Medicine From The Trenches

Experiences from medical school, residency and beyond.

Hospital Haiku

“hospital moonlight

cacophony of machines

teardrops cascading”

As we come to the end of National Physician’s Week and today, National Physician’s Day, I related this haiku from one of my most gifted and amazing friends. Some years back, he suffered a  critical and life-threatening illness that resulted in profound changes in his life with some time in the intensive care unit. This illness changed a man who is talented beyond belief, a brilliant creative genius and professor in ways that few of us can relate or even imagine. Still today, he’s affected by his illness and the events that surrounded it.

I share this haiku because it brings to mind, something that we as physicians must always remember about our patients. They place their health, their trust and many of the most intimate aspects of their lives in our hands. With our hands, we have to care for them; relate to them, in many ways hold them, and be mindful of the honor and privilege of having them place their lives in our care.

As such, we also have to be mindful that illness changes their reality and in many cases their lives profoundly especially when they are critically ill. We have to reach out and extend more comfort over the “cacophony of machines” that becomes the background of their intensive care and sometimes hospital care experience. We have to block that “cacophony” whenever and wherever we can.

I remember watching a tear roll down the side of the face of one of my ICU patients who appeared comatose. The nurses were bathing him and chatting with each other as they turned him. I saw the tear; asked them to speak with him over the ICU noise background. I asked them to play music in his room and I always held his hand when I entered the room to examine him. I am sure that my soul could feel his soul even though he didn’t ever speak to me. I never saw that tear again, after we began speaking and focusing on him, holding his hand, touching his face, and playing his favorite music even though he did not recover from his illness.

I seek to connect with my patients without exception as that is my honor as a physician/surgeon. I spent years learning the science and techniques of medicine and surgery but in these, the later years of my clinical practice, my focus is on the art of medical practice. Within that art is my chance to give some of my heart to those who have placed their trust in me (and my training). I strive to be more human and more comforting. To do less of the science and more of the art is great joy for me. My joy is in the connections; kind of strange for a surgeon.

On this National Doctor’s Day, I am honored to be a physician and grateful for all that this profession has given me. This profession has given me far more than I can give back but I will spend as much time as possible giving as much as I can to those who are in my care.

30 March, 2017 Posted by | medical school, medicine, practice of medicine | , , | 2 Comments

(Re-post) The Supplemental Offer and Acceptance Program (SOAP) Process

I am re-posting a previous post because Monday of Match Week is coming up. People may need to learn about the Supplemental Offer and Acceptance Program (SOAP) process very quickly. It is not anticipated that there will be huge numbers of positions available in this program but one does need to know how the program works and how to make it work for you. Good luck to all of those who match and those who are going through the SOAP process this year. It’s stressful but it’s exciting to move forward with the next career steps in medicine.

Introduction

In previous years, a process known as “The Scramble” existed for:

  • People who were unmatched on the Monday of Match Week
  • Unfilled residency programs
  • People who matched to an advanced position but not a first-year residency position.

The Scramble was also utilized as a primary residency application process for people who didn’t want to go though the Electronic Residency Application Service (ERAS) who often submitted their application materials via fax to programs who didn’t fill (from the list provided on the Monday of Match Week) or even contacted those programs via phone or e-mail. The Scramble does not exist any longer and programs who participate in the Match cannot accept applications outside ERAS. In short, the SOAP process is a different entity with hazards and plenty of opportunities for mistakes on the part of applicants.

SOAP is NOT “The Scramble”

Programs that participated in the Match are no longer allowed to interact with applicants outside of ERAS as this would be a violation of the Match participation agreement. This means that all applications to unfilled programs (those programs that are on the unfilled list) have to be submitted via ERAS. For programs, this means that e-mails, fax machines and phone lines are not jammed with people attempting to submit application materials. Frequently in previous years, many applicants (IMGs, FMGs in particular) could pay for a mass fax service to fax applications to every program on the unfilled list as soon as the Scramble opened which often jammed machines. Most residency programs were only interested in filling with desirable applicants who may not have matched (by mistake usually) and were not able to screen for those applicants because their fax machines, e-mails and phone lines were jammed.

SOAP should not be your primary residency application

If you are seeking a residency position in the United States, you need to meet the deadlines for ERAS with your application materials. In short, you need to submit your application materials (to your medical school if you are an American grad or to ERAS if your are an FMG/IMG) and participate in the regular Match.  If you are an applicant with problems such as failures on any of the USMLE Steps or failures in medical school coursework, do not make the mistake of believing that unfilled programs are desperate and will take a chance on you rather than remain unfilled. First, there are far more applicants in the regular match than ever before. Many people who will find themselves unmatched either overestimated their competitiveness for a program or were just below the cutoff for a program to rank. If a program interviewed you but you didn’t make the cutoff for them or you didn’t rank them at all, you have a better shot at securing a position in that program through SOAP than an applicant who didn’t interview at all. Programs would rather take an applicant that they have seen and interviewed rather than just a person on paper (which is why trying to use the SOAP rather than the Match is a poor strategy).

You are limited to an absolute maximum of 45 programs in the SOAP

In the SOAP, your maximum is 45 programs. You can apply to 30 programs during the first cycle (Monday) and 10 programs during the second cycle (Wednesday) and 5 programs on the third cycle (Thursday).  Applications do not roll over so that if you don’t get a match by the third day the start of the second cycle, you are likely not going to find much out there. There are more applicants who will be unmatched (because there are more people participating) thus the positions will go quickly because programs can review applications to chose the most desirable candidates with the SOAP system.

If you have problems that prevented you from getting any interviews in the regular Match season or you didn’t get enough interviews to find a Match, then you are going to be less likely to find a position in the SOAP. This means that you won’t have a position for residency. If this happens (you know if you have academic or USMLE/COMLEX problems), have a contingency plan in place. This means that rather than sitting around wishing, hoping and praying while your classmates and colleagues are going on interviews, you need to be looking at alternatives to residency that will enable you to earn a living and alternatives that will enhance your chances of getting a position in the next Match.

Strategies to enhance your chances of getting a PGY-1 position

If you know that you are a weaker candidate (failure on USMLE/COMLEX Step I, failure in medical school coursework, dismissal from medical school and readmission), then don’t apply to the more competitive specialties. Don’t apply to university-based specialties in the lesser competitive specialties and apply to more rather than less programs. If you have academic problems, you are likely not going to match in Radiology, Opthalmology, Dermatology, Emergency Medicine, Radiation Oncology or Anesthesiology. You are likely not going to match in university-based programs in Surgery or any of the surgical specialties, Psychiatry, Pathology, OB-GYN,Neurology, Physical Medicine and Rehabilitation, Family Medicine or Internal Medicine. In short, community-based programs in Family Medicine and Internal Medicine may be your best options.Do not believe that if there are unfilled positions in programs that are university-based or competitive, that you are going to snag one of those positions in the SOAP. A majority of those programs would rather go unfilled than fill with a less desirable applicant (in spite of what you hear, those programs are not desperate enough to take any applicant just to fill).

If you are an IMG/FMG, you have to meet the requirements for application which means that your USMLE Scores likely will have to be higher than those for American grads and you can’t have any USMLE failures. There are also cutoffs in terms of year of graduation from medical school for many programs. In short, you need to look at the application requirements for any residency program that you apply to and make sure that you are eligible (better yet, that you exceed) those application requirements.

The best resource for estimating your competitiveness for a particular specialty is to look at the previous years  National Residency Matching Program ( NRMP) reports for those specialties. You can look at the characteristics for matched and unmatched individuals to see where you fit. With a greater number of medical school graduates (most American medical schools increased their class sizes) and the number of residency positions staying static, there are fewer positions out there to be filled. There will be fewer position in the SOAP and the competition for those positions will be greater. Since the competition in the SOAP is greater, it is best to avoid having to use that system all together if possible.

If you know that you are a weaker candidate, apply for preliminary (not transitional) positions in either Internal Medicine or Surgery. You will stand a better chance of getting a preliminary position (more available) and you will have a job where you can demonstrate your clinical abilities for one year before you re-enter the Match for the next year. If you do a good job in your preliminary year, score high on the in-training exams and perform at a high level clinically, you may be able to secure a categorical second-year position in the same program where you do your preliminary position or you may position yourself to become more competitive for another specialty at another institution. The upside to this strategy is that you will not be relying on the SOAP as a primary means of residency application but the downside is that you have to be ready to perform extremely well in your preliminary position without exception. In short, getting into a preliminary position can be a huge asset if you are ready to work hard and prove yourself but can be a huge liability if you are not ready for clinical residency and perform poorly.

Things that generally DO NOT enhance your chances of matching

Doing graduate degree work if you do not match will generally not help your chances of matching. If you can complete a graduate degree (such as an MPH), you may enhance your chances but most graduate degree programs close their application submission dates before you know whether or not you have matched. If you anticipate that you are not going to match, then apply for graduate school long before Match Week or you will find that you can’t get into graduate school. Additionally, you need to complete your degree before the clinical year starts after the next Match. This means that you have to be able to ensure on your next ERAS application, that you will complete all of your degree requirements by the start of your PGY-1 year. Again, if you know that you have a high change of not matching, get your graduate school application done ahead of time or better year, delay entering the match and just apply for graduate school outright (can’t do a Ph.D) but plan on spending no more than one year away from clinical medicine.

Hanging out and “schmoozing” with residency attendings if you are not in their residency program is generally a waste of time. Doing additional observerships (IMG/FMG) generally will not help you if you have done enough before you applied. Working in “research” will generally not help you unless you already have an advanced degree (MS or Ph.D)  or you are able to produce a major paper or article for a national or international peer-reviewed journal. When I say produce, I mean first author not just run a few experiments  or enter data. If you can get yourself on a major clinical research project where you are actually gathering some clinical experience, you can use this to enhance yourself for residency but you face stiff competition for these types of projects and you need an unrestricted license to practice medicine (difficult to obtain without a passing score on USMLE Step 3 + 1-2 years of residency training).

Summary

Making sure that you match requires a bit of strategy and planning for everyone but for some applicants it will be a difficult process.

  • People who have academic and USMLE/COMLEX problems will have even more problems getting into a residency
  • It is important NOT to rely on the SOAP as a primary means to apply to residency programs because you put yourself at a distinct disadvantage in terms of the number of programs that you can apply
  • You need to make sure that you are even eligible for the SOAP in that you have to have applied to the Main Residency Match (at least one program) and are fully or partially unmatched.

Learn as much about the process as possible as soon as possible. The decisions that you make in the residency application process can profoundly affect your career in medicine. Educate yourself about all aspects of the process as there is little room for error.

11 March, 2017 Posted by | difficulty in medical school, Match Day, residency, scramble | , | 1 Comment

We Do This

Last evening I was visiting with my classmates in one of the ministry classes that I am taking. As we moved through our discussion of our readings, my classmates nibbled on German Chocolate brownies that I had baked the morning before. I love to bake, therapy for this surgeon, as it is very nice to create something and watch other enjoy it. One of my mates produced a bottle of Benedictine with a supply of glassware; brownies and Benedictine!

One of our discussions in class centered around meeting Jesus. Quite an interesting discussion for a couple of physicians; two of us in the class. I related a story about one of my first patients that I treated as a medical student. This wonderful little patient was affectionately named “Ratso” by my supervising resident at the time. He was a patient in our Veterans Hospital coming in when his lung disease would get out of control.

“Doc, I was holding hands with Jesus”, he exclaimed to me as he began to respond to our treatments. He had been quite disoriented when his blood carbon dioxide level had achieved values that would be incompatible with life for most people. This patient not only had high levels, he turned the corner pretty quickly. “Yes, I will believe you saw Jesus”, I said to him as he clearly recognized me at last. I was seeing Jesus too.

So this is why I do this. For Ratso and the hundreds of others that I treat with care and love. Remember that what we do is like no other profession out there.

9 December, 2016 Posted by | medical school | , | Leave a comment

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

End of the year reflections

At the end of each calendar year, I try to reflect on what I have learned and what surprises me. After some years of teaching and medical/surgical practice, one would believe that there is nothing surprising out there for an old surgeon but I have moments of amazement and wonder every day. This is the nature of my practice of medicine even today.

This past year, I have become more comfortable with my extreme connections with my patients and students. I see the greatness of their humanity and in the case of my students, I have had some moments of disappointment in their lack of humanity. In the case of my patients, I see more humanity because I spend more and more time with those who have cognitive, intellectual and physical impairments.

My patients with cognitive impairments often communicate without words. For me, this is the greatest gift that I have received from them and I am fortunate to be able to stop and make those connections. From a wonderful colleague (Daniel C. Potts MD; his blog is linked to this blog), I have learned to be more mindful which has enabled me to stop in the moment and appreciate all that this group of patients has to say and wants to say. These relationships are pure gold for me.

My patients with intellectual impairments show me the wonder of human achievement daily. Most of this group of patients thrive on having a physician that connects with them and not their caregiver or the person hired to accompany them on visits to the physician’s clinic. It takes a bit more time to make that connection but the relationship here is as rich for me as for the patient. I am thankful that I make and take the time to give these patients what they crave no matter how much it falls outside of the time constraints.

My students have been the greatest surprise this year; not always in a rewarding manner. Many have shown an unwillingness to meet goals in the professionalism that the practice of medicine demands. I know that it is my job, as professor, to make sure that they have the tools for practice but this year has been a challenge for me in many ways.

Many of my students have a fixation on comparing themselves to others. My mantra for countering these comparisons is to say that the only person with whom one can compare, is yourself. Every day, or every second for that matter, is a chance to change your thinking. What another person does or does not do, has no bearing on what you can do for yourself. I constantly remind my students to use social media for information but evaluate that information and surely do not use what is posted on Instagram, Snapchat or Facebook as a means of comparison with others. You have to be the best person that you can be and not compare yourself to what you believe others are.

The lack of appreciation for the humanity of those who would be the future patients for my students is also a challenge for me as their professor. I was fortunate to have mentors and professors in medicine and surgery who reminded me of the privilege of practice. My professors spoke often of the extreme trust that patients place in physicians. We earn that trust by mastery of our craft and by humility because we are not the healers; we are the instruments of healing. To practice medicine/surgery for ego is a straight line for burnout and exhaustion because of all professions, medicine will destroy an ego very quickly.

I am grateful for being able to climb onto the roof of my hospital (14 floors up) and just meditate in the early mornings. In the predawn darkness, I can hear the traffic below, smell the fuel of the helicopter as it lands and I can take a few moments in the stillness of that place to center myself. I can see for miles on some mornings but on others, I am surrounded by rain and fog which is equally comforting. My days of sailing have taught me to love the moments before the sun rises and appreciate the ever changing colors of each new day.

As the Christmas holidays approach and the first semester has come to an end, I try to take some moments to appreciate my wonderful friends. They are a source of wonder and discovery. This year, one very new friend has been a “touchstone” for me in terms of validating what I always knew in terms of the spiritual nature of medicine. His friendship has been truly inspiring and affirming. Though we are totally opposite in just about every aspect of our lives, we are in total agreement in terms of how we approach medicine. I am very grateful for all that I learn from him on a daily basis.

This year has been one of change for me as I have achieved many of my goals in terms of physical and mental conditioning. I have made running and weightlifting a significant part of my lifestyle. I was a varsity athlete in college but moved away from regular conditioning as I navigated graduate and medical school. I have reached many of my physical goals, being able to play rugby again but I am working on getting stronger and stronger.

This year, I learned to kayak (my new means of exploring nature) which has added a different range of being able to appreciate being outdoors. Being solitary in nature for me, has always meant hiking, again so that I can be alone with my thoughts and meditations. With learning to kayak, I have been able to explore rivers and two of the Great Lakes (Erie and Superior). Being on the water alone in a kayak is to perceive much in terms of spirit renewal. I strongly recommend finding some means to get away with your thoughts and enjoy what is around even if you are only able to take a walk in a nearby park.

This year, one of my extreme experiences was to spend a week hiking Joshua Tree National Park in the California desert. There is no location on earth like this magical place. The desert was magical, spiritual and allowed me to appreciate each grain of sand that surrounded me along with the huge stone formations of Joshua Tree. The Joshua trees were amazing in that no two are alike but all are like friends with arms outstretched in fellowship. I loved each spine on each cactus plant too. The desert, the surrounding mountains and the Joshua trees gave me a great sense of place in humanity.

As this semester ends for those who are in medical school, those trying to gain admission to medical school and for those who are in some stage of medical practice, I would hope that you strive to see your place in humanity by any means that you can. I would also hope that you enjoy the spiritual and connective nature of the profession that you have dedicated yourself to. There is pure magic in what we do on a daily basis and I am very grateful for the privilege to see that magic.

 

 

17 December, 2015 Posted by | academics, medical school | , , | 3 Comments

The Importance of Saying Goodbye

Introduction

I was consulted to place a chemotherapy port in a young man (age 14) who was going to need extensive chemotherapy in the coming weeks. These requests are not unusual but the lessons that I learned from my experience with this young man are with me today, years later. This was one of my earliest experiences as a newly minted attending physician. My learning curve at that point was so steep that I constantly risked falling backwards as I climbed.

Roger

Roger was a patient in the Pediatric Intensive Care Unit (PICU). He had recently been diagnosed with a fairly aggressive tumor that grew from his liver and pushed on his diaphragm. His presenting complaint has been shoulder pain for which he was worked up extensively. Since Rog, as he asked me to address him, was a volleyball player, the first thoughts were a hidden musculoskeletal shoulder injury but it became obvious as the workup proceeded, that something else caused Rog’s pain. The tumor was identified, biopsied and deemed inoperable as the malignancy had quickly spread throughout his liver. Thus pediatric oncology consulted me to place a port for chemotherapy.

Rog’s parents were adamant that they did not want staff to discuss Rog’s diagnosis (or grim prognosis) with Rog. They wanted no mention of cancer, metastatic disease or death with the patient. Since Rog was 14 years old, his parents wishes were followed by PICU staff whether they agreed with the parents or not. I spoke with Rog and his parents at the same time when I approached them for consent to place the port. Rog knew that he would need extensive intravenous medications over an extended period of time thus having a semi-permanent port would mean the there would be no repeated searches for a vein or multiple punctures if a vein was missed. I explained that I would place the port in the operating room with him practically asleep but definitely fully relaxed. He was fine with the procedure and his parents agreed. The next afternoon, I placed the port without problems.

Off and on over the next couple of weeks, Rog received his daily chemo and medications to mitigate the effects of the chemo. I watched a very athletic young gentleman begin to become frail, thin and jaundiced (yellow tint to skin).  His very lively team mates who came to visit were a stark contrast to the patient who seemed to age before my eyes. I stopped in to say hello to Rog often because we had enjoyed some lacrosse stories together previously. I also always greeted his parents who began to look more desperate with each day of chemo. I was sure that Rog, who was a very astute and sensitive young man, could see the changes in his parents even if they didn’t discuss his disease with him.  Rog’s 8-year-old brother often sat in the waiting room after school for a few minutes with his adored older brother. Charlie was a quite young man with sparkling dark eyes behind round wire-framed glasses and endless dark curly hair.

I always made it a point to ask Charlie about his scene. Charlie loved discussing flying with me and looking at photos of my little twin-engine Cessna plane. “Do you really fly above the clouds?”, he would ask with wider eyes. “Yes, I do get up there at times and I fly through them too but most of the time, I am beneath them, ” I would answer. “What you think is happening to Rog?”, I asked him one day. He said that the knew his brother was very sick and he was glad that he could wait outside in the waiting room because he didn’t like seeing his brother look so sick. He said that he was luckier than Rog because he wasn’t sick. Charlie wasn’t sick but he missed his brother and his world was forever changed by his brother’s sudden illness. Charlie missed his brother very much.

One of the PICU nurses who had also become very close to Rog, stopped by his room when her shift began and ended. She had been a flight attendant in her previous life; sunny smile, soothing voice and the stuff of a 14-year-old man’s dreams. She told us that Rog was worried about his little brother. She said that he wanted to say good bye to his family and brother but his mother wouldn’t let him say anything. She changed the subject when he brought it up. Rog’s favorite nurse decided to get a video camera and allow Rog to speak to his parents and little brother. She said that she didn’t know if she would end up fired from her job but it was clear that this young man knew he was dying and longed to say good by to those he loved. Shortly after Rog filmed his messages to his parents and his brother, he died.

As far as I know, no staff member discussed death or dying with Rog but he knew that he was not going to survive this illness. He didn’t have to be told by his parents. A couple of weeks after Rog died, Rog’s favorite nurse gave Rog’s parents the video tape. They were very grateful to have his last messages. Those precious words were a gift to the people that Rog loved most. Later in PICU rounds, we took the time to allow anyone involved in Rog’s care to speak about their experience with his case. The underlying messages from the fellows, the residents, the nurses and other caregivers was that not discussing Rog’s impending death with him sort of negated the feelings that we all knew Rog experienced. Rog knew that he was dying and desperately wanted to say goodbye to the people who meant the most in his life.

We have to learn to say goodbye

I am not going to criticize Rog’s parents. Their grief began when they were informed of the grave nature of their son’s disease.  Even my own grief in the loss of my husband came suddenly. He was healthy and with me one day and he was gone on the next day. I didn’t have an opportunity to say goodbye to him. Even today, I am still dealing with my feelings surrounding his death but my experience with losing someone that I loved very much has given me even more compassion for those who are losing loved ones. Dealing with grief and loss is individual and very complicated. When dealing with a prolonged illness, a patient with extensive burns, a major trauma or even a chronically ill loved one, part of my duty to the patient is to take care of their caregivers and in some cases, help them say goodbye to their loved one which starts the healing process for all of us.

Parents who are losing children and children who are losing parents know about death and often want to discuss their feelings surrounding their loved ones illness. In many cases, just listening to what they have to say without judgment is a very powerful act that can benefit both the patient and their family. As physicians, we want to attempt to solve every problem and move on but in the case of critically burned patient or a patient with a limited prognosis, we can’t solve the problem of making everything the way it was before the illness. Even for many physicians, dealing with survivors in these types of cases can result in us bringing those feelings of helplessness home where they can cause problems with our personal relationships.

I make sure to allow staff and family to openly discuss their feelings surrounding a critical patient’s illness. By having a safe place to discuss feelings of helplessness, anger and frustration can allow those feelings to be acknowledged. The simple act of acknowledging one’s feelings about a sad or tragic situation rather than attempting to hide them behind a professional mask. Sometimes as a physician, I have to cry with my patients (families) and pray with my patients (families) which is the best of humanity that I can give them. I can now do that with the staff too because we are as human as our patients. To pretend that Rog’s situation above was not gut-wrenching would have been dishonest because 14-year-old volleyball players are supposed to be worrying about acne and the prom; not worrying about how to say goodby to their parents and little brother because they know they are dying. Rog understood his death in the simplest terms and simply wanted to leave something behind.

Medicine in Today’s World

In today’s world of having to rush through patient encounters and get to the bottom of a diagnosis quickly so that one can move onto the next patient, we cannot lose our humanity. Our patients have much to share with us and as physicians, we are fortunate enough to be in a position to hear what our patients have to say. It is my belief that the profit-driven/cost-cutting world of medicine today where physicians are “burning out” and “dropping out” of medicine because of low job satisfaction is directly due to our loss of connections with our patients. It takes time and a willingness to spend time reaching our patients and their families. In the end, our “gallows humor” doesn’t make for us dealing with tragedy in a healthy manner as physicians are notorious for turning to alcohol and other substances or just repressing those feelings only to have them come out later and pathological for us.  Reversing the trend to spend less time with our patients is probably the best thing that we can do for ourselves as physicians.

I am also convinced that getting back to our humanity and our spirituality in medicine is vital for us as physicians. If we do not care for ourselves spiritually and emotionally, we are likely not going to meet the needs of our patients clinically. Medicine cannot be done by a computer or with “check lists” or pre-written forms. Medicine is done best human being to human being with ourselves open and listening carefully to what our patients have to teach us so that we can help them.

2 August, 2015 Posted by | medicine, practice of medicine | , , | 2 Comments

And there she sits…

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.

17 June, 2015 Posted by | practice of medicine, surgery | | 3 Comments

Conferences and Practice…

Introduction

If you practice medicine/surgery, you will undoubtedly attend a conference or two during the year. Some of them are gigantic like the American College of Surgeons which draw thousands of surgeons from around the country and some are a bit smaller but are,nevertheless great opportunities for learning, even perhaps widening one’s frame of reference. It’s always good to attend conferences at every level of your training from medical student to resident to attending physician. A good conference reinforces what you are reading in the literature and allows networking/exchange of ideas. Once in awhile, one can attend a conference (I did just this week) where one hears something that profoundly changes the way that one views aspects of one’s practice.

This Week’s Conference

First of all, the person who gave this amazing lecture is a genuine “rock star” of the highest magnitude in medicine. His talk was placed right before lunch (the conference had started at 7:15AM so you know he had to be good to fill that space) when most of us were contemplating just being able to get up and walk around ( opposite of food coma). The first thing that he asked us to do was drop the “compartmentalization” of our lives and integrate our roles as members of our communities (parent, neighbor, coach etc). Now why would someone of this caliber start right off asking his audience to “feel and not think about too much” “to let our professional guard down for a second” rather than absorb profound knowledge that no doubt, this eminent speaker could easily impart?

The Message

When we do what we do in medicine/surgery, sometimes there are not good outcomes. Sometimes we have to deal with families and by extension, communities that are suffering profound loss (losses). We are all very familiar with the tragedies that seem to be in the news more often these days. Some are so profound that they can be described by one word, such as 9-11 or a location such as Newtown, CT. “To get up and give a lecture on sad topics isn’t so much fun… but it’s such an important part of what we do”.

He encouraged us to think about the effects of the injury of a child on the child’s family and the effects of taking care of injured children (or adults for that matter) on our team. Often we do our jobs and put our feelings somewhere so that we can get those jobs done. Later on, those feelings, especially when little ones are involved, can well up and overwhelm us in ways that we might not be even aware of. He spoke of us being mindful of those in the family that might be left, our colleagues who have shared the job of caring and the community that might be feeling the loss (schoolmates, teachers and others). ” One child is injured, there are a lot of challenges for that child but the ripple of challenges begins to spread to other children who may have been involved in that event or near that event; to the parents and siblings of that injured child; to the community, their friends, their teachers,  their coaches, their clergy.” He also mentioned “ripple of challenges” can extend to the people who rescued and cared for that child. The effects can be profound even for the trauma surgeon.

While we, as surgeons, can move onto the next patient or the next challenge, often these families/communities have deep and long lasting effects. We have to be aware of those effects both in ourselves, in our colleagues and in our communities. He spoke of Post Traumatic Stress Syndrome which even though we might put our brains in a place to deal with the present, the cumulative effects of all things that happen to us can come back if we don’t acknowledge our feelings (ah,that word that we as surgeons don’t like much).

Honestly, I have never head anyone verbalize what this man spoke about. No psychiatrist could have imparted the message that was imparted, yet it came from a surgeon of all professions. I don’t think that many of the psychiatrists actually “get it” but I actually received validation that when I walk over to a younger colleague who has just finished dealing with an emotional outcome that is tragic and ask, “What are you feeling right now?” “Tell me and don’t try to explain it but just tell me your actual thoughts”, that I can no longer say, “Go home and decompress because for human beings, decompression may not be possible. This is a message that anyone who anticipates a career in medicine (or even the allied health care professions) needs to be very aware of. I have always been aware of how deeply my patients can affect my life/thinking but I always put that awareness in a place where I could think about it at some later time- often in my meditations or when I am out running.

Bottom Line for Me

I will now play even closer attention to my feelings and the feelings of my students, co-workers and colleagues in these situations. I will also pay closer attention to the families and to the communities. Events happen in our community and as physicians, we are often thrust into the heart of raw emotion. We have to speak about our feelings and not be ashamed that something touches us so deeply that we are brought to tears. Even better, we have to connect with the folks on our team and with those who surround the patients that we treat. When I walk into a family room, I now see everyone in that room and not try to “get out” as soon as possible. I look at the families, the siblings and friends of my patients, young and old, to try to get a sense of where they are. I will also try to keep a little closer watch on where they might be going. I am a teacher but even greater, I have been given the gift and trust of the ones who love the patients that are placed in my hands. I can’t compartmentalize anymore and somehow, I don’t think I should.

17 October, 2014 Posted by | medical school | , , | 1 Comment

Achieving a balance

Introduction

As I write this, my career has been shifted into a higher level of comfort. I have spent the years since graduation from medical school and residency honing my surgical skills and the craft of taking care of patients. If anything has suffered in the task to become the best physician that I can possibly be, it has been my personal life. In short, it became easy to head off to the hospital or university rather than deal with things in my life that just were not working. Well, working in medicine has a way of making one reflect on what is truly important and making one move past things that are not a good fit for life.  I had decided after ending a relationship that had somewhat sustained me through medical school and residency, that I would throw myself into my work with vigor and a quest for self-discovery.

Make a definition of your “complete” life

I always knew that I was a person who saw the miraculous in all of medicine and humankind. I am just an instrument for our creator does the actual healing. You can call the creator anything that you like, God, Mohammed, the Great Spirit but positivity and balance have a way of forcing one to move along on a plane that is stable. One gets used to “death” as part of “life” and one can sometimes feel how to be aligned with the universe in one aspect of life but “going through the motions” in another aspect of life. So it was with me and I attempted to fill in my “gaps” and “blanks” with interests, flying, sailing and so forth. Being above the earth or on the ocean/lake can allow one to exhale and just marvel at how wonderful the world is at times. I also knew that I wanted to share the miracles of my life with another soul; as a human we all reach out for intimacy in some form. We can have a close friend or we can have a significant relationship (marriage) that allows us to find that person who can help us complete our mission in life. At times, I believed that I needed to work on myself and put all parts of my life in compartments so that I could achieve a close bond with another human that doesn’t mind that I sleep on my abdomen hugging a pillow and look like a “street urchin” in the morning after my nightly pillow fight; that my phone frequently rings all night if I am on home call; or that I might be away for 30 hours straight taking in house call. These are the realities of being in a relationship with most physicians and certainly with a surgeon. I can also add the time that I must spend in reading and study to keep up with my craft. In short, any person who is involved with a physician needs to see that they won’t have 100% of our attention all the time but when we are “with” you, we are 100% committed and need you like we need oxygen, food and water to live. My definition of my complete life was to meet and find a person who could be my friend first and perhaps more later. The inhumanity that is sometimes represented in my trauma bay can color how I look at relationships between humans. Domestic violence is very difficult to deal with but deal with it, I must and I must have a place in my mind that allows me to give my best treatment to the victims and sometimes to the perpetrator too. I am not the judge but only an instrument to an end point – getting that person back to health and solving health problems. My complete life has to allow me to find that person who can allow me to complete my “mission” on Earth and I complete them.

What I tell myself…

I had told myself that my life could be complete and satisfying with a job well-done. I would enjoy “discovering new truths” in my research and writings. I would enjoy hearing the successes of my students and colleagues. I would have a rich and satisfying career giving back with my skills and teaching. Yes, my life was indeed full but not complete. I didn’t have that intimate relationship that adds the depth and richness that just needs to be there. And so I was going through my career, happily enjoying my friends, colleagues and adventures in surgery, medicine, flying and sailing.

No, one can’t plan everything…

I was happily moving along with the things that occupy my time. I decided to do some exploration in trying to reach out and expand my circle of friends. It’s good to be a trailblazer in some aspects of one’s life. I have always challenged myself to take some risk with something at various times. I took a risk and was happily enjoying the experience when a man reached out to me in a most unexpected manner. There was something in the things that he shared so readily with me. He knew that I was a physician/surgeon yet he said that he saw something that drew him to me. At first, my scientific training kicked in and I attempted to define what was going on here; I ran in the opposite direction. Well, there is no definition but only that one has to have the courage and sometimes the faith to know that your instincts are correct (much the same as how I treat a critical patient). In short, life does not always come with clear directions. I have been in uncharted “exploration” the past few weeks and it’s been both exhilarating and unnerving at the same time.  Here I am in a relationship that I can’t plan or define and suddenly my life that I thought was so full, seems empty before I was able to get to this point.

Why this is so vitally important…

In order to give our best to our patients and colleagues, we have to give our best to ourselves. My best now includes a very brilliant environmental engineer (he can’t stand the sight of blood) who inspires me to reach higher and further in all aspects of life. Suddenly the things that gave me immense satisfaction go beyond that and give me immense joy at the same time. I smile and laugh with my patients, my students and my colleagues. In short, he has made me a better and more fulfilled person. The only downside has been that my favorite OR music has moved from my signature “thrash metal” to a bit more “smooth jazz”. For those who work with me, that’s a huge change but they secretly like the music change. I am not playing as much Pantera or Goatwhore in the background. As you move through your university work and your preparation for medical practice, one has to have the best of humanity brought out from within themselves. To be able to give my heart, a myocyte at a time to this environmental engineer who can’t even see my lectures without getting sick, has made me a better surgeon, physician and human being. One simply has to find balance in all things in life and not shut off any part of life to focus on other parts of life.

10 October, 2014 Posted by | organization, relaxation, stress reduction | , , | 5 Comments