published October 1, 2005

SENCER E-Newsletter, October 2005, Volume 5, Issue 2

Seeing the Forest and the Trees, Part II

Wm. David Burns

The next piece is the second part of a two-part essay titled, "Seeing the Forest and the Trees," by SENCER PI, David Burns. The first part of the essay reflected upon some of the lessons learned through our recent work at the SENCER Summer Institute. In the second part of the essay, David shares how a personal experience, a trip to the doctor's office, further reinforced this notion of seeing the forest and the trees.

Now, finally, on to my visit to the doctor and what it had to do with seeing the forests and the trees. Though I hope it wasn't too apparent to all 330 who attended SSI 2005, the core faculty and my staff colleagues certainly learned from me that I was suffering from an annoying case of the hives that began just before the Institute and persisted through it. The hives were itchy and distracting, but were readily calmed with low-dose antihistamines. I wondered why I had them, and speculated on a range of possibilities that included a particularly authentic and tasty Oaxacan salsa I had eaten at a party at our house, all the way to acute anxiety about the Institute itself. (Everybody works very hard to make our five days together a success, but, for me, at least, the whole experience is not unlike having several hundred houseguests whose welfare and happiness are my sole personal concern: it's a wonderful experience, but it is not without stress!)

Our "camp doctor" Rich Keeling assured me that, in the overwhelming percentage of cases, the particular etiology of hives remains a mystery and that it is only rarely that hives betokens a serious malady. He suggested that, if the hives persisted much after I returned to New Jersey from California, however, I should probably arrange to see my doctor. The hives did persist, so I dutifully made the appointment.

Happily for me, by the time my appointment on August 31st came around, the hives had disappeared. Having no symptoms makes for a rather flat acute care visit, however. No symptoms, no evidence, and no persisting problem...why go?

I decided to keep the appointment anyway, in part because I wanted to re-establish contact with my doctor in prelude to yet another effort to focus on my weight, etc, which, in combination with aging, was beginning to exact a toll on my energies.

The experience at the doctor's office traced a pattern with which you are all no doubt familiar. First, I described my problem (or current absence of a problem) to a receptionist, who then recounted it to a nurse. Then I described my problem to the same nurse, who recounted it to someone else (I could overhear these recitations). That someone else turned out to be a third year medical student who entered the examining room and asked me if I minded being examined by him. Having held an appointment on the adjunct faculty of the very medical school this student was attending and being committed to professional education, of course I said yes and invited the student in.

Well, by now you've probably figured out, just as the student did, that there wasn't much to examine. Of course I cheerfully repeated my answers to the questions for the third time, trying to make them more interesting to myself, if not to the student. I also mentioned that I had been annoyed by some numbness in my extremities, which I attributed to my weight, but wondered if this might have anything to do with the hives. But even this embellishment of my "reason for visit" took us only so far, so I thought I'd ask the student some questions.

I asked where he had done his undergraduate work. "Boston" came his response, to which I further inquired, "Where in Boston?" "Harvard" he said.

I've noticed this before: some Harvard graduates seem weirdly reticent to reveal the identity of their alma mater (maybe this is conceit, I don't know). Somewhat later in our conversation, I suggested to the student that answering the question forthrightly, as in "I was graduated from Harvard," could have, in many instances, an instant beneficial, even "curative," effect on a patient! You should use all you've got to establish credibility was my thinking. The student, though, to his credit, felt that his claim to Harvard's legacy of excellence could just further widen the social distance between most of his patients and himself.

This led us to a discussion of Harvard and I have to say that the student painted a not-too-pretty picture of undergraduate pre-medical education there. Intensely "scientific," abstract, and technical, not problem based, highly competitive, a "memory contest" and extremely expensive, were just some of his criticisms. He compared his education at Harvard with the education his brother got at a state university out west and concluded that his brother had been better educated and left less poor as a result of his choice of schools.

What really seemed to be at the heart of this student's objections to his education, if I heard him correctly was something close to an objection to self-referenced snobbery and elitism. "No matter who you were when you came in, you emerged a Harvard man or woman." And, he didn't seem to want to be "that person" though he had succeeded at his studies there. He was repelled by his feeling that what Harvard was about was being a Harvard student or a Harvard graduate, and that was it.

Of particular relevance for our purposes, however, is a more alarming claim: The student had prepared for medicine successfully in the classrooms and labs of Harvard without ever being asked to think about health. And for him, this meant thinking a lot about what being a graduate of Harvard meant but also not thinking about other people, let alone "the public and its problems." He was quite unhappy about this particular under-preparation.

Burns Quote 2

This little part of the essay isn't about Harvard - and certainly couldn't be based on an "n of 1" and my memory of our conversation Rather, I recount this discussion in prelude to what happened when the "real doctor" finally entered the examining room. (This entrance followed, of course, the student's recitation, in a stage whisper just outside the door, of what I had just told him. I felt like I was in a medical version of the game of telephone.)

Years ago, I had chosen my doctor, Jeff Levine, on the recommendation of a colleague because Levine was both reputed to be quite good and because he was fat. I thought a severely overweight doctor might be in a slightly better subject position to understand and negotiate the very rough terrain, not to mention the via dolorosa, of my own lifetime experience of obesity. When Dr. Levine entered the room this time, however, I barely recognized him at ca. 140 pounds less bulk than he had been the last time I saw him. (I've subsequently learned that he participated in the new reality TV show, "The Biggest Loser." I understand that he's currently on TV.)

The acute care visit doesn't provide much time for conversation or for me to find out how he lost his weight. So we got to my specifics quickly.

Since the hives were not a continuing problem and since, when scheduling the acute care visit, I had also scheduled an annual physical, the examination shifted to a focus on the numbness. We established that the numbness was bi-lateral; the feet-falling-asleep issue is often "mechanical" when blood supply being constricted and that I had a family history of diabetes. My heart rate was, if anything, low, and my blood pressure was completely - amazingly - normal. I was in no apparent immediate danger of dying.

Shifting to his role as mentor/teacher my doctor then turned to the med student and asked: "Given the numbness, and given that we've got to get blood work done for his physical, what tests would you order?"

The student's first response was something like, "I'd check for vitamin B-14..."

Dr. Levine, who was visibly impatient, even distressed, interrupted his answer: "Wouldn't you want a fasting blood sugar?"

The student, chastened, quickly agreed.

So here's the forest and the trees problem again: the first thing one should think about is diabetes when in the presence of a morbidly obese, middle-aged patient with distal numbness and a positive family history for it. Yet, when quizzed, the student thought about an exotic explanation and not the obvious one staring him in the face.

It's an old story: as they say in medical education about diagnoses, if you are in New Jersey, think "horse" before thinking "zebra." The horse in the room in NJ that day was most probably diabetes. Maybe not. Given what was available and knowable at that moment (and what an educated person should know about the big public health issues of our day), it's where you'd start, even if you ultimately wind up in more exotic medical territory. (Of course, I am hoping we won't!)

Almost every woman college graduate of a certain age knows the classic mis-application of the horse not a zebra mantra painfully: how many times were you asked if you were pregnant when you thought you'd gone to the student health center for a stomach virus, or even a cold? But the advice to look for a horse remains a good rule of thumb.

Burns Quote 3

What may have been going on in the exchange I just recounted? For one thing, it's possible I was party to some testing anxiety, some need for the student to prove himself (after all, this was early in what was only our medical student's second clinical rotation). The student didn't come up with the simple answer (the one that was on my mind, for example), because he thought he had to come up with a complicated answer that would demonstrate his knowledge. Maybe he recollected one of the 10,000 facts he had mastered and memorized. He was flaunting his knowledge, perhaps, though he was personally a humble, respectful and eminently likeable young man.

What's this got to do with the student's undergraduate education? If I may be permitted this perhaps very large extrapolation for a very small bit of evidence, let me suggest that the pre-medical education this and many other students are getting is seriously deficient in that it wasn't "liberal" - in the sense that it missed the forest of health for some pretty noble and formidable trees, like chemistry, advanced calculus, physics and even world history, to name a few.

To be fair, maybe I'm just interested in different forests. Indeed, the SENCER approach would start with the forest - say of a public health issue like diabetes - and through it get to some pretty important trees - like biology, chemistry, biochemistry, immunology, and a host of others, as well. like physiology, nutrition, food science, marketing, psychology, sociology, education, communication, pharmacology and so on. This approach is, after all, what Jake Harney at Hartford and Phil Mason of Fairmont State and the other participants in SENCER's obesity caucus are trying to develop.

Others, however, would start with the forest of immunology, let's say, and go to trees with names like Type I diabetes or multiple sclerosis. Just one very impressive example of this approach can be found in Professor A. Malcolm Campbell's immunology course at Davidson, where students produced papers on a host of expressions of immunological and auto-immunological disorders. (For a closer look, see student Stacy Spolnik's homepage and web entry on Type I diabetes at Diabetes) So, Stacy and her fellow students in Dr. Campbell's class, at least, have had a chance to learn at least the biology of diabetes.

To its credit, Harvard's working to improve things, too. A note about nutrition on its medical school website, reports that it is doing something to bring a big, complex topic like nutrition into its undergraduate education:

A major effort has begun to provide Harvard undergraduate courses/seminars on healthy nutrition practices, international nutrition and nutrition research opportunities...It is anticipated that these initiatives will make undergraduates more aware of healthy nutrition and may stimulate them to enter a career in medicine and nutrition research.

It's too early to tell how this will work - who will have the time and space to take these courses once they are offered but, for fourth year medical students, at least, at the Harvard Medical School, things are looking up:

An increasing number of senior selectives, electives and advanced biomedical science courses have been added to the curriculum of those fourth year students wishing to obtain an in-depth experience in specific nutritional problems - obesity, diabetes, inborn errors in metabolism, genetics and surgical bionutrition, Insulin Resistance Syndrome, Syndrome X, AIDS, transplantation, critical care, and hospital nutrition. Future plans include obesity and cancer themes throughout the four years of medical school and the addition of academic nutritionists to the four medical school societies to reinforce the importance of nutrition in medical education.

This news would certainly qualify for a nomination in the "better late than never" award category. But shouldn't we use the occasion of improving undergraduate education -for majors and non-majors - to do a little better?

I think we should and that we can. Diabetes is a great place - a great forest - to explore. It's a terrific example of a complex, capacious, and unsolved problem. Its study gets one very quickly to a host of other issues, other disciplines, other places (including large parts of the world where diabetes is not an epidemic; why is that?). It has practical applicability in individual lives, in discussions of public policy, in planning menus at campus cafeterias, in understanding particularly vexing and seering aspects of race and poverty. It's an organizing idea that stands in silent testimony to the value and necessity of interdisciplinarity. And it is sufficiently a common, civic challenge that it justifies broad attention, beyond the lucky few students who get to take courses like Dr. Campbell's at Davidson.

The challenge is to link our aspirations for good general education - the ability to see connections among things, to think critically, to synthesize, and to use the strength of particular disciplinary expertise in the service of understanding transdisciplinary phenomena - with our commitment to preparing students to succeed in professional education, be it in medicine or another field. Do we have space and time to do this? Could we do this with science and non-science majors together? Is this a promising way to engage in general education? If and when we do this, will we not be collectively civically engaged with an issue of pressing, practical importance?

Burns Quote 4

This approach stands in stark opposition to the current practice of merely "passing" and thus "passing through" courses on the way to one's goal. We could say that in this condition we have many trees, but no forest, at all, maybe just a big thicket from which we simply emerge, like lucky princes do in fairy tales.

What forest do we want to explore? What resources and tools will we need to explore it? For those preparing for careers in medicine, it would seem essential that "health" be a necessary forest to be explored as an undergraduate. And when it is, such common challenges to health, like diabetes, will most surely be dis-covered (and maybe even covered in classrooms - in immunology and in economics, as well). Then, surely more certainly than now, when a student actually gets to practice at being a physician, s/he have in mind the big issues - the horses - as well as the more exotic species - and s/he have the capacities to do something for the individual patient and for the common good as well.

I'll find out next week what the lab results suggest or reveal in my own case and I look forward to seeing my "medical student" again. We owe it to him and his successors in undergraduate education to make it more likely that, in studying for a medical career, the subject of health will be part of the pre-medical, and maybe even everybody's curriculum.

The Forest and the Trees