Posts

Professionalism

CEO: Demonstrate a commitment to ethical principles pertaining to provision or withholding of care, confidentiality, informed consent, and business practices, including compliance with relevant laws, policies, and regulations

The meaning of professionalism has changed for me throughout my medical school career. During my first two years I was involved with the Honor and Professionalism Council, first as a class representative and then as president of the council. My desire to serve on the council stemmed from an understanding that as a profession, medicine requires physicians to demonstrate a level of professional knowledge and professional behavior. This is because professionalism is one of the basic tenets of the field of medicine. The OSUCOM Professionalism and Core Educational Objectives outline some of the key aspects of professionalism and requires students to demonstrate “compassion, respect, honesty, accountability, altruism, prudence, social justice, and commitment to excellence in all professional and personal responsibilities”. My goal with HPC was to ensure that all students had the opportunity to demonstrate those competencies but also to learn how to improve in areas where they may not be as strong. Given the diversity of backgrounds of OSUCOM students, we all entered medical school with varying understanding of respect, social justice and even accountability. However, the aim is that by the end we are all at the same level— and at our highest level possible. For me as I enter residency I hope to keep this same frame of mind and continue to treat my  patients and colleagues with compassion, respect, honesty and prudence; and that in my work I will demonstrate accountability, altruism, social justice and a commitment to excellence.

 

As I reflected on this CEO I thought about my clinical rotations and the various examples of professionalism and unprofessionalism that I witnessed. In each encounter I attempted to reflect on what I could emulate and what I would do a little differently. One example was during my family medicine ambulatory rotation. The attending I was working with on that day was about 30-minutes behind on each patient. As we got to the next patient he was irate. He felt that the attending did not respect his time because we were delayed. The moment that we walked into the room the patient was glaring at us stating  “you can’t be serious. Do you know the time?” Before the attending could even offer his apologies or an explanation the exasperated patient was raising his. While the patient was angry the attending maintained his cool and remained professional allowing the patient to continue speaking. From this I learned that professionalism is exemplified by our actions and also out reactions to situations outside of our control. The attending handled the situation by first diffusing the patient’s anger, and then secondly allowing the patient to feel heard. This left a great impression on me and caused me to feel that if ever in that situation I would know how to behave. I also felt that I learned about the patient and what things were important to him. I learned from that encounter the importance of timeliness to patients, but also the value of clear communication. By allowing the patient to speak and then clarifying the reason for the delay it was easier for the patient to understand an unplanned delay. This encounter was beneficial to me especially during my EM rotation when I often had to deal with hostile or inebriated patients while maintaining my professionalism. I tried to reflect on this encounter and utilize the same skills I saw the physician use: listen, apologize then chart a plan forward.

 

As I go toward residency my goal is to demonstrate professionalism and ethical behavior in my interactions with classmates, patients and faculty. Additionally, I hope to be a leader in helping to foster a culture of professionalism at OSU. One way that I have tried to leave that legacy was with working on the Class of 2020 Oath Committee. As part of the oath that every graduate will saying during the hooding ceremony is language which focuses on maintaining integrity, honesty and professionalism.

 

Image of the draft of the 2020 Class Oath:

Systems-Based Practice

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

 

As part of the LSI curriculum 3rd and 4th year students consider problems or potential for improvement within the healthcare system and develop a quality improvement. As part of the Primary Care Track program my project was developed for the Rardin Family Practice Clinic. Working with faculty and residents at the clinic we were able to identify hypertension control as a modifiable problem. This project focused on using system resources, considering quality improvement techniques and also interpersonal communication. Our project focused on promoting self-measured blood pressure monitoring for patients with hypertension to help increase the control rates. To improve the control rates for patients the area of intervention was with medical assistants who measure patient blood pressure during their visit. As part of the intervention we created a pre-test and post-test for the medical assistants as well as imaging in the room to remind them to encourage patients to utilize SMBP. The greatest success was the positive relationship with the clinic staff and the project. There was a great willingness from the clinic to allow us to implement our project and make an impact on clinic flow. In terms of barriers the greatest barrier to the project implementation has been the impact of the intervention  on the clinic work flow. By adding another element to the medical assistant rooming process, we added time to the patient visit, and increased the time from patient arrival to being seen by the physician. Overall our AHSS project was successful. We were able to submit an abstract of the project to STFM for presentation at the upcoming conference in May.

 

Photo below of Process Map for the project AHSS : A Multidisciplinary Approach to Improving Blood Pressure Control in the Ambulatory Setting

 

Photo below shows the abstract of this project which was accepted to the STFM conference this May:

In addition to developing quality improvement, I was also able to engage in individual quality improvement through patient education and health promotion about health resources. I completed one month of ambulatory Pediatric ambulatory during 3rd year at the Northland Pediatric Primary Care. During this rotation I had the most opportunity to engage in teaching with families as well as working with other health care professionals. I enjoyed the outpatient setting and the variety in acuity of patients that we took care of. In addition to being able to diagnose and treat patients, every day there was an opportunity to engage in health education. This is meaningful to me because it allowed me to refresh my knowledge so that I would be able to present it in a manner that was understandable to patients and families. Additionally, through my pediatric ambulatory rotation I was able to utilize my previous graduate training in health education and health promotion. Unlike the family medicine clinic where I focused mostly on helping adults to change behaviors (e.g. smoking cessation) in the pediatric clinic the focus tended to be on developing positive health habits. With infants the focus was on educating parents about safety inside and outside the home. Inside the home the focus was on proper sleeping habits to avoid SIDS, and outside the home the focus was on proper car safety. I enjoyed reviewing these concepts with families and answering questions, as I think this helped me to review and gain better knowledge of the concepts. In addition to engaging in teaching, I learned quite a bit during my rotation about the role of social workers in pediatrics and resources available to families. We had various encounters in the clinic in which patients needed social support, and it was beneficial to see how the social worker was able to close the gap in care. I would not have known of various counseling and support agencies that will work with families in-home and even at school.

 

Evaluation from my pediatric ambulatory rotation:

As I have reflected on system-based practice I have appreciated how the work of medicine happens both inside and outside the clinical setting. That means that when considering quality improvement we have to think of systems beyond our healthcare and consider how transportation or food systems can impact a patients health. I have also reflected on the benefit of quality improvement projects on patients access and utility of the healthcare systems. These projects may range from individual patient intervention to wider systems based interventions. As a resident I will continue to be engaged with quality improvement efforts to improve efficiency, patient care and safety.

Practice-Based and Life long Learning

CEO: Seek out and Apply best practices, measure the effect of changes and develop strategies to improve performance.

 

For non-traditional students there is often the idea that when you enter into the field of medicine you are to leave the old behind and pursue the new. For me, part of my motivation to pursue a career in medicine was propelled by the work I was doing in the field of public health. After studying public policy in undergraduate I pursued an MPH from Emory then went on to work for 2 years at the Centers for Disease Control and Prevention (CDC). At CDC I worked within the Division for Heart Disease and Stroke Prevention on knowledge translation. My work focused on taking scientific data and developing toolkits guides, webinars and policy briefs for state and county grantees. Additionally, I did a lot of work on creating evidence-based best practices particularly within the realm of program development and implementation.

As I have transitioned from working in the field of public health to medicine I have continued to think about the concept of evidence-based best practices and not only what is considered best practice but also how that is measured. During my clinical rotations there was a focus on being evidence based and using resources like UptoDate or field specific databases to determine the evidence behind a practice. I appreciated this perspective and the insistence of many attendings on knowing the evidence behind what I wanted to do for a patient. In some cases it was not always cut and dry, for example in psychiatry there were many times where the evidence was lacking or inconclusive and instead of depending on just the science we had to considered the art of experience and patient perspective.

 

Another way in which I have continued to engage with my public health background and continue in life long learning has been through the LSI curriculum. Health education and promotion is firmly intertwined into the curriculum. During my second year I participated in a interprofessional Community Health Education (CHE) project with students from the school or pharmacy, nursing and dietetics. The project, called the CarePoint East Patient Education Program (PEP Talk) aimed to improve the health of adults in the Near East Community who were at risk for metabolic syndrome. The Near East community of Columbus has a high rate of poverty, obesity and a large number of adults with low health literacy. The project used culturally competent health education to promote nutrition, physical activity, medication adherence and wellness. These areas were chosen to be representative of the participating students’ programs.

 

Photo from CPE Lifestyle Clinic: PEP Talk project which focused on using health promotion and health education delivered by an interdisciplinary team of students.

 

My goal is to continue utilizing my public health knowledge and experience to serve as an advocate. I hope to develop program and implement interventions to increase health equity particularly among underserved communities. Additionally, I think that advocacy at a population level has to involve policy. I hope to engage in advocacy for public health policies by working with public health organizations such as the Columbus Public Health Department and the CDC. Below is an image of a publication from work that I did while at CDC which was published last year.

 

Photo of accepted article published this year:

Hawkins, N. A., Bhuiyah, A. R.… Decker, A., … Schooley, M. (2019). A Replicable Approach to Promoting Best Practices: Translating Cardiovascular Disease Prevention Research. Journal of Public Health Management & Practice. Accepted for Publication.

 

Interpersonal Communication

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

There are many words that become a part of your vocabulary as you journey through medicine. Words such as disposition, SNF and consult become so common place we don’t often reflect on what they mean.

One word that I have often reflected on throughout medical school is the word Team.

Who are the members of the team? What are their roles? What does it mean to be on a team?

With each new rotation I have endeavored to discover what it means to be a helpful member of the team. During my 3rd year psychiatry rotation I tried to determine the anatomy of a good team. First, who are the members of the team. During my inpatient psychiatry rotation this included the attending, resident physician, nurse practitioner, social worker, medical student and patient. Before starting the rotation I thought the most important team member would be attending, being the most senior in knowledge, the “teacher”, and the arbiter of grades. However, as the rotation progressed, I learned that the most important member is the one that everyone forms the team around, and that is the patient. The patient is the greatest asset to the team because they provide the information for history upon which a diagnosis is built and for me the patient did the most teaching. From the patients I learned about the symptoms of psychiatric conditions and side effects of psychotropic medications. Additionally patients taught me about the human condition and how psychiatric conditions affect every aspect of persons life. My psychiatry rotation helped me to appreciate the value of interdisciplinary teams and to consider what I can learn from all the professionals on the team.

Below is my evaluation from my month on inpatient psychiatry.

Determining the role of the team members, and particularly your role as a student is the bane of clinical rotations. During my EM rotation of 4th year this rang more true than ever. With every shift I had to outline my Attending, the PA/NP and the nurses that would form my team. Once the team was determined I had to learn everyone’s role and then asked to be assigned my own. During my EM rotation my role focused on collecting a good history and physical on patients and then following-up on my patients until they were discharged or admitted. During my first few shifts I had not yet learned my role. I often found myself waiting to be assigned a patient or to engage in a trauma. Being able to receive feedback at the end of each shift really allowed me to improve and to own my role as the month continued. With each shift I learned to ask for tasks to be assigned to be such as completing pelvic exams, putting in IV lines or venipuncture. My taking initiative and then properly completing assigned tasks I was able to be entrusted with more tasks that were within my areas of interest (i.e. women’s health and psychiatry). As I have reflected on this rotation there were so many lessons that are applicable for me as I transition to being a resident, specifically being aggressive about outlining my role and taking on responsibility during every rotation.

During my EM rotation I also had the privilege to work briefly with another type of team. I spent a day working with the EMS as part of a medic ride along. This team experience highlighted to me what is means to be on a team. My day with the EMS of Station 7 was filled with adventure, camaraderie and learning to appreciate the scope and depth of the work done by these officers. I was excited to work with the medics and learn how to manage urgent and emergent medical conditions. However, I was worried I would not be of much help to my team outside of shadowing. My day fortunately surpassed my expectations. One thing I enjoyed about my day and learned from the EMS was the importance of community and treating everyone with respect. Throughout the day I felt comfortable asking questions, offering my help and also engaging with the patients. I was able to help with getting a POC glucose on every patient we saw and also transporting the patients into the hospital. This was a great experience and the highlight of my EM rotation. As someone going into FM I felt that many lesson were learned that can be applied to ambulatory medicine, primarily what it means to be a part of a team and how to treat your other team members with respect.

Below are some photos from my ride along (all EMS officers agreed to be in the photos):

         

 

My goal as a resident is to be a reliable and amiable member of every team that I work on. I aim to keep the patient as the central focus while also considering how each player (whether physician or other professional) plays into that team running smoothly. And finally I hope to keep the camaraderie and respect that I saw the EMS officers show as central to my interaction with all people.

Medical Knowledge and Skills

CEO: Understand the indications, contraindications and potential complications of common clinical  presentations and procedures and perform the basic clinical procedures expercted of a new PGY-1.

As a non-traditional student I entered medical school with a chip-on my shoulder. I was 4 years out of undergraduate and at least 6 years from my last organic chemistry or biology class. Now to complicate matters I had 3 years to complete 4 years worth of curricula information. The outlook seemed grim.

Every medical student has their strengths, weaknesses and areas of concern. I have always considered medical knowledge as an area of concern. I often felt like I was always just catching up, just understanding the concept or the pathophysiology. This feeling of imposter syndrome was worse during my 3rd year clinical rotations. Particularly in topics like Cardiology and Neurology which were blocks during LSI in which I struggled. Being aware of my need for improvement in medical knowledge I strived during my 3rd year to increase both medical knowledge and skills. My motivation for increasing my knowledge and skills stemmed from the fact that after 3 year I would become a resident. I was terrified of the fact that soon someone would call me doctor and all the responsibility that came with that title.

On the cusp of 3rd year I met with my portfolio coach Dr. Conroy and she asked me what my goals were for clinicals. At the time my primary goal was to do no harm and to be an asset to every team that I worked with. However, as I have reflected over 3rd year I have tried to think of 3 lessons that helped me grow.

Lesson 1: Challenge yourself by selecting rotation in topics that you struggle.

If someone asked me at the end of 2nd year what my weaknesses were I would have said 3 letters: EKG. During my dedicated Step 1 study period I realized my limited knowledge in the area of cardiac pathophysiology. Additionally, as I reviewed the curriculum for the OSU Family Medicine residency I realized that cardiology rotations are very important to the foundation of primary care training. This motivated me to seek opportunities for learning. What better way to learn cardiology than the ACS service at the Ross Heart Hospital. This 2 week rotation was one of my most stressful during 3rd year, however in that short time I learned so much. What I learned most importantly was that cardiology is a subject no one every masters and that being engaged and active in learning is the only way to improve. I am still working on my EKG skills but it is something I actively reach for in every rotation.

Lesson 2: Seize every opportunity, leave fear at home.

To improve in medical knowledge and skills one has to constantly practice. Practice makes perfect, and practice gives peace. Throughout my rotations I attempted to remain engaged and take the opportunity to learn new skills. I still remember asking to practice suturing during my surgery rotation and completing pelvic exams during ObGyn. It seemed at the time that those skills were rotation specific. However, now as a 4th year the skills that I acquired during 3rd year have helped me to confidently participate as a member of the healthcare team. One skill that I really struggled to acquire but that has become essential to almost every patient encounter was the neuro exam. I still remember the first time that I completed the exam I was terrified I would forget some component. Now as a 4th year on my EM rotation I complete a neuro exam on every patient.

Lesson 3: Solicit concrete feedback

The LSI curriculum has feedback built into every section, from mid-month feedback forms to end of rotation evaluations. However, one lesson that I learned from my clinical rotations is the importance of soliciting feedback in-person from as many team-members as possible. That was something I did not learn or appreciate until my 2nd ring. I heavily relied on the evaluation forms on Vitals, often puzzling over some of the comments. Now, I ask at the end of a shift or a week for feedback from the residents and attendings. I ask what I need to improve to get ready for intern year and what I have done well that I should continue.

Below evaluations from my Cardiology and neurology rotation

During my 4th year Mini-Internship with OSU Family Medicine inpatient I utilized all three lessons as I acted as an intern on the team. I challenged my self to pick up more patients and patients with cardiac or GI conditions that would typically intimidate me. I also asked to hold the pager and phone so that I could become comfortable interfacing with consultants. I also seized opportunities to gain procedural skills. During the month I completed skin biopsy and suturing as well as I/D with packing of an abscess. Finally, I constantly asked for feedback. This was essential as the intern and resident was constantly changing (particularly as I shifted from days to nights). This helped me to improve over the month I was on service and to reflect on what I needed to work on before intern year.

My goal for intern year is to continue using these lessons and growing in my medical knowledge and skills.

Below my evaluation from my Mini-I rotation:

Patient Care

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

 

Taking History.

As I reflect on my medical education and the lesson that I have learned about patient care there is on concept that remains firm: taking a good history is first and foundational. The importance and skill of history taking is one that has been reiterated, from that first longitudinal group session all the way to my fourth year. It is a lesson that I understood during pre-clinicals but really came to appreciate during my clinical rotation. I still remember the first admission I did as a 3rd year on my Internal Medicine rotation. I had gone through my checklist of questions and came back to present to my senior. He suggested that we go back together so that I could observe him obtaining a history. It was a great lesson for me in history taking, bedside manners and being patient centered in medical care. The first thing the resident did was to sit in a chair next to the patient to ensure that he was on the patient level. The second thing he did was ask open-ended questions, allowing the patient to respond. Finally, and perhaps what I have reflected on the most is when he asked the patient what made her come in and what she was worried about. For that particular patient, we were concerned about pneumonia but she was worried that her Crohn’s disease was getting worse. I have applied that last phrase to every patient thereafter, from my ambulatory pediatric to my psychiatry inpatient rotation. I have learned to appreciate what the patient can teach me from a history more than what I could ever tell. As I transition from medical student to resident I can honestly say history-taking is my strongest skill and the one I have worked hardest on honing. It is during the history that you get to know the patient, hear their voice and listen to their concern. My goal for intern year is to never lose sight of patient-centered care, even in the busyness of notes, order and discharge summaries. I also aim to keep my focus on the patients need an how I can work as part of a system in trying to address them.

Below is my third-year feedback from my 3 week IM Gen-Med inpatient rotation. The comments reflect my improvement particularly in terms of patient care and presentation.

Making History.

I started medical school in 2017 as part of the first class of the Primary Care Track program. I was excited to begin my medical education and to be making history. I was making history as the first physician in my family (my father has a PhD) and as a black woman immigrant entering the medical field. For me this history was not just my own but the opportunity to serve the communities I represented. Reflecting on that journey now in my final year has taught me that making history is not just about what you do, but more so what you learn and the legacy you leave behind. The photo below is my at the white coat ceremony, you can tell that I was excited for the journey. However, I could not have imagined how the process of medical school would change me and stretch me. My medical education has highlighted how all the tools I have acquired before—during my undergrad study in public policy and graduate study in public health—would be relevant and applicable even as a enter the specialty of Family Medicine.