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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

February 8th, 2018

Doctoring in Lipstick

Cassie Shaw, MD

Cassie Shaw, MD, is a 2017-18 Chief Resident in Internal Medicine at Saint Louis University Hospital in Saint Louis, MO

Why do I feel weird wearing lipstick in the hospital? Why do I have to announce myself as a doctor to gain respect from patients and other members of the hospital staff? In my short time as a physician, I have yet to find the answer to these questions, but they seem to lie in my set of XX chromosomes. As in all other areas of life as a female, being a doctor comes with a different set of rules than that of my male colleagues. These rules are never mentioned or taught, but they are apparent the first time you step foot into the role. We aren’t men, but we need to fit in with them and act like them — but we also have to act like women, in the right ways, of course. Confused yet? Same. Let’s consider some questions about the abilities of a physician who’s also a woman.

The photos in this post are dedicated to my female colleagues who are all creating their own mold as physicians. Brit, Physical Medicine and Rehab; Ellen, Internal Medicine and Michaela, Emergency Medicine

Question 1

Can she be a leader? Can she provide medical care and make critical decisions? Yes, with tremendous effort. I quickly learned to state my role clearly when walking into a room. “Hello, Mr. X, I am your doctor.” Of course, it’s inevitable that a patient, nurse, or family member will ask to talk to the “real doctor,” or say “oh, I’m not used to a lady doctor,” or reference a male colleague as “the doctor.” Even worse is when staff members double-check with a male in the room to see if my plan was the medical plan for the patient. Meanwhile, none of my male colleagues have ever been assumed to be any healthcare professional other than a doctor.

 

Manasa, Anesthesiology; Harita, Pediatrics; Alison, Dermatology

 Question 2

Can a woman who is physician also be feminine? If we do not wear makeup, we are asked if we are sick or having bad day. If we do wear lipstick or a skirt, negative assumptions are made about our IQ and our abilities as a doctor. Not only is our appearance a careful balance, but so are our interactions. A woman cannot use even the slightest tone of forcefulness when advocating for her patient without being labeled as that 5-letter word that begins with a b: bossy. In fact, if we aren’t sugary sweet, we are quickly written off as being angry, rude, or a another 5-letter word that begins with a b. (Use your imagination.) Meanwhile, when my male colleagues do the same, it causes a flurry of action to complete the task they’ve asked to be done without a single mention of his mood, how his day must be going, or his hormones.

Krishna, Internal Medicine

Question 3

Can women work as physicians and have a home life? Yes, but to many, your home life is more important than your career life. Ultimately, society doesn’t judge us by our accomplishments at the bedside, but on those within the home. Am I married? Have I had children? (Shouldn’t the real question be, why does it matter? I spent 23 years completing the rigorous education and training required to obtain the job I dreamed of and that accomplishment is swiftly diminished by these two questions.) I have a huge fear of moving forward with having children because I wonder what might  happen to my career. The life of a physician is far from flexible. My partner (and the would-be baby-daddy in this hypothetical scenario) is also a physician, but you can have one guess as to who society would expect to give up a portion of their career in order to raise a child. Or worse, if I did not cut back at work and hired help instead, I would be that terrible mother whose children are “raised by a nanny.” Again, not a word would be said about my partner’s work load as a physician who is male. 

Okay, if it wasn’t obvious, I’m being facetious when asking and answering these questions. Women can be, and are, accomplished, astute clinicians, who are leaders in their fields and at the bedside, all while wearing whatever makeup they choose and maintaining whatever work-life balance they desire. However, these are all challenges that they face daily. I attribute many of these challenges to the way women entered the role of a physician. Like all of our roles in male-dominated fields, women before me fought to obtain foothold here. They weren’t welcomed as physicians in their own right, so they squeezed themselves as closely as they could into the mold of a physician created by their male counterparts. It’s obvious, though, that we aren’t made to fit that mold. We have our own mold, but that does not preclude us from being excellent physicians.

Recently, as I reflected on all of these experiences, I decided to make a change. I started small: I wore lipstick while on service. Initially, it was uncomfortable and awkward but when I assisted my intern with her first lumbar puncture while rocking my sassy pink lipstick, it was a tiny, but empowering, salute to my femininity. I had both worlds exactly as I wanted them. I wasn’t blending into my male-dominated surroundings. I was forming my own mold. It wasn’t just about lipstick anymore.

Lauren, Ophthalmology; Steph, Pulmonology and Critical Care

So, to end this blog, I’m looking right at my co-physicians who also happen to be women. Remember, we aren’t female physicians or “lady doctors.” There is no need for that gender-defining adjective. We are physicians and, ladies, we are crushing it. We are balancing things our male counterparts would never dare to try and can never understand. However, we are still doing it all within the mold created by men. It’s time to break out of that mold. It’s time to show off our power and stop blending. It’s time to do things our own way.

 

NEJM Resident 360

November 21st, 2017

Thoughts on Stigma

David Herman, MD, is a 2017-18 Chief Resident in Internal Medicine at the University of Southern California / LAC+USC Medicine Center in Los Angeles

“What are we legally able to do? I don’t want to say the ‘quarantine’ word, but I guess I just said it. […] What would you advise, or are there any methods, legally, that we could do that would curtail the spread?”

These sentences were spoken by Betty Price, an American politician with a seat in the Georgia House of Representatives for the 48th district. Her questions were posed to Dr. Pascale Wortley, director of the HIV/AIDS Epidemiology Surveillance Section at the Georgia Department of Public Health, during a videotaped discussion regarding barriers to access of adequate healthcare for patients with HIV. Although she later stated that these remarks were taken out of context, in 2017, the uttering of these phrases, marked by what would appear to many to be discrimination and prejudice, should at the very least warrant swift and continual condemnation and, truthfully, should motivate constituents to question whether leadership proposing this type of strategy is the type that they deserve. This is especially true in a state where the rate of HIV diagnoses per 100,000 people in 2015 was second only to the District of Columbia, according to the CDC, and a state that demonstrates a need for true reform in HIV care.

What is all the more devastating about these remarks is that Representative Price is not only a politician, but, more importantly to the purpose of this piece, a physician trained in anesthesiology. She practiced her chosen field for more than 20 years in Roswell and Marietta, GA, serving on multiple boards, including the Medical Association of Atlanta and the Medical Association of Georgia. Moreover, she is a past president of the American Medical Women’s Association in Atlanta and a recipient of the President’s Award from the Medical Association of Atlanta and a Phenomenal Women of North Fulton Award. In short, she is an exceptionally educated and truly accomplished woman and a physician of considerable influence within and beyond her community.

AIDS stigma signThus, the implication from her, a respected doctor, that those infected with HIV should, by the very nature of their infection, be considered for quarantine, despite all that we know today about the nature of this disease, is incredibly alarming. It is a prime example of what drives fear among individuals affected by this disease. Comments like this are what attach stigma to this diagnosis. And for many, it is a contributing factor to keeping them from investigating their status or seeking appropriate care.

The comments by Dr. Price are just an example of how stigma persists. Defined, stigma is a mark of disgrace associated with a particular circumstance. It runs rampant throughout medicine and extends significantly beyond HIV and AIDS. Every time we apply our own sense of negative judgment to a disease or condition, we implicate those who may be suffering from it. Judgment often stems from our own prejudices against certain populations or behaviors. Societal conceptions of intravenous drug users or those who engage in sex work, for instance, can color our perception of hepatitis C or sexually transmitted infections and imbue those diseases with negative connotations. People at risk for contracting them may avoid evaluation or treatment rather than suffer the discrimination associated with diagnosis or follow-up. And this prejudice can expose itself in many ways: It can flow like an avalanche through the middle of a House of Representatives inquiry on barriers to care, or it can leak out in elevator conversations when cracking jokes about a patient’s new diagnosis of syphilis. Either way, it can have a rippling effect on those that hear it and tighten stigma’s hold.

This seems equally as evident in the discussion of mental health, a topic certainly on the minds of many as reforms to healthcare are currently being proposed. The way we deal with mental health in this country and around the world is a major problem. Not only is access to care among those with mental health disorders grossly inadequate, but the social stigma associated with a diagnosis or treatment of a mental health disease can further debilitate individuals already suffering from debilitating diseases. A survey of more than 1700 adults in the U.K. published in 2000 found that the most commonly held beliefs regarding mental health problems were that people who suffer from them are dangerous and that many mental health problems are self-inflicted. The authors concluded that these beliefs, among others they identified in their study, contributed to social isolation, distress, and difficulty in employment (Crisp AH et al. Br J Psychiatry 2000; 177:4). Though we can certainly acknowledge that mental health disease can of course lead to aggressive and violent behavior in some, the generalization that mental health disorders equal danger is a troubling stereotype to apply to an entire population, especially one that needs to be embraced with care and not pushed away by fear. Similarly, the implication that mental disease is self-inflicted is at its very core insulting to those inflicted, erecting walls around those in need.

HIV stigma stops hereThis is why stigma is so devastating; not only does stigmatization affect the way patients seek evaluation and engage in treatment, but it affects the way doctors engage and support patients in need. When this relates to mental health, for instance, it demonizes an individual who suffers internally from psychiatric disease and further isolates him or her. When this relates to transmissible disease it results in improper identification of those who require treatment and can facilitate the passage of infection between individuals. In general, it worsens outcomes and impedes solutions.

So, as doctors on the front line of this issue, what can we do? It is incumbent upon us as a profession to take care with how we conduct ourselves and communicate. When we allow our own prejudices to infiltrate our communications to patients or others, we do them a drastic disservice. Because the short answer to Dr. Price’s question is not to isolate or quarantine but to test adults as per CDC Guidelines for HIV infection and to plug them into effective and supportive care as indicated. And yet by saying what she said, she has already sewed her seeds, unearthed her own prejudice, and further affected the way in which a vulnerable population views the medical profession, preventing us, in my opinion, from truly being able to find an answer to the problem.

The specter of stigmatization is held tightly within our society and will not easily be shaken. As such, we need to look long and hard within ourselves and ask whether and how we are contributing to it. We have a duty to our patients and much of that is not allowing our own bias to affect the work that we do and the care that we deliver. This is as important in our treatments as in our communications. Ultimately, educating ourselves on various conditions and confronting our own views on them, advocating for the rights of our patients, supporting those patients through their diagnoses and treatments, working to normalize illness by taking it out of the social construct from which discrimination arises, and treating a disease for what it is — simply a disease and not a commentary or judgment on the individual with it — these are some strategies to employ. But the words that we use in our discussions are just as important. Hopefully, as we continue as a profession to discuss these issues, we will continue to grow to the benefit of our patients. And until such a time as stigma no longer exists, it is also important to continue to call out words such as Dr. Price’s and to mind our own.

NEJM Resident 360

November 3rd, 2017

Uncuffing Medicine from Guidelines

John Junyoung Lee, MD

John Junyoung Lee, MD, is the 2017-18 Chief Medical Resident in Internal Medicine at the University of Miami at Holy Cross, Fort Lauderdale, FL

During my first Cardiology fellowship interview, Dr. Schevchuck, one of the cardiologists on the admissions committee, opened the interview with the following question: “Guess how many guidelines there are in the United States?”

If you are reading this and you are planning on applying to a cardiology fellowship too, I have done some homework for you. According to the Agency for Healthcare Research and Quality (AHRQ), about 1732 active guideline summaries have been published in the U.S. since 2000.

The opening question stimulated an interesting conversation, during which Dr. Schevchuck shared an analogy pertaining to the relationship between guidelines and physicians. He said, “imagine a commercial airline pilot and a 1000-page manual about flight rules. If flying and navigating an aircraft were entirely dependent on the pilot’s ability to recall every single word in the manual, then the commercial airline industry would be facing greater troubles than disgruntled customers on overbooked flights.”

Silver Bullets

silver bulletIn 2004, the New York Times reported that some clinicians were not following clinical practice guidelines, and the public’s response spurred what we now refer to as core quality measures. The Centers for Medicare & Medicaid Services (CMS) — a federal agency that administers the Medicare program — decided to attach quality measurements to common afflictions, and they mandated that the measurements be met for medical reimbursement. As a result, organizations and clinicians are now rewarded or penalized based on how carefully clinicians follow the guidelines. This system is founded on the faulty belief that adherence to guidelines is a “silver bullet” to decrease all-cause readmission and mortality.

These solve-all guidelines are sometimes pitted against physicians’ clinical judgments; and slight aberrations from guidelines could now be punished legally. Depending on whether one believes the COMET study or the MERIT study, a physician could be thrown into a legal battle over use of metoprolol tartrate or metoprolol succinate.

Medical guidelines are supposed to help physicians, right?

Guidelines can serve as general checklists that clinicians use to meet “core measures.” However, guidelines must be viewed with discernment, as they are not always apace with the newest research discoveries, and they sometimes make recommendations that are bigger than the evidence. Organizations, clinicians, and the public must remember that guidelines are, after all, guides, which cannot be substitutes for clinicians’ judgment and acumen.

fiat lux -- let there be light

Let there be light

In the past several years, guidelines have been used not as a tool for clinicians to educate themselves and help their patients, but as a tool to micromanage and attack physicians in the legal battles. I believe that, to move forward, we need to simplify and better delineate the standards of practice and designate a knowledgeable governing body to administer the standard. We also need to define acceptable degrees of freedom from the standards. While I understand that guidelines attempt to curb the behaviors of those few who practice “scary medicine” and put patients’ lives in danger, guidelines are also intended to inform clinicians about best practices. In order for physicians to actually benefit and not be harmed by the guidelines, I believe we need freedom to interpret the guidelines in the setting of our own patients, and we need better legal protections when reasonable judgment conflicts with a guideline recommendation.

What are your thoughts?

October 17th, 2017

Be Human. Be Memorable.

Karmen Wielunski, DO

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

My dad died on May 11, 2003. It was Mothers’ Day. I was 18 years old. Those are the easy facts. The more difficult ones are those detailing the events that led to his death. My dad was so many things — a brilliant geologist, a loving father, an inventor, a pilot, and a Vietnam veteran — to name a few. He survived three tours on the front lines in Vietnam, but he didn’t come out unscathed. He was a victim of post-traumatic stress disorder and, subsequently, progressive alcoholism. Despite numerous attempts by my family to help him, and treatment in every form imaginable, we watched a truly amazing person become engulfed in a vortex of pain and sadness. One night he fell. There was intracranial bleeding, seizures, and then irreversible hypoxic brain injury. It was Police Lightstraumatic, unexpected, and life-changing for me and many others.  

Memories and Questions

I started residency more than 10 years later. Just like every other resident, I spent busy days and nights in the hospital caring for countless patients with umpteen ailments. I also spent a lot of time working in the ICU. Unsurprisingly, my ICU patients frequently triggered recollections of my dad’s last hours in a similar setting. I very vividly remember him lying on an ICU bed connected to a ventilator. He was slightly turned on his left side, and had thick, white dressings around his head. I remember a nurse entering his room and quietly saying, “Tim, I’m going to give you some Tylenol now for your fever.” At the time I thought it was odd that she was explaining this to him. At 18 years old, I knew what ‘no meaningful brain activity’ meant, and I knew she did too. But, at the same time, her gesture was comforting to me.

The more I cared for critically ill patients during residency, the more I started thinking about the providers who took care of my dad. I wouldn’t call it critical thinking by any means — more like nonchalant, stream-of-conscious thinking as I walked from one patient unit to another. I wondered, ‘Were there internal medicine residents similar to myself? Were they really tired? Was there a critical care fellow? If so, was he or she a jovial fellow? I hope so – I like jovial critical care fellows.’ These random thoughts continued for years. But, the more I wondered, the more apparent it became that I actually didn’t remember any of the physicians who took care of my dad. The only person I remembered was the nurse who gave him Tylenol. Initially, this was a surprising realization. In a situation where likely countless physicians, residents, students, and therapists participated in my dad’s care, how was it possible that I only remembered one person?

Humans and Answers

The answer actually came to me via Twitter. In a post on September 22, 2017, Mark Reid, MD (@medicalaxioms), wrote, “When you run out of doctor things to do for the sick person, see if there are any human things you can offer.” Though seemingly simple advice, this resonated with me. It reminded my of my dad’s nurse. Due to the severity of his injuries after his accident, we quickly ran out of medical things to do. The nurse, however, still took it upon herself to do human things. The Tylenol she had to give was medically useless, but she used its administration as a venue to express care from one human to another. She called my dad by his name. She explained to him what she was doing and why she was doing it, and she didn’t judge his situation. Even her soft tone of voice was a much-needed juxtaposition to the chaos that had occurred up to that point. Even if it took me years to fully realize it, all of this mattered to me. Actually, it still matters to me now. 

I’m sure that the other members of my dad’s care team were also great. I realize that circumstance and time likely also play large roles in my inability to recollect specific people at that time. However, I do think the concept of ‘doing human things’ is important to remember throughout medical training and practice. Our chosen careers often place us in a position of being participants in difficult, life changing events of patients and their family members. We won’t always have the answers. Even when we do have the answers, we won’t always have the solutions. But, we can always be human. And, as I can attest, even the smallest human acts can have a lifetime of impact.

Check out this NEJM article for a great review on post-traumatic stress disorder 

 

NEJM Resident 360

 

October 6th, 2017

We All Give Up Something

Cassie Shaw, MD

Cassie Shaw, MD, is a 2017-18 Chief Resident in Internal Medicine at Saint Louis University Hospital in Saint Louis, MO

We all give up something, usually many somethings, to become doctors. It all starts with medical school where we spend hours listening to lectures, studying books, reviewing slides and reading notes. It continues into residency where we have little control over our schedules, working weekends and holidays; cherishing each of our 4 days off per month. We miss birthdays, weddings, family gatherings, and reunions. Instead of spending holidays with our own families, we spend them with our patients and their families. After completing my first 2 weeks as an attending, I quickly realized that the 24 hour per day work while on service is unforgiving. I would wake drenched with sweat after a panicked nightmare about a missed diagnosis. I would check charts right before bed and first thing upon awakening.

Cardinals baseball game

Thankful for generous attendings who donate their Cardinals season tickets to poor, tired residents. This outing was a definite plus in the sanity column.

However, as I write this, I hear the words of my Program Director in my ears: “no one wants to listen to a physician whine.” He’s right. Being a doctor is a sought after, respected, and well-compensated position. I wanted this. In fact, I made deals with the universe for years to get where I am today: “I will study every single night if you just let me into medical school.” No matter the sacrifices required, I still want this, and I cannot imagine doing anything but exactly this. It’s not just that no one wants to listen to a doctor whine — we aren’t alone in this sacrifice. Many of our colleagues in other health professions and non-health professions sacrifice as well. Right or wrong, in this country, we often put our profession first and allow family, fun, and free time to fall in line thereafter.

So how do we deal with the losses of days, hours, and important events with our loved ones? How do we stay sane and have lives outside of the workplace? As kids say these days, how do we fight the FOMO (Fear Of Missing Out)?

Margaret Atwood with Cassie at a book club meeting

Bonus to my book club was having lunch with Margaret Atwood

Until this year, I thought that I had created a good work-life balance. For instance, while I was in residency, I averaged one concert per month. It didn’t matter if I was post call, pre call, or had to be at the hospital at 5 AM the next day, if there was an artist in town that I wanted to see, I was at that concert. I sacrificed sleep for sanity. I thought I was doing it right: living a perfect balance of both work and life. However, I still let a lot of other things that made me happy fall to the wayside. Namely, I rarely read for pleasure; I picked up a book only long enough to read a few sentences before falling asleep. I changed that during my chief year. I got a library card, and I started reading again. I also joined a book club where I could surround myself with individuals who also wanted to nerd out over literature. This was probably the first time in years where I came to a table and discussed something other than labs and images and medications and barriers to discharge. It was invigorating.

Another strategy for maintaining a positive work-life balance is addition by subtraction. I did this more by accident and technological ignorance than by conscious choice. My hospital switched their email program from Gmail to Outlook this year, and when I put the new application on my phone, I didn’t know how to turn on the notifications, so I just didn’t. Since then, I only check my email once per day and rarely on the weekends. Checking my email on my own terms has been life changing. Although I’m not exactly “unplugged,” I feel unplugged. My attention is focused on the present. My pocket is not constantly pinging, and I don’t feel the pressure to always be available. This isn’t a new strategy, I know, but I always felt like I was somehow required to be immediately responsive as a physician, even when I wasn’t on call. I felt as if I was going to miss an opportunity or let someone down. In reality, the only thing I was missing was my own life.

In the last few months, as I’ve made these seemingly minor changes, I’ve noticed that I’ve felt more whole. I have realized that I’m not defined by my profession. I’ve felt more like me. I’ve also noticed that my interactions with others have been more meaningful and far less stressful. I’m able to apply myself to tasks in a more efficient way. This isn’t just a feeling I alone have; researchers at San Francisco State University looked into their own employees and found that those with creative outlets and hobbies outside of the workplace perform better and interact more positively with their colleagues (J Occup Organ Psychol 2014; 87:579).

Cassie's labradoodle, Izzy

My sweet, patient and thankfully very well house trained Labradoodle, Izzy.

It’s no secret; we are all busy. We all want for more hours in the day and to use those hours to be supportive and present for our patients, our residents, our students, our family, our loved ones, and our Labradoodles. Okay, maybe that last one is just me. The reality is that we can’t have more hours. We have 24 of them: no more, no less. How we choose to spend our hours makes all the difference. I am not advocating for you to spend less time devoted to providing the best care to your patients, and I know that means you will be put in a difficult position where you have to, again, give up something. I am advising that that “something” not be yourself. Cherish those things that make you you. Keep going to concerts, keep reading, keep writing, keep running, keep dancing, keep watching your kids’ cross country practices, keep playing chess. The person who was accepted into medical school and subsequently into residency was the entire you, the whole you, and that is the you who is the best at your job.

 

NEJM Resident 360

 

September 27th, 2017

Thoughts on Caring for Sexual-Minority Patients

David Herman, MD, is a 2017-18 Chief Resident in Internal Medicine at the University of Southern California / LAC+USC Medicine Center in Los Angeles

According to recent polling, approximately 4% of the population of the U.S. identifies as gay, lesbian, or bisexual, which equates to more than 10 million people scattered from coast to coast. In truth, this number likely underestimates the true prevalence. Despite the progress that we have made as a nation towards LGB acceptance and equality, people who identify as LGB still experience discrimination and hate, such that many feel pressured to remain “in the closet.” Even those who do open that closet door often live in the daily reality that, in many ways, in many minds, and in many places, they remain second-class citizens.

I am one of them, a gay man who lives in West Hollywood, California.  I count myself fortunate in that I have lived, worked, and studied among accepting individuals and in accepting institutions; aside from the adolescent and early adult struggles that I experienced prior to coming out — teasing and name-calling, feelings of inadequacy, fear of disappointing those around me, all of which are relatively common amongst my LGB peers — I have emerged relatively unscathed and now live a life in which I feel supported, and which gives me opportunities that I am thankful for on a daily basis.

Albuquerque vigil for vistimes of Orlando nightclub shootings (2016)

By Kaldari (Own work) [CC0], via Wikimedia Commons

Yet, I am reminded frequently that my sexual orientation classifies me as a vulnerable minority.  The recent rescinding of protections for transgender military personnel (Note: my omission of transgender individuals prior to this is intentional, as I believe that the topic of transgender people and their healthcare deserves special attention: I will be addressing that in a future blog), the numerous attempts to pass “Religious Freedom” bills around the country, and the still deep wounds inflicted by the senseless tragedy in Orlando, Florida, for example, remind me that we still have far to go to achieve true equality, legally and beyond, and that we remain in many ways, the targets of a discriminatory society. I am further reminded of this when I read the news or watch the talking heads debate our rights on cable television — as though arguments to codify our status as second-class citizens are valid ones to be discussed and are not simply discriminatory statements. And all of these things are contributing factors in the overall poorer health of LGB youth compared with their heterosexual peers. Mental health, especially, is affected: studies have demonstrated significantly higher rates of mood and anxiety disorders, higher rates of depression, and a dramatically higher rate of suicide attempts and ideation amongst LGB people.

So, as a gay man, I do the best I can to channel my feelings into promoting and expanding the health and welfare of my community. As a gay doctor, however, this strikes a different chord in me. It is not solely because of obvious health disparities that exist amongst members of the LGB community, although they are real and extensive and, many times, inadequately addressed in healthcare settings (NEJM JW Gen Med 2016 Aug 1 and JAMA Intern Med 2016; 176:1344). Higher rates of sexually transmitted infections in men who have sex with men (with the growing emergence of antibiotic-resistant organisms), dramatically lower rates of adherence to national guidelines for cervical cancer screening amongst lesbian women, higher rates of smoking and substance use and abuse amongst LGB people in general — these should be of concern to all physicians in Internal Medicine, especially as we shift more of our focus toward preventative care. The National LGBT Health Education Center, a program of the Fenway Institute, has a tremendous amount of resources to address some of these specific concerns, and I would challenge you to access their materials to educate both yourself and your peers and keep up to date on very pertinent issues that affect your LGB patients.

LGB Patients Sometimes Fear the Healthcare System

Rainbow FlagMy fear is that those of us in the medical profession avoid many basic issues of sexuality and orientation. In 2003, for instance, a survey published in the Journal of Homosexuality revealed that 71% of medical residents did not regularly ask sexually active adolescents about sexual orientation; when pressed, 93% reported that this was because they were too uncomfortable to do so (J Homosex 2010; 57:730). In 2002, 6% of physicians surveyed by the Kaiser Family Foundation reported that they were uncomfortable treating gay or lesbian patients. Attitudes can change, of course, and these surveys were conducted over a decade ago. Yet, a recent publication in the American Journal of Public Health revealed that amongst 200,000 surveyed healthcare providers, including physicians, implicit preferences toward heterosexual patients over members of the LGB community existed among heterosexual providers (Am J Public Health 2015; 105:1831). This attitude (whether conscious or unconscious) further solidifies the already thick wall that exists around many LGB people, one built of distrust for the medical profession due to fear of judgment or discrimination and a history of both: It was not long ago that we doctors classified homosexuality as a mental disorder. And these fears are present even among our peers: A 2015 study in Academic Medicine concluded that sexual and gender minority medical students often conceal their identity during training (nearly 30% of such students), with nearly half of concealing students reporting fear of discrimination (Acad Med 2015; 90:634).

Clearly, we need to do better, for our patients and for ourselves. The first step in addressing the many health disparities that exist in the LGB community is to confront the issues that we, as a medical community, have with sexuality and orientation. That is where we, as residents, especially as residents in Internal Medicine, can take a special role. Residents are the next wave of attending physicians in community and academic centers across the nation, and we have the opportunity to re-create atmospheres that have traditionally been less than inviting to those with differing sexual orientations. Furthermore, as residents now, we are often the first ones to take full histories for our patients, the first one to see them in the ambulatory setting, and the ones that strategize with them to establish treatment or follow-up plans, which leads to continuity and building of lasting relationships. To do this well, we need to know our patients; and this includes understanding their sexual orientation and how it directly and indirectly affects aspects of their lives. I can recall the first time that my physician asked me about my sexual orientation; it changed our therapeutic relationship immediately as I felt a comfort level as of then unachieved, and allowed me to discuss issues openly and honestly to the betterment of my own health.

Caring for LGB Patients

So… what are some steps that we as medical professionals can take?

  • Strive to create a welcoming, supportive environment in which to care for and learn from your patients.
  • Focus on your attitude, demonstrate your willingness to work with others, and be open to the situations of your patients without the perception of judgment or preconceived notions.
  • Get to know your patients outside of their medical complaints.
  • Use inclusive language; avoid assuming someone’s sexual orientation or the gender of his or her partner, for instance.
  • Make your line of questioning regarding sexuality and sexual orientation routine for all patients; this will normalize the discussion for you and your patients and will help to ease some of your discomfort as you continue to practice.
  • Take a full sexual history of all your patients and understand the screening guidelines; many members of the lesbian, gay, and bisexual community require special consideration for screening for sexually transmitted infection, for instance, or special attention to substance abuse and mental health.
  • Acknowledge your own discomfort or ignorance (if any) and work to move past it.
  • Ask for clarification of words or topics that you do not understand; your patients will be happy to explain and this will give you an opportunity to not only learn about your LGB patients specifically but also to learn about them in general.

The LGB community is a strong one whose history is driven by resilience and survival. But that history has been marked by judgement, discrimination, and persecution, and that history affects each member of the community differently. It is important that we, as healthcare providers, respect this history and work to build strong and lasting relationships with our LGB patients. It is in this way that we can truly start to address the health disparities that this community experiences.

NEJM Resident 360

September 18th, 2017

Beast Mode Is Back! When Actions Speak Louder

John Junyoung Lee, MD

John Junyoung Lee, MD, is the 2017-18 Chief Medical Resident in Internal Medicine at the University of Miami at Holy Cross, Fort Lauderdale, FL

Cal Football

I bleed blue and gold. No, I am not talking about Michigan, West Virginia, or Notre Dame. I am definitely not talking about UCLA Bruins (by the way, UCLA fans, a bruin is a brown bear). That’s right — I am a die-hard Cal Bears fan.

Thanks to Cal football, and particularly to legendary Marshawn Lynch, my college days were filled with excitement. (I am counting on you, Coach Wilcox.) Marshawn, an Oakland-native running back, is one of the best football players to graduate from Cal, and he happens to play for my team, the Oakland Raiders. Known for his power running style and ability to break tackles, he is one of the best running backs in the NFL, and I think he makes the world a better place. You think I am being dramatic? Let me prove you wrong:

  1. Marshawn blesses us with his famous unfiltered one liners. Sometimes he will grant an interview, but mainly so that he doesn’t get fined.
  2. Fam1st Family Foundation, which Marshawn helped to co-found with his relative, Josh Johnson (NFL QB), provides education and empowerment to underprivileged youth.
  3. Have you ever seen anyone better at “ghost riding the whip”?
  4. Marshawn Lynch sat down during the national anthem at Raiders preseason game against Arizona Cardinals. Judging by the national uproar that followed, actions still speak louder than words. Just ask Marshawn about it. Oh, wait — he might not answer your question.

Aug 12, 2017; Glendale, AZ, USA; Oakland Raiders running back Marshawn Lynch (24) prior to the game against the Arizona Cardinals at University of Phoenix Stadium. Credit: Matt Kartozian-USA TODAY Sports

Marshawn did not immediately elaborate on his action, but his sit-down happened in the wake of the violence at the white supremacist rally in Charlottesville and followed Colin Kaepernick’s protest against racial injustice and police brutality against people of color. Marshawn’s simple action, or inaction, polarized the football community and ultimately achieved its intended purpose: to sustain and stimulate conversation about what happened at Charlottesville and across the nation.

When pressed by the media about his anthem sit-down, Marshawn said, “So my take on it is, $#!t has to start somewhere, and if that was the starting point, I just hope people open up their eyes to see that there’s really a problem going on, and something needs to be done for it to stop. And if you’re really not racist then you won’t see what he’s doing as a threat to America, but just addressing a problem that we have.”

Racism

Individual and structural, overt and implicit — pervades every state and every industry, and medicine is not immune to it. While we doctors use objective measures, such as lab tests, to diagnose patients’ ailments, we also use heuristics in our medical decision-making, depending on our categorizations of people based on physical characteristics, such as race and ethnicity. And sometimes, a patient’s race becomes a confounder: A black patient’s pain is treated differently from a white patient’s pain.

The patients also bring their own biases and stereotypes to the hospital. A typical male Floridian octogenarian, meaning a white-haired transplant from New York or a ‘snow bird,’ presented to our emergency department for acute heart failure exacerbation. He was huffing and puffing until we put him on a noninvasive positive-pressure ventilation. Remarkably, between his gasps for his next breath, the patient managed to point at one of our residents of Middle Eastern heritage and to spurt out the following string of words: “I… Don’t Want… His Kind… Treating Me.” It was a paradigm of how not to start a vulnerable yet trusting relationship between a patient and a physician.

The story might seem to show an isolated incident, but our hospital has been getting such requests, with increasing frequency, in the past few months. Why? We are not sure, but we know that since the last presidential election in the U.S., there have been multiple reports of racist- and hate-fueled harassments and acts of intimidation around the country.

How Do We Fight Racism?

How do we approach such a sour situation in medicine?

Our duty as physicians is, first and foremost, to treat and to stabilize patients. Once patients are stable, those with competency have the right to refuse care under informed consent. In other words, patients can refuse care from unwanted physicians. In turn, physicians are also freed from our Hippocratic Oath to “consider for the benefit of my patient and abstain from whatever is deleterious and mischievous.” It would be deleterious and mischievous to force a professional relationship that was built on bigotry.

While letting patients choose physicians based on race, ethnicity, gender, or sexual orientation seems like allowing hate to win, stepping away from the ‘fire’ helps physicians to protect themselves from unwarranted verbal assaults and constant emotional abuse. Physicians are allowed to acknowledge their human emotions, too.

We must perform our duties as physicians, but we do not have to tolerate hate. I recommend physicians to remove themselves from hurtful encounters, but I also encourage physicians to advocate for, or at least try to understand, someone from a different background. Unfamiliar does not have to equal uncomfortable: See it as a learning opportunity. After this blog, I might even become the recipient of racially charged comments. I am, however, willing to embrace whatever comments are directed at me. Why? Because that’s exactly what this is about: to break bread and generate conversations as a way to break barriers and hate. And besides, I could not turn down an opportunity to write about Beast Mode in the New England Journal of Medicine.

Go Bears!

p.s. Marshawn, holla back at your boy! Maybe when Raiders come to play Miami Dolphins in November?

 

NEJM Resident 360

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