Dr. Viswanathan is the Director of Telestroke Services at Mass General Brigham Healthcare and an Associate Professor of Neurology at Harvard Medical School. He is a staff neurologist on the Stroke Service and in the Memory Disorders Unit at Massachusetts General Hospital and in that capacity he models the best elements of a doctor. He is a teacher and advocate to both patient and trainee alike.
While on service Dr. Viswanathan punctuates each day by sending a reflection that is as entertaining to read as it is educational. Over the course of the past year these "snowflakes" as he calls him have grown into full-fledged Nor'Easters of insightful, delightful, and impactful explorations that begin with an idea discovered on rounds and ends far, far afield into philosophy, art, fine cuisine --- anywhere, really.
We sat down with Dr. Viswanathan to ask about what's behind this dedication to epistolary teaching.
Why do you refer to your post-rounds write-ups as "snowflakes?” Where does that word come from?
A former US foreign policy leader, when he headed the Pentagon, would write memos on white paper to his staff. These daily communications served to update them on what was happening in the US government. The small memoranda, eventually totaling greater than six thousand documents, came to be named by the staff as “snowflakes.”
Out of what initial instinct or intuition did the first snowflakes crystalize?
At the end of a long day of rounding, there’s a lot of learning that gets pulverized by the grind or buried under too much scut work. To make these lessons stick (as much for me as for the team), it was helpful to synthesize or distill our clinical thinking surrounding the patients we met and the neurology we encountered. It was a way for me to refine my own clinical processes and also share my thoughts with our trainees. The exercise reminded me of the Pentagon snowflakes.
Did they undergo any thematic or stylized changes from what you've started writing to what you write now?
The snowflakes initially started out as totally clinically or scientifically based. They summarized cases or provided additional data from epidemiologic or laboratory experiments. Over time, though, their focus has changed to offer readers with clinical signposts to help them in formation of their own style of doctoring, as well as delve into related issues in the humanities, arts, and sports—which I think also informs a person’s practice.
What (and who) are your influences in writing them? Why might that be (why select consciously or subconsciously those authors or works?)?
I would say that most of my influences for these snowflakes are subconscious in nature. However, as a form of self-psychoanalysis, if I were to guess at these influences, I would cite the following writers. Sir David Tang, Thich Nhat Hanh, Siri Hustvedt, Niall Ferguson, and Karl Ove Knausgård. Here’s an example of what I mean from a recent snowflake.
“One wonders why these cases send shivers down our spines (Gnathostomiasis can do that too by invading the spinal cord!), and I think it is related to a deeper-seated human fear. Parasites crawling under our skin and feasting on our eyes without our knowledge of their entry has the flavor of horror films (which are artistic manifestations of these human fears). One thinks of the brilliant filmmaker Luis Buñuel and artist Salvador Dalí collaboration on the 1929 silent surrealist film entitled Un Chien Andalou (An Andalusian Dog) in which an eye figures importantly. https://www.youtube.com/watch?v=79h05vqezJ0 Watching this sequence still sends shock-like sensations through my limbs. Because our eyes are so integral to how we experience the world and thus so close to what we define as “ourselves,” I think anything that threatens the eyes causes us uneasiness.”
I look again at this short excerpt from a recent snowflake, beyond the obvious influence of horror films, it may have ties to the Norwegian writer Karl Ove Knausgård’s essays whose subject matter examines some of our everyday experiences and emotions. The collection entitled Autumn has essays titled “Blood,” “Mouth,” “Loneliness,” “Infants,” “Flies” and “Vomit.” Read like this, it does seem like a horror film, doesn’t it? [laughs]. Or this:
“In tennis, we talk about quieting the mind to focus on the moment without thinking about the result or the past. World-class players like the Bryan brothers (identical twins who won more tournaments and Olympic gold medals than any other doubles team) talk about having the patience for the clean ball strike, which requires total focus and enjoyment in the movement and swing of the racquet. In tennis, this is called playing “in the zone.” Roger Federer says this about playing in the zone: “I feel like I have been in the zone a few times. When I am in the zone, everything for me happens in slow motion, and for my opponent, everything happens in real time. You almost feel like you have more time, you are more serene, more relaxed.” A friend of mine, who goes on survivalist trips describes this very same sensation when he is alone in the wilderness having to solve problems or negotiate complex terrain. I think of it as a state of extreme focus coupled with a feeling a joy. In psychology this is the so-called “flow state” by the renowned psychologist Mihály Csíkszentmihályi. His book entitled “Flow” describes many of the normal people he and his group had studied and what they had done to achieve their flow states.”
If Thich Nhat Hanh, the highly influential Vietnamese Buddhist monk who established a wonderful Buddhist monastery called Plum Village in the Dordogne region of southern France, had played tennis or had been a Roger Federer fan, he may have written the above. [laughs]. Thay, as he came to be known, was strongly engaged in the teaching of mindfulness practice, has a worldwide following, and his teachings have helped thousands, even after his recent passing at age 95. His book of short essays, Peace is Every Step is a wonderful introduction to these teachings. I cannot rule out for certain that Thay wasn’t a Federer fan, though. [laughs]. And here's another influence:
“The famous Piazza del Duomo in Milan (the home to a beautiful medieval cathedral which is the largest cathedral in Italy even larger than the Renaissance masterpiece designed by Michelangelo and others, St. Peter’s Basilica in Vatican City) was used by some Italian neurologists to test neglect in their patients. Instead of pulling out the OKN stripes from their magical black doctor bags, these neurologists took their patients on a field trip to the Piazza.
Two patients with neglect were asked to imagine themselves in two specific locations on the Piazza (one looking toward cathedral from the opposite side of the square and the second the reverse perspective of being at the doors of the cathedral looking outward onto the Piazza). These patients were able to vigorously name shops, buildings and landmarks in their non-neglected visual field, but had significant trouble in the neglect field (left sided neglect). While they were able to name a few buildings on the neglected side, this was much more difficult.
If you go to the link, you can see the plaza in Milan from the first perspective described in the paper. https://email@example.com,9.1890065,2a,75y,101.52h,90.9t,356.54r/data=!3m6!1e1!3m4!1s5x--REeWW8Yfj1s12R76Hg!2e0!7i13312!8i6656 You can manipulate the mouse to also view the reverse perspective. Not much has changed there between 1978 and 2022! This may be another reason why “old Europe” and its historical structures are so impressive to us former English colonists.”
Sir David Tang was as a Hong Kong businessman, philanthropist and socialite. He is known for founding the Shanghai Tang fashion chain and owning various successful businesses including the China Tang restaurant at the prestigious Dorchester Hotel on Park Lake and Deanery Street in London. For many years, he wrote the "Agony Uncle" column in the weekend Financial Times, my favorite salmon coloured newspaper, where he responded to readers' questions around etiquette and various social dilemmas in an eloquently cosmopolitan, often cheeky, and sometimes hilarious prose. His book, Rules for Modern Life: A Connoisseur's Survival Guide, sits prominently on the bookshelf in my office and is a go-to reference book.
What (and who) is the kind of feedback/responses/criticism/analyses that you've received from readers? What do you think about those responses and has it shaped subsequent draftings?
These snowflakes seem to have accidentally gained a bit of an international following [laughs]. Trainees have told me that they enjoy them and have shown them to spouses, friends, and colleagues in their home countries. Like micro-finance, this seems to have become a form of off-the-gird publication distribution [laughs].
Why do you write them (what is your pay-off, reward, satisfaction, etc., that makes you spend hours writing these?).
There is no formal or conscious ‘why’ [laughs]. They just spontaneously come out, catalyzed by the energy of my wonderful interactions with our residents, fellows and our patients. I am only the vessel that transmits this beautiful energy to the audience.
Do you have advice for other attendings on how to frame their insights and experiences into impactful reflective pieces like your snowflakes?
Everyone is different in how we teach or convey our approach to our trainees. The attendings in our department are a wonderfully talented group of neurologists with an incredible depth of knowledge. They have so much to convey to our trainees. In whatever form they choose to frame their insights and experience, I would only encourage them to be true to themselves.
What do you hope will come of them (still always in this form, or in some other platform or format?)?
As Rafael Nadal recently said in the press conference after losing a match in the Madrid Open, “I have no expectations. The only thing that is important and which I focus on is the daily practice.”
Dr. Viswanathan is an executive member of the Massachusetts Alzheimer’s Research Center (MADRC). His research program at the J. Philip Kistler Stroke Research Center focuses on the contribution of stroke and vascular risk factors to dementia. His group has engaged in numerous multidisciplinary interactions and collaborations, including with artists and writers, in order to further develop and foster humanism in medicine among young physicians and medical researchers.
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