A Point Well Taken Nov 5, 2013

by RICK RADER, MD * EDITOR-IN-CHIEF

The struggles and challenges of parenting a child with special needs have been met by parents "pointing" out their rights, their needs and their obligations to many deaf ears; ears that couldn't or wouldn't hear. Seems like "pointing" comes in handy when you want to make a point and you need something beyond mundane words.

The other day I observed one of our nurses working with her non-verbal patient trying to ascertain his pain level. The patient pointed to a chart with numerous facial expressions and, in particular, to one specific frowning face indicating what he felt best reflected his discomfort. No words, just pointing.

But like the use of words, the "pointing" allowed him to express his feelings. And, if fact, perhaps even more streamlined, when one recalls the Gloria Estefan lyrics to a popular song, "The Words Get in the Way." While words would have been a nice touch, the "pointing" did the trick; and like all tricks it culminated in the "reveal." The purpose of a medical exam is to "reveal" a problem and to come up with a diagnosis and subsequent treatment plan. Pointing is one of the tools used to that end.

Clinicians can approach the "presenting problem" in one of two ways. They can offer, "tell me what hurts," or "show me what hurts." The two invitations are not quite the same. I had a legendary professor in medical school who taught us to take note of "how" a patient demonstrated the character of their pain. If they had a chest pain and used their index finger to point to the area it was probably of a different origin if they used a clenched fist to "describe" it. Patients tend to describe the angina pains with the flat of their hand horizontally across the middle of their chest; they tend to describe oesophageal spasms with a clenched fist at the upper xiphisternum edge, moving in a vertical manner.
Of course these are not definitive and a thorough examination requires additional laboratory and diagnostic screens. But they are valuable in beginning to create a meaningful set of "possible" culprits.

Culturally, "pointing" has been a valuable part of the doctor-patient relationship. According to Harry Finley, the curator of the Museum of Menstruation, (really, look it up), "For centuries in China, for example, doctors carried palm-sized examination dolls to give to the servant or relative of an ailing woman of high social status. The sick woman would point out the place that hurt on the doll and the intermediary would relay the information to the doctor. The feet of the doll would be covered, just as the woman's would be; the feet of the woman herself were never revealed to anyone, not even her husband."

It's still common for clinicians (behind closed doors) to use their index finger to portray a patient with a mental illness by pointing to the top of their heads and rotating their finger as if to signify a "Rube Goldberg" malfunction.

The power of "pointing" is demonstrated in our everyday language. We have "Power Points," expressions like, "point the way,", "point and click," "point and counter-point," "talking points," "case in point," "get to the point," "sore point," and "in point of fact." The point being (couldn't resist) that humans seem to be hardwired to "point" things out, to direct one's attention by gestures, for the purpose of being sure you "get it." Pointing leaves little to the imagination or allows for ambiguity. Pointing is definitive, it's revealing and it doesn't require translation. By design, safety "pre-take off" instructions given by flight attendants are all "point provided," requiring no language proficiency. Next time you're in a crowded restaurant stand up at your seat and "point" to your throat, see what happens.

Pointing has a cultural standing in America. In the 1932 World Series Babe Ruth pointed to center field (Wrigley Field) as a declaration where he would place a "run," that's where he hit his fifteenth, and last home run, in his 41 post-season games. It is known as "Ruth's called shot." The Chicago Cub players (especially Charlie Root, the pitcher) and fans got the "point."

The American artist James Montgomery Flagg designed 46 posters for the U.S. government during World War One. His most famous work was his Army recruiting poster featuring an illustration of Uncle Sam pointing a finger at the center of the poster declaring, "I WANT YOU" (for the U.S. Army Enlist Now). It was such a popular icon that an adapted version of this poster was also used during the Second World War.

The American author, Henry David Thoreau, best known as the author of Walden, was also a major figure in civil disobedience. A "poll tax" was imposed (later declared unconstitutional) as a tactic to prohibit blacks from voting in public elections and Thoreau refused to pay the tax and was jailed in Concord, New Hampshire. It is believed that the poet Ralph Waldo Emerson visited Thoreau in jail, and asked: "Henry, why are you here?" to which Thoreau pointed to Emerson and replied, "Ralph, why aren't you here?" The point was well made.

Humans don't have the exclusive franchise on pointing. In a recent article in the journal Current Biology, it was revealed that elephants understand "pointing" without being trained. Researchers believe they may use their trunks to "point." The ability to "point" may have evolved from the complex social system elephants inhabit, which involves the recognition of unspoken signals. According to Professor Richard Byrne (University of St. Andrews in Scotland) "What elephants share with humans is that they live in an elaborate and complex network in which support, empathy, and help for others are critical for survival."

While that may describe elephant society, it certainly describes the complex network in the lives of "exceptional parents and their children with special healthcare needs." Exceptional parents are no strangers to strangers to "pointing." For decades they have endured other children pointing to their children, other parents pointing to their children and regulatory agencies "pointing" out why their children are ineligible for services or accommodations. The struggles and challenges of parenting a child with special needs have been met by parents "pointing" out their rights, their needs and their obligations to many deaf ears; ears that couldn't or wouldn't hear. Seems like "pointing" comes in handy when you want to make a point and you need something beyond mundane words.

Thanks to decades of extraordinary "exceptional parents" leading the way, the current exceptional generation is still pointed to; but out of respect, admiration and awe. A point well taken!

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