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March 14th, 2019

Musings on Match Day, the Conception Day of our Residencies

Ellen Poulose Redger, MD

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

Match Day. The one day that medical students across the United States all simultaneously look forward to and also fear. It’s really a whole week of roller-coaster emotions: on Monday we find out if we matched somewhere, and on Friday we find out where. (And, in between, if we unfortunately didn’t match, we scramble to find a position that is hopefully what we wanted to do but that at least gives us a job for the next 1-7 years.)

I’ve been through several Match Days for residency now, one as a spouse of a MS4 and one as an MS4 myself. (And, I guess, two others as the child of MS4s, but I didn’t know enough then to have any idea what was going on.) These days (weeks) are stressful and exciting at the same time.  Stressful waiting — to find out where we are going, what the algorithm determined is the best fit for us based on our preferences and the preferences of the programs at which we interviewed. Stressful wondering — to find out if we’re going to have to move somewhere new or if we’re going to know anyone else who’s going there, or if we’re going to find new friends at a new place. Stressful excitement — to think of a fresh start and another step in our training in medicine. Scary to contemplate it all. And very confusing to explain the process to anyone who isn’t in medicine. Yes, a computer algorithm analyzes preference lists from applicants and programs and then figures out a very important piece of our careers and commits us to a training program.

My Match Day as a student was a complete collection of all emotions. I was excited to see where I was going to train for the next 3 years, really hoping it would be at the same place my husband was going, and scared to find out. Scared because, if we didn’t end up at the same place, the 1 year of training in separate cities that we’d already done could end up being 3 or 4 years of living apart. And very nervous that, if all went well, we’d be moving halfway across the country to city where we didn’t know anyone.  I remember very nervously walking up to the stage with my husband to get my envelope, opening it with him, and then turning to the microphone to announce where I [we] was going. (My husband, clearly, was very excited that we were going to the same place for the following 4 years.) I remember cheering on my classmates and friends as they found out where they were headed to for the next stage of their training. Some were ecstatic with their matches, and a few were mildly disappointed, but everyone was proud that they had made it to the next step.

As a resident, I also look forward to Match Day. It’s exciting to find out who is coming to join our program, because those matches are a reflection on our program and its current residents, faculty, and leadership. It’s also a reminder that I’m almost done with another year of training and am that much closer to a fellowship or a job. There’s a palpable energy in our program during Match Week as we wait to find out if we filled all of our positions (phew) and then anticipate who will be joining us, and then finally find out who they are. A perk of being a future Chief Resident last year was that Match Day was also the day we found out who the social butterflies of the incoming class would be, as the social media friend/follow requests came flying in.

Match Week marks the beginning of the end of medical school and the start of residency. It’s the time when the promise of graduation becomes very real (which is awesome), and the idea of having a job shortly becomes more concrete. It’s when we start getting paperwork to fill out for hospital privileges and licenses and NPI numbers. It’s when we realize that the last few months of freedom until we retire are coming up and when we look for cheap flights to somewhere to celebrate our accomplishments. And it’s the start of new Facebook groups and WhatsApp groups so that we can stay connected to our medical school friends and make new residency friends.

There’s a temptation to speed up the time between finding out where we are going for residency and actually starting residency. A thought of getting ahead by reading something or learning something or practicing something to help us hit the ground running as interns. Don’t do it. Relax and breathe in those last few weeks of freedom before residency starts. Take the 3 months between Match Week and Intern Orientation to learn more about yourself and take care of yourself and your loved ones. Deepen the friendships you have with your medical school classmates, and be open to new friendships with residency colleagues. After all, once the algorithm has decided where we are going, it’s up to us to make the most of it.

NEJM Resident 360

March 8th, 2019

The Oncology Service

Ashley McMullen, MD

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

I won’t forget Mr. H’s face that morning, my very first morning on the medical oncology service. I skirted into his room behind my attending as she was called in to see him on the fly. With a slight smile, he sat quietly in the corner of the exam room, a tall black male of average build, alone. His open collar shirt and slacks were both wrinkled, his eyes were sullen, his close cropped hair was thinning diffusely throughout the top of his head. Outside this place, perhaps I would’ve pegged him for a car salesman, just working hard to get through the daily grind. Yet inside these clinic walls, I traced the large T-shaped scar extending from his collarbone down to the midpoint of his sternum. I took note of his soft, raspy voice. I observed how his ashen skin was in agreement with his dangerously low blood pressure. But that’s all I knew of Mr. H right then.

Anaplastic thyroid cancer radiograph

Anaplastic thyroid cancer (Mme Mim [CC BY-SA 4.0] via Wikipedia)

My eyes blinked and my attending was back out of the room. She needed to check on the results of Mr. H’s most recent labs and imaging studies. As she scrolled through his chart at a mind-numbing pace, she summarized the medical history… 42 y/o African American male, presented to the ED 4 weeks ago, found to have a mediastinal mass, diagnosed upon surgical removal to be anaplastic thyroid carcinoma. My First Aid lied to me! According to the text I had painstakingly committed to memory, this type of cancer was supposed to be extremely rare, popping up occasionally in elderly white females — not this middle-aged black man with four kids at home. When my attending got to the radiologist’s report, her head dropped slowly into her hands. The poisons we had dripped through this man’s veins last week had managed to shave off 15 lbs of his body weight, his appetite, his hair… basically, everything but the tumor, which had grown back to 3x its size since the initial surgery.

We’re back in the exam room. Now the attending is sitting down, next to Mr. H, her eyes meeting his eyes directly as she speaks (ironically, a bad sign in a busy specialty clinic). “I’m sorry Mr. H, but the chemo isn’t working. We can try adding radiation to slow the tumor growth, but in all honesty, this is not likely to do much. You should tell your family, and start making arrangements.” Mr. H accepted his fate with inspiring equanimity and quiet resilience. He even thanked my attending for her efforts as he headed towards the infusion center for IV fluids to bolster his decreased blood volume. I can’t help thinking that, that same evening, while I’m at home hovering over medical journals, Mr. H would be surrendering news of his prognosis to the four young children he was trying to protect. What are you supposed to do, when you’ve effectively derailed a man’s life in the course of a 15-minute visit? What’s the next step when you’ve sent a man home to tell his family that, by Christmas morning, he will be lying in a casket?

 

 

NEJM Resident 360

February 26th, 2019

My Primary Care Manifesto

Scott Hippe, MD

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

“She is meant for more than just primary care,” mused an attending on my internal medicine rotation in medical school. He was referring to a particularly adept resident with whom we were working. This resident was planning on practicing clinic-based general internal medicine. I wasn’t sure why this attending disclosed his thoughts regarding this resident to me, but the implication was clear: “primary care” — whatever is meant by the term — is an easy career path, meant for the mediocre clinician.

The comment left me scratching my head, because the general internist who said it worked in the outpatient setting almost exclusively. Something about the outpatient care he provided was apparently different than “primary care.”

A year later, I matched in a family medicine residency. I chose the field not because I had low test scores (I didn’t), but because I couldn’t find a single area of medicine that wasn’t interesting to me. I didn’t want to give anything up. I was attracted by the never-ending challenges afforded a generalist who is willing to push the boundaries of his or her knowledge. Asking “how much can I do [before reaching my limits] in the care of my patient?” is more compelling to me than saying “I know nothing about this particular organ system; this patient needs to go see another specialist.”

Medical education fails trainees interested in primary care

I did my medical training in the Northwest U.S., where the attitude towards primary care is generally favorable. My medical school actively encouraged students to consider primary care fields. But it isn’t that way everywhere. Trainees are frequently told explicitly or implicitly that primary care specialties are second-rate. Family medicine is seen as a convenient fall-back option for students who didn’t ace Step 1. General internal medicine and general pediatrics are the fields for residents who don’t match in their perfect fellowship.

A handful of medical schools even lack a department of family medicine. You might recognize just a few of them on the list mentioned in this article.

Rewriting a paradigm

The attending I mentioned in this post envisioned primary care as stuffy noses and pap smears. The way I see primary care is different. For the docs out there who look down on primary care fields and medical trainees who have received inadequate exposure to generalist medicine, I want to share this paradigm with you.

Primary care is the entirety of care that I provide for my patients as their first provider. This is far more than those stuffy noses and paps. My specialty’s broad scope of training incorporates services such as comprehensive obstetrics including cesarean section, reproductive health, addiction medicine, inpatient medicine, emergency medicine, screening colonoscopy, treadmill stress testing, treating hepatitis C, and end-of-life care. My domain encompasses the clinic, hospital, emergency room, delivery room, and nursing home. And I still visit patients in their homes.

To the undifferentiated medical trainee: staying general in medicine begets a land of huge opportunity and variety.

Generalists, and more of them, please

Image result for primary care physician graph

We’ve all heard about how the US has the highest health costs of any country in the world.

It takes a specially trained eye to focus on the big picture, to treat the whole person, and to be effective in varied care settings. There are 36 countries in the world that deliver better and cheaper healthcare than the U.S. What do they have in common? A strong base of generalists. I am grateful for the well-trained specialists who help me at the limits of my abilities. But the U.S. cannot specialize its way out of its poor-performing and exceedingly expensive health system.

Our hyper-specialized, fee-for-service health system deters many physicians from becoming generalists. Every medical trainee doesn’t need to choose a primary care specialty. But we need more than are

Although a bit out of date, this figure highlights the dearth of GPs in the US.

choosing primary specialties now. I advocate against the notion that generalist medicine is inferior to specialist medicine (partialist medicine? for some humor). Primary care is more stimulating and requires more clinical acumen than many realize. Until our medical community changes the way it thinks about generalists, I don’t see our health system improving — whatever political or policy “fixes” might be on the way.

 

 

NEJM Resident 360

February 19th, 2019

Do You Have a Peer Mentor? Do You Need One?

Cassandra Fritz, MD

Cassandra Fritz, MD, is a Chief Resident at Barnes-Jewish Hospital and Washington University Medical School in St. Louis, MO

Cassandra Fritz, MD, is a Chief Resident at Barnes-Jewish Hospital and Washington University Medical School in St. Louis, MO

Mentorship is a common topic in medicine. We, as a profession, spend significant time discussing, attending workshops about, and researching the role of mentorship. Mentorship is key to personal development, career choice, and improved academic productivity.

mentoring pathwayYet, it wasn’t until recently that my understanding of mentorship was challenged. I have always viewed mentorship as someone more senior than myself helping me to achieve my goals.  I have always been the mentee in such relationships. I was expecting the opportunity to mentor incredible residents during my chief resident year, but I have been truly surprised by the importance of mentor–mentee relationships with my co-chief residents. For the first time, I am recognizing the invaluable role that my peers play as my mentors. So, this made me wonder… is peer mentorship important in academic medicine?

Peer Mentorship

Peer mentorship is two people at similar stages in their career mentoring one another in a reciprocal fashion to advance both careers.  It is a nonhierarchal relationship with equal commitment and accountability. These definitions perfectly sum up the relationship I have with my co-chiefs. We work together to make advancements in our program, but we have also mentored each other through personal and professional projects, emails, disagreements, fellowship applications, and research. A peer mentor is likely more relatable and can challenge you in ways that a traditional hierarchal mentor may not be able to. A peer will have a better understanding of your day-to-day successes or shortcomings and can provide a bird’s eye view on the best way to push you toward your goals.

The field of business has established the importance of a nonhierarchical mentor. A recent article in Forbes magazine defines peer mentorship as a “safe place to share difficulties or even failures… as a way to strengthen relationships among collogues and help build resiliency.”1 These principles hold equal importance in medicine, especially in academic medicine. So, what should one consider in establishing a peer-mentoring relationship?

1. Trust and understanding

Trust is critical for obvious reasons, but most importantly, this relationship needs to feel safe. Both people need to provide a protected environment to have open and honest dialogue about goals and career plans. You aren’t depending on your peer to give you opportunities or promotions, unlike traditional mentors. Therefore, you may feel safer in sharing your challenges and be more open to pointed feedback. In my short experience, I have found it easier to hear feedback from my peers, since they aren’t responsible for my advancement. Moreover, this relationship can provide a venue to discuss your concerns prior to taking issues to your traditional mentor.

2. Shared goals

A peer mentor does not necessarily need to be from your field. In fact, having a peer mentor outside your own field might provide better perspective. However, peer mentors must understand each other’s goals and visions and be able to understand the specific pressures within different specialties. If your peer mentor doesn’t understand your vision, he or she can’t help you correct course when necessary.

At the beginning of my chief year, our Chair of Medicine asked us to read Monday Morning Leadership by David Cottrell.2 One of the main points of this book was the importance of “keeping the main thing the main thing.” This concept seems simple, but with competing demands and time limitations, this can be hard in practice. Your peer mentor can be vital in helping remind you what your “main thing” is and how to build your body of work around your overall vision. In short, your peer mentor should understand your goals and provide accountability in your pursuits.

3. The importance of resiliency

At the end of the day, a peer mentor should be a supportive resource. Someone that knows how to help you change your view point or plans as necessary. When something negative happens, your peer should be someone that can help you view challenges as opportunities. This relationship should be built on encouragement. You need someone to build you up, help you stay focused, and remind you that academic medicine is a marathon, not a sprint.

My understanding of mentorship has been expanded by my peer-mentoring experience this year. I appreciate that traditional mentorship models are important to career success, but I have come to welcome mentorship from my peers. I wonder if having an effective peer mentor is not only helpful, but is necessary to be successful in academic medicine?  Based on my experience this year, I think that it is.  Should we, as a profession, be discussing, facilitating, and researching the importance of peer mentorship and its role in retention and promotion of aspiring trainees and junior faculty?

 

References:

  1. Toledo M. Four mutual mentorship ideas to enhance your business. Forbes, Forbes Media Corporation, 15 October 2018.
  2. Cottrell D. Monday morning leadership: 8 mentoring sessions you can’t afford to miss. Corner Stone Leadership Inst, 2002.

NEJM Resident 360

January 30th, 2019

I’m Sad That Interns Don’t Want to Do a Palliative Care Rotation

Justin Davis, MBBS

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

It’s an exciting time for final-year medical students in Australia. Exams are over. They’re in their last-ever clinical rotations, and they’ve finally found out in which hospital they’ll be starting their careers. Most are happy. Perhaps some aren’t, I dunno. But most are simply excited to finally start their intern year as doctors, having spent 8 or more years in college and medical school. Finally getting to practice medicine. I suspect the fact they’ll be getting a regular wage is also something they’re looking forward to. I was surprised when, all of a sudden, I could afford a bigger tv after a few weeks of work as an intern.

The final day of my own medical school time. Cricket on the right, Mario Kart on the left. And beer, of course.

Of course, finding out which hospital you’ll be working at also comes with finding out about rotations. These are definitely more varied than hospital choices — your new hospital will often offer a gajillion different rotations. (I wonder how many zeros a gajillion is? *looks it up* — Oh, it’s an unspecified large number. OK, so a gajillion is correct.)  Here in the Land Down Under, our interns are required to have an emergency medicine rotation, a surgery rotation, and a general medical rotation in order to satisfy their intern training requirements, so those are not optional. The others could be anything. Perhaps even rotations you wouldn’t necessarily choose.

So, I was chatting with intern friends about their rotations. Overall they were pretty happy with their particular list of rotations for next year, but several people noted that their colleagues who were assigned palliative care rotations were trying to swap them out. And they wondered why anyone would agree to swap anything for a palliative care rotation.

This really saddened me. It made me muse and reflect on my own experiences as a palliative care intern and how good that rotation had been for my medical learning and growth. Why wouldn’t our newly minted doctors want to experience the personal improvement that working in palliative care could provide?

Of course,  there is a story behind all of this (like most of the blog posts I write, I’ve come to realize). I was quite happy with my own intern rotations: with the aforementioned emergency, surgery, and general medicine already allocated, I was given palliative care and orthopaedic rehabilitation as my optional ones. My own intern year started in emergency medicine.

The next paragraph is tricky. Emergency medicine was a… difficult rotation. Outside of intensive care, which I would experience later as a registrar (have you ever felt the dread of standing alone at 2am staring at an ECMO machine while your patient has just crashed, having never seen an ECMO before or had anything to do with one and wondering what the next steps are? I have.), emergency medicine was, by far, the most challenging experience I have had as a doctor. I think everyone, when they start out, has an existential crisis when they realize they have the responsibility of, you know, caring for sick patients. But, if you start in general medicine, you have ward-based registrars to run decisions through, which lessens the brunt of that responsibility.

Palliative care is about endings, but endings can be beautiful. I love sunsets, so putting nice ones into this blog goes with the spirit of palliative care.

There is a different culture to emergency medicine. Cold neon lights illuminate that place, no matter what the time or weather is outside. Like all of medicine, it’s a grinding wheel that never stops, but the relentless pressure there is something else. I remember walking down the corridor one day, with monitored cubicles to my right that continually beep and alarm like every patient is going into VT (they aren’t) and my second-favourite staff base to my left (you can have favourite staff bases. Don’t look at me like that), and thinking I had just wasted the last 8 years of my life. I should have stayed working at Dan Murphy’s (Uncky Dans is a liquor store chain in Australia, and I have to admit, if you’re going to have a part-time job to support yourself through university, you couldn’t ask for a better one). And all that excitement about working? Starting out? Finally being a doctor? Gone. Extinguished under the cold neon lights, while another category 2 comes into resus 3, and the monitored cubicles alarm for no good reason.

But, something happened that changed my perspective. That “something” was my palliative care rotation, my second rotation after the battering and brutal introduction that emergency medicine gave me. Instead of having to move patients to somewhere, anywhere, as long as it’s out of emergency, quick! Quick! And the relentless pressure … palliative care was a completely different experience. We had time for patients and their families. To sit down and talk with them about the issues they were having and what we could do to make their lives better. We didn’t need to investigate everything to make sure it wasn’t dangerously lethal, or to do things quick! Quick! Instead, the focus was on comfort, dignity, and making people’s lives better in what time they had left. Focusing on their needs and how we could best address them. Time. Empathy. Compassion.

It changed my outlook on wanting to work as a doctor and my enjoyment of the job. It was a liberating experience to be a part of a team of doctors and nurse practitioners (whom I cannot thank enough) who simply made people’s lives better without investigating, referring, testing, or moving patients. Just talking, focusing on essential medications that would take their symptoms away, and having the time to spend with patients and their families, listening to their concerns. You could tell it was a valuable experience for the people whom we consulted on, and it certainly was for me as well.

And another sunset, taken one night on the three and a half hour drive to my rural hospital placement.

The business that is specialist medicine has the potential to draw out the worst qualities of the medical grindstone. Sometimes, we simply have too much to do in one day. This is why I was saddened to learn that others wouldn’t want to experience a rotation like palliative care during their own intern years. Perhaps they won’t come to it from as low place as I did, but the experiences and the satisfaction of just making people feel better is something that new doctors shouldn’t miss out on. When I fnd myself having difficult discussions with patients and their families, I  often reflect on the conversation skills that palliative care taught me. But mostly, it was nice to do so much for people by doing so little. A palliative care rotation is definitely worth swapping into.


“With time, every epilogue extends into a sequel.”

NEJM Resident 360

January 5th, 2019

I Call BS on Work–Life Balance

Ellen Poulose Redger, MD

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

Physician wellbeing, burnout, and “work-life balance” are pretty common topics in training.  We start at intern orientation, discussing how to work 80 hours a week, eat, sleep, exercise, and still have some semblance of a social life.  It’s like we’ve forgotten the origins of our job title: “resident” or “house staff” — implying that, until recently (and even now, in places outside of North America), we, the physicians-in-training, lived at the hospital.  And that sometimes (often times), we still spend more time at the hospital or clinic than we do anywhere else in a week.  There are 168 hours in a week, and just under half of them are considered reasonable for us to work.  That’s double a “normal” full-time job (40 hours/week).

I’m definitely not saying that medical training, should be shorter or encompass fewer hours.  If anything, sometimes it feels like it should be longer (or maybe that’s just the slight fear of my first “attending” shifts coming up — because now it really is my call on things). We have huge responsibilities, and that responsibility requires intensive training.  In all honesty, another key component of medical training is the lesson that we are all life-long learners — that our education cannot and does not stop simply because we graduate, get an attending job, and go into practice.  There it is again — a word that, if we look at it, reveals the origins of medicine.  We practice.  We try things, we learn new things, we keep working at getting better.  This is not to say that the first patients I see on my own will be poorly taken care of, but just that (as with many professions) we all get better at our jobs over time.  We hone that sixth sense, trust our guts a little more, get better at pattern recognition, and know when to call other experts to help us and our patients.  We keep practicing, trying to make perfect.

That search for perfection is inherent to many physicians.  As a group, we are type A, driven, competitive people.  It is one of the things that allows us to give nearly a decade of our lives to school and training to do our jobs — prime years, usually in our 20s and 30s.  Those same years, though, are the ones when other people are starting careers, developing hobbies and interests, buying first homes, and starting a family.  When we do go looking for our first jobs (as residents, fellows, and first-time attendings), we are expected to be ambitious, well-rounded, compassionate, and well-developed people, not automatons.  So, during our medical training, we have to fit a life into the 88 hours per week when we are not at work.

This brings me back to the idea of balance.  I take issue with the phrase “work–life balance.”  When I picturebalance pan scale a balance, I picture something where the two sides offset each other, like old-fashioned scales.  With this picture in mind, then, work–life balance would mean that the two sides are equal.  In my 88 hours of “personal” time each week during residency, I drive to and from work (round trip totaling at least 1 hour each day), sleep (hopefully at least 7 hours each day), shower/get ready for the day (and, since I’m a girl, that realistically takes an hour each day), and cook/eat/do laundry/clean my apartment/see my husband.  That doesn’t really leave a lot of time for any sort of a life, hobbies, research, or anything else that would help me to be a thriving and well-rounded person.  Something always gives when people are busy (regardless of their field), and it is usually their personal lives. 

I don’t necessarily have a way to fix this: We need long and intensive medical training to be good at our jobs.  We need to find time to sleep and take care of ourselves so that we can first do no harm (to ourselves).  I just don’t think it is fair to say we are striving for balance, because we aren’t.  We are striving for survival, until the next step in our careers, when we might get more time for ourselves.  We are putting off relationships, families, houses, retirement funds, and many other things while we train.  Maybe one way to help with this is to develop robust programs at every institution to help trainees (and honestly, all physicians) accomplish some of these life tasks (e.g., laundry, food, cleaning services).  But I think one (free) thing that would to help with this is to just stop calling it “work–life balance” and admit that it will always be unequal and weighted toward work while we are in training, and perhaps for a large part of our careers.  One of my husband’s attendings once told him that you can have two out of three: family, fame, or fortune — but not all three.  Something will always give in medicine.  It’s just easier to accept that we’re giving up something if we don’t pretend we can have it all.

NEJM Resident 360

December 26th, 2018

Trapped – Chronic Pain and Opioids

Ashley McMullen, MD

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

“I feel like a caged animal” — My patient offered me this lens through which to view his life seeped in chronic pain. For him, pain dictated his entire sense of being — it was something that simply could not be distilled down to a single value on a 10-point scale. The cage represented the restriction of life and the boundaries within which he was allowed to experience, let alone enjoy, even the most mundane of activities. It also represented a loss of control. Long before our paths crossed, this patient had access to high doses of prescription medications that danced with the mu-receptors in his brain and dulled his senses. From the time he woke up in the morning, to the time he went to bed at night, these pills offered transient entry into a perceived life of freedom.

However, somewhere in the intervening years, the line between freedom and captivity became blurred. Questions of safety were raised as doctors struggled to define whether this patient was controlling his pain, or was being controlled by his pain medications. He was ultimately diagnosed as having an opioid use disorder. Thus began a long tapering plan that slowly drained this man of what little semblance of sovereignty he had in his life. He felt he was being backed further and further into this “cage,” whose walls were now personified as his doctors, who were locking him in and throwing out the key. This is the situation under which I first met this patient in clinic. —

When it comes to treating chronic, noncancer-related pain in the context of a burgeoning opioid epidemic, I feel weak and disempowered. It is my personal primary care Kryptonite. Although we have many great multi-modal treatment options, it can be incredibly challenging to impanel patients who, at one time or another, received chronic prescription opioids. Currently, no fancy blood test, imaging, or invasive procedure exists that can objectively measure the physical and emotional burden of pain. Patients therefore are beholden to the subjective disposition of doctors who must decide how to treat pain, and in whom. So, when disagreements arise with patients on this topic, as they often do, it can mean the difference between a good day in clinic and a hellacious one.

Today’s trainees are grappling with a crisis that is in large part attributable to yesterday’s standard of practice. It is one of the many toilsome aspects of general medicine that pushes trainees to choose specialty over primary care. In April of this year, I was fortunate to attend C.R.I.T., a conference on addiction medicine run by top leaders in this field from Boston University. The conference is designed for chief residents, fellows, and faculty mentors to gain immersive training in managing substance use disorders. The experience also involved learning best practices for supporting residents in taking care of these patients who, while challenging, incur a substantial amount of stigma from healthcare providers. 

One poignant take-away from this conference came from the keynote speaker, Michael Botticelli, a former director of the White House Office of National Drug Control Policy who also struggled with addiction. To paraphrase his comments, he stated that, as doctors, we no longer have the luxury of choosing whether or not to deal with pain and/or addiction. This epidemic affects all of us and, as such, we all have a responsibility to get informed and to treat patients as safely and empathically as possible.

In the short time we’ve known each other, my patient has already managed to run me through the gauntlet of emotions. He’ll offer me glimpses into the depth of his suffering then immediately blame everyone from distant relatives to Barack Obama. Although I have learned to set strict boundaries with patients on my tolerance for diminutive language, I recognize how opioid use disorders can destroy even the most beloved of personalities. It might just take a stronger effort on the part of physicians to see the human beings stuck behind the thick veil of this particular disease. My hope is that, with time and trust, my patient and I can work together to find a way out.

 

December 20th, 2018

Medicine Robbed Me of My 20s

Scott Hippe, MD

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

Medicine robbed me of my 20s. I’ve heard the line many times in my medical training. It often comes accompanied by a long sigh, a slow sip of coffee, and a glazed stare off into the distance. “Imagine what could’ve been,” the seasoned physician muses, “if I had my 20s to do over, without medicine.”

But now, I am mere months away from leaving my 20s behind. To be completely honest, I often feel similar to those physicians I heard earlier. I see my friends outside medicine doing exciting things and visiting exciting places. And then there is my brother, a teacher, who is off work for summers and every single family holiday. Sometimes — especially on 28-hour shifts — I wonder if medicine is really worth it. I wonder if the journey is leading me to my best self.

Lamenting the things I’ve missed

We have a maladaptive tendency as humans to focus on that which is not, rather than appreciating the good in what actually is; we define ourselves by what we miss, rather than by what we catch. In this vein, I started making a list of things I missed in my 20s. Then I got depressed. But here is what I had, to start:

  • Missed lunch today and many days; man, am I grumpy today
  • Missed going out last Friday
  • Missed my alarm and a call to deliver one of my pregnant patients
  • Missed calling my mum on her birthday
  • Yikes, missed zipping up my fly before ICU rounds
  • Missed pickup basketball on Saturday, and the Saturday before that
  • Missed registering for the CME conference all my friends attended
  • Missed being home for the holidays
  • Missed diagnoses, including DKA, stroke, and heart failure
  • Missed family weddings, reunions, and a tragedy
  • Missed the chance to travel abroad with friends

What misses mean for resident wellness

Focusing on misses like this has a negative effect, not just on big-picture life satisfaction, but also on day-to-day wellness. The bitterest pill to swallow in residency for me is not the long hours. The most soul-crushing piece is being drawn away from places you want to be and people who are dear.

There is dissonance here: I desire to be well in my life and work, but medical training is challenging and exceedingly time-consuming. The realities of residency take me away from the things that make me “well.”

Residencies are waking up to the idea of wellness. At my residency, we have been trying to increase dedicated administrative time to decrease charting outside of clinic. Our wellness committee puts on quarterly events to build community. We have a supportive faculty.

Having adequate time to sleep, exercise, and experience a loving community forms the perfect foundation. Yet without feeling good about the work, efforts to improve life outside of residency responsibilities ultimately fall short at achieving whole-person wellness. We just work too stinking much for this not to be the case.

Encountering a low point

sleep deprivation effects

Mikael Häggström, used with permission. [CC0], via Wikimedia Commons

Long hours and some uncertainty about my future after residency caught up to me recently. While transient, this bump in the road put me in an anxious and sleep-deprived condition. My work felt devoid of meaning. Fifteen-plus hour workdays are long ones if you feel empty.

Without prompting, the wife of one of my middle-aged male patients said “Dr. Hippe, you’re the first doctor my husband has been able to tolerate in 50 years.” That hint of positive connection made me start paying attention again. The next day, two infants I’d delivered in previous months came in for checkups. They were thriving, their families were happy, and I shared in their joy of new life. Unknowingly and in subtle ways, my patients helped me find my center at work again.

 

Finding wellness at work

An alumnus from my residency recently sent a message about wellness. She quoted an article published in JAMA, in which the author relates “I can think of no other dichotomy so damaging to a young physician or the patients he or she will treat, than to imagine that life begins only once a shift has ended” (JAMA 2018; 320:343). This former resident then added her own thoughts: “How can we re-frame and experience work as an enjoyable part of life rather than something entirely separate from who we are and how we live?”

What I appreciate most about the question is that there is no singular best answer. Personally, I often find wellness at work through connecting with my patients. Other times it has been support from my resident community, or the exhilaration of becoming competent at a new procedure. The answer to the question will be different for everybody, and can change along the way.

I am sure of one thing, though: the answer to what makes us well at work is worth pursuing, both individually and as groups of residents and physicians.

NEJM Resident 360

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

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