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June 27th, 2017

Four-Oh-Wonk. The Reboot.

April Edwards, MD

April Edwards, MD, is the 2016-17 Chief Resident for Internal Medicine/Pediatrics program at the University of North Carolina School of Medicine.

At the beginning of the year, I wrote about the rude awakening I was experiencing with regard to my own finances. I heard from more than a few other imminent or recent resident graduates who expressed some degree of similar feelings of being inadequately prepared in the financial realm.

At the risk of being incredibly rudimentary, I thought now was as good a time as any to try to share a few small lessons and gems of information I have been gleaning during the past year. I am finally trying to take an active role in my finances rather than continuing to bounce from paycheck to paycheck, still naively thinking that “Financial Literacy” was something I’d “get around to later.”

Disclaimers:

  • I probably represent a rather extreme version of financial ignorance, and I suspect that most residents likely are a bit better versed in some or many of these basics. But this is targeted at others who might still be lacking financial savvy. In no way do I think this is the “right” way or only way to start trying to boost one’s financial IQ, but I wanted to offer it up as a way for people to at least get started.
  • Almost all of what I am going to write comes from a book I happened upon that knocked the rose-colored glasses right off my face, “I Will Teach You to Be Rich,” by Rhamit Sethi. I have absolutely no ties to the author, and I will get exactly no props or cash money for talking about it, as he has no idea who I am or that I have read his book. But I did find the book (despite the title, which I initially found a bit off-putting) to be a FANTASTIC financial primer for typical resident aged/minded folks. (I may or may not have found it when Googling “finances for dummies”…)

So here are a few of my thoughts — if you find any of them useful, amazing! If not — totally fine, too. I just want to keep re-circulating this topic into the general conversation for residents. And, I’ll probably sit on my porch in a rocking chair looking at the shiny fresh new resident Whippersnappers who are about to start their career, wave my cane, and say “Don’t be like me! Learn from my mistakes!”

Ok. Here goes.

1. Download Mint (www.mint.com)

Mint app

Mint App

Or something like it. Mint is an app/website that will let you track every single (cash or non-cash) penny that you spend. You input your various bank/credit/debit card/savings accounts, and then it shows them to you ALL IN ONE PLACE. Which is amazing. Because this is probably a good place for financial novices to start  — take inventory. How much money do you have? How much do you owe and to whom? I’m sure many Attendings used to do this sort of thing with an Excel chart or even by hand, which is also totally fine, if that is your style. The point is, take inventory. Do it now.

2. Look at where your money is going

Now that you have all of your financial info in one spot, look at what you are actually doing with that money. Mint (and Mint-like apps) makes it simple, because it automatically labels each of your transactions and keeps track of each category. Then, it provides nice visuals, like a pie chart that shows you what proportion of your money you are spending on, say, Travel versus Eating Out. It’s a nice way to catch things you probably don’t think about regularly — like the various monthly subscriptions you bought for Netflix/Hulu/Spotify, since those usually autodraft (and, out of sight, out of mind, right?) You can play with the categories as much as you want to make them make sense for you — for example, I have a category labeled “Colby” for pet-related expenses for the world’s greatest dog, Steven. T. Colbert Edwards. An expensive booger.

3. Determine fixed vs. flexible costs

From the inventory you made (of the things on which you are spending money), figure out which of those are true fixed costs — i.e., they are monthly or weekly “must pays.” scrabble tiles -- budgetThese generally consist of things like rent, utilities, cell phone, groceries, pharmacy, gas, car insurance, and debt/loan payments. Plus any of those recurring monthly subscriptions. Go back several months to look at the average cost for each of those, and write them down. Then look at “everything else,” which are your flexible expenses: Eating out. Trips. Gifts. And all your myriad one-time and unplanned expenses: License renewal fees, Board registrations, QBanks, interview hotels/rental cars, parking tickets. (FYI, I could write an entire other post on all of the hidden costs of finishing residency — Turns out that it costs a lot to graduate into being a real doctor.) Anyway, now zoom out. Is that what you thought you were spending on that stuff? In my case, I was spending way more than I realized, just not by really paying attention to where my money was going each month.

4. Make a conscious spending plan

Now that you know where your money went when you weren’t watching it particularly closely, you can turn the tables (on yourself), take the Code Team Leader lanyard, and start being the one calling the shots. Use the data you collected to actually plan how you want to spend your money. You already know the monthly amount of your incredibly exorbitant resident salary, and you know the unavoidable/fixed costs you have each month. Some general thoughts about how you should divvy up your money. Some “experts” suggest that, generalishly, your categories should look like this: All of your fixed costs together, ≈60%; savings, ≈10%; retirement and other investments, ≈10%; guilt-free spending, ≈20%. Again, this is a rule of thumb and, in this particular case, my thumb ala Ramit Sethi. But you get the general idea. Also, quick word(s) about those groups:

  • Fixed Costs (60%): Get rid of the stuff you don’t actually need to be eating into your money. Never watch Hulu? Cancel it. Have a subscription to a medical journal you always pretend you are going to read, and never do? Cancel it. (Plus, your university/hospital probably allows you to access most of the big name medical journals, so you can still read them if you want.) Make sure you’re only paying as much as you need to for stuff like your cell phone bill (downgrade to a lower-cost plan if you don’t need “unlimited minutes and messages”) or your cable bill. Seriously, call up the companies and ask them to slim you down to a plan/package that “fits” your usage.
  • Savings (10%): This one is hard, but try to have some. Some big-ticket items will require residents to have extra money around at some point — a wedding, a car, a baby or three, a down payment on a house. We probably all envision ourselves spending a good chunk of money on one or more of those things “later,” but it makes a lot of sense to put some money in those pots, so there is something from which to actually draw on when it gets to be “later.” Also, another less sexy category that you need to fund is “emergency/rainy day account”. (Or, more likely, lost job+got injured+unforseen repairs needed+rain). The rain alone you could probably deal with. You know, because, umbrellas.
  • Retirement/Investment (10%): Your hospital has some sort of retirement account that you should ask the GME about, so you can fill out the (generally single-page) form to get started. This is the 401k, 403b, 457b stuff. It’s alphabet soup — but it’s worth Googling to understand. Basically, start saving for retirement now, if you haven’t already. Most hospitals will help you out by automatically funneling some of your salary (as long as it follows their guidelines/contribution rules) directly into a retirement account associated with the above alphabet soup. And this happens before you ever see that money. Which means it is a whole lot easier not to miss it — because it was never part of what you were taking home in the first place. Huge psychological win. And if you want to be super fancy, you can also have your own (not necessarily work-affiliated) investment/retirement accounts. Like an IRA or Roth IRA. Turns out that if you put money in investment accounts, instead of under your bed (or even in one of the super low-yield savings accounts that most of us have), it will probably grow over time. Which is why people recommend investing. Giving investment advice is way beyond my pay grade, but learning at least a little about it is worthwhile. Investment managers make essentially the equivalent of a nicely arranged manila folder with the right balance of individual investment-colored papers in it — called index funds. They are pre-mixed investment portfolios for people like me who do not know how to build a “well diversified portfolio.”
  • Guilt Free Spending (20%): The point of this category is that, if you have done a good job at knowing how much you are going to be spending on fixed costs, then whatever money you have left over each month you can spend with a relatively clear conscience. You don’t have to worry that you’ll default on your credit card payment or won’t be able to make rent, because you already set aside that money. This is where eating out, travel, gifts, and concerts come in. No one wants residents to be any more burned out that they already are. So, with a little work on the front end, you can feel relatively assured that you can truly use the left-over bit for things/hobbies/extras that are important to you.

5. Make your credit score sexier

Credit scores matter a whole lot going forward. They are basically the financial health equivalent of a Medical Record FaceSheet. It’s a snapshot look at your financial “health.” How good are you with money? People who you will need to lend you money (banks, credit cards issuers, car salesmen, mortgage brokers) want to know how risky of a move it is to trust you. In this realm, instead of looking at medication adherence, health maintenance screening, and number of chronic medical conditions, lenders look at several dimensions of your financial health. The basic components are:

credit score factor pie chart

By User:Pne [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

  • What is the balance of credit/other people’s money that you owe vs. how much you have available to you/been approved for (credit utilization rate)?
  • For the money you already owe, how good are you at paying on time?
  • How long have you been at this whole borrowing money business (i.e., length of credit accounts, old vs. new credit)?
  • How varied are your credit types? (Better to have your risk spread around in different types of credit — credit cards, student or car loans, mortgages — than all in one type.)

You want your score to be basically as high as you can get it, because this means you look “healthier” to potential lenders, and they are more willing to offer you credit, without making you pay through the nose. Many banks and credit cards have programs that will keep tabs on your credit score month to month (so does Mint), which can be useful. Scores range from 300 – 850. Above 700 would be a good goal. But how?

  • The non-sexy answers are: Be a good steward of your credit. Pay your bills on time. Don’t willy-nilly accept credit card offers for which you’re “pre-approved,” just because you got them in the mail, or because you saw a funny commercial with Alec Baldwin. Don’t borrow more than you need (and, hopefully, you have a good idea of what you actually need, based on the steps above).
  • One quick move you can try that actually helps is to ask for an increase in your credit limit on your current credit cards. As mentioned above, part of calculating your credit score is your credit utilization percentage (amount used/total available or offered). So, harkening back to the days when we did actual math — increasing the denominator will make the overall percentage amount lower. You can literally call up your credit card company and say something to the effect of “Hi there, I’ve been a loyal customer for X years, I pay my bills on time, and I would like to request a credit line increase.” As long as you have been pretty reasonable with your accounts, they will often just do this for you on the spot! One of my cards tripled my limit during a 5-minute phone call. **Important: The point of doing this is to make you owe a lower percentage. It is NOT for you to spend more! That will literally defeat the purpose and shoot you in the foot.

6. Automate good decisions

Now that you have a basic background on how you have been spending your money and how you want to be spending your money, set it up so it happens automatically each month without you having to think about it! Get direct deposit for your paycheck. Then, link your checking, savings, and retirement accounts so that money is taken from your now replete checking account and neatly and automatically distributed into the other “pots,” loosely based on the allocation suggested above. This way, it happens without you having to remember or choose to do it each month. It will help you be fiscally responsible while you sleep (or more realistically, while you are on call)!

Phew. That was a lot. Bottom line, take a look at what your current spending is like on a granular level. Then decide what is important and what you need to be spending and saving. Set up your system to make that happen automatically so it doesn’t have to be another check-box at the end of each month. Be smart about credit, pay your bills on time, and push your credit score as high as you can get it.

I hope this was helpful to at least a few residents. Perhaps, like me, you didn’t get a solid background in this stuff earlier on, for whatever reason. It’s not the only way to think about finances, but it helped me, and I want to pay it forward. I know you guys are busy. Pouring your hearts and minds into doing good work. Keep it up. If no one has told you already this week, Thank You for what you do. Hopefully this can fall into the realm of “self care” and will help you build a solid foundation going forward.

Be well.

NEJM Resident 360

May 31st, 2017

What I Love About My Medical Students

Kashif Shaikh, MD

Kashif Shaikh, MD, is the 2016-17 Chief Resident in Internal Medicine at the University of Central Florida College of Medicine.

We all start with medical school

I still remember the day I got the welcome letter from my medical school. I was super excited and proud. My dreams of becoming a physician were now a reality. So, I pushed myself during my two basic science years and awaited my clinical years.

I bought my first stethoscope and white coat in anticipation of my third year. (By the way, I still have the stethoscope that I bought almost 15 years ago, and it is the only stethoscope I still use.) I started my first rotation in community health sciences and family medicine. I was thrilled! But, the first patient I saw described his chief complaint in a most interesting way. My patient said, “I have a gas that starts in my stomach and goes into my head.” Even though I have been practicing history-taking for some time, it took me a moment to collect myself and to complete that medical history. Anyway, things got better with time. Nothing beats being a third year senior medical student in a white coat with a stethoscope hanging around your neck.

books

Johannes Jansson/norden.org [CC BY 2.5 dk] via Wikimedia Commons

 I began my medicine clerkship. By that time, I could take a comprehensive history and physical without losing a beat. I started interacting more with residents and attendings. I wanted to be a teacher, and I started identifying role models.

During medical school, I knew what kind of resident I wanted to be. I wanted to develop the same virtues that I admired in my role models: Kindness, passion, and dedication to teaching, and supportive and encouraging when the medical education process became very stressful. I wanted to be my students’ biggest support in a nurturing environment. I wanted to make learning fun, easy, and enjoyable. And I wanted to guide them through all phases of learning, from the medicine wards to residency applications.

med student doing physical exam

By U.S. Navy photo by Mass Communication Specialist 2nd Class Gary Granger Jr. [Public domain], via Wikimedia Commons

A plan for teaching medical students

As an attending and a chief resident, I have been applying some of the key concepts about teaching medical students that I learned at the APDIM chief resident meeting.

  • 1. I start orienting medical students on day 1. I discuss learning objectives, expectations, and how they can get the most out of their internal medicine rotations. I explain the residency match process in detail. I guide them on how to get LORs and write personal statements.
  • 2. We do 1-hour teaching sessions, three times weekly. Each student gives a 10-minute presentation (2 students per session) to learn how to present and to become teachers — as residents and attendings, I hope they will carry on this tradition. They receive feedback  and some clinical pearls, and we work on board questions with explanations and test-taking skills and strategies.
  • 3. To help develop clinical reasoning, we have a student-style morning report session. We simulate an actual patient scenario. I ask them to take a history and to tell me what they would do on the physical exam to come up with a differential diagnosis. Then I ask them to narrow it down, based on labs and imaging they would order.
  • 4. I assign new patients to a medical student and an intern. The patient sees the student first, followed by the intern. We all sit down and critique the student’s presentation of the case. Then I round with them to do bedside teaching. Our team comes up with a consolidated plan for the next day’s rounds. With this teaching method, students begin to master clinical reasoning.
students in a lecture hall

By HBS1908 (Own work) [CC BY-SA 3.0], via Wikimedia Commons

The best part of being an educator

I hear a lot of people complain about medical students. Do teachers and educators take responsibility for orienting them and teaching them? Patient care can be time-consuming, but students need direction. What’s the point of being on a rotation if no one is teaching? We have all been students. Engaging students more, and emphasizing how important they are as team members, makes a huge difference.

graduating students

By DariaRomanova (Own work) [CC BY-SA 3.0], via Wikimedia Commons

I am amazed by medical students’ learning potential. They just need a little motivation to get things moving. I ask these students to be the future educators and be role models for their future students. Students learn best when they are given constructive and objective feedback through examples.

I am very proud of my medical students. They are my responsibility when they are rotating with us, and they should get maximum education out of the rotation. I dedicate this blog to all the medical students who are our future educators and physicians. Make us proud. Work hard, and don’t let anyone discourage you. There is a reason why you were selected for medical school. Best wishes and good luck to everyone in their future goals.

education innovation

By Willow Brugh (education innovation) [CC BY-SA 2.0], via Wikimedia Commons

    • “What the caterpillar calls the end of the world, the Master calls a butterfly.” – Richard Bach

NEJM Resident 360

May 16th, 2017

Constructive Criticism

Joseph Cooper, MD

Joseph Cooper, MD, is a Chief Resident in Internal Medicine at Geisinger Medical Center in Danville, Pennsylvania.

Here are some questions that are still on my mind as I approach the tail end of my chief year. I’m thinking about the best ways to offer constructive feedback.

  • What is the best way to approach a struggling learner?
  • What is the best way to give guidance and feedback without being perceived as a tyrant or overbearing?
  • How can I maximize the potential of my team members and the trainees with whom I work, based on performance evaluations?

A senior colleague surely did not lie when he told me that his year as chief resident was “one of the best years of my life.” Our institute might be unique — I have an unrestricted medical license, I function as a teaching hospitalist for 11 weeks of the year, and I precept in the outpatient general internal medicine clinic 1 day each week teaching residents. So, I might have the perfect transition from resident to “junior attending.” But these activities come in addition to the teaching responsibilities, leading of daily morning reports, troubleshooting, and being the mediator between the residency administration and the residents that are the essence of being a chief.

Governors Island. New York City

Governors Island. New York City, NY. My own work. Iphone.

I think about the great mentors I’ve had throughout my training, and I try to emulate the feedback given to me (whether direct or indirect) when I interact with the learners under my tutelage. But during my short time as a “junior attending,” this year, the above plan is a lot easier said than done.

 

The trick is to emulate mentors who thought about the 3 questions at the top of this post, and NOT to fall into the trap of saying what trainees want to hear. For example, I remember feedback sessions with attendings who would say: “You’re great, you’ve done everything right, only thing to improve is that you should read more.” Read more? Read more? I always got a bit upset by this, because we all should read more. Medicine is life-long learning, for medical students coming out of basic science to the seasoned triple-boarded subspecialist/physician scientist. So again, back to the original questions at the beginning of this entry. How do clinician educators and mentors provide actual “constructive criticism,” that is appropriate, non-threatening, and useful in the future?
I’m by no means an authority on the matter, but here are some helpful hints on that seem to have worked well this year:

  1. Set the stage: Provide clear expectations. Sometimes this requires going the extra mile and providing a written document rather than verbally setting expectations at the beginning of a rotation/week on service. I have drafted my own “expectations,” that I email to all learners prior to coming on service. This step is key to providing useful feedback at the end of a rotation, because the learner can’t say “well, I didn’t know I was supposed to do XYZ.” Setting the stage also applies to the environment in which feedback is given: in a timely manner, and one that is private, protected, and confidential.
  2.  Ask open-ended questions: You can never go wrong with this. With patients or with learners. This is a skill most of us accept as important, but often fail to use correctly. Beginning a feedback session by allowing the learner to self-reflect on his or her successes will usually allow for an easier transition to discussion of areas where the learner needs improvement. A simple introduction such as: “So, what did you think of the past week?” is non-threatening, open-ended, and allows the learner to start and (importantly) control the dialogue.
  3. Use the “sandwich” technique: This is only a bit different from the infamous “breaking bad news,” dialogue, but the sandwich technique is an effective way to deliver constructive feedback and promote change in the skills and behavior of the learner. To use the sandwich technique, first reinforce and give positive feedback on skills and behaviors that you directly observed. This fosters confidence in the learner, promotes positive reinforcement, and usually encourages the learner to seek feedback from others. After this step, ask the learner to identify deficiencies and areas in which he or she thinks improvement is needed. If the learner has already identified areas that need improvement (in the open-ended dialogue in step 2 above), you already taken the first step. Provide them with specific examples on how they can improve and in the behavior/skills that you directly observed that could be refined. When giving positive feedback, it is best delivered immediately, while “on the spot.” When giving constructive feedback, I’ve found it best to keep a log, and review situations at a formal feedback session near the end of the learning experience.
  4.  Seek confirmation and end with a plan: The goal of a constructive feedback session is to be non-confrontational and to give the learner tools and skills to facilitate change. At times, these sessions may be emotionally charged, and the learner may take the feedback personally and feel “singled out.” Following steps 1-3 above will help avoid this angst. Finally, have the learner make an action plan before leaving the session. (E.g., exactly how to approach a patient and care plan.) Have the learner give you their summative assessment and then facilitate and form an action plan for moving forward.

Educators should continue solicit guidance from mentors and institutional leaders about how they provide constructive feedback to learners. Lastly, the educator should always solicit feedback from their learners, confirm constructive feedback, and have an action plan to improve deficiencies.

On that note, I will leave you with a“throwback” New York City photo, in preparation for my return to the “big apple.”

 

New Yorker building in NYC

Garment District Rooftop. New York City, NY. My own work. Iphone.

 

March 20th, 2017

Resident Wellness in Graduate Medical Education

Kashif Shaikh, MD

Kashif Shaikh, MD, is the 2016-17 Chief Resident in Internal Medicine at the University of Central Florida College of Medicine.

Happy Endings:

Living in Orlando, one cannot escape Disney. Disney movies are a delight, because one subconsciously anticipates that the happy ending is going to make up for the rest of the characters’ struggles. It works for me!

Be it Simba, Cinderella, Snow White, Belle, or  Elsa, every Disney fairy tale gives us the desired ending of a happy and prosperous life. These characters go through many adversities, and new pages turn in their stories, but there is always a ray of light at the end of the tunnel.

Simba in the Lion King

By Loadmaster (David R. Tribble) (CC BY-SA 3.0 via Wikimedia Commons)

So, without a predestined Disney ending, how do people in healthcare professions cope with the daily stress? For me, music and movies allow me to recover and recuperate. For others, the escape might be sports, arts, travel, music, family or social time, or something else that provides social support. Life is full of challenges and surprises, but it would be absolutely boring without any challenges, right?

The beginning of the story:

The first and the last day of medical school are unforgettable experiences for most of us. We are anxious, nervous, and terrified on day one, because we don’t know what the future will bring. But that last day makes up for it — we look back and smile — we have made it and can embark on our next adventure (residency).

As they say, success is not a destination. It is the direction in which one is traveling. First, let me describe my own situation: During the first month of my internship, I went through a big learning curve, like most of us do. (Just for context, I was in the last batch of interns who were allowed to work 24 hours shifts. When I became a second-year resident, the ACGME decreased the maximum work hours to 16 for the interns.) Long hours are stressful, even under the best of circumstances.

graduation photo

By Joe Hall [CC BY 2.0], via Wikimedia Commons

I have supportive family and friends, and I found a little group where I could share my problems and support others — bottling up frustration does not help! My colleagues gave me perspective on handling stressful situations or scenarios. As I advanced, my friends were one of the reasons that I looked forward to going to work every day. My biggest support groups during residency were my patients (who made me feel tremendously happy and fulfilled, because I was taking care of them), my colleagues, and my wonderful medical students.

doctors at a conference

[CC BY 4.0 ], via Wikimedia Commons

Healthcare is, no doubt, one of the most stressful professions. It requires utmost dedication. As residents, we make sacrifices in our social lives, like missing holidays with our families and our best friends’ birthdays and weddings. (Not to mention the obligation to work on presentations and research projects and to study for ITE exams and boards.) Residents must apply for fellowships and jobs after graduation. All of this happens at such a fast pace that we barely keep our heads above water. So how does one find a balance when one works so much and socializes so little?

Achieving Resident wellness:

Most medical graduate programs struggle with promoting resident wellness. In a 2016 systematic review by KS Raj, resident well-being was lower than that in the general population (J Grad Med Educ 2016; 8:674). Notably, PGY1s reported less satisfaction with their lifestyle than did PGY2s and PGY3s. However, the reviewer also noted that resident autonomy, competence, and social relatedness was associated with greater resident well-being:

  • A sense of control and autonomy
  • Pursuit and achievement of goals
  • Opportunities for learning
  • Confidence
  • Increasing mastery of techniques and interactions
  • Positive feedback
  • Positive colleague relationships

Sleep is another important factor in resident wellness. Residents who were not sleep-deprived reported better well-being. Residents with more personal-time availability for activities such as exercise, socialization, and errands were more likely to report positive residency experiences and positive emotions. Being in a relationship was associated with overall improved well-being.

Residents identified their well-being as affecting relatedness (specifically, the quality of discussions with patients and interactions with colleagues), competence (performance and decision-making), and autonomy (motivation with both daily work and career).

In a 2017 JAMA analysis, Shanafelt et al. found greater mental well-being to be associated with greater empathy in internal medicine residents. Also, ITE scores and academic success has no correlation with well-being (JAMA 2017; 317:901). Interventions such as faculty meetings at scheduled intervals to discuss progress and goals did not improve resident well-being or decrease burnout rates.

workout room

www.localfitness.com.au [CC BY-SA 3.0], via Wikimedia Commons

Should residency programs implement wellness programs?

According to Raj, residents who are most likely to participate in wellness programs are those younger than 32, females, and whites. Men more often question the utility of participating, whereas nonwhite residents are more likely to be concerned about confidentiality. Other factors associated with not utilizing a provided wellness program are a feeling of helplessness and perceived stigma.

As I was surviving my intern year, I promised myself that I would help my interns and medical students. I told myself that I would support them, that I would create a nurturing environment for learners and treat them not only as my colleagues but also as my comrades and friends. I would encourage them to share their problems; I would give counsel and guidance and support. Now, I’m a Chief Resident and I’m trying to keep my promises I made to myself. I try to make sure my interns and students don’t have to go through the difficult times alone.

physician-themed cupcakes

By Clever Cupcakes from Montreal, Canada (Doctor Themed Cupcakes) [CC BY 2.0], via Wikimedia Commons

My recommendations to Chief Residents and residency programs:

1. Provide and ensure resident autonomy, competence, strong social relatedness, adequate sleep hours, and time away from work.

2. Encourage and promote perseverance, which is predictive of well-being, and greater well-being is associated with increased resident empathy.

3. We don’t yet know which specific interventions enhance residents’ well-being. Therefore, wellness committees from different programs should create a forum wherein they can share strategies that have been effective.

4. Provide third-party counselors to avoid stigma from seeking counsel.

5. Form support groups, where people can share their own experiences and provide support to others.

6. Organize more social events and group activities for team building.

7. And, most importantly for all of us:  Look after your colleagues and friends, including medical students.

race finish line

Joshbdork [CC-BY-SA-3.0], via Wikimedia Commons

Please feel free to share any intervention that has improved well-being of residents in your program or anything else that you think might help.

“Health is a state of body. Wellness is a state of being.” — J. Stanford

 

NEJM Resident 360

February 24th, 2017

Z71.1: Worried Well

April Edwards, MD

April Edwards, MD, is the 2016-17 Chief Resident for Internal Medicine/Pediatrics program at the University of North Carolina School of Medicine.

I took my dog to the vet today. You’d think this would be a straightforward sort of thing for a medical professional. You’d be wrong.

When I woke my dog up at 5:15am (my new daily start time, as it’s apparently the only way I can find time to do board questions, and is also the excuse I use when I miss the majority of said questions), he seemed sleepy. He’s a really hyper, ADHD-type dog, so slowly slunking about was not his usual M.O. Despite my rational patient-assessing abilities, I naturally assumed he had cancer and checked his lymph nodes and examined his poop. I stuck my stubby “people” otoscope in his ears desperately looking for otitis. No dice. He was still sluggish even after being more awake, so I took him in to the vet’s office at their earliest appointment today. Where I then proceeded to be the worst patient ever.

Nurse: “What seems to be wrong?”

Me: “He’s just not right.”

Nurse: “Why do you think that?”

Me: “I mean, he’s peeing and pooping fine, and can still walk and chase balls and stuff. He just seems not right.”

Nurse: “…..” (*uncomfortable eye contact*)

Nurse: “Okayyyy. Well, what medicines does he take?”bulldog

Me:  “Just the regular stuff.”

Nurse: “Flea, tick, and heartworm protection?”

Me: “Yeah. The regular stuff.”

Nurse: “Which brand?”

Me: “You know. The kind in the red box. The red box from PetCo. I mean PetSmart. Or is it PetCo?”

Nurse: (*protracted sigh*)

I consider how I must sound to her, and I laugh out loud. The nurse continues to stare. But now that I’m laughing at myself, I think I’m funny, and I decide to continue my roll …

Nurse: “What kind of food does he eat?”

Me: “It’s in a blue bag.”

Nurse:  (*staring*)

Me: “You know — it’s little brown pieces.” (*bursts into giggles*) “Sorry, couldn’t help myself. “

Anyway, after getting through the triage questionnaire, the vet checked out my dog, rectal temp and all. He’s fine. Completely and totally fine. But I’ve become one of the patients I sometimes see in my clinic. And I know, without a doubt, that the ICD-10 code is Z71.1: Worried well.

I need these moments. These times of transposition where I am reminded what it feels like on the receiving end of a stethoscope. How, despite having a smart watch, I am not adhering to a diet and exercise plan of which anyone would be proud. And even though Zyrtec reliably helps my seasonal allergies, I can’t seem to be bothered to remember to take it every day, and then tell colleagues how my allergies aren’t well controlled. How the morning after I eat beets, I temporarily think I have renal failure. Every time. And a thousand other examples, some scary and serious, others mundane. Examples of being human.

My patients remind me of my own humanity.

 

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January 13th, 2017

Ganbare

Jamie Riches, DO, is a 2016-17 Chief Resident in Medicine at Memorial Sloan Kettering Cancer Center

Jamie Riches, DO, is a 2016-17 Chief Resident in Medicine at Memorial Sloan Kettering Cancer Center

“May I never see in the patient anything but a fellow creature in pain.”- The Oath of Maimonides

I am not immune to the post-election frenzy. Never in my relatively short life, nor in my even shorter existence on social media, have I seen people so divided. Shortly after the president-elect was named, I found myself wondering, “Are you one of us, or one of them?” I had to sit myself down and ask what that even means… I am no party loyalist. I am an American. I voted for a candidate who I thought represented my fundamental values, and against a candidate who has incited a furor with which my values do not align. It occurred to me that most Americans have made the same decision, with varied outcomes. 

Spoiler alert: I didn’t vote for Donald Trump. I spent a good few days wondering how anyone could. I stayed quiet — a passive observer of Facebook and Twitter. I watched as documented hate crimes filled the news, as people’s relationships became publicly strained. I told my dad that I was “heartbroken” after the election, and he said, “Why? I couldn’t stand her.” He was one of them. We quickly changed the subject. My dad is probably considered an “uneducated white male,” when it comes to polling stats and media representation. My father doesn’t have a medical degree, or even a college degree, but he has a knowledge base and skill set that allowed him to perform a job that I am not capable of. He’s a retired New York City firefighter, along with his brothers, his nephews, and my mother’s cousins and their sons. He’s a smart guy. They all are. They’re good men. They do good work. I started to dissect the term “uneducated” and even become offended by it. I moved into a new apartment last week and hired a team of people to help me disassemble and move furniture. These were probably “uneducated” or “working class” people, who again were able to do a job that I simply could not. Their education, their training, is different from mine. Their electoral decisions may (or may not) have been different from mine. We are people. We are Americans. I am part us and part them. 

As I frantically refreshed my Facebook feed, I continued to come across divisive language. The same people who think Matt Maloney has no right to ask his employees to resign if they disagree with his criticism of the president-elect think it’s OK to ask people to leave the country if they disagree with their religious views and vice versa. I thought about my own workplace and what it would mean to allow such discrimination (on either end of the political spectrum) to prevail. 

I work at a major cancer center with more than 10,000 employees. My colleagues, of all races, religions, nationalities, genders, sexual orientations, political affiliations, all come together day after day for the same cause: to conquer cancer. Period. Patients come from all over the world to be seen by experts in their disease. We do not ask, “To whom do you pray?” as a part of the history and physical. We do not ask, “To which government are you loyal?” We treat, we care for, we heal. We fight for our patients’ dignity throughout their illnesses and at the end of their lives. We stand with them and their families. We share their hopes and their fears. Their successes are ours to celebrate and their failures are ours to grieve. 

People in the world are scared right now. Those who are scared now felt safer on November 7th, and those who were scared on November 7th feel safer now. Fellow creatures in pain. As I was driving to work the other day and quite honestly, musing on the election results, I noticed a sign that said, “Hill blocks view.” Therein lies the metaphor: We see the worst parts of ourselves when our security and our stability is threatened. I’ve experienced this first-hand. We, as physicians, preside over what are often the most terrifying moments of people’s lives. Our job is to understand and clarify those fears and to mitigate any exacerbating factors. We do not dismiss them as fabricated or unfounded. What would it look like if we did? What if societally, we adopted this principle of “selective tolerance” and how would it affect our immunity?

Midwest Farm

Painting by Howard Horii

My grandfather-in-law, a Japanese-American (who had never even visited Japan), spent a number of his formative years interned in a camp after the attack on Pearl Harbor. Could this happen again in our lifetime? I don’t know. Could my [same-sex] marriage be federally nullified? I don’t know. Am I overreacting? I don’t know, but the line between simply doing what is right and standing up for what is right has become more prominent. Grandpa Horii died at 92 years old, a successful architect, professor and artist, father, grandfather and husband, whose resilience and determination were nothing short of awe-inspiring.   

I’m a big-picture thinker. I’m moved by systemic reform. I’ve been unable to wrap my head around the big picture lately, so I’m attempting to train myself to see smaller-scale… daily human interactions. My family, my profession, not my politics.

water tower

Painting by Howard Horii

In his incredibly moving New Yorker piece called “Health Of The Nation,” Atul Gawande writes, “Our hospitals and schools didn’t suddenly have Reaganite values in the eighties, or Clintonian ones in the nineties. They have evolved their own ethics, in keeping with American ideals…The helping professions will stand by their norms… Our fundamental values — values such as decency, reason, and compassion.”

Ganbare is a Japanese term of encouragement, often likened to the American expression, “Hang in there!”

In the fight to preserve decency, reason and compassion, “ganbare,” my friends.

December 28th, 2016

A Reflection on The Hippocratic Oath

Kashif Shaikh, MD

Kashif Shaikh, MD, is the 2016-17 Chief Resident in Internal Medicine at the University of Central Florida College of Medicine.

Questions for young physicians:

Do you remember and recall the series of events that inspired you to become a healthcare provider? Are you satisfied with the field of medicine? Have you ever thought about your perceptions of healthcare before and after becoming a physician? Have you ever been a patient yourself? What attributes in our healthcare system do you wish didn’t exist or need to change?

After finishing my rounds in the ICU, I was speaking to one of our charge nurses. We were discussing the advent of electronic health records and charting and its effects on patient satisfaction. She has been a nurse at our hospital for more than 25 years. Her thoughts: She was able to chart effectively and efficiently before the advent of EMRs, and she was also able to spend considerable amount of time at the bedside speaking with patients. But now, she must meet the excessive demands of EMR charting, which are strictly enforced. This has led to a decreased amount of time spent at the bedside with patients.

Patient satisfaction scores and charting are key determinants in hospital reimbursement these days. Insurance companies are the main driver in the relationship between adequate charting and hospital reimbursement. But the required “adequate charting” affects patient satisfaction scores in inadvertent ways: A frequent complaint that we hear from our patients is that the providers don’t spend enough time talking to them at the bedside!

Papyrus text: fragment of Hippocratic oath. Wellcome Library, London. Wellcome Images (http://wellcomeimages.org). Copyrighted work available under Creative Commons Attribution only license CC BY 4.0.

Here is he modern Hippocratic oath, to refresh our memories:

“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”

I had another conversation, similar to the one I had with our nurse, with one of our senior vascular surgeons. He has been a surgeon for more than 30 years. He mentioned how he spends hours working on his daily progress notes on the electronic health record. We also discuss how much time is spent on charting in the U.S. compared with other countries. For example, in the U.K., charting is done specifically to document pertinent patient information, for the sole purpose of patient care, rather than to justify requirements of insurance companies for billing purposes.

Sadly, today, most providers at the hospital are busy charting and documenting patient care in front of computer screens. Providers go to great lengths to meet requirements for healthcare reimbursement, and most of them are under time constraints to complete their paperwork. They also put in orders  electronically. These tasks directly affects the amount of time spent at the bedside talking to the patients. The components in the history & physical and progress notes mandated by the insurance companies require a substantial effort, and some of those requirements have no bearing on patient care.

By Jerry Berger [CC BY-SA 4.0], via Wikimedia Commons

By Jerry Berger [CC BY-SA 4.0], via Wikimedia Commons

I agree that EMRs are a more cost-effective and efficient way to track patient care than is paper charting. It is also an effective way to put in orders. But a universal EMR would save tremendous resources. But we need to define an effective universal EMR system for documentation and charting that targets patient safety, quality, and continuity of care. Those functions would allow us to do what healthcare providers need to do: Spend time at the bedside talking to our patients and their families (read: increase patient satisfaction). It would also foster good rapport between healthcare teams and patients.

Foto de la Biblioteca Vaticana scan from book

Foto de la Biblioteca Vaticana scan from book. User: Rmrfstar [Public domain], via Wikimedia Commons

 

Clinic Painter [CC BY 3.0], via Wikimedia Commons

Clinic Painter [CC BY 3.0], via Wikimedia Commons

I hope as the time goes by, we see some positive changes in more effective utilization of EMR. Should we allow insurance companies and legislation to define healthcare practice?

I would like to end this article on the last paragraph of the Hippocratic Oath.

“If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.”

 

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December 22nd, 2016

“Pimping”: Malignant or Not?

Joseph Cooper, MD

Joseph Cooper, MD, is a Chief Resident in Internal Medicine at Geisinger Medical Center in Danville, Pennsylvania.

One of the most respected and skilled clinician-educators (and, of course, he is an Infectious Diseases specialist) at our institute came into my office, sat down, and immediately starting eating pretzels. “Let me know what you think about this,” he said between bites. He went on to recapitulate a recent interaction he had with the members of the Internal Medicine team (medical students, house staff, and the attending physician) about a week ago.
He described a presentation to our emergency department of a young woman with headache, neck stiffness, and fever, who was previously well and had young children at home who were currently ill. He reported the lumbar puncture results to the house staff — the results included a mildly elevated protein level, normal glucose level, and pleocytosis with a predominance of neutrophils and monocytes. He then asked the house staff to formulate a differential diagnosis and explain their reasoning for said diagnoses. Later, he addressed the case again, and changed the values of the cerebrospinal fluid on the patient to clearly illustrate a bacterial source rather than a viral source, and he asked this question: “The pharmacist is standing at the Pyxis machine asking what medications to give. What are you going to tell her?”

Granted, I was not present for any of these interactions, but the vignette seemed more than reasonable to me. He was clearly trying to teach and have the house staff work through the differential diagnosis of deranged cerebrospinal findings — different disease states, offending pathogens, and treatment modalities. From the tone of his recitation of the events, I knew he was expecting a bit more than what he received from the house staff. He then asked me, “How do our residents learn today without being questioned?” I answered, “I’m not sure, but I’ve always found that questions are the best method.” The ID specialist left me with one last question: “Do you think I was too hard on them? Was I being a ‘malignant pimper’? Because I surely don’t want to be that.”

Frederick L. Brancati first coined “the art of pimping,” in his 1989 JAMA article: the practice of posing particularly difficult questions to learners. There are undertones in Brancati’s article (which is older than Justin Bieber) about the separation of power between the teacher and the trainee. Notions of respecting the teacher and expecting the trainee to follow the “chain of command.” Critics state that much of the article was written tongue-in-cheek, and it even prompted a response article twenty years later by Allan S. Detsky about learners taking back their power. Although each article illustrated differing approaches to pimping, they agree pimping confers some value to learners.

Wear et. al published a study in 2015 in which researchers examined interview responses from 4th-year medical students on perceived harms and benefits of pimping. The results were quite interesting, and although the cohort of medical students was not large (and no residents were included), many fundamental issues came to light. Students saw the value of pimping as allowing them to learn on their feet, develop the proper diction to speak with their colleagues, handle anxiety and pressure, and, ultimately, to motivate them to learn on the spot or later if they did not know the answer. “Malignant” pimping was identified by the students as situations in which the teacher was exerting hierarchical power, asking questions which were outside the scope for the learner (much too difficult), was buffering the ego of the teacher, or was simply humiliating the students by exposing deficiencies in knowledge rather than trying to create new connections.

Hospital de Sant Pau. Barcelona, Spain. My Own Work. Canon DSLR.

Hospital de Sant Pau. Barcelona, Spain. My Own Work. Canon DSLR.

Hugh A. Stoddard and David V. O’Dell made the ultimate comparison in their 2016 publication in Journal of General Internal Medicine, stating that psychological safety is the key difference between Socratic method of teaching and pimping. They defined the Socratic method as “prompting students, through cross-examination, into acknowledging their own fallacies and then asking them provocative questions to steer them towards realizing true knowledge via introspection.” The importance of psychological safety is highlighted when the learners feel they are in a safe environment, are comfortable with themselves and others, and feel valued and mutually respected without hostility and the threat of possible humiliation. The authors note that, even in a psychologically safe environment, Socratic teaching does not allow for a sub-par performance and that accountability is not a trade-off for the said safety.

This brings up a very strong and often overlooked point. I hear my administrators say all the time that residents should be more accountable. Accountability must be clearly defined and, at times in medical education, it is not. Sure, we have ACGME benchmarks and standards of what a “normal and average resident should be achieving by the time of independent practice.” At times, the sense of urgency and accountability seems to be lacking within the millennial generation. Learners expect to be spoon-fed lectures with important concepts and have protected time to learn those concepts, yet a very few seem to really possess that internal drive or accountability to own medicine, own the concepts, own the pathophysiology and disease process, and own their patients, because ultimately it is about their livelihood.

Returning back to the pretzel-eating, bow-tie wearing ID specialist’s question: Was he too hard on them? Was he being a malignant pimper? Although I did not witness the entire interaction, I would have to say no, absolutely not. I know he wants the house staff to learn, and he does not exhibit hierarchical power in his line of questioning, and he does not need to buffer his ego (he has won numerous teaching awards at our institution) or humiliate anyone. I offered him a morsel of constructive criticism, echoing what I’ve detailed above.

Lembongan Island, Bali. My Own Work. Canon DSLR.

Lembongan Island, Bali. My Own Work. Canon DSLR.

As I continue on throughout my chief year and move into fellowship, I must heed my own advice. Setting the stage and creating an environment of psychological safety is key when questioning learners. Numerous studies and evidence prove that posing questions at an appropriate level to the learner is the foundation to clinical reasoning and teaching, and we should not stray from this. Posing questions to our learners gives us a better understanding of their knowledge, their ability to explain concepts, and their deficiencies. The best clinician-educators take this information from their learners and expand on information that fills in deficiencies, or explain concepts in a way that the learners will never forget. Better yet, they motivate the learner to independently seek knowledge or skills they are lacking, with a continued thirst for learning.

 

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November 4th, 2016

From the Prescription Pad to Reality

April Edwards, MD

April Edwards, MD, is the 2016-17 Chief Resident for Internal Medicine/Pediatrics program at the University of North Carolina School of Medicine.

A harsh reality I am coming to terms with, as a newly minted “pre-tending,” is that we don’t know the cost of the care we provide. There are recommendations for things like High Value Care, from organizations like the ACP. But how much do things actually cost? Certain apps and websites, like the Healthcare Bluebook, give you an idea of the cost of tests, procedures, and medications that you are ordering for your patients. But often, especially at hospitals like mine, public hospitals that serve many uninsured, under-insured, and Medicare/Medicaid patients, we encounter situations  where patients can’t afford the services and medications that they need. I often find myself turning to sites like Good Rx to get coupons for patients, but, beyond this, the reality is that I don’t know where they can get affordable care.

I live in North Carolina, and I recently had a patient with presumed Rickettsial illness who was unable to afford doxycycline. I assumed this antibiotic was so basic and simple and been marketed for such a long time that surely it had to be accessible. But he wasn’t able to afford it. So how can we help? What tools are at our disposal?

Good Rx is one. If you type in a drug name, it will show you the pharmacies near the patient’s home that have that medication; the patient can compare prices at different pharmacies in the area. You can get printable coupons; you can print a voucher for the medication. We use the old standbys of the WalMart $4 list and the Target $4 list, and many medications are on those. Other resources exist, like Formulary Search, to tell you what is preapproved by a patient’s insurance. Remember all that prior auth paperwork? There are budding apps to help you with that.

But this is one of the things that we just don’t receive any training on during medical school and residency. I wish that it doesn’t matter — that “I’ll just prescribe the Best Therapy for my patient.” But I’m realizing that is a real struggle. In real life, if the benefit of the Best Therapy is something like 0.05%, but that Best Therapy is 10 times more expensive than the next best drug, sometimes it makes sense to recommend the one that is technically inferior but affordable. Because my patient will then actually be getting treatment.

red tape

By Lilly_M [GFDL or CC BY-SA 3.0], via Wikimedia Commons

It’s hard when your best intentions are met with a roll of red tape. It’s a real issue for all of our graduates fresh from residency. We are still shiny and hopeful. We haven’t become so jaded that we don’t want to Do Good. But we could use the tools to help us accomplish that.

Post your favorite resources that help you Do Good! Help others to stop grasping in the darkness!

 

 

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October 7th, 2016

Work Mimics Life: A Failed Attempt at Separation

Amanda Breviu, MD, is a 2016-17 Chief Resident in Internal Medicine at the University of Utah.

Amanda Breviu, MD, is a 2016-17 Chief Resident in Internal Medicine at the University of Utah.

As physicians, we generally attempt to separate our personal lives from our work. Some of this comes from modeling behavior of others during training, some comes with further experiences in coping with the patients we encounter.

I recently had the pleasure of caring for an elderly gentleman who was brought into the hospital by his loving wife and son. He had Parkinson disease, as well as dementia, and his family reported that his memory had declined considerably over the past several months.

I could not help but to be reminded of my own grandma — a fiercely independent and hard-working woman who had suffered her own declining health and memory recently — also as a result of Parkinson disease.

The family of my patient mentioned that, over the past 3 days, he had declined to the point of sleeping all day. When I first saw him, he was fairly somnolent but roused to voice, and he was not oriented to place or time. He referred to the nurse in the Emergency Department as his girlfriend, which his somewhat-embarrassed family members immediately apologized for. I stated that it wasn’t unusual for patients with memory problems to experience further confusion in a new setting.

I thought of my own grandmother, who had been unable to respond to questions without significant delay and effort, who at times could not remember all the names of her children who she dearly loved.

As we interviewed the patient further, he coughed on his own secretions; several minutes passed before he was able to breathe comfortably again. His wife noted that he had been doing that a lot during the past week. He needed oxygen now, although he never had before. I broached the subject of goals of care, knowing from chart review that the patient’s primary doctor had discussed this before. The grave expressions on the family’s faces conveyed their understanding of the severity of the situation. They looked at me expectantly. “Doctor, please tell us the truth about what’s happening.” The reality of the story — what his family members shared — was that he was in a stage of dying. Over the past several weeks, he had not been getting out of bed. He had not been eating or drinking, and he was losing weight. He could no longer safely swallow and was aspirating his own saliva.

I had recently watched my grandmother in these same stages. First, she could no longer eat bread, because she could not do so without risk of choking. Later, she could not go long without coughing on her own saliva.

One of the many beautiful quilts my grandmother made during her lifetime.

One of the many beautiful quilts my grandmother made during her lifetime.

The patient’s wife understood clearly when I conveyed his poor prognosis. She and her son did not hesitate when I discussed care options for their loved one; they immediately stated that they wished for him to be comfortable and not to undergo aggressive measures such as a feeding tube. His wife commented that “his life has not been living.”

Again, I thought of my grandmother. The gardening and quilting that she enjoyed so much during her life had become a distant memory by the end. My grandfather lovingly had visited her every day in the facility where she received hospice care.

Our patient passed away only a few days after I had met him. My grandmother had also passed away comfortably after receiving hospice care, only a few weeks prior. When I saw him, I saw my grandmother. When I saw his grieving family, my eyes filled with tears.

Resident Bloggers

2016-2017 Chief Resident Panel

Amanda Breviu, MD
Joseph Cooper, MD
April Edwards, MD
Jamie Riches, DO
Kashif Shaikh, MD

Resident chiefs in hospital, internal, and family medicine

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