Melina Manolas

Rotation in the Neonatal Intensive Care Unit

The first thing that stood out to me was the prevalence of art in the NICU. Every wall is covered in a colorful mural displaying nature. The art brightened the typically institutional feel of the hospital and distracted from the flourescent lighting and white-washed walls. I noticed that it brought vibrancy, color, and optimism not just to the pediatric patients and the families of neonates, but also to the physicians. I believe that art has a place in hospital design and in healing, and not just in the Pediatric or ICU setting. It was refreshing to see the literature on the impact of art on recovery being applied in the real hospital setting.

 

In the Neonatal ICU, I was exposed to the role of physician as mentor, teacher, and leader, by following daily rounds with the attending Dr. Bainbridge and director of neonataology, Dr. Rajegowda. The physicians taught me how to use the facial expressions and body language of the mothers in order to discern their feelings that day about the health of their neonate. Dr. Bainbridge made sure to teach me how practicing medicine is as much about developing relationships with people and judging their emotional wellbeing as it is about the biology. I developed my self-agency by asking questions during rounds and attending pediatric conferences about issues such as congenital HIV and patent ductus arteriosus. Speaking frequently with the Pediatric residents about their schedules and lifestyle painted a picture of the rigorous training, hours, and dedication that go into the intern and residency years.

 

I learned a great deal not just about the fascinating practice of neonatology, but also about the social responsibility and awareness embedded within it. The context outside of the patient beyond the walls of the hospital was always taken into account. The physicians openly acknowledged their responsibility to the physical health of the baby and to assure that the baby will be placed in a home where it will be parented properly with nurture and love. In the presentation of the patient’s background and vitals during rounds, the physicians also mention the social context of the patient- they discuss the baby’s prenatal care and predict the quality of the baby’s future care at home. They make note if the mother used drugs or consumed alcohol during pregnancy, which is often the case at Lincoln, and must consider the implications of continued use on the level of parenting they can provide. The regularly correspond with social services. Additionally, each major hallway held a framed "Parents' Bill of Rights", demonstrating the hospital's respect for the family's will in the NICU.

I believe that such transparency in medical communication is both useful and necessary, especially in departments like the NICU where at-risk newborns do not yet have the voice or capacity to be advocates for their own health and wellbeing. This concept is at the center of what Edgar Schien terms the “value clusters”; the physicians’ decision to spend their time and energy this way means that they highly value the social responsibility they have to the neonates, just as much as they value the science.

Rotation in the Pediatric Clinic

I learned quickly how many families in the South Bronx use the clinic as the line of first defense for their children, because they lack primary care physicians. The clinic exposed me to a variety of health issues through pediatric nephrology consultations with Dr. Prosper as well as well-child visits or "checkups" - they ranged from nephritic syndrome to jaundice to untreated infections to Down syndrome babies presenting with heart murmurs, and an even larger variety of social contexts. I recognized how drastically different medicine can be in its application to a child versus an adult, not just in the science but also in the demeanor, approach, and communication with the patient. I took note of how the types of questions the pediatrician asks the child shifts as the age goes from five to twelve to seventeen, in accordance with their changing physical and social environments.

I now believe a physician should know how to be a patient in his own exam room, to put himself in the shoes of the patient in order to feel empathy and provide them with comfort, not just a biomedical fix. Only then can a mutually enriching relationship evolve. Above all, I have learned how a hospital cannot care for its local patients without knowing the social and political history of the community in which it finds itself to be a part, and neither can individual physicians.I appreciated Dr. Prosper's emphasis on the health problems that are most relevant to the South Bronx - asthma, obesity, and diabetes. I learned how to write asthma action plans and discuss BMI index with patients, in combination with advising on nutrition and exercise.

All in all, it was quite obvious that each patient who walked through the exam room door came from a unique context (home life, family life, social conditions, etc.) that helped shape the kind and quality of health care they sought and received from the clinic. This is why I think the concept of “health care as a universal human right” discussed in class is much more complicated than it appears to be at its surface. For now, I think we ought to be asking about the contexts that shape people’s “moral networks” and standards.

Organizational Culture of a Public Hospital

Throughout my weeks at Lincoln I noticed how the culture of the hospital is, as Haworth describes it, the “glue” that holds the organization together and the “compass” that provides trusted guidance and direction to its physicians, patients, and community. By comparing the culture of Lincoln Hospital with previous shadowing experiences in private hospitals, I learned that health care is by no means the same everywhere. Health care has a sense of place that makes health care problems differ in scope and intensity in the South Bronx, for instance, as compared to the Upper East Side or the suburbs of Long Island. This sense of place is an innate part of the patient context and something to be considered in diagnosis and treatment.

Most importantly, I have noticed the impact of hospital design on patient and family interaction with the medical professionals. I asked myself questions such as 'What do you see first?' and 'Who is the most accessible?' As you walk into the NICU, the nurses' station is far more visible and the nurses are consistently more available than the physicians who are running around in between pager calls and C-sections or glued to the computer writing orders. As a result, the families of the neonates at Lincoln tend to build stronger and more trusting relationships with the nurses, such that the physicians have to consult often with the nurses about how often the mothers visit and breast feed, how much they seem to care about the wellbeing of their newborn, etc.

I also greatly appreciated how Lincoln prides itself on being a teaching hospital, where the hierarchy of the medical professionals – from attendings to residents to medical students to undergraduates like me – participate in lifelong learning partnerships. It creates a pleasant and relaxed environment where everyone feels part of a team rather than followers of a unitary leadership. Thus, I became aware of the role of inclusion in organizational culture – “If people feel included, knowledgeable, inspired, and motivated, they are more likely to stay” (Reingold and Yang, 2007). In turn, a sense of teamwork stood out to me at Lincoln, perhaps because they all felt they were critical point people for the patient at hand.