Specialties & Topics
- Arthritis/Rheumatic Disease
- Breast Cancer
- GERD/Peptic Ulcers
December 18th, 2015
He nervously shifted in his position in front of the audience of his peers. His voice was a little shaky, and the few words trying to escape his lips were chewed and swallowed. He was narrating a case in which a colleague’s sense of urgency, or rather, her lack thereof, likely negatively affected his patient. She sat in the front row with her head down, scared that the presentation might eventually lead to the revelation she was the one at fault. That would not be the case.
This is Morbidity and Mortality (M&M) conference. Most attendings and chiefs will tell you that it is, far and away, the most valuable educational experience in residency… and I agree. It is a conference in which there is objective iteration of a case in which a physician, team member, or system error occurred. Emphasis is on what could be done so that the error is never repeated. Sometimes, the issue is one that never affected a patient’s care but could have, in another scenario: a “near miss.” Other times, the conference focuses on an error that directly affected the welfare of a patient and, rarely, resulted in or contributed to the death of a patient. Classically, M&M felt like a firing squad in which elders in the hierarchy of medicine picked apart residents who always seemed to make the most egregious gaffes when faced with a room full of people pointing their figurative rifles. There was a lot of sweating and stuttering and apprehension. Thankfully, things have changed across the medicine academic realm, and M&M has changed from a blame game and target practice to a time to reflect and develop.
Humans make mistakes, and doctors are human. Therefore, doctors will make mistakes. This paradigm must be acceptable for medical academia to have a culture that results in the production of competent and confident physicians. M&M conference is the teaching modality that makes an error… a mistake… a point of reflection and a motivator for improvement, not a finger-pointing blame game.
The presenter concluded his case presentation, and the room stayed quiet for a moment. The burden of that silence is immense. Somebody died, and one of us could have done a better job to try to prevent it. That burden often results in tears. Every doctor in the room knew what it feels like. We have all been there. We all have a personal M&M folder locked away in the recesses of our psyche that highlights our limitations, reminds us of the blunders we have made, and impels us to never make those mistakes again.
The boss in the back of the room broke the silence with a reflection after seeing the intern up front with tears in her eyes. “It is completely okay that you cry about the mistakes you have made when it negatively affects your patient. It means you care.” I thought about those words of wisdom and appreciated how important it is to have a safe venue, especially during residency, to regret something you have done. The conference concluded with a list of learning objectives everyone in the room should take to heart so that countless mistakes do not have to be made for the physicians in the room to gather insight. We succeed together, and we fail together. And then… back to the floors so you can do it better.
December 15th, 2015
The name of the patient has been changed to preserve his privacy.
“Donald passed away.”
We had been sitting in the chiefs’ office with a few of the attendings who had all had Donald on their service at one time or another. Everybody exhaled a collective sigh, soaking in the sting of the knowledge of Don’s death; then, within a few seconds, everybody had smiles on their faces. The smiles were born out of a personal experience with him in the hospital. He was a special man. He was a dogged veteran who had fought in two wars: Vietnam and the war against the disease and illness that riddled his body. His words were rarely sweet, his blood pressure was always through the roof, his bone marrow had burned out to MDS, and his kidneys had begun giving up under the stress of his uncontrolled diabetes. On top of this, he was never adherent to his prescription regimen and medical recommendations.
He was the quintessential ‘frequent flier.’ When you saw his name on your patient list in the morning, you were usually unsurprised, a little frustrated, and somewhat satisfied you would see again the familiar, hardened face of a man who ‘wouldn’t take nothing from no one.’ Despite the difficulty in dealing with his tenacious personality, he always left you with a smile on your face — whether out of incredulity or amazement.
The attendings in our office began to share some of their stories about Donald:
“Once he was in renal failure because he had an overenlarged prostate, and when I told him we needed to put in a Foley catheter to relieve the pressure, he looked at me sternly and said, ‘you know, Doc, friends don’t hurt friends’.”
“One day I found him with a bucket of KFC despite strict sodium restriction recs, and I asked the nurses what happened. They told me there was no way they could stop Donald from doing what he wanted when he put his mind to it.”
“He was always hungry. He would tell the techs to get him Chinese food secretly and would give them a couple of extra bucks for egg rolls so they would keep their mouths shut.”
I listened to the stories, and in my heart, I thought that Donald would have gotten a kick out of knowing we were remembering him this way. I thought about how I would like to be remembered. Hopefully, the day I leave this world, some people I care about will have some good stories to tell about me that will make them laugh and think and reflect.
Donald lived his life the way he wanted. He was pathologically stubborn and irritatingly argumentative, but he still had that bit of charm that showed through most in the moments when he was most ill. Donald should have died long before today, but he was too stubborn, even for death. He clawed and scratched every last breath and every last heart beat in this world, and he left a mark on all of us. We all knew that this day was coming. That we would hear that Donald had finally met his maker… and just like the countless times we saw his name on our patient list, we were unsurprised, we were a little frustrated, but we had little smiles on our faces.
Rest in Peace.
November 27th, 2015
I watch as my almost-2-year-old daughter awkwardly climbs the stairs. I do not hold her hand, but I do not turn my back on her either. She is still clumsy, and her little bowed legs often miss their targeted landing spots. She holds on to the rail with a vice grip that steadies each monumental step forward and upward. Every so often she wobbles as she miscalculates the distances and her toes barely catch the edge of the next step. Her knuckles become white as she reorients herself, recalculates her next move, and ensures she does not tumble backwards. My palms sweat and my muscles tense during every mishap and sway… I want her to get to the top… but just as importantly, I want her to do it herself. After she regains her composure from a mini-spill, I cheer, “Good Girl!” I am close enough to catch her if she falls all the way down but not close enough that she can use me as a crutch to get where she needs to go. I think she senses this, and it gives her just enough confidence to keep going. Every fiber in me wants to get up and carry her the rest of the way, but I know the consequences down the road: She will always expect me to do it for her. She will cry and whine and, when it gets too hard, good old Baba will come to the rescue and move her to safety. She gets to the top and turns to look at me. I consciously look away as if I wasn’t watching her every move. “Baba… up!” The grin on her face makes me fall apart, and I run up the stairs and tickle her until she cannot breathe.
This is an everyday occurrence with her. Sometimes she fails and cries and looks up at me with her big green eyes begging for a hand to Providence (at which point I melt like any man would and give in to her tiny wishes) and other times, she gets back up by herself and tries again… and gets the job done.
I want her to be safe, but I do not want her to be ‘soft.’ This is the dilemma that most physicians in the academic realm struggle with every day in training the new generation of doctors. Psychology Today recently published an article that discussed what seems like an epidemic of individuals in college who are unable to cope with even the simplest unavoidable day-to-day adversities.
Although the article dismisses the fact that, historically, most psychosocial troubles that students faced were undiagnosed and swept under the rug and that the increase in numbers of those seeking help may just represent a generational recognition of the needs for those services, it still surfaces a serious concern. Many people in teaching/training positions in the medical academic realm believe that many medical students and residents lack resilience and self-sufficiency. With much discussion focusing on how to decrease burnout, increase physician (and docs in training) access to psych support, and better resident well-being, are we in danger of going too far the other way? Are we setting ourselves up for a generation of ‘soft’ doctors who lack the ability to handle the stress of an occupation defined by its intensity? Internists come face to face with mortality, familial strife, and enormous amounts of emotional distress, all while being expected to remain calm, cool, collected, and objective. The reality is, it’s the physician who is expected to carry the brunt of the stress and mold plans of action for multiple patients every day. Can a ‘soft’ doctor handle that level of responsibility? SHOULD a doctor handle that responsibility?
Then the question becomes: How do we turn out quality physicians who are armed with the tools (knowledge, skill, AND personal fortitude) from training systems in which the major concern is preventing burnout? This question is difficult, and the process will alienate many as being ill-equipped to handle the job.
Finding the balance between developing physicians with the capabilities needed to handle the realities of the job AND not burning out a large portion of them before they even get so see a patient autonomously must be the focus of those who control the avenues of training. I do not have a good answer for this question — both endeavors are extremely vital for the future of medicine. Perhaps the answer can be found somewhere in the tale of how a parent deals with his or her child climbing the stairs: letting them take risks, experience the consequences, know the taste of failure, encourage persistence, and celebrate eventual success. All I can say for certain is that the best part of parenting is when you get to celebrate with them when they’ve reached the top.
November 20th, 2015
My final year of residency is almost halfway complete. The job market for 2016 is heating up. For last month, I have been starting my day by browsing job websites and checking emails from the recruiters. After completing two residencies in two different specialties and one research fellowship, I want to get an academic hospital medicine position, but choosing the first job is no less intense than choosing the right residency or fellowship program. The challenge starts with creating a comprehensive CV, which summarizes all my achievements, including education, training, research, and administrative experiences. Undoubtedly, my chief residency experience fills up some paragraphs in the CV, including teaching, leadership, and administrative roles. The next step is getting good letters of recommendation from the program director and other senior faculty as required by some academic institutions.
Making my career decision of academic vs. community or private practice is not easy at this juncture of my professional life. This is not just choosing between academia vs. more money. Part of it could be that I am not very familiar with job roles outside of academia. Deciding whether to stay at my alma mater vs. moving to a new system or facility is difficult as well.
Job interviews are different in many ways from residency and fellowship interviews. It’s not just about all-expense paid trips, staying in nice hotels, and chauffeur-driven cars. The question I have been asked so far in every job interview is, what can I contribute besides clinical medicine? The next 2 years as a junior faculty member will be a crucial foundation step for my long-term goal of excelling in academic medicine. This will be the time to not only boost everyone’s (including my own) confidence in my ability but make myself prominent in the department. Outside of clinical work, I also need to focus on an area of interest, which could administration, medical education, or clinical research.
I was never good at reading legal documents, but this is time to read in between the lines in the contract paper. Starting with compensation, number of shifts, protected time, malpractice, tail coverage RVU, and productivity bonuses to name a few.
I want to become a physician researcher, so it’s imperative for me to choose a senior faculty member as my mentor whose interests match mine.
Very excited and maybe a little nervous… I am ready to take the plunge in the real world after years of training.
Wish me luck.
November 13th, 2015
It’s 2 am, and the patient’s blood pressure is beginning to rapidly decrease. Every IV line is occupied by an antibiotic or IV fluids, and we are in need of a vasoactive medication. The nurse comes to my computer and sternly states, “We can no longer avoid it. I think the patient needs a central line.” I quickly say “OK,” but I don’t move. I am momentarily frozen by my unease with the bedside procedure ahead. My mind is racing and questioning whether I can make any other treatment or management decision to avoid this procedure. I’ve got nothing. This is definitely what the patient needs. The nurse asks, “Are you signed off?”
I reply earnestly, with a strong “yes,” to convey to her that I am confident in my skills and comfortable. The honest reality is that I am nervous about doing this central line procedure and am finally facing my procedural comfort level straight on. Although I met the institutional requirement for quantity of this procedure needed for unsupervised performance of this skill, my comfort had waned in the few months since I had performed the procedure.
The real question I faced that night as a second-year resident was whether my level of comfort reflected my competency and ability to complete the procedure safely. If we assume that comfort reflects competency, our current quantitative benchmarks for performing unsupervised procedures may not be enough. In one prospective study of residents’ comfort with 9 aspects of 4 common bedside procedures, the residents reported lack of comfort in at least one aspect of 51% of procedures performed over the course of a year (1). Higher procedure numbers and direct supervision were associated with greater comfort.
What feels like a recent development of more physicians being less comfortable with bedside procedures may really be a result of procedures transitioning primarily into the hands of specialists. A survey of internists from the American College of Physicians showed that primary internists regularly performed 16 in-office procedures in 1986, versus 7 in 2004 (2). There has also been a recent movement to provide procedure-service models on many inpatient services that serve as exemplary models of procedure execution. These models offer expert supervisors, consistent teaching technique, and a controlled environment for the patient. Although these models are a plus for the patient, some would argue procedure services are performing procedures that previously would have been performed by trainees — the same trainees who must develop into our next generation of experts.
So how do these issues affect our journey to procedural safety for our patients and the training of future procedural experts? In recent years, the American Board of Internal Medicine has transitioned away from quantitative requirements to determine if physicians-in-training are ready for unsupervised performance of skills and has implemented milestone-based assessments. These milestone- and competency-based assessment tools require trainees to demonstrate effective mastery of needed technical skills and to understand and be able to manage complications (in addition to reaching a defined number of each procedure). Although the ABIM has embraced milestone-based evaluation, many of our training programs continue the longstanding “signed off” culture after 5 or so of a common procedure are performed. Which, in my case, was not the point of comfort and may have not been the point of competency. As procedural training often is considered one of the most important aspects of training, I hope with innovation and diligence we can continue to train competent procedural experts.
Do you have thoughts on bedside procedural comfort or competency? How can we improve procedural training? Please feel free to share your comments.
- Huang GC et al. Beyond the comfort zone: Residents assess their comfort performing inpatient medical procedures. Am J Med 2006 Jan; 119:71.e17.
- Wigton RS and Alguire P. American College of Physicians. The declining number and variety of procedures done by general internists: A resurvey of members of the American College of Physicians. Ann Intern Med 2007 Mar 6; 146:355.
October 23rd, 2015
I spent the first two weeks of October in rural Shizuoka, Japan, rotating through clinics and hospitals in Mori-machi and Kikugawa, and observing medical education at Hamamatsu Medical School. The University of Michigan Department of Family Medicine has a unique and positive relationship with the Shizuoka Family Medicine residency program that allows for collaboration. I lived in Japan for 1 year before medical school, and I was thrilled to be accepted to the international rotation in Shizuoka. Below are some of the most striking observations from my time in rural Japan.
During an afternoon clinic session with Dr. Yamada at Mori-machi clinic, I observed a stretch when she saw patients aged 83, 77, 86, 91, and 96 — consecutively. The two patients older than 90 were both women who lived independently, and who were able to walk to clinic unassisted for their appointments.
The proportion of the Japanese population older than 65 is projected to increase from 12% to 40% between 1990 and 2050, and was estimated at 22.7% in 2009. In comparison, the U.S. elder population is projected to increase from 12% to 21% over that same time, and was estimated at 13% in 2009 (1, 2). The two major variables that are driving Japan’s rapid demographic shift are the incredibly long life expectancy (86.1 for women, 79.3 for men), and the relatively low birth rate (1.41 births per woman) (1).
Healthcare financing in Japan — Containing costs
Japan’s health financing structure is very different from the U.S. system. Japan has achieved universal health insurance through a combination of employment-based and government-financed insurance. The Japanese government keeps healthcare costs low through setting a strict national fee schedule on all services and procedures, which results in lower payments to physicians and hospitals than in the U.S. The fee schedule sets the price, and doctors are then paid fee-for-service (1). Prices for services that increase in volume over time tend to be lowered to control cost. For example, the price for magnetic resonance imaging (MRI) of the head was recently reduced by 30% to 11,400 yen (US$104) (3). Because of efforts like these, Japan spent just US$2878 per capita on healthcare in 2009 (8.5% GDP), compared with the US which spent US$7,960 per capita on healthcare in 2009 (17.4% GDP) (2).
Universal coverage in Japan improves access and eases transitions of care
One afternoon, I accompanied Dr. Tsunawaki on a home visit to see a 90-year-old woman with advanced stomach cancer, who had been discharged from the hospital 1 week prior with a plan for home healthcare services with focus on comfort care. I asked him about the process of discharging a patient with home services or to a long-term care facility. I voiced my frustration about difficulties I often encounter when trying to find placement for patients who are uninsured or underinsured in the U.S., which can delay discharge. He explained that because of the universal healthcare system in Japan, the process of discharging any patient home with home services, or to a long-term care facility, is a relatively simple and efficient process.
Brief comparisons: U.S. vs. Japanese healthcare systems
Although several aspects of the Japanese healthcare system work well, the strict national fee schedule isn’t perfect. As a result of low reimbursements, physicians must see a high volume of patients per day, squeezed into shorter visit times, which can disrupt the physician-patient relationship. Although the Japanese system provides less benefits for physicians, there is no shortage of well-qualified doctors, and it keeps costs low and access high for consumers, making it a successful system, in my opinion.
The U.S. spends the most money in the world on healthcare with variable results on quality metrics compared with other countries (2). The Affordable Care Act (ACA) helps by decreasing the number of uninsured patients through the Medicaid expansion and other measures, and by creating measures to increase access and (potentially) lower costs. However, it fails to provide universal coverage, and how the ACA will affect spending in the near future is unclear (4). Because of this, the U.S. would be wise to continue learning from healthcare systems with universal coverage that have been successfully implemented, like those in Japan and other industrialized nations.
Opioids are rarely prescribed in Japan
While I was working with Dr. Horie one morning at Morimachi clinic, we saw a 66-year-old man with chronic low back pain that had acutely worsened. Dr. Horie refilled his prescriptions for Tylenol and topical menthol-based pain-relief pads, and provided some stretching and strengthening exercises for his low back.
Outside of the patient’s room, I asked Dr. Horie about how often opioids are prescribed to patients in Japan.
“Almost never,” he told me. “Really, only for terminal patients to help with their pain.”
“What about postoperatively? Or for acute pain relief after injuries?” I questioned.
“No, we primarily use NSAIDs, Tylenol, and pain relief pads.” He explained matter-of-factly.
He then showed me a chart (pictured left) that visually displayed how the U.S. and Japan are on opposite ends of the spectrum in terms of opioid prescribing habits: The U.S. prescription rate is represented by the bar on the far left of the graph, and Japan’s rate is the barely visible bar on the far right. In comparison to Japan’s strikingly low use of opioids, the epidemic of opioid drug abuse and misuse in the U.S. is well-documented: An estimated 259 million prescriptions were written for opioids in 2012 — enough for every American adult to have a bottle — and every day an estimated 46 people die from prescription medication overdoses (6).
I saw several patients with complaints of acute and chronic pain while working in clinics and hospitals in Japan, but the only time I saw opioids used was for terminally-ill patients with cancer-related pain during home visits.
Finally, Japan is beautiful
If you are searching for a spot to spend your next vacation or work-related adventure, I highly recommend the rolling green hills of the Japanese countryside. The natural beauty of the countryside is matched by the warmth and hospitality of the people. Thank you to everyone at Shizuoka Family Medicine for making me feel at home during my 2 weeks there; I hope to see you again soon.
Special thanks to Dr. Machiko Inoue, the program director at Shizuoka Family Medicine, for helping to coordinate my experience in Shizuoka, and also to Professor Jersey Liang, for the education he has provided through his Health Systems course at the University of Michigan Executive Master’s Program in Health Management and Policy, which helped provide some of the material for this post.
1. Bodenheimer T, Grumbach K. Understanding Health Policy, Chapter 14. New York: McGraw-Hill Medical; 2009.
2. Squires, David A. Explaining High Health Care Spending in the United States: An International Comparison of Supply, Utilization, Prices, and Quality. Issues in International Health Policy. The Commonwealth Fund. 2012; 1.
3. Ikegami N, Campbell J. Japan’s Health Care System: Containing Costs And Attempting Reform. Health Affairs. 2004; 23:26.
4. Connors E. Health Care Reform—A Historic Moment in US Social Policy. JAMA. 2010; 303:2521.
5. Cancer Palliative Care Guidebook. Nihon Ishikai. 2013. pg 10.
6. Centers for Disease Control and Prevention. CDC Vital Signs – Opioid Painkiller Prescribing. 2014. (http://www.cdc.gov/vitalsigns/opioid-prescribing/)
October 9th, 2015
I dropped the little booger off at daycare today. I was over-prepared, and the nanny’s face said it all, “this is your first time, huh?”
It was. Before this, Safiya was being taken care of by her loving grandmothers and a wonderful nanny that was literally like family. But now she is almost 2, the nanny had moved on to greener pastures, and grandmothers have jobs and other things going on in their lives. I know this post has started off like a mommy/daddy blog, but this is different from the cliché “First day of Daycare” sob story (or, I like to think it is, at least). This is how I felt today:
We have a story:
Safiya was born at 3:39 PM on 11/8/13, even though she was due 8 weeks later. She was an SGA neonate born to a mom suffering from pre-eclampsia whose blood pressure was twice the normal range. After 2 days of labor and 2 days of steroids, she came into the world with a little squeak that literally almost made me fall to the ground as I understood what that little mouse noise meant. I imagined that, at that very moment, her blood circulation reversed as her lungs went from unwelcoming high pressure to loving and kind low pressure. Blood rushed into her pulmonary vasculature, and, as she took another deep breath between squeaks, oxygen diffused across tiny, wet alveoli and was delivered to her 3.5 lb body. As the NICU team worked on her, I looked over their shoulder at the acrocyanotic newborn and instantly fell in love. My wife gradually recovered, I was a wreck, but the baby was fine.
She spent the next 28 days in the neonatal ICU surrounded by the beeping of her telemetry monitor that alerted the doctors that she was apneic for short periods of time… Those moments of breathlessness left her mommy and me in a state difficult to describe: Imagine floating alone in a pool in the dark of night and, when you come up for a breath, you hit a glass ceiling. Your body begins to panic as it starves for oxygen, and you slam on the glass as the blackness envelopes you. You hear the beep. You see the number on the monitor go from 60 to 30 and then to 0, and you punch harder. The nurse runs over and stimulates the tiny being from behind the NICU incubator, and she awakens. And just as she takes that deep breath, you break through glass, get your head above water and gasp with her. That happened for 28 days… every day. We were a wreck, but the baby was fine.
We took her home on a cold, rainy day at a fighting weight of 5 pounds on an apnea monitor and caffeine. She felt like a feather in my palm, and her gray eyes stared at me like I meant something. I would place her chest to my ear and hear the harsh sound of blood rushing through the hole in her ventricular septum during systole. Every time, I was relieved that it was beating. Relieved that she was breathing EVERY TIME. Being a physician didn’t help. Being a pediatrician who had just spent his final senior month in the NICU didn’t help. As a matter of fact, it made it worse. I dreamt of intraventricular hemorrhages, pulmonary hypertension, and cerebral palsy. I tested for spasticity as she weakly sucked on a bottle, and I would wake up in the middle of the night to reach over to her bassinet and make sure I could feel her chest rise. When she arched her back from reflux, my heart arched with her. When she turned red from infant dyschezia, I would find myself unable to swallow. When her arms jerked in her sleep from benign neonatal myoclonus, all I could think about was getting an EEG. When she slept through a meal or had two consecutive spit-ups, I wanted a blood gas and an ammonia level because I was sure it was a urea cycle defect. My wife and I were a wreck, but the baby was fine.
All this while, my wife and I were in the throes of residency. My wife commuted to the city and sat in hours of traffic on the cursed Cross Bronx Expressway while covertly pumping breast milk that provided immunity for her little bundle of joy and anxiety (yes, she pumped while driving). I would run a code at work and give a family bad news and then rush home to have Safiya sleep on my chest while I read about inflammatory bowel disease and the side effects of a variety of HIV meds. I would come back from night call exhausted but exhilarated to hold her and sleep with her close enough to me that I could feel her breath on my face. We were drowning in our everyday lives, but it kept us from drowning in our worry. We were a wreck, but the baby was fine.
Here we are today: A day when I entrust her to a group of strangers surrounded by more adorable little strangers that may bite or kick or even kiss her… I dropped all the hundred or so little containers of random foods that my wife had packed into her little cubby and moved towards the door as she was distracted by a coloring book. She cried a little when she caught me sneaking away, and I took that as an excuse to run back to her. I picked up her now 30 lb frame and gave her a hug and told her I was right down the street. She looked at me in the eye through angry tears and clearly did not approve. A few seconds later, I ran out of the room when she was again distracted by the clock in the room. I watched her through the daycare window for a while as she played with her new friends and toys. I took a picture… or 7… and sent them to my nervous wife in the Bronx. We were a wreck, but the baby was fine.
September 25th, 2015
Do doctors work too much? Residents would probably say “Yes! I’m burnt out,” and supplement it with some form of “I’d much rather work less.” Outside of residency, the answer may be a mix of yes, no, and maybe.
Recently, Lancet published a meta-analysis on work hours and its effect on incident coronary disease and stroke. The study showed that those who worked more than 55 hours weekly on average had an increased relative risk of 33% for stroke and 13% for coronary disease. Stroke risk increased linearly as average work hours rose. NEJM Journal Watch’s Dr. Bruce Soloway reviewed this article; his comment is below:
“Mechanisms for an association between long working hours and incident CHD and stroke are unknown but might include prolonged or repetitive stress, physical inactivity, and excess alcohol consumption. Average working hours vary widely among developed countries and represent modifiable social decisions. Social policies encouraging or requiring people to work longer hours could have substantial health implications.”
These results must sit in the consciousness of nearly all residents, regardless of specialty, as our average work hours usually are greater than 50 and often average greater than 60 or 70 hours on a busy inpatient month. At our residency program, we realize a personal work/life balance is key, given our rigorous clinical demands. Wellness initiatives at Emory this year include more happy hours, a research mentorship program, Fitbit competitions, and food at conferences. Even as residents graduate, attending/fellowship life does not get any less stressful, although work hours usually are fewer. But how do we prevent burn out? After all, we are a primarily service-oriented occupation that often requires selfless sacrifice in the name of greater good for patients’ well-being.
One solution might be a Stanford ER program that relies on the concept of ‘time-banking’ to save physicians from burning out (Washington Post article). This $250,000 2-year pilot rewarded ER attendings who spent extra time at work mentoring residents, covering shifts for colleagues, or spending time on committees. The extra ‘banked’ time resulted in benefits such as grant-writing help, dry cleaning pick-up, or even food deliveries to home. The result was astonishing, as most physicians improved their work-life balance and job satisfaction and, importantly, wrote more grant proposals (22 were submitted, with an above average 40% success rate for a whopping $10 million in support). The latter alone is a compelling reason to fund these types of time-bank pilots elsewhere, as they can very quickly pay for themselves. A second reason is that the culture within this emergency department became more collegial and friendly — many attendings volunteered to cover coworkers’ shifts as they realized their service would not go unappreciated because of the time-bank system.
This innovative method to avoid burn-out and improve work-life balance may be a way to address the stress that can contribute to excess strokes, especially because work hours will not go below 55 anytime soon for residents or attendings. Physician-wellness curriculums are also key to teach physicians how to cope with stress or manage their time effectively. My own personal tip to is to not lose whatever defines you as you go through medical training — for me this included playing basketball or Frisbee, talking to loved ones, and attending church whenever possible.
I would love to hear any other social-wellness initiatives that were successful for you personally or within your residency!
September 16th, 2015
With the start of the residency year comes a new batch of excited residents who will have many of the same successes and failures as those who tread the path before them. They will quickly fall into cliché niches within the residency class: the gunner, the humanitarian, the slacker, the superstar, the researcher.
Their medically immature hands will explore their new environments the way my 2-year-old discovers that things that are hot will burn her and that sand is icky but shapeable and that every action has consequences. The new interns will learn that what comes out of their mouths can be the shovel that buries them with the scrubs of residency or the rocket that elevates them into the ranks of legendary residents before them. A few will reveal themselves as superstars, and a few unfortunates will come out on the dreaded bottom. The reality is that most residents are average, and average doctors are great!
So what are 8 (semi-serious) categories of residents that you do not want to become? If you are labeled as one of the following, your residency experience will be a bit rougher than it needs to be. And, then, 7 things that will help you be above average!
- Lazy/Apathetic: This is the category of death for an Internal Medicine intern. If you gain the reputation as the doc who does everything he or she can do to NOT do anything, you will have a hard time. Word travels through residency programs like poison gas. You may not know it is around but, by the time you realize you have been exposed, it’s too late to recover from the fumes. NEVER be the lazy one.
- Debbie Downer: Every resident complains. You should; it is natural to complain about the absurd torture that is residency: sleepless nights, stressful days, and immeasurable workloads, mixed in with the gumbo of constantly coming face to face with mortality and suffering. In fact, it would probably be strange if you did not commiserate with your colleagues after a long day of work. Debbie Downer, however, takes it to another level. Nobody wants to work with someone who never has anything positive to say. At the first chance for a break in the hectic day on the wards, the last thing a team of residents want to hear is one of their own constantly reminding them how bad they have it. You have to bite your tongue once in a while and try to find a silver lining, even if that silver lining is simply being able to go home at the end of the day.
- Always Late Guy/Gal: This is self-explanatory. If you want to get extra negative marks, walk in 10 to 15 minutes late with a cup of coffee, a perfectly crisp white coat, a big awkward smile on your unpunctual face, and muffin crumbs in your beard. Everybody wants to get home to their family, food, and bed… Don’t mess with that.
- Arrogantly Ignorant: In traditional Islamic scholarship there is this concept of simple vs. compounded ignorance. A teacher’s goal is to move people from compounded ignorance to simple ignorance and with that achievement, the teacher can claim that he or she did his or her job. The major ingredient that differentiates failure from success is the presence or absence of a dose of humility. Examples of each:
- Simple Ignorance — this is OK!
- Question: What is behind that wall?
- Answer: I do not know.
- This is a completely acceptable answer. In fact, we know you do not know! That is why you are here, to learn. Take it a step further and follow that up with, “I will go look it up,” and all of a sudden you look like a go-getter superstar!
- Compounded Ignorance — NOT OK!
- Question: What is behind that wall?
- Answer: There is a lion behind that wall… ?!?!
- The problem is this: You do not know what is actually behind the wall, because you do not yet have the tools to see over or behind it. You have confidently (and likely overconfidently) answered a question about which you had no clue. This is frustrating for team members and, more importantly, dangerous for your patients.
- Simple Ignorance — this is OK!
- Missing the Forest for the Trees: BUN went from 11 to 12, MCHC is at the lower limit of normal, and the patient’s left toe nail is a little green… The problem? The patient is hypotensive and crashing, and you have wasted 10 minutes telling me that he has a pet dog with a family history of anxiety, and you forgot to mention the meningeal signs you elicited on exam. Sometimes you have to take a step back, take a deep breath and reassess. Asking your seniors will also help big time.
- Jaded on the First Day of Residency: You have no reason to be jaded on your first day of residency. If, by the end of your first week, you come into work with beard stubble, a stained white coat, a litany of derogatory things to say about ‘all of the drug-addicted low-lifes’ for whom you provided care, and you sigh every time you get an admission, you may need to check yourself. You should be coming up with wide differentials with zebras at the bottom and not just be assuming that your poor patient is ‘just another drug-seeker.’
- The Rambler: Say what needs to be said and nothing more. Present objective facts and not how you feel about every ‘normal’ or ‘abnormal’ finding. You are an intern, and your job is to collect and disseminate information while learning during the process. One of the most painful things to see is a resident who does not know when to say nothing… Do less talking and more nodding and listening, and you will be golden.
- Improper Hygiene: How expensive your clothes are does not matter… whether they are clean and ironed does matter. I am a proud member of the Marshall’s and Kmart clubs, and they have worked out just fine for me. Hygiene includes smelling ‘neutral.’ No heavy cologne or Axe spray required… you are getting very up close and personal with many people, and their nostrils will appreciate not smelling you (good or bad).
So far, I have given you insight on what to avoid. Here are some things you can do to rise to the top and survive that first year of residency:
- Come to work on time, and be grateful for the opportunity to treat people and to make a phenomenal living while doing so.
- Keep your head down, and get the work assigned to you done before you go home. You would be surprised how just doing exactly what you are instructed to do in the expected time translates into people knowing that you are ‘one of the good ones.’
- Recognize that perception is everything. This may often seem (or be) unfair, but no matter how smart, efficient, and compassionate you are, if you have an image problem or a bad reputation, it is very hard to shake.
- Be optimistic! You are in a field many would love to be in. You get to be closely involved with people who are at the most vulnerable moments of their lives; accept the responsibility, and own it.
- Know your strengths and weaknesses. If punctuality is a weakness for you, plan to get to work 15 minutes earlier than you have to. Not being punctual can really ruin the reputation of an otherwise solid resident. If you’re bad at documentation, spend extra time on it. (If you’re good at it, help your colleagues!)
- Remember that nobody in the room knows everything and that nobody expects you to know everything either. Be willing to be humble and say you do not know. Use this as a motivation to go find the answer in a book or through a senior/attending.
- Usually interns have the most book/basic science knowledge on their team, but the least clinical sense. This is expected, because the only way you pick up the latter is with sheer volume and exposure. You need to see everything many times before your Doctory Spidey Sense becomes reliable. Give yourself a break and be willing to make controlled mistakes so that you can learn what really matters.
That’s it! You got this! Keep your head up, caffeinate often, and ask your seniors/chiefs for help. You are going to be great!
September 11th, 2015
BEEEP BEEEP BEEEP BEEEP – I pressed a button to silence my pager and rose groggily from the bed in the on-call room. I hadn’t truly been asleep, just catching a quick rest between pages. It was 2am. I was 19 hours into my shift and, from the looks of the page, there was a new patient ready for admission to our family medicine inpatient service. I picked up the phone and called down to the ER to get the full story.
“New admission: 47-year-old male who’s dehydrated and needs IV fluids and pain control before upcoming flight to his home in east Africa. He’s got widespread metastatic cancer; oncology thinks days-to-weeks to live, without additional options for treatment. Enrolled in hospice last week but hasn’t seen them yet. He bought plane tickets for him and his sister, and his plan is to fly home in 2 days to be with his wife and child for the remainder of his life.”
The ER physician’s words echoed in my head as I reviewed the patient’s chart. This was not the typical admission to our service. I slipped on my white coat and began the long walk from the 8th floor of the hospital down to the basement — the home of the emergency department. As the senior night resident, it was my job to admit this man to the hospital.
As I approached his room, I remembered a lesson from one of the palliative care specialists in our department. He taught that, at the end of life, it’s most important to first determine the patient’s goals and then let those goals guide recommendations and therapy. For critically ill patients, we have IV fluids and medications to support dropping blood pressures, oxygen and mechanical ventilation to help with breathing, and strong antibiotics to stave off disease. However, if the patient’s goals are to be comfortable and at home, surrounded by loved ones at the end of life, then these invasive and often-times uncomfortable medical interventions are better left on the sideline, replaced by medications to help make the patient more comfortable.
I knocked on his door, waited for permission, and entered. Inside the dimly lit room were two people: A middle-aged woman adorned in a beautiful light-blue hijab stood and introduced herself as the man’s sister; and the patient, bald and with sagging eyes, laid on the hospital bed looking up at me. I introduced myself to both of them, glanced at the monitor, saw with relief that his vital signs were within the normal ranges, and then sat in a chair next to his bed. He sat up and extended both of his hands towards me, enfolding my right hand in a warm and gentle handshake. He smiled and told me his name. Despite these signs of strength, he looked cachexic and weak.
“What are your goals for this hospitalization?” I began.
“I know I do not have long in this world, and I am at peace with this,” he began. “I want to go to my home country to be with my family for my remaining days, but am worried because I have not been able to eat or drink.”
BEEEP BEE… I pressed the button to silence my pager and urged him to carry on. Whatever it was, it could wait.
“I would like to get fluids to regain my strength,” he continued, “and medication to help with pain and nausea so I can endure the flight to my home.”
I nodded in understanding. I reviewed his medications and discussed what had worked best for his symptoms in the past. I assured him and his sister that our objectives as his doctors would be in line with his goals, and we would aim to get him safely on his flight in 36 hours.
At the end of our conversation, he smiled at me. “Thank you for your humanity,” he said.
I never saw him again. I ordered IV fluids, and medications for his pain and nausea. I gave sign-out to the morning team to let them know his goals and, when I followed up with the team later that week, was happy to hear that his symptoms had improved and he was able to get the appropriate prescriptions in time to make his flight.
I played a very small part in his care, but the brief interaction still sticks with me. And, I hope that by doing my part as the overnight resident physician, I helped to make him more comfortable on his journey home.