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May 6th, 2016

Declaration of Death

Ahmad Yousaf, MD

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

“Is he dead?”

death for life -- Der Artz

I stepped up closer. He was yellow. Bright yellow. Steve had been admitted to the hospital for altered mental status when his last PET Scan revealed that the pancreatic cancer had spread from the tail of his pancreas into his liver where it now blocked the ducts that carried the bile out of his body and left him jaundiced.  I had been paged a few minutes earlier by a frantic nurse who told me that the patient had stopped breathing. It was 1AM and although I could have been asleep, I was in my 2nd month of residency and too scared to rest my eyes.  I rode the elevator up to the 9th floor with almost no idea of what I was going to do if, in fact, he was no longer breathing.

I had received sign-out from the day team that the patient was on inpatient hospice and ‘no heroic measures’ were to be taken if his heart stopped beating overnight. “Heroic measures?” I thought to myself. What did that mean? Thoughts of Superman performing super effective chest compressions and pushing epinephrine crossed my mind. The elevators opened, and I walked toward his room.

Earlier in the evening, I had introduced myself to his family who had been sitting by their dying father and husband. I had tried to smile warmly but was afraid I came off as an insensitive, grinning madman. I probably had stayed too long to overcompensate for my awkward smile; I had rambled about things that didn’t really matter. I almost made a joke… then thought better of it. I had ended the torturous encounter with a “so sorry” (I was not sure if I was apologizing or just searching for any words to fill the void) and a “if you need anything at all …” After fleeing the room I prayed to God that this patient would not die on my time. Unfortunately, my prayer was not answered that night.

Now, I stepped into Steve’s room and quickly realized that it was no longer his. It smelled of death, and I felt like I was walking into a room frozen in time.  I had this eerie sense that I was walking in right after another had left with something more valuable. The silence was profound… except that there was something… I heard the sound of breathing.  I approached his bed, and then I saw her. His wife had pulled up a chair next to him and was fast asleep, unaware of her husband’s passing. I stared at Steve and then back at his wife. How long should I leave them like this? She needs to know… but how terrible a thing to wake her up to the worst news of her life. I did not want to be the one to do that. I was supposed to be a preventer of death…


“Pssst!” The nurse was now at the door trying to get my attention. I looked over and shrugged my shoulders. I had no idea what to do. “You have to tell her,” she whispered sharply, “you have to pronounce him dead!”

My confusion must have been apparent because she rolled her eyes and said, “You need to listen to him and give him a time of death!” I nodded as if I knew that already. Much later, I heard about another intern in a similar predicament — she had been told that she was to pronounce a patient dead. She entered the room, which was full of the deceased’s family and stated loudly, “I now pronounce you dead!” She then exited hurriedly and told the nurse that the ‘pronouncement ceremony’ was over.

I exited the room and told the nurse to give me a second. I pulled out my Intern Manual and found the section about how to pronounce a patient dead. The manual told me to listen for heart sounds with my stethoscope placed on patient’s chest for an entire minute and, if heart sounds were absent, I should pronounce the patient dead and document the time of death in the chart. I re-entered the room with a bit more confidence and looked at the sad portrait in front of me — a loving wife lying with her beloved husband. It felt like a dream. I observed her chest rise and fall with every breath and his stay so motionless. He looked far more at rest than she did; her brow was furrowed, the area around her eyes dark with circles of worry and sleep deprivation. I moved close to her and placed my hand on her shoulder. “Ma’am… Ma’am.” She stirred a little… I glanced back at the nurse in the entrance of the room and realized she was growing more and more impatient.  “Ma’am… we need to talk.” Her eyes began to open slowly as she rose to consciousness and then, suddenly, she sat up…

“Is he dead?”

The words hurt me.  As if she had thrown bricks into my chest. I could not find the yes that was buried somewhere between my heart and my throat… I nodded. She let out a deep sigh and with it, tears fell from her eyes.

“I’m… I’m sorry.”  Those words again. I really do not know why they always seem to fall out of my mouth in moments of perplexity. I stood there for a while watching the two of them. Watched her wrap her arms around him and speak to him as though he would answer. The nurse came in. She went over to Steve’s wife and asked her if there was anyone she wanted to contact. The nurse got a number and left the room. I still had not moved. This was the first patient I had ever pronounced dead. I looked at the clock: 1:54AM. That would go into a record somewhere, because I had stated it was the time he died. The moment was heavy… heavier than I had ever anticipated.  I was no longer one who just tried his best to prevent death; I was now also an announcer of its arrival.


April 27th, 2016

The Dark Side of Medicine

Ahmad Yousaf, MD

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

The following is paraphrased documentation, authored by a physician I know, regarding an intoxicated patient in the ER:

1AM: Patient is telling nurse, “Before I leave, I need everyone’s name for my lawsuit. Tell the phlebotomist that if he’s good, he’ll  get a cut.”

1:40AM: Patient is making inappropriate sexual comments and is verbally aggressive with medical staff. He is advised to stay in bed.

2:02AM: Patient (who had been sleeping comfortably) wakes up and begins screaming obscenities at everyone. When a nurse asks why he was angry, he says, “What do you think , mother f*****? I will wipe your a**.” Multiple attempts to calm patient fail.

depressed girlI will stop here, because the insulting language, obscene physical gestures, and eventual threats of physical abuse only become more vulgar and inappropriate. The attending recorded in the chart, word for word, the things that spewed from the patient’s mouth and, eventually, when he became physically aggressive, called the Crisis Team who came and restrained the patient.  The story was shared with me by one of the residents who had witnessed the entire discourse, and we laughed about the absurdity of some of the drunken babble. We also smiled in speaking about the state of mind of the doc who documented the conversation so meticulously in the chart. She must have just had it with the abuse and decided she was going to permanently record all the nonsense in the EMR.

As I sat by myself, thinking about the somewhat comical story, I realized that it really was not funny at all. This is the status quo. Healthcare professionals deal with patients like the one above every day. The verbal abuse and physical threats are so common that we have settled in to just trying to find some humor in them. This type of abuse is not unique to the healthcare field, but the difference is that you cannot just stop treating your abuser. You have to make sure he or she gets better… You cannot fire a patient in an ER who would die in the street if you kicked him out. Every doc or nurse has an anecdote in which they have been spit on, urinated on, cursed at, assaulted, or threatened.

In the medical world, we do not talk a lot about this aspect of our training and experience. Incoming residents have no idea that, along with their medical education, they will be getting a pedagogy in dealing with some seriously aggressive personalities. Whether it is a drunk patient in the ED, an angry family member, or the overtly psychotic patient on the psych ward, being on guard becomes second nature.

I remember one resident laughing hysterically as he described an enraged patient using the TV remote as weapon against his caretakers, swinging it in circles like a lasso. Or the time a family member broke into the medical lounge and attempted to physically intimidate a resident into changing a medical plan for a dying patient in the ICU. I have seen female trainees and attendings cat-called, harassed (both physically and verbally), and made to feel unsafe by the people they care for. It is tough to diagnose and treat someone when you cannot put your hands on them without fear of a violation of personal space.

This is medicine. There is so much beauty in the patient-doctor relationship and so much that I could say about the wonderful people whom I have learned from and loved while they were under my care. But, like anything else in life, medicine has a dark side that we rarely discuss with people outside of the field. With an increasing percentage of doctors feeling unappreciated, abused, and depressed, maybe it is time to share the whole story (N Engl J Med 2016 Apr 28; 374:1661).

Please share your experiences.

P.S. God bless nurses, who deal with this stuff even more often than docs do.

April 8th, 2016

The Costs of Being a Doctor

Ahmad Yousaf, MD

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

I start this article with a disclaimer: I am not here to comment on the decreasing salaries of physicians or the knowledge that I will never get paid the way the prior generation of doctors got paid. It is hard for me (and the American public) to feel bad for anybody making more than $200K a year when the median household income is in the mid-$40K range.

median US income

BrendelSignature (, CC BY-SA 3.0

What this article is about is the absurd costs of becoming a doctor (both in medical school and residency)! Let me tell you my story to put things in perspective:

I went to a state undergraduate university and, thankfully, left that school with no debt. I then entered a public medical school, with no way of paying the tuition on my own. I faced the decision of taking out loans or dropping medicine and doing something else. I stuck with it — like many of my colleagues — because I could not imagine NOT being a doctor… and honestly, I was naive about the financial hardships I would undergo.  I lived at home for 2 of the 4 years of med school, was single for 3 of those 4 years, had no kids, and had amazing parents that subsidized my living arrangement with home cooked meals and car insurance payments.

empty wallet

Despite that, at the end of my med school education, I had acquired $180,000 in loans (close to the national average), almost all of them with an interest rate of 6.8%. To put that into perspective: My monthly interest accrual was ~$1020 a month, and good old Aunty Sallie would capitalize the interest into the principal at the end of every year! Then came residency. Finally a salary of my own… or so I thought. The average resident’s salary starts between $40K and $50K a year. At 70 to 80 hours a week of work, that comes out to $9.50 to $12 an hour. Most residencies prohibit moonlighting (for reasons beyond my comprehension), so the money you get from your institution is the ONLY money you get.

I live in northern Jersey, where monthly rent for a 1-bedroom apartment is around $1000-$1400… a 2-bedroom ranges between $1500 and $2400. I… lived in a 1-bedroom. I cleared about $3000 a month after taxes. $1000 went to paying just the interest on my loans and never touching the principal, and $1200 went to paying rent. I was left with $800 to spend on food ($100-$300, thank God for a mother and mother-in-law who have phenomenal cooking skills), gas ($160), car payments ($200) because you cannot move between three hospitals on public transportation, insurance payments ($200), cell phones ($80) with no landline, internet ($50), and, well… there is no money left. So, I guess I could have just paid the minimum on my loans and have had money for heat and electricity. Problem is, that after 5 years of residency, I would have owed Ms. Mae close to ~$250,000.

borrowing-repayment cycle

This is the thing… I was better off than many residents. I had parents who gave me money when I was short and paid my EZPass bills. I went to a public undergrad school(many people I know have debts in the $350K range when starting residency). I never had any large unexpected costs during my training (e.g., medical bills, big car bills/accidents). For much of my training, I was not yet a parent. Residency sucks… and not just because of the intensity of the training and the stress of trying your best to become a decent physician.

This article is not over yet. The real impetus for me to write this has to do with the loads of money I recently dumped to fulfill the next step of my “training.” What many people outside of medicine might not know about are the enormous costs of tests/licensing that doctors are REQUIRED to complete/obtain/maintain to practice medicine. USMLE Step 1,2,3 tests cost about $2200. The American Board of Internal Medicine exam costs about $1200, and the American Academy of Pediatrics board exam costs a whopping $2250. Most residents spend about $1000 to $2000 on prep courses and materials for each of these exams WHILE IN residency.  And then, there is licensing: NJ state license is about $1100, the DEA/CDS licenses cost another $760, and there are others, depending on your practice. All of this occurs BEFORE you make ‘doctor money,’ all while your student loans continue to grow.

government loans

My concern is not for my own misery…. that time has passed. My concern has to do with the next generation of physicians who have already started pre-med tracks in their undergrad colleges.  What type of candidates will medicine attract when the associated costs of becoming a doctor are no longer the extreme intellectual rigor and high academic expectations of the training… but instead, financial suffering?  To put it in plain English… Who in their right mind would do this when you know you are putting yourself, and potentially your family, in great financial peril?

My inner optimist tells me that there will always be a group of highly motivated people who will bear the difficulties, because the goal is lofty and righteous enough to keep their eyes on the prize. But what are we saying as a society when we make an education in healing so difficult to attain?


March 14th, 2016

The Era of the Ill-Prepared Medical Student

Ahmad Yousaf, MD

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

What is wrong with medical students nowadays? This question has been circulating in the academic medical world for years. As an intern and resident, I would hear complaints about how ‘unready’ they seemed. The grievances often include adjectives like ill-prepared, lazy,  or uninterested.  The complaints have burgeoned over time, and the examples are numerous in my institution: Students show up late to rounds with coffee in their hands; one med student had the gall to go directly to the attending and request early dismissal because he ‘had nothing to do.’ The problem seems to permeate all schools.  Beyond the effects of this behavior on student culture, it results in underprepared interns and residents.alg-school-test-jpg

As a chief resident, I have set aside weekly teaching conferences with the students, and I think I have begun to better understand the issues. Just 5 to 10 years ago, medical school expectations were high. You were expected to show up early to rounds, leave late, be at the beck and call of your resident, and have absolute respect for an attending physician.  Respect for the process of education was standard.  You dressed appropriately. You studied to impress, and you came to rounds prepared to try your best. So why have these standards changed recently? Because none of these qualities are rewarded appropriately in a student’s medical school ‘report card.’


Medical student grades, and therefore class ranks, theoretically are based upon two major components: clinical evaluations and test scores (i.e., shelf exams). But the truth is, in medical education today, evaluations completed by residents and attendings of students on their medical teams are essentially useless. Most evals result in clinical grades that are essentially the same, no matter how hard-working or lazy a student was on the floors.  Many reasons are put forward to explain why this occurs, but I think the most important is ‘evaluation burnout.’  Academic medicine is riddled with so many unneeded and redundant evaluations that most physicians do not put the time or mindshare into making them useful.  This results in clinical scores that do not help discern who put forth the work to excel and who just showed up because they needed proof of attendance. It is for this reason that the test scores are weighted so much more heavily than clinical evaluations in the eyes of the average medical student.

“Why get to work early and learn about my patient when my test score and a review of ‘high yield’ facts from a review book will further my career more effectively than learning how to do a good physical exam?” “What is the point of having a well-prepared presentation for rounds when I will get the same score as my colleague who spent the morning going through review questions?” “What is the point of impressing my attendings when all that really matters is my grade and class rank?”


These questions guide the behavior of students, and I cannot blame them. Medical school is competitive. Long-term career plans depend on more than whether a resident team thinks a student is not putting quality time in on the wards.  The finger must be pointed at our medical education system, which values test taking over clinical knowledge and skill. How can we expect to produce a generation of quality practitioners without ensuring that we instill the value of actually practicing that theoretical medicine they learn in textbooks and are quizzed on in exams?  We somehow have to shift the tide of education toward, or perhaps back toward, an environment in which becoming a physician means more than a number or letter grade or a class rank.

Do you agree that students are ill-prepared? Do you see a solution to the problem of students being less interested in the work on the wards?


February 26th, 2016

Caring For Today’s Veterans

Briana Buckner, MD

Briana Buckner, MD, is a 2015-16 Chief Resident in Internal Medicine at the University of Pennsylvania in Philadelphia.

For most of residency, I missed the opportunity to care for veterans — mainly for selfish reasons, including my unwillingness to learn a new EMR and hospital. Once I became a chief resident, I realized that I would be spending 4 months at our local VA hospital. When I first came to the VA as a chief, my goals were similar to that at any other site at which I work: Get to know the staff, present quality conferences, and look after the residents. Little did I know that the VA would open my eyes to the special concerns of the millions of Americans who have served in the military.

On my first day, I was incredibly touched by how different it was to walk in the hallways at the VA, compared with my other sites. A casual trip to the cafeteria was showered with “Good morning, Doc. How you doing, Doc? Have a great day, Doc” and any other respectful salutation that you could think of. It initially seemed to be casual conversation, but I soon realized it was a sign of the culture. A military culture of respect that was palpable even in the hallways or cafeteria!

Seal of the Department of Veterans AffairsAs I continued to adapt to my environment, I learned that this patient population had unexpected  subtle differences from my other patients. There was a spirit of stoicism that often led me to underestimate how much pain a veteran was really in, and often left me surprised when I would check the medicine administration record to see my patient with an impressive wound had not requested any pain medication. Then there was communication of treatment plans — the veterans, as a whole, did not like uncertainty. I often found patients telling my team, “Doc, I don’t want to be no guinea pig. You know what you’re doing, right?”

I often stopped in my tracks and felt a gut check when a veteran opened up to me about seeing the death of a friend, being away from home for years, or having nightmares from their time in the military that often was many decades ago. I was most humbled by the patients who were the same age as I. The young man or woman who, if I saw him or her in the mall, I would never know the depths of the service they had given. Today’s veterans have new faces that I wasn’t prepared for. They are not just the faces of my Great Uncle and Grandfather (both veterans), they look like friends I went to college with.

There are more than 2.6 million service members that have been deployed to Iraq and Afghanistan since 2001 (Ann Intern Med 2013; 159:ITC1), and many of these Americans have returned to civilian life after serving their country. This generation of veterans are jumping back into the civilian workforce and seeking care from civilian healthcare providers. The medical needs of this population are specific and include monitoring for post-traumatic stress disorder, substance abuse, depression, and long-term sequela of traumatic brain injury. Without my time working at the Veterans’ hospital I might never have learned how to appropriately care for this population. I truly feel a tremendously deep appreciation for the sacrifices that these patients have made. Many of them are homeless and have yet to recover from what they encountered while in the military.

Today’s veterans are a heterogeneous group who deserve physicians who will adapt to their needs and see them in respectful light. I encourage all young medical students and residents to see their time in Veterans Affairs hospitals as a unique opportunity to learn, connect, and truly see this special population through an honest lens. My own lens is forever changed, and I hope to say, “thank you for your service,” a little more often than just on Veterans’ Day.


February 12th, 2016

What Have I Learned as a Chief Resident?

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

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

At my institution, next academic year’s chief residency application email was sent out last week. The APDIM spring meeting for chief residents and program administrator is going to be held in Las Vegas in April 2016. The 2016 chief residents need to be selected before that meeting.

That e-mail brought a flashback memory for me. I met Charleen (the NEJM JW Resident blog editor) at the last APDIM meeting, and that’s how my association with ‘NEJM Journal Watch Insights on Residency Training’ started. I clearly remember walking up to the NEJM booth and seeing a card on a table that read ‘If you are a chief resident and interested in writing, please stop by.’ We spoke for a while, and I decided to apply. My journey as a chief resident and a blogger started at the same time. Now, I have finished 70% of my tenure as a chief resident and a blogger. It’s probably time for introspection about what I have learned during this journey and what I have delivered to my institution. 

Last year at APDIM, I attended many different sessions, including morning report teaching, keeping residents engaged, making call schedules, preparing an academic calendar, addressing conflicts between residents, and dealing with difficult residents. I did not realize at that time that most of my learning would actually come in the form of real life experiences in all of these areas. 

looking in a mirror

By Charles Williams (Own work) [CC 2.0 via Flikr]

I surely have evolved into a more mature individual from dealing with these issues. It’s not just about what to say, but how to say it. It’s about what to write in an official email. How to get work done without offending the majority of people. How to improvise new teaching strategies to keep the audience engaged in different situations. Acquiring the ability to stay neutral and unbiased as an administrator and to maintain confidentiality. 

I learned to identify weak and strong people from a team and mentor them accordingly to achieve their individual goals. And, the most difficult situation I faced was saying no to my best friends’ call change requests but still hanging out together after working hours. I definitely see and appreciate the enormous amount of work done by graduate medical education staffs to run residency programs in academic institutions — working closely with people who have administrative roles has been an invaluable learning opportunity.

At times, I struggle to balance clinical work, study, administrative work, and family life. However, I am not complaining. This is what I wanted! I have enjoyed every day so far as a chief resident. So, a few more months of this, and then a new journey begins. What I have learned as a Chief Resident will stay with me for the rest of my life. If you’re thinking of becoming a Chief Resident, prepare yourself for a whole new learning experience, and enjoy every moment of it!


February 5th, 2016

Don’t Give Up!

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

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

There comes a time in most people’s training when adversity threatens to become overwhelming and swallow them whole. It could be as a medical student, while spending countless hours in the library or when on demanding rotations. Or, it could be during residency, from the 80-hour work weeks or the stressful patient care situations. It might even happen well into training, when the weekly grind just becomes too much. Burnout, generally defined as “loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment,” is more common among physicians than other American workers – 46% of physicians responded that they had feelings of burnout in a 2015 survey, with the highest rates occurring in physicians on the front lines of care, in specialties like emergency medicine and primary care.

When I was young, I wanted to quit everything I tried. It happened first at age 5. Tears welled in my eyes when I was unable to kick the ball correctly during my second soccer practice. The coach tried to help me, but the ball just wouldn’t go where I wanted it to. I was a stubborn child, and on this occasion, I stomped off the field after practice and cried all the way home. I told my mom I was never going to play soccer again. I took a pen and stabbed holes in my jersey to prove the strength of my 5-year-old will.

The next day, my mom and dad sat with me during breakfast, and calmly told me that despite my wishes, I was actually not going to quit soccer — that they wouldn’t let me. I was still angry, and I fought back. In the end, we agreed to a compromise: that I would finish the season, but afterwards, if I didn’t want to play anymore, I could stop. By the end of the season, I loved soccer. I played throughout high school, and I continue to play today in adult men’s leagues.

It happened again when I was 11, this time during summer camp. It was my first experience spending a significant amount of time away from home, at a sleep-away camp in northern Michigan. By day three, I was homesick and miserable. The other kids were too loud at night, and I couldn’t sleep. I didn’t like the food. The activities were boring. I wrote my parents every day, begging them to come pick me up. Again, my parents pushed back, reminding me that just a few weeks earlier I had begged them to go to camp in the first place and that I must finish my commitment.

In medical school, it very nearly happened again, this time threatening to end my medical career before it really even got started. I took a year off before starting medical school, working as an English teacher in Japan. Not only was it difficult for me to transition back into the role of student, but I also wasn’t prepared for the difference in intensity and volume of medical school work compared with undergrad. After 3 months of courses in anatomy and biochemistry, I was performing poorly and not putting in the time needed to succeed. I began feeling more and more overwhelmed, and those old tendencies that I had as a child started to creep in.

Maybe this isn’t for me, I remember thinking. I was so much happier in Japan, so much more carefree! Maybe I should quit medical school and go back… I could get another job as a teacher…

This Abies concolor tree shows immense perseverance after it was decapitated (by some unknown natural cause).

By Wing-Chi Poon (Own work) [CC BY-SA 2.5 via Wikimedia Commons]

I thought back to those childhood lessons on the importance of perseverance. Instead of giving up, I decided instead to dig in and work harder, because I remembered why I entered medical school in the first place — my dream of becoming a primary care physician. I spent more time in the library. I joined study groups. I did extra practice problems and took more thorough notes. Better results came almost immediately. My scores improved, as did my mood. Now, nearly 7 years later, I am so relieved that I stuck with it. I am enjoying my final year of residency, and I’m excited about my future career as a family medicine doctor.

Medical training is hard, no doubt about it. The hours are long, and the job can be demanding and stressful. Although burnout and stress are sometimes unavoidable, my advice from personal experience is to try to keep those feelings at bay when you see them approaching. If the stress becomes too much and threatens to overtake you, think twice before giving up. Maybe what’s needed is some personal time, a change of direction, or a conversation with someone you trust and admire as a mentor.

For me, what was needed during that first year of medical school was a long look in the mirror and a greater commitment to my long-term goals. And, I’m not sure I would have made the same decision without some timely lessons throughout my childhood.

Thank you, mom and dad!

February 3rd, 2016

Zaatari: Day 3 with Syrian Refugees

Ahmad Yousaf, MD

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

This is my third post about my trip to the Zaatari Refugee camp in Jordan with the Syrian American Medical Society (SAMS). I will continue to share my daily journal entries with you in hopes of educating the American medical and nonmedical communities about what I saw, erasing the irrational fears that have guided the discussion of refugees in this country, and as a form of therapy for myself.


Reflections from Day #3 with Syrian refugees:

1) The Zaatari refugee camp is both a fascinating human achievement and, simultaneously, a mark of shame on the record of humankind. There are organized shipping container-like abodes set up in miniature communities, with tiny malnourished, barefoot children roaming the streets despite the freezing cold. The supply distribution system is impressive, but the condition of 80,000 innocent human beings stuck in a place far from the comforts of home is horrendous. There is a combination of hope and horror intertwined into the mundane life of waiting/surviving in this limbo — people seem to just stare off into space, daydreaming of a home that probably doesn’t exist.

mom with baby

2) The human spirit’s ability to simply survive is remarkable. A living hell exists in this world, and children with nothing to be happy about and EVERYTHING to cry about, push through and flash peace signs and smiles. We were unworthy of those smiles but they graced us with wide eyes, excitement, and imagination we truly didn’t deserve.three children on the street







3) The human touch in western medicine is severely underrated. Putting your hands on people, giving a big bear-hug, holding a child to your chest, shaking the hands of an elder respectfully… It is all we have to offer sometimes…


Photography by Amal Rass and Joshua Margaritondo


One Syrian refugee described the refugee experience as a “slow death.” He contemplated whether or not going back to Syria was better because, at least if he died, it would be swifter than what he and his family were experiencing at the moment. He spoke of his people coming together again, in heaven. The following is a poem inspired by that conversation in combination with the news of the siege of the city of Madaya in Syria.

The Slow

His cold fingers tighten around our necks, clasped,
The last bit of air escapes and with it hope, collapsed,
The deep sleep is to follow but the screams keep us from the Light,
Dreams of feasts call us closer to slumber, but the pains of hunger keep us up this night,
Our mothers’ hands run over our bellies to fill them, a mercy,
Our fathers take up arms against the devils, to kill them, bravery.
But they are murdered by the victory of a false god, an evil wrought,
We only have prayer, the bitterness of salt and water sustains us not,
He now surrounds us, his barrels facing the barrels of our chests,
Our ribs now part, what is inside now visible through the skin and bones of our breasts,
We are but target practice, our hearts the bullseye,
Our names unknown, our value mistaken, too dry to cry,
We see him now, his darkness begins its plodding embrace,
Squeezes us gradually, tightly towards his face,
We meet his eyes and know the suffering is soon to be done,
We now welcome his coolness and the calm that lays beyond, the One.
We go limp in his arms, and up goes an army of lifted souls,
He carries us from Zaatari and Madaya to another heaven above, an incomplete people to be again made whole,
And so the screams are replaced with laughter. Tears of joy, not despair, now fill our eyes,
The Slow Death has delivered us and now we indulge in the everlasting supply of His Love in Paradise.


To donate to the Syrian American Medical Society, click this link and scroll down to Jordan missions.

If you have questions or are interested in volunteering, please reach out; even if you’re not in the medical field, you’ll be of help, especially if you speak Arabic.

January 29th, 2016

Zaatari: Day 2 with Syrian Refugees

Ahmad Yousaf, MD

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

aerial view of the Zaatari regugee camp

Google Maps image of the Zaatari refugee camp

This is my second post about my trip to the Zaatari Refugee camp in Jordan with the Syrian American Medical Society (SAMS). I will continue to share my daily journal entries with you in hopes of educating the American medical and nonmedical communities about what I saw, erasing the irrational fears that have guided the discussion of refugees in this country, and as a form of therapy for myself.




Reflections from Day #2 with Syrian refugees:

There were two moments today that are going to be hard to forget.


1) When I’m caring for children, I often make corny old doctor jokes with moms and their kids in the office in America. This day in the Zaatari clinic, two children with viral infections came into the exam room with their mother. Their mother, a woman in her mid 20’s, was concerned her kids kept getting sick. I asked if they played with a lot of other kids or go to school. She said that they are often with a lot of the other refugee kids. I made my ‘go-to’ joke: “At ages 4 and 6, children hate sharing anything with each other, except for the things we do not want them to share. They love to share their boogers and illnesses with each other, their mamas, and their papas …” There was a pause… It was heavy. I had 25assumed that the children’s father was alive, not imprisoned, and not separated from his family in the escape from Syria. The mom’s eyes welled up with tears. “They don’t have a papa anymore.” The words hit me hard, and shame overwhelmed me. I thought of my own baby girl and the absolute terrible thought of her not having me to love her, care for her, protect her, and provide for her. I offered weak condolences and tried to refocus on the kids’ infections. Before they left, we stuffed extra lollipops in their pockets and gave them hugs. We can treat the infections, but how do you treat a problem that doesn’t have a cure?



2) A mother came in with four children who all had chronic coughs and congestion issues. The mother was funny and warm, and when I asked her what her kids’ names were, she said the names of her three older sons and then the name of her youngest daughter, Shaam. She looked at us with a smile and said: “That is where we are from in Syria. We love that place, and my daughter is a reminder that we will love the day we finally get to go home with her.”

16Shaam was born a refugee. She knows nothing of her homeland. Her entire life has been spent in a shipping container that has served has her temporary abode in the camp. May her parents’ wish be granted that she one day return to her namesake.

Photography by Amal Rass and Joshua Margaritondo

It has now been almost 2 weeks since my return, and I still have images of the children of Zaatari imprinted in my memory. I hold up my own 2-year-old daughter and look into her eyes, knowing that if I work hard, I will  provide her with everything she ever needs. The children of Zaatari do not have that. Their fathers have been killed, imprisoned, or stripped of any opportunity to protect them or provide for them. Their mothers are left caring for entire families. (I saw one woman caring for 12 children, mostly nephews and nieces who had been orphaned.) Many of the caregivers are teens. The devastating war that has ravaged Syria is still ongoing — the factor that actively produces Syrian refugees is still happening. And for the most part, we do nothing. That feeling of hopelessness is immense.


To donate to the Syrian American Medical Society, click this link and scroll down to Jordan missions.

If you have questions or are interested in volunteering, please reach out; even if you’re not in the medical field, you’ll be of help, especially if you speak Arabic.

January 22nd, 2016

Today’s Medical Care — A Trap for the Sick and Elderly ?

Andrew Ip, MD

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

One of the great things about serving as chief resident this year is the opportunity to attend wards.  Below is a short story about a patient that was admitted to my team for less than 1 hour, but whose impact on me will last the rest of my career:

In November, I had the privilege to take care of Mr. E. Mr. E had an anterior STEMI last summer with a resultant EF of 25%, leading to several heart failure (HF) exacerbations that required hospitalization.   When we, the medicine team on call, were asked to admit him in late November for yet another HF exacerbation, my resident astutely noted he was cold and wet. I agreed, and we sent him immediately from the ER to the CCU to receive inotropic support. He never returned back to my team, but stayed in the ICU for more than 30 days.   I visited him regularly in the CCU – he was always in good spirits, despite becoming inotropic dependent and undergoing a heart transplant evaluation.


On the 28th day of his hospitalization, a special occasion occurred – his 55th birthday. We had a heart-to-heart, and he expressed his desire to continue to live. I asked him what he meant by that, and he said he wanted to go home and to be with his family. That was ‘living’ for him. He expressed his strong belief in God, and he asked if I could pray with him, to which I agreed.   Throughout his 36-day hospitalization, he underwent multiple procedures and diagnostic tests to see if he would qualify for a heart transplant, only to be denied. His hopes to return home and to be with his family were denied as well, as his condition quickly deteriorated with cardiac arrest from ventricular tachycardia (he survived that, however, after 1 shock) and multi-organ failure. Mr. E passed away on the inpatient palliative care floor at our hospital at 4 am on Christmas day, with no family at his bedside.

When I first started medical school, my naivete was that the art of medicine was practiced with the idea that the patient should be at the center of anything we deliver, as I wrote in August. Mr. E did not want to spend his last hours and days alone in the hospital, but that is exactly what happened to him. Why? I think now, 8 years after I started my journey into medical training, I’ve become jaded: I think that, despite what is preached in school and academic hospitals, most healthcare is still delivered with a culture of paternalism.

bear trap

Perhaps a better way to say it is that medical care for our sick and elderly is a winding maze of never-ending appointments, procedures, treatments – a total trap. What do I mean by this? Once a sick patient is seen in multiple medical/subspecialty clinics, or admitted to the hospital and seen by multiple services, the patient, such as Mr. E, feels like he or she is at the mercy of what the doctor decides is the best course of action. Often, patients may not even realize, due to poor socio-economic status, that they have a voice in their care — an all-too-common scenario at my county hospital.

Another extension of our health care system, nursing homes, is another great example of how we trap our patients, this time the elderly, into an environment that caregivers and families believe is in the patient’s best interest.   Often, this results in a total loss of control and alienation of our aging population, which (by the way) will only continue to become older AND healthier (Jagger C et al.  Lancet 2015NEJM Journal Watch’s post) .


Being Mortal book cover

Atul Gawande wrote a fantastic book, Being Mortal, detailing his thoughts and sharing his stories about the perils of aging and modern medical care in today’s world.   Topics mainly centered around how the sick and the elderly are treated more like inanimate check-lists or to-do lists, with providers focusing on fixing the disease or caregivers focusing solely on activities of daily living. He eloquently writes that our medical profession seeks to ensure health and survival, rather than “to enable well-being.”

*Please note, the next paragraph is heavily influenced by my recent viewing of the hit Netflix crime documentary Making a Murderer, which I HIGHLY recommend :)*

Recently, I’ve mulled in my head that a great parallel of our current healthcare system ‘trapping’ our sick and elderly once admitted to the hospital is our current judicial system ‘trapping’ an accused defendant who has a criminal past. Just like in healthcare, where many providers ask “how can we fix this disease?” and forget the patient, so do many in the court system ask “how can we convict this killer?” and forget the defendant is still presumed innocent until proven guilty. The medical team in a hospital has powers such as ‘medically holding’ a patient against their will, just like a judge can overrule a defendant’s pleas to throw out illegally obtained evidence.   The physically afflicted and the accused – both deserve to have a fighting chance to preserve their well-being and innocence, but both can be trapped in systems that have different agendas.

How do we avoid this trap? I would propose a listen-first, treat-second approach to most of our patients, with shared decision-making being the ultimate goal. This is not a new idea, but certainly patients like Mr. E remind me I have to be much better at empowering my patients and advocating for them.

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