How do I contribute to a more just and equitable medical system?

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

During my time in medical school, the US has been at a watershed moment politically, and that has led me to seek opportunities to get involved and seek to promote positive change in our politics. In the summer of 2017, just when I started medical school, “repeal and replace” was the talk of the town. The newly elected Congress and President were putting the Affordable Care Act on the chopping block. As the process went on, it became apparent that Congress had a lot of appetite for “repeal”, but less ideas for “replace”, and I worried that we would return to the bad old days of high risk pools and no protection for preexisting conditions, and that millions of people would lose their health insurance. I wrote letters to my congress people and called them, but I felt a mounting sense of helplessness as the process seemed to barrel to an inevitable conclusion. Ultimately my worst fears did not come to pass and the law was saved, for the moment at least, in part thanks to a deluge of activism and opposition from across the country. This early experience pushed me to think about the role of physicians in the healthcare system.

As physicians, we are large stakeholders in the health system and perhaps its most visible face, but we do not possess all or even most of the power within it. This power rests in the world of politics, which exists to answer the question of “who gets what?” in a world of limited resources. The health outcomes of our patients often stem not from the quality of patient care that we rightfully spend most of our time thinking about, but from systemic factors such as insurance availability and affordability, food systems that promotes unhealthy behaviors, the safety of consumer goods and the built environment, and numerous other factors. As advocates for our patients and the face of the healthcare system despite our limited power in it, it is therefore our responsibility to push for positive political change to secure broadly equitable and improved health and safety outcomes throughout our society. I slowly realized the importance of the political side of medicine over the course of medical school, and how it threads in to every portion of our profession. There was no discreet moment, just a long series of patients and situations that were impossible to resolve in the way I would want by the time they arrived in front of me. One that sticks out to me was a patient at the VA who had lung cancer, likely as a result of being stationed at Camp Lejune, a Marine base in North Carolina at the center of a massive waterborne carcinogen scandal. I wrote about this scandal in a college class years ago using a piece in Newsweek and other sources.

The cover of the Newsweek article I wrote about in college

And there in front of me was a victim of this environmental irresponsibility of the government and military. After reading so much about systemic failures leading to death and disability, here was someone in front of me living it in a way that was so much clearer than the typical shadowy relationships between exposures and chronic disease. Since then, I’ve seen others; a homeless person with frostbite from the cold Columbus winter, a chemical worker with bladder cancer, uncountable numbers with metabolic syndrome or coronary disease; but this patient sticks with me as the first time in medical school that a whole towering unseen chain of causality and callousness coalesced into its end product, a middle-aged guy with kids and a beloved German Shepard dying before his time.

White Coats 4 Black Lives event I attended in 2020

The frustration I felt from that visit has grown the last few years, driving me to volunteer my time and money for various for pro-health care access candidates in the 2018 and 2020 elections, and to participate in various events surrounding the 2020 Black Lives Matter protests. I want to continue to make these causes part of my career and advocacy. I will continue to work on these causes during residency and as an attending, and I will always look for ways to use my talents to do what I can.

 

Goals:

  • Become a regularly contributing member (attend >75% of meetings/events) of a racial or economic justice focused group during residency.

How do I improve my study skills?

2.1: 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.

 

In second year, I struggled academically which I think was the result of a number of factors. I really struggled with severe anxiety during that time, and it was challenging to battle a mental illness and succeed in medical school. I think it also reflected a weakness in my studying skills, which I were used to my previous experience with engineering school, which is vastly different in content and style than medical school. This reflected in some of my test scores in second year, which were not as good as I was hoping for.

I was concerned about this trend affecting Host Defense, Step studying and future work in medical school, so I pushed myself to improve both my coping mechanisms and my studying habits. I moved from mostly passive study by repeatedly reading notes and lectures during first year and the first part of second year, to a more active study. I focused on finding question banks and anki decks, and tried to stick to a schedule for the anki decks. I tried to answer questions I would find myself asking from reading answer explanations in First Aid, and try and connect the material together and take notes in the First Aid margins with additional info I learned from UWorld. I implemented this first during my Step 1 studying time in the spring of my second year, and it wound up paying off as I got a solid Step score of 233.

I continued to use this strategy during third year for the shelf exams, supplementing UWorld question banks with Anki decks and targeted readings for concepts that I would encounter during rotations. I did well on each of these shelf exams so I used a similar strategy for fourth year rotations, minus the UWorld question bank, as it was too expensive. For Step 2 CK, I adapted a compressed version of my Step 1 study, redoing the UWorld question bank I had worked on during third year, utilizing Anki as well as taking notes in a Step 2 First Aid book. This strategy was successful, and I wound up scoring a 250 on Step 2 CK.

Overall, I am happy with my modified study routine, and I wish that I had implemented it sooner. In the future, I will have Step 3, boards, and possibly other academic obstacles to surmount, so I plan to use what I did here as a template for these. As for day to day learning during residency, I aim to read something every night to reinforce what I learn during the day, in keeping with the spirit of the successful changes I made during second year.

 

Goals:

  • During residency, read a journal article/review/abstract or uptodate article/summary related to something I saw or learned about that day.

How can I be a better teacher?

Learning Objective 4.6. Effectively prepare and deliver educational materials to individuals and groups.

During high school and college I spent time in various teaching roles, such as camp counsellor, TA, and tutor, which led me to my interest in teaching, which I have developed throughout medical school. Medical teaching happens at all levels of skill and knowledge, from the universal need to adequately explain to patients and laypeople what is happening and what the next steps should be, to experienced attendings learning a new technique in their field. I knew at the beginning of medical school that this would be important to my career, and I worked to collect many different types of teaching experiences through the years. Throughout medical school, I have participated in ultrasound teaching, starting with proctoring during my first few years and culminating with my leadership role in the Anesthesia Ultrasound Community of Practice (AUSCOP). This involved working with small groups of students through Ultrasound Interest Group (USIG), which in a normal year would focus on teaching various ultrasound scans and procedures, such as echocardiography or vascular access. This allowed me to build on my previous experiences with one on one and small group tutoring to designing and implementing a full curriculum, and having to adapt rapidly to the pandemic. Our group experimented with video tutorials and online events during COVID, because holding in person ultrasound scan sessions during a pandemic was not safe. Educational materials will always change with the times, and it is important to stay up with them. This was my first experience producing video and running education events over Zoom, both of which are skills that I see being useful someday, such as producing content for conferences or running teaching sessions via teleconferencing. We decided to pivot to making and polishing high quality “how to” guides for setting up future workshops, and to continue our journal club and didactic sessions. We had a successful year, and are currently looking to hand off the group to younger members. Ultrasound was a throughline in my medical school career, and it taught me many things at different points. At first, I learned more about one on one teaching and teaching in small groups in my first and second year. By the time I was a fourth year and leading an organization through a full year, I was running meetings, developing curricula, and stoking a sense of common purpose and drive. Ultimately, ultrasound served as the foundation for my other teaching ventures at OSU, such as my research experience.

During my first and second year, I was involved with research through the OSU department of anesthesia, where I contributed to some literature reviews, and did a research project of my own, the poster of which is below. It is a challenging task to aggregate the key data and findings from multiple papers to synthesize a coherent view of the current state of the literature, so in struggling with the material I learned how to better communicate ideas through writing and presentation, which proved to be useful during my time on the wards in third and fourth year.

On my clerkships, I got many opportunities to present about specific topics relevant to the rotation I was on. This was a good first experience at teaching my peers about the current approaches to diagnosis and treatment for a particular topic, a skill which will be useful for teaching colleagues throughout my career. My trajectory for making these presentations followed a rewarding progression, as I started out mostly taking info from my first and second year notes, but over time I moved to using review articles and peer reviewed medical literature to compile my presentations after discovering that my information about hypertension guidelines had already been out of date. I had an attending during my acute pain rotation halfway through my fourth year comment that I had done a good job with assembling up to date info and explaining it well to my colleagues, mentioning that I had discussed some tricky points that she had recently educated some colleagues about in a way that was understandable for medical students. It was good to have this encouraging feedback right before I went into the most teaching focused time I wound up having in medical school.

My time in the Teaching in Medicine elective served as a good capstone for all these experiences. This was a formal course in teaching that explained the latest theory and practice of medical education and how to apply them. A paper which I read during this elective details the “one minute preceptorship” teaching framework, which systematized the best teaching I received on the wards. The steps of this framework are, in order, 1: asking students to commit to and explain a thought process used in their presentation, 2: reinforce what was done well and give guidance about what was incorrect, and 3: use the discussion as a teaching moment for a more general principal. This was a useful framework to encounter before intern year, so I am going to incorporate it into my interactions with medical students as a resident and beyond. In another part of the elective, I got the opportunity to develop a curriculum for future iterations of AUSCOP, a sample of which is below. This was an excellent final project to cap off my throughline of ultrasound, and I was happy to leave a lasting contribution to my group’s future.

 

Overall, my focus on teaching made me a more patient clinician who is better able to explain complex concepts to patients and students. I will use what I learned often in the future, and I hope that I get the chance to use some of the finer points of curriculum development someday in my career.

Goals: focus on adult learners, innovative use of technology, develop one minute preceptorship teaching skill.

  • Teaching medical students
    • Practice one minute preceptorship teaching with each medical student I am rotating with at least two times while they are on service with me.

How do I best incorporate feedback into my practice?

3.4: 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, and c) seek help and advice when needed.

During the first part of my third year, I was dealing with anxiety that I had struggled with starting in second year. This affected some of my first rotations negatively, as it started to manifest as imposter syndrome. It was scary to walk into rooms and essentially pretend to be a doctor. I knew it was necessary practice, but it was hard to push through feelings of inadequacy. I would freeze up, and it was like I could not access all the knowledge that I had worked so hard to build up over first and second year. This clearly translated into my evaluations at the time.

At the time, I considered it to be more of an academic failing, which I can see in my portfolio writing from that time.

I think this was at least partially true, as I was still revising my study habits at the time, after a rough second year inspired me to change them. That information would probably be easier to recall if I had felt more comfortable with it in the first place. But I have reflected a lot about this time in the years since then, and I think that my biggest problem was that imposter syndrome. I struggled with it in following rotations, although never quite as badly as I did during my family medicine rotation that summer, which I had to remediate. During the mid-rotation feedback session for that rotation, one of my preceptors told me something that has stuck with me: “The buck stops with me right now, but pretty soon its going to stop with you. Its ok to be worried about not doing the right thing, the important thing is using all your resources to figure it out.”

I wrote that I went home that weekend and studied hard and did a bunch of things to try and put me on a better footing for the rest of the rotation, but what was more important in the long term is how that moment changed how I approached rotations and medicine in general. I wanted to appear like I knew everything I expected an attending to want me to know at all times, and whenever there I did not know what to do next I would freeze up. This interacted with the stutter I have dealt with my entire life, so I would then stammer through presentations and offer a half-hearted thought process for a plan.  After that, I prepared more extensively for rotations, if I did not know what to do in a patient room, I would take my time and be more thorough, and I practiced my presentations to get them to flow better. After working on my baseline, I worked to get more comfortable with showing my true baseline, rather than clamming up if I did not produce a perfect assessment and plan. The feedback I received from that attending, and what I did afterwards ultimately made me a better physician and paved the way for the success that I’ve had during the rest of medical school. Since then, I have really tried to seek out feedback much more aggressively and incorporate it into my practice. I want to continue to do this in residency, and it is my goal to sit down with attendings whenever possible so that I can be the best doctor possible for my patients.

 

Goals:

  • Sit down with attendings at least once a week for a longer feedback session, ask for this if not offered.
  • Ask for some quick feedback after each shift
  • Ask residency classmates what has worked for them, or if they notice things that I need to work on.

 

How do I best care for patients at end-of-life?

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

During medical school, I have had several encounters with end of life care, and they have been some of my favorite experiences in medical school, and a good way to track what I have learned about shared decision making, and deeper questions of mortality and death we face as physicians. My first year, I met several patients at the VA seeking out living will advice. Utterly out of my depth, I wasn’t doing the talking during those sessions, but I was keenly aware of the coming need to be able to explain how to die to people much older than me. Or at least, the parts of how to die that they can’t answer for themselves, the quotidian details of the differences between living wills and MOLSTs and DNR-CCA vs DNR, not whatever larger interior or spiritual questions they have for their own gods and families and souls. Of course, the details of such a momentous time are important in their own right, and their correct resolution gives patients more time and space to reflect on the deeper mysteries. If these details are in doubt or not resolved correctly, it can lead to tragedy.

On hematology service during third year, I saw what happens when things go wrong. A patient who had stage IV leukemia and end stage renal disease was on our service, and, as the week progressed, things took a disheartening turn as his kidney function deteriorated he headed for multiorgan failure. He was off dialysis, and initially did not want to go back on. However, he had a family meeting which I was not present for, where he was apparently convinced to give dialysis another try after previously deciding to opt for comfort care. The next morning, as one of the residents was putting the dialysis line in, he became bradycardic, followed by losing his pulse and coding. He got CPR, but they were unable to achieve ROSC and he died. He had just been talking to his family, and they had to be hurried out of the hallway while the code happened. It was a violent way to die, and traumatic for his family. I reflect on this often, comparing this to another situation with a vastly different outcome I witnessed in the SICU. He had had a similar downward spiral, getting hospital acquired pneumonia following a surgery, resulting in several intubations. He did not want to be intubated again, so a family meeting was called, and together they made the decision for him to go to hospice. Following the meeting, the family gathered around his bedside in the SICU, sharing memories and enjoying the time they had left together.

 

The contrast between these two experiences is going to stick with me for a long time. I don’t know what happened in the family meeting in the first case, but that patient had terrible luck, gambling and losing on a play for more time. I recently read a book called Being Mortal by Atul Gawande, a succinct voice in the swelling argument for a change in end of life care in the US from focusing on doing everything possible to emphasizing hospice and comfort care.

Dr. Gawande’s approach puts an emphasis on balancing quality and quantity of life in a matter ideal for each patient. This is not the standard US culture surrounding severe disease care and end of life matters, which often casts disease as a “fight” to be “won” at all costs. Many patients, if asked, are going to want everything done for them, and I know that I won’t always agree that’s what is best. I think this poses a challenge to me in the future when I’ll be facilitating shared decision making: how do I present information neutrally to patients, indicate my recommendation, but not make them feel like I’m pushing something on them? What is the line for advocating a position vs pushiness? I think that is something that I’ll have to keep in mind during my career that will come up in places that have little to do with end of life care, and the line will probably differ by patient and situation. So, I need to be sure that I am attentive to the feedback of my patients and mentors during these situations. That is why I will be sure to reflect on them as they happen, and work to use anything I learn from this reflection during all interactions in the future.

 

Goals:

  • When a patient indicates some dissatisfaction or negative feelings towards a shared decision making interaction, I will take ten minutes at the end of that shift to reflect and think about what happened, and how if there are any specific ideas from this experience to keep in mind during future interactions.

 

What does it mean to be a professional?

6.1: Consistently demonstrate compassion, respect, honesty, integrity, accountability, altruism, prudence, social justice, and commitment to excellence in all professional and personal responsibilities.

 

During medical school, I have thought often about how to make the best of a situation with little hope for improvement. These hard times can make you frustrated at the situation, the system, and even the patient for reasons beyond your control. Early in medical school, I wrote about a patient at the VA who was refusing to take the needed actions to safely monitor the apixaban he was taking following a PE, most likely due to his anxiety or his social situation.

Reflecting on this case now, it is easy to see themes that would reappear often these last four years, and it posed that central question of “what to do in these situations?” that I would see answered in many nuanced ways by many different mentors and colleagues. This patient was not beyond help scientifically, but his mental health and social situation seemed to make him feel that he was. Was there something that I could say or do that would change the outcome? At the time, I think I leaned toward believing that there was. Now with more experience, I know that some of these situations are probably insoluble, but you never know which ones are until you do everything that you can.

During my third year hospital pediatrics rotation at Nationwide Childrens, I saw what I have seen since then as the gold standard of doing everything in a hard psychosocial situation. There was an 18 year old boy from Cleveland who was reportedly having seizure like events. His family were disagreeable and would frequently threaten litigation, despite repeatedly breaking ground rules they had previously agreed to, like not taking the patient outside to smoke. They were the only people that had ever seen these seizures, despite repeated hospitalizations at NCH and Rainbow Babies in Cleveland, which perhaps suggested malingering. The patient was on the spectrum and had some sensory and behavioral issues, and would act aggressively if something was not to his liking. These factors made it impossible to continuously observe him in a room with a camera or to get a cEEG. All of the floor staff were frustrated, and I wrote about some of the poor coping mechanisms people deployed in a previous portfolio entry.

The attendings response to these challenges is something I will always remember. She had an afternoon long conference with the family to get an extremely deep history, and to attempt to establish a more durable path forward instead of bouncing between institutions. She spent all night doing a deep dive into the patients chart and writing the most comprehensive note I have seen. She did get them to agree to go back to a specialist they had significant history with at Rainbow Babies, after hearing from them that they felt like their concerns weren’t addressed up there and telling them that they were going to get similar answers elsewhere and that they needed to do their part as well. I think that the amount of time and energy she spent on them was not lost on them, and they started to trust her enough to give the neurologist another try. At the time, I was focused on how team members reacted to this frustrating situation behind closed doors, but the longer I get from this encounter, the more I appreciate what the attending actually did, and that it seemed to actually get through to them. Even if it was a frustrating encounter for everybody, they deserved the best care possible, and I think that is what they received at Nationwide that week, even if staff weren’t as kind behind closed doors as they should have been.

When bad outcomes happen, they usually don’t happen because of bad intentions, but because of systematic incentives. While this kid and his family had a good outcome this time, thanks to an extraordinary provider, their care took up most of the care teams time during that week, and there were about ten other patients assigned to that service. If those patients had been sicker or more complex, there would not have been the time in the day for the kid to receive the intensely focused care that he did. If that were the situation, would the attending be at fault if the family had decided to leave again after an insufficient attempt at trust building cut short for time? I do not think so, because I don’t think it is a breach of professionalism to be at the mercy of staffing ratios and things outside of your control in medicine. More families like that would likely receive better care if there were smaller patient to provider staffing ratios, as there would be more hours in the day for time consuming trust building and history taking opportunities. But harsh circumstance does not excuse you from the responsibility of doing everything that can be done for the patient, and I think that “everything” means working in the moment, and later, to change the systemic incentives that lead to these outcomes. So, I want to make both of these ideas core to my practice in the future: I’ll do everything for my patients individually, and seek to change what I can systemically. I would be in breach of professionalism if I did not do these things.

 

Goals:

  • Take a leadership role on a QI project during my intern year.
  • Schedule time once a month for a personal reflection time regarding times during the previous month when I felt like I was not doing my best.