Medicine From The Trenches

Experiences from medical school, residency and beyond.

Accepted! I’m Going to Medical School!

This is just great news! I am so proud of this young woman who persevered.

Potential Doctor

On behalf of the Faculty of Medicine of McGill University, I am delighted to offer you a position in the Fall 2016 MDCM…program. Congratulations!

On behalf of the Admissions Committee, allow me to compliment you on your impressive candidacy. We are confident that your unique experiences and perspectives as a Non-Traditional Pathway student will enrich the McGill learning community and we look forward to your favourable response.

Yours sincerely,
Assistant Dean of Admissions

Words cannot express my joy when I received my offer of admission to medical school yesterday! This is a dream come true for me and after years of effort, three attempts at the MCAT, and my second attempt at applying to medical school, I have finally made it!

Yesterday and today have been  a whirlwind of events as I have spoken to many friends and family members. I have received an outpouring of beautiful messages from all…

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17 May, 2016 Posted by | medical school | 1 Comment

Getting a Bloody Nose…

“Far better is it to dare mighty things, to win glorious triumphs, even though checkered by failure… than to rank with those poor spirits who neither enjoy nor suffer much, because they live in a gray twilight that knows not victory nor defeat.” -Theodore Roosevelt
Well, my first marathon ended with me in the Emergency Department after having collapsed from hypothermia. I don’t remember falling but I do remember waking up under a circulating air warming blanket wrapped from head to toe with warm packs surrounding my neck and groin. My FitBit says that I collapsed just after Mile 10.
When the race began, the temperature was 37F but there was little wind and no precipitation. As I ran, I warmed up, removed my over-jacket but kept my gloves on because my hands get cold easily. I had three light layers on but as I approached Mile 3, snow started to fall, mixed with rain. My footing was good and I felt a bit chillier but I picked up my pace and thought the temperature would rise.
Around Mile 6, the wind picked up and the rain fell in sheets. I was soaked to my skin. The temperature didn’t move much but my hands became too cold to work. I couldn’t get my jacket back on but I kept running; hoping that I could warm up with a quicker pace. I shortened my stride but picked up my cadence.
I don’t remember much after Mile 8. I remember feeling OK but still my hands were so cold and painful that I couldn’t move my fingers. My fingers had begun to turn white. My next memory is waking up in the hospital. The ER physician, when he found out I was a physician, said that I collapsed and was brought in by ambulance. I have no memory of the ambulance ride or the fall. For this, I am very embarrassed. It is quite strange for me to not remember or be aware of my surroundings. I don’t remember feeling faint or light-headed but I do remember the intense pain in my hands as my gloves were soaked along with my clothing.
Right now, as I write this, I am bruised,  with multiple abrasions, sore and very humbled. God decided that I wasn’t going to run my first marathon on this day even if I was determined to do so. I was so excited to have the fellowship of other runners on this cold and blustery day and I am infinitely grateful for those who attended to me after I fell. I have learned much about myself during my training and from this experience. I live to fight another day and I continue to dream of running the 26.2-mile distance.
My friends have sent me many notes of congratulations and I adore all of them. I am very fortunate to have my health and my resolve to get back to training for the next marathon that I can run. Today was not a day of victory for me but it was a day of experience and for this, I am grateful.

15 May, 2016 Posted by | hypothermia, life in medicine | | 4 Comments

A Weekend of Affirmation

I am now down to 4 days to my first marathon. I had a great last long run this past Sunday with one week to go. I feel great; passing the time between elation that I have done my best in terms of training and a little fear that I can’t finish the race. I have not run a total of 26.2 miles in a training run having been advised against running the total distance by my coach. She is confident that I can complete the distance.

My friends, save the one whose friendship I miss most, have been very supportive. My heart is glad for having set this goal and worked diligently toward it. I pray and meditate on hoping that my lost friend finds his way back into my life as he is such a generous and energetic spirit that I miss unspeakably. I am totally at peace with his decision but I can’t get past that I am without his lively character and his affirmation. That affirmation went in two directions.

I spent some great time with two of my professors from residency. It was a wonderful experience of seeing two men that profoundly affected the way I practice surgery and medicine. They are generous and wise teachers whose wisdom whispers into my ears when I am in a tough clinical situation. One, who was my residency director, is the most heroic person I have ever known, a former marathoner. The other, just joyful in his generous sharing of his knowledge and teaching. It was a great experience to see these men after many years of development on my part. I am at profound peace with where I am and how I practice.

I had many opportunities to exchange ideas and information with some of the brightest and best minds from across the nation in surgery. Such rare opportunities are not to be taken lightly. I found my brain brimming with ideas and commentary on my two long runs of last week. The weather was warm with clear blue sky and plenty of lake water to run along side. I couldn’t help but smile at every biker and fisherman that I passed, sampling the good will of people that I will never meet again. Such is the stuff of affirmation.

My running is for me and myself alone. I haven’t had an opportunity to sit on the roof of my hospital lately but I am philosophical as I take on the challenge of completing my academic duties for the semester and year. Before I left town for a short trip, I had become embroiled in a useless “ego” trial that cost me a friend, my ultimate academic friend, and shook my confidence in my teaching style/ability. My experience in reconnecting with my former professors restored my resolve to be the best that I can be without engaging in any type of “ego” exercise.

Medicine and teaching have no room for agendas other than imparting the best knowledge possible to those who are students. I renewed my resolve to impart the best and explain all that I can explain to my students. Still, as I was on the verge of my ultimate “burn-out” for many reasons, I now have a calmness and peace that my experience has been a great teacher for me. Still, I have so much that I would love to share with my lost friend, I am sad that I won’t be able to do this.

My research continues and will be running “full steam” during the summer season. I look ahead with great expectation that we will accomplish much. I will get through my marathon in the coming weekend and move forward with the things that are on my agenda for “after” the marathon. I feel that my end of week affirmation, along with my taper and rest will be the best part of my training.

Yes, I worry that I won’t finish but I will give my best. Yes, I worry that I might suffer an injury in the start of race jostling but I will give my best and keep my eyes open. I have the positive wishes and prayers of my spiritual companions from my theology course along with my wonderful and wise friends. I have learned many lessons in the past week and I have been very sad but I keep my eyes focused on where I go from here. I prepare my head and my heart for what is to come. I have no doubt of the gifts that I have been given and I am infinitely grateful for all of them; even the painful experiences.

10 May, 2016 Posted by | academics, life in medicine, medical school | | 3 Comments

One Week to Go to My First Marathon

What have I learned about myself? With every mile that I have run in my training runs, I have learned that I have a mental toughness that I found quite elusive a couple of weeks ago. Now, I have learned to face my mental “demons” with calm reserve, much the same as I approach a difficult case or patient.

I had found myself sinking, for lack of a better word, into a spiral of self-doubt and mental vulnerability. My mental shenanigans cost me a wonderful friend but I now move forward with every step and pick up the pace without fear. I can’t reason why I spiraled a bit over my academic work but I did and it’s done. From here on out, I deal from a position of strength rather than questioning myself and my motives.

This past week, I have had the pleasure of thinking long and hard about my medical and academic career. After many years of practice, I believe that self-examination is not an entirely bad exercise but I have also learned that I cannot ask anyone else to “walk in my shoes” or “understand” the things that can send me into self-doubt. My questions were not about my training or my ability but about how I handle adversity in matters that I didn’t fully understand.

Yes, I have plenty of regrets that I lost the friendship of a gifted colleague but I discovered new insight into myself and new support from unexpected colleagues and friends. I took the time today on my last long run, to think of each of my friends and thank them as I ran. I am very grateful for their friendship and I know that I will continue to move forward professionally and personally.

I thought about setting goals and achieving those goals. Certainly, there is no guarantee that I will finish my first (and only) marathon race next week but I feel calm and physically prepared. Mentally, I am in a state of surprise in that I have been able to train for this race and that I will have the toughness to make the needed adjustments to my pace and form that will allow me to complete the distance.

This training has make me something of a philosopher in terms of what I see and hear around me. I have taken great pleasure in simple things like a wonderful warm shower or that drink of water when I have pushed myself to the brink of dehydration. I have tended to avoid the “sports” drinks because I haven’t felt the need for sugar/salt loading. Plain water, not too hot or too cold, has been my best friend.

My training has increased my need for rest and sleep. For most of my career, I have had a love/hate relationship with the number of hours of sleep that I require. Most days, I cannot sleep more than 5 hours but with my increased running mileage, I have moved into the six to seven hour range. More sleep has allowed my body to rest and heal for the pounding that the increased mileage required.

With the end of the school year, I am looking forward to taking a week or so off and heading to California for some much-needed relaxation. I love being near the Pacific Ocean, smelling the salt in the air and just watching the fog cover the Golden Gate Bridge from the deck of where I stay in the Bay area. I have also completed my longest and best runs up and down the hills of San Francisco, a place of unrivaled beauty and wonder.

Finally, I know that I cannot be “all things to all people” and I just need to let things fall as they will. For a surgeon who is quite used to affecting something definitive in most cases, letting go is a new feeling for me. Most of the time, things just work themselves out and I am the instrument. This has been the best part of my marathon training; seeing how I am an instrument of my training and experience.

This training for a marathon has been something of a metaphor for life for me. I set this goal and I have made some progress toward it in some manner over the past year. Though I didn’t reach the distances that one typically associates with distance running, I am very grateful for every step as I have moved along. Yes, I know I am a very secure middle-distance runner but stretching the distance has been good experience for me. With the stretch has come great self-knowledge.

 

8 May, 2016 Posted by | medical school, medicine, practice of medicine, relaxation, stress reduction | , | Leave a comment

Meeting the Challenge

I continue to train for an upcoming marathon. Making the change from middle distance to long distance has been a great mental and physical challenge. My goal is to complete the 26.2 miles even if I find that I am walking part of the distance. To complete this challenge is my goal that I have contemplated, trained and taken steps toward. I have to have the confidence to continue to train and make positive movement toward this challenge/goal much as I have met other challenges in my life.

Yes, thoughts of not being successful creep into my head from time to time but the sheer pleasure of my longer training runs has been of great comfort. I can’t say with certainty, that I will cover the distance. A shorter run this past week was uncomfortable (cold damp weather) and difficult to complete. Each mile was harder then the previous mile but my mind would not allow me to give up. Even if I am the last person to cross the finish line, I was determined to finish and I finished standing up. I learned a bit about my mental toughness and I greatly appreciated those standing along the route who cheered me on; gave me Hi Fives and were so affirming.

Losing the friendship of one of my best marathon advisers weighed heavily on my mind in a couple of my training runs. I was saddened by his rejection of my friendship but I respect his wishes. Respect is something that I have to keep for him. He is brilliant, sensitive and not in medicine/surgery which is why I can respect his wishes. If we were good friends , as I thought, time will allow us to resume communication at some point in the future but for now, I run, I study, I read and I keep moving forward, one step at a time because that is what my nature and my work requires me to do.

The loss of my friend was heart-breaking but my work is of great reward. I found myself assisting others more than I could imagine this week; a task that brought affirmation for me professionally. I found myself renewed in my search for excellence in everything that I touched. I found myself looking back into why I considered medicine/surgery in the first place. These “look-backs” and self-examinations are great for renewed energy when work seems to become a bit routine or even stressful. As I have said in other posts, nothing about medicine/surgery is ever routine because we touch the lives of our patients (and students, residents) in ways that we can’t imagine.

Sometimes I am prone to forget that the practice of medicine is a great privilege. I have been given the opportunity to put excellence in my work and see the results of that excellence. A bad day or week here and there, is the price that I pay for the privilege of my medical practice. There are journals to be read; studies to be reviewed, a book chapter to be completed and student work to be assessed and graded. I want to be fair and accurate in my reviews and grading which can cause long hours on my part.

I also have a trip coming up that will put me in contact with some of my residency professors whom I have not seen in more than 20 years. To see these gentlemen scholars, both of whom are great teachers/mentors will be a wonderful experience. I am looking forward to seeing how much they have changed and allowing them to see the changes in me. These men profoundly changed how I practice and how I approach my patients. I am grateful for all of the training and “busting of chops” that these men put me through during residency. Since they didn’t “kill” me, they made me stronger and resilient; I suspect that they know this fact well.

One of the greatest joys of a professor is seeing their trainees move into practice and develop. Much of medicine and surgery is learned from mentor to trainee in a one-on-one manner but overall, there is great joy in seeing the results of that one-on-one relationship. I don’t want my trainees to be exactly like me for I want them to take what they can from my teaching and flourish in their own style. I want my trainees to go as far as they wish and I wish them “Godspeed” in what they accomplish and in their triumphs.

To this end, there is no ego on my part but only a sincere wish that they do more, accomplish more and move past my training. Training under me is such a small part of all that they will do as any training period is just preparation. In medicine we put much emphasis into getting into medical school and getting into a solid residency training program but actually, the emphasis should be on the daily practice and keeping it from not being routine.

After all, we as physicians can never know the impact that we have on those around us. This impact is the best part of the practice and it is the part over which we have the most control. This is why I take each day for the wonder that it is, as this is the challenge that I must meet daily.

1 May, 2016 Posted by | medical school, residency, surgery | | Leave a comment

“It’s not a sprint, it’s a marathon.”

I am in the process of training for my first marathon. As a middle-distance runner at university, I always toyed with the idea of running 26.2 miles but after running a race of 10 miles about 20 years ago, I discovered that I didn’t enjoy running after the 8-mile mark. This put running the marathon distance on my “back-burner”, so to speak. There the marathon goal stayed until the idea surfaced about 4 months ago when I began running again for physical conditioning.

After graduate school, I attended medical school and found that I didn’t have much time for running as study was my constant companion.  If I had been wiser, I would have carved out time to keep up with my running, even 30 minutes three to five times per week, thus I would not have gained weight in medical school. My medical school weight followed me through surgery residency and fellowship. I kept promising that I would “get in shape” but never quite put a sound schedule together.

Well, after many years of practice and my sister’s wedding-photos of me were terrible, I decided to revisit getting in good physical condition. Since my weight slowly crept up to the heaviest that I had weighed in my life, I made the decision to lose a few stones so that my knees would hold up in my recreational rugby play. I kept up with my weight-lifting but my cardiovascular work was lacking in a major manner.

In the back of my mind, I knew that my knees would not want me to start out running, thus I began walking at least 30 minutes per session. I used my walking time to meditate (and pray) largely for stress relief. I had found that while lifting weights did relieve some of the stress, I missed running. I decided that I would attempt to get back to the point of being able to run a 10K if the opportunity presented.

Along with my dedicated walking, I changed my diet to no fried food, no candy, no processed food and certainly no “junk food”. My dietary habits were probably the easiest part of my journey because my wise sister had always been a great example for me. She simply doesn’t eat food that her precious body doesn’t deserve. She always said that it was better for her not that eat food that was processed. As I visit her often, I found that her consumption of fresh fruits and vegetables along with lean meats was a good strategy. She is lean, strong and wonderfully alive.

Soon, I found that by eating three nutritious meals with proper portion control, my weight was dropping. As I lost weight, I became faster finally able to jog and then run. Three weeks ago, when I was in beautiful San Francisco, I broke the 20-mile mark running those delightful hills as my training. It also helped that I have a wonderful colleague who was a world-class marathoner, until a devastating knee injury, but still maintains that wonderful thin body build of a marathoner. I envy his metabolism but he’s a great resource.

Today, I am many pounds lighter and running daily runs of 10 miles with great joy. My stress level is zero; my mind calm and at rest, my body continuing to thin out as my distances increase. While I am a bit worried that I won’t be able to finish the 26.2 miles, I keep running and keep running. I set the goal of completing a marathon and I work toward it daily by running, stretching and weight training also with keeping my diet sound. In short, I understand the concept of a “bucket-list” and I hope to mark “completed a marathon” off my bucket-list.

Another benefit of my running and weight loss is that people who haven’t seen me even as short as one month ago, barely recognize me. I have to say that losing enough weight to become unrecognizable is a wonderful benefit of this training. The only downside for me is that since I suffer from a hemolytic anemia (same as my father), I have to keep an eye on my blood counts. So far, even though I can chew red cells on my long slow distances (LSD), I remain asymptomatic. I can also indulge myself with an occasional beer or glass of wine without thinking about calorie counting. I have learned to savor those little treats of Sam Adams or Cakebread Chardonnay, my rewards for training hard.

Setting a long-term goal, working/training for that goal and getting that goal accomplished are items that are very nice for spiritual growth. Stress-reduction is great for intellectual and physical growth. In short, training for this marathon has been a great learning experience for me physically and intellectually. I can’t say  with certainty that I will finish those 26.2 miles but I can say that the journey so far, has been very positive. I am stronger and more resilient in all aspects of my life as my marathon training has spilled over into my academic and clinical practice making me calm, positive and accepting of things as they come, one step at a time. All in all, not bad and quite joyful at times. Bring on those 26.2 miles!

10 April, 2016 Posted by | life in medicine, medical school, practice of medicine, relaxation, stress reduction | , , | 2 Comments

New Beginnings!

A couple of weeks ago, I attended a STEM (Science, Technology, Engineering and Mathematics) presentation for young women (ages 7-9) from the inner city. I watched wide-eyed young people explore experiments with wonder and discovery. For many of these children, this was the first exposure to science at this level. Each young woman more excited to see the next and the next station. I found myself just enjoying their pure joy and excitement in learning new materials; with much encouragement from the professors (male and female) in attendance. I brought some of my surgical instruments with me combined with photos of them in use in the operating room. The whole experience was joyful and wonderful for me. I found myself back in primary school, excited at the prospect of all of the new knowledge that was in front of me. It made my heart glad once again.

This past week, I was notified by one of my colleagues who works in the Information Technology field, that she has been accepted into Physician Assistant school, the culmination of several years of careful preparation to change into a completely different field. The sheer joy that she expresses with the prospect of entering medicine is visceral. Once again, I saw and felt the same joy as seeing those young woman who dream of something far beyond their everyday worlds. It’s a great feeling. I was taken back to the time when I received that first medical school acceptance, something that I didn’t anticipate was possible yet was in my hand.

Many folks are in the residency application process, the medical school acceptance process, the university acceptance process and other changes from their present state. I would invite you to dream big but enjoy the process, even the uncertainty. From my vantage point after years of practicing medicine I can say that there is nothing better than solving problems for my patients and their families. I can say that to have the privilege of the practice of medicine, in spite of the flaws in our health care systems, is still quite magical.

I can also say that the privilege of teaching those who seek to first prepare themselves to enter this profession is one of the greatest gifts for me. Just recently, a colleague, one of the greatest academics that I will ever know, said that the hours I spend in office are a sign of a “true academic”. These words from him touched my heart like no others. My response is that at this point, as I am teaching physical exam skills, my students need my presence and my guidance at this critical time. In short, I remember wanting as many “skill-checks” from my physical exam professors in medical school as I could find. I always thought I was worrying them but now I know that as true professors of medicine, they welcomed my presence.

As I watch young women daring to dream, my IT colleague about to enter Physician Assistant school and my wonderful students, some struggling but all “testing ” themselves with new horizons, I find myself grateful, no thankful for being here to witness these new beginnings.

6 March, 2016 Posted by | medical school, medical school admissions, medicine, physician assistant school | , , | Leave a comment

The Fastest Way to a Surgeon’s Heart

As I sat in my office yesterday lamenting my lack of love on this upcoming Valentine’s Day, I stared at my Mardi Gras beads left over from Tuesday’s dinner. Tuesday had been a long day that was filled with endless paperwork coupled with cold temperatures and snow. I am training for a spring marathon thus I needed to get some road mileage but couldn’t run outside in the new falling snow (ice underneath) and sub-30F temperatures. As I finished the last signature, closed the last chart and checked to make sure my dictations had been sent, I decided to go to a Mardi Gras party with a few friends. It’s the last fling before the Lenten season begins and for me, an opportunity to enjoy the company of some folks who have little to do with medicine. I jumped at the chance.

As I entered the Mardi Gras location, the sound of New Orleans jazz coupled with the fragrance of jambalaya filled my senses. I was enveloped in beads (no I didn’t have to display a bare chest to get them) and hugs. “It’s going to be a good Lent”, one of my friends remarked. “I can’t believe that Ash Wednesday will be here tomorrow. It’s so soon”, I remarked. Both of us scooped up the jambalaya (mine vegetarian) and settled in to enjoy our treats with a glass of wine. What a nice way to shake off the cold and snow outside.

Yes, Tuesday was a great experience; so needed but Ash Wednesday began and then came Thursday and my mini-despair at not having a special someone in my life to acknowledge on Valentine’s Day. This whole St. Valentine’s Day is “hokey”, I reminded myself as a couple of my married partners ordered roses for their wives. Yes, I was a bit envious of those lucky women who would receive them on “the day”. Even my unmarried partner was planning a nice dinner with his new love interest. Oh, this was too much for my cynical heart to bear. I decided to hit the gym and pump some iron to shake off these feelings.

As I was leaving the surgeon’s lounge, the nurse manager of the operating room touched my shoulder. “Hey doc, here’s a package for you”, she said. “Gee”, I thought, “someone is actually sending me something?” She handed me a small parcel that was sealed with iron-clad tape, addressed to the hospital operating room that was clearly from a surgical supply company. How did she know it was for me?

I tore open the box with my car keys. Inside, there were several small shiny instruments. Ah, new Castroviejo’s (instruments for delicate work). Be still my beating heart. Someone remembered me and my Valentine Day came early.  Yes, I am feeling the love!DSCN0534

 

13 February, 2016 Posted by | medical school, practice of medicine | , , | 1 Comment

Square Pegs in Round Holes

Introduction

At a luncheon, I listened to one of my primary care colleagues explain the realities of the 20-minute office visit. She happens to be very knowledgeable in treating developmentally challenged pediatric patients but her problems apply to any patient with developmental, physical or intellectual challenges. Like most physicians who are employed by health systems, she has productivity quotas and goals that are set by people who are outside the realities of medicine, usually administrators/business managers.

Medicine is not a Business, even a Home Business

The reality of being the primary care physician who treats patients with cognitive, physical or some combination of both types of challenges is that these patients have needs that will affect every aspect of their office visit. Many times, their transport to the health care location will involve public transportation or some other means adapted for them. Sometimes just getting to the transportation source requires hours of planning by the patient/caregiver only to find that their transportation left early or did not show up at all.

Imagine if it takes 20 minutes for you to dress your special needs daughter, it’s going to take 20-minutes to get that same child undressed for vital sign measurement and evaluation in the physician’s office. Keep in mind, that many special needs patients have behavioral and cognitive issues that prevent them from understanding the vital nature of complete and comprehensive health care assessment. For them, they are out of their secure and familiar environment; in a place where there may be excess and unfamiliar stimulation that will affect their behavior for the rest of the day.

The other reality for the intellectually or physically disabled is that they may have very complex health problems that they may not be able to address or their caregivers may not be able to relate to the physician. Couple this with unfamiliarity of the physician in terms of the diverse needs of this population, just because that physician may not have more than one or two challenged patient sin their practice and the business of medicine has created a situation where problems may not be properly addressed. My solution in terms of wound care for these often fragile patients has been to go to their facility/home but my primary care colleagues do not have the luxury of leaving their clinic to do home visits with any regularity.

Why we entered medicine in the first place

Most of us were trained to solve patient problems by identification of those problems and application of extensive medical knowledge. With the emphasis on getting patients in and out of clinic as rapidly as possible, many problems are never addressed or solved. Imagine if you are not cognitively or physically challenged but are the appointment following or concurrent with the patient who has these issues. Not only will your visit be abbreviated or affected, much of the office staff will be spending time and resources on the patient who needs more help. As a result or dealing with possible frustrations on the part of the needy patient, the physician may not be able to focus on your needs or the needs of other patients in the office because they have been frustrated as they are attempting to give the best care possible to their impaired patients.

At this time, we are better in terms of identifying those with physical and intellectual challenges as opposed to addressing their medical needs. We know that great rewards come with treating these populations especially when we are able to prevent or slow any discovered disease processes. Providing the highest level of care is always paramount in the mind of the primary care physician. To this end, my primary care colleague said the the primary care visit should be longer, because it’s often more comprehensive and the specialist visit should be shorter, because it’s more focused. Regardless  of specialist or primary care, the office visit should reflect the needs of the patient and should not be limited by a “one size fits all” approach to office visit length. Rather than decrease the costs of health care by shunting more bodies through the door, the “numbers” approach likely ends of utilizing more health care dollars because of missed opportunities to address the comprehensive needs of patients.

Those Patients

On another occasion, I listened to a colleague speak about not wanting to treat any patient who would not fit in the chairs of her waiting room. This was her way of stating that she would not treat obese patients. “They bring down my productivity,” she said emphatically. I can’t afford to lose money on treating these types of patients so I made sure that they don’t fit in the chairs in the waiting room if they weigh more than 200 lbs. Imagine if you are a patient who is morbidly obese, more than 100 lbs overweight, who enters a physicians office and can’t find a chair that will accommodate you so that you can attend your office visit.

Imagine the embarrassment if you have to ask for a properly sized chair so that you can sit and even fill out the paperwork to prepare for that visit. Imagine how welcome you would feel if you receive less than respectful and comprehensive care.  The morbidly obese, the developmentally challenged and the mentally challenged individuals in society all have medical issues that need to be addressed. By its nature, morbid obesity is a chronic metabolic problem yet my colleague who makes sure the chairs in her waiting room discriminate against morbidly obese individuals, would treat them differently from the Type I diabetic or the patient with chronic obstructive lung disease. Is is ethically sound to discriminate against a population of patients who are simply seeking, and paying for your services by not accommodating them in your office?

Taking Back Medicine

Imaging a situation where patients get the care that they need without exception. In this situation, the physician determines the patient’s needs and has the time to address those needs. Rather than being pushed by time constraints, the physician (and office staff) would have plenty of time and resources to treat patients with special needs. In truth, patients do not come to physician offices to socialize but come because they need care. It is up to the physician to take back the delivery of that care and set the parameters in which that care is rendered. When a patient receives less than optimal care because of the time constraints placed on the physician, the physician bears the brunt of the criticism. “Those money-grubbing doctors didn’t take time to talk to me”.

As physicians, we need to set the standards of patient care, much the same as we set the standards of practice of medicine. One of those standards needs to be ensuring that the limited resources of primary care physicians are addressed. A good primary care physician can be the resource that decreases health care costs if giving the tools to address all problems in a comprehensive manner that reflects the individual needs of the patients. As specialists, we are often given an advantage at the expense of our primary care colleagues and their vital work. This leads to burn-out and frustration on their part but also leads to increases in health care costs because patient needs are not addressed.

These problems are not solved by increasing the number of mid-level practitioners who often lack the medical knowledge/training to lead the comprehensive care team. While mid-levels can assist with comprehensive patient care, they are not the solution to effective or efficient delivery of comprehensive care. It is the primary care physician who should and does leads the best comprehensive care team and who can provide the most cost-effective care if given the tools and resources for their work. The greatest and most needed resource right now is time to deliver care. The public enjoys greater satisfaction and those of us who are in specialties, are able to obtain the best information to perform our services when the primary care physician can expedite a sound referral. In short, we as physicians need to take back the management of health care and deliver the best health care on our terms as the patient needs not according to a general plan that is even frustrating for relatively healthy people let alone those who have multiple chronic problems.

15 January, 2016 Posted by | medicine, practice of medicine | 4 Comments

Holding Out For a Hero

Occasionally, I have an opportunity to do a case with my senior partner,  a surgeon who spent the first 15 years of his career in the United States Army, having graduated from West Point before attending medical school. He retains many of the armed forces characteristics; not the least of which would be his closely cropped grey crew cut/buzz, no facial hair, excellent physical condition and minimal chatter with a clipped mid-western accent. When he walks into any room, we all tend to “stand at attention”.

On this occasion, he asked me to place a vascular access port for chemotherapy, for this patient who had cancer. He had another portion of the case to perform with a resident but thought it would be more efficient for me to place the port while they completed their portion of the case. Of course, this was a chance for me to enjoy the pleasure of doing a case with another physician; always a pleasure for me.

As I entered the operating room, I heard the wonderful sounds of one of my holiday albums (I realized that he had purloined my “Come to the Celebration” CD by the Birmingham Southern College Alumni Choir) thus, the atmosphere in the room was joyous and wonderful. A twinkle in the eyes of all participants in this case (light anesthesia); positive sounds for the patient.

I set about the work of placing the chemo port, finished and then took a seat at the circulator’s table. The lights were then lowered; the laparoscopic portion of the case began. The resident was in the middle of his first year; still becoming comfortable with the mechanics of the operation of the foot controls for the electrocautery. My partner, ever patient and calm, spoke encouraging words as the resident struggled with nerves and the foot pedal a bit.

Here I sat, an opportunity to listen to soft and melodious holiday music along with observing a master teaching surgeon. “How about if you hold the cautery this way, you can have more control,” he spoke softly as he corrected the hand position of the resident. I could see the nervousness of the intern start to dissipate with the touch and words of the professor. The dimmed lights, the soft holiday music and voice of the professor.

“Try to keep the instruments in the center of the field”, he said to the physician assistant who was driving camera for the first time on this case. “Move slowly but follow the case,” he said. I was reminded of my first camera drive when I was a medical student. Certainly, my professor back at that point wasn’t as nice or as instructive. He took the time to correct the PA too.

As the case moved on, the professor and student took turns making the repairs that were needed; hundreds of moves in almost perfect choreography. It became time to close the small incisions from the procedure. “Have you closed these before?”, he asked. The intern said that he had watched but hadn’t actually closed. “Let me show you the technique,”, my partner said. He took the suture from the scrub nurse and explained every hand position, needle angle and move that he made.

“Now you close the other one,” he said to the resident. He softly talked the resident through the simple stitch to close the small incision. He adjusted the hand position and kept encouraging the young surgeon. “I will show you a couple of ways to practice this at home so you won’t forget what you have learned today. You are coming along fine.” he said.

I was lost in absorbing the encouragement, the teaching and the affirmation that the professor imparted to his trainee. I was reminded that surgery is taught from master to apprentice. The better we teach, the better our residents become. It was wonderful to watch this master at work and savor every moment!

I was listening to a couple of the senior residents talk about the confidence factor that every physician has to develop. “Sometimes you have just be a jerk in order to get respect,” one of them observed. As I watched my partner teach his intern, I realized that being a jerk is the last way to earn the respect of others.

Here was a surgeon who had spent time in Army hospitals in Europe and the Middle East. He had attained the rank of Lieutenant Colonel before leaving the Army for the life of a civilian surgeon. He stood arrow straight most of the time with his 6’3-inch slender frame but readily adjusted the height of the operating table to accommodate the 5’7″ height of the resident.

As I watched my partner teach a relatively simple case to an inexperienced intern, I had nothing but infinite admiration for this father, husband and physician. I realized that with his day-to-day performance of his teaching and patient care, he is the “hero” that those of us in an academic practice should seek to become. With my years of experience, I had picked up a couple of new bits of knowledge by just observing  this case. I hadn’t said a word because the conversation from master to apprentice was a great instructive experience for me. “You still here?” he questioned when he finally looked up from the case.

There was never a time, even when the intern didn’t know the answer to a question, that this professor uttered a negative word. Perhaps it was the affirming holiday music, perhaps it was my presence in the operating room but I suspect that it was the result of just being an “everyday” hero.

 

9 January, 2016 Posted by | general surgery residency, intern, medical school | | Leave a comment

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