I have wanted to push this post out for many months. This is very difficult to write about because I am still so close to the raw emotions and feelings. I want my readers to understand how much many of us who take on the task of teaching others medicine care about our teaching and our students/trainees. This was very close to me and stays with me because the young person that I write about left behind two young sons and a young spouse who is somewhat adrift even today when I spoke with them.
I met this young resident physician when they entered the program where I teach. That first day when everyone met and introduced themselves as we all sat around a large oval table. The PGY-1s and the faculty members who would get to teach them and get to know them. The resident was full of hope and anticipation being so happy and grateful for a match into our program. Everyone was so hopeful even knowing that residency pushes one to limits physically and intellectually in the case of surgery. Many believe that the major test of medical school is the measure of a physician but residency is where practice begins and starts the foundation of what will be a life of practice and learning. While medical schools gets one ready for residency, the experience of managing patients and performing surgical cases first as surgeon junior and then as resident is the making of a surgeon.
This resident started out on a ward-intensive rotation under a chief resident who was a patient teacher and generally supportive of the junior residents and medical students who were on the service. All reports were good and the resident was progressing well-not superior but more than adequate. All PGY-1 residents need to sleep more, read more and get out of the hospital as much as they can. The faculty in our program work with the chiefs to make sure that the workload is challenging but not oppressive. I love to do patient care along with my residents because I love taking care of patients. On many weekend mornings, I round, write my own notes and inform the chief of what I have been doing so that the junior residents and medical students are not so burdened.
By the end of the first half of the first year, all of the new interns (PGY-1 residents) seemed to be getting into a groove. The major services: general surgery, colo-rectal surgery, minimally invasive surgery and surgical oncology, were humming along well. The specials: vascular, pediatric, thoracic, critical care, cardiac and plastics were well-covered with interesting cases and patients. It seemed like the year was going to roll along in that predictable manner so that we could all gather at the end and make fun of ourselves while sending the graduating chiefs off in appropriate fashion. Mid-way through this year, one of the new interns started to unravel a bit. I was asked to do a bit of counseling and unloading. I am happy to play this part for the program.
It is a general fact that most interns will not ask for help when they are getting overwhelmed, especially in a surgical program. There is the code of the surgeon being tough and resilient, thriving under pressure and invincible. Some of my fellow attending physicians still subscribe to this code of conduct but I am having little of this. I love showing my vulnerable side, and often do, because it enables me to show my strong side at the same time. Yes, I am a human being that is the same as my patients and those I train. I learned from a very wise surgeon colleague that I have to allow those who encounter tragedy and stress to decompress immediately and to keep decompressing. As a leader, I owe this to those who work with me in this profession.
The intern seemed to have a difficult time dealing with the night float where one has to shift rapidly to cover the incoming patients. On my call nights with this intern, I would generally cap their load so that some rest and learning could take place. I calculated the average for the past week and capped when that number was met. Anything over the cap, I admitted, worked up and handled with the chief resident. This generally didn’t amount to many patients but it created a sense of teamwork and accountability for all of us. I loved presenting new patients in morning rounds and having the chief question me (same as the interns) about management. This is a great experience for all of us and continues today.
Along with difficulties on the night float service, personal problems at home began to creep into the picture. The spouse was having an affair and the children were feeling the effects of the strained marriage. Being single, I am surely not equipped to counsel anyone on marital stresses but I did strongly encourage this resident to seek some outside counseling. I assured this young physician that I would be as supportive as possible in making sure that my colleagues understood the grave nature of the home front problems without betraying any confidences. I know of great love and feeling for another person and the loss of that person can be raw. I also know that every person deals with loss in different ways and that with the stresses of a surgical residency, seeking some marital counseling is probably a sound idea.
Three week later, this intern was still trying to balance work and family struggles. Things were unraveling and I suggested taking a leave of absence for the remainder of the year. When things can’t be worked out and work can’t be done, a leave of absence is often the best solution. This was arranged by the program director with an offer for this resident to attend teaching conferences and educational classes as much as possible. We offered a research position that had been left by another candidate so that this resident could have some income. We all offered support and fellowship but substance abuse came into the picture.
I don’t know how substance use began but I noticed the smell of alcohol during one of our educational conferences. I immediately asked the resident to leave because the smell of alcohol can’t be on any physician who is in a clinical area without exception. I was deeply disappointed but asked to chat the next day when possible. The resident never contacted me. Later an admission for overdose of opioids (deemed accidental) along with alcohol. I rushed to the emergency department to find the resident semiconscious and unable to communicate. Clearly, as I spoke with them later, I emphasized the need to spend some extended time in counseling but I could sense a drift away. The shame of losing a training license and a residency position was more stress and deeper into a despair that I was not equipped to handle. I begged this fellow human being to reach out for the sake of the family and children.
Medicine and medical school into residency and practice attracts a person who becomes comfortable with work toward long-term goals. One has to have a high degree of comfort with the long term process because the journey is long. Along the journey goes the family and friends but the resident is the common factor. I know that my colleagues who have families are happiest when they spend as much time as possible with those families. One of my colleagues always says that he can’t understand where my recharging takes place (my spirituality, my adventures and my sheer wonder of all things as I go through this life). This experience rattled my entire experience with medicine and still does.
When this resident committed suicide, I plunged into a depression that only my faith could keep me going. I prayed myself to put one foot in front of the other one so that I could get out of the door of my house in the morning. I know intellectually that I couldn’t force another adult human being into making better choices but I still can’t fathom leaving behind precious children. It is my firm belief that children can weather the disintegration of a marriage if the spouses involved are dedicated to raising them. I also believe that children only want your time and unconditional love (my experience with my nephews). In honor to this resident who felt so much pain and was unable to get the help needed, I listen intently to my trainees. In honor of this resident, I search intently for any shred of hopelessness in my colleagues, residents and students. In honor of this resident who was kind to their patients and to others, I strive to be kind to others. In honor of this resident, I try to learn the lessons of life and to be thankful for life.
Many who read this blog will begin their studies of medicine in a few short weeks while others will move into new roles perhaps with more responsibility and duties. I wanted to take a few lines to write about moving into your new roles be they medical student, intern (PGY-1), resident or attending physician.
A mentor from my first days of medical school, actually during orientation, said in his soft southern accent, “Now go out and grab a copy of The New England Journal of Medicine and read it from cover to cover.” “You won’t understand it at first but keep reading it and studying the words of medicine.” Little did he know that he had just added more fodder to my constant journal reading and now had stoked a fire so huge that I could have been consumed in the flames, so to speak. As I look back now, years from those words and others that have shaped my current practice. Listen to those little bits and pieces of wisdom from people who will enter your medical education early on.
For those of you who will begin the study of medicine, your preparation is to open your mind, your ears and to consider the privilege of what you are to undertake. Yes, you will be “sipping from that fire hose of facts and materials” to be mastered but you have been given the gift of being able to study those facts and materials. You may want to allow yourself from time to time to marvel in what you will learn from the application of science to the practice of medicine. In short, take a moment to breath and enjoy the process.
For those who move “up in rank”, take a moment to look back on the things that you have studied. Every time one encounters a familiar concept, there will be new insight. For example, my intern year was spent learning the craft of patient care preoperative, intraoperatively and postoperative. As the weeks went by, I became expert, perhaps efficient in being able handling patient admissions to the hospital post-surgery, from the emergency department or from the clinic. Additionally, I learned to anticipate and manage the needs of those inpatients from their first moments under my care to their discharge from my care. My insight at this point was how my studies of symptoms and signs coupled with science now allowed me to care for my patients and see how amazing the human body and human spirit can be.
On my first rotation, as my learning curve was steepest, I felt as overwhelmed as I felt in my first week of medical school when biochemistry, anatomy and microbiology came flooding at me in torrents. At this point, it seemed that the work of history and physical exam with admission orders, checking tests/studies, checking wounds and discharge summaries would consume me but one week in, I was thriving and looking for every chance to get into the operating room in addition to my ward duties. I could take that moment to appreciate interaction with patients, nursing staff and get to scrub surgical cases. I was “basking in the glow of bright lights while playing with cold steel, “as one of my professors would say.
When I look back, one of my gifts on those first rotations was being assigned as the intern to the chief resident that everyone had whispered being the most difficult in our ranks. I came to appreciate my chief, the only person that I know who is as compulsive and anal as myself when it comes to the practice of surgery, is that I actually found that I could “get down there and nail things” faster than he could after three weeks. He made me stronger, faster, more efficient and more comprehensive. This allowed more time for me to obtain operating time which is why I became a surgeon in the first place. What other surgery interns avoided, I happily sought out. I was also the recipient of more valuable study advice from my chief, “Force yourself to read at least 30 minutes every day, more if you can, and at least 2 hours on the weekends.” There again is that gift of study. I stuffed my pockets with articles, pages from my textbooks and the surgical atlas. Even if I was exhausted, I had something to read or study in the back pocket of my scrub pants.
Back to my professor of surgical critical care: “Surgeons are not made, they are forged” was one of his favorite quotes to me. I thrived in the forge of residency because I didn’t look at study and learning while performing medical/surgical care as being in some sort of purgatory or prison. I was getting the opportunity to build a solid foundation of knowledge and skill that I would use for the rest of my life. I learned through being forged that I could solve problems and touch a multitude of fellow human beings in ways that others would never appreciate.
My professor would later say at my graduation that I never complained or said that I was tired when he knew that I was the oldest resident in the ranks. (I had attended medical school after graduate school). He said that he found that somewhat remarkable because as he had aged, he felt entitled to complain more and accept less mediocrity. He said that I was a person who accepted everyone as I found them without agenda. (Still one of the most interesting comments that I have heard about myself).
Under the scrutiny of my mentor in residency who like my first chief, was known for having a very challenging personality, read malignant here, I learned the clarity and performance of surgical skill. My mentor (faculty adviser), taught me to waste no movement in honing surgical skills. He loved that I studied as I learned and assimilated what I was taught in craft and theory. Again, back to those study skills.
Little did he know, I cut the spines from my surgical texts, punched holes in the pages so the they would fit in a ring and were more portable than the entire text (Sabiston’s Textbook of Surgery). My best memories of my faculty adviser are of him folded in a lounge chair in the surgical lounge with his Danskos next to his feet grilling me on how to handle this complication and what would happen next as this was more valuable than gold for me.
Even today, the residents, medical students and physician assistant students appreciate my high expectations of them in terms of work and study. I do not subscribe to the practice of berating as a means of teaching but go back to my very tough first chief resident and my faculty mentor in residency who generously gave of themselves to guide me towards performance at the highest level. I don’t have the difficult personality traits that were characteristic of many of my fellow surgeons but I have high expectations of those who have been assigned to me for instruction.
The gift of the study, and later practice, of medicine (if you are fortunate) is still one of the most divinely mystical and satisfying acts of a lifetime. Even if you are beginning your studies and are not enjoying much patient interaction, try to cultivate a love and appreciation for the gift of study. Those studies will allow mental efficiency which can lead to some of the most intimate and spiritual gifts from one human to another. Appreciate those gifts without complaint because many others will never have the privilege of enjoying them as you have them now.
I want to share this post by a gifted physician, husband and father who writes about his father. This post which can be found here: A Father’s Story is an honor to a father from a son who is a father. For me, this wonderful post reminded me of my father who was a physician and my first and best mentor. Please enjoy this post and honor your father on this upcoming Father’s Day.
I was called for consult on a patient in the “memory care” section of the long-term care facility affiliated with our health system. My partners hate to consult on patients in this facility and tend to “leave” these consults for me to work up because they just don’t care to do them, read, they say that I work with them best. For me, leaving the “mother ship” is a welcome time at the beginning of my day to drive over and see the patient in their surroundings as the first part of my work-up. You might ask why the patient isn’t transported to my clinic to save time for me but if the problem isn’t particularly emergent, I go to visit the patient and I am happy to do so.
She sat there in a wheelchair in the dayroom surrounded by other residents who were in various stages of behavior from a chair-bound woman who had removed most of her clothing while shouting to anyone who walked near her to a gentleman who sat in a chair by the window looking out at the bright sunshine reflected off the rich green leaves of the plants outside. I would have loved 5 minutes in that window for my sanity. She was surrounded by about 25 people some ambulatory and some sitting to watch the large television in the corner. As I called her by name, she looked first at my bright red suit and then at my small white chihuahua that I often take with me to this facility. This little white fluffy dog with alert tan ears and a bright red collar often provides comfort and serenity to patients while I perform an exam.
She sat there looking at my little dog who climbed into her lap and began the obligatory dog greeting. “Do I see a smile?” I said in a cheery voice. “I came to see you because you might need to have minor surgery on your arm”. “I thought we might get to know each other here rather than you coming to my minor surgery clinic with all of the hustle and bustle”, I said. She looked at my dog who by now had curled up in her lap. She didn’t say a word but didn’t appear to be frightened or even nervous by the dog.
The nursing assistant came over to let me know that my patient doesn’t talk and that she doesn’t understand what I am saying to her. “You should talk to her son and the nurse if you want to know anything” she said. “I said that I am doing fine and that I will speak with everyone but thanked her for letting me know. My patient sat looking at my red skirt as I sat in a chair across from her; still holding the chihuahua. (Being little and cute has some advantages that I will never know). “I just want to meet you and speak with you because I try to get to know my patients before surgery, if that is OK”.
My patient moved her hand to stroke the dog who was now dozing with her chin on my patient’s other forearm (the area that had the lesion). I looked at the arm that she kept so still as not to disturb the sleeping dog. She gently stroked the dog with her other arm as I examined the area of concern quietly leaning in as close as possible. She reached out to touch the material of my bright red suit and my arm. Still, she looked at the dog and not at me but put her finger to her lips in a manner to tell me to be quiet because the dog was sleeping.
“Now, I lay me down to sleep, I pray to the Lord, my soul to keep”, she said in a very soft voice. “I repeated softly with her. “If I should die before I wake, I pray to the Lord, my soul to take”. She still stroked the sleeping dog and a tear ran down her cheek. I completed my exam and moved my chair next to her as we both stroked the chihuahua. I can slow down my day, enjoy the bright sunshine and green leaves while my patient enjoys the company of a small dog.
I sat there for about 20 minutes thinking of who this very quiet but very kind woman might be and how best to treat her and keep the stress of the potential procedure to a minimum. When I see patients in the office/clinic who have come for workup for minor surgery, I generally complete the exam and information setting in 20 minutes but when I do a house call in the long term care facility, I like to take as much time as I need to get as much information about my patient as I feel is necessary. If this one patient takes my full morning, then that’s how much time she and I need.
My practice partners prefer to have a root canal done rather than visit the long term care facility. One of them remarked that if he slowed down for these type of patients, he would probably stop practicing. Another said that visiting the nursing home was just uncomfortable for him and that he didn’t want to be reminded of getting old as if entering this type of facility would speed up his aging process. Another partner said that he didn’t want to think about losing his mind and that these types of patients do this to him. “You are a woman and you do better with that stuff”, he said as I picked up the consult package on my desk.
I find their reactions interesting and somewhat distressing at the same time. Yes, they are admitting that they have a bias for treating older patients and I applaud them for recognizing that they are biased. Recognition of bias is a great way to overcome a bias if that is your goal. I am distressed because they attribute my being female to my having some extra ability to see the dignity and spirit in all of my patients (No, I am not a saint, I just feel privileged to be able to do surgery and see the wonder in all humans). Things like vomit and eye surgery are problematic for me but not my patients regardless of age, location or ability to communicate with me.
When I went back for follow-up post-surgery, I took my flute and played one of my favorite Bach Inventions (I seem to be able to remember those). My patient gravitates toward my dog, my music, my prayers and my brightly colored dresses that I often wear (when I can get out of green scrubs and a white coat, I do so). She longs for colors, sounds and the touch and interaction with others. As her wound heals, she has said few words but radiates the spirit and dignity of being a human being.
My partners may be right in that I am better at that “stuff” because that “stuff” is the “stuff” of my humanness. I have to bring that humanness to my practice even though a majority of my practice is procedures and acute. For me, being able to slow down and take the time to interact with patients who have lost some of their ability to communicate in a conventional manner is something that I enjoy and treasure. This is a gift from medicine to me and I treasure it.
As medical offices, clinics and hospitals move to electronic/digital medical records, skilled use of these devices is critical to modern medical practice. While nursing and other ancillary staff can get away with asking questions (usually from a form) and typing answers as a patient answers those questions, a physician can’t afford to perform in that manner. This means that there are some vital skills that must be mastered as quickly as possible.
Yes, information is generally entered into digital record systems via keyboarding. As a physician, one needs to be skilled at keyboarding to become efficient in completing medical records as quickly as possible. If you did not have a mother who insisted that I “learn to type” so that I could make some college cash typing papers for my classmates, then you will need to learn to type accurately and efficiently. There are many convenient typing instruction programs on the market. Choose one (or borrow one) and learn to type. This skill takes practice, well, learning to obtain a medical history took practice too, and takes constant work in terms of learning the proper finger positions for the keys so that one can type without staring at the keyboard.
Almost daily, I hear from my patients that the medical student, physician assistant student or resident is “so busy staring at the computer that they don’t look me in the eye”. This practice is interpreted by the patient as non-communication. “He was so busy tying to fill out the form that he didn’t are about me”. When patients are making these types of observations, this generally means that the visit is not going to yield the best information for getting the best outcome for the patient. Patients expect their physicians to communicate verbally and non-verbally with them. If one is busy “staring at the computer” one has cut off one of the most valuable means of non-verbal communication which is eye-contact. While you may be very adept at typing and listening (I was a master of this in medical school), your patient starts to feel neglected because they feel that they don’t have your total attention. In short, eye-contact is a valuable means of communication for both you and the patient.
The patient history
The patient history is perhaps the most important aspect of the physician-patient encounter because generally if one is listening very carefully, one can get an idea of why the patient sought your care very quickly. Obtaining a good medical history does not mean that one simply fills out those check boxes on a form in the medical records system but does mean that one obtains the key information that will help identify the problem that brought the patient to your care during the history. This is why one has to become adept in allowing the patient to tell their story (in their own words) and why one has to be constantly listening and processing the information, not attempting to fill in check spaces.
One has to constantly review and upgrade their history-taking skills as long as they are in patient care. Find a good history taking flow and stick with it long enough to make sure that you are efficient. Once you become efficient with the flow of the history, fine-tune that flow so that you can add or subtract items as the patient care situation directs. As you learned from your physical diagnosis course in medical school, the patient directs the history which directs the physical exam which directs the assessment which directs the plan. If you neglect any aspects of obtaining the most accurate and complete patient history, it will follow that your examination, assessment and plan will be neglected too.
When a patient enters my care, especially for the first time, I ask them to spell their name (sometimes those sheets are wrong) and I ask them for their date of birth (you don’t want to end up with notes on the wrong patient). After that, I put my pen, notebook, computer or tablet down and sit across from the patient and listen. I have my check list (form) in my mind so I don’t have to keep referring to a form or computer. This skill during initial history-taking, frees me to concentrate on communicating with the patient fully. I learned to keep the initial patient history in my memory long enough to either dictate it into my medical record or enter it after the patient has left my care.
I also learned to perform a review of systems while I am examining the patient. As I examine the patient’s head, I ask questions about any symptoms related to the head and move to the eyes, ears and so forth. If my exam is to be focused, then I just go through the systems are are related to the initial chief complaint and make sure that I ask about things that are move peripheral towards the end of the encounter. Again, I made sure that I became adept at either dictation or writing in performing these tasks so that my patient feels that they have my complete and undivided attention.
Novice physicians always feel that they are going to miss asking about some important fact which will result in a poor outcome for the patient. If one sits and thinks about good communication skills and obtaining the most relevant information, then one is less likely to miss something important. Another way to think of this is to think of yourself as a news media reporter who is on a city hall beat. When you first begin on your beat, you don’t know all the players well but you start to make observations and note what and who is key to your getting the best information. This same skill applies to getting the best information from your patients. You have such a short window of time in which to gather information thus you must use the best observations and make mental notes of what is most important. The more one practices this skill, the more one becomes accustomed to their “beat” so to speak, and the better the information obtained.
If your patient feels as if you are so rushed or that you are not interested in working with them i.e., you are more focused on getting your note in the computer, they they have a propensity to stop trying to communicate well with you. In short, if you have a patient who feels more uncomfortable with you in addition to the discomfort that brought them into your care in the first place, you have a situation that can’t turn out well for either you are the patient. In these days of patient satisfaction surveys, one cannot afford to concede even the smallest item because of trying to keep up with a medical records system.
The medical records system
While these digital masterpieces are wonderful for making sure that everyone involved with a patient has up to date information and billing, they vary in ease of use and interface. The data obtained from these records is only as good as the data that is entered into these records. When one enters a health care system, becoming fully familiar with the electronic data system is a significant part of one’s orientation to the place. Most large health care systems will use one system which was chosen by a few of their members but every employee has to work with and in that system. It is vitally important that you as the trainee or new employee receive a solid orientation on the system that you use so that your patient’s records remain secure and accurate.
If you are or become the person who is in charge of selecting a new electronic medical records system, you need to be fully familiar with the system that you are evaluating, the ease of entering information and making sure that everyone who uses the system is able to navigate the interfaces that apply to their specific jobs. Don’t rely completely on the sales person for a particular electronic medical records system because that person’s loyalty is with their company first (they want you to buy their product) and any potential commission that they might make in selling their product to you. This means that if you are in the position to evaluate potential digital software and hardware, make sure that you obtain solid advice and consultation with your company’s technical staff and that you know something about information systems yourself. In short, in today’s world of medicine, physicians have to make both clinical and administrative choices that can profoundly affect patient care. You need to make those choices from a position of having the best information possible not just being pushed by price (most expensive or cheapest systems may not be any better or worse).
Patient perception or put yourself in the patient’s place
As the physician that directly interacts with the patient, one has to make sure that every interaction is the best possible. If you want to get an idea of how you communicate with your patients, sit in front of a mirror, in your white coat and practice a patient encounter. Look at how you make eye-contact, how you hold your sitting position (one should never tower over a patient and ideally be on the same level as the patient). Make sure to time yourself and see what happens when you speed up or slow down your speech. Tape a mock patient encounter and critique yourself. You can do this with a digital camera and a colleague but look at whether or not your are actually communicating with your patients. In your practice encounter look at how your communication style changes when you are typing on a computer/tablet, writing or just looking at the patient and listening.
Read those patient surveys on a regular basis to see if you are developing any habits that may be detrimental to making your patients feel happy that they are in your care. I promise you, as a specialist, that my time is short on a regular basis but none of my patients would ever know that fact. This means that I do the following:
- I never type while speaking with the patient
- I never allow my cell phone or pager to be on anything except vibration/silence when I am with a patient
- I do not allow my staff to interrupt me when I am with a patient unless there is a life or death emergency in the next room
Finally, I have learned to keep patient historical information in my head until I can get that information into my record system. As a surgeon, because I have to produce operative and procedure dictations, I am more adept at dictating than writing out procedures but I learn to produce both digital and written records efficiently. I generally do not take work home from the office because I always worry about patient information security as my home. I also make sure that the people that I am training learn to impart compassion, empathy and interest to their patients and not impart that they are more interested in entering information into a computer.
We have made it through another academic year. We will welcome the Class of 2015 into the fold of graduates (from undergraduate programs, medical school and other graduate programs). I always try to reflect on what has been surprising for me during this past academic year and what goals I will set for myself (as a professor and as a physician) for the upcoming year. I am reminded of my own graduation from medical school with my hopes and fears of the unknown aspects of starting the next chapter in my career/life. Now, many years out, I am very happy that I see that I have challenges ahead, goals ahead and things to reflect upon.
As this year comes to a close, I am surprised that the gaps in delivery of health care to under-served populations is getting worse and not better. I have seen people come into my office with conditions that have been left for years that could have been taken care of in early stages but now are life-threatening. I read many medical journals each week to keep up with new advances yet seeing a patient with end stage renal failure because of untreated/improperly treated hypertension and diabetes is rampant. My colleagues who are on the front lines of treating under-served populations are frustrated with systems that still marginalize their patients, are frustrated with fighting for and not being able to see their patients get even basic medical care.
I am surprised that there is a disconnect between those who are responsible for running health care systems are so dedicated to making a profit that they are comfortable with denying services to people who desperately need them. This disconnect is getting greater. I don’t understand how those CEOs can look only at the “bottom-line” and not see the implications of their decisions. Running a health care system is not like running an oil company or a bank. If patients don’t have access to basic health care, they don’t have life.
I am surprised that many of my colleagues can look at patients and blame them for getting ill. Being sick is not a moral failing but a fact of life in terms of being alive. Yes, one does need to look at lifestyle changes that will enhance health but it’s not a personal or moral failing if patients are not able to make those changes. In this time of economic troubles, many patients simply do not have the financial resources, community resources to make the lifestyle changes that will enhance their health. We also have companies that again, look for providing the cheapest foods (usually fatty and sugary) while making healthier food choices far more expensive. Many of my patients eat from the fast food “dollar menu” not because they want to but because they have to. They are simply making choices that allow them to live indoors and are one pay check away from being homeless.
I am surprised that in this world of so many electronic/web informational resources, my students are less informed rather than being more informed. I say this with a bit of ambivalence because I don’t believe that my students’ lack of information is because that resources are not there but that my students are overloaded and their way of dealing with that overload is to turn-off rather than be selective and critical in their consumption of informational resources.
As a professor, I am charged with providing the critical thinking skills for my students to navigate the world of medical information. We, as physicians, have unprecedented access to the best evidence-based/science-based health care resources in the world. As a scientist/scholar, I am charged with questioning everything that I read regardless of how my information is delivered. Critical thinking and evaluation of the vast amounts of data about populations and individuals is a challenge that I must meet and teach to the next generation of physicians and health care providers. I must and I am constantly striving to evaluate and deliver the best evidence-based medicine based on data and research. I have to be confident that I am making sound decisions and I have to teach how to make sound decisions.
I am challenged to provide preventive strategies to my patients, where they live, that they can incorporate into their lives for the best outcomes. If I overwhelm my patients, they disconnect with preventive strategies and with health care in general. This means that I have to be able to explain what and why I am recommending a treatment strategy and I have to be able to recommend other treatment strategies and why I am not recommending those strategies no matter what they have seen on the telly or read online. I have to keep “one ear to the rail” in terms of what is circulating online and I have to keep the “other ear” to what is sound medical practice.
All of our challenges
Practicing medicine is more difficult today largely because of documentation issues. We are clicking away into our computers with poorly designed electronic medical records systems and filling out duplicate “paper work” late into the evenings after a long day in the clinic where we have been charged with seeing an impossible number of patients (again because our employers want us to turn a profit for them). Our challenge is to provide good delivery of health care but we have little support and assistance to do just that. At the end of the day, even if one has completed all of the documentation, there are few feelings of a “job well-done” and more feelings of “I failed on some many levels today.” Our biggest challenge is to remember that we are not the problem but we can be part of the solution by demanding that our talents and energies be focused on our patients and not on “paperwork”.
Our challenge is to look at anything and everything that we can change from within. We cannot allow a flawed system to push us further away from treating our patients because we can’t even “look them in the eye” because we are typing into a computer. We can’t keep skipping lunch, dinner and priceless interaction with our families and loved ones (our sanity) because we are so tied to trying to keep up. We can’t keep looking at the color, size and sex of a patient and dismissing them as individuals with unique needs. We can’t keep “writing off” whole populations of people because they are difficult to treat and because their culture is so different from ours. We can’t afford to say, “It’s someone else’s job and I will just refer them because they are too complex”.
We have to be challenged to take care of ourselves in terms of spiritual, physical and emotional health. No, self-care can’t be our only focus but we need to look inside of ourselves and figure out what is most important for our health and do things to keep ourselves both physically healthy and emotionally healthy. We can’t allow a very flawed health care system to result in our individual spiritual and physical to deteriorate to the point that we become a liability to ourselves and our patients. We have to learn to be selfish with our time and we have to have some outlets that will nourish us spiritually and emotionally. In short, we are crucial to our patients and we have to keep ourselves healthy and happy. Anything less is not going to work.
We have to learn to question everything. Do not just “take the word” of professors, websites, books, journals and other information resources as the only truth out there. Medicine is based on science and not on faith. You can have faith in your spiritual life (valuable) but you have to have the ability to cast a questioning eye on information in medicine. Look at alternatives and look at alternative solutions. Evaluate everything with a questioning eye. It is fine to question someone who is advocating a treatment and it is incumbent upon the advocate to explain their ideas. If you have questions, get them answered and constantly question others and yourself.
Finally, think about your experiences and learn from them. None of us was born knowing everything and our experiences are always learning opportunities. To evaluate yourself and your learning experiences is a very healthy way to learn to discard that are not working and to embrace the things that are working well for us. Always looking for a way to do our daily tasks, job and learning in new ways is a great growth exercise. Again, my professors and my colleagues who constantly questioned me make me stronger rather than tearing me down. We all lamented about those “pimp sessions” but in the long run, they are opportunities for growth and reflection. As long as one is alive, there is opportunity for growth and learning; seize those opportunities.
This is an excellent blog for life affirmation. Glad to have found (and linked) to this one. Enjoy! I am constantly looking for good blogs (and posts) that help with keeping the modern medical professional on course. This is great reading during this time of finals for many students. Please enjoy and keep coming back to this great blog.
Originally posted on James Michael Sama:
We can spend as much time as we want talking about how men and women ‘should’ act in their relationships or while dating, but one thing will always remain true: The most important relationship you will ever have is with yourself. If that one isn’t healthy, none of your others will be.
For that reason, we need to get our own lives in order first and then be able to share ourselves with someone as a whole, complete person. Happiness is a choice, it comes from within, but sometimes we need to put in work and effort in order to uncover it. What are some of the best methods for doing so?
1. Set consistent, realistic goals for yourself.
Having defined goals is the lifeblood of progress. It gives you something to look forward to as well as to work towards. Goals are the checkpoints along the road of life…
View original 1,010 more words
This is a very nice post on studying tips for Physician Assistant School. These tips work for any professional school thus I am reblogging them.
Originally posted on Pance Prep Pearls:
By LaurMG. (Cropped from “File:Frustrated man at a desk.jpg”.) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)%5D, via Wikimedia Commons
STUDY TIPS FOR PA SCHOOL (PHYSICIAN ASSISTANT PROGRAM)
As a professor for both clinical and didactic year at 2 PA schools for 12 years, I have seen a lot of students come and go. PA school is one of the hardest things I have done in my life, but if I had a better roadmap when I was a student, the task would not have been as daunting. I started undergrad with 4.0 average and upon starting PA school, I quickly learned that what I did to get the 4.0 had to be DRASTICALLY remodeled for PA school or I would have kept drowning. Here are some tips to help new PA students stay afloat and survive the medical monsoon that is PA school. Before jumping into tips, one must have a complete understanding of the…
View original 3,393 more words
And there we were, sitting in orientation in medical school, contemplating our futures as physicians. Sure, there were the warnings, “Look to your left and look to your right…” but we were anxious to get on with the business of becoming physicians. We would change the world one patient at a time and we would have instant intimate relationships with our fellow human beings so that we can solve their health problems and get them on to healthy life styles. As we moved from orientation to our first courses in medical school: Cells and Tissues, Professionalism along with a healthy dose of “you can’t learn it all”, we were introduced to the science of learning how to study the diseases and structures that would make up our careers in the future. Nothing in those preclinical science courses prepared us for some of the intimate probings that we would have to learn to perform on our diverse patient population. For many of us, we lost the art of doing a complete and thorough physical exam largely because we say that we don’t have the time or we don’t want to embarrass the patient because we just met them.
My early experiences
Let’s look at how I learned to perform the rectal exam. My first experience with the rectum was in my studies of gross anatomy, microbiology, histology and pathology. If I even do a mind stretch, I can say that my first experiences were back when I was a child, recently toilet-trained, thanks to my older brother (age 8) who was a master at using the “porcelain convenience”- even at that age, he sat in there for hours reading comics and contemplating his life. I, on the other hand, was fascinated with how things would disappear in the swirl of blue water, never to be present in my life again. Some things, fecal matter, vomitus and urine, were great to get out of my life but my hair brush and toothbrush, things my brother and sister would lovingly flush when they were angry with me, were things that I wanted to keep around but would have to be replaced once they were flushed.
My earliest experiences with urine and feces, by smell, let me know that these were things that were not wanted as keepsakes. My parents were adamant, “Don’t let that dog poop in the house!” “This place smells like an out house, why didn’t you let the dog out when she was at the door?” What was in “dog poop” that was so awful and even more interesting, what was in my fecal material that encouraged me to flush as soon as I detected odor so that I wouldn’t be teased by my siblings? Being a budding scientist, I obtained a sample of my feces (very small sample) and my dog’s feces so that I could examine them closely. I even had a microscope where I examined these items very carefully and made notes. Yes, I grew up in a household with three physicians (my uncle, my aunt and my father) who encouraged me to explore all parts of my environment and log what I saw. I could ask questions or even better, go to the library (we had one in our house) and look up the answers. So, I asked what was in feces and looked for the answer. The encyclopedia and a couple of medical books stated bacteria (accounted for the smell), sloughed intestinal cells and indigestible materials from food that was eaten earlier.
As I moved through my undergraduate coursework (chemistry and math major), I learned about chemical compositions of biologic materials and bacterial physiology. These courses came in handy for my graduate study in biochemistry and molecular biology. There was nothing about the human body that I couldn’t break down into elements and macromolecules; the bacteria, the indigestible materials, the bilirubin and sloughed enterocytes. In short, the process of digestion and peristalsis (loads of study of neurotransmitters), vomiting, formation of urine and feces could be studied scientifically and eventually broken down into biochemistry. Yes, I have found the keys to all things in life and they are chemical elements with chemical characteristics. All things in life could be studied, characterized and explained by their chemical characteristics and properties. This was heady material for a budding biochemistry and molecular biology researcher. I would go on to design my experiments with these elements in mind and a healthy dose of skepticism that all scientists must cultivate. In short, there is likely alternative explanations for what I am observing and I should make sure that I look for them.
As I moved into my first year of medical school, we were required to rotate in a clinical area. I chose Emergency Medicine and the Emergency Department because I was pretty sure that I would not be entering Emergency Medicine but I wanted the experience of working in this area without doing a 4th-year elective. My clinical preceptor wanted us to get the most didactic learning out of our experience but knew that we had only been in medical school for one week (orientation week). He knew that we didn’t have much basic science background, outside of what we had brought into medical school with us. Trust me on this, for the vast majority of us, the pre-med courses in science are a good basis but not enough to understand complex pathology. He opted to teach us how to elicit a solid history from a patient which is an exercise that anyone can learn without much clinical background. “You want to know why they are here and what convinced them at this point in time, they should head to the Emergency Room”, he told us in the beginning. “Besides, anyone can ask questions and those who don’t have preconceived notions are the best questioners so I want you to dive in and try to figure out what is going on with your patient”.
He taught us the proper form to write up a patient history and most importantly, he taught he to relay clinical historical information to an attending physician in a form that is useful. This was a fabulous experience for me because our medical school was located in an inner city with a very diverse patient population. We had a diversity of ages, sexes and ethnicities with a dose of religious diversity thrown in. Everyone, regardless of age, socioeconomic status, ethnicity, sex or religion gets sick and all human beings want their clinical problems solved, especially those that are in the emergency room. As novice history takers, we started out with the patients that had been triaged to the “non-critical” areas which gave them something to do and provided valuable experience for us.
What I learned right away
Patients interact with their gastrointestinal tract on a daily basis and under many different occasions during that daily interaction. When we are frightened, we may have an urge to run but also an urge to defecate. We feel disappointment “in the pit of our stomachs”. We may eat something new that causes the experience of nausea or we may experience nausea and vomiting by eating something that is contaminated or cooked improperly. We can have an allergic reaction to a food or we may have an adverse reaction to a medication that is gastrointestinal from difficulty swallowing a tablet to stomach upset to diarrhea along with rash and swelling. In short, the GI tract can give important information as to the systemic condition of a patient or can give clues that the GI system itself is the source of pathology.
It is up to the physician to ask the patient about gastrointestinal symptoms if they don’t volunteer this information. A patient may tell you that they have a stomach “ache” which may mean that they have nausea, intestinal cramping or heartburn (may be reported as chest pain too). Patients need to be asked about fever, chills, vomiting, diarrhea in addition to difficulty swallowing, eructation, changes in the color of their urine/feces (darker colored to lighter colored) with or without mucus or blood streaking. Are they experiencing bloating, vomiting blood or blood streaks on the bathroom tissue. Is there rectal itching present or increased passage of intestinal gas or a feeling that they are not emptying their bowels completely? Do they have pain with defecation or does defecation relieve their pain? Have they noted a change in the size or odor of their stool? Have they developed problems with certain or all foods that were usually a part of their diet? All of these symptoms especially those that deal with defecation may not be volunteered by the patient.
Some patients, especially young and older men are not going to want to discuss their bowel habits with a female physician. Perhaps their religion will not allow them to speak with a female or they feel embarrassed and will reluctantly give any information at all. I have encountered male patients that would not consent to an examination by me, a female surgeon even though they were in pain from an incarcerated hernia. I make every effort to safely accommodate their wishes but sometimes, especially if I am the only surgeon on call, I have to explain the situation and the danger of delaying the examination.
Some of my physician colleagues will not perform rectal exams on patients. I vividly remember my physical diagnosis professor from medical school saying that the only reason not to perform an indicated rectal exam is that the patient doesn’t have a rectum and you don’t have a finger. Indications for a rectal exam are any suspected acute abdominal pathology or as part of a screening physical examination. I can’t relay the sadness of finding a rectal tumor that has metastasized through the rectal wall that is within the reach of a finger in a patient that hasn’t had a rectal exam in several years. This situation is commonly encountered in elderly nursing home residents especially those who with poor mobility and limited ability to communicate. Often these patients have pages and pages of physical exam findings but “deferred” when it comes to the rectal exam.
Your patients entrust their health in your hands. When it comes to their health, language and cultural barriers on the part of the patient or the physician must not delay or defer good medical practice. It is incumbent upon the physician, who is the professional to present sound clinical reasons for any exam and alleviate any embarrassment on the part of the patient. No, rectal exams are not fun but they are necessary and in some cases, they are life saving. A physician is not performing a rectal exam to make the patient more uncomfortable but to make sure that the patient gets the most complete care possible. To defer a necessary test because one does not want to “bother” the patient is not sound medicine. In today’s world of pushing patients through offices and emergency departments as quickly as possible, to skip something that is warranted is equivalent to not giving care at all. We as physician are entrusted with the care of our patients and in many cases, we have to explain that our care may be uncomfortable or embarrassing but it will be complete and necessary.
The Rectal Exam
As with any aspect of a patient’s examination, we perform what is necessary for the alleviation of a patient’s clinical problem. If a patient stated that they had a sore throat, would you allow them to leave your care without ever looking at their throat? If a patient has gastrointestinal symptoms that warrant a rectal exam, will you allow them to leave your care without performing a rectal exam because they talked you out or it? Will you allow your patient to talk you out of doing what you know is sound medical care?
I hurried to get my last notes typed in because I had ordered a CT Scan on a patient with a new fever whose recovery had been very long and complicated. I had notified the floor that I wanted to be called as soon as the CT Scanner was free and that I would personally accompany this fragile patient to the scanner. He had been making steady progress and had been out of the surgical intensive care unit for two days but still needed plenty of watching and care because of his complicated course. I had spoken with the chief resident earlier this morning and we both agreed that we needed the scan because we were worried that the graft, inserted because of an abdominal aortic aneurysm, might be infected at this point. I finished my note, grabbed a cup of coffee to get through the latter part of the afternoon (my one vice- caffeine but no later than 2pm) and off I went to the floor to check on my patient’s progress.
As I rounded the corner to the surgical floor, I heard the dreaded words “Code Blue CT Scan”. As I burst through the door to the ward, and entered my patient’s room, I saw an empty bed pushed to one side. They had moved my patient to the CT Scanner without notifying me and now I knew that the “code” had to be my patient. I dashed down the back steps glad that gravity allowed me to move even faster and into the back entrance of the CT Scanner. Yes, it was my patient, still on the stretcher and in full arrest. One of the intensive care physicians had already placed an endotracheal tube (for airway and ventilation) while the CT technician was doing chest compressions.
“He just went down as soon as we got here”, said the transporter. The chief resident came in and asked why no one from the surgical staff had been notified that the patient had been moved to the scanner. He pushed a round of drugs into the central line that I had placed and looked at the vital signs on the chart. The monitor, which had now been placed showed ventricular fibrillation which meant that we were going to defibrillate; a slow sinus rhythm with a very low blood pressure. “Let’s get him moved to the ICU”, the intensive care physician said. “We can’t get the scan now”. I headed back up to the floor, my patient now in the hands of the intensive care staff. I wanted to find his wife and let her know that he would be moving back to the intensive care unit.
I found her sitting in the waiting room of the floor. “Is it him?” she asked me when she saw my face. “Yes, it’s him and he’s being taken back to the intensive care unit right now”, I said. “Let’s go down there so you can see him.” We took the elevator down one floor to the surgical intensive care unit and I asked her to wait until I found where her husband had been taken. When I entered the room, they were pushing drugs, ventilating and performing chest compressions. “I am going to bring his wife in now”, I said. She needs to see him now. The intensivist agreed with me and I brought his wife into the room from the hallway. “Please stop”, she said. “I don’t think that he can take any more”. Immediately, everyone stopped what they were doing and looked at the intensivist who said, “Stop everything and give us a moment please.” The frail woman walked over to her husband’s bedside and took his hand. She said, “I have loved you for 45 years and now, it’s time for you to go”. “I will be OK and it’s OK for you to leave now”. The intensivist and I stood in the doorway for a second but then backed out into the hallway. The nurse silenced the alarm which was picking up the very slow heart pattern and then turned off the monitor and left the room.
The wife stood by her husband’s bed for about 3 minutes and then came out into the hall way where we all were gathered. “He was tired of fighting all of this and had given it all”. “I know that he would have kept on fighting but we had so many good years.” ” He’s at peace and I am OK”. This is why this job is very difficult. It’s not difficult for me to get up at 4AM every morning. It’s not difficult for me to read 30 journals each week to keep up with changes in medicine. It’s difficult for me to watch an elderly woman stand at the bedside of her newly deceased husband and tell him that it is OK for him to move on. She and her sons later thanked all of us for everything that we had done.
At the Mortality and Morbidity conference, we presented reviewed findings and concluded that the graft was likely showing early signs of infection with the fever spike but with no post mortem exam, we couldn’t be sure. This is where this job is difficult. Were there any signs that we missed? Could we have moved any faster? Probably not but still, it is difficult not to question every time we looked at that chart and every vital and physical sign that we reviewed. As I keep doing this job, I never allow myself to forget that everything I do affects the lives of my patients and those who love them. The death of a patient is never routine and I remember something of every patient that I have lost.
It’s not just the loss of life because death is very much a part of life. It is what is left behind with me and with the family and friends that are left behind. My chief resident and I talked about this patient with the junior residents and medical students. “What did you feel when you were standing there in the intensive care unit when the wife came in?” “How does that affect you, as a physician and as a fellow human being?” “Do you believe that there is a life after this one?” “Do you think that it is a good idea for a family member to be present when we are resuscitating a loved one?” “Do you want to keep having these types of conversations even if it’s not on the occasion of losing a patient?” They all answered a resounding “Yes”.