Our Homebirth Experience

Choosing a homebirth was a gamble. This is not because homebirth is unsafe. It was a gamble because if anything went awry, our first major decision as parents would be questioned.

Research has recently shown that the chance of perinatal death (i.e., during labor and up to 28days after birth) is 0.18% for hospital births compared to 0.21% for homebirths. However, after adjusting for maternal risk factors, which are worse among planned hospital births, there is an estimated 0.16% increased risk associated with planned out-of-hospital birth.

We want share our positive experience to help demystify homebirth and explain why we found it best for our family.

Although Kai Vanderveer Hidaka was recently born in our living room on Wednesday (March 30th, 2016), having a homebirth was a process that began a long time ago.

Hannah was interested in a non-mainstream approach to childbirth after watching the documentary The Business of Being Born. After watching it myself, I wanted to learn more. There is a newer documentary called Why Not Home about doctors and nurses choosing homebirth for their families.

We were connected to a midwife practicing in the Kansas City area through a friend. She came over for tea and explained her philosophy and approach; her values were completely congruent with ours. She answered our questions, told us to think about a partnership, and left us her 5-page, single-spaced, informed consent paperwork.

After her departure, Hannah and I agreed that she felt like the perfect provider for us. We read every word of the document she provided. It included an explanation of her training and experience as a Certified Professional Midwife (CPM), a brief summary of homebirth, a background of obstetric research and outcomes in different birth settings, a description of how responsibility of care would be transferred should we go to a hospital, an explanation of the specific services she provides, an articulation of philosophy and trust, a summary of what her visits and exam entail, a thorough list of potential hazards and risks of pregnancy & childbirth, and her privacy policy. We felt very well oriented and excited to work with her.

MamaSara, our midwife, returned a week later and we officially agreed to embark on this adventure together. She took a complete medical history of Hannah and shared her cell phone number. She encouraged us to contact her at anytime with questions or concerns. Throughout, she responded quickly to text messages and always answered her phone.

Upon reflection, attending a potluck picnic was pivotal. It was an annual event for families whom she had served. There were dozens of kids running around and parents from all walks of life. The families were living proof that we were not alone. It solidified our decision.

The care was as evidence-based as what I saw during my obstetrics and gynecology rotation. MamaSara ordered a set of prenatal labs (CBC with diff, CMP, blood type, rubella titer, syphilis, hepatitis B, HIV), a urine culture, and a vitamin D level for Hannah to have drawn at a reference laboratory. We were offered options for birth defect screening. We had an obstetric sonogram at 20weeks gestational age, at which we requested no gender revelation. We checked for Group B Strep infection at 36weeks. We were given options (with thorough, balanced informed consent) of the following recommended interventions at birth: prophylactic antibiotic treatment of Group B Strep, vitamin K injection, erythromycin eye ointment, hepatitis B vaccination, metabolic screening, hearing screening, and heart defect screening.

Similar to standard prenatal care by an obstetrician/gynecologist, we met every four weeks, then every two, and then weekly toward the end. In our home, our midwife tested Hannah’s urine, measured blood pressure, listened for the fetus’ heartbeat, and measured fundal (top of the uterus) height. At each visit, she had questions for us and answers for ours. Most importantly, she always had time for us. My experiences as a medical student helped generate questions for her.

We cultivated a healthy pregnancy that began with a wholesome diet. We often had green smoothies for breakfast. We continued our dinners of sautéed vegetables (in organic virgin coconut oil, organic extra virgin olive oil and/or organic pastured butter) with a whole grain and a protein (meat, eggs, tofu, nuts, and/or cheese). We did not stop indulging, e.g., homemade waffles, Topp’d pizza, Glace ice cream, and Ibis croissants. Our supplements included a B-complex, magnesium, kelp (for iodine), vitamin C, fish oil, and vitamin D; we don’t take all of them everyday, but most on most days. Hannah was super-proud to have the highest vitamin D level MamaSara had ever seen: 67ng/ml. I believe that our balanced diet and supplementation regimen contributed to Hannah not experiencing stereotypical pregnancy cravings, e.g., pickles, clay, etc. To Hannah, basil and balsamic vinegar were repulsive, so I enjoyed her share on her behalf. Hannah occasionally enjoyed a half-glass of wine on a full stomach.

Our midwife gave Hannah an endless supply of an herbal pregnancy tea consisting of nettle leaves, alfalfa leaves, red raspberry leaves, and oatstraw; she drank a quart on most days. I was impressed, because the tea tasted bitter and bad to me. Following MamaSara’s advice (based on a randomized controlled trial), Hannah started eating 6 dates a day at 36weeks.

Hannah also continued to practice yoga and walk often. Toward the end, we were taking multiple walks together each day.

Throughout, MamaSara armed us with knowledge via DVDs, handouts, and books. I read The Expectant Father, which gave me helpful tips for being a more supportive partner to a pregnant person and inspired me to get life insurance. Hannah read Expecting BetterAll Joy and No Fun, Birthing from Within, Happiest Baby on the Block, Easing Labor Pain, and Journey into Motherhood. The books empowered Hannah with real, factual experiences of labor; these stories replaced the only other childbirth images in our culture, Hollywood’s. Several DVD’s and handouts gave us helpful pain management strategies.

We recall one poignant conversation with MamaSara and her student, Catherine, who said that “pain” is not the right word for it, because pain is something to avoid and move away from; the intense sensations of labor are instead something to move toward and through. Hannah viewed the discomfort as a mountain to climb; she said her experience running a half-marathon (and training for it) last year is a great analogy.

We were very excited to reach 37weeks, because, no longer “preterm,” we could have a homebirth. We prepared the home by rearranging and gathering everything on MamaSara’s recommended supply list. She and Catherine brought us a birthing pool.

As our due date approached, happened, and then passed, our anxiety rose. MamaSara reassured us that the baby would come when it was ready. She was not concerned about us being “overdue,” because first-time mothers usually go longer than 41weeks and her experiences had not shown “late” newborns to look overcooked. If we got to 42weeks, she suggested that we get a biophysical profile to ensure everything was okay.

For two weeks, we woke up thinking the baby would be arriving that day. On the evening before day 41wk5d, Hannah felt her first contraction. Contractions occurred sporadically throughout the next day, gradually increasing in frequency. We spent the day cooking, making art, walking in Loose Park, playing a game of Bocce ball in the backyard, and relaxing at home with a movie. The waves became regular and with shorter intervals. Labor began in earnest around midnight.

At that point, we followed MamaSara’s advice to get some rest, because, although it was very exciting, it was important to be well-rested for a process that was probably going to last a long time. So we rested until 3am. I slept in bed while Hannah dozed between waves on the couch. This time was important for her to gain control of her breathing and embrace the ebbs and flow. 

When the waves were happening every 2-4minutes, we asked MamaSara to come over. It was 5am and she said that if we are doing okay she would take a shower and be over in 45min. She said to call if we needed anything. Shortly thereafter, the waves changed in character; they went from just being super-intense menstrual cramps to having an additional intense urge to defecate. Fortunately, we had prepared for this moment.

Evidently, it is wise to resist the urge to push, because that gives the perineal tissue time to stretch, thereby making tears less likely. Hannah tried her best not push. Hannah wondered if we should start filling up the birthing pool, but I told her that we could wait until MamaSara got there. I would later be proved wrong.

I held Hannah close. The waves were raising their intensity. We transitioned from the bathroom to a chair, which she sat in backward on top of a folded towel. I massaged her lower back and squeezed the outside of her hips and encouraged her to breathe deeply through the contractions. I said things like, “Your body is amazing,” “You’re doing so well,” “Remember to breathe,” “Long, deep inhale. Slow, deep exhale.” My experience as a yoga instructor probably helped.

MamaSara arrived around 6am. She surveyed the scene and immediately began setting up all of her tools and equipment without saying much. She had told us at one of our appointments that she generally tries to keep out of the way, but she is willing to do anything (within reason) that we think might help. We asked her if she thought it would be okay to start filling the pool, which she initiated. After she got the water flowing, she brought a soft floor cover and multiple flat soaking pads out to the living room and laid them in front of the chair. I asked her what she was doing. She said that it usually takes about 30min to fill the pool and she just wanted to make sure that we had a plan in case we didn’t get there.

I suggested that Hannah try a different position, since that can help. She transitioned to the floor; she was on her hands and knees, with her head in my lap. She was in the zone. She rested between contractions, resisting the urge to push. I did what I could: I held her head, supported her shoulders, massaged her back, and held her hands, which she sometimes squeezed in unison with her uterus. In between contractions, the house was calm and quiet.

Catherine arrived, was quietly oriented by MamaSara, and kneeled behind Hannah with comforting words of support. After the next contraction, they motioned to me that the head was crowning. Catherine donned sterile gloves. Hannah reached with her right hand and felt the baby’s head and said, “Oh my god, that’s the head! What do I do?!” Catherine told her that she doesn’t need to do anything, that she should continue to try and relax and that she was doing great. “Okay,” replied Hannah. MamaSara offered to switch places with me so that I could catch the baby. It was 7:00am.

I sat down at Hannah’s side with my hand on her back and glanced at the top of my baby’s head. MamaSara encouraged me to take off my nice, new watch, which Hannah had gifted me 24hours prior. After two more contractions, the head popped out and there was a gush of clear liquid. It was the amniotic fluid; her water had finally broken. The baby began crying while the shoulders came through with another push. I was there to catch the baby. I brought him (I saw a penis and scrotum!) through Hannah’s legs and into her arms.

We held our slippery baby, laughing, awing at it, and kissed each other. Waves of joy crashed over us. Hannah noticed his genitals and said, “We have a baby Kai!” We sat against the couch and savored our first moments with our first-born son. Time then becomes a bit blurry. It seemed within seconds that someone offered Hannah a straw to sip from a mug of warm, sweet, herbal tea to help her uterus contract and shrink. She downed it immediately and had three more whole mugs before retiring to the bedroom. Within a couple of minutes, Kai had successfully latched onto Hannah’s right nipple and began to suckle. It was surreal.

Meanwhile, Catherine was checking Hannah’s uterus and for evidence of a bad bleed. There was no hurry to deliver the placenta or clamp the umbilical cord. The placenta arrived. They ensured that all parts had successfully detached and put the placenta in a Tupperware container next to us.

At one point, they helped Hannah to the bathroom. Catherine ushered Kai and me to our bedroom; she walked close carrying the placenta-filled Tupperware that was still tethered to Kai’s abdomen. When I reached our bedroom, I found that it had been prepared for us. Hannah joined me and they did a pelvic exam at the bedside. She was found to have a couple of small tears and one moderate labial tear. After discussing the pros and cons, Hannah elected to allow the moderate tear to heal without sutures. Hannah promised to heal by keeping her legs close together for two weeks, which includes no steps or stairs.

I cut the umbilical cord, which Catherine tied off. The rest of the cord and the placenta would be dehydrated and given back to us within 24hours. The placenta was pulverized and encapsulated, which Hannah is taking as a supplement to support lactation, energy, sleep, and mood during the postpartum period.

Catherine performed a newborn exam, weighing him (8lbs 1oz), and demonstrating the neat reflexes. We were then fed scrambled eggs and muffins in bed. We were oriented to temperature tracking (of baby and mom), goals for pooping and peeing (for baby and mom), and the tinctures to allay uterine cramping (extracts of Black Haw, Cramp Bark, and Motherwort). It was slightly overwhelming, but they left us handouts. During all this time, they were cleaning up the pool and everything else.

By 10am, they had left us with our new son in our bed in a clean house. Until the afternoon, we stayed in our bedroom, took a couple of naps, and stared at him. We had warned our family that we needed 24hours to just our ourselves, which they honored (not easy with my mom living right next door and Hannah’s mom a couple blocks away, visiting from Texas!). But we felt so good that we broke our own rule and invited them over for a little bit that evening to meet their grandson.

The next day, Catherine and MamaSara returned to check on Hannah and perform the newborn screenings to which we had agreed. They shared how happy and impressed they were by us! Labor normally lasts much longer for first-time mothers. MamaSara came again two days later. She will visit again in one week and will follow with us for as long as we need. We feel like her one-time, all-inclusive fee of $3,000 (which is the fee if paying out-of-pocket with cash) is a bargain for the quality, breadth, and depth of care we have received.

In summary, choosing to have a homebirth was right for us, because Hannah and I share a mindset of aiming for the best, working for it, and manifesting it by expecting it. We had sketched out a plan B, but we did not dwell on terrible things that might transpire.

Labor and delivery is inherently uncertain; nobody can predict what will happen. Childbirth in a hospital aims to make disasters least likely. For us, homebirth was an opportunity to make our best-case scenario most likely. We were blessed with exactly that.

We cannot imagine a better start to our family’s newest addition.

 

 

Message to my 18-yr-old self

Don’t ever allow school to get in the way of your education.

Speaking notes for my address to freshman at KU’s Opening Convocation on August 25th, 2015.

I want to start by commending you all for being here, because I did not even know about this ceremony when I was a freshman in 2004. You’re off to a great start!

I’m here to share a few of my experiences as an undergraduate here and tell you things that my 18-year-old self needed to hear.

First, you should know that you can do anything at KU. There are hundreds of groups with which to get involved. If you don’t find an exact fit, then you can start one of your own! After spending a Spring Break volunteering for people with ALS (Lou Gehrig’s Disease), a friend and I started a campus organization called Students for ALS Activism, or SALSA. We did not foresee how much confusion this would cause and we ended up referring almost all of the interested students to the Ballroom Dance Club.... The point is that you, or your parents, are paying a lot of money to be here; know everyone at KU is here to help you. It’s their job.

I want you to both revere your instructors and recognize that they are real people too. It’s important to be able to hold two opposite ideas in your head at the same time. Get to know your professors. I’ll never forget when my mentor’s family was out of town. I went over for a research meeting and ended up playing Rock Band with him in the basement. I had no idea he could drum!

Be curious. Ask for clarification and raise your hand. Or hold onto that burning question and wait until the end of class. Visit instructors during their office hours and learn from your mistakes. As a freshman, I signed up for a 600-level history course called “The History of Tibet,” because I wanted to know what those “Free Tibet” bumper stickers meant. I earned a D-plus on my first essay. I asked the professor why? He said that it seemed like I hadn’t really done the reading. Sobbing, I admitted that I hadn’t! Rather than complaining and stagnating as a person, use your time in college to stretch yourself. Rise to meet your challenges, rather than changing your goals to conform to your habits.

Learn to forgive yourself, because you will make mistakes. For instance, you may walk into a final exam armed with only a pencil, learn that it is open-note & open-book, earn a 25% and drop yourself a whole letter-grade. It could happen. But life goes on.

If you haven’t already, learn to love reading. A book can change your life. I went from reading a book that rocked my world, to introducing myself to the author at a conference, to corresponding with him by email, to working together in an international group of scientists and educators, to recently publishing an article together. My point is that I hope you find a book that changes your life too. And if the author is still living, go ahead and send them a “thank you” note. They’re real people too.

I hope you quickly learn that college is about more than making the grade. Don’t ever allow school to get in the way of your education.

I encourage you to go and sit next that intriguing character in class. In college, there’s no assigned seating. Your heart is pounding; you’re wondering how to break the ice with that attractive person just 2 feet away. Here’s a good place to start, “Hi, I’m Brandon.” Or, whatever your name is. You can learn to conquer your fears one “hello” at a time.

Be intentional with your friends. Learn to relinquish friendships that don’t bring you closer to your goals; and strengthen those that do. Our peers profoundly influence us. And realize it’s a two-way street; we lead by example everyday with the choices we make. Be mindful of the power you wield just by being you.

Lastly, do your best to cherish your time here. Spend it wisely. You will probably never have more freedom than you do now. Yes, you will be busy, but we all get the same amount of time.

Busy is not an excuse. Our activities reflect values. Try to live congruently.

I wish you all the best of luck. Rock chalk!

 

 

 

I Love Science!

Like a preschooler, a scientist never stops asking “why?”

Every scientist dreams of a discovery so monumental that it earns him or her the Nobel Prize. I feel my chances have increased after recently reading The Beginner’s Guide to Winning the Nobel Prize by Peter Doherty. He was recognized in 1996 for co-discovering how the immune system checks for viruses hiding inside cells. In his short, witty book for a broad audience, he describes scientists, the culture of science, how societies support science, and how scientists can better society.

Doherty defines a good scientist as one who is curious, industrious, honest, and somewhat skeptical of authority. Like a preschooler, a scientist never stops asking “why?” My passion for evolutionary science stems from its capacity to lend answers to “why?” questions in medicine.

Scientists can generally be classified into two camps: observers and theoreticians. Observers collect and analyze information, while theoreticians try to tell us what the data mean. Theoreticians tend to be glorified, as review articles are usually cited more frequently than original research (in science the number of times others cite your work is a way to measure your influence), but it is the observers that actually drive the field. Nobel Prizes are typically awarded to observers unless a theory is particularly powerful at predicting future observations.

Doherty does his best to dispel the stereotype of how scientists are depicted on screen. He notes that young people could be more interested in a scientific career if they knew what fun we are! I have bore witness to some true party animals at national conferences… However, he does lament the frequent lack of communication skills. One of his guidelines for winning a Nobel is to learn to write clearly and concisely. I contribute to this blog in order to become a better ambassador of science, one that is articulate, accurate, and interesting.

Unlike many of the famous scientists from previous centuries that worked solo, most research is done collaboratively now. As in the business sector, your team’s performance depends on playing to the strengths of each member and working with the right people.

During my first research experience in a biology laboratory, I came in one morning to find something odd about my cells in the Petri dish. I asked my supervisor what she thought. She glanced into the microscope, pulled away, picked up the dish, held it in front of me and asked, “Brandon, how did one of your hairs get into a sterile environment?!” Stories like this have helped me to recognize that the lab is not for me. I am a bit of a hazard there. I value others who can do that type of work well. I look forward to writing successful grants in order to pay them handsomely!

Doherty encourages budding scientists to surround themselves with stimulating colleagues. As I look to the future, I imagine finding a scientific home full of brilliance, but balanced with a reasonable work culture. Prestigious institutions have a reputation of being toxically competitive.

Of the wide array of scientific activities, I most enjoy understanding a dataset, discussing what question is most important, and applying the proper statistics. Hours fly by when they are spent organizing a database, building variables, constructing models, and designing graphs, especially with the right music (Sigur Ròs, Taylor Swift, et cetera). I also find sharing our observations in text, picture, and orally very rewarding.

I lean more toward being an aforementioned theoretician than observer. With my unique background (there are not an overwhelming number of medically-trained nutrition scientists with a passion for evolutionary biology), I can often offer a fresh perspective. I grew up believing that I was not creative, because I was good at math and did not excel in art class. In college, I remember telling myself that I was not creative in the classic sense, but I was good at connecting ideas that had not before been linked. In part thanks to The Midnight Disease by Alice Weaver Flaherty, I now recognize that that is creativity. Albert Szent-Györgyi, who discovered vitamin C and parts of the citric acid cycle (our fundamental metabolic pathway that connects fat, carbohydrate, and protein), once said, “Discovery is seeing what everybody else has seen, and thinking what nobody else has thought.”

I foresee that my biggest challenge in science will be to pick the right question. Doherty stresses that it’s best to focus and not be a dilettante. I have dabbled in many fields. In the past decade, I have researched: 

(a) ringed, sulfur-containing molecules for drug discovery,
(b) how aspects of our modern lifestyle contribute to depression being more common now,
(c) how kidney cells react to a potent vasoconstrictor that our body naturally produces,
(d) how early fetal development may influence risk of alcoholism in females,
(e) how the types of fat women consume are related to their chance of developing breast cancer,
(f) how timing (before vs. after menopause) may influence the effect of diet on breast cancer risk,
(g) the effects of high-dose omega-3 fatty acid supplementation in women with a high risk of breast cancer,
(h) why economically disadvantaged women are more susceptible to the most lethal type of breast cancer,
(i) how much medical schools teach about evolution, and
(j) how to characterize the diets of preschool children in the Kansas City metropolitan area. I have hopped around as a consequence of my diverse interests and a knack for seizing opportunities.
However, I have come to realize that saying “yes” to things now necessarily means saying “no” to future opportunities.
 

In a world flooded with choice, time becomes the most valuable commodity. We must force-rank. Doherty points out that Nobel Prize winners often set out to solve major problems. Right now, I am most seriously considering dedicating myself to understanding (a) how best to improve the quality and quantity of life for individuals (and their family) grappling with a diagnosis of cancer, (b) why autism is more common now, or (c) how best to treat and prevent behavior that causes personal, family, and social strife, namely addiction and crime.  

Doherty devotes a great deal of effort toward defining the characteristics of cultures that embrace science. He supports public radio and television. Love it. Science-friendly societies value public education. Although it appears that our country values education by the amount of money we spend on it, our outcomes lag behind other comparable Western nations. Unfortunately, the same is true also of our healthcare system. On a positive note, Doherty praises our funding structure for biomedical research; he cites the National Institutes of Health (NIH) as the single greatest reason that so many Nobel Prize winners have worked in the United States. But since 2003, the NIH budget has increased by a mere 11% in absolute dollars; after accounting for inflation, this is a decrease 21%. I am glad that my U.S. representative, Kevin Yoder, is working toward increasing NIH funding; he must have read my letter!

My major qualm with most of the federally funded biomedical research comes from asking “why.” Why are we doing this? What is the point? The majority of my colleagues are studying the genes and proteins that govern various disease processes; they are trying to understand how things work. The idea is that this knowledge will give us targets to manipulate, usually with small molecules, which are increasingly antibodies. While I do think that this type of basic biological research has value and should continue, I must point out that it is all directed toward a common goal: a patentable solution.

Why? Medical treatment is lucrative. For example, pharmaceutical companies enjoy profit margins of about 30%, due in part to spending twice as much on marketing as they do on research and development. Nevertheless, industry plays an important role in clinical research, funding nearly 75% of clinical trials in the U.S. Research is expensive and clinicians need well-designed experiments to make evidence-based decisions in medicine. The problem is that companies invest in clinical trials. The goal is to make money, not elucidate the truth. The ethical dilemmas of privately funded clinical trials are exposed in this heart-wrenching tale of an “adverse event.”

Industry funding research is analogous to industry funding political campaigns. Science seeks to understand the nature of reality, government to serve the people; these goals can be co-opted by ulterior motives. Corporate lobbying now dominates American politics. When lobbying, companies are betting that they can earn the greatest return on their dollar by spending money influencing politicians. This creates tax and regulatory structure for the interest of profit, not the public. Circling back… the rhetoric of politics contrasts starkly with that of science.

In simplest terms, the lay press writes to entertain and generate controversy, while scientists write for accuracy and interest. In scientific discourse, facts must hold up to scrutiny; unfortunately, this does not happen as often as it should. One can massage the message, but never the data! Scientists have peer-review; politicians now have Politifact. After repeatedly finding unrecognizable quotes of his in the newspaper the day after giving a talk, Doherty recommends combating misinformation by distributing written copies at all speaking occasions with press present.

Doherty also describes how he has changed his tone and goals when communicating broadly. He works toward an outcome of compromise with diplomacy and persuasion, rather than using harsh honesty to humiliate those that hold opposing views, which is (somewhat) acceptable in science. It is better to do right than be right. It’s unfortunate that self-righteousness feels so good!

There are two other major distinguishing characteristics of scientific culture that Doherty defines. First, scientists must be able to holding opposing views simultaneously: it is a grave error to be inappropriately certain. One must have constant vigilance against type I error! Scientists are also allowed to change their mind, i.e., flip-flopping is okay. Doherty describes how scientists end up tanking their careers because they cannot let go of a failed idea. As detailed in Thomas Kuhn’s The Structure of Scientific Revolutions, breakthroughs come from the abandonment of a reigning paradigm, i.e., an accepted way of knowing. Extraordinary science forces colleagues to reevaluate their beliefs. Unfortunately, scientists are also prone to our irrational defense mechanisms against inconvenient information.

In conclusion, it has been a privilege to train as a scientist at the University of Kansas Medical Center. I had an excellent mentoring team, both official and unofficial. I was allowed to pursue my passions and make mistakes. My primary mentor half-joked that she likes to give her students “just enough hope to hang themselves with.” I struggled. I had to engineer solutions to problems I could not have imagined; Murphy’s law is real. I have experienced a few nirvana-like moments of discovery, when I are the only person in the world to know something. In fact, I love science so much that I am continuing to do research during medical school because it’s fun! I hope that my contributions will help improve the lives of others.

I will end with my favorite quotation from the book. It comes from Doherty’s 8th grade teacher, Miss Thompson. “Good, better, best. May you never rest, till your good is better, and your better best.” Maybe one day, my best will deserve a Nobel Prize!

Do we treat people with mental illness for their benefit or for ours?

To believe in something that nobody else does makes one either crazy or a visionary.

I have noticed that mental health professionals are quick to point out that “things have changed a lot” whenever One Flew Over the Cuckoo’s Nest is mentioned. The novel by Ken Kesey is seared into the American psyche. Reading the book prompted me to consider conforming to our cultural norms, as well as how modern psychiatry contrasts with the portrayal of a 1950’s Oregon insane asylum.

 The story is told through the eyes of a Native American patient, the Chief, but it revolves around the protagonist, McMurphy, challenging the authority of Miss Ratched, a.k.a. the Big Nurse. Her interventions blur the line between treatment and restraint. The distinguishing feature is that the purpose of restraint is to control behavior, while treatment is for a disease.

What is a mental illness? There is a codebook of diagnoses. But for me, a mental illness is way of thinking, feeling, or behaving that is either distressful to the person, others, or both.

Conformity begets comfort. Different beliefs and ways of living challenge the status quo. When McMurphy joined the ward, he dared to ask why: why can’t they do their chores earlier so they could watch the World Series? Why did Miss Ratched have to play the music so loudly over the speakers? By questioning Miss Ratched’s authority, he gave the other patients permission to deviate as well.

Coercive authority rules with fear, harshly punishing the first to be defiant. Most people are willing to tolerate injustice until they either cannot pretend it doesn’t exist or they are very unlikely to be singled out for resisting it. We often need a brave soul, willing to become a martyr, to catalyze movements against oppression. In spite of the warning signs, Martin Luther King, Jr. remained steadfast in pursuit of justice. Recently, Edward Snowden sacrificed his comfortable American life so that we may know the truth about our government’s surveillance programs. How often is the crazy thing to do the right thing to do?

In the daily group counseling sessions led by Miss Ratched, fear and shame are her principal therapeutic tools. Her goals are more to assert power and reaffirm their sickness rather than prepare patients to reintegrate into society. McMurphy is appalled in the first session by how the patients tear into her chosen target of the day, similar to how chickens peck at an injured compatriot. Fortunately, the inpatient group counseling sessions that I recently witnessed were grounded in respect; everyone was encouraged to share his or her perspective with the goal of cultivating skills to better handle stressful situations. Rather than pointing out what is wrong with someone, good psychologists lead their clients to self-discover how their pattern of thinking and behavior can be improved.

McMurphy has been arrested for repeatedly gambling. He uses his shrewd street skills in the asylum to pilfer other patients; however, they admit that he is not “cheating.” In one famous scene, he checks that the Chief can lift a heavy control panel before getting all of the doubtful patients to bet against him. Though deplorable a half-century ago, betting has become a more socially acceptable mode of income. For example, professional gamblers are now profiled on popular poker television programs. Sports betting is legal in some states and, arguably, normal behavior when male college basketball teams annually vie for supremacy. What portion of our economy is related to betting on the stock market? As a portion of our gross domestic product, the finance industry has tripled since 1947, rising from 2.5% to 7.5% in 2010. My point is that the negative moral (and in his case, legal) judgment passed on McMurphy is inconsistent with celebration of other forms of gambling in our culture.

Gambling isn’t bad in itself. I believe all adults should have the freedom to use their money however they choose. However, gambling is a problem when a husband loses his family’s retirement savings. It is a major problem when people do not pay their losses, which is precisely what happened when President Bush bailed out big banks. There is a glaring double standard to punish $200 stolen from a gas station with prison time and administer nothing for holding our economy hostage. For the richest, the rules seem to be, “heads I win, tails you lose.” The only sane thing to feel is outrage.

After realizing that he will only be released by abiding by the rules, McMurphy begins to conform. During this time when he is not himself, his jolliness disappears. The other patients are disappointed, but they understand that it is “the smart thing to do.” This is applicable to my career.

The default path for me would be to proceed into a residency program after medical school, and possibly a fellowship thereafter; this would undoubtedly make me a competitive candidate to be hired by a hospital as a board-certified physician in a given specialty (I have not decided what kind that would be). I would be fully sanctioned to practice medicine. Among other reasons, I am most concerned that it would be impossible to maintain my desired lifestyle with the workload of a resident. My contact with friends in residency gives the impression that entering it is equivalent to crossing an event horizon. My goal is use science to improve the health of others. Toward that end, I am weighing whether I should try to fit the mold or sculpt something from scratch. To most in medicine, not doing a residency would be “crazy.”

Electro-convulsive therapy (ECT) is used in the book as a form of punishment. I would like to highlight how the procedure has changed and the evidence of its efficacy. First, with the use of anesthetics and muscle relaxants, patients no longer convulse, i.e., activate all their muscles in a tonic-clonic seizure from the waves of electrical activity throughout the brain. As a result, they no longer wake up feeling like they just ran a marathon. ECT has short-term efficacy as treatment for depression; now, it is largely reserved for severely suicidal patients and those who have not responded to treatment modalities. The major adverse effect of ECT is memory loss, which predominantly affects short-term memory and cognitive function shortly following the procedure, but some patients have reported persistent memory deficits. ECT is an important example of treatment that (a) has been around for a long time, (b) has proven efficacy, and (c) still lacks an understanding of its mechanism(s) of action. So, it is okay to help people without understanding exactly how. To maximize my healing powers, I plan to hone the placebo effect. Given our culture’s belief in research, my scientific training should help.

For the two patients that commit suicide in the book, death was their only escape. People wish to die after losing hope; unfortunately, this is common. Suicide is more frequent than homicide in the U.S. This means that Americans are statistically more likely to die at their own hands than those of another. But we do not hear about suicides, because the victims are socially isolated. This is a silent epidemic.

Mental health facilities are investigated when individuals commit suicide. Do we need an audit of our culture? I lay some of the blame on greed. In America success is often measured in dollars. What does it typically mean when someone says, “He’s doing very well?” Your worth as a human has been monetized. Frustratingly, careers nowadays are plagued by trade offs between pay, purpose, workload, and required training.

I do not insist that all mental illness is a consequence of our perverted culture, or that mental illnesses are merely a myth created for control. However, I am concerned that our culture’s maligned values contribute to unnecessary suffering. And I am concerned that some behavior is labeled as mental illness purely for power and profit; many mental illness diagnoses confer an indefinite prescription to medication.

If mental distress is the consequence of a mismatch between one’s inner and outer world, then there are two general solutions. The medical model claims that the problem lies within the person, that he or she has a brain chemical imbalance that can be remedied with a pill. Conversely, a social change framework seeks to correct the features of a pathological environment. Those who cannot or will not participate in society often end up either homeless or in prison. Our legal system has a full-blown mental health crisis.

Mental health treatment has moved away from punishment and control toward a model of rehabilitation. This is a good. Furthermore, the wide array of pharmacologic options now available has helped countless lives. We should continue to pursue better treatments for individuals suffering from mental illness.

One Flew Over the Cuckoo’s Nest remains relevant today. Kesey’s novel demands that we continue to ask difficult questions about the nature of mental illness and its treatment.

Why is that children born today have a higher risk of developing a mental disorder than their parents or grandparents? Have our genes changed or is it our way of living?

When we treat mental anguish, are we being numbed into complacency?

When we medicate away non-normative thinking and behavior, are we prone to stagnate as a culture? To believe in something that nobody else does makes one either crazy or a visionary.

Do we treat people with mental illness for their benefit or for ours?