Tuesday, December 10, 2013

Desirable Personality Traits and their Relation to Burnout in the Medical Field

In Weekends at Bellevue, Julie Holland, a psychiatrist who worked the weekend night shifts in the Bellevue Hospital psychiatric emergency room for nine years, details the ways that she approached her taxing job. Early on in her career, she begins developing an identity that allows her to deal with the highly stressful environment and obligations of her work. She calls this identity her “hardened persona” and describes it as both “[her] blessing and [her] curse” (Holland, 189). While the persona that she has created allows her to be able to work in an extremely high-stress, high-risk job for many years, it also causes negative emotional and professional impacts on her and those around her. In the end, she realizes that, even with her persona, she cannot endure the hardships of her work, and she decides to quit. Holland’s memoir is a stark reminder that the medical profession is one that is unbelievably harsh and this idea is reinforced by the characteristics that are strongly desired and encouraged in the medical field. I will argue that the traits that are most desired are also the traits that can be the most destructive professionally and emotionally for the medic, and that over time, these “blessings” can evolve into “curses” and result in burnout. I will describe in detail Julie Holland’s account and through this, I will explain how initially positive personality traits can be destructive and how attempting to deal with stress in a negative manner can lead to burnout as well. I will then briefly reflect on possible solutions on how to prevent or ameliorate this issue and comment on their successes currently.
In her memoir, Julie Holland recounts the experiences that she has faced throughout her nine years working in the psychiatric emergency room in Bellevue, one of the most famous (and psychiatrically, notorious) hospitals in the United States. She makes it evident that the environment that she must work in is extremely high-risk, fast-paced, and saturated with grief—she receives countless patients every night, many of which are involuntarily sent either by family, the ambulance, or the law. They are mentally ill, violent, addicted, and homeless and frequently, their time spent in the ER is only a quick fix rather than a step towards long-term rehabilitation.  As someone who has a “hair-trigger empathy switch” and “emotional incontinence”, she realizes that if she is to continue working at Bellevue, she must stifle her kindness and empathy in order to protect herself from the constant barrage of negativity (Holland, 51). Her emotionally exhausting work causes her to form a persona that allows her to deal with the overwhelming obligations for nine years. For this reason, she calls her “hardened persona” a “blessing”. She dons a fa├žade of callousness and toughness and learns to focus only on what is crucial—whether the patient is a danger to himself or others and whether he should be let go or kept. However, her persona does not come without consequences, for it causes serious issues, both professionally and emotionally. As she realizes her limitations in aiding her patients, she becomes more confrontational, aggressive, and rude toward them. Her attitude toward the mentally ill in general is insensitive, dehumanizing, and objectifying—she calls her patients “crazy” (Holland, 50) and refers to them as “live ones” (Holland, 3). Her behaviour not only negatively affects the care that she provides, it also physically endangers her. She is threatened and physically assaulted by patients who she has behaved to in an aggressive manner and toward the end of her stay at Bellevue, she is forced to recognize the danger that she continues to put herself in because of her conduct. Holland’s persona also causes an emotional inability to deal with problems outside of her workplace—when her good friend and colleague, Lucy, develops cancer, Holland cannot bring herself to visit her at the hospital and refuses to deal with her impending death. This also causes a rift between herself and another friend of Lucy’s, Daniel, and this widens considerably when Daniel becomes Holland’s superior. She recognizes the damage that her persona has caused and acknowledges that it has turned her into an individual and a doctor that she detests by calling it a “curse”. She attempts to ameliorate her behaviour by seeing a therapist, but she cannot impede the progress of emotional exhaustion that she ultimately faces. Holland becomes burnt out and decides to resign from Bellevue.
From Holland’s account, one can see how initially beneficial personality traits, such as empathy and compassion, or “blessings”, can transform into “curses” because of the way they force one to develop a personality that is detrimental to the well-being of many. Nevertheless, these traits are strongly desired and encouraged in the medical field. For example, the American Medical Association notes that a few of the characteristics that are required for student success in medical school are integrity, cognitive ability, reliability, dependability, dedication, and motivation (Casey, 2). HealthECareers, a site that medical professionals can use to find available jobs in their chosen fields, states that the five most important traits that a nurse practitioner should have are good physical endurance,  good communication, patience, a caring nature, and to be encouraging (HealthECareers). In addition, a medic should have perseverance, emotional endurance, empathy, fast adaptation skills, leadership and teamwork skills, the ability think clearly and quickly in grave situations, the ability to take criticism or failure, a willingness to take risks, and fast adaptation skills. All of these characteristics are sensible and realistic if one is to be successful in one’s line of work (“blessings”). However, when one places a person with these traits in certain situations or specific environments (usually involving high levels of stress) frequently, there usually occur negative ramifications for the professional, their work, and their personal life (“curses”). In addition, an excess of the traits mentioned above and the exploitation of them by others adds to their “cursedness”. For example, if one is too patient and accommodating, learning to say “no” may be difficult and one might overextend oneself to the point where one would get burnt out very quickly. Having good physical endurance and perseverance might cause short and long-term health issues if one were to take these traits to an extreme. For example, having the ability to work on limited amounts of sleep and nutrition is not ideal for a doctor because it can cause impairment of one’s ability to make proper choices. Excessive ambition and determination might cause an individual to lose track of his priorities and engage in professional competitions which may cause a lack of empathy toward colleagues and potentially patients. One might also become biased toward other opinions and this might cloud one’s judgment concerning patient care. As Julie Holland shows, experiencing kindness and empathy might overwhelm one emotionally. If one has good leadership skills, one may feel pressured to constantly make a decision and one may not take other opinions into consideration well. On the other hand, if one has good teamwork skills, one might be so comfortable not taking the lead that if a situation arose in which this action was necessary, problems might ensue. Risk-taking in itself is a dangerous situation—not risking enough or risking too much may result in an extremely serious mistake. Finally, concerning adaptation skills, there is a possibility that one may not be able to completely process the adaptation at the time, and this may lead to dependence on harmful coping mechanisms. The necessity of having to portray and balance most, if not all, of the characteristics mentioned above in a trying environment leads to professionals using certain coping mechanisms in order to deal with their stresses (Straker). For example, Julie Holland uses humour, distancing, acting out, avoidance, provocation, and compartmentalization (by attempting to separate her different jobs and personas into different bags) as her coping mechanisms (Holland, 189). The personality traits that she develops from these coping mechanisms are what make up her “hardened persona”. Thus, the negative manners in which Holland chooses to handle her situation and her abundance of empathy are what exacerbate her inappropriate behaviour and lead to her burnout.
The phenomenon of burnout is described by Christina Maslach as “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do ‘people work’ of some kind” (Maslach, 3). Holland is an apt example of this kind of burnout, portraying what might occur as a result of overextending oneself emotionally, or of being overly empathetic. Other physicians have explained that burnout is due also to “excessive workloads […], subsequent difficulty balancing personal and professional life, and deterioration in work control, autonomy, and meaning in work” (Dyrbye, Shanafelt). In addition, Ryan Flesher, the director of “The Vanishing Oath” explains that for him, an emergency room doctor, burnout is also caused by the inundation of bureaucratic demands and performance anxiety. This issue is extremely common in the United States, with 30% to 40% of physicians experiencing burnout at any given time (Fortney, Luchterhand, Zakletskaia, Zgierska, and Rakel, 412) and with up to 70% of specialists experiencing it on a general basis (Nido, Grimshaw, SayGan, Jensen, Williamson). There are serious consequences related to the syndrome– besides depersonalization, reduced personal accomplishment, and emotional exhaustion, doctors are more likely to leave their practices, and become depressed and suicidal. Professionally, doctors suffering from burnout are more prone to making medical mistakes and the quality of their care is considerably lowered, thus lowering patience satisfaction and further deteriorating doctor-patient communication (Drummond). In essence, this condition is caused by the excessive use of destructive coping mechanisms in order to deal with the stressful environment that negatively influences the personality traits that are strongly desired in medical professionals.
As the crisis of burnout has become more prevalent in the past century, there have been more efforts in attempting to improve and prevent it. Recent studies and medical opinions suggest that essentially, what is needed to counteract the issue is the application of more constructive coping mechanisms. Examples include: managing one’s time more effectively, taking time for oneself throughout the day to reflect on one’s mindset, becoming more self-aware, engaging in mindfulness training (Drummond), staying connected to loved ones, establishing healthy physical habits, attending therapy (Laws), keeping up with activities that one enjoys, and learning to say “no” (Nido, Grimshaw, SayGan, Jensen, Williamson).. More drastic examples include resigning or changing one’s field of medicine. However, there have been no holistic studies that prove that these recommendations decrease burnout on a large scale and there must be more research implemented in order to more definitively conclude that the ideas mentioned above succeed.
Works Cited
“5 Traits Employers Seek in Nurse Practitioners  – 4/29/2013.”HEALTHeCAREERS Network. 29 Apr. 2013. Web.
Casey, Barretta R. Enhancing Attention to Personal Qualities in Medical School Admission. Rep. 2008. Print.
Drummond, Dike. “Physician Burnout: Why It’s Not a Fair Fight.” The Happy MD. 2013. Web.
Dyrbye, Liselotte N., and Tait D. Shanafelt. “Physician Burnout: A Potential Threat to Successful Health Care Reform.” Journal of the American Medical Association (2011). Web.
Fortney, Luke, Charlene Luchterhand, Larissa Zakletskaia, Aleksandra Zgierska, and David Rakel. “Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study.”Annals of Family Medicine 11.5 (2013). Web.
Holland, Julie. Weekends at Bellevue. New York: Bantam, 2009. Print.
Laws, Jenny. “Start Early: Avoiding Physician Burnout Begins in Medical School.”LeadDoc. American College of Physician Executives, 21 Mar. 2013. Web.
Nido, Derek, John Grimshaw, Jasmine SayGan, Lauren Jensen, and Brandon Williamson. “Avoiding Professional Burnout.” The Mobile Physician. Web.
Nido, Derek, John Grimshaw, Jasmine SayGan, Lauren Jensen, and Brandon Williamson. “Professional Burnout and Physicians.” The Mobile Physician. Web.
Straker, David. “Coping Mechanisms.” Changing Minds. Web.
The Vanishing Oath. Dir. Ryan Flesher. Perf. Ryan Flesher. 2009. DVD.

Saturday, November 30, 2013

Polenta with Sour Cream and Feta Cheese

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Very easy to make, took less than five minutes. Unfortunately, it hardens extremely quickly and if you want to eat it in a mushy condition, you have to consume it within five minutes. Very good with sour cream and feta cheese, gives it the taste it lacks by itself. 

Recipe (for six servings):

  1. Acquire cornmeal.

  2. Put 1 quart of water in pot and boil.

  3. Add 1/2 teaspoon salt for taste (or 1 teaspoon if you want it to be saltier, depends on what you plan on adding afterwards)

  4. Add 1 cup cornmeal SLOWLY to the pot and mix it as you add it in so as not to clump. Continue stirring it until it is at the consistency you desire. (I prefer it to be mushy rather than hard).

  5. Add things on top to make it taste good.

Sunday, November 10, 2013

Nutella Stuffed French Toast

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...Nutella-stuffed French Toast (two pieces of bread) and three pieces of French toast (the two other pieces in the picture are one slice cut in two, and the other two slices of bread I had made I ate before I took this picture).
I didn't want to use too much bread so I ended up just pouring the egg mixture on top of the bread, which made it extremely eggy. Very oily as well but I think that's because i may have put too much butter in the pan.

Recipe: http://closetcooking.ziplist.com/souschef?url=http%3A%2F%2Fwww.closetcooking.com%2F2007%2F06%2Fnutella-stuffed-french-toast.html

Ingredients: however many slices of bread it takes to take care of the mixture, nutella, one egg, 1/4 cup milk, 1 teaspoon vanilla extract, a pinch of salt, 1 teaspoon butter, 1 tablespoon powdered sugar
1. Make a nutella sandwich.
2. Mix the egg, milk, vanilla, and salt.
3. Dip both sides of the sandwich in the mixture.
5. Cook the sandwich on both sides until it is golden brown…about two minutes.
5. Top with powdered sugar.

Crepes

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...5 crepes. I'm very proud of myself for making these because I had attempted this a few years ago and it was a disaster. I think I got the recipe wrong. The only hard part about making crepes is making them circular...and flipping them correctly.

Recipe: http://closetcooking.ziplist.com/souschef?url=http%3A%2F%2Fwww.closetcooking.com%2F2007%2F09%2Fcrepes.html

Ingredients: 1/2 cup flour, 1 egg, 3/4 cup milk, 1/8 teaspoon salt, 1 tablespoon butter (melted)
(makes 4 crepes)*
1. Mix all the things in one bowl.
2. Pour 1/4 cup of the mixture into a lightly oiled pan, heated at medium.
3. Tilt the pan so the mixture coats the entire surface evenly.
4. Cook until crepe is golden brown-ish…about two minutes.
5. Flip and cook the other side.
* I made five.

Strawberry Muffins

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I had three eggs left so I disposed of them in the following fashion: 9 strawberry muffins (there are only eight in this picture because I ate one)...

They turned out to be good, and pretty. (My food never really looks all that pretty but that's okay).

Recipe: http://allrecipes.com/Recipe/Strawberry-Muffins/Detail.aspx?evt19=1

Ingredients: 1/4 cup canola oil*, 1/2 cup milk, 1 egg, 1/2 teaspoon salt, 2 teaspoons baking powder, 1/2 cup sugar, 1 3/4 cups flour, 1 cup chopped strawberries
(makes 8 muffins)*
1. Preheat oven to 375 degrees F.
2. Combine oil, milk, and egg in one bowl. Beat lightly. In another bowl, mix flour, salt, baking powder, and sugar. Stir in chopped strawberries and coat with flour. Pour in milk mixture and stir together.
3. Fill muffin cups. Bake at 375 degrees F for 25 minutes. Cool for 10 minutes and remove from pans.
* Instead of canola oil, I used vegetable oil. Is there a difference? If so, I don’t think it’s very discernible.
* I made nine instead of eight muffins.

Tuesday, October 29, 2013

Pasta with Egg, Parmesan Cheese, Pepper, and Marinara Sauce

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I saw my father first make this eggy pasta last summer and I fell in love with it. I’m not kidding. It’s incredible. Of course, he put a lot more spices than I did (I only have pepper and salt) and he probably did a better job, but my pasta didn’t turn out too shabby. I decided to try to make it but the first time, I panicked even though I was on the right track. My second attempt, I remembered to add oil (I make very stupid mistakes, please remember that I haven’t been on this cooking path too long) and I was a bit more patient and it turned out pretty good. Very proud of myself, and an addition to the ‘will do again’ cooking list.
Fail cooking story: I was putting a Tony’s pizza in the oven, the cheap frozen kind (that are oh so addicting) and somebody had to tell me that usually, you put in the pizza without the plastic wrap…I had no idea…
So basically what you have to do with this one is make the pasta (boil water, put pasta in, stir occasionally for 7-10 minutes) and then pour it back in the pot (put oil at the bottom!!), turn up the heat, crack a few eggs in there, and wait until it looks like the eggs are scrambly shredded through the pasta. It shouldn’t take too long. Then put toppings.

Saturday, October 19, 2013

Baked Avocado with Egg

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This turned out to be pretty good. Not a life-changer, as historical-inevitability claims, but a tasty snack nonetheless. A bit salty, though that's because of my overzealous salt-pouring.
Ingredients: one avocado, one egg, salt, pepper
1. Preheat oven to 425 degrees.
2. Remove pit from one avocado.
3. Place pitted avocado on tinfoil on baking sheet.
4. Crack an egg in the pitted avocado.
5. Season with salt, pepper, what have you.
6. Bake for about 13 minutes.
7. Enjoy.

Saturday, August 10, 2013

Death & Dissection Essay

I.                    
The night curls its fingers around the sun, slowly pulling it down from its reign in the sky. The trees’ shadows darken, lengthen and headlights become brighter and insistent. It is dusk in Allen Parkway and I am running as fast as I can across the grass to the cemetery that I saw a few minutes ago from the car window. I don’t know how much time I have—my mother’s run usually lasts about an hour but I could have mistaken the distance from the parking lot and I am running out of breath fast. I am sixteen, upset, and desperately in need of a place where I can find a little peace and quiet. I am heaving now, completely out of shape, and alternate between powerwalking and jogging in short bursts of renewed energy. Before I know it, I come across grey marble headstones and slow down to walk the narrow path between them. I plop down beside an especially big one and close my eyes to catch my breath. As my heart rate slows and my lungs cease to hurt, I make myself more comfortable, lean back against the cool stone and whisper “It will be alright. Everything will be alright.” I force the cogs and gears that are constantly whirring in my head to slow down and instead, concentrate on what my senses are telling me—I see the light through my eyelids, feel a slight breeze on my arms, and let the sounds of evening traffic flow over and through me. Years later, I nickname this kind of meditation “Being” or “Simply Living”, and only as I’m writing this do I realize the irony of specifically going to a cemetery to “simply live”. After a few minutes, I open my eyes and smile. The sun has fallen to tree level, and the remaining rays of light are shining through the branches, reflecting off the tombstones. I glance at the one I have been resting against and am surprised to see a Star of David. I look around and notice dozens more. Somehow, it seems strange to have landed in a Jewish cemetery. Having been raised Orthodox Christian, and knowing painfully little about other religions, I have thought, until now, that only Christians used cemeteries. Nonetheless, I touch the engravings with my fingers, whisper “Thank you”, get up, and start walking back to the parking lot, calmed.  

II.                  
Medical dissection has always been and continues to be one of the biggest issues that society and the medical community has had to face. Though there have been many articles written about the benefits toward medical students’ understanding of the human body and thus, the benefits toward society that this practice presents, one should not take for granted that support and acceptance are universal. Due to a history of unethical procedures concerning the attainment of human bodies and dissection, cultural, religious, and spiritual beliefs that do not allow the action, and personal issues, there are many institutions that are wary of granting medical students access to cadavers. While reading Body of Work: Meditations on Mortality From the Human Anatomy Lab by Christine Montross, I was especially drawn to the author’s explanations of Christian and Buddhist views on dissection and I decided to delve into the religious points of view to understand the reasoning behind the support or the opposition to the practice. I will begin with a brief history of dissection and present a few different religious views on death and dissection and then discuss the relevance that these views have to the current opinions on autopsies.
Though the acquirement of knowledge about the human body had been present before, the first indications that such a practice was seriously being explored was in Egypt at the beginning of 1600 BC, as the findings of a few ancient papyrus papers written by scientists in that time show. During the first five centuries BC, Hippocrates, followed by Aristotle, Herophilus and Erasistratus began to advance the knowledge of human anatomy and dissection in Greece and in ancient India, an anatomist named Sushruta was also performing autopsies. It is not known for certain if dissections were performed in the Islamic world, but there have been speculations that there were a few physicians in the 12th and 13th centuries that did. By the time Galen began his work in the 2nd century in Rome, there was a slight understanding of the functions of the organs within the scientific community. However, because Roman law forbade dissections, Galen and other physicians were unable to study cadavers and instead, dissected primates and other animals. During the Middle Ages, Europe did not prohibit dissections universally (though there were a few religious edicts that did not allow it) and so they were performed more regularly as medical interest and studies grew. However, throughout the centuries, the societal and religious views on anatomical dissection fluctuated. For example, though Vesalius was one of the most lucrative anatomists of the time, he was frequently required to obtain his cadavers through unsavory means due to the increasingly hostile environment surrounding dissection. In England, dissection was prohibited until the 16th century, when a few edicts allowed very limited access to cadavers. Even after the Murder Act of 1752 was passed, which allowed anatomists to use executed criminals for dissections, the number of models was still extremely limited. Cadavers had always been difficult to obtain, but as the need for more accurate anatomical models and society’s fear and disturbance grew, anatomists began to go to illegal and immoral lengths to acquire human bodies. A black market arose and out of it, the profession of “body-snatcher” was born, where paid individuals would dig up corpses and sell them to medical schools. This heightened society’s fears even more and until the Anatomy Act of 1832 and the emergence of the 21st century, many were extremely skeptical of the benefits of using cadavers for medical lectures. Nowadays, though it is more widely accepted, there are still reservations about the process, even in medical communities. Considering the oftentimes violent history of dissection, it is not surprising that there is still opposition to the procedure. However, while researching the history of dissection, I noted that the majority of it is Western—I found little mention of it in Eastern culture. This amplified my curiosity as to how big of a role religion has played in views about the procedure and how much the lack of information is due to spiritual beliefs. 

III.
I began identifying as an atheist at the age of sixteen. For a few months beforehand, I had declared myself a pantheist, and before then, a struggling Orthodox Christian. Though my beliefs in the existence of gods have changed, my spirituality has not. Cemeteries have always been, not quite ironically, places of rest for me; I have rarely found locations more comforting to me in moments of distress and suitable to meditation. Though I do not usually share these experiences, I do not think I am alone in this sentiment. It would be difficult to think that the beautiful cemeteries across the world are maintained solely for their eternal inhabitants. However, the comfort I find from these places is only the first layer of my spirituality, the one that deals with Death. Though I have never been to a funeral nor had a loved one die, I am always conscious of Death, patiently hovering in the backdrop of Life. I have had my fair share of brushes with it, though I am ashamed that the few times I have been afraid of the idea of my own death have been when inebriated. I have attempted to end my life multiple times and so the thought has occasionally comforted me and at times, has even seemed the most logical course of action. Most of my loved ones have either already acted on their thoughts of suicide or regularly consider them, and so I constantly fear and visualize the deaths of those around me to the point of paranoia. When I philosophize, I wonder about the dichotomy of Life and Death, and I personify them, give them character traits, and in the process, attempt to accept and become more comfortable and familiar with them. Before I step into the anatomy lab for the first time in June, I have only seen dying and dead animals, and before I make the first incision on human flesh, I have dissected only mice. 
The night before the first day of class, I ask my mother, who is now completing her residency in neuropathology at the UT Southwestern Medical Center in Dallas, and who completed medical school in Romania at the age of twenty-four, how her experience with dissecting a human body for the first time was. Easily, she responds, “The first time I dissected a cadaver was when I was eighteen, so around your age. And it was fine. When you’re young, you don’t think about it and you do your work and you’re done. But when you’re older, around your late twenties, early thirties, because you’ve lived more, you start feeling things.” I press her, “What do you mean, ‘things’?” She hesitates. “You start wondering about their souls. You start asking yourself how they lived, why they died, and if they hadn’t been so stupid sometimes, how they could still be alive now.” She quickly adds, “But you probably won’t have to deal with those kinds of deaths. And you’re young, so you’ll be fine.”  Lying in my bed, I turn these words over in my head. What if I’m not fine? What if I’ll wonder about their lives as well? I don’t believe in souls and I know I’m young, but…

IV.
Christianity holds that after one dies, there is an afterlife where one’s eternal soul is either sent to heaven, hell, or in Catholicism, purgatory. After death, the body is usually buried or cremated, though these customs are different for each denomination (for example, in Orthodoxy, cremation is not allowed while in other Christian denominations, it is). Judaism also holds that death is not the final step of human existence. However, unlike Christians, Jews do not hold such a strong regard for the afterlife and so many opinions of what happens after death exist. Judaism does not condone cremation, and only burial is allowed. Muslims, like Christians, believe that one’s soul lives on after one’s physical death and that after the Day of Judgment, depending on the deeds performed in one’s physical life, there is either reward or punishment. Like Jews, Muslims do not approve of cremation, and the dead are only buried.  Hindus believe in reincarnation, the process of the soul to come back into a different physical body time after time. This cycle of birth and death can only be broken if one “reaps one’s karma” before one dies. Liberation (moksha) is achieved by figuratively waking up from the illusion of individuality, but can also be achieved by different rituals, depending on the culture. Bodies are cremated, as it is believed that cremation conducts the soul to the next body for reincarnation. Buddhists, like Hindus, believe in reincarnation and the idea that the ultimate goal of the individual is to escape the cycle of birth and death. However, unlike Hindus, who believe that individuals have eternal souls, Buddhists believe that they have anatta, or a collection of memories, habits, emotions, desires, sensations, etc. that is a delusion of a stable, lasting self. Though a delusion, this anatta reincarnates every time a body dies until the point that one reaches Nirvana, or liberation. Both in Hinduism and in Buddhism, the body is seen as negative, for it is the source of all desire and want (and therefore suffering), which is the opposite of liberation. The goal is to realize the delusion of anatta, or false self, and terminate it, thus leaving nothing to reincarnate, and nothing to suffer from, thus being able to reach Nirvana. After death, the spirit of the individual goes through a process that either ends with Nirvana or with reincarnation into a different body. Buddhists usually cremate their dead, but occasionally bury them as well, depending on cultural practices. Each religion and each culture has its own rituals and practices that they perform after the individual has passed away. 
Over the centuries, there has been extensive controversy over the permission of medical dissection in each of the five religions I have mentioned. The physical body is the vessel in which the soul, or the sense of self, resides, which is essential to the dogmas of these faiths. However, this vessel is still very much cared for and is given a certain respect even in death, as can be inferred from the numerous and various cultural practices of funerals. I am going to describe a few of the specific issues that each religion has with dissection and the conclusion that has been reached as of recently. 
Despite the turbulent history of dissection in Europe, Christianity does not reject medical dissection and though there have been many religious rules against the procedure (for example, the edicts of Pope Boniface VIII), no religious text speaks of the issue. Currently, autopsies are usually accepted, as long as the body is respected. It seems that in Christianity, the issue is not so much a religious one as a historical and cultural one. In Judaism, the concept of pikuach nefesh(saving human life) is the most important commandment in Jewish law. This idea is the main point that is cited for the allowance of dissection, for through it, human lives are saved. However, there are still the issues of desecration, the delay of burial, and whether one benefits from the body itself (which is prohibited). These problems have been (and still are) debated extensively and there have been numerous laws either prohibiting or allowing the procedure. In general, autopsies are permitted currently because of pikuach nefesh, as long as the body is respected, intrusion is minimal, and the burial is performed as soon as possible after the procedure has terminated. Muslims have similar issues with dissection. Islamic funerary rituals entail that the body should be buried as quickly as possible and as close to the site of death as possible. In addition, the dismemberment and modification of the body during the medical procedure is viewed as a violation of the sanctity of keeping the body complete. However, the principle ofmaslaha (public benefit) states that when the benefits of an action outweigh the harm of it, the action should be done. This concept has been extremely important in the allowance of dissection, for many religious leaders have stated that the procedure is necessary for the furtherance of scientific knowledge and the numerous societal health benefits that would be the cause of allowing the act. Respecting the body and only intruding in the areas that is absolutely necessary is crucial when performing the dissection. Hindus believe that after the body dies, the soul is still aware and must continue its journey either to liberation or to reincarnation. Since death is not seen as a final point, autopsy is viewed as a possible disturbance of the soul’s journey. However, it has been argued that since the lifeless body has no more karma, then an autopsy might be acceptable. In general, Hindus do not usually perform them but if the law of the country in which they reside requires them, they concede. Buddhists, on the other hand, highly value the benefits that come with medical dissection and they believe that the procedure is a form of compassion in order to help save future lives. Similar to Christian, Jewish and Muslim views on desecration, Buddhists also believe that the body should be treated with respect. However, desecration largely depends on the intent, and it is seen that the intent of autopsy is not to harm the body, thus the procedure is not viewed as desecration. 
While reading these different religious points of view, I was extremely surprised to discover how complex the issue of dissection actually is, and that though autopsies, or medical dissections are not always advocated, most religions do not have an outright objection against the procedure. It is completely dependent on the interpretation of the religious texts, the culture itself, the community, and the individual’s personal beliefs. The main complaints of dissection are that the body is harmed and that it is desecrated because of the removal of limbs and organs. However, the benefits of the procedure (scientific advances, the benefits to society as a whole because of these advances, medical diagnoses, and the saving of lives) are deeply considered, and in most cases, the religious leaders of the community assent that the practice of autopsy is permitted, as long as the body is respected.



V. 
Journal entry from the first day:
I walk inside and am slightly surprised to find metal tanks on wheels covering most of the area of the large lab. Are these where the cadavers are? There must be at least thirty, maybe more. I think to myself, I'm surrounded by dead people. How does it feel? It feels uncanny. The room is well lit, the same way a hospital is well lit, with glaring, ugly lights. And it's so incredibly clean. The man who takes care of the bodies is talking to us and I barely listen. They use formalin for the embalming fluid. I don't smell much, but that may be because I'm too busy smelling my extremely dirty lab coat that smells incredibly familiar, but I can't place why. The students receive those who died of natural causes and the faculty work on murderers, suicides, etc. the first tank is opened and the body is raised--the undergrads' body, our body. The moment I see it, my heart constricts. This is a dead body. There is no fear though and no disgust. But my heart constricts and I cannot stop staring at the body. I have completely tuned out whoever is speaking. I look at my classmates, try to read their faces. They are all blank, serious, emotionless. I suppose I was expecting more reaction, even a few gasps or grimaces, but there is nothing. Dr. P and the head morticians' tones don't change. We are not looking at a person who used to be alive who we are now expected to cut into and apart, we are looking at a diagram, a powerpoint, a piece of equipment.  There is no room for emotion, there is only time for instructions and action. Do you understand what you need to do? Yes? Good, now do it. I want to stop and think, I want to process the heart clench, but it was only a moment, and now I've gotten slightly more accustomed, and I'm putting on my gloves. I go see the other cadavers. The male looks fit, about fifty or sixty maybe. I see the other woman. Her mouth gapes open, and in horror, I hurry back to our body. Her mouth is closed thankfully, closed by the mortuary school students before she came here. She has bad scoliosis and when we turn her over to do the back dissection, we noticed a huge sore on her lower back. My group wonders what role this injury had in her death and contemplates what we can see of her body. They start cutting. I have not touched her yet. I do not want to, for fear of disrespecting her. I do not want to touch her unnecessarily, only cutting her as the Dissector instructs. Prof. V picks up her arms, her legs, moves them in a way I find forceful to show us and brainstorm with us the cause of death. I look at her, pleading with her with my eyes to comfort us, to comfort me, to say "It's okay, I understand. Take a moment to collect yourselves." Instead, we move forward as though everything is perfectly natural. I wonder if this attitude of complete professionalism is a way to desensitize us faster, keep us moving forward so as not to think about it. I look over at the male cadaver and notice that he has a bit of stubble on his chin. They're supposed to be completely hairless. This shocks me slightly. I say aloud, "It looks like he's sleeping." Sadness washes over me inexplicably, and confusion. I look back at our cadaver. I am asked to pick up a scalpel and help with the dissection. I gingerly do so and am surprised to find how easily the blade slices through the skin. I become completely focused on my task and all conflicting emotions and thoughts are pushed aside. I'll think about it later, I have to do this now. I step back from my work and it hits me--this used to be a person. She used to have a life. No. I can't think about that right now. I step forward and continue. This takes first priority. At about five o'clock, we finish, and we all leave the lab to our lockers to change and go home. How do we feel, I. asks. I feel alright, I say. And I do. I'm tired and I feel slight pressure from the thoughts I have shoved into a corner, but I feel alright. This is not the appropriate time to let them out. I need to be alone to analyze. I. mentions how when he pulled the skin back to its original place after reflecting it, he was hit by the realization that this was a human, a person, a woman. When you're working, you completely forget that. It's an ascension and descent into two different mindsets. Prof. V told us that we have the cadavers until August and once our badges start working, we can come whenever we want. I am extremely pleased and delighted. I decide to come back frequently, alone, to work on her, to simply sit by her side and talk to her about how I feel. This decision is made simply because I want to give her the respect I think she needs. This isn't the first time I've talked to the dying or dead. I have talked to the mice, to the graves in the cemeteries I used to frequent when I was younger and needed peace, one that I couldn't find anywhere else. Talking helps, even if it's one-sided. I want to come back because I want to let her know I care, let her know I'm grateful for giving us such an incredible opportunity. I want to thank her for donating her body and I am struck by several thoughts. Did she know how much damage her body would go through when she signed up for this program? I remind myself that this was a voluntary decision and that she's dead, that she can feel no pain. Do I still want to donate my body to science after seeing the actions performed and knowing that by the end, she will not be recognizable anymore? The idea of my body being mutilated in such a way shakes me. I have to remind myself that I'll be dead, that it will be for a good cause, that it will help save lives. I can now understand why it was and still is such an ethical issue to perform autopsies, why it was considered horrific in the Middle Ages to dig up graves and take the cadavers out to dissect them. But at the same time, it's necessary, and as long as it's voluntary and consent has been given, it should not be a problem. I now understand the Thai traditions of honouring and respecting your cadaver--the ceremonies, the knowledge and memorization not only of the age and cause of death, but name as well. I understand why the title "Great Teacher" is bestowed.
I want to write about those mice. It is interesting to note that I had to euthanize (the blunt term would be kill, because that is what I did) them using carbon dioxide. I saw them walk around the box and as they realized the danger they were in, I saw them scramble, saw them reach out with their paws to claw at the walls, saw them heaving, struggling for air, saw them piss themselves, curl up, and finally die. And I saw all of this without blinking an eye, without feeling any remorse. Because it's for science. I have to do this. I have to kill them, to dissect them, to further our knowledge of disease, so that we can live. At the time, it didn't feel wrong, but now I'm not so sure. I consider myself a relatively moral person, someone who values life and consent. Someone who knows that doing those things is wrong. Yet I didn't even bat an eyelash while killing those mice.  I did what I was told. I only followed orders. I can't be blamed. Shaking my head while writing this, I think "No. No. That was wrong." Am I afraid that I will treat the cadaver the same way, the way I treated those mice? I don’t know. But it is haunting me now after I saw her.


VI.
After realizing how complex the attitudes toward dissection are, I decided to see if I could find how much of medical students’ first reactions and emotions in the anatomy lab are  due to religious and spiritual beliefs and how much they are due to other factors. I determined it would be significant to investigate an issue that dealt with death, dissection, and religion from the horse’s mouth, so to speak. I found four different studies, all concerning the emotional reactions toward cadaver dissection: Indian, Nigerian, and Pakistani. I will summarize the results of each briefly and evaluate their results. 
The Indian study was completed in 2010 on 300 medical students over the course of three years in medical school. The mean age of the participants was eighteen years. Though there was no question of what religious beliefs the students held, when asked if cadaver dissection is ethically acceptable, 66.66% of the students responded yes, 19.66% responded no, and 13.66% responded that they could not say. When asked if they respected the cadavers and regarded them with sanctity, 70% responded yes, 10.66% responded no, and 19.33% responded that they could not say. To the question, “Do you feel anatomy dissection is an important part of the medical degree”, 78.33% responded yes, 7% responded no, and 11.33% responded that they could not say. On the other hand, when asked if cadaver dissection should be replaced by plastic models, computer assisted training, etc. in the near future, 33.33% responded yes, 36.66% responded no, and 30% responded that they could not say. On the initial visit to the lab, about 30% of students felt fear, but by six weeks later only about 15% reported the emotion. 
In the first Nigerian study, done in 2010, 104 first year preclinical students were surveyed.  Again, the religion of the students was not determined. 78% of the participants responded that cadaver dissection for anatomical learning is ethically acceptable, 6% disagreed, and 17% could not say. 53% felt emotional shock to the initial exposure to the cadaver (44% did not), 33% were upset at the beginning of the dissection (64% were not), and 35% experienced considerable anxiety and stress immediately before and during dissection (57% did not). When asked if cadaver dissection is still considered important and indispensable in anatomy learning, 90% said yes and 7% said no, but when asked if dissection can be replaced by plastic models, etc, 45% said yes and 39% said no. In the other Nigerian study, done in 2012, 65 students participated in the study and the religion and ethnicity of the participants were noted—73.3% were Christian, 25% were Muslim, and 1.7% were of other religions. When asked if they were upset at the beginning of the dissection, 46.7% replied yes and 50% replied no. 38.3% felt emotional shock to the initial exposure of the cadaver (58.3% did not), 36.7% experienced considerable anxiety and stress before and after the dissection (60% did not), 90% believed that dissection  is ethically acceptable (3.3% did not), 98.3% considered dissection to be indispensable in anatomy learning (1.7% did not), 45% thought that the technique could be placed by other methods (51.7% did not), 91.7% thought that dissection is culturally acceptable (3.3% did not), and 86.6% thought that it is religiously acceptable (6.7% did not). 
In the Pakistani study, done in 2011, 500 first and second year students were surveyed. The mean age was twenty years. It was found that about 43% of the students spent their course time actively dissecting, while 57% avoided these activities. Out of the latter group, 37% did so out of moral and ethical reasons and 18.6% out of religious reason. Therefore, out of 500 students, 285 did not participate, 106 (21.2%) on moral and ethical grounds and 53 (10.6%) on religious ones.
         From these four studies, one can conclude at least on some level that medical students’ negative reactions to cadaver dissection are not largely due to religious reasons. Ethically, the majority of the students surveyed believed that the procedure is acceptable and that it is indispensable to their educations, though more than a third of them also believed that it could be replaced by other methods. Interestingly enough, cultural acceptance was higher than religious acceptance in the second Nigerian study and there were twice more students in the Pakistani study who did not attend cadaver-based activities because of moral and ethical reasons rather than religious reasons. However, three of the studies do not take into account what religions the students believe in and this sample is extremely limited and not completely representative of international medical students’ beliefs. Nevertheless, the studies are a window into the perspectives of current medical students and allow us to understand their attitudes on dissection and religion from a first-person point of view.  

VII. 
            The morning of my second day of anatomy class, an indescribable sadness washes over me in the bus. As a man in scrubs sits down next to me, I am overcome with the urge to grab him and ask how he felt after the first time he saw a cadaver. He must understand, for we are now in the same secret club, we are now on the same boat. We are set apart from those who have never had to see a cadaver, to take a blade and cut through the skin, to strip away the likeness of the human body. And yet, though the man in scrubs and I might be able to discuss our experiences, there is still a wall between us. This is the strangeness of being in a club with countless others, and everyone having a different secret password. As Montross states, “No one speaks up, and as a result each person believes that she is alone in her experience.” Feelings are deeply personal and there is a fear that if one shares them, one will be rejected—oh that’s weird, I don’t want to hear that, you shouldn’t be feeling that, don’t you think that sounds slightly sociopathic? There is not much understanding or empathy from the rest of those who have not experienced what we have, and we cannot fault them for it. But if one needs a release, if one must talk of one’s feelings, there should not be fear of rejection from one’s community. Montross’s Body of Work and the discussions with my group mates helped immensely, but the realization that I was not alone in the way I felt came about a month after the class ended when I was searching for students’ responses to their first year of medical school. I came across the study “Respect for Life, The Final Gift: A Qualitative Inquiry into the Experiences of First-Year Medical Students in Cadaver Dissection” by Michelle D. Skinner and began reading the quotes from the students themselves. The moment I read one student’s response, “I felt a connection. Sometimes I would even hold his hand as we were dissecting”, I began breaking down with relief. Having been terrified of being ridiculed for my reactions toward the cadaver if I had spoken up, it was incredibly comforting to know that I was indeed not alone in feeling my most private emotions. 

VIII. 
         On a high mountaintop in Tibet, a vulture picks at its food. Flesh rips from bone and one can see the ravaging to its prey. More vultures join the first one and soon, it has become a veritable feast. Lesser predatory birds, crows and hawks, wait impatiently on nearby trees, eager to snag a piece. The meal is good and before long, the bones have been picked clean. Only after the big birds have flown away can one see that the bones of the animal are in the shape of a human.  
         Tibetan Buddhists, instead of cremating or burying their dead, place them on mountaintops and wait for the vultures to devour their loved ones. When only the bones remain, rogyapas, “body-breakers”, break them with mallets, ground them up with flour, tea, and yak butter, and give them to the hungry crows and hawks to eat. Occasionally, the rogyapas dismember the bodies themselves and ground the flesh and bones to a pulp to then offer to the vultures. This is not a solemn ceremony, for the workers laugh and converse as they would at any other physical task. The family of the deceased sits nearby to watch the entire scene unfold. This ritual is known as jhator, or a sky burial and signifies the transitory nature of life. As brutal as it sounds, there is nothing more natural. It is raw and it is honest and it is, for lack of a better word, human. Life, death, spirit, giving, receiving, laughter, sadness…It is all there, an authentic expression of who we are. 

IX. 
         It is the day after the final anatomy test and I am heading back home after my morning class. Three weeks ago, I had told myself that I would come after hours to talk to our cadaver, to reassure and thank her for her donation but until now, I have not been able to find the time. As I sit on the bus, rapidly approaching the medical center, I decide that today, right now, I will go to say my goodbyes. I get off at the stop and walk slowly toward the medical school, thinking about what I will tell her, hoping that no one will be in the lab for this intensely private moment. I swipe my badge at the door and am surprised to find the room dark. I wash my hands slowly, deliberately, and find the gloves marked small. I take a deep breath and open the tank, pull down the levers, and elevate her. Her entire body is covered with the soaked cloth and I carefully pull all of it back so she is completely exposed. After gazing at her for a few moments, I decide to bring the light down and turn it on. For a few minutes, I touch her fleetingly, her arms, her legs, her face. I inspect her organs, run my fingers over her ribs and begin muttering anatomical terms and names, trying to remember everything I’ve studied for the past three weeks. I apologize to her for not doing as well as I could have on the tests. Somehow, it seems like a sign of disrespect that I did so badly, as if her gift of her body to us was wasted. I pick up her brain gently and start stroking it. I tell her that my favourite moment in the lab was when I held her brain for the first time and do you remember? I kept saying “Can you believe it? Can you believe how incredible this is? This is so incredible. This is a brain. This is what we are, what I’m holding in my hands right now.” I was shocked that the key to our humanity could fit in my small hands, that it was so heavy and smooth. That entire day after we had removed the organ, any chance that I could, I would hold it in my hands and run my thumbs over its gyri, exclaiming “Isn’t this so incredible?” at random intervals. I put the brain back in its place and having grown bolder, I trail my fingers across her skinned face. Words start pouring out—I tell her that she’s beautiful, how grateful I am that she donated her body to us, how lucky we were to receive her. I tell her that I wish I knew her name and that over these past three weeks, I’ve developed a sort of bond with her. I pull up a chair and clasp her hand in both of mine. I’ve started tearing up now. I tell her that she has the most beautiful hands, long strong fingers, and apologize for the horrific pain she must have been in before she died. For the first time since the first day of class, I let myself wonder about her life—did she have any children? When she was dying, did anyone come see her? The last question, I whisper. Did anyone hold her hand the way I’m holding hers right now? It feels natural, and good, and I don’t want to let go and I realize that I have never held anyone’s hand in this way. I have now been here an hour and reluctantly, I tell her I must go. I say my last thank you, place the cloth back over her body, close the tank, turn off the lights, and head to the bus stop. 
On the bus, I open Body of Work and my shoulders start to shake as I sob, whispering the final words of the book:
Great teacher, I give you flowers. I carry your body to the funeral pyre. When you burn, may every space in you that I have named flare and burst into light. 





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(first and third photos from http://en.wikipedia.org/wiki/Sky_burial and second photo fromhttp://deformutilation.blogspot.ca/2012/06/sky-burial-remnants.html?zx=bc171811ceef3615







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