Medicine From The Trenches

Experiences from medical school, residency and beyond.

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

New Year and new things!

We have changed into a new calendar year and some of you will be taking on new challenges in academics or medicine. The important thing to remember is that challenges are to be looked upon as a chance to change anything that needs to be changed but keeping a good course if your course has been fine. Change is inevitable in life and medicine thus embrace the change/challenge and keep your perspective.

Your perspective must include facing each challenge/change as it comes and doing your best. If you need help, don’t be afraid or so caught up in your ego, that you don’t reach out if you need to reach out. At the first sign of a problem, analyze situation and take care of it, seeking help when you need help. I am always amazed when residents or students tell me that they were afraid of what I might “think” if they sought help.

What I actually “think” is that if you need my assistance, ask and it will be provided. No one was born knowing everything in medicine. I certainly seek the assistance of my colleagues when I need them and never give a passing thought because the welfare of my patient is my only concern.

This tactic applies in academics too as you need to seek the help of your faculty even if you believe you are on the right track. Check your understanding to make sure that you are on course. If nothing else, you make get a better perspective and do even better. Faculty office hours are there for you to get help, get an understanding check and to keep you on course for your best performance. I can’t emphasize this fact with any more emphasis.

Your faculty are experts in their subject matter without exception. Take full advantage of that expertise and strive to get the best instruction possible. You are paying good money for that expertise so get everything that you can. It is far easier to be proactive concerning your studies than to do “damage control” because your ego was in the way of your judgment.

If you are starting clinical rotations, remember that your evaluations will be subjective. A good first impression can often make more of a difference in your clinical grade than anything else. You don’t have to “fake” an interest in everything clinical but you do have to learn to perform your best in a clinical situation. Be enthusiastic about the learning even if you don’t plan on entering a particular specialty. There is a baseline clinical knowledge that every clinician needs thus you need to be sure that you are well above that baseline.

I entered medical school with the idea that I would be a pediatrician, as I had an interest in adolescent medicine. I savored all of my tasks on my pediatric rotation (my first). Midway through clinical year, I found that I loved surgery more than anything I would ever do but that pediatric, family medicine and psychiatric knowledge (the rotations that I did before surgery) have been very useful in my career as a surgeon. In short, while you may change your mind as you are getting clinical experience, everything clinical is useful. Listen, learn, read, learn and ask questions as you go.

My last clinical rotation was Neurology/Neurosurgery. I learned to perform an accurate and thorough neurological exam. These skills have proven to be invaluable in the treatment of trauma and burned patients. In short, all clinical knowledge is useful for a physician or a physician assistant. In the middle of the night, that sound clinical base may make the difference in a patient’s outcome.

Again, mastery of the knowledge of a discipline is useful at the pre-med or pre-PA level too. Don’t approach a course as just something that you have to get an “A” in but look upon those courses as learning practice and useful for your future patients. I remember when I remembered that exogenous insulin did not contain Peptide C (cleaved out when endogenous insulin is synthesized by the body) thus checking a Peptide C level is a good idea in a patient who appears to have high insulin levels. If the Peptide C levels are low and the insulin levels are high, that insulin is coming from outside the body and not from something like an insulinoma (insulin-secreting tumor). I learned about Peptide C as an undergraduate student at university; reinforced in medical school.

Also remember that your faculty, undergraduate, graduate or medical school is there to see you successful. No faculty member gets “points” by having a high number of students fail to navigate their coursework. As a faculty member, my job is to help my students and residents to become the best professionals that they can become, without exception. I can’t “dumb down” the curriculum but I can give you every strategy that I know, to help you get the material mastered. My only hope is that you seek out help and get any assistance that you need.

My next point is for you to try to put yourself in the place of your patient. They are putting their health and trust in you to give them the best care that you can achieve for them. For me, this is the honor of being able to practice. The trust of a patient is something that I cannot violate under any circumstances. I might not have all of the answers but I have the stamina and the resources to get those answers. As I said above, I do not hesitate to consult a colleague when I need their expertise for my patient.

Finally, take time on a regular basis, to relieve the stress of being in an educational system. As a faculty member, I place a premium on my stress relief. For me, physical activity in the form of running, has been great for stress relief. I use that time for meditation/prayer, problem-solving and for the sheer enjoyment of pushing myself to the limit of my stamina. When I feel as if I am too tired to exercise, I go to the gym (or for a run) and I always feel better. If you can’t do 30 minutes, do 10 minutes but do something physical.

Trust the process because the process will get you where you want to go. Trust yourself and your feelings along with the process. If you find that your anxiety level is too high, do something to alleviate the stress. School or residency is not torture but a chance to see something new or learn something new. I can promise you that even a jaded old surgeon as myself, learns something new everyday!

 

 

5 January, 2016 Posted by | medical school, physican assistant, residency, stress reduction | , | Leave a comment

We have a mess here…

I settled into an evening of reviewing my lecture for the next day. It is a lecture on the early recognition of the signs of shock, a topic that is “near” and “dear” to most surgeons. This lecture is one of my favorite topics because I deliver this information in a “user-friendly” manner that I wish I had received in medical school. It took years of training in graduate school, medical school and residency/fellowship for me to “make peace”, read comfortable, with early recognition of signs and treatment of shock. Once the peace had been exchanged, I worked out what experience has taught me and my colleagues and pass that on to my students.

As I tweaked a slide here and there, the emergency tone on my phone sounded. Odd, I thought, for me to get this call on this day because I was not even on back-up duty. I called the number and heard the voice of one of my colleagues who is a trauma surgeon. “I have a young woman; shot multiple times in the upper torso and neck”. “Can you come in because we have a mess here and I need another pair of hands?” Of course, I would come in if called, without hesitation as one of the sheer joys of what I do is the old surgical mantra “A chance to cut is a chance to cure”. Besides, if I had made the same call to any of my colleagues, they would be at my side as soon as they could.

I drove my 1997 rusty gold Toyota Corolla through the sheets of rain that were falling as I made the 20-mile trip to the hospital. If I had been on call, I would have stayed at the hospital but since I wasn’t, I had to drive in. The rain pounded my wind screen in the early evening darkness. Why do these  types of situations happen on cold, rainy and foggy nights? Even my chihuahua would not venture out on a night like this. (I left my heated throw on low for her to snuggle into as I left my townhouse). ” A night that is not fit for man nor beast.”

I arrived at the hospital, parked the car and headed in through the emergency department. This was the quickest way to get to the operating room and would allow me to check out the radiographic studies before I headed upstairs. I scanned all of her films with the radiologist on duty and headed up the four floors to the main operating room. “They are in Room 6”, the desk clerk said as I removed my wet coat and entered the women’s locker room.

I changed into scrubs and grabbed my headlamp from the top shelf of my locker. I piled my wet hair on top of my head, pulled on a scrub cap, shoe covers and then placed my headlamp; tucking the cord into my back pocket. I peeked into the room where my partner,covered with blood, winked at me as a sign of relief. I  grabbed my surgical loupes from their wooden box, already placed on the circulator’s table, and said I would be right in as soon as I finished scrubbing.

The surgical scrub is where I take the time to center myself and get into the ritual, the mood of beginning a case. I always say a prayer for God to guide my brain and hands and to guide the hands of those who will operate with me. This has been my brief meditation as I scrub since medical school. I take the time to relax my arms, shoulders and breathe slowly, deliberately before I move into the operating room. With all of the tension of the drive, the rain and the run up four floors gone; I am ready to get to work.

I never want any surgical case to be mindless. I want to be mindful of every step and every event that will unfold. For the patient on the operating table, nothing about what I do is ever routine and will in all likelihood, be a sentinel event in their lives. Once something is cut, it’s never the same as before the cut. No, there is no mindless routine for me or for the patient but for me, there is a sense of compulsive perfection to get it right and to get it done.

The patient had been shot multiple times with wounds in the neck, upper torso, abdomen and shoulder. She had been standing outside her house with a group of friends when a car pulled up and multiple shots were fired. A policeman, was present in the operating room to take all bullet fragments that we would remove. As I donned my surgical gown and gloves, my partner motioned for me to take over the shoulder vascular repairs that he had been working on so that he could move to the abdomen. From training and experience, get control and make the necessary repairs and move onto the next task.

My partner had completed only a tiny portion of what needed to be completed in this complex wound. The bullet had shattered two bones in its trajectory but the vascular damage was immense. I completed a couple of repairs to larger vessels and proceeded to take care of some of the smaller vessels. It was going well and she would have a good blood supply around this mobile joint.

I moved to the upper arm as my orthopedic surgery colleague moved in to do his part with this case. The bone repairs needed plates and screws. Not great to put hardware into places where filthy bullets had been but there are techniques to avoid infection. Most of the tissue that had been in direct contact with the projectile had been removed because it was not salvageable.

The upper arm wound was a clean pass-through which I explored and closed. This would need broad spectrum antibiotics but not a major vascular repair. My trauma surgery colleague had started to explore the abdominal wounds assisted by a resident as I completed the upper arm repairs. The anesthesiologist said that she was holding well and wouldn’t need any further transfusions. We were getting ahead of the damage one “mess” at a time.

“I am going to run the bowel and get out of here”, my trauma surgeon colleague said. “How’s things going up there?” , he asked. “We are almost done,” my orthopedic surgery colleague said. I looked at the neck wound which had amounted to a superficial graze with no penetration of the platysma, a sign the residents had not missed on their initial exploration in the emergency department. The torso wounds had been superficial largely, because of the angle she stood from the shooters.

I helped the orthopedic surgeon close above his work and then turned my attention to helping my colleague close the abdomen. In all, there were seven people around this patient, a diminutive young woman of 19 years. She would not remember those of us who worked on her that night in that operating room but she would bear the scars of being in the wrong place at the wrong time. She would live with some loss of range of motion in her left shoulder but she would be able to live a relatively normal life.

What would she change about her life after this event? Even more important, who is she and why was she in front of 8 bullets on a cold, rainy and foggy night?  Who was so cruel that they inflicted this on this woman who was approximately 25 feet from the car when she was shot? This woman is 19-years-old and just starting adulthood but could have been dead from this event. I would receive answers to some of these questions in the coming week after this case but some of the answers will never be known.

There is no “ego” to making these repairs and doing this work. There is a compulsion, on my part, to try to get the best outcome possible for every patient. I see damaged vessels and try to affect the best repair possible for restoration of their function. The wounds have to be explored, evaluated and repaired. There is no value judgment on these types of wounds; only repairs and restoration of blood flow. Get control and get the repair done as safely and as completely as possible.

This young woman is an honor student today with a passion for the study of literature. She has almost completed her undergraduate degree and is poised to enter graduate school. She is mindful, contemplative and readily shares her story with those who have a life of violence either by choice or not. She was visiting her grandmother the evening of the shooting and had just arrived in our city. She didn’t know any of the young people in the car, that shot her.

 

 

 

27 December, 2015 Posted by | medical school, on-call, practice of medicine, surgery, trauma, vascular surgery | | Leave a comment

Christmas in the Hospital 2015

I always readily volunteer for duty at the hospital during the Christmas season. My church celebrates one of our biggest services on Christmas Eve (I can usually get coverage for this) but I always spend Christmas Day covering for my partners who have families and children on this wonderful day. I am happy and grateful to have these duties.

On past Christmas Days, I have sometimes seen tragedy, loneliness and despair but I always see a joy in those who are working with me. We generally try to discharge as many people as possible for the holiday but we often have a smaller staff even with less patients to care for. This means that there is a wonderful “pitching in” by all of us, no matter what our jobs might be.

I have gladly transported patients to radiography humming along the way. I have gladly greeted all who are working on this day that is usually a welcome rest and get-together with family and friends. My Jewish colleagues always find great Chinese food to share, my Christian colleagues have brought in more food and goodies that I should be allowed to see in one place. (I am happily snacking on grape tomatoes and carrots).

The weather has been unusually warm for December for most of the country. This is welcome for us because we have not been dealing with the cases of hypothermia that sometimes fill our unit when winter sets in. We have seen an uptick in gunshot violence which is disheartening but in any urban area, this is something that we have come to expect regardless of warm weather.

For many young people, shooting another human being with a gun is an answer for presumed slights and many other problems. I have asked many of these young gang members, “Why?” because I just want to understand why they choose to kill, hurt and carry these acts with them for the rest of their lives. Too often, they can’t answer because they don’t survive; another grieving family who has lost a child.

On Christmas, I have tried to remind each of my friends and colleagues that I appreciate their role in my life. Some have been a lifeline for me this past difficult year and some have just been a joy because they are simply in my day to day life and breathe air. My partners have been a wonder and an education at times but always I am thankful for their knowledge and professionalism.

As the year ends and a new year comes in, I am looking forward to more challenges. Each year, I want to “push the envelope” of experience and knowledge. As medicine gets increasingly more scientific, I challenge myself and my students/residents to make medicine more human. I challenge them to take the time to listen and appreciate the wonder of another human being who has put their health and trust in your hands.

The wonder of medicine is that we are privileged to enter the lives of our patients and their families, many times, under raw and painful situations. It is up to us, as physicians, to bring as much comfort, skill and humanity to these difficult situations. I find that as I have aged in this profession, I cry more and feel more; not less. I never want to become immune to the humanity and suffering of my patients.

I also, as the leader of the health care team, want to continue to be mindful of the feelings of the first responders and the others on my team. We all have the same sense of despair when we find that despite our best efforts, a 14-year-old dies. We all feel that same sense of grief when a Mum cries out in pain after being told that her 14-year-0ld son did not survive.  I encourage all members of our team to share these feelings and feel them fully.

As I sit here in my office on this misty, foggy and rainy Christmas Day of 2015, I am thankful for this profession that I love. I am thankful for my life, colleagues and friends but most of all, I am thankful that it’s Christmas Day and the joy, lights, sounds and smells are everywhere.

25 December, 2015 Posted by | medical school, on-call, practice of medicine | 4 Comments

A Wonderful Christmas Present

I have been fannying about the hospital, home and church doing all of my duties for the Advent holidays and so forth. I have a wonderful internet friend (New Zealand) who writes some of the most beautiful words that I have the pleasure to read. Here is a Christmas treat that applies to physicians, physician assistants and all who need to just stop and take a close look at all of the wonder around us. Medicine is magical especially at this time of year but everything is magic; so enjoy! How I See The World

21 December, 2015 Posted by | medical school | | Leave a comment

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