Tag: Building Trust Essay Contest

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

“Social determinants of health” – four words that compose one of the most significant phrases to ever traverse health care. They have prompted me to explore exactly what these words mean: to myself as a person, my education, my future practice, and my impact on my community. How could I, a single medical student, work within the teams I have formed with my mentors, friends, and colleagues to improve the social determinants of health experienced by the members of my community?

The major public health threats of diet, exercise, smoking, addiction, housing, and so much more, can be resolved through the development of trust between health care professionals and the community members they serve. That trust also has to overcome a history of systemic racism, language barriers, and individual anecdotes of providers with implicit biases against gender, racial, and ethnic minorities.

I was recently part of a team that helped run a flu drive and perform diabetes and hyperlipidemia screenings for members of a predominantly Spanish-speaking community in South Dallas. During the event, I began to recognize the trusted sources of this particular community, especially of those who did not speak English.

I went to the flu drive equipped with only a 10^th grade level Spanish education and attempted to engage in conversation as I screened people for hyperlipidemia and diabetes. I was eager about the event, but nervous about how I would communicate with the participants. I immediately witnessed the immense trust many older participants placed in the hands of their children and grandchildren who knew English, as they straightforwardly relayed test result interpretations.

Over the next few hours, as the insecurities about my Spanish-speaking abilities diminished, I began to understand the importance of being able to communicate directly with whomever I was serving. Most of the interactions I made with a patient went this way: I would greet them with “Buenos Dias,” and then would preface the rest of our interaction with “Lo siento, mi espanol es muy mal, pero yo voy a intentar y quiero aprender mas,” or “Sorry, my Spanish is very bad.” This well-rehearsed phrase of mine was always answered with a reassuring chuckle from the other side of the table and “Bien.”

The people I spoke with understood that even though I could not converse with them fluently, I was trying to communicate with them as well as I could. I was given reassurance that they trusted what I had to say when they would fill in words for me as I spoke to them about their test results and lifestyle modifications. 

At the same event, I also saw the impact of a community’s leadership as a source of trusted information for its members. The health fair was hosted on a Sunday next to a church, and the biggest waves of participants came to us within the hour of the end of each service. I realized that we, as servants of our community, need to tap in to the currently trusted platforms of information held by the community – like the local church. We can use this foundation of trust to improve our relationship with the community to serve them in a more impactful way – a way in which they will feel comfortable disclosing conditions beyond their physical health, so that we can also address their social determinants of health. 

I’m now exploring the causes of vaccine hesitancy within this community. To improve trust, we do not need to start from scratch, and we do not need to work alone. We can continue to learn about the viewpoints held by this community to unlock where their trusted sources of information are to use these platforms to deliver accurate information.

During the flu drive, not only did we see the important role that young family members served – as translators for their community – but we also saw the importance of the local church in their social lives. We experienced the synergistic impact of the drive’s coordination with the church’s leaders in boosting participation in the flu drive. This clued us in to how we can continue to use places of worship to provide accurate information about vaccines, healthy lifestyle habits, and other public health information to the community. This is how we can serve our communities beyond the four walls of our hospitals and clinic buildings so that patients can take control of their health status on all fronts. 

Suman Vadlamani is a second-year medical student at UT Southwestern Medical Center in Dallas. She is also in her second year of her MPH degree through UT Health. She has an interest in Women’s health, which is the direction in which she wants to take both of her degrees. She hopes to become an OB/GYN doctor and focus her public health work on progressing women’s health initiatives.           

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

Learn more about this year’s contest: www.abimfoundation.org/essaycontest

It took exactly three Tuesdays. Each week, I knocked timidly on the door, waiting for his characteristic gruff “come in” before I dutifully entered the room clad in the paper gown. I would approach the bed, chipper as ever, as he glanced at me through lidded eyes of disdain.

A brief history of our interactions would read as:

Tuesday #1: A cup of Jell-O and please turn off the lights.

Tuesday #2: Do you guys have Call of Duty? Fine, can I just have FIFA.

Tuesday #3: I’m good for today.

and then…

“Tomorrow was supposed to be my prom, you know,” barely a whisper behind me.

My tongue felt as if it was glued to the roof of my mouth as I turned ever so slightly, waiting. I could sense the air saturated with tension.

He laughed bitterly. “They told me I’d be out of here by now. I promised my girlfriend I would take her.”

Each word dripped with acid that ran off his tongue and pooled at my feet.

I swiveled slowly, afraid I might spook off this moment of rare vulnerability. I mustered a weak, “I can’t imagine.”

I had hoped this would be a benign offering, but his head snapped towards me so sharply that I stepped backwards.

“No. You CAN’T imagine. I bet you got to go to your prom, didn’t you?”

It was more of an accusation than a question. Bracing myself for his next inundation of rage, I nodded my assent wordlessly.

But his anger dissipated as quickly as it came. He shut his eyes tightly and leaned his head back against the steel bar of his hospital bed. The movement was so familiar, so practiced, that I could tell he had assumed this exact position before, searching for meaning in this unholy campground.

I suddenly realized that when I entered every week, I was intruding on the most intimate moments of his life. I could see it more clearly: my knock, the threat of an invader as he haphazardly tucked in the corners of his Tuesday.

“They promised I would be out of here. I don’t know why I believe them anymore.”

Suddenly, I remembered a slight caveat, a correction to my previous answer.

“Well actually… I only made it to one prom. The other prom I was in a full leg cast because I tripped and broke my knee.”

He glanced at me beneath the curtain of sandy-brown hair as I looked back at him, no longer afraid to meet his eyes. We challenged each other in silence for a few moments until his bubbles of laughter burst forth.

“That has to be the dumbest thing I have ever heard.”

We were both doubled over at my clumsiness as I assured him that I had fallen onto the pavement with a satisfying thwack.

There was an imperceptible shift. Our Tuesdays were now intertwined. In sharing a piece of my history (and an embarrassing one at that) I had reminded him that I was also fallible and human.

“Damn. Well at least cancer is a better excuse to call a raincheck than being a klutz.”

I see medicine as an opportunity to forge relationships in unexpected ways, its core remaining the in-between moments of people connecting in shared spaces. As the hours of my shift unraveled, he confided in me his tricks to get extra dessert and his frustrations that his hair was falling out in clumps.

It took three Tuesdays for me to learn that fostering trust is a broken and messy process, oftentimes taking one step forward and three steps back. It is no easy feat for someone in their most vulnerable moments to invite you into the complicated prism of their lives. Instead of expecting an easy connection, I have learned to sit with the awkward and uncomfortable. Even when it feels like no headway has been made, continuing to knock on the door is its own kind of promise. I may not always find a quick joke or common thread, but I can choose to show up anyway.

As I stepped outside onto the slick sidewalk that Tuesday, I knew without turning that he was watching from the window. So, I let my feet skid on the asphalt as I pirouetted dramatically to the ground.

From a dimly lit window on the 4^th floor of a children’s hospital, I was rewarded by a toothy grin and slow clap before the curtains swung shut.

Meher Kalkat is a second-year student at the Johns Hopkins School of Medicine and is originally from West Palm Beach, Florida. She is passionate about medical education, physician and trainee wellness, and combating mental health stigma. In her free time, she loves to sing karaoke, bake, and take photographs.

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

“A woman is a puppet; she only knows to cook the meals and wash the clothes of her husband and to care after the children.” My research informant, a 24-year-old in her seventh pregnancy, was describing why she felt a talk therapy program for perinatal mental health could not help women like her, living with antenatal anxiety in the cultural norms of Pakistan. Her words, an expression of powerlessness and distrust, were among the most powerful that I encountered in my studies. Her account gave voice to the lifeworld—one at the intersections of women’s disempowerment, gender norms, and psychological distress—in which she experienced her illness. 

While we are decades removed from Elliot Mishler’s 1984 study, The Discourse of Medicine, the patterns of distortion and fragmentation that he observed in doctor-patient communication remain as relevant as ever, even as the specific barriers—technocratic models of medicine, layers of electronic or virtual discourse, etc.—continue to shift. The permanence of this challenge is rooted in the timelessness of what our patients are urgently seeking from us: to be heard and seen as whole people. The art of building trust with our patients requires, above all else, the humility to meet them in the lifeworld they occupy.

This was a lesson first taught to me by my grandfather. Scribbled in the margins of his worn mus’haf—his copy of the Quran, passed down to me after he died—my grandfather left me a final reminder: that we are closest to God or al-Haq (the truth) at that moment of prayer when our heads touch the earth in prostration. It is humility, he wrote, that brings us closest to an understanding of truth. I imagine he penned these words toward the end of his 23 years of diplomatic service in Central Asia and the United Nations. Having lived through violence in Ladakh and exile from his home in Tibet, he dedicated his career to empowering communities that, like his own, were uprooted and marginalized by conflict. I internalized his ethic of service.

Inspired by my grandfather, I brought to medical school aspirations of helping the vulnerable, specifically to find within contexts of illness or crisis avenues of healing and relief. Of the many challenges that I faced while studying to become a physician, however, the most difficult was not relinquishing my humility along the way. Education and expertise are defined as much by what we learn to forget as by what we learn to remember.

In medical school, while memorizing dizzying amounts of information and formulas for efficient clinical communication, I am afraid I would at times unwittingly learn to forget my own limits—the limits of not only my own knowledge and abilities, but also the limits of my own importance. This was evident in every instance that I thought myself too busy or considered my time too precious to speak with my patients rather than at them.

I’ve since experienced firsthand the difference that empathic listening—listening with the heart as well as the ears—can produce in gaining patient trust.

Recognizing the distress in the voice of a teenage driver I was evaluating for whiplash injury in the Pediatric Emergency Department, I was moved to offer open-ended questions and extended moments of silence, thereby learning that he had been running from home at the time of the collision after his mother discovered a suicide note in his bedroom.

While caring for a terminally ill nursing home resident during one of several repeat hospital admissions, the patient and I decided together to explore the benefit of a palliative care consult. During the resulting discussion with her and her husband, I learned that while neither wished to pursue aggressive or curative treatment, both had a yet unspoken need for the other’s permission to accept that the patient was approaching death.

“Listen to your patient,” William Osler would tell his students. “He’s telling you the diagnosis.”

I believe our patients are telling us much more than their diagnoses. For our communication with them to produce genuine trust, for our care to be patient-centered, and for our interventions to produce therapeutic change in their lives and the lives of their families, we must be committed to always considering our patients as among our teachers: confronting complex yet intimate connections between health and social context, hearing their meaning-filled narratives, bearing witness to contextually-grounded suffering or dysfunction, and humbly recognizing behind each of our patients the multifaceted identity and lifeworld that they offer us.

Armaan Ahmed Rowther is a final-year MD-PhD student at the Johns Hopkins University School of Medicine who completed his doctoral studies in International Health at the Bloomberg School of Public Health. His thesis focused on structural and sociocultural factors shaping the design and implementation of novel telemedicine and task-shifting approaches for improving maternal and child health services in Pakistan. Prior to this, he was a research fellow under the Fulbright US Student Program in Jordan conducting a study on digital health intervention development and evaluation for cardiometabolic risk screening in medically vulnerable women receiving care from the Noor Al-Hussein Foundation’s Institute for Family Health near the Baqa’a Refugee Camp. Currently, his clinical interests include Reproductive Psychiatry while his research interests center on applying social science theories and mixed methods to understand perinatal mood and anxiety disorders and innovations for advancing maternal health equity.

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

Learn more about this year’s contest: www.abimfoundation.org/essaycontest

How would your trust in your physician change if they disclosed that they had the same health condition as you?

Physician self-disclosure – wherein the physician tells the patient something personal about themselves – is an understudied phenomenon in healthcare communication. Yet, it occurs so frequently and innocuously within clinical encounters, especially in the form of “small-talk” (family or hobbies, for example) that its impact is often unnoticed.¹

But what if the physician reveals a personal illness? What risk does this pose to the archetypal patient-physician relationship, in which the “sick” and “healthy” roles are plainly differentiated? What gains in rapport may arise from such self-disclosures? 

These questions first captivated me a decade ago, when I dealt with a medical issue that brought me to a provider who had recovered from the same condition. He possessed unique expertise largely because he understood the problem from the perspective of both patient and healer. I found him to be a kindred spirit. The therapeutic alliance we built over a mutual tribulation manifested in the ways he anticipated my doubts before I even uttered them, the optimistic attitude accompanying his pearls of wisdom, and his ability to instill in me an enduring sense of hope in the midst of uncertainty. My trust in him, which made me confident in his treatment recommendations, ultimately proved integral to my healing. 

This novel experience of self-disclosure affected me so profoundly that I decided, after getting well, that I too would care for others struggling with similar health concerns. This commitment eventually drew me to medicine, where I could walk closely with patients in the loneliness of their pain and suffering. 

In medical school, I sought to learn how patients perceive physician self-disclosure. Was my experience normative? Does revelation of shared illness typically enhance the therapeutic alliance? Or does self-disclosure actually do more harm than good? 

Guided by my research mentor, I explored these queries by surveying 924 patients with chronic pain. I asked them to imagine that they were seeing a physician who had chronic pain themselves. Would they want their physician to reveal this to them?

Sixty percent of patients said “yes.” Among those who responded affirmatively, a prevailing theme was trust.

“I would trust their opinion more, because they lived with pain,” wrote one patient. “Part of the challenge with chronic pain is feeling believed; I think that if a provider has experienced chronic pain, sharing [this] can create an innate trust that they do understand,” wrote another.

Chronic pain is a deeply isolating affliction. Corroborating the published data, our respondents often recounted having their pain minimized or dismissed by others, including their physicians, whom they counted on to validate their struggle more than anyone.²

I discovered that patients did not desire sympathy, but empathy. They longed not to hear “I hurt for you,” but instead “I hurt with you.” 

After reading nearly a thousand comments from patients with chronic pain, I appreciated anew how truly delicate it is for patients to entrust their lives to people they barely knew. I also gleaned that when delivered without the patient’s utmost wellbeing in mind, physician self-disclosure can deteriorate trust.

While the majority of patients we surveyed wished to know about their physician’s ailment, seven percent did not, and 33 percent were unsure. Chief among patients’ misgivings was that their singular narrative would be overridden by the imposition of their physician’s subjective experience. They also feared that self-disclosure would divert the focus away from them and onto their physician. Principally, patients yearned to be heard as unique persons, not be told that they were just like anyone else. 

Our respondents imparted to me a clear imperative: to earn and never assume the trust of my future patients; handle it always with the tenderest care; and disclose the details of my journey only when conducive to these intentions.

The physician-as-patient occupies a cherished space in modern medicine. Historically, the predominant view within the medical profession was that divulging personal information to patients would blur professional boundaries and imperil the integrity of patient-centered care.³ In certain contexts, this may invariably be true. But Western ethos has increasingly respected the humanness of the physician, particularly in light of a pandemic that has touched everyone, especially healthcare workers.⁴

I believe that the more we acknowledge and celebrate our bondedness – one teeming with all the familiar joys and sorrows of the human condition – the more patients will become empowered when they hear from their perceptibly unbreakable healers: “I hurt like you.” 

Howard is an LA-native who is currently a fourth year medical student at the Johns Hopkins University School of Medicine. He intends to pursue a career in neurology and is broadly interested in optimizing functionality and quality of life in individuals with neurodegenerative disorders. He hopes to discover and employ ways to improve patient-physician relationships through communication, trust-building, and shared decision-making. Outside of medicine, he loves reading, writing, basketball, and bubble tea.  

References

1. Beach MC, Roter D, Larson S, Levinson W, Ford DE, Frankel R. What Do Physicians Tell  Patients About Themselves?: A Qualitative Analysis of Physician Self-Disclosure. J Gen Intern  Med. 2004;19(9):911–6.

2. Buchman DZ, Ho A, Illes J. You Present like a Drug Addict: Patient and Clinician Perspectives  on Trust and Trustworthiness in Chronic Pain Management. Pain Med. 2016;17(8):1394-406.  

3. Candib LM. What should physicians tell about themselves to patients? Am Fam Physician.  2001;63(7):1440–1442.

4. Søvold LE, Naslund JA, Kousoulis AA, Saxena S, Qoronfleh MW, Grobler C, Münter L.  Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public  Health Priority. Front Public Health. 2021;9:679397.

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

A sense of excitement and apprehension filled my thoughts as I started my first emergency department shift of clinical year. It was the tail e­nd of the latest spike of COVID-19 cases, and I steeled myself for a tense environment given the numerous notifications I had received over the past few weeks about an overwhelmed emergency department with wait times over 24 hours for in-patient transfer.

I met my preceptor for the day—Dr. Joshua Stillman, a grounded and perceptive emergency medicine veteran—who would observe and guide me through patient encounters. His gentle and approachable demeanor paired with an emphasis on learning opportunities set me at ease in this new environment, and I went to find our first patient of the shift—Mr. A. The chart listed his chief concern as a wound check. I walked into the packed waiting area and began calling the patient’s name. I received no response and continued searching among the numerous masked patients waiting to hear their name. Silence or head shakes followed each call until, I noticed a young man with bandages wrapped around his left hand rising from his seat to approach me.

“Are you Mr. A?” I asked.

“What do you think? You made me wait two hours!” he replied raising his voice.

I apologized for the delay and attempted to confirm his name again. As we walked from the waiting room to one of the emergency department stations, the patient continued to vent:

“I’m here with a wound that could have been bleeding out, and you just leave me out here for hours. Do you all even care? Of course, you don’t. It’s just another day for you, and you’ll get your money either way.”

Amidst his statements of slander and profanity, I felt like all I could do was listen, validate, and use “I wish we could…” statements. Having been on clinical year for only one month, I had a limited repertoire from my oncology and step-down unit experiences. For me, it had only been a few minutes into my shift, but for this gentleman who had been waiting with a wounded hand, it had been hours. Telling Mr. A that as a medical student I was not being paid—or more accurately I was paying to be there—felt like an inappropriate response as it would not have changed the outcome of delays in care that he experienced. I chose to focus on Mr. A by talking about his hand, but he refused to show it to me and instead continued to vent his dissatisfaction with the healthcare system.

I alerted Dr. Stillman who soon took over—he continued with heartfelt apologies and attentive acknowledgements of the patient’s frustrations, and finally asked the patient how we could make it up to him and offered to care for his wound. After a few minutes, Mr. A stormed off. We went to look for him but couldn’t find him.

I was reassured by Dr. Stillman that Mr. A would likely be back. He suggested the patient still needed to feel in control, but we had gotten through to him by being receptive to his needs. He shared his strategy for managing conflict—Three A’s: Apologize, Acknowledge, and make Amends—and his hotel analogy helped paint a clear picture of the strategy. When a hotel guest complains about dirty sheets, the hotel manager will apologize, acknowledge the mistake of dirty sheets, and make amends by offering the guest a free night or a complementary meal. The guest might still be upset in the moment, but after calming down, they usually realize that the hotel is customer centric, is on their side about the mistake, and wants to make it up to them.

About an hour later, Mr. A returned to the emergency department. He apologized, and his calm demeanor starkly contrasted his earlier presentation. We also apologized again for the past, acknowledged the initial difficulty with the hospital system, validated his frustrations, and expressed how glad we are that he returned, so we could ensure he received care.

He confided in us about his mother’s hospitalization, financial hardships, and worries of his wound impacting his employment. After examining his hand, we ordered an x-ray, cleaned, and wrapped it. Mr. A continually expressed words of appreciation throughout his visit, and he left the emergency department reassured about the state of his wound, with instructions for cleaning and pain management, and details about infection and follow-up.

For most patients, it’s encouraging to have a clinician who shows empathy, takes time, validates their worries, and respects what they have been through so far. By being gentle, respectful, and reverent, we preserved his dignity as a patient and restored his broken trust in us as caregivers. This lesson in humility has already shaped my response to other patient interactions and will remain with me for the rest of my career.

Paul M. Lewis is a third-year medical student at Columbia University Vagelos College of Physicians and Surgeons (VP&S). He holds a Bachelor of Arts degree from Harvard College where he concentrated in Neurobiology with a secondary in Global Health and Health Policy. Passionate about education, mentoring, and public health, Paul created the International Young Researchers’ Conference (IYRC), which hosts an annual Medicine and Research Summer Program at Columbia VP&S to teach youth from around the world about foundations of clinical medicine. Outside of medicine and mentoring, he enjoys immersing himself in books, novels, and stories.

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

When I was a caregiver at an assisted living facility, there was a resident, Imogene, who would bellow at every worker, “I can’t hear, I can’t see, I can’t speak.” As I helped Imogene in her room, I would stop by her bed, and ask if there was anything I could do for her and her response was always “No!” After a couple of weeks of the same routine, she finally stopped yelling at me, but remained wary.

One day I asked about the teddy bear she clutched. She told me that she missed her son, who gave her the bear. I took the opportunity to ask her more questions, since she was finally willing to talk to me. Imogene told me that she used to live in Austria, and that her son took her to operas. It didn’t take much time or effort on my part – but the genuine interest I showed Imogene, changed our relationship.

Every time I entered the room, Imogene’s face would brighten, she would smile, and speak to me about her life in Austria – I believe she finally trusted me more, which let me provide better care for her.

Before starting medical school – during my time as a caregiver – I valued listening to patients’ stories because I knew it established mutual trust. I suppose I thought that practicing medicine would be like my time as a caregiver. But, it hasn’t taken me long to see that doctors do not always provide empathetic care that prioritizes patients. Patients want to trust their doctors and know their doctors are formulating plans that best adhere to their wishes. Understanding a person’s background can help doctors treat patients in a way that is better for that individual. Even if people have the same disease, their illnesses manifest differently, and therefore, each patient should be treated as a unique case.

Some may argue that complex emotional conversations with patients are not worth a doctor’s time and that social workers or nurses could spend time dealing with patients and their suffering. However, I believe doctors have the responsibility to take the time to have difficult conversations with their patients.

A doctor’s words and actions hold significance to patients. Patients tend to cling to every meeting with the doctor and analyze all aspects of their interactions. They assign more power and authority to what doctors say, over others – because doctors are the experts.ⁱ Therefore, doctors need to be willing to bring up difficult conversations with patients rather than relying on others on the medical team, because the patients trust them.

As a first-year medical student, I had the opportunity to participate in an “Early Hospital Experience.” I was caught off guard by some of the realities of medicine that I witnessed: we spent most of our time discussing patients rather than spending time with them since the attending preferred to keep rounds to thirty minutes. I now realize how easily doctors can become detached from patients and jaded; that what I’ve been learning in my longitudinal humanities curriculum might be lost once I start clinical practice.

I can’t understand how medical students (who typically enter the field full of empathy) lose this part of themselves throughout training. I wonder how we can genuinely connect with patients to establish trust, despite the health care system prioritizing efficiency and productivity. This is where I believe the medical humanities has the capability to help future doctors provide better patient care – because it underscores that medicine is inherently interpersonal.¹

My experiences and my introduction to medical humanities have made me passionate about integrating these concepts into patient interactions. I founded my school’s medical humanities club to reiterate that we should provide holistic patient care, take time to reflect, and address the detachment I witnessed.

The club creates a space outside of the curriculum for students to engage and discuss these concepts without the pressure of grades. Sometimes reflection, like remembering what initially drew you to medicine, can reinvigorate doctors to engage their patients in authentic conversations about the realities of illness and suffering.

My hope is that by creating this space to have these conversations, my peers and I will become the kinds of doctors I hoped to encounter during my Early Hospital Experience that will take the time to connect with patients.

Clarice Douille is a second-year medical student at the Creighton University Health Sciences Campus in Phoenix, Arizona. Douille earned her BS in Biological Sciences from the University of California, Santa Barbara. She is interested in implementing the medical humanities into her future clinical practice. In her spare time, Douille enjoys the challenges of sudoku puzzles and is an avid rower.

References:

1. Piemonte N. Afflicted: How Vulnerability Can Heal Medical Education and Practice. MIT Press; 2018.