YL5 Week 1 @ASMPH + The Doctor as a Watchman

YL 5 Week 1 @ASMPH + The Doctor as a Watchman

This is my first week officially studying at ASMPH, the Philippine Jesuit college that promises to teach the next generation of physician-leaders through its MD/MBA program with an emphasis on Public Health. I won't speak about the transition semester as there wasn't that much studying but may refer to it throughout this project. Though I will say that there is a requirement on performing the Jesuit "Examen", perhaps emphasizing the "studious" nature (study yourself too!) that hinges on Jesuit philosophy– faith and reason ideally does not contradict, and pushing reason at least may leave the door open for faith in people's hearts later on. A long and risky game indeed. 

We started off, as all Jesuit institutions do, with the Mass of the Holy Spirit and Opening Ceremonies. The Mass was presided by our president, a Jesuit himself. It is unfortunate to report that many had wanted to skip it. I am rather concerned with the spirituality perhaps of my peers first and the school second; perhaps it is merely a retreat into the interior, stay tuned. 

This first module was on Principles and Perspectives, introducing us medical students to a variety of approaches (medical anthropology, applied psychology, family medicine) that contextualize the Filipino and the Medical vision the school wants to teach us (or at least expose us to). Here, we got exposed to what I can only call the hermeneutic of the doctor and patient– stories matter. If you're not inclined on getting a short summary of each sub-module, feel free to skip to my proper reflection by clicking --> Doctor as a Watchman .

Biopsychosocial Approach

The first sub-module was on Engel's biopsychosocial approach, playing on the narrative against the reductionist "biomedical" approach that only looked at the biochemical imbalances or causes that can be summed up as "disease-oriented". Concepts were thrown around like "single factor model" and "reductionist model", nuances that aren't really appreciated by people who already know the concept of "naturalistic" or "scientistic". I know I know, more concepts but there are so many ways of explaining how one looks at a disease through a lens of a single cause-effect relationship, reductionist I know. Why do psychologists have to over-conceptualize things?

We are supposed to distinguish this approach from the "integral medicine" or "holistic health care model" that seems to be elevating homeostasis/allostasis failures to the illness/disease level. Holistic, here, emphasizes less on illness but on optimizing a "high-level wellness" that purportedly is used as a medical model in traditional medicines such as herbalism, homeopathy. Not much more is said, which is a little troubling to me and perhaps for those who aren't so easy to dismiss one thing just because its weakness is more system-wide approaches rather than the "single factor model approach". I'd suggest adding references in the slides! Briefly we talked about an ethnomedical model, that was really just conveniently enough the "other side" of whats going to build up to the biopsychosocial model of health.

What was more interesting perhaps are the pictures (because medicine likes pictures) of systems theory that instead of being circles in circles were boxes within boxes or a curved boomerang that works its way up as systems of systems of systems. We should move on.

Social Medicine and Families

The next submodules (2 of them) was what I'd call the anthropologist's art of subjectivity (again stories matter). Really the fundamentals of each of these can be summarized in a few sentences, watch. 

First, Social medicine applies humanities and social sciences to medicine. There are some medical anthropologist terms to take note of: mastering competencies (i.e. knowing jargon), eptitude (really it means prudence no joke), ethnocentrism, cultural relativism. Aside from this, the entire lecture was filled with examples of public health: pandemics in the past, pandemic now, and a pitch for universal health coverage. 

Second, the culture of the Philippine family is shifting. Some terms to contextualize the Filipino family were thrown in: matrilocal, extended, and some facts to learn of past vs. present. In the past you could marry at 14 or 16 (F/M) but 12 during spanish, now it's 18 for both. Stories matter again: sometimes marriage can't occur due to expense so common-law; divorce is still illegal; simulated births are a thing (foster child birth certificate forged for you so less hassle) and now legalized for ease (RA11222). More terms to learn to describe the stories: sandwich (parent/child/grandparent taking care of other 2), boomerang (millennials come back home!), blended (step-siblings) families. With more tools to describe them, we can identify decision makers ("gatekeepers" to health) and more applications! (Applied) phenomenology, Social interactionism (remember sociology? roles and meaning), and political economy (laws/ public policy). Everything else was perhaps a "phenomenological" approach by the lecturer as he gave his opinions on sexual orientation, the good and bad in sub-groups (bros, barkada, professional associations, etc.), and COVID studies he found interesting.

Psychology in the Time of Stress, Burnout, Secondary Trauma by Coping y defense mechanisms

Two more sub-modules: 1. Pop Psych on Stress and 2. Freud resurrected 

If people weren't already familiar: stress (against a perceived stressor body-wide), allostasis, and anxiety were redefined. A stress pathway was outlined: through the adrenal gland via amygdala for cortisol. A little context on why knowing about stress was given with COVID's unique stressors. More psych terms were put out: intrinsic vs. extrinsic motivation and awareness of perceiving pressures implicitly or explicitly. Allostatic overload was discussed and how chronically, that's what causes burnout. Symptoms were described that are perhaps "biopsychosocial": fatigue, sleep problems, lower immune system, irritable, etc. what you'd find in stress. Don't forget about the amygdala and epigenetic expressions that make it hypersensitive if overstimulated, "traumatic learning" being an example. The hippocampus too, but learning here is better. And we know serotonin on mood disorders and fog (literally the only neurotransmitter mentioned so far). 

Some I/O stuff were put forth too: presenteeism vs. absenteeism (physically or mentally absent to work). The emphasis is on intention and commitment to stress management, culminating in the RAIN method: 

Recognize! it's part of life! Accept and allow. Investigate with kindness (unconditional positive regard); find motivation for what's being studied (salience). Non-identify.

Psychology really likes those mnemonics. STOP TECHNIQUE! Stop. Take a deep breath. Observe. Proceed. Oh and that Ivy Lee Method, you remember? Write 6 stuff down go in order per day, replenish the list as you go. Really this will change per year, it's so different to last year's so don't count on getting an edge in this (or perhaps any of these lectures).

For submodule 2: We go back to Freud with a slight review of Id, Ego, and Superego, conscious, preconscious and unconscious mind. All these contextualize defense mechanisms which start with the ID fighting with the superego, which the ego compromises– voilá a defense mechanism. This is a bit wordy and detailed but a summary is below. 

There are 4 kinds of defense mechanisms classified by Vaillant: Narcissistic, immature, neurotic and mature defenses. The way I see it, until Psychiatry, it's best to work on understanding rather than manifestly know all these terms so let's personalize it. 

Nancy is a narcissist and every time I try to tell her she denies it. Though she's my friend, I understand she tries to distort reality because it's unacceptable to the standards that only she can provide– narcissist I know. She often tends to project her feelings on me, which really is outward and applied distortion rooted in the same denial of reality.

Next, I have a kind of immature friend too. His name is Imman, whom I've known since we were pre-teens. His parents had an inconsistent parenting with him and tries to cope with this by acting out, throwing books when he's angry. When I ask him what's wrong he tends to be passive aggressive and can identify me with elements of his father– fancy term is introjection, I hear. With all this stress, it gets to him sometimes, where he gets too tired and his emotional pain is somatized to physical symptoms. He tends to go off on his own sometimes when this happens, a schizoid fantasy into his own world. Immaturity is the root here and it tends to regress to childish times, when really this shouldn't happen– need to mature and grow up! 

Neurotic Nero is very keen on his grades. It's hard to work with him because he's so controlling with his group mates. We know he's angry but shameful in public for it, he displaces his anger by rigorously typing loudly to our annoyance, trying to inhibit his feelings. I imagine he types out fancy terms that describe our incompetence, calling us buffoons or some other intellectualization instead of just talking it out. He prefers to be isolated and rationalizes his rigidness as part of his genius or dissociating his self from his work. It gets a bit weird with his teacher, a clear authority figure, where he is the exact opposite and is really nice to her, I can see a reaction formation; I suppose with her, he represses his past with her.

Though, you know I admire the maturity in my role model Greg. Though an introvert who likes to keep to himself, when faced with difficulties, he copes by first anticipating them, reminding himself of the long term takeaways that can happen in enduring it. Not only that he's altruistic with his brothers and helps them when he himself needs help, and shares his humor with them. He is kind of a patriot though and channels his protest urges by sublimating it into singing chants. He really suppresses a lot of his desires and is very successful because of it.

Okay that was an interesting exercise. We get a rehash of the same info next, classifying the above into classes of coping mechanisms (take note defensive mechanisms vs. classes of coping mechanisms). Starting with the highest, the high adaptive coping mechanisms on top corresponds to mature defensive mechanisms, which are the best. Now back to the lowest going up we can think of this like Hegel's phenomenology of spirit: we start with the defensive deregulation level, truly a denial of even sense-certainty– breaking with reality. The next we have the action level, which is outwardly doing something (acting out or passive aggressive). Major image distorting level is next which has to deal with perception of the other distorted. Disavowal is next which is to deny one's own perception of things. Less bad and next is the minor image distorting related to self-esteem (chunibyou or depression). Mental inhibition is the last before the best; trying to deal with 2nd it compromises by giving excuses, believing them, and acting in that way (reaction formation, repression, intellectualization).

Once again, the takeaway is concepts can help form stories and then help you reinterpret those stories.

The Proud Family Systems

Now finally onto a branch of medicine itself: family med, founded by Dr. Salvador Minuchin! Really, we get to see terminology that helps build the clinical case. The family system is homeostatic and is made up of parts that affect each other. With this accepted, illness occurs in a widespread way when one family member is sick, how it's dealt with affects how the family approaches health moving onward. The structure of this system consists of repeated behavior patterns– rules (overt or covert), roles, subsystems, boundaries, coalitions, and power structures. With this terminology one can create a system of questions to unearth the system's features, family processes, and make family genograms/maps. You can get to the structure/system of the family by asking a "series question"– how does one affect the other when x happens. A who does what and when question implicitly defines the roles. Who's closer to the patient elicits resonance (distance) and who agrees with whom talk about coalitions (subsystems). I perhaps will leave it at that, because the rest are to be practiced (squares, diamonds, circles baby!). Also, some of the terms are self evident. For example, enmeshment means to enmesh oneself in another's business. Really, it's not recalling APGAR that's important but understanding why it is so. As the acronym suggests it's a measuring tool of relationships in the family– how they adapt, are partnered, grow together, extend of affection, or resolve. The point really is similar as an assessment tool of relationships, it's just important to know it can be put to use. 

Among the submodules in principles and perspectives, these really are systematically useful tools and I'm quite fond of it. The family is the bedrock of society, after all and it's important to meet them where they are, as the good Lord did, does and will do for us, since He is after all, theologically, pure relationship (Father, Son, and Holy Spirit). Imagine applying this to that? Or to the Holy Family of Jesus, Mary and Joseph!

Triple-threat

To end the week, we got a treat for clinical consultations, but just a treat– a glimpse into the encounter and where healing takes place. In the clinical encounter, my takeaways are about the elements, trust, types, and secular translations of religious concepts (didn't expect that last one eh?).  From the first submodule in this section,  I remember mainly to sit 45 degrees so they could naturally look elsewhere if they prefer, and to note the reality-based vs. fantasy-based elements. The boundary really is objectivity versus subjectivity. The reality-based is on training whereas the fantasy is on cultural stuff like community beliefs or personal attitudes. 

The next sub module was on personality types and communication. Really it's to anticipate extraversion vs. introversion, sensing versus intuition, thinking versus feeling and judging versus perceiving; most of which are pretty self-explanatory when you know the framework. Sensers are process oriented people, intuiters like me are more about motivation. Thinking is philosophical/rigorous whereas feeling again is about relationships and meaning. Judgers make snap decisions whereas perceivers like to weigh things out first. That's about it, but very important to be aware of. 

Finally the clinical exam is kind of dear to me. I worked as a scribe and remember doing these charts for the doctors. HPI me all day. OPQRST– origin, pain, quality, radiation/relieving, severity, timing. PMH, SH, FH. All of these shorthands I've used in real life to quickly type out the clinical encounter. It is good to review though and to expand stuff like the pediatric history and all. Nevertheless, this won't be the last time to practice this.

The doctor as listener

Finally, there is a submodule for active listening skills, which are to be practiced with other people
other than my group. We're set on meeting on monday during the protected time for group work. In this time of virtual pandemic, it is the norm. This is where I build up on my comment earlier, really the doctor as active listener for a Christian is agape, but called "unconditional positive regard" by Carl Rogers. This may be easier for INFPs maybe, I don't know, but really it feels intuitive or second nature to me to bracket my prejudices aside, be attentive, ask (in)direct questions, and reflect back your understanding to people. This really is what it means to be with people and is one of the reasons I want to be a physician.

The Doctor as a Watchman

Son of man, I have made you a watchman for the house of Israel (Ezekiel 33:7)

My year group was assigned to sponsor one of the novena masses that ASMPH does for the PLE board takers. We were assigned day 3 (Friday), on the memorial of St. Gregory the Great. It felt as if the entire week surrounds this day and through this person, whom I've come to know about through praying the office of readings that day. A homily by him on the quote above from Ezekiel. St. Gregory, a man who sold all his possessions to start monasteries and became a monk himself, was elected pope. And in this homily, the profound humility of his reflection came through to my heart. 

He spoke of identifying his role (Pope) with being that watchman, who must "stand on a height for all his life to help them by his foresight". Anticipating is a highly adaptive defence mechanism/ coping mechanism isn't it? His role is also altruistic, because of the life he left at "the monastery [where] I could curb my idle talk and usually be absorbed in my prayers. Since I assumed the burden of pastoral care, my mind can no longer be collected; it is concerned with so many matters". In becoming chief shepherd of the Church, the great Pope admits of being "forced to consider the affairs of the Church and of the monasteries", who "must weigh the lives and acts of individuals.", who is "responsible for the concerns of our citizens", who "must worry about the invasions... and beware of the wolves..." and he must "become an administrator... put up with certain robbers without losing patience and at times I must deal with them in all charity". 

I identified in St. Gregory the Great myself as a future doctor– a doctor as a watchman– also in a time of turmoil and crisis, and actually even now in my initial training. "With my mind divided and torn to pieces by so many problems, how can I meditate or preach wholeheartedly without neglecting the ministry of proclaiming the Gospel?". Those words ring true, and I automatically add healing to "the ministry of proclaiming the Gospel"– the ministry of healing as proclaiming the Gospel. This program will divide my attention into so many priorities. I sometimes wonder if I can maintain a consistent liturgy of the hours schedule with the work starting to pile up. 

I too, share the sentiment with St. Gregory: "I do not deny my responsibility; I recognize that I am slothful and negligent... And because I too am weak, I find myself drawn little by little into idle conversation... What once I found tedious I now enjoy." I realized at this point St. Gregory is doing an examen, whose five steps: thanksgiving, grace, reflection, reconciliation and hope, are laid out in a confession. he admits "How hard is it for me to say this, for by these very words I denounce myself. I cannot preach with any competence, and yet insofar as I do succeed, still I myself do not live my life according to my own preaching." 

In this moment of critical reflection, Gregory acknowledges the need for reconciliation. This is his grace that imparts itself on all the other steps. The thanksgiving is put at the end and paired with hope. He concludes: "So who am I to be a watchman, for I do not stand on the mountain of action but lie down in the valley of weakness? Truly the all-powerful Creator and Redeemer of mankind can give me in spite of my weaknesses a higher life and effective speech; because I love him, I do not spare myself in speaking of him". The first sentence almost seemed like he was ready to quit, but in grace, he is thankful and hopeful that his reconciliation with the Lord stems from this love of the Lord. 

So too, must the doctor as watchman recognize that we lie down in the valley of weakness but are nevertheless "made a watchman" for the house of healing. A doctor must climb the heights of science, art, and humanities– the very things that make man the rational animal, not to look up but to look after the wellbeing of the "flock". For a doctor, his flock can be anywhere between the "family" as in family med approaches I've learnt this week, the patient herself and the "biopsychosocial" system to work towards health, or the staff of people under me who needs administration "lest [they] go in want". The very term of the watchman is in the eyes– the verb to "watch", where sight can not only be visible but physical. The healing encounter comes from touch, communication and compassion, all of which can be "watched" in the instant healing begins to take place. 

Working with systems of this varying size and complexity was only touched upon in the biopsychosocial task, but in my anticipated reading this week of my Principles of Management book for next week, I got to see more of a glimpse on how this program ASMPH built is really designed for the future and will conclude with a few remarks from it. 

Management is key for a watchman– pope or doctor (or both). From that principles of management chapter, I learnt for one that they use key words just as profusely as psychology does, but in more concise terms (see appendix A below). There is much to learn from this in that sense then. For an organization as large as the Catholic Church, pastoral leadership may appear to take precedence over one's former duties merely as a skilled priest. The manager has to be a generalist, anticipating the needs of the employees and set agendas, goals, organize, lead and control, all of this. 

The doctor too has an organization on a lower scale to be a manager– a generalist– to their patients, who are themselves the experts of their health. And this is the case even as the doctor may choose more focused training– in residency, in specialties and subspecialties– the patient is the specialist of himself. In this sense, I find myself at home, for a philosopher too is also a watchman. He, too is a generalist. But sometimes generalists are more rooted and foundational than a specialist, because they can see the general roots that contribute fundamentally to the development of an idea; and the idea the doctor searches for is health. I don't mean this poetically but platonically– for as Aristotle says, health is the form of the body. And the body can only be made known by both a metaphysical foundation in natural law and the lived experience that the metaphysics contextualizes/surrounds. 

Ultimately, then, at the end of this week, it goes to show that the reason St. Gregory says at the end "truly the all-powerful Creator and Redeemer of mankind can give me in spite of my weakness a higher life and effective speech", isn't just because He's creator and Redeemer, these things are "true" truly. It is so because He is "the Son of man", and He is therefore "the watchman for the house of Israel". I'd imagine this is also why true healing only occurs because the Holy Spirit is present in the space between; my own watching over and managing others can only be so if I let Him open my eyes to the realities of the world and how one can see it through agape. 

Thank You, O Lord, I never tire of speaking with You, because I love You. 

Amen

Bonus management concepts (Appendix A):

Management chapter 1 key words: Plan, Organize, Lead, Control, Informational, Interpersonal, Decisional, Monitor-disseminator-spokesperson, Interpersonal, figuerhead-leader-liaison, Decisional, entrepreneur-disturbance handler-resource allocator,  Technical skills, conceptual skills, human skills,