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October 4th, 2018

Diapers During Residency

Cassandra Fritz, MD

Cassandra Fritz, MD, is a Chief Resident at Washington University Hospital in St. Louis, MO

I had the fascinating experience of interviewing for residency at 20+ weeks’ pregnant. Although a number of people told me that I was doomed, I found the experience to be quite enlightening. Since I couldn’t hide the fact that life outside medicine was going to be important to me during residency, I felt empowered to ask the “don’t ask” questions during my interviews. What did I have to lose? The perk of interviewing while pregnant was that it was very apparent which programs were going to be supportive of work-life balance and which programs were trying to wish away my protruding belly. This experience helped me to determine where I was going to have the most support, academically and personally.

baby with diapersSome people find the thought of having children during residency unimaginable, but a growing number of us not only contemplate having children while in training, but decide to take actually the plunge into changing diapers. Pregnancy during residency is not a new concept. In 1986, a study reported that 12% of women from Harvard-affiliated programs had at least one pregnancy during residency training (N Engl J Med 1986; 314:418). Jump forward to 2013–2016, when another study showed that approximately 40% of residents had or were planning to have children during residency (Acad Med 2016; 91:972). Although diapers during residency continues to gain traction, residency programs have a paucity of standard guidelines that outline how to best support residents with children. So, do residents feel like they are blazing a new trail at their program if they decide to have children?

If you decide diapers are going to be in your near future, here is some advice:

  1. Be organized!Cause mama doesn’t have time not to be

You will be wearing many hats: resident, mommy/daddy, wife/husband/partner — and all of these roles will require scales of work-life balanceyour attention. My personal secret was to compartmentalize my life as much as possible. When I was home, it was family time until my kids went to sleep. While I was at work, I focused on work. But compartmentalization doesn’t get you out the door on time in the morning, organization does! Our family has a routine, and we live and die by that routine. When I walk in from work each day, I don’t pass go until bottles and lunches for the next day are prepared. Organization at home will allow you to be efficient, on time, and present at work.

  1. Don’t be afraid to ask for help, because the only way to do it all is with A LOT of help.

I am blessed that I have a great support system around me. If I know my schedule won’t allow me to pick up my kids from daycare at a reasonable time, I have a list of people who are happy to spend time with my boys. I don’t worry about how this looks to outsiders, or the fact that I probably have the longest list of people on my “approved for pick up list” at daycare. Who cares? What is important is that my boys are well cared for and loved. Having a strong support system means that I rarely have to call off from work because of child care issues. Because, let’s face it, we still work in an environment when “mommy issues” at work are frowned upon.  Although it was initially hard for my type A personality to let go and ask for help, it is the only way to have it all.

  1. Advocate for yourself: Understanding the difference between equity and equality is imperative

"equity" written in baby beadsTraditionally, I think we fall into a trap where we think that everything should be equal. If resident A gets a thing, then so should resident B. But in truth, maybe resident B doesn’t need what resident A needs. We need to move to a system that values equity over equality. This is not intuitive, so when you are resident parent, you must be your own advocate. You are inevitably going to have different concerns than your co-residents who don’t have children and/or significant others. There was one point during my intern year when my husband was traveling for work, and I made it a priority to pick up my son from daycare on time each evening (other than call days). Although my rush to get out of the hospital at the end of the day could have been seen as a negative, I had a co-intern and a senior resident who were extremely supportive, because I communicated with both of them what my needs were that week. Obviously, I always got my work done, but our team dynamics were improved because our open lines of communication were open. Fast forward to my second year, when another co-resident fell ill and needed coverage during an ICU month: I happily volunteered to cover his shifts. When you and your program focus on equity over equality, everyone can get what they need to be successful. It really does all balance out.

At the end of the day, if you are ready to become a parent, don’t let residency stop you. If you are in the special position of choosing a program while expecting a child, ask those “don’t ask” questions during your interview to gauge programs’ receptivity to resident parents. I promise you, they will show their hand.

Some might say I am too positive and naïve, but I think we can do it all (with a lot of help and the “right” supportive program). When you are a doctor, there is never going to be a “best” time to have children. Finding and doing what makes you happy both in and out of the hospital is an important aspect of developing resiliency and experiencing joy during these 3 hard years. Although you will laugh when non-parent residents complain about sleep deprivation, you will also find that babies can teach you a lot about yourself and keep you grounded during this journey. Personally, my boys brought me so much joy during my training years that I truly can’t imagine doing residency without changing diapers. So, as far as my personal belief about changing diapers during residency: do it well and do it often because no one needs a “blow out” right before walking into rounds.

September 25th, 2018

Medicine-Induced Metabolic Syndrome

Justin Davis, MBBS

Justin Davis, MBBS, is a Chief Resident at Barwon Health in Geelong, Australia.

I run a clinic a couple of times a week as part of my nephrology training here at Barwon Health. I love my clinic. In addition to enjoying the longitudinal follow-up of patients and the relationships you build with them (one of the quintessential things that drew me toward physician training, and nephrology in particular), I like that it is rather varied. On any day, I might be dealing with relapsing glomerulonephritis, seeing one of our long-term haemodialysis or transplant recipients, or managing something like recurrent renal calculi. But far and away, the biggest number of patients that we see are those with chronic kidney disease (CKD). CKD is an interesting beast. While you get occasional cases that occur after severe acute kidney injury or are associated with a single kidney or perhaps obstructive uropathy, most CKD cases occur in people who are lumped into the category of “renovascular disease/diabetic nephropathy” — a nebulous miasma of patients who, more often than not, have raging metabolic syndrome or at least a whole bunch of cardiovascular risk factors that presumably have driven their CKD.

And, it was seeing these patients in clinic — these patients with obesity and relentlessly progressive CKD and a multitude of other chronic, incurable issues — that made me reflect on my own metabolic health. And while I don’t want to sound pejorative, it also made me vow to never turn out like them. I don’t want to be the overweight chap with uncontrolled diabetes who is sitting opposite the specialist. But what I want to touch on in this post is exactly that – how easy it can be to fall into that downward metabolic spiral, particularly with a job like ours.

basketball team

The Cornered Badgers. Quite possibly the greatest basketball team you could be a part of.

Let’s all sit down for story time with Uncle Justin. I love playing basketball. I have loved it since I started in … what? Under 9s? Under 10s? (Somewhere around there). I’m tall, lanky, and completely uncoordinated, which makes me a terrible basketball player, but I still enjoy getting out there and running about (and the team aspect of it). Back in medical school, I was playing on three different teams a week (including one with the other medical students, called Rebound Tenderness, which is simultaneously the dorkiest and best name for a medical school basketball team ever). This was my major form of sport and activity, and it kept me in reasonable fitness for the 15+ years that I played.

Then something happened. That something was the physician’s exam; specifically, the written component of the exam. Suddenly (although “suddenly” is the wrong word, given you have well over a year to prepare and study, but I think it encapsulates just how disruptive that exam is to your life and schedule), I was heading to lectures that were broadcast by the Royal Australian College of Physicians every Thursday evening. (I’m aware I could have watched them later, but I wouldn’t have (a) paid attention or (b) learnt stuff that way. It’s just how I am.) Thursday was my one remaining basketball evening (the others having been whittled down slowly by demands during my intern and residency years). And just like that, I went from being a reasonably active kind of guy to doing no exercise and slaving over a computer. I wrote over a million words for this exam during the course of a year — the number of hours I put into it is kind of staggering. I was studying late, working long hours, and eating poorly. That, naturally, is a recipe for the kind of unhealthy lifestyle and diet that I like to call “the medicine-induced metabolic syndrome.”

watching a lecture

A typical night at the RACP lectures, me being the only person there studying, happily watching (and clapping, apparently) alone.

It was just after the written exam when I realised just what the sequelae of study and work with no exercise had done to me. I had just come off my intensive care unit rotation, which I found exceptionally challenging, both because of the unique work involved and the nasty hours. (Physicians are not a critical care–trained specialty in Australia. I can happily work up a patient with raging lupus nephritis, but ask me which vasopressor to use next or how to fiddle with some ventilator settings, and you’ll likely just get a blank look from me.) The paradigm of 7-day, 12-hour shifts, week on– week off, plays absolute havoc with your circadian rhythm, particularly if you’re using energy drinks (like I was) to stay awake during the long nights and then spending off weeks doing nothing but study for an exam.

And so, just like that (although really, it was the consequence of the previous year of little exercise and an unhealthy diet), I had put on 10+ kg (I have no idea how many pounds this translates to, for our American audience. [Consults Google.] Ok, it’s about 22 pounds.) Although I was still a tall and (now, slightly less) lanky guy, most of that extra poundage had sneaked its way directly onto the stomach region — you know, the exact area that poses the highest metabolic risk, and where you don’t want extra adiposity.

It was a surprising wake up call, one that is echoed every time I’m in clinic with patients who have raging metabolic syndrome (and there are a lot of those people). Because I can understand how easy it is to fall into that trap. For me, it is associated with the particularly in the high-stress environment that calls itself medicine and with studying for the once-a-year, high stakes exam that you must pass. Why would I waste an hour running when that hour could be used for study? It’s the pitfall that causes medicine-induced metabolic syndrome – we need to look out for our own health, too.

Geelong countryside

How could you not want to go for a run around my hometown of Geelong, when it offers up views such as this?

I’m thankful to my fiancée (for this and many other reasons), because she encouraged me to eat better, and I started to run with her, which I’ve found is a fantastic way to stay active and avoid the dangers of the work/study black hole. I’ve figured out that running also is a great way to fit in the video game podcasts I enjoy listening to (and when else would I have time to listen?) I’m much healthier than I was at this time a couple of years ago. I’m currently 15 kg down (33 pounds, for our imperial system friends) from where I was right after the written exam, and that’s a good thing. Because I don’t want to be that guy on the other side of the doctor’s desk with unchecked metabolic syndrome, if I can help it. I just wish I had thought about that while I was studying.

“Do not allow the quest for knowledge to become paralytic. Only through action can you iterate on your belief.”

* The quotes from the unnamed source continue for my own amusement. Although I understand a few people have Googled it to come up with the answer.

 

NEJM Resident 360

September 19th, 2018

I Was Nearly Kicked Out of the Cafeteria

Scott Hippe, MD

Scott Hippe, MD, is a Chief Resident at Family Residency of Idaho in Boise.

The nature of the crime? Bringing my reusable food container down for meals. I just wanted to avoid the Styrofoam plates and plastic silverware, but the lunch ladies were convinced I was asking for two portions’ worth of side dishes and then only paying for one. I wasn’t, although I admit to once sprinkling cheese from the salad line on my soup [gasp!]. But by that time, I already had a large target painted on my scrubs.

My innocent food container — my small attempt at being mindful of waste — was barred from the cafeteria. The exclusion sent a clear message: Eat on our single-use plates, or do not eat at all. Coming from the same organization that tosses all the contents from its recycling bins into the landfill, I shouldn’t have been surprised.

My cafeteria episode apparently was a big deal in the world of hospital food preparation. One of the cafeteria supervisors sent a message straight to my program director. “Your resident isn’t coloring inside the lines,” was essentially how it read. No matter how trivial the issue, having to explain yourself to your program director is obviously undesirable.

Medical waste is a bigger problem than you might realize

Our medical-industrial complex exerts a significant negative effect on the environment. I am likewise not impressed by the degree to which healthcare contributes to pollution. A 2016 study reported that 9.8% of national greenhouse gas emissions are attributable to the healthcare sector (PLoS One 2016; 11:e0157014). For reference, the study authors explain this amount of emissions supersedes total emissions from all but the thirteen highest-producing countries worldwide.

The problem is bigger than just greenhouse gasses. Medical waste takes up space in landfills. Healthcare practices create chemicals that are carcinogenic to humans and toxic to the environment. Particulates generated by hospitals and by production of medical goods are spewed into the air. All of these things have implications to the health of the patients we are supposed to be helping.

What can be done?

With a last name like Hippe, I had best not get too far out in left field on environmental issues. Clearly, some amount of energy has to be devoted to powering our facilities and providing health services. But, “how much energy?” is the important question. In my opinion, we can be doing much better.

There are many levels on which the discussion of environmental health needs to occur, from top tiers of hospital administration down to each individual person. The environmental impact of our activities needs to be highlighted at the organizational level, but lofty aims like this are not readily accessible for the majority of healthcare personnel.

If you find yourself just trying to survive from one day to the next (cough, I’m talking to you, fellow residents, cough) rather than participating in high-level policy discussions, a more realistic place to start might be to decrease your personal waste. Use a coffee mug rather than disposable cups. Stop using sterile gloves for minor skin procedures, because they are associated with no difference in infection rates. (Wash your hands!) Among acceptable surgical techniques, choose the one that employs the least amount of single-use equipment. Save trees by writing concise hand-off reports.

I would be curious to hear other ideas about how you have individually reduced environmental waste, and any inspirational facility-wide policies that have been successful at your institutions.

Lastly, for the truly brave folks out there: Bring your own dish down to the cafeteria — but watch out for the lunch ladies!

 

NEJM Resident 360

September 19th, 2018

Coffee and the State of the Hospital

Ellen Poulose Redger, MD

Ellen Poulose Redger, MD, is a Chief Resident at Stony Brook University Hospital in Stony Brook, NY

I think you can tell a lot about how things are going in a hospital based on the amount of consumption of coffee by its employees. Visit the Starbucks, Au Bon Pain, Roasterie, Einstein Brothers, or whatever coffee shop inhabits square footage in your hospital, and I’d venture to say that you can take the pulse of the hospital. Lots of large coffees to go? It’s either just about shift change and people are rushing into their jobs for the day (or night), or the hospital is bursting at its cup of latteseams and everyone is go-go-go. Is someone ordering an Americano? He or she must know that the dregs of the day’s coffee are all that’s left and is instead gambling that a freshly pulled espresso shot is a safer bet. A latte? That lucky person might have a little time to spare and might even sit down to enjoy his or her drink right there instead of hurrying back to the floor/clinic/unit/OR. How about the counter with the milks and sugars — are all the sugar or sweetener packets gone? Must be insanely busy. Milk or — gasp — half-and-half all gone? The shop’s been busy, so much so that they’ve run out of the dairy product within the allowed 2-hour serving time. You see — if you happen to have time to take note of these things — there’s a lot to be observed.

coffee potsHow much coffee does a residency program go through during a conference? Are the residents burning the candle at both ends while on service?  If so, we’ll go through a pot of coffee in 5 minutes as they sit down for afternoon conference.  [My co-chiefs and I have carried on the tradition of providing coffee with conference — there is no excuse for sleeping if you have access to caffeine.]  Things have been a little bit calmer on the floors and they have a few minutes to decompress? We might need to fire up another pot of coffee after conference, just to give everyone a few more minutes to sit together and chat. How fast are we going through the half-and-half or almond creamer? Are all of the caffeine lovers on service at the same time, or has it been an unusually busy time and everyone’s reaching for a cup during conference? Or perhaps there are days when our “proprietary blend” wasn’t that popular, and most of the coffee went down the drain. (I will never again buy French vanilla coffee. Sorry, everyone.)  Even for those who don’t drink coffee, I think just having it there and knowing that someone got there early to set it up and set out the accoutrement for serving shows that we, the nebulous chiefs behind the email account, care.  We want our residents to know that yes, the days are long, and the pages are nonstop, but there’s a hug in a cup waiting for them.

to-go coffee cupLet’s go back to the coffee shop in the hospital — maybe it’s midafternoon, and a senior resident or fellow or attending has taken an intern there for a quick feedback session.  (Please, everyone, do sit down with your learners to give and receive feedback!)  Maybe it’s 6:30 am and the senior resident is buying five specialty drinks to celebrate the end of a block with her interns and students.  Maybe it’s 9 pm and there’s a couple there, both on call, stealing a few minutes of time with each other before heading back to their respective domains.  There is so much to observe in just that little area.  That shop is a measure of the pulse of the hospital, if we just look up from our smartphone long enough to see what is going on.    

 

NEJM Resident 360

September 12th, 2018

Good Things Take Time

Ashley McMullen, MD

Ashley McMullen, MD, is a Chief Resident at UCSF in San Francisco, CA

My Patient

The day I met you was early in my second year of Internal Medicine residency. After much of my internship had been spent on arduous inpatient rotations, I was finally ready to lead my own team of young doctors and students on a high-acuity wards service. Yet, in my continuity clinic, I was still fresh, insecure, and naive. The day I met you, your abdomen was swollen, your eyes were yellow, you were drowsy and seemingly apathetic. Years of heavy alcohol use had sclerosed your liver, leading to hepatic disease in its final stages. You were my patient, I was your new primary care doctor — and I didn’t speak your language. We fumbled through the interpreted conversation, hindered by your lethargy, my inexperience, and a 20-minute visit time. We talked about abstinence from alcohol, and we talked about liver transplant. I got you what you needed: diuretics and a paracentesis for your ascites, lactulose and rifaximin to remove the toxins clouding your consciousness, a referral to hepatology to start the process of future transplant evaluation. However, what we both needed was more time. 

Our Visits

I would see you in clinic for many more visits in the ensuing months. I would review my check boxes of primary care for cirrhosis – slow disease progression, check; prevention, screening, and treatment for complications, check. All the while, the prospect of transplantation and new life hung in the air like an apparition we could partially see but which remained out of touch. After your second relapse and hospitalization, we met in clinic once again. I remember that your mind was sharp that day. I was running behind, with several patients sitting restlessly in the waiting room, but in that moment, it was just the two of us. In the hour that I didn’t have, we talked about “goals of care.” You told me you wanted a chance at a new liver, I told you about the challenges of both transplant candidacy and surgery, you told me you understood. You told me you wanted to keep pursuing all possible care, you told me how much you missed your family back in Central America. I told you we would stay the course towards transplant, but I also promised you I would do everything within my means to get you back home — even if just to say goodbye. After 13 months as patient-provider, this moment was the first time we actually heard each other. You trusted me. We embraced after that visit and every visit thereafter. But what we both needed was more time.

Transplant Evaluation

In the fall of my last year of residency your kidneys began to fail. The pressure in your portal system was pushing up to 12 liters (over 3 gallons) of ascitic fluid into your peritoneal space. Yet, the frequent paracenteses needed to alleviate your discomfort added more strain to your kidneys that were already starved for perfusion. The rise in your creatinine mirrored a rising MELD score, indicating a looming mortality. By the spring, it was time for an evaluation by the liver transplant team. A day you had been waiting for finally came — you were seen, you were tested — you were deemed not a candidate. The clock was reset — it would be another 6 months of documented sobriety and social support before you would even be reconsidered. The news was devastating for you and your partner. I was away on another inpatient rotation, only peripherally involved via messages that accumulated in my ever-expanding inbox. 

You would go on to endure 6 more hospitalizations over the next 3 months, spending more time boxed within four sterile walls than at home in your own bed. You would encounter more than 30 primary and specialty physicians and have multiple goals-of-care conversations, which would at times leave you confused and frustrated. I was losing steam, closing out the end of residency training and preparing to embark on a new journey as chief. You needed me, and I needed more time — time to reflect on your clinical course, time to reconcile your prognosis and goals of care, and time to help you make sense out of the madness. 

Going Home

When I saw you in clinic a month ago, you were headed towards yet another acute hospitalization for renal failure. This time, I was present. We met together with the inpatient teams, and I could say to you with confidence, “it’s time to go home.” You were brave and magnanimous — you found humor in a dire situation, and the love shown by you and your devoted partner was inspiring. We met for one last clinic visit after this. You told me you were getting ready to return home to Central America. After we embraced, you winked at me and said, “I’ll see you next time.” Three weeks later, you died at home surrounded by your family. You were out of time.

By Jon Rawlinson (The Long Road Ahead) [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0), via Wikimedia Commons]

In my role as ambulatory chief, I oversee trainees who maintain their primary care clinic at our county hospital where we care for a population of incredibly diverse and vulnerable patients. I routinely recognize the frustration in residents who are expected to provide necessary care to medically and socially complex individuals, in a system that increasingly restricts our time for those who need it most. What I tell residents is that primary care is an endurance sport. The road is long and the effects that we see in clinic come much slower than what we’re used to on the inpatient side. Yet despite its challenges, primary care uniquely positions us to be our patients’ best allies, advocates, and defenders in a healthcare system that in many ways is unjust – what we need, however, is more time to do it right.

 

NEJM Resident 360

September 4th, 2018

The Power of Intellectual Humility

Don’t ever be afraid to say, “I don’t know.”

Scott Hippe, MD

Scott Hippe, MD, is a Chief Resident at Family Residency of Idaho in Boise.

Those were parting words from one of my physician mentors in medical school. I had asked him for wisdom in making the transition to residency. “In my career, I’ve seen hundreds of physicians who cannot bring themselves to say those words. They are generally the ones who get burnt out. They are the ones that shout at you when you consult them over the phone. They are the ones who leave medicine, one way or another.”

My mentor’s point was to stay intellectually humble. The practical application to clinical medicine is obvious. We’ve all learned about the different types of biases that lead to medical errors and diagnostic misses. As trainees, we have seen physicians who exhibit too much hubris make mistakes.

I am reminded of my mentor’s comments now that July has arrived and a new class of interns has started their training. Their enthusiasm for residency and the pursuit of learning is a breath of fresh air. Along with the enthusiasm has come a multitude of “I don’t knows”:

  • “I don’t know where to go when we start in the hospital tomorrow.”
  • “I don’t know how the attending likes case presentations.”
  • “I don’t know my dictation number.”
  • “Can my patient eat?”
  • “Can I eat?”
  • “What is the best flavor of enema?”
  • “Do I need an enema?”
  • “She brought her service animal into the hospital, but she didn’t say it was a python.”
  • “I don’t know what to do about his pain­ — he told me he’s allergic to everything but Dilaudid.”

Residency is endlessly humbling, but interacting with interns has shown me how much I have grown as a physician. I can answer all of the questions mentioned above, and even a few more.

One thing is getting harder to say

"I don't know" post-it noteAs my years of residency have gone by, and I have made the transition to senior resident, it has gotten harder to say “I don’t know.” Just like my mentor predicted. Not knowing things on the wards or missing something in clinic stings my pride more now than it did when I was an intern.

The most common feedback I give to medical students and interns is to be decisive with their plans. This was also the feedback I received on my own medical student rotations. I imagine it is feedback most learners receive. Being a competent clinician requires synthesizing large amounts of data and committing to a plan of action. But it is also possible to take “decisive” too far. A phrase has stuck with me:

“Sometimes wrong, never in doubt.”

A surgeon said this, while preparing to take a patient with abdominal pain to surgery for suspected appendicitis.  In this particular instance, appendicitis is exactly what the patient had. It was one of those times to be decisive, and rapidly decisive. But whether through conscious effort or subconscious tendency, we often take “fake it until you make it” too far. We become insecure and isolated clinicians hiding behind façades of confidence. This tendency leads to worse outcomes.

Benefits of intellectual humility

Although “I don’t know” gets harder to say, I am convinced it is one of the most important phrases in the practice of medicine. Embracing the intellectual humility necessary to utter those words has many benefits:

  1. Encouraging curiosity: this leads to broader differentials and more effective diagnosing
  2. Counterbalancing “intervention bias”: the tendency of clinicians to do something — anything! — when the best course of action might be to do nothing
  3. Effective teamwork: clinicians who admit they don’t know everything are more open to the input of others and more likely to see the patient’s big picture.
  4. Better education: A safe environment, where learners are empowered to disclose their gaps in knowledge, allows educators to address those gaps more effectively.

For newly minted resident physicians, my advice is to embrace “I don’t know.” You will do yourselves and your patients a great service. I will continue to say those three words as well, no matter how sharply it hurts my pride. If any of this inspires passion, positively or negatively, please leave a comment. I am looking forward to communicating with you this year through the Insights blog.

–Scott

 

NEJM Resident 360

August 28th, 2018

So Let’s Chat About Extracurricular Work Activities

Justin Davis, MBBS

Justin Davis, MBBS, is a Chief Resident at Barwon Health in Geelong, Australia.

Well, we’re finally here. Somehow, an Aussie has sneaked onto a United States-based Chief Resident blog panel dealing with pertinent issues within medicine, and I actually have to think about what to write. (I’m being slightly facetious here, by the way.) So let’s start, shall we?

One of the things that has been on my mind recently, and I think even more so since starting advanced training, is the amount of extraneous work we have to do in this career (read: lifestyle) we call medicine. (Note: for context, for our American audience [and I assume most people who read this will be from the U.S.], in the Land Down Under, physician training requires you to do 3 years of basic training as a medical registrar [internal medicine resident] and sit two exams before applying for specialty training, which we call advanced training.)

“You is unpaid overtime” — A wiser man than I annotated this poster up in our ressies room. Personally, I think it speaks volumes to the amount of extra work we have to do in our profession.

Now I think it’s important to realise that I’m not talking about unpaid overtime here – that topic has been done to death in previous chief resident posts because it’s a hotly debated topic in several spheres of medical influence. I mean, who amongst us hasn’t done it? From patients being unwell, to clinics being overbooked, to the emergency department somehow having soothsayer-like ability to know exactly when to refer a patient (i.e., half an hour before you think you’re going home for the day, on time for once), to just generally being overworked because that’s what the system demands of you. Rather, what I’m talking about is extra work that we have to do, which isn’t directly related to patient care. And there is a surprisingly large amount of it.

I started to ponder this one evening as I sat in what I affectionately call “the Bungalow” (the name for my office [see included photo], which I’m, in reality, quite appreciative to have this year – it sure beats the old medical registrar office that I used to sit in to do these sorts of things).  I think it was a typical sort of day; you know – start work at 8 am, finish at 7 pm (only 1.5 hours late this time), cook dinner, and then return about 8 pm to work until about midnight on things that are not directly related to your clinical role per se, only to wake up at just before 7 am to do it all again. I also realised that I really probably shouldn’t complain – my surgical colleagues work much more ridiculous hours than I do, and our hours are a lot better than what is mandated over there in the U.S. It is also true that medicine is nowhere near unique in having these sorts of extracurricular (I honestly cannot think of a better name for this than that) requirements or unpaid overtime-type issues. But, it still affects us, our partners, our lifestyles in general, and thus I think it remains an important topic to talk about.

“The Bungalow,” complete with my own laptop for music. I feel the $10 plastic plant I got from Kmart adds a class of sophistication to it. Maybe.

What I want to chat about today is the amount of extra activities we find ourselves doing outside of our clinical role, just to progress through the world of medicine. We know why we do them – they’re resume building, and a chance to impress superiors and build important relationships that determine your future eligibility for employment. The work is important and does need to be done, but it’s all done outside of usual working hours because it simply cannot fit into that time (how could it possibly?) and thus ends up being lumped into this misery mire I call extracurricular work activities.

As I’ve noted, it is important work, and it does provide you with important skills that are translatable in clinic and in life, but it does take its toll. I think back on all of the extra stuff I’ve done outside of work hours in this previous 6 months – I’ve organised part of the Royal Australian College of Physicians clinical examination (it’s surprising how long it can take to organise a patient’s complete medical history, medication list, investigations, and imaging requests, when 20+ of them need to be done), prepared morbidity and mortality meetings, prepared several manuscripts for … um, five research papers that are currently active, prepared multiple choice questions for medical students, prepared talks to give to other specialties, and attempted to do a Bland-Altman plot in Microsoft Excel (this was really hard, by the way) to plot 15000 data points of ultrafiltration values. All this is before I do things like my own regular self-directed learning (I think people may have the wrong idea that study stops once your exams are over. It doesn’t. It just becomes more clinically focused and relevant to your chosen specialty.) I can’t see my patient with primary focal segmental glomerulosclerosis (FSGS) who has already failed glucocorticoid therapy without having some idea of what to do next now, hey? I’m also attempting to keep up with the latest research/commentary from publications such as the New England Journal of Medicine Journal Watch (sneaky plug here), or just, you know, having a life outside of medicine (I really do enjoy playing video games. Ah, well).

Sometimes, I’d much rather be putting my feet up with Einstein next to me. These moments are rare, so I appreciate them when I have them.

But … we know why we do it. We love this job. I went into nephrology not only because the kidney is awesome and is clearly the best organ (subjective personal opinion), but because my favourite part of working is building up those longitudinal relationships with patients, being with them through a hell of a lot of different circumstances, from their first presentation with renal failure to dialysis to transplant to failing transplant and back to dialysis and so on. And I know that an important part of being a well-rounded clinician is not only knowing the clinical side of things but all the extra work that goes into keeping the grinding wheel of medicine turning – how else could we train future generations? How else could we improve our own practice or systems processes except with an M&M meeting? How else could we improve clinical practice without research into how we can be better? So despite the hours it takes away from my own life, I realise there is a point to all the extracurriculars, and they are an important part of things. Although I do admit it would be nice sometimes to be putting my feet up on the couch and turning on my PlayStation with a nice glass of red wine — as opposed to sitting in the Bungalow, iPhone blaring Mozart’s 21st piano concerto in a really tinny way, and working on some extracurricular thing into the late hours. But hey, would I choose anything else? Realistically… probably not.

“It is not the height of the cliff, but the struggle of the climb that clears my eyes.”

Note: Every blog post I do will be followed by a quote from a particular source for my own amusement which shall remain nameless – there are, of course, bonus points to anyone that can figure out from where I am sourcing these quotes*.

* These bonus points have no monetary or other value. Just my respect.

 

NEJM Resident 360

August 17th, 2018

Things I’ve Learned from My Patients

Ellen Poulose Redger, MD, is a Chief Resident at Stony Brook University Hospital in Stony Brook, NY

I recently completed my internal medicine residency training.  Three years, thousands of hours, thousands of patients, thousands of decisions.  I certainly learned a lot from the past 3 years: everything from what “HFrEF” means and how to manage it, to treating recurrent C. difficile colitis, to how to share decision-making with patients about whether or not to start anticoagulation in atrial fibrillation.  Despite the multitude of lessons I have learned from my co-residents, my fellows, my attendings, the nurses, the pharmacists, and everyone else involved in my training, I think that the deepest lessons I’ve learned are from my patients.

Lesson 1:

Earlier this year, a patient gave me a recipe for leg of lamb.  He had been fighting a hematologic malignancy for years and had spent the better part of the past 6 months severely neutropenic — and then came in with invasive aspergillosis, which led to emergent and disfiguring surgery. At first, he could laugh about “being a pirate for Halloween” [this was months away from Halloween].  Later, he refused to speak to the team when he realized just how seriously ill he was.  There’s nothing worse than watching someone decline like that — and so, I pulled up a chair to the bedside, let his wife have a well-deserved break from being in the room, and asked the patient what he liked to do.  He eventually started talking about cooking, which is something I enjoy, too.  Naturally, I had to ask him what his “signature dish” was.  It was a leg of lamb.  As he described how to remove the fascia from the meat, and how to properly spice it, and at what temperature he would roast it, he became more than “the patient with invasive aspergillosis.”  I saw a small glimpse of the man who had loved being the center of his family and celebrating with them.  When the hours and stresses of residency add up, it’s important to remember to spend time with those we love.

Lesson 2:

doctor and patientSome of the things I’ve learned from my patients aren’t as bittersweet.  There was another patient, the victim of another drug overdose in the ongoing heroin epidemic, who came under my care last fall.  Just as soon as she was remotely stable, she wanted to leave.  That instant.  So, I went in to talk to her, to see if I could convince her to stay at least a little longer.  She had back pain, and if we couldn’t give her pain medications, she was going to go back out on the street and find something that would work.  Eventually, she agreed to stay and to try to get help for her addiction.  After her estranged daughter showed up to see her, the patient opened up about what had happened to her — after a car accident, she had back pain and had gotten her first prescription for opioids.  Years went by with monthly refills, until her physician abruptly cut her off, at which point she turned to the street to get pills, and later, heroin (N Engl J Med 2016; 374:154).  Heroin was cheaper; surprisingly cheap, when I asked her how much it cost.  Perhaps she was the victim of a well-intentioned effort trying to curb opioid use in this country.  Now, though, she wanted to get clean — the condition her daughter set for being able to see her grandchildren.  This patient taught me of the importance of looking beyond just “another addict” or “another XYZ” patient, because each of these patients is someone’s parent, partner, child, or friend.

Lesson 3:

cookiesSeveral of the things that I’ve learned have been much lighter in nature, too.  The retired jeweler in my clinic who gently chastised me for wearing my engagement ring while pulling gloves on and off in clinic.  He didn’t want me to accidentally throw away something that’s priceless.  The kind older bus driver who recommended places to go for vacation (you were right — Austin was a really fun place to go for a long weekend).  The patient who very much misunderstood what I was saying (“I like Boston,” in reference to his Red Sox shirt; not, “I like boxing”) and peppered me with questions about which weight class I liked.  The lovely and very chatty patient with whom my attending once left me, as he ducked out of the room, telling her that his resident (me) liked cookies, thus leaving me to debate the merits of thin and crispy vs. thick and chewy cookies for 20 minutes and prompting the patient’s family to show up with bags of cookies for me the next day.  These patients taught me to really listen to what people are saying, because these human connections are worth their weight in gold (and chocolate chip cookies).

It can be very difficult when the hours are long, the learning curve is steep, and the patients are sick to remember to learn something every day.  Reading books and journals and doing questions is important, but so is learning from our patients.  And I am so glad they are willing to teach.

 

NEJM Resident 360

August 17th, 2018

2018-2019 Chief Resident Bloggers

The staff and editors of NEJM Journal Watch welcome our new panel of Chief Residents! We look forward to their thoughts on medical training and work-life balance for young physicians.

Our 2018-2019 panel includes:

 

  • Ellen Poulose Redger, MD – Ellen is a Chief Resident in Internal Medicine at Stony Brook University Hospital in Stony Brook, New York.
  • Justin Davis, MBBS – Justin is a Chief Resident in Medicine at Barwon Health University Hospital Geelong, in Victoria, Australia.
  • Cassandra Fritz, MD – Cassandra is a Chief Resident in Internal Medicine at Washington University in St. Louis, Missouri.
  • Scott Hippe, MD – Scott is a Chief Resident in Family Medicine at the Family Medicine Residency of Idaho in Boise.
  • Ashley McMullen, MD – Ashley is an Internal Medicine Chief Resident in Ambulatory Care at Zuckerberg San Francisco General Hospital in San Francisco, California.

We welcome readers’ comments on blog posts.

May 14th, 2018

Bitcoin, Medicine, and More

Karmen Wielunski, DO

Karmen Wielunski, DO, is a 2017-18 Chief Resident in Internal Medicine at the Medical College of Wisconsin in Milwaukee, WI

What’s the big deal about Bitcoin and digital currency? For the past year, my husband (who has a business background) has been enthusiastically researching digital currency. Thus, the terms Bitcoin (BTC) and MaidSafeCoin (MAID) have become commonplace in my household for some time. But, to be honest, I hadn’t been paying much attention to any of it until recently. Don’t get me wrong — it’s not that I don’t listen when my husband talks. Rather, my medically trained mind tends to wander due to an inaptitude for many business and technological concepts.  

With all the Bitcoin buzz and a New Year’s resolution to be more up to date on current events, I attempted to become informed. I asked my husband to, once again, break down this whole digital currency thing for me. About 2 minutes into his explanation (I’m sure he could see my mind wandering), he paused and said, “You know what, why don’t I just show you how it works.” And, with that, I was buying (a fraction of) a Bitcoin.

bitcoinI started by creating an account on Coinbase. This was easy and only required verification of my email address and phone number. I then linked it to my bank account. With a click of a button, I was the proud owner of 0.0021 Bitcoin (worth US$25). Actually, I had to wait a few days for the transaction to process, but it was less complicated than I imagined. By creating an account, I also acquired a public address that consists of a long string of numbers and letters (for example, mine is 166ZUjHuWRGBFm71irtEXLhJRKCv4JooqM). While I won’t be committing this to memory anytime soon, I learned that the public address allows for easy transfer of digital payments from one party to another.

A Frightening Revelation

With my newly acquired (though, admittedly still minimal) knowledge, I wondered how Bitcoin might affect healthcare. It only took about 30 seconds of internet research to realize that Bitcoin and digital currency are already very much affecting healthcare. I read an article that detailed a cyberattack on the U.K.’s National Health Service (NHS). During the attack, hackers created an electronic lockdown that affected the NHS and then demanded a Bitcoin ransom to release it (N Engl J Med 2017; 377:409).

hackerAnother article detailed a very recent cyberattack on a hospital in Indiana that targeted more than 1400 files. The hospital paid 4 Bitcoins (about $47,000) to hackers to regain access to their files (Health IT News 2018 Jan 16; [e-pub]). The reports of these attacks went on and on — institutions in Texas, California, and Kentucky are all recent victims. Each story detailed some combination of patient record and computer access involvement, and many involved Bitcoin ransom requests.  

WHAT? This is a big deal! My simple quest to learn about a trendy form of currency led me to recognize a very serious threat to healthcare system security. As I continued to read through more accounts of recent cyberattacks, I felt embarrassed about my obliviousness up to this point. I worried about the seemingly routine nature of these attacks. Are we all just sitting ducks waiting for our healthcare information to be breached?

Hope For The Future

With a sense of urgency, I again consulted my husband. “Did you know this was happening?” I asked. He was excited about my continued interest in the topic and began catching me up. It turns out other people are (understandably!) worried about this, too. Many companies are attempting to create programs using Blockchain — the technology upon which Bitcoin is based — to improve data security. 

cyber securityOne company called MaidSafe, he explained, is taking an entirely different and exciting approach to solving this problem. They are currently developing a new technology using datachains to create a SAFEnetwork which is, essentially, a decentralized, anonymous internet. The network data is encrypted, broken into pieces, and stored across many locations, making it anonymous and secure beyond existing systems. The live version could possibly launch in 2018 and holds great promise for countless applications including the safe keeping of healthcare information.

As previously noted, my knowledge of technology is limited at best, and I don’t claim to be an expert on this topic. The above explanations are likely drastically oversimplified, but I feel it is important to discuss the concepts and what is being done to combat this threat to healthcare security. In the meantime, I still feel like a sitting duck. However, it’s encouraging that people are working to come up with a solution, and hopefully one will be available soon.   

 

NEJM Resident 360

Resident Bloggers

2018-2019 Chief Resident Panel

Justin Davis, MBBS
Cassandra Fritz, MD
Scott Hippe, MD
Ashley McMullen, MD
Ellen Poulose-Redger, MD

Resident chiefs in hospital, internal, and family medicine

Learn more about Insights on Residency Training.