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“Demonstrate leadership and collaborate effectively with other healthcare team members and professional associates”

One of the main reasons I wanted to go to medical school was to have more opportunities to interact with people daily and directly help those in need. As a bioengineer, I felt to disengaged from those that I was helping, and I wasn’t enthused by the prospect of working from a cubicle for the rest of my years. Bioengineers work towards the betterment of public health and treatment of those ailed by illness, but unlike careers such as teaching, law enforcement, or medicine, bioengineers are extremely limited in their ability to directly interact with those people in need. Bioengineers aren’t front-line in assisting people, and that’s one of the most important reasons I want to be a physician. I want to use my strengths in problem-solving and critical-thinking in the assessment of patients. Additionally, I view medicine as an opportunity to strengthen my communication and leadership skills which I previously felt was a weakness of mine. Between clinical rotations that move me from team to team each week and all of the patient care I’ve been involved in, I’ve met thousands of people I could have never interacted with otherwise. I look forward to all of the professional interactions and relationships to be formed with other healthcare members and associates.

Outside of medical school, I’ve had significant increase in leadership responsibilities, which has further strengthened my interpersonal communication skills. Two aspects of life outside of medical school that I dedicated notable time to are research and teaching.

From a research perspective, I was blessed with the opportunity to continue my Masters level bioengineering research from the University of Louisville after graduation. The work is based in computational modeling of tumor growth dynamics and how the microenvironment influences different therapeutics including chemotherapies, immunotherapies, and nanotechnologies. Since the work can be performed on my laptop remotely, I’ve continued to collaborate with the researcher from UofL and produce more publications through medical school. This link demonstrates my research with blue text indicating those completed while at OSU: Publication List. Despite being away from the lab in UofL, I actually took on a more significant leadership role in the lab. Not only did I work on projects individually, but I was able to serve as a mentor for students in the lab at UofL. I trained them through email and Skype on how to operate the system and how to troubleshoot issues. It was useful practice for me to try to view a problem from their perspective and help make suggestions to fix their difficulties. These relationships helped strengthen my leadership skills, and also helped progress the lab overall as a unit. Additionally, I served a new role in the lab as I traveled to multiple conferences to present our data and form relationships with new colleagues in the field. This experience forced me to essentially think more like a salesman – pick up on what people are interested in and collaborate effectively.

For further demonstration of the work, here is an example of an abstract from one of my more recent publications while in medical school:

“The influence of tumor microenvironment characteristics on cancer progression and efficacy of chemotherapy has been the focus of intensive research. In particular, macrophages are a dynamic cell population that can assume various phenotypes based on tumor microenvironment characteristics. The influence of macrophage phenotype on therapeutic efficacy remains poorly understood. Macrophages can either aid or hinder tumor growth, with disease prognosis hinging on the proportion of pro-inflammatory and anti-tumorigenic M1 vs. anti-inflammatory and pro-tumorigenic M2 phenotypes. Repolarization of macrophages in the tumor microenvironment from the M2 to M1 phenotype has emerged as a potential approach that harnesses the body’s own immune system to fight cancer. Methods: Understanding the complex interactions between chemotherapy and macrophage populations in the tumor microenvironment could benefit from mathematical and engineering principles. We implement a modeling framework to evaluate tumor response to chemotherapy, including the effect of macrophage phenotypes in the tumor microenvironment on tumor growth and therapeutic outcome. M1 and M2 phenotypes are integrated into a model of tumor growth representing a metastatic lesion in a highly vascularized organ such as the liver. Behaviors simulated include M1 release of cytotoxic nitric oxide and M2 release of growth-promoting factors. Results: We simulate a hypothetical therapy-induced macrophage repolarization regimen from the anti-inflammatory M2 phenotype to the pro-inflammatory M1 phenotype in conjunction with chemotherapy administration. Surprisingly, the model predicts that chemotherapy applied in a tumor microenvironment that contains mixed M1 and M2 macrophage phenotypes is more effective than with only M1 macrophages. Conclusions: Fine-tuning the ratio of macrophage phenotypes in the tumor microenvironment during chemotherapy may be therapeutically beneficial. A proposed mechanism is that M2 macrophages potentiate the chemotherapy effect by promoting tumor cell proliferation that sensitizes these cells to agents acting on dividing cells.”

In addition to the research, I spent a significant portion of time in my first two years of medical school working as an instructor for Kaplan Inc.

This was a intimidating role at first, as I was responsible to lead classes for talented students who gave their limited free time at not the cheapest price (I’ve purchased three classes myself so I’m fully aware of the cost) to learn skills to excel in their exams. I initially was brought on to teach the MCAT, but class after class kept getting cancelled before starting due to low attendance. So I decided to cross-train in other exams by taking that standardized exam, viewing Kaplan’s training material, then preparing my lectures for the group. I went through this process for the DAT/OAT, ACT, and GRE.

Teaching required loads of preparation, patience, and time. Additionally, even if I perfectly understood everything I was teaching, I had to ensure I was communicating that material in a clearly understandable fashion. This took some trial and error to accomplish, but I feel like this experience strengthened my interpersonal skills significantly. I learned how to guide people towards solutions, how to interpret their body language, how to speak loudly with inflection, and how to show passion in my voice. I also strengthened my leadership abilities. The success of their class was dependent on me taking the first step each way, and I put a lot of pressure on myself to be that role model. I also gained further experience in mentorship with 1-on-1 individual coaching services I provided to help guide students successful through their course material.

In reflecting on my research and teaching experiences, I underestimate how much time and effort actually went in to these roles, and how much I’ve grown from them. I used to be too nervous to raise my hand in class and speak up, and now I’ve served as the person asking those questions and ensuring the quiet person in the room is grasping the material. I’ve gained confidence in public speaking that will guide me through my future in medicine.

For the future, there’s no question that I hope to develop further in terms of teaching and research. My personal statement for residency interviews was based around these principles: Personal Statement. I plan to get involved in research during my residency, although I’ve been warned how difficult that may be. I also plan to be involved in teaching through residency. During my interviews, I asked programs what roles would be available for teaching beyond clinical duties, and it sounds like pursuing a role as an Education Chair of the residency is one option for me. I look forward to what the future will hold in growing as an effective teacher, researcher, clinician, and effective communicator.

Professionalism is a complex definition that has so many different connotations to me, but ultimately it is a key feature of the respected physician. I think the best way to describe professionalism is the ideal behaviors and attitudes congruent with one’s own profession. These behaviors and attitudes are universally accepted as positive qualities in society, and the idea of professionalism conjures endless synonyms in my mind: honesty, courage, accountability, compassion, humility, altruism, and more.

Most people would think of themselves as honest and compassionate people. But if you reflect on those friends, family members, and strangers around you, are they all equally honest and compassionate? I certainly don’t think so. It creates less cognitive dissonance to think of yourself in the best light possible, so our personal judgement may be skewed. So how do you know where you stand? There’s no magical point system measuring behavior that you can reference, like on NBC’s “The Good Place”. One way to truly know whether your actions fit the professional standard is through verification by those around you.

One positive, although cumbersome, aspect of the medical school curriculum at OSU is the “death by evaluations” we receive and perform. These are formal articles of communication for every lecture, skill lab, group project, and rotation to hear how you are performing versus the professional standard. In particular, the Clinical Performance Assessments (CPA’s), which we receive after our rotations, are exceptionally nerve-racking to read, and I simultaneously dread and enthusiastically await their release. In very busy clinical services, there often isn’t time to provide much feedback or deliver praise on the day-to-day, so I find these personally valuable in reflecting on my performance. I was overwhelmed with joy reading the feedback I received from two of my rotations in particular, and feel that they both fit descriptions of professional behavior I described earlier.

From the Medical Toxicology narrative:

“Louis was an exceptional student who performed well throughout his elective in pediatric Medical Toxicology. He was enthusiastic and eager to learn, quickly taking ownership of his patients and actively participating in all aspects of their care. Louis displayed an excellent fund of knowledge, sound clinical judgment, and mature problem-solving abilities. He efficiently and thoroughly obtained patient histories, characterizing all major problems. Louis’s notes were consistently accurate, organized, and complete. His presentations were well-organized with developed problem lists, prioritized working differential diagnoses, and complete management plans. He impressed the team with his ability to offer accurate interpretations, especially under challenging situations, his participation on rounds, and how he was consistently well-prepared. Louis sought out feedback, quickly incorporating any necessary changes into his daily routine. He was a strong team player, who was always willing to go above and beyond to assist other members of the team in any way he could. He knew his patients well and was compassionate and empathetic with patients and families, even under duress. Louis’s diligence and humility made him a pleasure to work with and a true asset to the overall functioning of the team.”

Form the Neuro Critical Care narrative:

“Louis completed his AMHBC mini-internship on the Neuro Critical Care rotation at the Ohio State University Medical Center. During this time, he did an excellent job on the rotation. He was an outstanding team member and sought responsibility for the care of his patients. He was hard working, calm and composed even in the context of a sometimes busy and chaotic neurocritical care unit. He managed his patients well and was an asset to the neuro critical care team. His case presentations were excellent and demonstrated a sound understanding of pathophysiology. He was able to developed thorough and complete management plans for his patients. He was highly professional and interacted very well with other members of the neuro critical care team as well as other staff in the unit and with patients in their families.”

However, there is evidence of my own lapses in professionalism. I attended my longitudinal community (LC) meetings through my first two years of school, but as clinical rotations began in my third year, I thought it’d be easier to simply not go to these meetings anymore. After multiple mass emails emphasized that these meetings were required, I still failed to put the meeting on my calendar and attend. I was met with this email, followed by my response: Apology Email

As detailed in the email, for my lapse in professionalism, I was required to write a reflection on professionalism. I chose to discuss a relevant experience in recent months where I witnessed unprofessional behavior: 030419 Professionalism Paper

Despite the professional behavior detailed in my evaluations above, my failure to meet my responsibilities to LC showed poor judgement and neglect in recognizing the effect my absence had on other people. How does this experience play in to my professionalism overall? Are the words from my evaluations no longer accurate or diminished?

Overall, in reflecting on these experiences, I can better appreciate that being professional doesn’t mean behaving ideally 90% of the time, but being professional in all aspects of life, clinical or not. In my future, it will be important for me to maintain this attitude. As I progress further and further into this profession, my behaviors and actions will have even more drastic effects on the people around me. Not being accountable and maintaining integrity could mean accidentally doing someone harm. With professionalism in mind, this means attending every requested meeting or at least acknowledging my future absence. This means being on-time to clinic every day. This means being committed to excellence and not settling for mistakes without an apology. It’s a dynamic topic that will continue to evolve as I process through medicine. As I graduate and take the Hippocratic oath, I must live by these principles.

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

Before medical school, I had experience in biomedical product development, translational clinical research, and more theoretical computational modeling. All of these avenues of work developed technology or results that could have some sort of potential to reach clinical use. At the time, I had no appreciation of how that would happen. Who decides which devices are used in the OR? What level of data is required to change clinical practice from one medicine to another? What determines if a hospital will participate in a clinical trial or not? These are difficult questions that even today I still don’t have complete answers to, but my clinical rotations have provided insight into the complexity of medical decision making and the systems-based approach required to produce change in day-to-day processes in a hospital.

My third and fourth year project in HSIQ, Health Systems Informatics and Quality Improvement, provided significant insight into how difficult it can be to modify established systems in the hospital setting. As a quality improvement project, our goal was to identify a population or specific process in the hospital that was amendable with the most benefit for the least invasive change. Our intervention focused on the pediatric population, and through meetings with Dr. Bapat, a neonatologist at Nationwide Children’s Hospital, we aimed to address post-operative temperature management of NICU patients that has largely gone on unrecognized. Through many months of QI meetings and iterations in our project, we eventually discovered that temperature measurement in PACU patients could be optimized, with the goal to lead to the early identification of patients that requiring additional warming, thereby reducing hypothermia rates. 

The process was standardized and adopted in the PACU by using the same temperature monitoring guidelines utilized by the NICU. By using evidence-based practice guidelines and uniform equipment already utilized by staff in the NICU, the intervention was more easily adopted by staff, and if any issues were to arise, they would be able to communicate with their knowledgeable NICU staff colleagues. The new protocol was communicated through daily morning meetings with the staff, and our intervention was revisited in monthly QI meetings. We provided reminders of the intervention by hanging these flyers through the PACU: Keep me Warm_Flyer. 

Despite the eventual success of the project in terms of its ease of application, we encountered several barriers that caused delays in our intervention planning and rollout. One such delay early on was that the original data analyst assigned to this QI project left his position, and so there were months where we did not have access to data. Also, our initial intervention that was supported by the executive sponsor was deemed unworkable, so we had to go back to the drawing board. There were also delays in our rollout due to wait time for ordering/shipping of new equipment (temperature probes and cables) required for our intervention.

AHSS Poster (4)

In reflecting on this experience, after a year of planning, meetings, and delays, at the end of the day the intervention was simply to use a protocol from a different area of the hospital in a new area of the hospital. That certainly emphasizes to me the difficulty to enact serious change in a hospital, especially without strong leadership or support from supervisors higher up.

Although frustrating, this project did excite me for opportunities for QI in the future. It was satisfying to see how such a simple change could have value to patients in the future. I plan to seek out opportunities through residency to get involved in clinical research, and QI might be one of the easier ways to do that. This project empowered me with confidence that changes are possible if you notice something could be done more efficiently. That just comes with the caveat that interventions in medicine move slowly and iteratively, and it takes a team effort to ensure system-wide change.

“Understand the clinical relevance of scientific inquiry and demonstrate the ability to evaluate emerging knowledge and research as it applies to diagnosis, treatment and the prevention of disease”

When it comes to the medical school curriculum, medical knowledge is the most obvious competency required, and it’s probably the most widely recognized requirement of a good physician. Before entering medical school, I assumed the first two years taught you everything you needed to know, and the next two years were opportunities to practice patient-doctor skills before graduation; however, there was so much to learn in terms of patient management and how to actually apply knowledge to patient care. I also underestimated how much teaching I would perform through medical education. Not only is medicine a career of lifelong learning, but also of lifelong counseling, educating, and leadership of colleagues, patients, and future doctors.  Our curriculum has prepared us with multiple opportunities to demonstrate these teaching skills outside of the basic science curriculum.

My first teaching example is a presentation that was recorded in my first year during the cardiovascular block. In multiple blocks, I was given the opportunity to present cases to our Longitudinal Group, and in this picture I am discussing the psychosocial factors to consider in a patient with heart failure. It’s a topic you could consider at a glance to have an understanding of, but it’s a whole different task to present studies related to the topic and answer questions regarding modern therapies at play. I’ve attached a screenshot as the video was too large to upload.

A second example of teaching in medicine was during my AMHBC Mini-I in the neuro ICU. I was tasked with selecting a topic to present to the team that was relevant to the rotation and at the level of an intern. I chose status epilepticus as the topic. Again, it’s another tier of difficulty and understanding coming from familiarity of a topic to presenting the topic to other learners. Not only do I feel that I was able to help third-year medical students with their board exam, but that I was able to dedicate time to strengthen my own understand and study our clinical practice guidelines in detail.

Status Epilepticus

One last example includes an opportunity to evaluate system processes through my internal medicine rotation. We acquire the knowledge in the basic science years that patients with atrial fibrillation need anti-coagulation, but it’s a different task to actually safely, cheaply, and efficiently provide that service to your patient. We were tasked to create a  flowchart which described presenting clinical features for diagnosis, the stepwise treatment, as well as some potential areas for delay/waste in the management of this patient population.

AtrialFibrillation Flow

In reflecting on this work, I’m proud to have demonstrable material, beyond a letter grade, that shows I was able to create something of value that was impactful to those around me. It also reinforces to me that there was so much more that I learned in my third and fourth year that will carry me through my future, and that medical knowledge isn’t all about accumulation of basic science facts. Patients require compassion, understand of psychosocial factors, and management beyond just knowing an antidote to a problem.

I look forward to my future in residency where I plan on having many opportunities to teach. My role as an educator will no longer be just as student-teacher, but as patient-physician. I understand and appreciate that I cannot simply give patients the answers and send them on their way, but I have to prepare them to ask questions of themselves and provide the tools to answer those questions. Additionally, I’m looking forward to the educational opportunities that will come through residency in teaching fellow residents on my team, physicians who consult me for assistance, and budding medical students to come. As a fourth year student, I’ve thoroughly enjoyed the opportunity to guide new third year students smoothly through roadblocks of integrating into the health care system and preparing them with questions to anticipate. I hope through the next step of my training that I will put myself in situations to nurture my skills as an educator and strengthen the knowledge of those around me.

“Identify one’s own strengths, weaknesses and limits; a) seek and respond appropriately to performance feedback; b) maintain and appropriate balance of personal and professional commitments; c) seek help and advice when needed”

Medical school has been a humbling experience in many ways. Unfortunately, I came into medical school with more confidence in myself than I am leaving with. However, I can summarize my experience as a tale of two stories: one half of disappointment and one half of discovery and growth.

There were so many facets of my experience in the first two years of school: basic science curriculum, research, Kaplan tutoring, health coaching, community health, interest groups, HSIQ. In reflecting on it all, there are only a few areas I performed to my potential; the rest left me with regrets on my performance. I remember each of my portfolio meetings during LSI Part 1 blocks like Foundations, MSK, Cardio, etc. with Dr. Sangvai.  I’d admit to her how I felt I was underperforming, how I felt I was distracted, and how I felt I could improve. And following each new portfolio post in which I stated my goals for improvement, I’d fall back into the same routine. One example of my performance is my neuroscience block report attached: Block Performance Report (2). This was the last block before the end of my first year. I had the goal of finally performing up to my standard and ending the year on a high note. I believe I set the goal for a 90% aggregate score, and the report shows that I failed to reach that goal. I was below the class average in the anatomy practical, the final exam, the OSCE, and I even lost points for accidentally missing a patient panel.

Why did I miss my goal? Simply because I didn’t put in the work necessary. I knew I needed to watch each lecture and review it twice at minimum, but I  there were a few lectures I never even viewed. I would be so far behind on viewing new material that I missed opportunities to review the old. Why couldn’t I complete the workload? This is where many hours of self-reflection still hasn’t provided me the clear answer. Maybe I had too many extracurriculars. Maybe I had too many distractions in my apartment. Maybe I’m not as smart as I once thought I was and needed more time to learn, But I think the most likely culprit is more psychological than procedural. At that time, I coped with stress by neglecting my responsibilities without even realizing how stressed out I was. I’d wake up some mornings feeling that there’s no way I could be productive and focus, so I’d relax, watch my shows, and plan to catch up later, while all along I was wasting time and making my eventual stress worse in the future. “Why do today what I could put off to tomorrow” became an unconscious mantra. In a more structured setting like high school and undergraduate college where there were daily homework assignments, quizzes, and weekly exams, I couldn’t “put off to tomorrow” because it was due today. But with 10 week blocks in medical school accumulating to one final assessment week, my daily anxiety prevented me from doing the daily things I needed to do.

I didn’t fully appreciate what I was doing to myself until midway through the second year as USMLE Step 1 Prep was looming. I knew that substandard performance here would be detrimental for residency placement, and I was aware that my study style wasn’t allowing long-term retention of information either. I adapted the simple attitude of “just do it”, and started to improve my study habits. There were good days and bad days similar to the past, but I improved a bit. After Step 1, my biggest reality check came in the form of my first clerkship. It was a strong reminder that this basic science knowledge isn’t a never ending list of useless facts, and that this knowledge is  essential to recognizing danger in patients and avoiding harm. I could cope with being a poor student in the past, but I’d never be able to accept being a poor doctor. I set the goal for myself to place above “Satisfactory” for the ring, which is the score I had for every block previously. I worked hard during my rotations, and studied every night for at least an hour consistently. I was worn out, but in a much different way than my fatigue of my first two years. This was a fatigue that I was proud of and grew from. I met my goal and received a Letter distinction for my Neurology rotation and my first 16 week ring, UPSMN. UPSMN Report. Throughout my clinicals, I also received Honors in my rotations in peri-operative care, neuro-ICU, neurosurgery, stroke, and received a Letter in my Medical Toxicology rotation.

Despite struggling early on and still carrying regrets of the past, I know I am capable of much more. Time will tell where I can go, but I am proud to be graduating with personal confidence to succeed in the future. I am not the world-beater I thought I was, but I am capable of being a good doctor. The narrative from my Stroke Sub-I rotation is one I am most proud of:

“Louis completed his elective on the stroke service at the Ohio State University Medical Center. During the rotation he did an excellent job. He was a highly effective and helpful member of the team. He consistently took the initiative to come in early and pick up patients to follow and manage each day just at the residents would do. He also worked to mentor and advise the 3rd year medical students on the team. He did a great job with the assessment and management of stroke patients. He picked up on things quickly and was and astute learner. He could conduct an effective and efficient assessment of patients presenting with stroke symptoms and give excellent well focused but still detailed patient presentations. He understood how to manage both simple and complex stroke cases and knew the indications for acute stroke intervention.” 

This narrative verifies what I am capable of, and that my frustration with my basic science years of medical school did not limit my potential for the future.

Looking toward the future, I cannot set an objective or goal to score a certain grade in my residency, but there is a personal standard that I’ve now set for myself and can feel when I stray from it. I hope to maintain this professionalism and dedication to life-long practice for the duration of my medical career. I think the most objective way to maintain that track is to set the personal goal to study something relevant to patient management at least 20 minutes every day outside of my shift throughout residency. I think this is a conservative but difficult goal, especially on my hardest days to come, but it’s any important goal to have. I still have so much to learn, but I’m not faced with the same overwhelming anxiety I once was, and I will continue to practice developing my coping skills through the future.

“Understand the role of disease prevention and health promotion in relation to individual patients and/or patient population and utilize these principles in clinical encounters”

My exposure to medicine through these four years has been spread across the spectrum of time that patients would interact with the health system: family health visits, health coaching, ED visits, in-patient service, pre-operative, post-operative, and even post-mortem. However, there was only one experience through medical school in which I felt I was able to reach patients in the community as a whole population. This experience was my Community Health Project during my second year.

I teamed up with students from my Longitudinal Group, and we were paired with Godman Guild House. This association serves the community through two main areas: Youth and Family Education and Workforce Development. After assessing the needs of the community with the staff, our project focused on assisting community members with limited internet and computer access to better keep and organize their relevant medical information.  The objective was to create a binder for people to write out and retain documents on different categories such as past medical history, medications, physician contact information, appointment history, and several others.  Our project involved designing the physical binder for the patients to fill out their medical information, cheaply producing them in bulk, distributive them as the Godman Guild Health Fair, and followed up with questionnaires to receive feedback on ways we could improve the efficacy of the binders. Working with Godman Guild House was a positive experience overall, and our liaisons from the Godman Guild were very enthusiastic about this project. This project has the potential to improve a vulnerable community’s ability to keep track of their personal medical information without needing to access an electronic device. Here are the pages that filled the binder we distributed: CHE Medical Binder V2. In the months following the distribution, we were able to present our findings and assess our success with our poster presentation. We divided the creation of the poster and its individual tasks evenly throughout the course of the project. Our collective work can be seen here: Group 21-Poster Submission-1

Having this project early in medical school was valuable in terms of gaining perspective on social determinants of health before having significant opportunities to see patients in clinic. In reflecting on this experience, I don’t think I appreciated the value of this project in the moment as much as I do now. Yes, the binder was cheap and flimsy and many people may have quickly discarded it, but it serves a more subtle but important purpose – to give the community more responsibility and initiative in their own health care and personal knowledge. As I’ve progressed through clinical rotations, I’ve ran into many patients who couldn’t report their medical history or medications and simply tell me to “look it up in the computer”. This ignorance of their own health care could be dangerous if they are involved in care outside of their electronic health network, and it certainly limits their ability to catch any mistakes in their record or medications if any came up. Overall, I think the message of distributing a health binder and its importance is more impactful to me than the binder itself.

I hope through residency that I can put myself in more situations like this to recognize opportunities to prevent disease and promote health through patient education. I think most applicably to my immediate future in my neurology residency will be counseling stroke patients on risk factors and preventative measures to avoid future neurovascular events. No matter how much effort is put into the management of in-patients, long-term outpatient care will fail if patients aren’t educated in their diseases and take responsibility for their wellbeing. It can be very difficulty to make the time on in-patient services for patient education before discharge, but I plan to make that a priority in my future. Saving lives isn’t always as action-packed as intubating and providing CPR, but it can be as simple as distributing this paper binder.