Archive for February 21st, 2009

Elephant Based Medicine

I have sent  this article to the Jourmal of Family Medicine. Waiting to hear. What do you think?

Elephant-Based Medicine

title-card-300x224 Elephant Based Medicine

How to for Professionals

In Medical school, we learn how to diagnose and treat diseases. When we graduate, we are disease specialists, but not necessarily well-rounded physicians. It would be like learning the technical aspects of surgery without ever learning how to wash our hands. Basically, our ability as physicians to relate well or poorly to our patients is either genetically predetermined or acquired from identifying with our parents. But, in the end, does it really matter if physicians don’t relate well to patients?
The Joint Commission recognizes ineffective communication as the leading factor (70 percent) in causing sentinel events.1 Today, with a greater emphasis on patient safety, reducing patient mortality, avoidance of medical errors, and maintaining quality of care, medical professionals need to improve their ability to communicate and relate.
In fact, I offer the following proof: Had elephants been our mentors, our ability to relate well would have been vastly expanded. Elephants? Yes, elephants. They are famed for their memory, their intelligence, their social skills, and their sense of family and community. Elephants know how to relate.
An elephant’s eyesight is relatively poor; its eyes aim down from the trunk. Elephants must get close and raise their head upward to look forward to study and size up every aspect of an approaching animal. This teaches us to keep the distance short between us and our patients. We must develop a visual thread, an external vision connecting us to our patients that remains unbroken during visits. When thinking about the information at hand, we should shift to our internal vision, pausing to contemplate, reflect, and ponder. The ebb and flow of this process shows patients that what they are saying is important and valuable to us
Elephants have hearing receptors in their ears, and their trunks and feet are sensitive to vibrations. They are keenly aware of the communication nuances of their fellow elephants and other animals. While listening attentively, every member of the herd will lift one foreleg from the ground and face the source of the sound. Our posture and position convey to patients, family, and staff that we are listening intently. Isn’t it ironic that shuffling the letters in the word “listen” spells the word “silent.” Listening silently is an important communication attribute.
Through the use of bellows, roars, and trumpeting, elephants are superior communicators. When they encounter another elephant, they make noise, flap their ears, twirl around, and sometimes urinate or defecate in excitement. Although it is probably wise not to go that far, it is desirable to greet our patients by name. Project your voice, vary the volume and intensity, speak clearly, and explain medical terminology. Be self assured enough to say what you know and what you don’t. Invite your patients to partner with you in figuring out the subtleties of their illness. Anticipate your patient’s questions and like the FAQs that accompany a computer software program, state the most commonly asked questions and their answers upfront. You can also direct patients to Internet Web sites you know and trust. Informed patients, and their families, are our best ally.
Some elephants exhibit mirror self recognition (MSR). MSR is verified if an elephant passes the “mark test” by spontaneously using the mirror to touch an otherwise imperceptible mark (e.g., a white dot or stripe) on its own body. Elephants are highly empathetic animals known for so-called “target helping”[i.e., helping that takes the specific needs of others into account.]2 Gallup was the first to hypothesize a connection between MSR and empathy.3 Only through careful self-recognition of our own imperceptible feelings expressed silently and subtlety in our body language can we better understand the body language messages of our patients or their families. The physicians that know themselves have a head start at knowing their patients.
Elephants have no problem showing their feelings. When they meet an old friend, they laugh and show joy. When they loose a loved one, they grieve and cry. In a January 2009 CBS news story Tarra an elephant resident of the sanctuary in Hohenwald Tennessee held a three week vigil for her long time friend Bella, a dog who had been injured. We must not be afraid to show our feelings to our patients, their families, or our staff. Done carefully and professionally, emotional expressions — communicated verbally and with our eyes — deepen relationships. It is always best to acknowledge and deal with feelings. And, of course, don’t forget to smile.
Baby elephants are born with fewer innate survival instincts than many other animals. For example the calf lacks the ability to use it’s trunk with any real skill. They must rely on their elders to teach them the things they need to know. On the opposite end of the spectrum, medical students, interns, residents, and fellows also lack innate survival skills but have a sparse number of mentors who are willing to teach them. Just as elephants teach their calves, isn’t up to us to teach our trainees and peers about people, teamwork, and hospital culture. The “fraternity hazing”-type clinical education model must stop, and be replaced by a helping supportive one.
Rogue is a term used to describe lone, violently aggressive wild elephants. Left unchecked, it can destroy property and kill people. Often, the male elders round up these disruptive elephants, surround them, and retool their behavior before letting them back into the herd. What about the rogue professional? In a survey of VHA member hospitals4:
•    67 percent of the respondents felt there was a link between disruptive behavior and adverse events
•    71 percent to medical errors
•    51 percent to patient safety
•    71 percent to quality of care
•    27 percent to patient mortality.
In March 2004, the Institute for Safe Medication Practices (ISMP) said that, 7 percent of survey respondents reported they had been involved in a medication error during the past year in which intimidation clearly played a role. 5 Clearly, the medical profession has its rogues. Shouldn’t we muster up the courage to round them up? Let’s identify not ignore, embrace not exclude, and re-educate not punish.
But the following question still remains: How many elephants does it take to make a difference?
Join the herd and find out.

1.    The Joint Commission: Sentinel Event Root Cause and Trend Data. (accessed Jun. 23, 2008).

2.    De Waal, FBM (2003) in Feelings & Emotions: The Amsterdam Symposium, eds Manstead, T., Frijda, N., Fischer, A. (Cambridge Univ. Press, Cambridge. UK) pp. 379-399

3.    Gallup G. G. Jr. (1970) Science 167:86-87

4.    Rosenstein, H. Alan, M.D., M.B.A.; O’Daniel, Michelle, M.H.A., M.S.G. A Survey of the impact of Disruptive Behaviors and Communication Defects on Patient Safety. The Joint Commission Journal on Quality and Patient Safety August 2008, Volume 34 Number 8, pp. 465-466
5.    Intimidation: practitioners speak up about this unresolved problem. ISMP Medication Safety Alert. (Part I) March 11, 2004. Volume 9 issue 5. Page 2.


, , , , ,

No Comments