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December 11th, 2018

No, I Am Not Patient Transport

Cassandra Fritz, MD

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

“Oh, you’re here to take me to my test.”  I have heard this too many times to count, and I have come to perfect my response. “No, I am not patient transport, your social worker, or your nurse. I am your doctor.” After a moment of confusion, I usually see a facial expression signaling that the patient is reframing his or her initial thoughts. Maybe I am misidentified because I am young, or black, or female. No matter the reason, I get annoyed instantly every time this happens.  Do patients have some preconceived notion about who I am? I always conclude my internal dialogue wondering… Will they trust me?

happy doctorIn sharing these experiences, I feel that women, especially minority women, deal with this more than other physicians. Although this issue may seem insignificant to some, continually having to define your role drains morale and can erode confidence. In spite of my white coat and MD,  patients mistake me for everything BUT a doctor. I have joked that, even if I tattooed MD on my forehead, there would still be misperceptions about my position. All kidding aside, the repeated misunderstanding about women being physicians speaks to the strength of implicit bias in medicine.

Implicit bias stems from our past experiences and stereotypes. It is an unconscious process that allows our brains to make automatic associations based on initial yet superficial qualities. Basically, implicit bias is one way our brain sifts through the information constantly bombarding us.  Patients may be more at-risk of relying on automatic unconscious associations when they are stressed or sick. Yet, I have often wondered, do these interactions affect patient care?

So if you find yourself annoyed by repeatedly stating “I am your doctor,” here are a few things to consider:

Implicit Bias Is Strong

doctor with patientPhysicians’ implicit bias toward patients is commonly discussed. Yet we aren’t taught how to deal with being on the receiving end of bias. Nonetheless, the “hidden curriculum” during medical school and residency has provided models of how to navigate these situations. What I have found most helpful is to quickly establish common humanity with patients. By sharing small aspects of my story, I can help people disassociate from their previous bias.  Giving patients the opportunity to reconstruct their thoughts about who I am, and hopefully establish a trusting and a therapeutic relationship.

Confronting Bias Is Important

find your voice noteI would be debt free if I had $10 every time a nurse asked for orders from my 6 ft+, usually white, male medical students in their short white coats. We all have biases about the type of person we look to for help.

During my second year of residency, I worked with an amazing female fellow in the ICU who helped me find my voice in high-stakes situations. She encouraged me to correct people when they were looking to the wrong members of the team for orders or guidance. She taught me something important in that moment — you have to confront bias head on.

Acknowledgement Is Key

As I mentioned above, confronting bias provides an opportunity for people to reconstruct their initial associations. This confrontation can be tricky though when a patient is involved. What is the appropriate way to “check” your patient? I think most of us already do this in a proper manner: We politely correct patients (no matter how many times it takes). Is it hard to repeatedly define your role? Absolutely! Yet this is why I think acknowledgement of the bias against you as a physician is very important.

Physicians need to acknowledge to their team that they are being bombarded by waves of implicit bias.  Because I just can’t believe that this doesn’t affect us. When this happens to me, I conscientiously tell my team about the interaction. I do this not to make people feel uncomfortable, but to make sure I am scrutinizing my own bias so as not to affect patient care.

Implicit Bias Is Everywhere

We are all guilty of making quick associations, especially in high-stakes situations. It is important to make patients feel comfortable, but there isn’t anything wrong with clarifying and re-clarifying your role. Most importantly, we should all try our best to support each other during these situations. Be open to the fact that some colleagues might need to air their frustrations as a way to manage their own bias toward patients. Acknowledging our human flaws and supporting each other really is what’s best for us and for our patients.

 

NEJM Resident 360

December 4th, 2018

Conferences Are Really About Mental Health Breaks

Justin Davis, MBBS

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

I recently attended the Australian and New Zealand Society of Nephrology’s (ANZSN) annual conference. I had a really good time. I had been to one of these before, when it was in Perth a few years ago, but that was way before I was accepted into the nephrology program. I remember the weekend being a whirlwind of getting out and back to Perth on a Friday and Sunday, attending as many of the talks as I could, and also missing a live event for one of my favourite video games that only ran that weekend (go figure). While that first conference was an enjoyable experience, the one I went to recently in Sydney was so much more enjoyable, and, naturally, when I notice something like that, I get to musing as to why that’s the case.

Darling Harbour on one beautiful morning. Only made better by the addition of coffee (not pictured).

I had been looking forward to this conference for a while. Before I went, I was excited both about attending a conference hosted by the society to which I had just been accepted into training and about the scientific talks and learning that would happen there. But, as the week went on, I started realising that it wasn’t just the lectures that I was appreciating. Instead, as my blog title suggests, it was more the time off, the break from the grind that is clinical work — a few days where I didn’t have to battle the phone or the clinic, or try to solve the multitude of issues that crop up on a daily basis. Instead, my biggest worry on any conference day was where was I going to source my morning coffee from so that I could be awake enough to pay attention to the aforementioned talks. (I am not a morning person, and this is especially true before I have had some sort of warm caffeinated beverage. I can’t start my ward round without one. Also, if anyone is curious, my hotel had a café in the lobby that did pretty good coffee, so this issue was solved very quickly).

Appreciating the poster viewing part of the conference, mostly by pointing out our co-regs specific posters for our amusement.

But it’s more than just the simple time off from work that made the conference enjoyable. If that were the case, I would be writing about every weekend that I have off.(Curiously enough, I’m writing this blog post on a Sunday evening where I have had a lovely little weekend off. It’s sunny and warm for the first time in ages here in the Land Down Under [well, the Victorian portion of it. I mean, Queensland is always sunny. Like Philadelphia]). I mentioned above that I was looking forward to my first nephrology conference as a nephrology registrar, and that’s because, in a speciality program, there’s something nice about being part of a group of varied, but still sorta-like-minded, people (after all, there was something that all drew us all to the kidneys). Where I work, I’m the only renal advanced trainee, which is nice, as I have formed close relationships with the staff around the unit (after all, I am the conduit for most things going through that unit). But this year, I’ve also been privileged to meet and become friends with a lot of the other nephrology trainees in my state, through various events and phone calls between hospitals. But I don’t have much to do with my registrar colleagues on a day to day basis, so I was appreciative of this year’s conference for the social aspect of it and for getting to spend some time with everybody else. Aside from Friday night travel, which was a scrambled mess of trying to get to the airport on time, every night at the conference was spent out for drinks, good food, and generally gallivanting about Sydney. (Have you ever noticed that if you’re trying to leave the hospital early or, at the very least, on time for something, instead of having a nice quiet day the hospital is insanely busy every time? I swear Murphy’s law and medicine have some sort of pact.) Admittedly, even on the Friday evening, I ran into some of the other registrars at the airport and had a nice chat (as well as the rather amusing group chat situation about the storms in Sydney that were cancelling various flights and the social media messages that created). And this, to me, was the key reason why I enjoyed this conference so much more than the last one; even though they both had scientific talks, it was the social aspect of this one that made it much more enjoyable. (Curiously enough, I also missed out on the first weekend of a launch of the newest edition of the same video game that I missed out on in Perth a few years ago. Go figure again, hey?)

The offical ANZSN dinner. Or at least the dancing afterwards.

Conferences aren’t just about the talks, the time off, or the social aspects. There’s also the opportunity to explore new places. I’ve actually been to Sydney a few times (including a rather amusing time where we stayed in what I swear must have been the hottest, most cramped, and non-air-conditioned backpackers’ hostel in the world during the middle of summer. It was great!), but this was the longest time I’ve spent there. Sydney has a heap of cool things to see in it, and Darling Harbour (on which our conference was held) is always a very pretty and pleasant place to visit. It was nice to get out and explore some more of the city, including going for a run pretty much every day I was there — including the opportunity to run around Circular Quay and enjoy the  Harbour Bridge and the Opera House. (It’s fun to be a tourist even in your own country sometimes). Even getting the time to sit out on Darling Harbour with a beer and a book (my favourite author managed to release his newest book right in the middle of the conference, which was excellent timing — I actually devoured it in a couple of days) watching the sunset was a refreshing experience, one I don’t have the opportunity to do during everyday life.

Of course there is a selfie in front of the Sydney Harbour Bridge. I mean why wouldn’t you take that opportunity whilst you’re there?

It’s important to note that I did also enjoy the talks that were given during the conference, especially the one emphasising updates in granulomatous with polyangiitis (GPA) with a discussion on the recent PEXIVAS trial. I feel like this one is going to create controversy in the nephrology world for a while yet. It probably was the highlight for me. But the conference was so much more than that. It was time off work, socialising, the chance to explore a new city, and even just little things like going for a run around Darling Harbour listening to music (from the same video game I was missing out on. Don’t look at me like that …) or sitting with a book and wine, watching the sunset. That was the conference. And that’s what made me come to the realisation that conferences are more about the mental health break than anything else. And hey, if you get to experience that every year or so then it makes conferences more than worth it.

“The greatest Warlocks understand how little they understand.”

What’s that? More random quotes? Sure, why not?

 

NEJM Resident 360

November 6th, 2018

Making the Most of the Holidays as a Resident

Ellen Poulose Redger, MD

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

It’s that time of the year again — Halloween has passed (and with it, the best excuse for an adult to dress up in costume), and the winter holidays are just around the corner. I was in a store on November 1st, and Christmas decorations were being put up.  Already.  Whether or not you happen to celebrate a particular holiday, this time of the year is associated with friends and family and togetherness. For many residents, though, it might be the first time that they spend many (if not all) of the holidays away from family and friends they grew up with. We all make new friends (and some would say, family) in residency and beyond, but there is also something about being home for the holidays.

roasted turkey dinnerAs a kid, I lived within 45 minutes of all four of my grandparents and was lucky enough to have them all around until 2010. Many Thanksgivings were spent at my dad’s parents’ house, where aunts and uncles and family friends and really, anyone, came to have an American Thanksgiving and then a second round of Indian food. It was a tradition that started in the 1970s when my grandparents, immigrants to the U.S., wanted their children to grow up with a true “American” Thanksgiving — turkey and trimmings, pies, and enough food for four times as many people as were actually in attendance. Christmas for us was not as stereotypical. Both of my parents are physicians, so Christmas happened sometime around the 25th of December, whenever they could both be off and awake at the same time, and the focus was not on gifts (although we did receive them). The focus for Christmas was being together.

Holiday celebrations during residency

Fast forward to residency, when my husband and I moved literally halfway across the country (Kansas to New York). Our first year in NY, I worked Thanksgiving, Christmas Eve, New Year’s Eve, and New Year’s Day — somehow, I managed to have actual Christmas Day off. [I’m sure he worked at least one of those, too, but while the urology service slims down for the holidays, the various medical services I’ve been on over the years do not.] My second and third years weren’t quite as bad, but in a two-physician household, you can bet that on most holidays, at least one of us is working. That’s how it goes — patients will always be sick and in the hospital — it’s part of being a physician.

Being away from our families during the holidays isn’t fun or easy, but my husband and I have learned to make it work. We participate in Friendsgiving (coincidentally the afternoon/evening after the urology in-service exam), our co-residents have organized “Secret Santa” gift exchanges, and we try to have a Christmas meal with members of our work family. We’ve even experienced our first Hanukkah, where I made very non-kosher lasagna.

“Holidays for the strays”

About 10 years ago, my parents started hosting “holidays for the strays.” This was an open invitation to their colleagues and residents to come over on Thanksgiving or Christmas or some random day near to the holidays to share a meal and spend time together. Over the years, this has morphed from a last minute “oh, no, these residents are going to be all alone on Christmas” to a fully planned, official headcount, catering-to-various-dietary-restrictions event that everyone looks forward to each year. [In fact, one of the Jewish attendings had his first Christmas dinner last year!]

When the “stray holidays” first started, my siblings and I understood that it was about bringing people together, but now, as a (chief) resident, I see how it is so much more than that. Holidays for the strays is a way to make sure that residents and faculty know they belong to a bigger family than the one they grew up with — they belong to the family of medical professionals where someone must work 24/7/365 to take care of others. Holidays for the strays are a way to make sure no one is sitting at home with leftovers or takeout on a day when everyone else is crowded around a table with family and friends. It is a way to get to know your colleagues outside of the hierarchy of the hospital or clinic. And most importantly, it is a way to ensure that even for those of us who work most (if not all) holidays, there’s still a table full of family and friends waiting to squeeze you in.

This year, as I made one of the residency class schedules, I notated where various holidays fell (including major Jewish and Muslim holidays) and tried to give the appropriate people days off on the appropriate holidays when it was possible.  It was my way to try to ensure that the residents had a chance to pull a chair up to a table and spend time with those they love.

Maybe I can’t have you all over for my Christmas tenderloin, or bake up a bunch of pies for everyone for Thanksgiving, or share my famous French toast with you for New Year’s brunch, but I can encourage everyone to do something together, even for a few hours on just one of the holidays. You can bet that once we finally move on from living in apartments, we’ll be having our own “holidays for the strays.” And, for any of my residents reading this, I’ll see you on Thanksgiving — at the hospital.

NEJM Resident 360

October 25th, 2018

Part of the Equation, but Not Equal

Ashley McMullen, MD

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

Fall is finally here — the weather is changing, good TV shows are back on, and, for residency programs, interview season is fast approaching. That means it is time, once again, to choose the next class of interns to take the formative next step in their careers. In this process of selecting a few from many qualified applicants, the concept of diversity is one that comes up often. Its value is especially relevant in medicine as we seek to build a workforce of providers that is, at least partially, representative of an increasingly diverse patient population. However, while we recruit more trainees who are underrepresented in medicine (URM), it begs the question – “What are residency programs doing to both assess and address the environments in which their URM physicians practice?”

URM Residents at UCSF Holiday Party

The results of a survey that went out to residents at my own institution found that, among the demeaning interactions encountered either directly or indirectly in the workplace, the vast majority originated from patients or their families. It comes as no surprise that the intense divisions playing out across our TV screens and social media do not cease to exist inside the hospital walls. Indeed, several recent mainstream and peer-reviewed publications have documented instances of overt discrimination leveled at physicians. Likewise, in a 2016 New England Journal of Medicine perspective, Paul-Emile et al. cite a particularly egregious incident that took place at one of our hospitals (N Engl J Med 2016; 374:708). Here, they outline an approach to dealing with racist patients. However, more often, the subtle instances of perceived bias present the biggest challenges.

One evening on a particularly arduous shift in the emergency department, I was readying myself to deliver bad news to a patient’s family. The medical student rotating with us that night asked me if he could come observe the conversation as a learning opportunity; I replied, “of course.” To be sure, delivering bad news is never easy, but I felt I’d had enough experience at that point in my training to confidently model this skill. Upon entering the waiting area, several of the patient’s family members were sitting patiently with silent apprehension. Anticipating the challenging news to come, they wanted to wait for one more relative to arrive before starting the conversation. When this person walked into the room, she moved with authority and purpose — clearly, she was the spokesperson for the family. I stood up to greet her, and although we made eye contact, she continued moving right past me and up to my tall, white, youthful-appearing, male medical student. “You must be the doctor,” she said.

male doctor in lab coat

From: https://www.publicdomainpictures.net

This story is not unique among those who are underrepresented in medicine, but I can tell you how it uniquely affected me. In that moment, when I needed to evoke empathy and compassion for this family, I found myself trying to sit taller and to speak louder and with more confidence. I was trying to increase my psychological size as way of compensating for the fact that I couldn’t be the doctor this family expected or wanted at this difficult time. I often find myself going to meet a new patient and wondering how they will react when they see me — will they be pleasantly surprised, disappointed, angry, or indifferent? Regardless, I know that whether the patient is wearing a red MAGA hat or a red Colin Kaepernick jersey I must afford them the same level of care and professionalism. It is yet another example of how the rigors of medical training are compounded by the realities of our current sociopolitical climate.

As long as physician burnout continues to be on the forefront of conversation, we must also address the additive impact that these types experiences have on URM trainees and attendings. Many institutions do well to incorporate talks on implicit bias, diversity training, and cultural competency in the workplace. However, we should be allocating equal time and resources to surveying the institutional climate, discussing concrete policies around dealing with discrimination, and building a supportive community around those most often on the receiving end of biases, both implicit and overt.

By Wallpoper [Public domain], via Wikimedia Commons

In a recent meeting with a mentee who is applying to medical school, we discussed this topic over coffee. She reminded me of the lyrics from Janelle Monáe’s song, Queen, in which she states, “Add us to equations, but they’ll never make us equal.”  It is true — although we’ve made impressive strides in adding more URM physicians to the equation, we’ve got a ways to go in terms of making those physicians equal.

 

NEJM Resident 360

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

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.