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August 28th, 2015

How Do You Teach Art?

Andrew Ip, MD

Andrew Ip, MD, is a 2015-16 Chief Resident in Internal Medicine at Emory University in Atlanta, Georgia.

Andrew Ip, MD, is a 2015-16 Chief Resident in Internal Medicine at Emory University in Atlanta, Georgia.

When I first applied for medical school, I beamed about exploring not just the science of medicine, but also the art.  But what is that art?  Some would say it’s clinical experience, combined with being cultured and compassionate and communicating with clarity/conviction.  But how would one teach that art?

Journal Watch’s Dr. Allan Brett recently reviewed a multicenter US study following ~300 metastatic cancer patients who had failed initial chemotherapy (NEJM JW Gen Med Aug 6 2015).  The study showed that additional chemotherapy for patients with poor life expectancy <6 months had no better quality of life or prolonged survival.  In fact, patients who had the highest performance status had worse quality of life when given additional chemotherapy.

Even with our remarkable scientific discovers in medicine, we still have a very tough job to deliver the science of medicine in a patient-centered format.  Oftentimes, it is a judgment call to decide if a patient with end-stage liver disease or heart failure or COPD or cancer would benefit from any additional aggressive treatment.  From my experience, many patients, and their families, are initially resistant to accept a terminal prognosis and want to pursue aggressive measures.  What happens next involves a moment in which the physician can analyze the situation, with risks/benefits in mind from a scientific point of view, and then deliver a message that keeps the patient’s goals of care in mind while also informing the patient that you do not wish to harm them with interventions that may be not in their interest.  This is one of the toughest things to do as a clinician, often leading to many of us tip-toeing a fine line.

One story that has stuck with me from residency is the story of Mr. G, an Ethiopian patient.  Mr. G had end-stage cardiomyopathy and had been in the hospital for 3 months while on inotropes.  Unfortunately, he did not qualify for any advanced heart failure therapies. As our team was trying to explain the dire situation, he initially wanted all aggressive measures. He also said to me, “please, don’t tell my wife and children.” He squeezed my hand as he spoke to me, and I squeezed back.

As a clinician who prides myself on my empathy and compassion, this was one instance where I had to go against honoring all of my patient’s wishes.  Our team felt aggressive measures would not give any quality of life and would likely lead to more harm than good.  We also contacted his wife and children to inform them their loved one was going to die soon.  This was the most difficult part, as Mr. G was extremely upset from a cultural and personal standpoint that his family knew his prognosis.   It was a judgment call that, because I misunderstood the cultural implications, fractured my physician-patient relationship with Mr. G at the time.  However, I did not give up on delivery of care, and I treated Mr. G and his family as my own family — and a remarkable turnaround occurred in our relationship.  His children delivered a card and flowers to me, thanking me for all the personal care I gave to their father, and Mr. G embraced me as his physician, holding my hand yet again.  Mr. G died peacefully 2 days later, with his family at his bedside.

 

A gift from Mr. G's children

A gift from Mr. G’s children

 

Maybe the art of medicine is not something you teach.  Maybe it is an individual style you develop with experience with direct patient care or with role models and mentors.  But what we often forget is the patient should be at the center of anything we deliver in medicine.  That may be the art.

I would love to hear thoughts from others about their experience developing their own art of medicine, or in scenarios where sometimes treating a patient may have caused more harm than good.

August 25th, 2015

Motivations of a Doctor in Training

Ahmad Yousaf, MD

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

As my co-chiefs and I try to figure out how to best serve our residents and deliver a worthwhile education to them, I have begun contemplating what it is that really motivates doctors in training. What is the driving force behind a resident striving to be a more knowledgeable clinician? How do we convince them that they need to work hard and take an immense amount of time and exert an enormous amount of effort to acquire both the didactic knowledge and the clinical sense required and expected of them by their profession and patients?

After a lot of thought and discussion with colleagues, I have found that the drive for each resident is a unique combination of 4 major factors; every resident’s makeup varying the exact ‘amount’ of ingredient that needs to be tapped into to make their training experience worthwhile and productive:

  • Fear/Guilt… That knot in the pit of your stomach… that globus sensation that makes it impossible to swallow… that nightmare that wakes you up in the middle of the night as you replay all of the things you missed earlier in the day. It is the fear of killing someone — a drive that is so potent that it leaves residents googling the side effects of the Benadryl they just prescribed as they sit on the toilet between bouts of irritable bowel syndrome at 2AM. This fear and guilt is healthy, but, if not tempered at the beginning of residency, it can be all consuming and harmful.  It is a powerful motivating factor when you recognize the immense responsibility that you have — that your order might permanently change the lives of another human being and his or her family.
  • Signs that your resident is highly motivated by fear/guilt:
    • Twitchy and nervous on rounds
    • Frequent bathroom breaks
    • Checking and then rechecking orders and notes the way Jack Nicholson checks his door locks in “As Good as It Gets.
    • Jack Ncholson

  •  Shame… Do you remember when the teacher called on you and asked you a question that you definitely should have known the answer to, and you froze? Can you recall how you felt the warmth of embarrassment crawl up your chest, pass your palpitating heart, move through your almost completely closed throat and into your now red cheeks? Do you recall the deafening silence that you were responsible for weighing down on all your peers, and the 9-month-pregnant pause your teacher allowed to mature into a full-grown baby of shame and self-loathing? Do you remember thinking about that time over and over again and re-living the terror of that moment of humiliation? That is the moment of shame that drives some of your residents to read, to work harder, and to always be prepared.
  • Signs that your resident is highly motivated by shame:
    • Crumpled up notes in overstuffed white coat pockets
    • Coming to the hospital 2 hours before the next resident for pre-pre-pre-rounds with multiple cups of coffee on board before the team attending has even rolled out of bed.
    • Overly concerned about evaluations that peers and attendings spend about 4.7 seconds of mindshare completing.

hiding cat

  •  Ego… or the Id, if you want to get all Freudian on me. It is the impulse to want to be the best and to triumph over all others. This is the drive that makes you seek the admiration of all, the respect of those beneath you, and the recognition of those ethereal beings we know as attendings and administration. It is the desire to attain a status in which you can look in the mirror and say you did it and declare to everyone, or sometimes nobody but yourself, that you are the epitome of what a doctor should be. I also take the liberty of placing attainment of loftier position/money in this category of motivation — i.e., fellowship and dollar bills.
  • Signs your resident is highly motivated by ego:
    • Aspiring cardio fellow (likely a ‘gunner’ intern) that walks around with calipers in his pocket despite being on an outpatient rheumatology elective.
    • Pristine white coat over an Armani suit, far too much hair gel or the clickiest shoes in town.
    • The resident who takes every opportunity to quote obscure papers from Scandinavian research cohorts written in the 1950’s that almost never pertain to the patient or patient population at hand. Impressive? Yes. Clinically applicable? Never!

Ego

  • Vocational Aspiration… Close your eyes and think about the physician you always wanted to be like. The one who gets down to eye level with his/her patient, speaks confidently about the matter at hand, shows love and compassion that cannot be faked or learned in a textbook, and exemplifies the characteristics of a healer. You see this in the resident who has taken medicine on as a vocation… as a calling. It is who they are and as a consequence, they take it as their responsibility and duty to strive for well-rounded excellence because, to them, there is no other option. This is the drive we strive for but only catch glimpses of when we are not devoured by our fears and shames and egos. If you ask every resident why they do what they do, they give answers that fall into this category: “I want to help people.” “I want to make people better.” “I want to make myself a better person and doctor.” It is what we write in residency application essays but seldom see in ourselves while in training. This is the most important motivator to trigger and mature in the residents we work with. All of the others are important tools to get people going, but without this, we are producers of machines and not physicians.

 

Factors/Motivators that deserve an honorable mention:

  • Golden Child Syndrome
    • “My parents made me do it.” You know these people. They were told what to do and are good at being told what to do.
  • The Challenge
    • The intellectual challenge of medicine drives so many physicians. The puzzle that a clinical case represents can be enough of a driver for some residents.
  • Silencing the Naysayers
    • There are some who do what they do because they have been told they cannot do it. Medicine…then Mt. Everest. See Ego for further detail.
  • The Narcissist
    • “Let me take a selfie while I sew up this laceration like a plastic surgeon.” Are you noticing an ego trend?

There are probably tons of other motivators you see that get people going. Share them in the comments and tell us the tell-tale signs that come with someone who is motivated by that factor.

~Yousaf

August 14th, 2015

The Answer

Ahmad Yousaf, MD

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

“Please answer my call.”

 

That was the text I received over the weekend from a friend after having missed his call. I called back and he was panicked: “what is alpha… al… alteplase?”  There was a pause as I waited for context… “My mother-in-law… she went into cardiac arrest. They got her heartbeat back, but they said she needs that medicine… should they give it?”

After hearing the context, I advised him that I thought it made sense — that they should give alteplase a try, given how critical the situation seemed. I hung up the phone. I had been sitting on a lawn chair in my backyard studying for the boards and, although I knew what the answer to this clinical question was on the ABIM, a feeling of uncertainty filled me. Without knowing what had just occurred on the phone, my wife saw my face and could tell something was wrong.  I explained what was happening and that I needed to go to the hospital to be there for my friend.

hospital hallway

By the time I arrived to the hospital, the situation had deteriorated further. The patient’s loving family was in all stages of grief as their mother/sister/aunt held on to life with the support of pressors and a ventilator.  I wanted to do something but knew it was not my place. I was a doctor in an alternate universe but today… today, I was just a friend. I gave a hug or two and awaited news on the status of the sweet woman who lay critically ill behind the ER curtain. She was the mother of 5 wonderful adult children, 2 of whom I have the pleasure of knowing. They are the type of people who never meet you without warm smiles and that ‘big-family’ type of love. On this day, however, I only saw pain in their eyes. I stood in the ER corridor with family I had never met and bowed my head and prayed with them.

An ER resident emerged from behind the curtain with a walk I was all too familiar with. He had bad news, and I could see his mind racing with the words that were going to be needed as he approached a large family who sat on the edge of hope and despair. The family collectively leaned forward as the resident fumbled with medical jargon like “coded,” pulmonary embolism, tPA, vasopressors, and futility. The eldest son frantically asked the questions on the mind of everyone except me: “What does all of that mean? Is she going to be okay?”

The resident took a deep breath and reworded his initial statement in an even less coherent manner.  He was struggling. They were struggling. He concluded his ramblings with a request of clarification of code status and ‘DNR.’

It has always been a personal frustration of mine to see a physician drop a bad-news bomb on a family and, then, in the time of their biggest vulnerability, saddle them with the burden of a perceived ‘decision’ that never really existed to begin with.  I put my hand on the shoulder of the resident mid-sentence and asked him to give us a few minutes. He gave me a look of relief and quickly escaped away to the sanctuary behind the nurse’s station.  I have always felt comfortable delivering bad news and saying what needs to be said, but this day was different.  I felt like a man between the two worlds of healthcare: the deliverers and the receivers.

She peacefully passed away about an hour later with her caring family around her.  She was surrounded by their affection and prayers.  I was a witness to their love and in awe of their display of absolute class and dignity. At one point, I absconded to my car and looked at the stethoscope and white coat that lay in the passenger seat. I concluded that so little of medicine had to do with those archetypal items that lay there and so much more of it with the intangible… The figurative space between a physician and his patient/family is full of that unquantifiable mixture of love, respect, fear, and worry. It is up to us to manage that space. That is our domain and our responsibility. The white coat… the stethoscope… the prescription pad… never has and never will be the answer.

doctors around a patient

~Yousaf

August 7th, 2015

Cat Herding

Gregory Shumer, MD

Greg Shumer, MD, is a third-year resident and 2015-16 Co-Chief Resident at the University of Michigan Family Medicine Residency Program in Ann Arbor.

Greg Shumer, MD, is a third-year resident and 2015-16 Co-Chief Resident at the University of Michigan Family Medicine Residency Program in Ann Arbor.

“The day you earned your MD, you became a leader… A leader to your future patients, a leader in your community, and a leader within the healthcare system.”It’s May 7th, 2015 – day 1 of the annual Chief Resident Leadership Development Program in Kansas City, Missouri.  It’s an event meant to welcome the  newly selected chiefs from family medicine programs around the nation and instill them with leadership skills and enthusiasm as they enter their third year of residency and chief years at their programs.  The program’s director is delivering an introduction speech to his audience – roughly 150 bright-eyed chief residents, including myself and my co-chief, who traveled from across the country to be part of the 3-day conference.

Cat Herding“And as chief resident, you are a leader of leaders – not an easy task!” he continues.  “Leaders are often independent and opinionated, and trying to direct an entire group of them is as easy as trying to herd a group of cats.”

He pushes a button on his handheld pointer, and a video begins on the big screen projector, showing images of rough-and-tough cowboys trying to circle up and direct large groups of small cats.

“Anyone can herd cattle,” one of the cowboys says as cats meow in the background, “but holding together 10,000 half-wild shorthairs, now that’s another thing altogether.”

We had a good laugh, and the chief conference was under way.

During our 3 days together, we learned that we all share common challenges.  Scheduling conflicts are near the top of the list.  Low morale and burnout are other common themes — attributed to long hours and the natural stress that occurs during residency.  We also realized that family medicine programs across the country share several positive themes, such as the sense of community and teamwork that exists within programs, and the strong bonds that develop through working together at the hospital and in clinic.

We learned that as chief residents, we wear many different hats.  In an average week, we serve as leaders, organizers, motivators, negotiators, problem solvers, teachers, and of course, third-year resident physicians in clinics and at the hospitals.  Through Myers-Briggs personality testing, we discovered our different leadership styles.  As an ENFP (Extroverted, iNtuitive, Feeling, Perceiving), I fall in the category of “idealist,” with strengths that include diplomatic persuasion and cultivating morale, and weaknesses that include an aversion to conflict and difficulty with setting limits for bad behavior.  We learned about five leadership practices: model the way, inspire a shared vision, challenge the process, enable others to act, and encourage the heart.

By the end of the conference, I felt inspired and ready to take on this whole chief resident thing.  I had been performing chiefly duties for about a month — dealing with scheduling conflicts, leading the annual residency retreat, participating in monthly meetings, etc — and it was the perfect time for this type of motivating and thought-provoking experience.  Now, close to 3 months later, I think back to my time in Kansas City whenever I start to feel tired or overwhelmed.

My co-chief Laura and I, at the chief conference in Kansas City

My co-chief Laura and I, at the chief conference in Kansas City

July 1st has come and gone.  The new interns arrived with their nervous smiles and freshly ironed white coats, and we all moved up a rung on the ladder.  As a chief resident, the beginning of a new academic year brings new challenges.  But it also allows for new and exciting opportunities — chances to serve as a resident advocate, to “model the way” for the interns and second-years, and to inspire positive change, little-by-little, day-by-day. Thankfully, my co-residents and faculty here in Ann Arbor make it rewarding and fun.

So, onward and upward.  Cat herding — ain’t a feeling like it in the world!

July 31st, 2015

Do I Want My Daughter to Be a Doctor?

Raktim Ghosh, MD

Raktim Ghosh, MD, is a 2015-16 Chief Resident at St. Vincent Charity Medical Center, in Cleveland, Ohio.

Raktim Ghosh, MD, is a 2015-16 Chief Resident at St. Vincent Charity Medical Center, in Cleveland, Ohio.

It was not a very typical Saturday morning in Cleveland, at least not to us. My soon to be 1-year-old daughter woke up with surprise in her big doe eyes. That’s right… she woke up not in her nanny’s lap or in her crib, but in between both of her parents who were still sleeping. This was probably the first time since she started recognizing us that she found both of us beside her in the morning.I smiled at her. “That’s how it is supposed to be, dear, but your parents are still residents, they are budding physicians. Moreover, for you, my little munchkin, your mom and I split calls so that one of us can be with you, although that leaves us in a situation where we live together but don’t see each other for days. Now I can see the obvious question in your innocent mind, ‘why do you work so hard, mom and dad?’ I could give you a simple answer, like, to get you more toys.”

A sudden cold zing waved through my back and jolted through me this lazy morning. I asked the same question to myself… why did I choose this path? More than 12 years ago, when I started medical school on a different continent, I actually had to work harder than this to get there. I thought it would be cool to be in a profession that involves saving lives. I chose clinical pharmacology as my residency specialty because I felt I needed to know about drugs that can cure suffering people. After I finished residency, I decided that my path wasn’t good enough. Call me ambitious or an overachiever! But the reality was, that feeling was chasing me. The decision to leave my country, my parents, and an established career was not easy. Now, when I’m in the final year of my second residency, have become a chief resident, and have almost started seeing the glimpse of light at the end of the tunnel again, part of me is back to asking hard questions. “That’s it? Or shall I go for subspecialty training?” I don’t know the answer yet. The only truth is ‘miles to go before I sleep.’ The primary reason I chose to apply for chief residency was to teach and give back to my juniors what I have learned so far. This is the most satisfying part of practicing medicine to me — being intellectually challenged every morning. However, this ambition takes away a few extra hours from my daughter’s play time, as daddy is still busy with his Ipad after coming home from work. I’m now used to switching between UpToDate and YouTube Baby Songs while she sits on my lap. But, it’s the rare Saturday morning that the three of us wake up together.

My daughter Rahi

My daughter Rahi

I never felt bored during my long course of training. Physically, I was tired at times, but mentally, I was never fatigued. It gives me feeling of extreme accomplishment and happiness when I see my patients can connect to me. They want to come back and see me again even when they’re not sick. This liaison keeps me going. There is no better feeling than throwing some rays of hope into some hopeless eyes.  Even when I have lost the track at times, my teeny tiny, but extremely strong, girlfriend-turned-wife and now mother of my child stood by me like a lone cypress for last 15 years. She has been my pillar of strength in my topsy turvy roller coaster ride, and undoubtedly, she’s the woman who made me what I’m today.

So I come back to the eternal question, “do I want my daughter to become a doctor?” Of course, I want her to make her own choice at the end, but my answer is YES. Because I think there is no better way to live than to feel content at the end of the day for what you do. I do sleep well at night, not because I am tired, but because I am happy.

July 24th, 2015

Heroes Do Exist

Ahmad Yousaf, MD

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

We live in a time of great cynicism and skepticism. We seem to see only the mundane and boring in even the most interesting and spectacular things.  The electrical rhythm of the heart that pulses through cardiac tissue and results in a coordinated muscle contraction that effectively ejects blood to the rest of the body for appropriate oxygen delivery is just… a bland grouping of chemical/physical terms that relay information, without the awe that should accompany it.  Perhaps it is the overload of data hurled at us from all different technologies that make everything seem ‘blah.’ Or maybe the cultural barrage of the age of ‘enlightenment’ that comes with modernity has left us so intellectually arrogant that we refuse to allow our hearts and minds the satisfaction of wonderment. Either way, it is as though we have lost the ability to appreciate the magnificence of existence around us and we have instead replaced it with dull expectation and assumed banality.

I was recently watching a debate between a few friends about which comic book superhero had the most depth. One of my friends claimed Batman was the most layered character, and his reasoning was as follows: Bruce Wayne was actually the costume and he was only himself (in his own voice and character) when he donned the Batman suit and cape.  Anytime he was Bruce Wayne to the people of Gotham, he was just acting and putting on a show. It was only when he was Batman that we could see what the real man was all about.  I mulled over the argument in my mind and could not help but think of the child-like awe comic book heroes still elicit from me, even as an adult. I thought: “Could it be that the heroes I adore are all around me already in suit and cape?” I began to think of the men and women that have affected how I think, act, and work.

Adapted from http://www.library.pima.gov

Adapted from http://www.library.pima.gov/

There is the one physician who carries so much medical knowledge in his superhuman mind that he nullifies the suspense of case conference by simply stating the rare diagnosis before anyone else can even process the differential. And the one doctor whose very intellectual prowess can result in the collective anal sphincter tightening of an entire intern class… And one whose eyes are surrounded by dark circles formed over a multitude of sleepless nights as he mulled over what else he could do for his ill patient. They all don their capes every day. The ICU doctor who conveys bad news like soft kisses or the one who seems to restlessly pace the halls of the cancer ward deep into the night like a vigilante there to stomp out any chance of pain and misery. There is the doctor who has been serving long enough to walk the corridors like a sentry, protecting the hospital from inappropriate care or unneeded costs. They move among us and look like us… but they are so much more. They are what we aspire to be. The one who doles out chocolate like justice or the one who holds the weight of the academic program solely on his shoulders. They uphold the honor and dignity of a profession that has turned to bitterness, misanthropy, and the bottom line. They live for this. For their patients. For their Robins. They are the heroes we need, if only we could see past the darkness of our preconceived notions of medicine.  They are there. On the proverbial rooftops of our hospitals… watching over us… teaching us… making sure that someone is ready to replace them when they are gone.

But then, they remove their white coats and return home to their families to continue their ‘normal’ lives as they try to convince the world that they are but mere mortals like the rest of us.

~Yousaf

July 17th, 2015

Good Luck! You Will Be Great!

Nicole Hugel, MD

Nicole Hugel, MD

Nicole Hugel, MD, is a 2015-16 Chief Medical Resident at University Hospital in London, Ontario, Canada

July 1st, the date of new beginnings in medical training. This is the day where we first get to use the title “Doctor,” start our first senior-level call, become subspecialty fellows, or finally reach the end of residency and formal clinical training. For me, July 1st marked the first day in my role as Chief Medical Resident (CMR). In my program, the CMR position is shared among six residents across two teaching hospitals. We have both teaching and administrative responsibilities, and, like most other CMR positions in Canada, we complete these alongside our regular clinical rotations.

Since discovering that I would get to be CMR this year, I have felt a mix of excitement and insecurity. I would go to sleep confident that I could excel in this position, then have nightmares that I would get in front of the whiteboard for a teaching session and completely forget everything I had prepared. As July 1st got closer, I got increasingly nervous.

Insecurity as I take on new clinical responsibilities is definitely not a new experience for me or for most other trainees and residents. As we progress through medical training, we are torn between feeling ready for more independence, and being worried we have not learned enough to complete more difficult medical assessments. These same feelings hit us with our first unstable patient, first time running a code, and first time on senior-level call. We are eager to make our own decisions and then second-guess every decision we make.

Part of this insecurity is a safety mechanism, and it helps motivate us to learn and make better clinical decisions. But, as residents, we need reassurance that our insecurity is normal. Mentorship is a huge part of building a career in medicine, but I find it especially important when moving toward additional clinical or administrative responsibility. Our mentors normalize our apprehension and build our confidence. They share their own successes and failures, and remind us that we are not alone in the challenges we face.

On June 30th, I was acutely aware of the big shoes I had to fill as CMR. The former CMRs have been wonderful teachers and mentors during my training. Exceptionally smart, they were an intimidating group of people. But as I walked into the CMR office for the first time, both excited to contribute to the program and nervous that I would not meet the standard they had set, the formers CMRs once again came through. I saw this simple sign posted in the office and was reminded that each of these individuals also had a first day as CMR. They each got through their first teaching session, call schedule conflict, and administrative challenge, and came out as leaders within our program.

A note from the former University Hospital CMRs

A note from the former University Hospital CMRs

Knowing I had the support of those who held the CMR position before me, I got through my first teaching sessions and now have several weeks of CMR behind me. I still have a lot to learn, but I already see an improvement in my teaching and clinical reasoning. I am ready for the new challenges this year will bring, and this simple sign makes me smile every day.

So, to everyone moving on to new roles this July, and facing the insecurity that comes with taking on more responsibility, I echo the statement of the CMRs before me, “Good luck! You will be great!”

July 10th, 2015

Transitions of Care

Andrew Ip, MD

Andrew Ip, MD, is a 2015-16 Chief Resident in Internal Medicine at Emory University in Atlanta, Georgia.

Brief HPI: 3rd year resident, Asian-American male, from Philly, presented to Emory University as a wide-eyed intern July 2012, currently admitted to become a new Chief resident at the VA

Meds: see EMR

Pertinent Labs: see EMR

Top Active Problems:

  1. Computer Codes – missing but awaiting IT approval
  2. Awaiting MRI of brain past 48 hrs – syncope work up
  3. Psychosocial – extremely anxious to start chief-ing and leave behind a transformative experience in residency

Sign-out: NTD overnight

Anticipatory Guidance: If starts to have a panic attack about being chief, ok to give Haldol 2 mg IM

Medical transitions of care are never easy – just the thought of signing out patients to a night float resident frightened me as an intern. Even as an upper-level resident, I was unsure at times of my ability to properly hand off patient care.  The above example follows a standardized format to give a cross-cover provider a succinct overview of a patient’s care, but things do get lost in translation. There is no better example of this at my residency program then the ICU month at our public safety-net hospital, Grady. Below is a graphic of our ICU sign-out structure:

ICU_Signout_structure

Our ICU signout process

This format keeps a team (1 resident, 2 interns) intact by avoiding any 24 hour calls; however it was extremely prone to sign-out mishaps and fragmented patient care. One case I will never forget ended up with a patient coding, likely due to hypoglycemia. During verbal sign-out rounds at 8pm, no one mentioned hypoglycemia; in fact, the call team (day team 1 in above graphic) did not even know much about the patient’s history or reason for ICU admission. The written sign-out also left out the critical information that patient had a blood glucose of ~25 on arrival to the ER. This was the infamous sign-out of a sign-out we all dread from multiple departments, let alone in the MICU.

While medicine transitions of care sometimes leaves a sour taste in my mouth (thankfully, iCompare, the flexible arm, will allow for a MICU 24-hour call system and hopefully address these sign-out issues), I want to now focus on a much different, non-medical transition – leaving residency.

As I signed out in the beginning, I’m going through the initial pangs of transitioning to my new role as a chief resident. It is a wonderful opportunity to teach, mentor, and work on the administrative side of academic medicine. But leaving behind the wonderful class of 52 residents I’ve worked with, laughed with, and cried with has made this transition so bittersweet.

EMORYMED-147_edited

Graduation June 17, 2015 for Emory Internal Medicine residents. Photo taken by Terrance Mason

Many in my class will move away from Atlanta, GA — in fact, will move to 13 other states by my count.  The time I’ve spent the past 3 years with these individuals has been transformative, a thorough ‘through-the-fire’ refining.  Residency launches many of us into a maelstrom of clinical duty mixed with scholarship and rounded out with lifelong bonds formed from shared experiences that only other co-residents can understand. My experience was so intricately tied with who I worked with that I know the friendships and memories made will endure much longer than my career. So if you’re a graduated resident, a graduating resident, or even a budding student doctor, remember to cherish the people you work with and the memories you make along the way.

Emory Internal Medicine residents at wedding of 2 residents!

At wedding of 2 Emory medicine residents!

One part of me is excited to transition to my new role as a chief resident, but the other part of me, ironically, doesn’t want to sign out of residency. Is that so wrong?

I would love to hear other people’s thoughts on transitions in their medical training, or even thoughts on transitions of care within the hospital!

 

 

 

 

 

June 30th, 2015

The Storm Is Coming

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

Ahmad Yousaf, MD, is the incoming 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

The tempest approaches. July the First. The interns approach the edge of their protected nests and prepare to jump into the whirlwind of senior-hood. The responsibility of managing a team weighs them down like the gravitational force, pulling them toward the unforgiving earth. They will flap their little wings and flex their intellectual muscles frantically in an adrenaline-rushed attempt to gain flight and legitimacy amongst their peers and attendings. If they look below, they will see the monsters they fear awaiting their failure: M&Ms, the furrowed brows of skeptical attendings, families with unrealistic expectations, and chief residents that appear more like administration than compassionate older siblings.As the interns graduate into medical adulthood, the miraculous circle of residency life repeats itself as wide-eyed, innocent, and fragile medical students crack the shells that have kept them from any burden of accountability. They will enter a coddled world of note writing, experiencing their senses and environments, and frequent feeds. Feeds packed full of tidbits of semi-pertinent medical knowledge regurgitated from seemingly reliable sources in the cited portions of UpToDate and Wikipedia. They will learn and grow strong and even feel, at times, that they could do what their predecessors had done without all of the ceremony and ritual. There will be many successes in the coming year, but even more moments of humility. The true question of the day is, do they have the grit and luck to survive the tumultuous time when they are most prone to insult and injury? … And, most of the time, they do.

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The final group to speak of during this momentous change of the seasons is the veteran horde of steely-eyed 3rd-year residents. Their faces carry the consequences of 3 years of struggle and perseverance. They are a collection of the wise, the hopeful, and the jaded. They glide through their final days efficiently and competently. Some look forward optimistically with eyes full of dollar bills, whereas others only see the mountains of debt that await them. Both groups, however, have begun the collective sigh of relief that comes with the conclusion of the most grueling, but satisfying, period of life they will ever experience.

And so the day approaches … July the First. The day when some will lift off into the stratosphere and others will be overwhelmed by the gale-force winds. Either way, the chiefs will watch over them, in hopes of catching those who fall and moving out of the way of those who soar. In the meantime, we hunker down … and prepare for the storm that is coming.

June 3rd, 2015

Work-Life Balance for the Uninitiated

Guest Blogger

Jenna Kay, MD, is a Chief Resident at Emory University Hospital. She will be starting her cardiology fellowship in July, 2015.

My daughter was born, 3 months premature, during my third year of residency. footprints-303798_1280Following a harrowing 3 months in the NICU, we joyfully welcomed her home. After 8 blissful but isolating weeks, I was eager to return to the wards. I happily reunited with colleagues and patients, but I also deeply missed being home. During quieter moments, I daydreamed about stroking my daughter’s tiny fingers and toes, bathing her in the kitchen sink, watching her breathe as she slept on my chest. I wanted to be everywhere at once.

I loved my growing family and was deeply invested in my training, but at the same time, many days felt unbearably hard. I was exhausted. Essentially, I was permanently on call, both at work and at home. There were no days off, no lighter months, no vacation. The support I received from my residency program was incredible, and my husband was an outstanding stay-at-home parent, but I still struggled with the adjustment. Spare time and independence were concepts of the past. A type A perfectionist, I reluctantly delegated tasks like laundry and grocery shopping to my husband, then felt disappointed if he didn’t do things exactly how I wanted. An avid runner, I discovered that I had to get up at 4 AM to feed my daughter, exercise, and get to the hospital by 7 AM. We ate a lot of pasta and canned soup. I finally understood why my older sister with two young children only called me when she was in the car. Multitasking was essential.

I couldn’t be everywhere at once, and I felt guilty leaving my daughter at home. The feeling was partially allayed by my staunch commitment to provide her with breast milk, which was especially important for a preemie. Every 4 hours, I had to excuse myself, find a private room, set up the apparatus, store everything in a specialized ice pack, and clean everything meticulously. Twice during pumping sessions, I had to abruptly detach to run to codes in the MICU. The lactation room was filthy, and I was terrified that I would give my daughter C. difficile. When I felt like giving up, five faculty members offered me their offices to pump. Not a single attending ever rolled their eyes when I asked permission to step out to pump. On the contrary, I felt celebrated and brave. And I kept going. Every time I hit a new low, the pendulum swung, and I soared higher than seemed possible. When my daughter was born, we weren’t certain she would live, and now she was thriving. We felt indescribably blessed.

When I began my year as chief resident, my head was slightly clearer. I was determined to pay it forward. Apart from pointing out lactation rooms (and offering my office) and optimizing schedules, I focused on checking in with new parents. How was life with baby, and how could I support them? We shared stories, advice, photos. Life is a constant juggling act, but somehow it gets easier. It helped to know that we were figuring it out together.

I never questioned my ability to handle both motherhood and medicine. No one told me it was impossible, and I wouldn’t have listened if they did. But a seamless “work-life balance” was impossible. Being in one place always meant I was missing out on the other. Balance is an ever-changing ideal that I set my sights on, but know that I will never permanently reach. It helps me reflect on what I want in the moment and figure out where to spend my energy. I can’t be everywhere, but I can make the most of every situation. My best is more than enough. Repeat.

Resident Bloggers

2015-2016 Chief Resident Panel

Raktim Ghosh, MD
Nicole Hugel, MD
Andrew Ip, MD
Gregory Shumer, MD
Ahmad Yousaf, MD

Resident chiefs in hospital, internal, and family medicine

Learn more about Insights on Residency Training.