we will find there. There is no such thing as a completely neutral clinical encounter—just more or less transparently personal ones.

In the next installment, we will consider some more principles from this case. In the meantime, I want to leave you with a link that dramatically highlights how our brains filter and/or frame reality. It’s a review of a fascinating story of a non-religious neurosurgeon reflecting on how his near-death encounter helped him to see how our brains can “screen out” spiritual realities that are right in front of us…

The Nashville Fellows Program

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In addition to our Community Health Immersion program for next summer, there is another, exciting new initiative in Christian formation starting in Nashville in 2013.

The Nashville Fellows Program is a new leadership development initiative for recent college graduates that is spreading across the United States.  Three different local congregations (Christ Presbyterian, West End Community, and St. George’s Episcopal) are partnering in ecumenical fashion to introduce the program, which offers a dynamic combination of theological training, discipleship, and workplace internship experience over a period of 9 months beginning shortly after students graduate from university. Think of it as a little bit of a year-round Immersion program without the refugee apartment complex!

This program is obviously not restricted to pre-meds, but those with an interest in health care are certainly welcome to apply and may end up doing their 25hr/wk internship at Siloam or a like-minded setting in 2013-14. Please forward this link along to any current college seniors whom you feel would be interested to learn more!

Sabbath Science

ImageMorgan Wills writes…

Sometimes science and wisdom converge!  A  recent study published online by the journal Academic Medicine confirmed what many of you may have suspected all along: “a short, midday nap can improve alertness and cognitive functioning.”

Tired first-year resident physicians everywhere may soon be clamoring to implement the protocol of this study, where a placebo-controlled sample of their peers were instructed to take a 20 minute nap in a reclining chair after lunch—and found to have better reasoning and fewer attention failures through the rest of the day.

But the rest of us should probably take note as well.  There are well-known physiologic factors which justify some modified version of the well-established practice of “siesta” that is practiced throughout many Latin cultures.  But until I met an accomplished physician who routinely wove a mini-nap after lunch into his work schedule, I’d never dreamed that such a practice might be feasible for a practicing clinician. 

Ironically, this particular doctor learned the practice on a birding trip to the Arctic Circle with one of the most prominent theologians of the 20th c., the late Anglican leader John R. W. Stott.  After setting up camp together, the esteemed teacher curled up unannounced on the tundra and quickly fell asleep for 20 minutes!  When his physician colleague learned that the incredibly busy and productive theologian had practiced the rhythm of a daily “kip” for decades, he realized that perhaps even a practitioner in the 24/7 world of modern medicine could benefit from acknowledging his limits in such a humble, regular way.  For him it was a daily extension of the biblical concept of Sabbath—regular patterns of rest which acknowledge the simple truth that we are creatures, not mini-Gods.

So, have we set up a cot in the back room at Siloam yet?  Let’s just say that we have a committee working on a proposal!  In the meantime, we can all stand to ponder the wisdom of Sabbath.  As Wendell Berry puts it in his poem by the same name: “The mind that comes to rest is tended / in ways it cannot intend.”

Siloam Scenario (Part 3 of 3)

Morgan Wills writes…

In our previous two posts, we presented the case of a Vietnamese woman with arm pain who was noted to exhibit signs of a folk healing practice known as “cupping.”  So what is the relevance of this finding?  Is it just a curiosity of caring for patients from exotic homelands? 

Jina Hawk Lotze, Family Nurse Practitioner, educates a patient about carpal tunnel syndrome.

Well, such “X-factors” do make everyday problems at Siloam a bit more fun and complicated!  But there are important learning points as well.

First, an awareness of such practices by health care personnel can prevent some major problems.  Although not every folk remedy is benign, cupping is neither particularly harmful nor mean-spirited.  Unfortunately, some Southeast Asian immigrant parents who apply this practice to their children in the setting of minor illness have been unjustly accused of child abuse by well meaning but uninformed American health care personnel.

Second, we need a posture of humility and teachability in practicing cross-cultural medicine.  It is important to be continually learning about our patient’s social and cultural context.  The pursuit of such knowledge constantly re-frames the possible list of diagnoses and treatments.  As much as we want and can benefit from protocols in medicine, the bottom line is that each patient is ultimately an individual.  A truly whole person care plan will respect that unique, God-given particularity in each of us and keep the wonder in the medical encounter.

Third, this case is a reminder that all medicine is to some degree or another “cross cultural”—whether at an academic Medical Center or your neighborhood “doc-in-a-box.”  In the end, Cultures are the outward and systemic manifestations of a people’s basic faith commitments or worldview (a set of lenses for viewing reality, religious or otherwise).

We all bring our own understandings of “health”, “illness”, and “good treatment” to bear in the setting of illness.  We may see this reality more clearly in treating someone from a significantly foreign culture, but culturally-bound belief structures play into the care of less exotic patients as well.  Consider the degree of confidence (faith?) modern American patients put in antibiotics, stimulants, or mega-dosed vitamins.  Or the similar trust that the biomedical system implicitly places in expensive laboratory tests and imaging studies!

Whether and how to assess what we should trust in the wild world of health care is beyond the scope of this blog entry.  But the point is that our perceptions of health are affected by the influence of both faith and culture—and often in ways we don’t expect.  If the Siloam Institute of Faith, Health, and Culture does nothing else, it seeks to foster in its trainees increased self-awareness about their own worldview and how it influences the care of patients.  

We hope this leads to humble respect for both the benefits and the limitations of the biomedical model.  To the extent that this leads to a genuine openness to considering what the ends of health care really are, then the process of forming whole person caregivers has truly begun!

Siloam Scenario (Part 2 of 3)

 Morgan Wills writes…

Welcome back!  If you’ve had a chance to ponder our recent case, you may have made the following assessment:  This woman has multiple, scattered round, flat lesions of varying size on her right upper arm.  The color is a little difficult to appreciate in the context of her moderately dark skin, but appears to be a reddish purple, both homogenous and uniform, implying that they began at the same point in time.

Depending upon the time of onset, the differential diagnosis could include such possibilities as:

–          Mongolian spots (type of birthmark)

–          Hemangiomas (overgrowths of small blood vessels)

–          Eczema

–          Ecchymoses (medical speak for “bruising”)

–          And other complicated sounding problems such as phytophotodermatitis, erythema multiforme, and idiopathic thrombocytopenic purpura

At this point, the history can help to clarify the possibilities.  As Jina recounts, this woman was complaining of gradually progressive pain and numbness in her right arm, especially over the past four days.  The pain was primarily in her right wrist and forearm, with some numbness in her hands, and an aching feeling all the way up into the right shoulder at times.  She is a married mother of two and works a cleaning job in a nail salon, but adds, “I don’t do nails.”

The physical exam revealed some diffuse tenderness throughout the arm and positive Phalen’s and Tinel’s signs (reproducible numbness and tingling caused by compression of the median nerve at the wrist).   Clinical types out there will pick up on the likely diagnosis of carpal tunnel syndrome—a compression neuropathy of the median nerve. 

But what about the skin lesions?  Carpal tunnel syndrome does not explain them, but two pieces of the history do: the woman is unconcerned about the skin findings, and . . . she is Vietnamese.  Why would that make a difference?  Well, you see these lesions are actually bruises, and they are self-inflicted.

This phenomenon, known as cupping, is a common folk remedy in Southeast Asia.  The marks are caused by a lighting a match inside a cup or similar device to create a vacuum until the puckered skin surface is bruised.   A similar practice, called “coining,” involves rubbing a coin in heated oil up and down the skin until streaky bruises are created. [see photo of a previous Siloam patient below].  Both practices are performed to treat “wind illnesses,” ailments that result from lack of internal balance or harmony in a person’s life.

Fortunately, in this case Jina did not show alarm at the signs of cupping but was able to acknowledge the patient’s understanding of her own illness and also explain the nature of carpal tunnel syndrome as she understood it biomedically.  By building this bridge, Jina and the patient were able to establish trust and mutual understanding of how to relieve the pain through a splint and behavior change.  If and when the patient develops a more serious illness, the patient’s experience of such a collaborative relationship will be all the more important.

In our next installment, we will briefly explore the implications of this finding for the clinicians and health care professional students.  In the meantime, an excellent website to learn more about such practices—and other aspects of crosscultural health—can be found at www.ethnomed.org.