Lessons From Clinical Medicine And Loss Angels Inner City Kids

 Lessons From Clinical Medicine And Los Angeles Inner City Kids 

M. Bakri Musa

 

Excerpt # 9 From Qur’an, Hadith, And Hikayat:  Exercises In Critical Thinking

 

Early in my surgical training I had a patient with myriad complicated medical problems. His heart was failing, as were his kidneys, lungs, and everything else. He was bloated with retained fluids that flooded his lungs making him struggle to breathe. His lack of oxygen affected his heart and kidney functions. Compounding that was his electrolyte imbalance, and combined with his lack of oxygen, he was becoming confused.

 

         Any attempt at addressing one problem would risk aggravating the others. Restricting his fluid intake, the obvious solution that the kidney, heart, and lung specialists had earlier suggested, risked aggravating his confusion and heart failure from the consequent reduced tissue perfusion.

 

         Our brilliant attending surgeon Dr. John Hinchey, a Markle Scholar, made us draw up a list of all the patient’s malfunctions, and for each, the factors that would help or aggravate it. Then we discussed what or where would be the easiest to intervene first, as well as to monitor the effects so we could stop immediately should the patient become worse with our intervention.

 

         The patient’s low serum sodium concentration was the easiest to correct; simply infuse hypertonic (more concentrated) saline (sodium) solution. The cardiologist was horrified with our suggestion. When you are in heart failure, you restrict salt intake, not add. Any medical student knows that, he berated us not-too-bright surgical residents.

 

         Nonetheless we argued that if we could improve the electrolyte composition of the blood perfusing the heart, then that would improve its function. Basic physiology! Once the heart starts pumping well, all the other organs would improve in tandem. A well perfused kidney could then filter out the excess fluid to be flushed out in the urine.

 

         So that was the treatment option we chose. Sure enough, as soon as we did that, the heart beat became stronger and its rhythm improved. The kidneys began putting out more urine because with the improved perfusion, the diuretics (medicine to increase urine output) given earlier became effective.

 

         Soon a virtuous cycle of positive changes began, and the patient improved. Had the cardiologist been right about the infusion of hypertonic sodium being harmful as with the patient becoming worse, we could have easily stopped the intervention.

 

         By critically analyzing each problem and then not being held captive by rigid dictum, we were able, through trial and error but ready to retreat should we be on the wrong track, to solve what was previously a complex problem with multiple competing demands and contradictory solutions.

 

         The importance of critical thinking extends far beyond the clinical setting, as in solving complex intractable social problems. In the 1970s and 80s there were concerns on the low mathematical scores of Hispanic students in the Los Angeles public schools, a problem all too familiar with Malays. Many however, did not even see the problem. These were Hispanic students from poor families and neighborhoods. What do you expect? They fit the stereotype.

 

         It took a teacher new to the district and to America but familiar with the culture, a recent immigrant from Bolivia, to diagnose the problem and institute an effective remedy. Jaime Escalante saw the problem as one of under preparedness, a teaching problem, and low expectation, a cultural one.

 

         Escalante focused on the teaching component, his forte. He started summer classes for them. Two things happened. One, being in class those students had less time for mischief or being distracted. Two, being in that special class with other students having the same difficulties, they did not feel discouraged or ashamed when Escalante started at the very basic level. They were eager to learn when ordinarily they would have responded with, “You think we are that dumb?”

 

         To cut the long story short, his students excelled such that when they took the Advanced Placement Test in calculus, taken only by the top 10 percent of American high school students, they excelled. That prompted the College Board, the test administrator, to suspect mass cheating and forced them to retake the test. They again excelled!

 

         Escalante’s success was chronicled in the 1988 movie, “Stand and Deliver.”

 

         His secret was that when confronted with a complex problem, instead of resorting to stereotypes and pat “explanations,” he teased it into its smaller components, and then attacked the simplest or easiest ones first. That in turn would trigger positive cascading changes that could reverberate and amplify all around, reminiscent of my earlier approach in treating that sick ICU patient.

 

         That is the power of critical thinking in solving complex problems.

 

Next: Excerpt #10:  Religious Texts As Exercises In Critical Thinking