A More Humanistic Lens

A few weeks ago, you purchased a digital single lens reflex (dSLR) camera for the first time. You were excited about all the pictures you were going to take – they were going to be way better than those pics you were taking with your cell phone.

Of course, there was a bit of a learning curve with all the buttons, settings, and adjustments, but after exercising your Google-fu and practicing a bit on your own, you learned quite a bit in a relatively short time and you are a bit proud of yourself. You aren’t a master photographer quite yet, but you have quickly learned that there is a relationship between a camera’s:

• focal length: the ‘35’ in a 35mm camera; the larger the number, the greater the zoom, and the greater the distance between the image sensor (‘film’) and the aperture
• aperture: a measure of how big the hole in the lens is, the hole allows light to pass into the camera. Measured in a fraction of the focal length (e.g. f/3.5), the larger the aperture number, the smaller the hole that the light passes through
• shutter speed: the amount of time the camera lens allows light to enter the camera, usually measured in fractions of a second
• ‘film speed’: perhaps you remember going to the store to pick up 200 ISO or 400 ISO film for everyday use, before the advent of digital photography…the larger the number, the more light sensitive the film (the values are standardized by the International Standards Organisation, thus ISO)

Fig 1. The cat in the foreground is overexposed.

You have been tinkering with the dSLR for a few weeks now, and you have a pretty good feel for things. You have come to realize that there is an ideal amount of light that needs to strike the image sensor (virtual ‘film’) to create a good picture. If too much light strikes the sensor, the picture will be over-exposed and will appear too bright (Fig 1). If too little light strikes the sensor, the picture will be under-exposed and will appear too dark (Fig 2). You now appreciate that the lighting in your environment dictates the ISO you choose (200-400 for daylight, 1000+ for low light conditions – but be careful, the more sensitive the ISO, the worse the noise). You realize that if your subject is moving, you need a faster shutter speed so that the picture isn’t blurred. You understand that a faster shutter results in less light hitting the sensor, so (in that instance) you would need to compensate by increasing the aperture size (ironically adjusting the value smaller, because it is the denominator of a fraction, whose value you wish to increase).

Fig 2. The building is underexposed.

Now imagine for a moment that you just purchased a new lens for your dSLR camera. The lens that you received with the camera (often referred to as your ‘kit lens’) quickly proved to be inadequate (you think) and you needed to upgrade so that you could take pictures with more flexibility than was afforded you by the simple 18-55mm f/3.5-5.6 lens you have been using. Some folks will go to a reasonably priced prime lens as their first lens purchase, but many (like yourself) decide to go with a bigger ‘zoom’, so they obtain what is termed a ‘telephoto lens’. In this instance, you have selected a lens that should work in most instances under typical lighting conditions: an 18-300mm f/3.5-5.6 lens.

If you are not a photographer, perhaps it would instead be easier (at this point) to imagine that you have just graduated from PT school and you realize all too quickly that – while you are now licensed to practice – your skills seem inadequate; you are not helping as many people as you may like, so you elect to go to a continuing education course. The course is designed to hone in on a certain aspect of your care and improve your expertise in that specific area. In doing so, you are improving your ability to ‘zoom in’ on a subject/patient. In other words, you have the basic know-how to operate the camera, but increasing from 55mm of available focal length to 300mm feels like completing the first 4 courses of a certification program – only (for $800 USD) the lens is considerably cheaper and is likely to bring you greater pleasure.

In many instances, though, while the telephoto lens helps you take pictures of things in the distance (i.e. birds or your kid playing a soccer game), you will quickly discover that the telephoto lens has limited utility. The farther you zoom in, the darker the picture becomes – the mechanics of the lens dictate that the aperture can move no larger than f/5.6. To compensate, you need to increase the ISO, which adds more noise to the picture. You could avoid adding noise by reducing your shutter speed, but now there is likely going to be increased motion blur in your picture. And then there is the issue with perspective…

What about perspective?

If you take a picture from the same angle each time, how can the perspective possibly change if it is taken with one focal length versus another?

Fig 3. Compressed Skyscrapers

Firstly, the picture taken with a telephoto lens will appear compressed or flattened. Look, for instance, at Figure 3, a photograph of skyscrapers which appear as though they have been built atop one another when photographed with a 300mm focal length. It is a neat effect in the photo, but the loss of depth is undeniable and often undesirable.

Secondly, the background of the subject photographed with a 300mm focal length from a distance is narrow; it is physically incapable of capturing the surrounding environment (see Fig 4).

Meanwhile, if you wish to photograph a subject in their environment, capturing context, you need to use a smaller focal length. You need to move closer to the subject, much closer. With a shorter focal length, the larger (f/3.5) aperture is now available so more light can come through the lens. With more light available, you can adjust down the ISO, reducing the noise in your picture as well. The closer you get to your subject (with your wide-angled, 18mm focal length), the brighter and clearer your picture can become and the greater your field of view.

Fig 4. The photo on the left is taken with a telephoto lens from a greater distance, the photo on the right was taken with a wide angle lens from close up

Of course, then you realize that your kit lens could shoot at 18mm too. Sure, every once in awhile, you may find a use for the 200mm or 300mm focal lengths, but (for the most part) you could have saved $800 and mastered the kit lens, instead. There are occasions when the extra focal length may be helpful, but you will not rely on it every day.

.   .   .   .

In a competitive marketplace where every continuing education purveyor is trying to get you to buy their special telephoto lens – each with its own special features – consider honing your skills with the kit lens first and foremost. The small focal length on the kit lens is what encourages you to stand closer to your patient and develop a relationship. Moving closer to your patient helps clarify the picture you are trying to capture; it reduces the noise. The different/closer perspective affords you the opportunity to see more variables that surround, stress, and influence a patient embodied in their unique environment with its particular circumstances.

Fig 5. A telephoto view of the patient

The telephoto lens encourages you to zoom in on one area, only to zoom out and back in on another. The telephoto lens directs us to look at the parts, in isolation. It is the telephoto lens that separates the biological from the psychological from the sociological. The telephoto lens has fractured and fragmented our patients. The world is filled with clinicians with 300mm lenses – far fewer have mastered 18mm.

My only question: can you be a wide-angle PT?

Fig 6. A wide-angle view of the patient

Passive Listening and Therapist-Centered Care

She had 2 falls yesterday, after the surgeon had told her that she can start putting more weight on her foot; after a month of toe-touch weight bearing, the x-rays had (apparently) looked good. She denies any pain, which is (hopefully) a good thing, considering her hip has already dislocated twice in the last month.

“Did I dislocate again?” she asked.

“Did your hip have pain when you dislocated last time?” I asked.

“No,” she replied, “but it hurt like a mother fucker going back in.”

I asked her to lie on her back; she actively moved from sitting to supine independently, without difficulty. Upon assessment, her hips were not overtly asymmetrical; her motion was within restricted limits (considering her dislocation precautions) and she was still pain-free.  She actively flexed/extended her hip without pain, but when she fully extended her hips/knees I noticed the obvious, “When you went in for surgery, did you have a leg length difference?” I inquired.

“Oh sure, I had a shoe with a big honkin’ sole and everything,” she told me. Phew. “Do you mind if I see it?”

She didn’t and kindly directed me to where I would find the shoe on the floor in the other room. As I was scanning the room, looking for the shoe, she yelled from the other room, “I hate that thing.”

“I can imagine that you would,” I replied.

I brought the shoe out to the living room; it was still a pretty good match for her present leg length discrepancy post-op. I wondered aloud if, by trying to walk with a flat foot yesterday (without a lift) she was compromising her balance in a way that may have contributed to the falls. With my gaze focused on the knuckles of my thumbs over her medial malleoli, I said, “I’ll just ask that we try that shoe on for a second to see if it is still successful in evening out your leg length discrepancy.”

Then she wept…uncontrollably.

She really hated that shoe. I should have asked why.

Hyperbole?

half glass full: we are living each day – hopefully to its fullest potential

half glass empty: day by day, we are all dying slowly (some faster than others, some more predictably)

.    .    .    .

I get it. This is not going to resonate with everyone (anyone?). My typical patient has multiple comorbities, is incapable of leaving their home due to challenges with their mobility and has varying degrees of pain (often not their primary complaint). They are weak, alone and (often) depressed. They are scared and fearful of the uncertainty that awaits them. This is not everyone’s typical patient, but it is mine.

As I reflect back on my metamorphosis these past few years from who I was to who I am, I realize that (for better or worse) my way of being with patient’s has been most informed by my working with those with terminal conditions, weeks/months before their inevitable transfer from home- to palliative-care.

Most clinicians recognize that patient’s who receive palliative care deserve a dignified level of care that is often absent in typical settings. This care often emphasizes the clinician’s efforts to gain trust through inter-personal interactions and being present in a relationship that both the patient and the clinician goes in the direction of the other.

What would physical therapy care look like if every PT worked to earn patient trust, rather than assuming it is conferred on them by title, degree or position?

What would physical therapy look like if we interacted with each patient as if they were dying?

Expectations of Actions, Not Results

I recently entered the home of an 88-year-old woman that, as Dr. Kyle Ridgeway, PT, DPT mentions in a recent post, “everyone dreads.” She is ornery – but I would be too. She cannot hear well, yet has no hearing aids, so is shut off from TV, radio and most conversation on the phone – which prevents her from talking with her children who live 3,000 miles away. Most of her friends are dead. She has grown accustomed to living alone, yet now she has visitors daily (strangers from an home care agency) to address venous ulcers. She mentioned that she has had falls in the past, prompting a PT referral which triggered a visit from yours truly. She spent the first 20 minutes of my visit yelling at me about how disgruntled she is with her doctors, the upkeep on her home, the daily intrusions… These are all variables that I have no control over and they will certainly confound any progress that I try to make with this patient, but my expectations need not change. After all, I only have expectations of myself – to simply walk into each home being courteous, respectful, reflective, quiet (when appropriate), and poised.

Before I left her home, I apologized for interrupting her day and openly empathized with how challenging and disruptive my visit must be. She (surprisingly – in turn) apologized to me for being “such a grumpy old lady” – she was now empathizing with me. In one hour, something special had happened: not only was I able to stand in her shoes, but she was also able to stand in mine. We developed something mutual, something to share.

Today, I plan to enter her home gently and to kneel beside her chair again, as I did the first day. I plan to yell at her politely, but slowly, so she can hear me. I plan to let her complain as long as she needs to before steering the conversation toward something that could be recognized as physical therapy. I plan to serve as I can as a purposefully courteous, respectful, reflective, quiet (when appropriate), and poised medical professional. Hopefully, she is willing to give something back and join me again in that space where therapy might happen.

Time will tell – after all, the outcomes are out of my control.

Never Lie

Eight months ago, she felt sorry for me. She was a woman of strong faith, and she was visibly pained when she discovered that I held no religious beliefs about what happened to my “soul” when I die.

“No heaven? No hell?”

“I fear not,” I (think) I told her. “Just a world that continues to move on (for better or worse) without me.”

“Never say never,” I remember her telling me.

“I didn’t say I won’t ever have faith,” I said. “I said I don’t have faith today.”

.     .     .     .

Today, she cried as she spoke of her life’s experiences and how she has been buoyed by her faith despite a lifetime of chronic illness, the early loss of her daughter decades ago and the recent passing of her husband. She is a strong woman and while she doesn’t see it that way, she is grateful for the strength that thinks has been given to her.

Today, for nearly an hour after her visit, she shared her testimony with me. She has seen Jesus. She has witnessed miracles. She has had her prayers answered. After wiping away her last tear with her handkerchief, her gaze moved up and her eyes fixed on mine. “Of course, you don’t believe any of this do you?”

I could have been openly skeptical. I could have dissected each experience, easily explaining away each and every one. I could have asked her what percentage of her prayers have actually been callously dismissed by her creator. I could have asked her why, when she talks to her husband (or Jesus) in her sleep, she considers it is a powerful vision, but when cats walk on stilts while singing She’ll Be Coming ‘Round The Mountain it is but a silly dream. Instead – I decided to tell her the truth:

“Your experiences are real; what I believe has no bearing on that. No one can ever take those experiences from you – they are a gift for you alone to cherish.”

She smiled and reached out for my hand. “You know,” she said, “I believe you’re right.“

Guised As Therapy

While I was first visiting Maddie 2 weeks ago, I learned she hasn’t walked any significant distance in her home in the previous 3-4 weeks. She eats, sleeps and socializes with family in her recliner. She is 83-years-old and obese. She has a pressure ulcer on her sacrum, for which she is receiving nursing care in the home. She is receiving antibiotics for a newly diagnosed urinary tract infection, which has been forcing her to urinate once every hour. She has a history of depression and anxiety, each of which has been controlled (historically) by her current medication regime (I am not convinced that these are any longer effective and have requested a psychiatric evaluation).

A once proud and socially active pillar of the community, Maddie doesn’t leave the home any longer, but she welcomes friends for a weekly game of pitch at her dining room table. To move to the table, she has (with significant physical assistance from her son) stood and turned to sit on her rollator, which he then pushes to the table. She has been moving the same way to the bathroom to void her bladder – more than 20 times daily.

Today, after 6 home care physical therapy visits, her son greeted me at the front door smiling:

“Mom is doing much better – thank you. She is getting up to go to the bathroom on her own – she didn’t even call me in the middle of the night last night.”

Considering her history, I might have considered her increased mobility a triumph. Instead, I still felt guilty.

.     .     .     .

Two days ago, on Wednesday, she was crying. I held her hand while she told me she was okay, but I fear that she was saying what she felt was required of her under the circumstances. She had lost control – I had taken it from her.

Earlier on Wednesday, she had walked to the bathroom. It took some encouragement, but after walking only 12-feet on Monday, she walked nearly 30-feet to the commode with her rollator. She was a bit tired and anxious as she tried to maneuver herself directly in front of the commode, but she had good control throughout. I praised and congratulated her for the achievement; her son did the same. She seemed not to care – I imagine that, in her mind, she was just happy to have stopped the task without appreciating what she had accomplished. “Thank God, it is over,” she must have thought.

She told us she was too tired to walk back to her recliner, so she was transferred back to her rollator and wheeled back to the living room, where she again transferred to the recliner. She politely agreed to participate in a few seated exercises to improve sitting balance, before trying to transfer to standing a few more times before the conclusion of my visit.

Maddie and I adjusted her recliner (actually, it is a powered lift chair) so the seat was positioned an advantageous 15 degrees from horizontal and, with contact guard, Maddie pushed off of her chair with her hands and raised herself – with her creaky knees – to a standing position. She stood at her rollator for 10 seconds before returning to the chair with good control. “I’m tired,” she said. “I can’t do anymore.”

“That’s not true,” I told her. “You are far stronger than you give yourself credit for. You didn’t think you would be able to walk to the bathroom either, but you proved to yourself that you could. You are so strong – you just don’t recognize it. Come on – one more – then I will get out of your hair for the day.”

She patted my hand that was resting on the arm of the chair as I squatted alongside her, “Oh, you aren’t getting in my hair, dear.”

“That is kind of you to say, but I suspect you may be playing coy. Come on, what do you say? One more, okay? I’ll even give you a bit of a boost if you need a little extra umph.”

She yielded, nodded her head, closed her eyes, and slowly sighed. She placed her hands on the arms of the chair (I placed my arm under hers), leaned forward and began to push herself to stand until, half-way up, she paused. “No, I can’t,” she said.

“Yes – Yes you can,” I said, resisting her descent back into her chair with my own arm. “Don’t you dare give up on yourself, you deserve better. Come on. Keep pushing.”

She began crying, but she was almost there – “Keep going, Maddie. You can do this!”

And she did it. I only asked her to stand for 3 seconds before sitting back in her chair, where she began sobbing in earnest. I knelt beside her chair and handed her a tissue. After she wiped her tears, she placed her hand on her lap, I placed mine gently upon hers. “I’m sorry,” I said, “In the moment, I couldn’t let you give up on yourself like that. I know what you are capable of and you need to see and appreciate it. You can do so much more than you give yourself credit for.”

“I suppose you’re right,” she said, as she took a deep breath and exhaled, allowing her shoulders to ease to a more relaxed state.

.     .     .     .

She says she wants to walk to the table and sit in a chair to play cards with her friends. She says she wants to compose music at her piano again. She says she doesn’t want to rely on her son to help her pull her pants on and off. She says she wants to have some of her dignity back, but when she is faced with the challenge of achieving those goals, something gets in the way.

Perhaps she has never felt fatigue at this level before and it is overwhelming. Perhaps she is experiencing an acute exacerbation of her anxiety or depression. Perhaps her son is right: maybe she is just lazy.

All I know is that for one small moment of time, her goal was to sit down and I forced her to stand. I know that I (in part) made her feel something that brought her to tears. I know that life – with its obesity, social separation and isolation, psychological challenges, and physical deconditioning – has stripped so much from her over the last year, and that I (if even for a brief moment) stole something else from her as well. You see, up until that moment, for better or worse, she has been allowed to make her own choices. I stole from her one of the last few things that she could call her own – her autonomy.

Today she is moving much better than she was a week ago and I am able to document significant positive changes in her presentation. The patient’s family is thrilled with her progress; they will likely complete my discharge evaluation with a high patient satisfaction score, my boss will praise me again at my next annual review, and my director will continue to think that I provide some the highest quality care that the agency has to offer.

On Monday, I would have told you that I practice patient-centered care*. I am not sure how I would categorize my care if you asked me today, but I certainly wouldn’t call it ‘patient-centered’.

 

*link to Critical Physiotherapy Network blog posting titled, Why Physiotherapy Is Not Patient Centred by @DaveNicholls3. I recommend following CPN on twitter, if you are not already

A Better Father

“You are fine. Shake it off.”

.     .     .     .

Four years ago, I would have reacted differently if AJ (then 3-years-old) had begun to spontaneously limp and complain of posterior right knee pain in weight bearing and discomfort with active full knee extension.

But last night, on Father’s Day, I acted like every dad should. When Tori began to cry and limp after rising from the floor after playing with her toys, I held her in my arms, even though I knew there was “nothing wrong”. I asked her to point to where it hurt; I asked her to take my finger and point to the spot on her leg that was uncomfortable. I gently tried to help her straighten her knee without luck. We sat there cuddling for a few moments with my hands on her leg, doing nothing.

“I’m sorry that you hurt, but it is okay.
Everything is healthy and it will feel better in the morning.”

Last night, she received a playful piggy-back ride to the bathroom sink, where she stood on one leg to brush her teeth. She was tickled as she was swung side-to-side into her bedroom, giggling all the way – but she kept her knee flexed throughout. We laid on her bed, instead of sitting on the floor, to read her books before bed. She chose one story about Caillou, another about Clifford. I asked her to lay on her belly beside me and I purposefully read the stories wrong so that she could correct me (she has them memorized, after all). Before I was done with the first story, her knee was straight and she was still smiling.

After her stories were complete, I tucked her under her covers, kissed her on her forehead, and said, “Good night, hon. Sweet dreams – I love you.”

She woke up this morning and her knee pain was gone – or at least I assume it was; I didn’t ask and she didn’t limp.

.     .     .     .

She says that luke-warm bath-water is too hot, the dustbuster is too loud, the marinade is too spicy and the sun is too bright. One day she can also say that her father listens and allows her to express herself without judgement. Granted, she is only 4-years-old, and I understand that self-expression and understanding is something that she probably doesn’t appreciate today, but I know of no better way to improve her chances of having a happy and successful tomorrow.

Eastern Voodoo in a Small Town

Candice lives in an isolated farming community; she and I have worked together for the last 2+ weeks to improve her safety and to transition her from a walker to quad cane after she had been hospitalized for 3 weeks following abdominal surgery and a subsequent incisional infection. She is now ready for outpatient care and I was preparing to walk out the door.

.   .   .   .

Are there any additional questions or concerns that I can address for you, ma’am?

Yes. What do you think about acupuncture?

What do I think, or what do I understand?

What’s the difference?

Without pulling punches, I think that those who practice acupuncture are either uninformed, willfully ignorant or charlatans. I understand that acupuncture works no differently than a sugar pill.

Why do you say that it is a water pill?

Well, ma’am, after decades of research, where people receive real or pretend acupuncture, everyone gets better, but equally. It is no different than if we took 100 people in town with headaches and gave half Tylenol and the other half water pills. Both groups of people would get better to some extent, but the Tylenol group (on average) will improve more, because Tylenol has a meaningful effect. With acupuncture studies, they have discovered that acupuncture has no meaningful effect when compared to fake acupuncture.

So people get better, because they expect to get better?

Exactly. Someone dressed professionally, who is considered an expert, with a kind disposition and who speaks eloquently is going to increase your expectations of (and confidence in) success more than an unkept, unshaven, novice, who calls you ‘dude’. For instance, you are far more likely to feel better if you have me as a therapist than you would if you were to receive care from the guy in torn blue jeans.

I do really appreciate how you present yourself – you are very professional.

Thank you – but I also try my best to provide you with quality care, encouraging you to move in a way that is therapeutic, because movement has been proven, over and over again, to be more effective than a sugar pill and far exceeds the benefits of expectations alone. The same can not be said for acupuncture.

I see, I think I see what you are saying, but don’t you think they can find the right nerves to make you feel better?

First, I would question if sticking a nerve with a needle would be helpful – after all, people have back surgery, because the nerves in their back are being ‘poked’ by something, right? But to your point, nerves can be very small and they vary from person to person; your nerves have variations that are different than mine, that are different from your sister’s…Imagine for instance, taking a potted plant, pulling it out of the pot and shaking the soil from the roots. Then take the thin branches of the roots, set them on a flat surface, put a burlap over the top of the them (so you can no longer see them) and then find the exact same spot in the roots with a small needle three times in a row without peeking underneath. That is what acupuncturists claim to do – it is improbable, if not impossible.

I hear what you’re saying, but I don’t see how that can be true – I had acupuncture for my arm and it helped me.

I am glad that your symptoms have reduced, we just can’t be certain it was the needles themselves that helped you feel better.

Yes, he was wonderful. But I can’t see him anymore; he went to NJ to care for his aging parents. But he really knew what he was doing…and did I mention that he was Chinese? He was great – it’s a shame you never met, you would have liked him.

.   .   .   .

I just smiled – there was no way that I can compete with that.

She and her son still have 5 visits with the wellness office that they will never redeem; they had to prepay. She won’t go back because the ‘new guy isn’t as good as the old one.’

Like me, the new guy isn’t Chinese, which is only one of many variables that neither he, nor I, have control of.

Too Harsh?

I posted the following to my Facebook page today:

I was initially surprised and unsure what to say, so I bought myself an extra moment to think over my response:

“If you don’t mind, I am going to set these things down in the other room, then we can figure out some of the difficulties you may be having with your positioning.”

I walked through the living room, where the Mrs. Smith was sitting, into the kitchen, set my things down in a chair, and returned to the living room.

“I’m sorry, Joannie, could you review with me again your concerns regarding Mrs. Smith’s sitting?”

The nurse then repeated her concerns. The couch is too soft. Mrs Smith’s pelvis was going to ‘splay’ (this was a new one for me). Her back was going to be positioned horribly and result in pain. She referred to this as “Pain Management”.

My response could have been more pleasant. It could have been more balanced. It could have been more collegial.

I decided to go in a different direction. I decided to make sure that the patient had no doubt as to the veracity (or lack thereof) of the nurse’s concerns.

[To the nurse] I am not usually so forward, so please forgive me…but that is the most absurd thing I have ever heard.

[Turning to the patient] Here is the thing: your pelvis is indeed made of a few different bones, but they are fused, no different than your skull. There is no reason to worry about your skull bones shifting if you do a hand-stand; the same is true for your pelvis when you sit on it. It might have moved a little before your daughter was born 25+ years ago, but since then, I can say with confidence, it probably hasn’t moved a bit. For anyone to tell you that it is ‘splayed’ sounds flat out ridiculous. You need not worry about your pelvis.

And your back? It has been fused for the last 4 years; it is held together with the same materials they used to construct the space shuttle. You are made of space shuttle parts. A nuclear bomb could detonate down the street and the only evidence that you ever existed will be the left-over parts they used to fuse your spine together.

Don’t get me wrong, I know that there are moments when you are uncomfortable, and we need to work on that. But that is because your nervous system is sensitive; it is trying to protect you. It is working hard to do so, if it needs to or not. We will continue to work on reducing that sensitivity and affording you the opportunity to continue to move better, but I would be the worst therapist in the county if I left your home today allowing you to consider for even the briefest of moments if your back and pelvis are anything less than structurally sound and strong.

The Space Between Us

Perhaps I am swinging at a straw-man, but I fear not.

I find it interesting that I have often heard (or read) of the power of the internet, especially with regards to its potential ability to provide us (as clinicians, especially those working with patients with painful problems) a new medium through which we can interact with our patients. I encourage those who are considering such endeavors, however, to pause and watch this video.

Most of us work in hospitals, rehab centers, homes and clinics. We have an opportunity to consult with individuals face-to-face, in a shared space – the ideal context for empathy – yet some are advocating for adding distance between us and our patients for the sake of efficiency, cost, or convenience. Meanwhile, film-makers are trying as hard as they can to reduce the distance between decision-makers and the disadvantaged to enhance empathy and understanding.

In short – others see value in spending millions of dollars and hundreds of hours of time to create a space that we already work in, but may be walking away from.

The internet’s potential for connectivity is nothing short of amazing – but please remain acutely aware of its limitations.