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Professional Courtesy

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Objective: Produce timely documentation and communication that is clear, concise, and organized, in a way that optimizes patient care and minimizes medical errors.

Communication is my greatest strength, but it is also my greatest weakness. In fact, communication is the very reason I became a doctor. I suffered tragedy in the early years of my life that left me with a great deal of existential dread and communication difficulty. I understood the reactions of the people around me but I did not understand my own non-reaction and why I chose to hid it by mirroring the behaviors of others. I sought to understand the world around me because it did not seem to understand me.

Fast forwarding to medical school I have learned more about behavior and emotions, I believed I had a better understanding of myself and how to help others. I would soon come to learn that my efforts while significant required a more nuanced approach. I was now entering a world where the margin of error is slimmer, and where clear and timely communication is the hallmark of a good professional. Professionalism is about showing those around you the proper respect and for this communication is key.

In my first year of medical school I began to encounter difficulties with focus and efficiency leading to medical knowledge failures requiring me to repeat my first year and professionalism failures that persisted throughout my clinical years. The primary difficulty was maintaining an accurate and consistent schedule to address important deadlines and tasks. After some very thorough soul-searching, medical visits, and neuropsychological testing, I discovered that what I was dealing with was consistent with ADHD. While surprising to me, it was also clear to me how this explained other difficulties, I have faced throughout my life. This was the first step for me in recreating myself and developing a process to overcome my deficiencies. However, despite having this knowledge I struggled to develop a regimen that worked for me.

Neuropsychological Test Summary

Late or missing assignments and inadequate focus while studying continued to plague my efforts. Gradually, I learned that prior to the start of a rotation sitting down with the syllabus and making a list of important dates and deadlines was an effective strategy for keeping track of task. I also noticed that I had a great deal of anxiety surrounding task completion and keeping track of a list was paramount to decreasing this anxiety. However, the regular structure of a planner did not work for me. I was too distracted, so doing my own research I invested in a bullet journal which many people with ADHD and trouble completing tasks have used successfully.

 

Bullet Journal

A year later, things had settled down and being on the right medications, as well as, daily practicing anxiety reducing activities would allow me to meet the goals of decreasing late assignments. I took on yoga and even started a tai chi class to reduce stress and maintain better focus. That’s when COVID turned our world upside down and the house of cards I had built began to crumble. The daily coming and going from clinic to home and other places kept me moving with a physical framework for structuring my daily activities. Without this, I was lost in the minutia of the many distractors I have at home leading to difficulties over the following year with the residency application cycle, step 2, rotation assignments, and personal relationships.

My most recent deficiency during my EM rotation allowed me to further reflect on how to develop myself into a better professional. Prior to understanding its inner workings, professionalism has been a sense of duty. This was how I pushed myself to achieve the standards necessary to advance and assert my sense of responsibility. However, my process was un-refined. Professionalism is a consistent process of procedures, actions, and behaviors that decrease risks, mistakes, provides efficiency, and mitigates contentious or superfluous social interaction. It is a process that enshrines the sense of duty for the professional and communicates to colleagues and the consumer that their time is important.

Working with my ADHD coach has helped me to be more specific at developing a plan that won’t break down the next time external pressures arise. This includes creating weekly and monthly schedules and goals, designating specific spaces in my home for specific tasks, and soon developing a system to keep track of all these interventions for maintenance. A great example of this has been my use of an organization module to map out my process. This as well as finding a good support system to help and keep me accountable. Continuing this process over the next 2-3 months before the start of residency will propel me forward to having a successful transition and allow me to meet the increasing demands of residency. My immediate next steps however are to complete the assignments for my previous rotation and talk to the EM coordinator to communicate a better understanding of why I had these deficiencies and that I am working to prevent future situations like this.

Learning and Teaching

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Objective: Identify one’s own strengths, weaknesses, and limits

A)seek and respond appropriately to performance feedback; b)maintain an appropriate balance of personal and professional commitments; c)seek help and advice when needed

I’ve reflected continuously back on the first two years of medical school. I am a Nigerian American male, from an immigrant family, who was once without a clue on how to navigate the complexities of academic medicine. It is astonishing to me how, my fellow classmates and I, have been able to begin to approximate the vast array of knowledge required to acquire a patient’s history, gather pertinent data, and synthesize a plan for treatment. My PWP ring has allowed me the space for perspective.

At my first rotation, Family Medicine at Healthy New Albany, I met the most thorough and helpful teacher I have had to date. This physician helped me to drill the skills necessary to better relate my basic science knowledge to clinical reasoning and decision making. The saying goes that if you teach a man to fish you have fed him for a lifetime. The first two years and even through the first two rotations, I had felt like I was being given many different rods to catch different fish without a constant emphasis on casting a proper line or preparing an acceptable meal.

Furthermore, during this rotation, I also learned the importance of humility in teaching. I gained an appreciation for my responsibility as a role model and potential guide. I remembered the arduous personal conflict experienced when studying for hours on end only to arrive in clinic with clinicians, masters of their field, flying through teaching points without taking sufficient time to check for understanding. See one, do one, teach one, but when you teach slow down and be patient.
I saw a patient with a first-year medical student and tried to teach him components of the physical exam. Similar to previous teachers, I took for granted the painstaking work required to memorize all of these components. I, mistakenly, did not first ask or ascertain what level of knowledge he had yet acquired. A first-year medical student, having barely just learned a pulmonary exam, needs a more measured approach.

Finally, it is encouraging to feel the progress I have made with my presentations. Effective communication requires intentionality that is both clear and organized. But one of the most important aspects is to be confident in what you are saying. On my heme/onc rotation fluid and pain management were hammered into me. The repetition allowed me to focus more on the structure of my presentations and I now can orate without using wandering language or being indecisive about my decisions. By the end of the rotation my attending lauded my progress and commended me for taking the initiative.

A safe place to learn and practice, unfortunately I’ve seen, can be hard to come by in our current curriculum. It’s especially difficult when you see other learners being harshly scorned for their mistakes. Transparency and support are important alternatives. I was able to have a good conversation with a resident about effectively addressing the needs of learners, which shed light on the importance of healthy interpersonal dynamics on teaching. I’ve learned many important points for being a better medical student, resident, and I have become a more conscious instructor.

In the future, I will continue to seek opportunities to better myself and become a better instructor. I will hold myself accountable by creating 2-3 new goals per new rotation to achieve during residency and by asking instructors and students for feedback weekly.

Attention to Compassion

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Objective: Understand the role of disease prevention and health promotion in relation to individual patients and/or patient populations and utilize these principles in clinical encounters.

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

The month I spent on my family medicine rotation in New Albany was much unlike the first two years of my longitudinal practice at care point east. I had a stronger medical knowledge foundation which helped me to understand the needs of my patients better. However, I also realized that I was able to gain a variety of different perspectives on the approach to patient care. This included inter-practitioner differences to longitudinal care and maximizing the use of individualized adjunctive services.

Each practitioner had a different approach but how they used their time with patients was very interesting. I worked with a sports medicine doctor who was very efficient and had a very formulaic way of addressing patient needs without diving too deep into extraneous details of their lives or mental health issues. This seemed robotic, at the time, but I soon realized that his patients appreciated his professionalism and directness. On the opposite end of the spectrum, I worked with a practitioner who would always go above and beyond to address every need that the patient had, including social issues, marital problems, mental health, and most surprisingly very thorough patient education. These patients were also appreciative but seemed to have a better understanding of their health conditions and how to care for themselves. While, far more time was spent, often exceeding the allotted appointment time, much less time was spent answering questions from patients through my chart. The more efficient practitioner spent significantly more time addressing patient questions in my chart. This contrast, for me, highlighted the importance of being thorough and prudently ensuring communication of what was discussed with the patient was communicated. My instructors commended my development in this area.

PWP Instructor Feedback

PWP Instructor Feedback

Patient education was further addressed with other services within the clinic. One such service was individualized diabetes education. I was fortunate enough to spend time with a pharmacist who took me through all the patient education and care plans given to diabetic patients. The service was very thorough and was much like health coaching but with far more attention to detail. One exciting aspect was the introduction of wireless glucose monitors that could be accessed in the office to see how often patients are checking their glucose levels and trending their data to make adjustments without necessarily having to come in for an appointment.

I am blessed to have had the opportunity to see many aspects of longitudinal patient care and the differences that taking the appropriate time for patient education can make. In turn, collecting the appropriate resources to educate and individualize management will be important in my practice.

The Power of Advocacy

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Objective: Understanding the institutions and individuals that participate in healthcare delivery and the role of the physician in the health care system.

One of my motivations for pursuing medicine is the memory of my uncle being diagnosed with schizophrenia when I was 12 years old. It is a very difficult diagnosis as it completely shifts the nature of the person you once knew. It also requires an abundance of understanding and patience from friends and family.

During my first year I had the opportunity to sit on a patient panel where a mother described the harrowing account of her experience with her son’s schizophrenia diagnosis. She talked of the difficult treatment process of medications which provided only minimal improvement. After years of failed treatments, she finally stumbled upon a doctor who prescribed clozapine, and everything changed. He went on to be a fully functional member of society and she now shares her story. I remembered a similar situation with my uncle and considered how my life and his would’ve been different had we known about this potentially life altering drug.

That summer I was fortunate to work on an advocacy project for increasing clozapine use for treatment resistant schizophrenia. To achieve this goal our approach was to identify the mediators with the greatest potential to effect change. Broadly we targeted nurse practitioners, social workers, pharmacists, physicians, patients, and their families. I worked to create a poster to detail the current practice of clozapine administration and our action plan to address increasing it’s use.

This effort was in collaboration with NAMI Ohio, Mental Health for Ohio, as well as the very same family members at the patient panel. I gained a greater understanding of how physicians can create healthier environment for their patients by creating coalitions with local organizations to influence the practice of medicine in various systems of health.

Through this experience I also gained a better appreciation for the interfaces of the medical system interacting with a patient and interacting care. I had quite a few patients, during my consult liaison rotation, who would be transitioning care between nursing homes and the hospital who I realized were not being appropriately managed at the nursing home. Case in point was a patient who was being admitted for delirium. “She’s being aggressive and agitating the other residents. We can’t handle her.” I was told this over the phone when speaking to the nurse at the nursing home because we were perplexed by the indication for hospitalization. Looking at her medication list, she was being heavily medicated with benzodiazepines, antipsychotics, and anticholinergics. My previous experiences had taught me to gather information from a variety of sources to understand what the issues were.

I had extensive conversations with multiple nurses at the home and the patients family members. Everything, while difficult to handle, was consistent with her normal behavior as described by her family. The issue was that the nurses at the nursing home could not put up with how her behavior affected the other residents in the nursing home. While this was an understandable issue, this was not a good reason to send a patient to the hospital. However, the nursing home was refusing to take back this patient. Further chart review, revealed prior hospitalizations for similar concerns. Knowing that I have the some power to change something, I continued to advocate for this patient. In conjunction with our social worker,  we were able to find a nursing home that would accept this patient. We also decreased the amount of anticholinergics the patient was on and as expected, along with a more accepting environment, the patient was also less agitated.

Consult Liaison CPA

The power that a physician holds to advocate for a patient and change the course of their treatment for the better, continues to be impressed on me. This story is only one example of what I have learned is a common occurrence. I continue to challenge myself to learn all the ways the different areas of healthcare interface and the interventions I can take to better care for my patients. I learned something from the social worker who keeps track of the vast array of resources she finds in a folder. In the future, I will keep myself accountable to this effort by identifying at least 1 patient per week who could benefit from better resources management and documenting a the resources that I can more easily use to improve their overall experience.

Steering The Patient Interview

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Objective: Approach the care of patients as a cooperative endeavor, integrating patients’ concerns and ensuring their health needs are addressed.

The interview, more times than not, provides the most useful information for clinical decisions. The patient entrusts the practitioner with intimate details of their life while also indulging the pertinent history related to their chief complaint. This exchange allows for the practitioner to integrate the subtle life modifiers with the objective clinical history therefore creating a delicate rapport for holistically addressing the patients’ needs. However, some details may be superfluous and rather than shed light, may create confusion. In psychiatry, this can be particularly difficult when the linear reasoning of a patients’ psyche is in question. During my mini-I, I challenged myself to learn how to strike a balance between the importance building good rapport and obtaining pertinent information with acutely manic patients.

“How are you doing this morning?” I ask our new patient who our team suspects may be manic, along with some narcissistic personality traits. “Well, I’d be better if I was able to sleep without my roommate making all that noise… and I tried to get my iPad but the nurses aren’t listening to the order you gave them… there is no intellectual stimulation in this place… I was a respected researcher… I was on the board of…. I don’t think you all know what’s wrong… I feel like I’m TRAPPED IN A CAGE!” A flurry of comments and repeated statements is what I would receive from the simplest of questions. This was my first interview with a manic patient.  I was overwhelmed—not knowing where and how to steer the conversation in a productive direction without disrespecting the patient or injuring his inflated ego. So, to effectively interview this patient, I chose to make this a SMART goal for this rotation.

SMART Goal Reflection

I scoured the internet for interviewing methods for manic patients to no avail. Thinking more broadly, I realized that interrupting patients has been a consistent issue for me throughout some of my medical training. I truly care about the concerns of my patients and too often allow too much time to air out their grievances. So instead, I was able to find a simple pneumonic used to address and redirect patients in any setting in a professional and compassionate manner—The 7 Cs.

Calm down, Connect with the patient, show Concern, identify a Cause, Comfort the patient, agree to a Contract, and maintain Continuity.

On further observation, I also noticed this method, while not as discrete, being employed by my attending and my resident by forcefully interjecting as a means to connect and redirect our patient. Keeping this strategy and the 7 Cs in mind, I was able to cut down our normally long and drawn out interviews steadily by 15-30 minutes. I was ecstatic. While I was not able to completely exactly achieve my SMART goal, I was able to make significant improvement.

Mini-I Feedback

Throughout the remainder of the year, I continued to employ this strategy on other talkative, combative, or anxious patients. By learning the 7 Cs I now have a more discrete method to refer to when facing the challenge of being efficient and effective during residency. In addition, this will serve as an objective point to pass down to future medical students or residents who struggle with this concept in a variety of clinical settings.

Did I ask everything?

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Objective: Demonstrate a broad working knowledge of the fundamental science, principles, and processes basic to the practice of medicine and apply this knowledge in a judicious and consistent manner to prevent common health problems and achieve effective and safe patient care.

Surgery was my first rotation during my third year and was filled with many first introductions to the practice of clinical medicine. I chose to spend my time at Mt. Carmel for OB/GYN portion. Of these many introductions, the nuance of women’s health was impressed on me. One case, of particular interest to me, began when a woman came with complaints of irregular menstrual periods. She primarily was anxious about her and her husband’s desire to have a child which was being complicated by the newfound issues with menstruation. I considered the possibilities, ranging from recent steroid use to thyroid or growth hormone deficiencies. Nothing clearly fit the picture. The only pertinent history I was able to gather was a mild increase in facial hair, new acne, and a history of diabetes. However, new to the game and hoping to impress my resident, I confidently reported back to the resident and suggested Cushing’s syndrome. “Did you ask if her menstrual cycle has ever been normal?” I stared blankly into space now realizing what I mistook for a secondary amenorrhea is actually metrorrhagia—this woman, on further investigation, had polycystic ovarian syndrome.
Having missed this diagnosis, it stuck with me. So, I decided to use this experience to further supplement my understanding of menstrual disorders by presenting it during our weekly small group meeting. This case and the presentation not only helped me to learn about a common disorder in women but also highlighted how nuanced management and clinical decisions can become for even the most common conditions. One of the primary treatments for PCOS is oral contraceptives pills, indefinitely. However, as previously stated, this patient was hoping to bear children in the near future. With that in mind I learned about the use of clomiphene and was able to educate my small group on the keeping the pregnancy concerns of patients in mind in when making clinical decisions for patients of child-bearing age.

Interestingly, I also learned about the increased incidence of mental health concerns in patients with PCOS, due to the increase of circulating steroids and other unknown factors. Since my desired specialty is psychiatry, this understanding drove my interest in expanding the scope of my medical knowledge so I can be cognizant of easily ignored psychiatric symptoms of physical ailments. The intersection of different specialties within certain disease processes can sometimes be very subtle. The patient I presented on had described a great deal of anxiety related to her menstrual issues and her desire to become pregnant. While our clinical team, rightly, addressed her most immediate and apparent concerns, upon further investigation we may have discovered that she was also suffering from a mental health issue. Such a thorough investigation, in theory may have allowed us to refer address these concerns during the visit or have her referred for the appropriate psychiatric care, therefore saving her the cost of future appointments and the interim continued suffering.

Future endeavors would see me continuing to expand the scope of my knowledge to capture this nuance and being more prudent with patients with conditions associated with common psychiatric conditions. One example of this would be my choice to do a rotation in developmental behavioral pediatrics. As an aspiring child and adolescent psychiatrist, I may need to understand the nuances of early childhood development and the management of developmental disorders to better serve my future patients.