Thank You Letters

Medicine puts physicians in a unique position of having knowledge that greatly impacts their patients lives, while the patient may have a more limited view or understanding. While the medical provider will often believe that he or she has the best treatment and plans for the patient, I believe it is always important to keep the patient’s perspective of their illness or condition in mind. CEO 1.1 states “Approach the care of patients as a cooperative endeavor; integrating patients’ concerns and ensuring health care needs are addressed.”, and I believe that this is one of the most important facets of being a doctor. While we may be working on treating a wound infection, the patient may be more concerned about his pain levels. While the medical team might be focusing on treating sepsis and balancing a patient’s electrolytes, they may be more concerned about getting a good night’s rest and not having blood drawn and vitals taken every 4-6 hours.

Starting third year rotations, I was often much more interested in thinking through the medical side of my patient’s ailments. After all, I wanted to apply all the knowledge I had spent the last year or so consolidating. However, quite early on it became clear to me how much a patient’s perspective of illness actually matters. Being empathetic and making an effort at addressing a patient’s concerns will in turn make them more trusting in the treatments they are being offered, and will also lead them to trust their medical team more as well. Ever since I matriculated into OSUCOM, my mother has always told me to be “a doctor who cares and listens to the patient” and not “one of the doctors  who assumes he knows whats wrong without needing to even talk to the patient”.

One time where I was able to apply this advice was during my child neurology rotation. We had one girl on the floor who had been getting treated for new onset epilepsy, when one day she stopped taking her medications. When she would be approached to take her anti-epileptics, she would state that if she were medicated, she would try and kill herself. It was a bizarre turn of events and we wondered what could have possibly caused this child to start refusing her meds all of a sudden. I decided to spend some time talking with the child in the afternoons after rounds to try and get to the bottom of her medication refusal. In the end, it turned out that she was refusing meds because she thought that it would force her mother to come to visit her in the hospital. We worked with social work to attempt to arrange a meeting between the girl and her mother, and were also able to convince her to start taking her meds. I found it important to approach such patients in an empathetic and compassionate manner, and when we were able to glean her perspective, we were able to solve the roadblocks to her care and have her appropriately treated. By the end of her hospitalization, she even wrote our team a thank you note:

Thank you letter from patient on Pediatric Neurology at NCH (patient name blurred)

We also have a responsibility to make sure we give each patient the best possible care they can receive. In OBGYN clinic at Mt Carmel West, we had  constant struggles with providing the best possible patient care to the population, whether the struggles were due to language barriers, poor follow up, or due to lack of medical knowledge by the patients. Due to the high amount of Somali and Spanish speaking patients, we often found that it was often difficult to get interpreters with the high patient loads who required them. The situation can easily lead to shoddy care by attempting to communicate with the patient in broken english, so I took it upon myself to make sure I waited as long as needed to ensure every patient I saw was with a qualified interpreter. I would offer to wait on the phone line for the interpreter in patient rooms while the residents would see english speaking patients to keep the work flow efficient:

Did a good job improving presentations after receiving feedback. Willing to help in clinic. In particular, willing to wait a long time for an interpreter to interview a patient in clinic. -OB/GYN evaluation

One specific goal I have for myself for my intern year is to make sure I spend time with my patients to ensure I am taking care of their concerns. I hope to always maintain an empathetic manner with any and all patients I see in the future, and would like to see my bedside manner improve over the coming years as well. I know if I was a patient, I would prefer to have a good physician who spent time addressing my concerns over a great physician who brushed my concerns off, and ideally I will be a great physician who takes his patient’s concerns and perspectives into account throughout my career.

CEO 1.1 Approach the care of patients as a cooperative endeavor; integrating patients’ concerns and ensuring health care needs are addressed. 

Feedback and Championships

Prior to medical school, I find that I never really had a need to consistently ask for feedback to make sure I was progressing appropriately in my education. Pre-med education is sort of a free-for-all where all that matters is doing well enough of tests to maintain a high GPA. In medical school there is a very different dynamic when it comes to progressing in one’s education. Since so much of our career has to do with properly conveying information to both our colleagues as well as patients, I found it important to constantly get feedback on my weaknesses to turn them into strengths. Another aspect of medical school that differed from undergrad was maintaining a good school-life balance. The nature of undergrad studies always allowed me to have a school-life balance that was skewed towards the life side. I did find that maintaining a proper work-life balance was important to making sure I did well in med school as well.

An interesting aspect of medical education is that often ones weaknesses are not touched upon unless active feedback is sought. I noticed that in my first ring of 3rd year, many residents and attendings would not really bring up any faults with me, but I felt that some of my evaluations were not at the level I expected. No one ever pulled me aside and told me to work on things. When I noticed this, I brought it up during one of the mid ring feedback sessions, and was told to actively ask for feedback and incorporate it into my day to day work on rotations. When I started asking for feedback more often, I noticed that i was able to fix weaknesses, whether my differentials were not broad enough, or my presentations too verbose. I also noticed that my evaluations were much improved as well, and that asking for feedback was mentioned in several of my evaluations as well:

He was always well-prepared and actively engaged in all aspects of patient care. Farhan followed his patients closely, actively sought feedback, and quickly incorporated suggestions into his work. -Hospital Pediatrics Rotation

His notes were accurate and detailed enough without being verbose. He had a strong knowledge base. He actively sought feedback. He would stay late and always was enthusiastic and a hard worker. -Oncology Rotation

Farhan was a great medical student on a pretty tough and busy service. Although quiet, he has great medical knowledge, was very receptive to feedback, instruction and teaching. he was very interested in procedures which was great, he stayed late to see several of them. he even helped out for a code on one of our patients! – Oncology Senior Resident

While my work life balance during M1 and M2 were well balanced, allowing me sufficient time to enjoy my hobbies, play sports, while still getting through the daily lecture grind, I did have some moments throughout where this was much more difficult. A particular time that stands out was during step 1 studying. Due to the sheer volume of material we had to cover for the exam, I found myself more stressed than I usually allow myself to get. I got to the point where my only social contact was during breakfast and dinner with my family, spending the rest of the day alone studying. Of course, not taking as many breaks as I should eventually led me to getting burned out and not being able to study as efficiently as I normally would have. I feel as though my scores probably suffered due to this as well.

To avoid any future episodes of similar burnout, during my third and fourth year, I made sure I gave myself mandatory study breaks when studying for shelfs, I made sure to attend more sporting events, and to hang out with friends no matter how rough schedules became. I even jumped on a chance to go the Game 3 of the NBA Finals in Cleveland during my 2 weeks of dedicated Step 2 study time. I’m sure that schedules during intern year and residency are going to be tough throughout, but I hope that I’ll be able to apply skills I’ve learned in med school to avoid burnout and make sure I keep a healthy work life balance.

 

CEO 3.4 Identify one’s own strengths, weaknesses, and limits; a) seek performance feedback, b) maintain an appropriate balance of personal and professional commitments, and c) seek help and advice when needed.

Dealing with Insurance Companies

Dealing with the social issues, insurance companies, and other none medical parts of healthcare were aspects that I never expected to be a large part of my future as a physician. During the first couple of years of medical school, we focus on learning the basic science behind all the diseases we will encounter over the course of our careers. During third and fourth year clerkships, we start to apply knowledge that we’ve learned towards diagnosis, treatment, and safe discharge. The part that is rarely mentioned in lectures however, is what goes into ensuring a safe discharge for some patients, whether we’re dealing with social issues, attempting to discharge a homeless patient, or perhaps dealing with an insurance company that is refusing to pay for medical equipment that is required for the patient to make a complete recovery.

One place where it became evident to me how much “non-medical” issues affect patient care and outcomes was during my first third year inpatient rotation at Nationwide Children’s. Hospital. We constantly had patients who would otherwise be cleared medically to be sent home, but couldn’t be discharged due to an unsafe home environment. During the rotation, we had a failure to thrive child admitted due to failure to gain weight over a few outpatient pediatric visits. Further work up eventually revealed a subdural hematoma, which heightened our suspicions for potential child abuse, at which point we had to get social work and child protective services involved.

Another patient I took care of at NCH was a 12 year old with a neural tube defect causing paraplegia. He was initially admitted for urosepsis, and after a prolonged hospital stay, had worsened his pre-existing decubitus ulcers which developed osteomyelitis. After a few weeks of antibiotics, he was cleared medically to go home, at which point his main barrier to safe discharge was a special air bed costing about $3000 that was needed for his osteomyelitis and decubitus ulcers. After initially being denied the bed, the patient’s hospital stay proceeded to get longer and longer. By the end of his hospital stay he had been waiting for more than 3 weeks just for the bed, with no medical reason for being in the hospital. While I was on the team, I offered to write a letter to the insurance company explaining the need for the bed (draft below), and I acted as a liaison between the patient and the insurance company in regards to getting the bed paid for. I ended up leaving the service before the matter was resolved, but I learned a great deal from the experience of dealing with the insurance company.

“Farhan consistently read about his patients’ disease processes and quickly applied new knowledge to the care of his patients. He was always well-prepared and actively engaged in all aspects of patient care. Farhan followed his patients closely, actively sought feedback, and quickly incorporated suggestions into his work. He consistently offered house staff assistance with daily tasks and went above and beyond to write a letter to an insurance company advocating for a medical bed for one of his patients. He was compassionate and caring, and developed excellent rapport with patients, families, staff, and colleagues.” –Pediatrics Evaluation

So far during my M4 year, I’ve made sure to keep an eye out for similar types of issues that may arise during a patient’s stay. While I have not had the opportunity to be directly involved in situations as I was at NCH, I have always made sure to talk with social work when planning patient’s discharges on my mini-I, for example. As a prospective radiologist, I may not have to deal with safe discharges like my peers in IM and Surgery will, but I will still have to have dealings with insurance companies, billing departments, not to mention the fact that I will be doing a transition year where I hope I will be able to put what I have learned over my clerkships into practice.

CEO 5.2: Appropriately use system resources to assist patients in accessing health care that is safe, effective, patient-centered, timely, efficient and equitable.

Leaving my comfort zone

Throughout my life I have been introverted and suffered from some mild social anxiety. I recall dreading having to ask professors for recommendation letters, pushing it off as long as possible so I wouldn’t have to talk with them in person. I would worry about mis-speaking or saying something incorrect in an embarrassing fashion and usually found it easier to just attempt to avoid activities that would take me out of my comfort zone. While I was fortunate that my anxiety didn’t stop me from matriculating into medical school, I knew that one of the more difficult adjustments I would have to make was being able to talk to people I had never met before as an “expert”. Interpersonal Communications CEO 4.3 states, “Use effective listening, observational and communication techniques in all professional interactions.” I am quite proud to say that this is one particular aspect I feel as though I improved upon the most throughout my medical school education.

Starting LP in first year was one of my most memorable and anxiety provoking experiences in med school. I remember going to my first day in clinic, knowing on the very basics of asking HPI questions, not really knowing how to do a physical exam properly, and not really knowing much medicine at all to tailor the questions I would ask the patient. I observed the first patient encounter with my preceptor, and once I had the opportunity to observe, I was prompted to see the next patient on my own. I recall standing in front of the patient’s door psyching myself up, running through the questions I would ask the patient- “what brings you in today? how long has that been happening? does anything you’ve tried made it better or worse? have you had these symptoms before?”. After running through all the scenarios in my head, I entered the patient room. I nervously went through my checklist of questions, barely able t listen to the answers over my own anxiety. As the year went on and after seeing several patients, the questions flowed much better. As I learned medicine and how to do proper physical exams, I found myself asking better and more relevant follow up questions as I narrowed my differentials. I noticed that I didn’t have to spend a moment in front of the patient’s room just thinking about all the questions I would ask, as the questions had started to become second nature to me. Of course, I would still have some awkward encounters with patients, especially if the patient was dealing with an ailment that was uncomfortable to talk about. My skills at talking about issues such as sexual health or aspects of a patient’s social or psychiatric issues would take significantly more time to develop, and did so mostly during my third year clerkships.

 

During third year, we had our first inpatient experiences, a completely different beast from the outpatient half day clinics I had been doing for the past 2 years. I again had similar anxious moments when I had to see patients for pre-rounding. I would constantly run every scenario through my head- ‘ what if the patient asks me about her condition and i don’t have any answers, what if something goes wrong while I’m in the patient room, what questions is my attending going to ask on rounds’. My strategy to counteract my feelings of self doubt and nervousness was to take meticulous pre rounding notes, going as far as the rewrite the patient’s entire hospital course for my pre rounding notes on the off chance I would be asked about it. Luckily, as time went on I found myself becoming more efficient and confident in my skills in both talking to patients and talking to other medical professionals. As I learned what information was important I began to make my pre rounding more efficient. I was especially proud that my bedside manner had improved throughout the course of my inpatient months and that was one aspect particularly mentioned in one of my neurology evaluations:

“Farhan’s presentations were concise and he asked thoughtful questions. He was able to formulate rational differential diagnoses and thoughtful management plans. He always had a reassuring bedside manner with his patients. He displayed clear evidence of outside reading.” -IM ring narrative

He has a very nice, calm, and reassuring bedside manner and patients like his approach. -Neurology

While there are still occasions where I find I struggle with some mild social anxiety, I’ve found that these moments have become few and far between. As I carry a larger patient load on my sub internship and during intern year, I hope to continue to improve on communication skills I have gained throughout med school. Interpersonal communication is the trait I feel as though I have most improved on during my 4 years of medical school.

 

Interpersonal Communication CEO 4.3: Use effective listening, observational and communication techniques in all professional interactions.