Recent Posts

RSS

October 26th, 2020

Futility as a Cause of Burnout in Residency

Holland Kaplan, MD

Dr. Kaplan is a Chief Resident in Internal Medicine at Baylor College of Medicine in Houston, TX.

At the beginning of my residency training, one of our program leaders defined burnout as “work out of proportion to meaning.” In a sense, I think this also defines futility – performing a disproportionate amount of work compared with the results or meaning you are deriving from the work. The proposed causes of burnout in residency are broad – emotional exhaustion, depersonalization, lack of “resilience,” inordinate workload, sleep deprivation, and lack of time for leisure activities. However, the perception of futility also plays a significant role in burnout for residents. Below, I outline how feelings of futility contributed to my personal periods of burnout during residency.

In the ICU

I grappled for a long time with whether critical care was a good fit for me. I enjoyed the complex physiology, the consistent application of all areas of internal medicine, and the opportunity to help patients and their families through extreme illness and sometimes death. But I noticed as I completed my ICU rotations that I routinely started experiencing burnout and severe emotional exhaustion about 2 weeks into these rotations. Having experienced burnout of various durations in different settings throughout residency, I wondered what the precise cause of my burnout was in the ICU environment. Several years ago, I wrote about an experience I had as a second-year resident in performing CPR on an unfortunate elderly patient with multiple untreatable medical conditions. For this patient, CPR was never going to be helpful. I argued that my patient with severe anemia, heart failure, and metastatic cancer, had he been resuscitated, would still have had severe anemia, heart failure, and metastatic cancer. A portion of my ICU experiences centered on what I felt were futile efforts at resuscitation of patients who would never benefit from CPR. I reasoned that surgeons have the option to withhold interventions that have a low likelihood of success; why are we in medicine forced to perform a procedure (CPR) that in many instances has a success rate so low that a surgeon would never operate with those same odds? My disgust with performing CPR on patients in which it was futile reached the point that I rushed to run codes for fear of otherwise having to perform chest compressions. I spent many sleepless nights during and after ICU rotations grimacing at the thought of an elder’s osteoporotic ribs snapping beneath my hands like twigs in a futile effort to revive them. This perception of intense futility led me to burnout on all of my ICU rotations and ultimately turned me away from a career in critical care. Thankfully, many satisfying and rewarding aspects of critical care draw residents to this field, including the ability to see fast turnaround in very sick patients and interesting and complex pathophysiology. But the emotional aspects can truly contribute to feelings of futility and burnout.

On the inpatient wards and in the clinic

I remember inpatient wards and certain experiences in clinic during intern year being particularly rife with feelings of futility. The emotional distress on the wards and the clinic focused more often on the inability to provide patients with the care I felt they needed and deserved, but were unable to obtain, due to insurance or other systemic limitations. However, in these settings, a unique fuel for these feelings of futility centered less on emotional distress. I remember feeling inundated with endless documentation, phone calls for prior authorization requests, trying to meet unknown requirements to get patients to subspecialty appointments, and struggling to get help from ancillary services like physical therapy and social work to discharge patients to a safe living environment. I recall spending 60 minutes on the phone with an insurance company to ask them to approve an SGLT-2 inhibitor for my clinic patient, only to have them tell me they had to try two other oral diabetes medications first. I remember endless wait times with the appointment scheduling line for our health system, only to be told that the creatinine on the lab from last week was not recent enough for the patient to get a CT scan with contrast; I would need a more recent creatinine value. These experiences are not unique, physicians both in practice and in training report a significant administrative burden in the inpatient and outpatient settings that contribute to burnout. The feelings of futility regarding the time spent on an objective compared to the outcome achieved (or not achieved) was a major cause of burnout for me.

Combating burnout

So, how can residency programs alleviate burnout in their residents? This question is worthy of its own blog post, and I think the answer differs based on the cause of the burnout. However, with futility as a common thread among multiple causes of burnout, I think emphasizing and celebrating the things trainees are doing that are making a difference for their patients is critical. For a resident who just performed 30 minutes of chest compressions on a patient who was never going to survive, it makes a difference to say “Hey, I know those chest compressions were rough, but I think the way you called the code at the end and asked for a moment of silence was really meaningful for the family and for the patient’s memory.” Or for a battle-worn resident who has just gotten off a long call with an insurance company, a supervising physician could make an impact by saying, “I know those calls can be frustrating, but look at the improved glucose control you’ve achieved on this patient since meeting him. We’ll try these other meds first, and next time we’ll know the requirements for this insurance company.” Whether you’re a colleague or a supervisor for a burned-out resident, never underestimate the power of a few encouraging words in the face of feelings of overwhelming futility.

Sources:

Mian A et al. Medical student and resident burnout: A review of causes, effects, and prevention. J Fam Med Disease Prev 2018; 4:1510094. (https://doi.org/10.23937/2469-5793/1510094)

Ishak WW et al. Burnout during residency training: A literature review. J Grad Med Educ 2009 Dec; 1:236. (https://doi.org/10.4300/jgme-d-09-00054.1)

 

NEJM Resident 360

October 16th, 2020

Advancing Patient Safety in the COVID Era and Beyond

Frances Ue, MD

Dr. Ue is a physician at Cambridge Health Alliance in MA.

The U.S. continues to lead the world with almost 8 million COVID-19 cases and rising. The resurgence of coronavirus cases in areas previously unaffected or with cases under control shows how vulnerable our society is to the ravages of this disease and the devastating toll it can take on affected livelihoods and communities. It can feel at times that the progress made in the spring has been lost — but I urge you not to lose hope.

The COVID-19 pandemic exposes the weaknesses of our underfunded public health system and the challenges within our national leadership structure, both of which are needed to provide a coordinated response in this crisis. It also highlights the importance of our patient safety colleagues who continue to lead and innovate to ensure safe patient care. One such colleague is my dear friend, Dr. Liana Zucco. She is a Canadian British-trained anesthesiologist and a healthcare quality and safety fellow at the Beth Israel Deaconess Medical Center (BIDMC). I had the pleasure of interviewing her for this post.

(Interview transcript edited for length.)

Frances Ue: Tell us about yourself and what it’s been like being in the U.S. as a Canadian British-trained doctor?

Dr. Liana Zucco

Liana Zucco: I’ll first start by saying that I usually have to explain my origin, because when I say I’m a Canadian-born British-trained anaesthetic or anesthesiologist, everyone asks me what my accent is. There’s a lot of explaining, and everyone loves the story, they really do. And I find that I just keep on telling people about my life and about the journey that I’ve been on. It actually really makes me reflect on growing up and being a student in Toronto, moving to the U.K. for training, and now coming to the U.S. My experience moving from Canada to the U.K. was with my husband, and it became our adventure together. Whereas, this one is solo and trying to juggle a long-distance marriage comes with its own challenges.

It’s been very friendly coming to Boston and the BIDMC. From the anesthesia point of view, I am delighted that the drugs are the same and work the same way; the medicine is the same; the surgeries are the same. That’s really nice and comforting. Obviously the entire healthcare system is different. I thought that by being trained in the U.K. and constantly rotating from hospital to hospital, I was really good at adjusting, but this has been a whole different adjustment. It’s different adjusting to a whole new healthcare system.

FUe: Tell us about your experiences as a woman in medicine and anesthesia.

LZ: Similar to in the U.S., the anesthesia consultant (or attending physician) workforce in the U.K. is predominantly male (68%, Royal College of Anaesthesia, 2018). I certainly do feel that at many institutions, leadership roles are still male-dominated, but more and more, women are being promoted into these roles. Women need to see more women in leadership roles if they too are going to take them on.

I have been fortunate to have trained alongside many women and at times, female majority teams. There are days when I’m in the OR where I’m surrounded by female surgeons, female nurses, female anesthesiologists, and we certainly give each other a high five. And it’s really nice.

I think it’s important to have encouragement and support from the moment you enter medical school — making people aware that these specialties, like anesthesia, exist. And getting people involved and excited by it. It needs to be tackled early.

FUe: What makes you most excited about quality and safety?

LZ: I love the fact that, for most providers, especially junior providers, it is a ground-up movement. People get so frustrated working on the shop floor — they see problems, and they have no idea how to fix them, and they feel that they can’t. There are mechanisms in place for people to improve things from the ground up.

Quality improvement is looking at how organizations can not just be efficient but is actually examining why we should be doing x, y, and z, because it’s not just efficient but also benefits the patient and is safer. Good-quality care is safe care. And the moment that people recognize that is the most exciting. I am part of a specialty where that is literally the forefront — before you do anything else, it is safety first. In the U.K., I became the lead for quality improvement for DAPS (Doctors Advancing Patient Safety), and we published a how-to for junior doctors and started a program teaching quality improvement. That excites me the most — teaching people how to do quality improvement work. My heart just explodes with excitement.

It’s all different levels. Senior management get involved in one aspect, then interns get involved on another level. It’s not just doctors, it’s nurses, it’s super multidisciplinary. There’s a patient engagement aspect of it. It encompasses almost all of healthcare. And when I speak to patients on a daily basis, and they ask what my fellowship is in, they get excited when they hear that a fellowship exists in quality and safety.

FUe: Could you speak about your role during the COVID-19 pandemic?

caps to identify operating room personnel

An initiative to improve communication in the operating room with scrub caps made by Theatre Caps

LZ: As one of the quality and safety fellows within the department of anesthesia, we were tasked with figuring out how to minimize healthcare worker (HCW) infection. Specifically, how to minimize the risk of transmission and risk of viral exposure to HCWs who may be exposed during aerosol generating procedures. We knew from the Toronto SARS-CoV outbreak in 2002 that the majority of HCWs who became infected were intensivists, anesthesiologists, and nurses who were involved in aerosol-generating procedures, particularly in intubation and extubation.

It was our job to re-evaluate the entire workflow of a COVID-19-positive patient coming into the operating room, and we published these recommendations for the Anesthesia Patient Safety Foundation. We considered how to change the workflow, what measures we would change to enhance our infection control, and how to train the staff to follow these new guidelines. We created cognitive aids like checklists to be used in the operating room and trained staff through an in-situ simulation method which is in the actual work environment, to pick up the real hazards that exist and the real gaps in care. And every step of the way, we thought about how to minimize infection.

Our team disseminated the information that we developed, constantly made iterative changes to amend them if needed, and filled the gaps in our care, re-evaluation, training, etc. We started this about 1 month prior to the first COVID-19 case coming to our operating room. We trained over 400 providers in the perioperative department — nurses, surgical teams, surgeons, anesthesia residents, and others, and then we pulled in anesthesia providers from the community hospitals to do the same training. We did about 12 sessions a day for about 3 weeks. And then, that was it, and we just had to hope that it worked! And now we are measuring the impact of that, and we can safely say that not a single anesthesiologist became infected.

Now that the first surge is over, we are modifying all of these new standard operating procedures all over again to be ‘COVID-19 capable’ for the moment we know that a COVID-19 case is present. How do we go back to business as usual but be ready for a COVID-19 case? We had a COVID case the other day, and it was so delightful to hear the circulating nurses say, ‘yes, we need to do everything on the checklist and I have a copy here; we can’t start until we have a huddle.’ These are all things that we implemented, and it was so delightful that I didn’t even have to bring it up.

FUe: Where do you see your career headed?

LZ: My short term plans after this fellowship is done is returning to the U.K. to finish my anesthesia clinical fellowship (known as an advanced training module). In that time, I see myself trying to figure out how to combine a quality and safety fellowship and all the knowledge and experience I have gained, into a full-time working anesthesia career. I really thought I was a die-hard clinician and never wanted to spend a single day outside of the operating room or outside intensive care. However, this fellowship has really taught me that I actually really like a combination of both. I like the combination of having a non-clinical leadership role that has an immediate impact on clinical practice.

FUe: What words of advice do you have for residents who want to get involved in quality and safety research?

LZ: Quality improvement and safety research can be done efficiently, over a short period of time, and you will see the change happening in front of you — you will see improvement, or more efficiency, or a change in practice. It’s so rewarding. Do the online modules from the Institute for Healthcare Improvement to gain knowledge on the topic. Speak to your department because you will need a mentor for it, someone who believes what you believe and wants to change things in the same manner that you do. I have come to appreciate two phenomenal mentors — the director and supervisor of the fellowship, Dr. Krishna Ramachandran, and the director of the Master’s program, Dr. Anjala Tess.

FUe: Lastly, what do you miss the most about the U.K.?

LZ: I actually do miss the people. It’s really the people that make a place your home. I also miss having a role outside of the operating room from a professional perspective. Anesthesia covers everything in the U.K. — you cover intubations in the emergency department, you go on transfers from one hospital to another with an intubated patient. So you really feel like you have a family, not just at your own hospital, but in the entire region and city. I am a Southeast London trainee in the U.K., so I’ve worked at four different hospitals in the Southeast London region, and everybody does that and rotates around. So you feel like you have this enormous family from a professional perspective. From a personal perspective, I miss everything about London. I mean, what’s not to love?

Would love to hear from residents interested in quality and safety. What are your ideas to improve patient safety? Tweet at me, @TheFrancesUe or comment below.

 

NEJM Resident 360

October 7th, 2020

“We Did Everything We Could.”

Dr. Vivek Sant

Dr. Sant is a General Surgery Chief Resident at NYU Langone Health, Bellevue Hospital, and Manhattan VA in New York, NY.

Can we do better when delivering bad news in trauma?

On a recent trauma call, we had a busy night, culminating in a horrific motorcycle trauma that came in early in the morning. The patient had devastating injuries and ended up dying. The detectives finally tracked down the patient’s family. I cleaned myself up, put on my white coat, and had the family sit down in a private conference room. I entered with my trauma attending and a consulting specialist and we sat down with them. I told them their loved one had been involved in a terrible accident, and asked them what they knew so far. I filled them in on the rest of the situation, explaining that we’d done a lot of work to try to save him, but the injuries had been too much, and he had died. We spent as much time as we could answering their questions and being with them as they processed the horrible news, and finally took them to see him. Naturally, they were devastated; I will never forget the wail of sorrow from his widow. While I have delivered bad news before, this experience felt different and far more difficult, emotionally.

The SPIKES methodology

Delivering bad news to patients is difficult; but with a methodology and practice, it can be made less difficult. The SPIKES methodology was developed by physicians at the MD Anderson Cancer Center in Houston (Oncologist 2000; 5:302), for delivering bad news to oncology patients. Optimizing the following parameters helped improve their patients’ experience:

  • Setting – ensure a private, quiet place; sit down, invite other family members, avoid external interruptions
  • Perception – assess the patient’s baseline understanding of the situation before diving into an explanation
  • Invitation – provide initial information and offer the option of hearing further details
  • Knowledge – warn that bad news is coming, give information in small chunks, and avoid jargon
  • Empathy – address the emotional response with empathy
  • Strategy – summarize concrete next steps

doctor delivering bad news to a coupleIn retrospect, we had addressed most of these issues as recommended. However, unlike the oncology setting in which this framework was created, or even the surgical context I am used to, the emergent trauma setting presented several unique challenges:

  • No previously established rapport – in trauma, providers do not have an earlier visit to establish a bond with the patient or their family; in contrast, rapport in oncology is built over time, and a connection is formed with patients preoperatively, prior to elective surgery.
  • Traumatic injury is unexpected – a family member’s death is rarely on the family’s radar since trauma is unexpected. In oncology, patients have been considering their own mortality, and in elective surgery, families know their loved ones are being hospitalized for an operation.
  • Patients are younger – trauma patients often are younger, where the loss is more unexpected and perceived to be more unfair.
  • Fewer resources for grief support – traumas often present on nights and weekends, when the hospital is not as fully staffed with chaplains, social workers, and grief counselors who would otherwise be instrumental in supporting the bereaved family.
  • No control of the narrative – various professionals work together to identify and contact family of trauma patients; they may not have training in delivering bad news or accurate updates on the patient’s status. So families sometimes arrive at the hospital without the appropriate foreshadowing of the complete situation and are shocked by the news.

We might feel discouraged that some of these aspects are immutable. We can’t control trauma patient demographics nor the unexpected nature of trauma. However, with training and funding, we can better steer the narrative and improve resourcing. And on an individual level, we can soften the blow through a deeper understanding of the specific nature of their pain (“No one should die so young”) when talking with families.

Resilience in the face of delivering bad news

Delivering bad news is tough. Delivering bad news in trauma is tougher still. And this takes a toll on healthcare providers as well. Thirty minutes after we talked to our patient’s family, wails of sorrow still ringing in our ears, we headed to the OR to take out another patient’s appendix. New patient, fresh game face, another battle to fight — with the same sense of purpose and urgency.

What strategies do you use for delivering bad news in the emergent trauma setting?

 

NEJM Resident 360

September 29th, 2020

Below Hospital Deck

Dr. Braunthal is a Chief Resident at the Cleveland Clinic Foundation in Cleveland, OH.

There is debate about which of the many medically themed TV shows best depicts our lives in medicine. Is it the conundrums of House? The interpersonal drama of Grey’s Anatomy? The camaraderie and antics of Scrubs? While each of these capture unique problem solving, empathy, relationships, and burdens that accompany being a physician, I had yet to find a show that accurately reflected the day-to-day reality of being a resident. That is, until I discovered the Below Deck series on Bravo. Now, I know this seems silly. Below Deck? A reality show about the crew of super yachts that charter wealthy guests on luxury nautical vacations? Although the show does not feature a single doctor, save the occasional guest or local physician summoned to evaluate a deckhand’s injury, I find that, rather than constantly noting how inaccurate scenes are to real life (like I do with medical dramas), I instead draw parallels between the scenarios on the boat to those in the hospital. The show highlights struggles within a hierarchical work environment, discussions about duty-hour restrictions, occupational safety concerns, fast-formed friendships, and the occasional romances that strike as crews on each season work together to repeatedly achieve high-stakes outcomes. Starting to sound familiar? It certainly did to me.

The cast of each Below Deck series consists of a captain, first mate, engineer, chef, and two teams of deckhands and stewards. The latter each have an experienced lead (“bosun” on deck, “chief stew” interiorly), a moderately experienced second rank, and an inexperienced third rank. Structural comparisons are obvious. Residency programs have directors, program leadership, support staff, and chief residents who direct and oversee operations and the growth of the trainees. The residents themselves work in the hospital as pairs or trios, with a senior overseeing at least one intern. In the same way that crew members shuffle from yacht to yacht, residents rotate from service to service. While some characters recur, each season generally follows a new crew that has never worked together.  Our residents similarly assume a role with universal responsibilities based on their postgraduate year (PGY) level, which makes transitioning between diverse rotations relatively seamless. Medicine is not hospitality, but it is nevertheless a service profession. While residents are not required to prepare elaborate meals or frivolous theme parties, their creativity is constantly pushed to the limits, expanding their differential diagnoses and navigating seemingly insurmountable obstacles to get patients the care they need. Both professions rely on the success of the group to not only ensure the safety of human lives, but also for career-promotion opportunities, which in the case of Below Deck is thousands of dollars worth of tips.

The more episodes of Below Deck I watch, the more predictable the drama becomes: guests don’t like the food, the captain is disappointed in the crew, someone doesn’t answer the walkie-talkie, the chief and her stews aren’t getting along, and so on. Dissatisfaction, unmet expectations, and miscommunications are also common sources of tension in the hospital, particularly on teaching services where everyone has different degrees of experience. As they progress in training, the most successful residents not only learn to resolve conflict, they also develop strategies to avoid it.  These include taking the time at the beginning of the rotation to define roles and expectations with the intern and attending, team communication, proactively reevaluating team goals, and regularly delivering feedback. Incidentally, when the Below Deck crews employ these tactics, they navigate the gratuitous requests of their clients and the unexpected perils of open seas with relative ease.

While it might seem like I have been a fan since its inception, I only started watching Below Deck a couple of months ago as a frivolous escape from boards studying, chief responsibilities, and the serious realities of our world during the past year. I did not anticipate that the show would provoke so much introspection, nor did I realize how valuable it has been as a means of communicating my experiences during residency and chief year to my friends and family outside of medicine. Next time someone asks what it’s like to be a resident, I’ll simply say, “It’s like working below hospital deck.”

 

NEJM Resident 360

September 17th, 2020

What’s in a Number?

Sneha Shah, MD

Dr. Shah is a Chief Resident in Internal Medicine at the University of Colorado.

Does your doctor’s age matter?

If I had $100 for every time I walked into a patient’s room, introduced myself as the doctor, and was immediately asked, “Hey, how old are you?” I might be able to retire right now — at the age of 28. Of course, I am exaggerating, and yet this question echoes for me and my baby-faced colleagues constantly.

Whether it’s simple curiosity or blatant reverse-ageism, I find this question erodes trust before it is built. I haven’t yet found an agreeable way to bypass it; I usually just state my age, before quickly moving on. Rarely, some congratulate me on my accomplishments given “such a young age.” But these felicitations are like writing in the sand, which quickly wash away in the waves of emotions I begin to feel the moment they ask me that question.

“The Doctor Is In” by Joe Shlabotnik (CC BY-NC-SA 2.0)

Courtesy of Valay Shah

Why this question hits too close to home

Even though I am the oldest child in my extended family, my traditional Indian (specifically Gujarati) family considers me to be a kid. I keep hitting milestones — 16 to start driving, 18 to start voting, 21 to drink alcohol, 25 to rent a car — but I am still seated at the kids’ table at home. During holidays or celebrations, I often feel left out. Too old to play with the kids and too young to gain entry into adult conversations. I attempt to walk up to a group of aunties and uncles hunched over in a hushed conversation — abridging their conversation, they turn toward me and ask, “Aren’t you getting too old to not be married?” So, I am officially too young and too old at the same time.

I commiserate being in age-limbo with my brother, who shares similar sentiments. Nonetheless, there is a deep hurt that comes with never feeling trustworthy enough to hear family secrets. And, as I learned on my psychiatry rotation as a third-year student, I am using the mature coping mechanism of suppression to hide that hurt.

Similarly, I start to feel untrustworthy during patient encounters where my age is brought up — no matter how knowledgeably or confidently I began that interaction.

When your competency is questioned

As new physicians, we are required to start making decisions and to start practicing medicine. Even residents who haven’t had my cultural experiences know the feeling of doubting oneself for even minor decisions. We hold the precious privilege of caring for someone’s life, and mistakes can be grave. Knowing this, we double and triple check our work. Despite this, patients and colleagues continue to question us. When we are interns, they want the opinions of our seniors. When we are seniors, they want the opinions of our attendings. Even as an attending (my first time as a chief resident), a patient’s wife asked whether there was “someone above me” who could confirm my clinical judgment.

Unlike our patients, members of our interdisciplinary team might not blatantly ask our age, but there are undercurrents of skepticism. For example, nurses will look surreptitiously toward the critical care fellow lurking behind the senior resident who is running a code before acting on the resident’s requests. Pharmacists will congratulate interns for finally placing that antibiotic order correctly. We fall victim to the experienced physicians’ “back in my day” comments.

How we can grow together

Malcom Gladwell book cover -- Outliers

By Source, Fair use, https://en.wikipedia.org/w/index.php?curid=21063227

There are times when I simply want to reference this article (BMJ 2017 May 16; 357:j1797) about physician age and patient outcomes — no difference! But, I choose to remember that 3 years of residency barely surpasses the 10,000-hour rule popularized by Malcolm Gladwell. And I am thankful for the talented and experienced healthcare providers that surround me. Countless times, an ICU nurse has whispered in my ear about which pressor to start. Pharmacists have alerted me on near-misses and helped me write the correct medication order. Nurse care managers took the time to explain the difference between Medicaid and Medicare. And, experienced physicians have taught me how to hold a patient’s hand and be a guide through the toughest time in his or her life. But, currently, we lack robust evidence about how physician age affects patient outcomes. Thus, we, “young physicians,”  will continue to double-check our work, and those around us will wonder if we have done so.

Illuminating the lengthy path it takes to become a physician, a colleague jokingly replies, when asked the age question,

“Let’s see… 4 years of college, 4 years of medical school, and 3 years of residency, so I’m at least 11 years old.”

I pose the following question for our readers: How often, when boarding a plane, do we demand that the cockpit doors be opened so we can inquire about the pilots’ age? We don’t. We trust that they have enough knowledge and experience to competently fly hundreds of people  to their destination. Isn’t it time we afford the same trust to all of our physicians, regardless of their age?

NEJM Resident 360

September 11th, 2020

Emotional Intelligence During a Pandemic

Dr. Masood Pasha Syed

Dr. Syed is a Chief Medical Resident at Saint Vincent Hospital in Worcester, MA.

“We are the keepers of each other’s future,” my program director said in her speech on our graduation day. These words have resonated in my mind and inspired me in laying the foundation for my chief residency year. We all have the opportunity and responsibility to teach and learn from each other. I remember the first day of my internship, where I felt like a sponge trying to adsorb or absorb as much as I could. And here we are, 3 years later, ready to take the reins — some of us as attendings, some as fellows, and, a few of us, as chiefs.

Living in a world with COVID-19, one can’t help but wonder what this means to the new residents and medical students stepping into medicine. Medicine never was and never will be an easy science. As residents and medical students go through training this year, learning to truly appreciate and internalize what it means to be on the frontlines will be a unique experience. Although there is a formal curriculum for residents and medical students, which is absolutely needed, we also must be mindful about giving our residents the best tools to work through the pandemic. One such tool is emotional intelligence (EI).

EQ_5 traits

from Wikipedia: Dfrench17 / CC BY-SA

Emotional intelligence is the capability of individuals to recognize their own emotions and those of others, discern between different feelings, and use those feelings to guide behavior to achieve one’s goal(s). There is growing research and evidence that a doctor’s EI can influence his or her ability to deliver meaningful and compassionate patient care. But is EI is a trait we are born with or a learned skill that we acquire? I think it is a combination of both. Through this pandemic, I have found that we, as a medical community, are developing a stronger sense of emotional intelligence. To highlight this, consider the ‘Mixed Model Theory’ by the journalist/scientist Daniel Goleman which endorses five key elements that lay the foundation for EI: motivation, self-awareness, self-regulation, empathy, and social skills. I want to share this theory through medical binoculars with illustrations that I believe might help us become better physicians.

Defining emotional intelligence through the pandemic: 

  1. Motivation – the ability to go on in life, despite obstacles or limitations one may have. One big concern we had earlier this year was the new interns’ experience as they were about to start training. Would they be able to start residency training on time? Could medical graduates travel nationally and internationally to their matched programs to train? Would their learning be compromised as we innovated through the pandemic (while socially distancing ourselves)? It takes motivation and commitment to leave everything and everyone in your life at home and move to a new location or country to train and work during a pandemic. Our program is diverse, with residents from 14 countries on 5 continents, which means that we must work within all those countries’ rules and regulations to have our interns join us this year. As we traversed through varying timelines in getting our residents to our program, we learned from all their experiences and journeys. I appreciated our interns’ motivation and dedication as they successfully began their training this past summer.
  2. Self-awareness – the ability to recognize one’s moods, feelings, skills, and limitations. Being self-aware is essential, as this also has an effect on our patients and the care we deliver. Going through the pandemic with a surging number of cases and losing patients to this illness warrants reflective debriefing and addressing one’s own feelings associated with it. Self-awareness is vital to reduce physician burnout while maintaining hope and optimism and seeing the light at the end of this tunnel.
  3. Self-regulation – the ability to use self-awareness to control one’s own impulses and recognize our impulses while caring for our patients. This pandemic brought with it limited visiting rights, which meant families could not meet their loved ones who were in the hospital. This regulation usually was met with understanding, occasionally with grief, and rarely with anger. Self-regulation for a healthcare provider in this setting means controlling one ’s response to this challenging situation and advocating the importance of social distancing in keeping family members safe.
  4. Empathy – “going the extra mile” is the ability to understand other people’s emotions and reactions. Being motivated and self-aware while regulating one’s own emotions allows one to be an empathetic physician. Through this pandemic, I have realized the power our words and actions genuinely have. Whether it was using your phone to Facetime patients’ family members to allow them to see their loved ones in the hospital, covering for your colleague who may be sick, or staying beyond your shift time to stabilize your ill patient — there have been numerous examples of nurses and residents going the extra mile. I cannot do justice to all their efforts and sacrifices, many of which go unnoticed. I am reminded of the following quote: “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.” – Maya Angelou
  5. Social skills – the ability to pick up social cues during our interaction, as we find common ground with others. Being socially inclusive while socially distancing has been a new way of life. The key has been to consistently innovate to supplement our lives through the pandemic for our education, learning, and social wellness. As an example, we have a wall in our department where we mount an annual picture of all our residents with the program leadership. This year might have been the first in which we would not have a group picture of all our residents. We had to innovate, while practicing social distancing — which resulted in what I think is the most exceptional picture of all time.
    2020 Yearly SVH Residents Picture

    Saint Vincent Hospital Internal Medicine 2020 – Courtesy of Dr. Avinash Singh.

Our actions are a product of our mindset and ever-evolving perspective. Working through this pandemic has most definitely changed our perspective about caring for our patients and each other. As a chief resident, it is my honor to witness my residents’ and interns’ tremendous growth through training. Helping students find their true calling and meaning in their work is a rewarding experience for every educator. One such example for me is this poem penned by my intern, Dr. Vishesh Jain, as he worked through the pandemic and wrote about what it truly meant to him.

A Wandering Smile – by Dr. Vishesh Jain

In conclusion, I appreciate all my colleagues (physicians, residents, nurses, nutritionists, physical/occupational therapists, case managers, EMTs, PCAs, other frontline workers) preparedness to show up to work — be it during a pandemic or not, no questions asked, no less heroic than soldiers walking into war. During these times, emotional intelligence is vital, as it adds meaning to our lives and helps reduce healthcare worker burnout while allowing them to provide the best patient care. As we continue to care for our patients, not knowing the long-term complications of this disease, we must not forget our power as healers. One cannot cure every ailment, but perhaps one can help heal it.

 

NEJM Resident 360

September 3rd, 2020

“Never Waste a Crisis”: Perspectives from History and Today

Holland Kaplan, MD

Dr. Kaplan is a Chief Resident in Internal Medicine at Baylor College of Medicine in Houston, TX.

The mantra “Never waste a crisis” has stuck with me for the past several months. This statement was reportedly made by Winston Churchill in the 1940s, during World War II. However, a well-known internal medicine faculty member and leader at Baylor College of Medicine, Dr. David Hyman, who recently passed away, also gave us this advice in the midst of the COVID-19 pandemic.

The pandemic has taken so much from us. For some, it has taken away the lives of beloved family members, friends, and colleagues. For many, it has taken away financial security, jobs, the schooling of children, any remaining trust in our government, and the ability to enjoy a meal out at a restaurant. And, for all of us, it has taken away the life we knew before this crisis struck.

At my institution, the COVID-19 pandemic has seriously altered the way our hospitals, residency program, and individual lives function. Thankfully, we have not seen devastation to the degree that other cities experienced earlier this year. Nonetheless, even in the largest medical center in the world, I have witnessed hospital wards transitioned to intensive care units, rationing of masks and other personal protective equipment, shortages of high-flow oxygen machines, and reconfiguration of entire staffing models at both the faculty and trainee levels.

But there is hope that progress and opportunity can arise from any crisis, whether war, natural disaster, economic turmoil, or pandemic. And there is truth to the homage that, indeed, we should “Never waste a crisis.” Because out of the depths of any crisis can arise new ideas, previously unidentified opportunities, and real change. Below, I have identified five themes for making the most of a catastrophe. I have also provided examples of each item – one historical example and smaller-scale examples of how graduate medical education, in my residency program or at-large, has made progress in the setting of this pandemic.

1. Rapid innovation

Crises can prompt rapid innovation where there might have been none otherwise. Historically, World War I was an expansive and far-reaching crisis. Prior to this war, in the early 1900s, use of blood banks and blood transfusions was infrequent. The trench warfare of WWI resulted in particularly high mortality. During the war, blood transfusions became increasingly common, particularly as an approach for managing hemorrhagic shock prior to surgical intervention. Without WWI, the development of blood banking and blood transfusions as a standard of care might not have developed until significantly later in history (Transfus Med 2014; 24:325).

During the COVID-19 pandemic, almost all of our didactic time, including morning report, noon conference, didactic half-days, and simulation sessions have transitioned to occur virtually. Although there have been challenges with this innovative approach to learning, there have been positive aspects as well. Our morning report case sessions now regularly have over 100 attendees, including not only our own internal medicine residents but also faculty from across all of our pavilions, residents from other specialties (such as radiology and family medicine), medical students looking for additional learning opportunities, and prospective applicants to our program. This level of accessibility and exposure was simply impossible with our in-person conferences. The additional faculty attendance has made it easy to get a “consult” on a complex case in the moment during morning report. Our virtual noon conference has enabled us to create a recorded library of lectures. Thus, our residents are able to view any content they missed. Overall, this modality of learning has enhanced accessibility of our didactics.

2. New levels of teamwork and cooperation

Catastrophes have a tendency to force people to work together to overcome them. As a result of World War II, the United Nations became the most recognizable, powerful intergovernmental organization in the world. At its founding, the UN had 51 member states. It now is comprised of 193 states, including almost every sovereign state in the world. One can debate the effectiveness of various components of the UN, but this body represents the largest effort at global cooperation in history. Among a variety of other accomplishments, the UN facilitated the adoption of the Universal Declaration of Human Rights in 1948. Without a crisis to promote its formation, the UN might not have been founded.

The degree of teamwork and cooperation I observed during the worst of this surge of COVID-19 in Houston has been inspiring. Our internal medicine residents cumulatively stepped up to provide over 1000 hours of additional coverage due to the extra patient load. Residents happily helped cover when colleagues were sick. On a larger scale, after our institution declared ACGME “pandemic status” we received innumerable offers of assistance from residents in other programs asking how they could help with the extra patient load. From gastroenterology fellows helping in our COVID unit to ophthalmology residents backing us up in the intensive care unit to surgical residents covering a multitude of medical ICU patients, this crisis gave us the opportunity to form relationships with people we otherwise might never have had the opportunity to work with.

3. Needed systemic structural change

Disasters also have a tendency to spur on much-needed structural change. The 1918 influenza pandemic was the deadliest human event in history since the Black Death, killing 50 to 100 million people. Before this pandemic, the United States was woefully lacking in almost all public health measures. But by 1925, all US states participated in a national disease reporting system. Many countries started forming national health ministries in the 1920s, and ultimately, the World Health Organization was formed in 1946. This cascade of public health measures was brought on by the deadly pandemic of 1918.

In response to the surge of COVID patients in our county hospital, our intensive care unit was forced to increase its capacity. Prior to this pandemic, we frequently had a challenging volume of overflow ICU patients. However, due to the additional surge of patients in the pandemic, we were able to work with the critical care and hospitalist services to enlist additional assistance from hospitalists, ICU attendings, and critical care fellows for night and day coverage in the ICU. As a result, we have been able to establish a separate “teaching” ICU service that has a distinct patient cap. Without the pandemic, the impetus to have these discussions and form a separate team would not have existed.

4. Opportunities for improved communication from leaders

During great crises, people look to their leaders for reassurance and information. In response to the Great Depression, the greatest economic downturn in history, President Franklin D. Roosevelt enacted “fireside chats” to clearly communicate with the American people. The conversational, informational nature of these radio broadcasts served to reassure the country throughout multiple crises. Every president since Roosevelt has delivered periodic addresses to the American people, a tradition stemming from the disaster that prompted Roosevelt to enact his fireside chats.

Since the onset of the COVID-19 pandemic, the need for increased communication and transparency between leadership and our residents became evident. Social distancing forced us to utilize virtual approaches. Thus, we instituted twice weekly virtual town halls with our program director in addition to weekly “chief chats” with our chief residents. We provided an open forum for questions, in addition to soliciting questions beforehand. We also ensured there was transparency of information by posting daily updates on the COVID censuses at each of our hospitals, information that was otherwise not being provided. The virtual mechanism of these town halls made them more accessible, and the frequent communication enabled transparency about current events and future plans.

5. Increased resiliency for the next event

Our response to a catastrophe lays the groundwork for our response to the next crisis. In Houston, we are particularly attuned to hurricanes as a form of natural disaster. One of the recent damaging hurricanes was Hurricane Rita in 2005, which resulted in widespread power outages. The company that maintains Houston’s electrical grid reported that, of their 1.9 million customers, 715,000 lost power during the storm. Since Hurricane Rita, this company has deployed new technology such as smart meters and intelligent switching devices to limit the number and duration of power outages. Additionally, they started a program to change wooden power structures to concrete and steel. These efforts are all in response to a severe storm in the hopes that fewer people will lose power in the next hurricane.

Through this surge of COVID-19 patients, I have witnessed the rapid expansion and subsequent compression of our county hospital’s capacity to handle the patient volume in concert with the flow of the surge. We worked to design surge protocols, integrate new COVID-specific units, and find appropriate coverage for an ever-increasing number of critical care patients. This process was done painstakingly, and there were triumphs and failures in our efforts. But above all, when we experience our next surge of COVID-19 patients, we will already have a framework in place for approaching the increased patient volume.

In Houston, we are thankfully in the latter part of this particular surge of the coronavirus. But with the uncertainty of vaccine timelines, limited public adherence to masking and social distancing guidelines, and minimal support from our government, it is impossible to predict what is to come. One thing I have learned from this COVID-19 surge is to “Never waste a crisis.” And hopefully, as a result, we’ll be better prepared for the next surge.

 

NEJM Resident 360

August 27th, 2020

“Use The Force”: How Do We Teach in the Operating Room?

Dr. Vivek Sant

Dr. Sant is a General Surgery Chief Resident at NYU Langone Health, Bellevue Hospital, and Manhattan VA in New York, NY.

As I embark on my chief year in general surgery, the aspect I look forward to most is taking junior residents through operations. I am grateful to have had excellent teachers over the past 5 years, and I appreciate the opportunity to pay forward this mentorship. But taking what you have learned and teaching someone else turns out to be a very different challenge than learning itself! Suddenly, you realize your attendings have been doing a lot of behind-the-scenes legwork to make the operations look simple and to set you up for success.

For me, two things have set apart the best teachers: patience and communication. Patience is intricately linked with humility and remembering that “I too was in this position once.” In some ways, this is inherent to one’s personality and character; everyone can strive to be more patient, but I think this quality is hard to change. On the other hand, while everyone enters residency with different baseline communication skills, with self-reflection and practice, communication skills are amenable to improvement.

Communication is hard. The following three practices help me communicate better in the OR and make teaching more enjoyable.

Do the heavy lifting upfront
Many within the surgical education community encourage trainees and supervising physicians to have preoperative briefings to discuss operative approach and focus areas. I try to have this discussion with my attendings and have found it quite helpful to my own learning. When I operate with a junior resident, I try to discuss my game plan with them in advance, or send them my notes on the specifics of the procedure the night before. I have found that this elevates the level of discussion we have in the OR — from “how should we enter the abdomen?” to “here’s how you can optimally position your body, give better tension with your left hand, and make a cleaner incision with your right hand, in order to enter the abdomen more efficiently.” Instead of just learning what the moves are, we get to focus on how to do them efficiently.

Own the responsibility for understanding
One of my college professors used to say, “The responsibility for understanding should be on the teacher, not the learner.” So rather than asking “Do you understand?” he would ask, “Have I explained myself properly?” Taking a resident through a cholecystectomy, I tried to explain a set of moves to him: “Use your hook to get around that structure, turn 90 degrees, pull out, and burn.” “Uh-huh.” Something didn’t sound quite right, so I paused and asked “Just to confirm, does that make sense – what I said?” “Maybe not completely.” We were able to clarify, and the honesty was appreciated. As surgery residents, we become really good at saying “yes” — If someone asks us to get something done, we say “yes” and then figure out how to make it happen. Sometimes residents apply the same mindset in the OR and might feel reluctant to speak up when they are confused. In these situations, it is all the more important for the teacher to confirm that their directions are understood.

Tailor the approach to the individual and the situation
In these first 8 weeks of chief residency, I have become more attuned to the differences in personality, learning style, and experience among junior residents. In the OR, some residents appear very confident, whereas others are still finding their groove. Some have had more experience with certain procedures. Some respond very well to constant feedback, whereas others need encouragement. I myself have probably been in each of these positions at different points of residency! The best teachers understand that the needs of the learner are different for each learner — and in each situation! Modifying your teaching style constantly is hard, but once you figure out how to tailor your instruction, it is very gratifying to see your trainee achieve his or her maximum potential!

Despite my focus on clarity of communication, sometimes there are teaching moments that are beyond words and intellectual understanding. In the OR, one of my attendings occasionally exhorts, “Be an athlete!” It’s hard to explain exactly what he means or how it helps, but usually, I am able to re-attempt the maneuver with more agility and finesse! Last month when operating with one of my favorite attendings, I was struggling to laparoscopically drive a suture needle through a certain tissue into the right spot. He had me pause, he turned to me, and he said, “Use The Force!” The needle went exactly where it needed to go. Teaching and learning have a lot to do with patience and communication, but sometimes they verge on the realm of faith and understanding one’s heart!

 

NEJM Resident 360

August 19th, 2020

Residency Reflections from an Intern Gardener

Dr. Braunthal is a Chief Resident at the Cleveland Clinic Foundation in Cleveland, OH.

Starting Our Garden

Last year, my boyfriend asked if I wanted to join a community garden. As he handed me the paperwork, he said he would be the “primary,” I would be listed as a “helper,” and for only $10, we could grow our own vegetables. Distracted by whichever rotation I was on, I agreed without much thought, assuming that “helping” would be something similar to a community service project. To me, a garden was some sort of greenery that already existed, occasionally needed upkeep, and in this case, would result in a crop-share. Needless to say, I was a bit confused about his fixation on choosing seeds and pre-planning the garden. I was even more surprised when we walked over on a misty mid-March afternoon, arrived at an overgrown 10 x 10 foot plot, and was told we needed to start weeding by hand.

pulling weeds in March

Community gardening has provided a welcome source of activity and [distanced] socialization during the COVID-19 era. It has also inspired much reflection at a pivotal time in my career: the start of the pandemic, the end of residency, and the transition to chief resident responsibilities. Naturally, I have drawn parallels between them all.

Gardening (and Residency Training) Best Practices

To begin, like in medicine, best practices in gardening are hotly debated and change over time. As gardeners prepared their soil in March and April, they had seemingly endless conversations about the risks and benefits of tilling the soil, a practice that can be both beneficial and disruptive to soil health. My only contribution was telling the gardeners that they sounded like my fellow internists, grappling with whether the updated hypertension and aspirin guidelines could be applied to all of their patients, or to only those who were similar to the cohorts studied in the landmark trials. For those curious, we lightly tilled this year, added leaves to increase the organic matter, and will be doing “no-till” for the future. I am still not sure which strategy is the standard of care.

With our newly enriched soil, we were ready to plant. We had packets of seeds, shoots to transplant from one of my co-chiefs, and numerous gardening books from family members. We followed the instructions about depth, distance, and watering frequency. Then, we realized that, like patients, plants do not follow the textbooks.  Similarly, their outcomes rely heavily on their environment. For example, our five kale plants were growing at equal rates for the first few weeks until the butternut squash vines took over a third of the plot and started blocking the sun. Then, the kale plant that had the most sunlight and rain grew the largest, and the others have been lagging behind, only to grow when we move the leaves out of the way. Competing weeds initially suppressed the carrots; once they were removed, the carrot stems shot right up. On the other hand, the corn, squash, and tomatoes have grown in spite of everything.

Structure Affects Function

A principle that is fundamental, but not unique, to medical education is that structure affects function. An example from residency that stands out is how adjusting one of our subspecialty rotation’s call schedules garnered better continuity of care, which ultimately engendered improved resident performance and morale. Even within our first month, my co-chiefs and I have observed residents’ successes and struggles. We are learning how to optimize our program’s infrastructure so that it can benefit a diverse group of learners. Just as my boyfriend and I figure out how often to water, weed, pare down, and transplant, my chief group is recognizing how to appropriately intervene and when to implement systemic change.

One of the most valuable aspects of starting this garden at the beginning of my chief term has been the unique opportunity to revisit the uncertainty, vulnerability, and insecurity that accompanies being a new trainee. In the garden, I am the intern, or maybe even the first-year medical student, navigating a new environment and grasping the vocabulary of an entirely foreign vocational language. My boyfriend and I constantly ogle our neighbors’ more aesthetically pleasing plots. Until recently, we assumed that others had years, if not decades, of experience. Much to our surprise, some of them only started last year. The imposter syndrome reminds me of being an intern, when becoming as knowledgeable or efficient as a senior resident seems like an unattainable dream. Yet, I can see the same pride from these new second-year gardeners that I do in our new seniors, and that I did in myself, realizing that they can independently manage a team and care for patients in a way that they did not think was possible a year earlier.

Growing Confidence

It is now early August, and we are starting to reap the fruits of our labor. The garden is growing on me. Although I wax poetic about the reflections it has inspired, the reality is that I was not enjoying it until I began to understand how and why things are done. Aside from a delayed appreciation for anatomy lab, I initially could not think of a parallel feeling during my medical training… then, I remembered I almost quit before it even began. Midway through sophomore year of college, I had a sudden insecurity that I would not be able to get into medical school, which took the joy of learning out of any pre-med class that I was taking. I decided to take a semester to explore the myriad other intellectual avenues offered at small liberal arts colleges, later stressed about finishing the pre-med requirements before graduation, and subsequently enrolled in two biology and chemistry summer courses at a university closer to home. Whether it was a different teaching style, living with my family, or the exhilaration of being in a new school, something clicked. I left for study abroad confident in my ability to become a physician and returned to college that spring, eager to jumpstart the rest of my career. As for many in medicine, my journey has since been filled almost daily with peaks and troughs. Harnessing the reinvigorating moments has kept me going; the desire to teach others how to do so is part of what inspired me to become a chief resident. I look forward to the day I can bring some homegrown vegetables to guide the conversation.

 

NEJM Resident 360

August 12th, 2020

Welcome! Chief Residents for 2020-2021 Join the Panel

The editors and staff of NEJM Journal Watch warmly welcome our new panel of Chief Residents for the 2020-2021 academic year. This will be a challenging year for all healthcare professionals, and we are grateful that these five dedicated, talented, and busy physicians have agreed to share their concerns and triumphs with the NEJM Journal Watch community.

Our 2020-2021 panel:

Good-bye, 2019-2020 Chiefs!

We will never forget our 2019-2020 panel, who bravely pushed on in the face of unprecedented changes in every facet of their professional and personal lives during 2020. We’ll always remember their stories of courage and their calls for social justice. Their concern with the wellness of physicians during residency (and beyond) and their tips and tricks for maintaining work-life balance inspired residents worldwide. So, thank you, Prarthna Bhardwaj, MD, MBBS; Eric Bressman, MD; Allison Latimore, MD; Daniel Orlovich, MD, PharmD; and Frances Ue, MD, MPH! We congratulate you on your resilience (and offer best wishes on your new marriages, babies, and professional accomplishments). Thanks for letting us have a glimpse into your lives.

Dr. Eric Bressman

Dr. Bressman is a Chief Resident in Internal Medicine at Icahn School of Medicine at Mount Sinai in New York, NY

Dr. Prarthna Bhardwaj

Dr. Bhardwaj is a Chief Resident at UMMS – Baystate Medical Center in Springfield, MA

Allison Latimore, MD

Dr. Latimore is the Education Chief Resident at the MedStar Washington Hospital Family Residency Program in Washington, DC

Dr. Daniel Orlovich

Dr. Orlovich is a Chief Resident of Wellness at Stanford University

Frances Ue, MD

Dr. Ue is a Chief Resident in Internal Medicine at Cambridge Health Alliance in MA.

Resident Bloggers

2020-2021 Chief Resident Panel

Stephanie Braunthal, DO
Holland Kaplan, MD
Vivek Sant, MD
Sneha Shah, MD
Masood Pasha Syed, MBBS

Resident chiefs in hospital, internal, and family medicine

Learn more about Insights on Residency Training.