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Professionalism: Personal Priorities and Growth from Flaws

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One of the reasons I went into medicine is because I am largely motivated by feeling helpful and useful to other people. I almost always prioritize tasks that help someone in some kind of need.

In undergrad, a good portion of my free time went to tutoring classmates, helping talk people through tough situations, and in general learning to solve problems people had. It didn’t matter if it was the day before an exam or if I had a project due the next day. If someone had a need they expressed to me, I would address it. I’ve stayed up through the night multiple times before my own exams and projects to help someone study for their tests.

I thought that by going into medicine, I would be guaranteed to be able to perform my work as every task is related to someone’s needs, so I continued to prioritize tasks the way I believed was right in medical school. My own academic deadlines didn’t matter. I would stay up before exams, projects and other deadlines to write articles for LSIpedia, help my friends with research, or tutor acquaintances. I even stayed up a few times to talk to a friend I knew from my undergraduate years who was feeling depressed, and ended up staying up twice during exams to make sure they didn’t hurt themselves when they expressed some concern to me. In general, people acknowledged these efforts, and made me feel validated.

Unfortunately, as it turns out, blindly prioritizing other people’s needs isn’t conducive to good medical practice. In modern medicine, there are a myriad of bookkeeping tasks that are not directly related to anyone’s needs that must be performed with equal zeal in order to prevent future complications. I learned this very quickly during medical school. Previously, in my undergraduate years, I treated auxiliary tasks (such as reflections, timekeeping forms, and I’m ashamed to admit- documentation) as non-essential, and finished them when someone asked me specifically for them. Within my first two years I learned that “when someone asked me for them” was too late in the field of medicine. Medical school also had reflections, sign-ins to required events, and required documentation. In an effort to make sure we didn’t have trouble with these auxiliary tasks by the time we were actual doctors, OSU directly grades us on these in a “Professionalism” category, and at the time I was an M1 and M2, a single late assignment meant you failed the Professionalism category for a certain academic block. Despite my best efforts to develop habits to finish things on time, I still submitted an auxiliary assignment late for several academic blocks, as I was unused to keeping organizational habits.

It was harrowing. I hadn’t expected to find something unrelated to the direct work of medicine that I would have so much trouble with.

My motivation, as I’ve stated, is to feel useful to other people, and I hadn’t previously kept a checklist or calendar and maintained myself on it. In my undergraduate years, there were few enough tasks that I could prioritize them all in my head, so I had simply hopped from one task to the next based on what felt most useful. I feel like people trying to help me are frequently perplexed by this, as it is so incompatible with the typical pre-medical path that most people take to get into medical school. One of the first meetings I had to discuss with faculty why I had not submitted one of my evaluations on time, after I explained the circumstances regarding that particular late assignment, one of the faculty mentors  asked me “Why would you, on the week before a test, the day before several assignments are due, go off to print study material for other people?”

I didn’t know what to say to that. I can see why it seems foolish, but the reason I would go off to do that is literally the reason I entered medicine. I am here because I am willing to sacrifice my time to be helpful to others.

But the lesson I took from that meeting was not “if I want to be a doctor, I can’t prioritize other people’s needs directly.” It was “If I want to prioritize other people’s needs, I need to be more organized.” And so even if I failed a few times, I persevered. I learned to keep a checklist, I learned to keep a calendar. I learned to use technology to make these things available to me in all situations. Most importantly, I developed the habits to check and maintain these things regularly, and the habits to maintain redundancy in these so that even if one method fails, I have a backup. And this worked. I gradually made myself more organized and got to a point where I no longer missed auxiliary tasks. I didn’t have to give up my penchant for addressing other people’s needs to do it. I still do many of the things I used to do that made me feel helpful and fulfilled. I still occasionally tutor friends and family online. I still act as a support sounding board for depressed friends and acquaintances who use me as such. I still generate study material, and I still write computer programs for friends who find them useful. However I don’t miss any time-sensitive auxiliary tasks to do it.

I think that this has been one of my greatest successes in medical school, the development of personal organizational skills. I think that by going through the process, I’ve refined these skills to the point where they are above average, where I started well below average. I’ve been able to keep myself much more productive than I imagined I could be as a result, even for auxiliary personal tasks that I want to accomplish for myself. Over the course of my second and third year of medical school, I’ve learned new instruments (some basic guitar and basic violin), gone through flight ground school (in the middle of my IM rotation), learned some Spanish and Russian, and built devices that I’ve wanted to build (an endoscope). Thanks to the organizational ability I’ve developed, I’ve done all of this without sacrificing the things I want to do for other people, or sacrificing any part of my medical training.

I think sometimes having a flaw we are aware of teaches us how to improve much better than just believing we have some “natural ability” for certain things. At least, it certainly feels that way for me with organizing myself.

Thank you for reading about my journey of personal growth!

Medical Knowledge: New Technology in Medicine

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I’ve always been a fan of using technology to make work easier. Medicine is full of areas of workflow that can be improved by technology.

I realize that for many people (myself included, surprisingly) it sends a stab of fear into their heart to hear the words “workflow improvement.” That’s why I try to be at  least partially responsible for all the changes in workflow involving me. I also try to contribute what knowledge of technology and programming I have to improve the quality of life of other people who have similar workflows. To me, being involved in the workflow I’m trying to improve means I’m much less likely to unintentionally sabotage it.

I’ve done this in a few areas.

When I first arrived at OSU I discovered this wonderful student-led initiative called LSIpedia. It is a wiki page like wikipedia that students can edit and put their notes up on so that others can read them (our curriculum is called the “Lead, Serve, Inspire” curriculum- hence the LSI). It’s password protected so that we can discuss OSU specific lectures without accidentally releasing information that is supposed to be private. Very few students were involved in generating content for it, but I was one of them. I spent a great deal of time compiling my lecture notes and creating LSIpedia pages for more complex topics, like complement factors in the bloodstream. About half-way into my first year we also started using the site to generate practice questions and practice tests for peers. There was great interest in this and many people wanted to write questions, but wiki markup is not necessarily easy for writing things with complex formatting like exam questions, even to the initiated. So I called upon my programming background and wrote a little java program (it looks like this) into which you can type your question, possible answer choices, and explanation; and it will generate wiki markup which can be copied and pasted into LSIpedia or any other wiki to generate a nicely formatted exam question (which looks like this).

I identified a need, collaborated with my peers to teach each other, and offered one of my strengths to make the entire process easier.

I’m a big fan of filling in gaps in workflows before trying to improve existing ones; that is: providing something that the people who are doing the work actually want. It’s a fundamental principle of quality improvement- to make sure that people buy into changes you make, but sometimes implementing new technology seems to bypass this step. People will create solutions and implement them without getting feedback. For new technology outside of quality improvement, people just ignore technology that isn’t useful. However to maximize the usefulness of technology, you should go through the process of revising the technology with feedback from the intended user. I certainly went through a few iterations of the LSIpedia question writing program before I got it to a point where it was useful to everyone.

There was another case several years ago where I wrote a program for a friend and mentor of mine who was doing a retrospective research project. He was hoping to tabulate the results of transcranial dopplers from several hundred patients, and was trying to do it by manually reading the report and filling out an excel file. He specifically asked me if it would be possible for me to help with a program of any kind. Now I had previously written programs that went from plain-english text to numbers and sentence fragments or vice-versa (the LSIpedia program is an example), so within an hour I sent him a proof of concept program that you could copy-paste a transcranial doppler report into and get a list of numbers out. He was thrilled, of course, and sent me an example of his excel file and asked if there was also a way to specifically get an excel table out. I looked it up and found a way to use a table that could be again simply copy-pasted into excel, and made my program keep adding a new row every time you pasted in new patient data. His several hundred patients went by very quickly. Again- there was a feedback process to ensure that the technology was useful to the person using it. If I had just given him a list of numbers back, there wouldn’t be much improvement to the workflow, since he would still have to individually copy-paste each number into the corresponding cell in his excel sheet. But this way he just had to copy paste the patient reports into the program and it did all the work for him, greatly speeding up the process.

More recently I had the opportunity to begin to write a phone app to help consolidate several resources in one place for residents. It’s still in development, but it’s also based on filling holes in workflow rather than changing it. The app is meant to address the fact that there are multiple websites for different things for residents- calendars, contact information, and resources. The app puts them all in one easy searchable location, and is also convenient for quick access during clinical situations. I am still developing it, but I have already gone through several cycles of getting user feedback and rebuilding it accordingly.

Technology in medicine IS ultimately used for quality improvement, and so should be developed in a similar way. Thanks for letting me show off a few ways that I’ve done this!

Systems Based Practice: A system of role-modeling

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In a profession like Medicine, one of the most awe-inspiring things to observe is the passing on of proficiency and expertise from generation to generation. The entire field thrives on it, and I would argue it is a necessity for the perpetuation of the field. Any student of medicine learns to respect the expertise of those more experienced than them so that they learn to gain knowledge from a role model, and learn to model a role themselves. A large part of the way students establish their style of practice is by drawing from what aspects of different role models they’d like to emulate. As you may have gathered from my other essays, this system is a large part of why I was drawn to the field, the ability to draw from a wide pool of expertise to create your own system of practice.

I’ve been fortunate to have someone who models some aspect of what I want to be in every clinical rotation I’ve had so far, and I have built my own system for how I think about clinical work from the pieces of advice that I’ve received from the people who mentored me over the course of medical school.

The first thing I learned from a sort of mentor was how to survive as a relatively quiet person in the field of medicine. Fairly early in my surgery rotation I worked with a resident who knew exactly how to do this. She taught me that at the end of the day everyone is happy to work with you as long as you are helpful. You can accomplish this by doing two things: quiet people need to make it apparent that they are willing to help right off the bat. That should be something you should offer verbally, so that everyone knows you are available to help. Secondly, you should air your observations of the things happening around you so that people are aware that you are paying attention. Many people assume that someone being quiet is someone who is not engaged, and it’s important that people are aware that your offer to help isn’t just perfunctory. I noticed repeatedly over the course of my medical school career that this advice applies to many other situations, including patients. Stating your intentions up front enables you to be your quiet self, asking minimal questions and only redirecting the conversation to keep it on topic, and people will realize that you are observing them carefully and are genuinely interested in helping. I think that learning this really enabled the rest of my learning during rotations.

The next big things I incorporated from mentor figures was how to truly apply fundamental principles of medicine in clinical problem solving. It’s funny, my physics and engineering background predisposes me to thinking this way, but I got to a point at the end of second year where I almost abandoned this. I thought there were more situations where my reasoning was leading me astray than situations where it gave me an accurate answer. I do think that this is the reason many people abandon reasoning things out in medicine, and just stick to memorizing things (including memorizing the reason rather than understanding the reason). However, I had a series of mentors, the rotation director for radiology, several of my family practice attendings, both of my internal medicine attendings, who really took the time to show me that many of my deductions were actually accurate. You really shouldn’t abandon reasoning from the most fundamental principles as a doctor. It’s crucial to science to be able to reduce problems to the simplest form possible, and understand how complexity is derived up from there, and it ends up being very important to patient care as well. At heart, all doctors are scientists. We have a differential, which is really a hypothesis about what is wrong with the patient, and we test different treatments to see if our hypothesis was correct. Often times, this conclusion is reached indirectly. We often don’t directly go into the body and see the disease process, but we infer what it is from its response to different things we do. When testing hypotheses and making inferences like this is so crucial to patient care, it is equally crucial that you don’t abandon reasoning things out.

There is a saying, and I’m not sure who I picked it up from. “There’s no such thing as overthinking something if you have all the pieces of the puzzle.” That’s what I’ve come to understand about medicine. If you feel like you’re overthinking something, or unable to reason it out, it’s time to go looking for other puzzle pieces. A thorough history is your greatest weapon. I have had the fortune to train under several people who encourage this thinking. In my third year, during a pediatric neurology rotation, I had the opportunity to practice this. We had on our ward an adolescent boy with a two week history of headaches, sometimes with episodes of confusion preceding or following. He admits that during these episode “something just doesn’t feel right.” At the point where I became involved in his care, he had already had a head CT, an MRI, and 24 hour EEG, all of which were negative. Both he and his mother vehemently denied any history of head injury. He was eager to get out of the hospital at this point, because he had a wrestling meet to get to on the weekend. The key to this case actually came up incidentally. When I checked in with him one morning before rounds, he was asleep, but his mother was there, and I noticed he was snoring very loudly. I thought this was unusual for a kid of his age and habitus, and so I asked his mother if he’s always snored. His mother told me it was funny that I asked, and that this started happening after wrestling practice about two weeks ago. Apparently he had his face slammed into the mat by accident. I told her “Hold on, that sure sounds like a head injury to me.” To which she replied “You know what, you’re right! I totally forgot that that happened.” The missing puzzle piece fell into place. Everyone was expecting a head injury, but we ruled it out based on an incomplete history that was no fault of any of the clinicians. The whole team agreed that it sounded like he had gotten concussed, and then made it worse by continually wrestling and subjecting his head to impact.

Our clinical reasoning in this case was sound, but we were missing a piece of the puzzle, so it was leading us astray. An impact to the head hard enough to change the shape of someone’s nose may very well also cause a concussion, but because the patient didn’t think of it as a significant injury, we didn’t find it through ordinary questioning. Coming at it from another line of attack can often help elucidate the missing information.

The last thing I’ve learned from role models in the field is perhaps what I consider the most important: the art of teaching. Many of the things I’ve learned about teaching someone else parallel the other revelations I’ve had about medicine. One of the big things I’ve learned from my mentors in procedural fields is that you really don’t understand a procedure unless you understand the end goal that each step is trying to work towards. Too many times in medical education, students are taught the steps to perform a procedure without being told why they are done a certain way. When tying sutures, we aren’t taught to think about which string needs to go where. When drawing fluid or accessing a vein, we aren’t taught that the reason we hold certain things a certain way is to anchor them relative to the body or relative to a structure in the body. Actually that has honestly been the biggest unspoken thing about procedural skills that I’ve learned. If every step of a procedure, you can think about what you’re NOT supposed to be moving with respect to, and anchor your hand against that thing, you’ll probably perform the procedure with proper technique. This is, we could say, a fundamental principle of procedural skills, and proper technique can be derived from this principle. Proper teaching of the technique involves not just giving the exact hand motions required to do the technique, but giving the fundamental principle from which those hand motions are derived. This way the learner learns how to figure out the proper technique for slightly different situations. I had the fantastic fortune to have residents and attendings who handed these principles down to me, and I have found that handing these principles down to the people learning from me are extremely helpful in establishing a lasting understanding of the procedure. I’ve gotten the opportunity to teach M1’s how to do a fine-needle aspiration with ultrasound guidance, and understanding how to impart the fundamental principles of the procedure made it very easy for them to understand. One of the most rewarding things is getting to teach someone something on their career path far earlier than you learned it, and having them articulate back an understanding that makes it clear they won’t have the same struggles you did. I think that’s a large part of how the field of medicine becomes more advanced. I’ve shared some pictures of this teaching session below. That’s me on the right, overdressed as usual.

Thanks for your attention!

Lifelong Learning: Curiosity

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Learning is what takes the drudgery out of anything you do for extended periods of time. I’m of the belief that you can always improve. Even for tasks with a relatively low skill ceiling (there’s only so good you can get at doing them) can be done in different ways, or tied together with other tasks in an attempt to make them more efficient. Any field of medicine has an extremely high skill ceiling, so there is a multitude of ways to approach something mentally, and nearly infinite number of things to keep improving upon, and many perspectives to teach and learn for every topic.

The first step to this is to be observant, and willing to apply things that you’ve learned in other fields or from other people to your current field and current team.

I’ve said before that patient care is like solving puzzles for humanity. To me, solving puzzles is all about observation. It’s about being curious enough to look at all the details and think about all the possibilities, and combine many observations together into a novel solution. This is central to my philosophy of learning. I am well aware that as a medical student, “helping” can actually be dangerous, and I am liable to make errors and cause additional problems since there are a myriad of things in a procedure room that must be done just-so. But I observe. My first several times on a rotation or in a particular area, I will observe to find a few tasks that I am capable of helping with, then I’ll observe the exact steps that someone takes to perform that task. I will try that task once or twice when there is little time pressure and someone to watch me do it. I do this for even simple tasks, like pulling a sterile item for a scrub tech or opening a gown. Doing this in a busy clinical environment frees up little bits of time, and I suspect freeing those little bits of time is what allows people to give me so many teaching points. It’s surprising sometimes how much time and effort it takes to be helpful, but it is incredibly fulfilling when someone acknowledges that effort.

It’s this specific process that has enabled me to work with attendings and residents who most students find characteristically “particular” with no real difficulty. On my surgery rotation, I worked several times with an attending that was notorious for never letting students suture or tie knots. I spent my time simply observing what it was that he did. While I couldn’t mimic his speed, I could at least note his personal preferences – such as tying all his knots and then going back and cutting them at the end, and the fact that he liked to throw at least 7 knots on a nylon suture. At one point when he stepped out to let the resident close, I asked the resident if it would be okay for me to suture part of the incision. The resident walked me through it and helped me work on something that would likely be passable to the attending. The next time, the resident mentioned to the attending that I was able to suture pretty well, and he actually let me suture a small portion of the incision while the resident and he were working on another incision.

I had another attending who was very particular about surgical technique, and didn’t like students handling things because he didn’t trust our sterile technique. I understood a lot of his concerns about things like letting sterile packages fold back over, and making sure your waist was a hard line for what on your gown was sterile. He saw me open sterile packages a few times for the scrub techs, and after seeing how meticulous I was, he pretty much allowed me to help in every area of the operating room. I enjoy working with people, or working in areas, that require you to be particular. It teaches you to be conscientious of everything you are doing, and build not just habits, but a mental model that helps you establish appropriate habits for a certain situation.

 

I think this philosophy is part of why I feel that teaching follows naturally from learning. I’ve already been through the effort of understanding the nuance of a topic and building a mental model for it, and I understand what people currently learning it are going through.

I remember this being helpful when teaching third year medical students to suture as a fourth year. When I learned to suture, I remember being taught the exact hand motions required to create a knot one-handed and two handed. This seems sufficient in principle, but everyone has their own variations on these hand motions, and their own way to keep track of which way to throw the knot to maintain a square knot. I had reduced these to a few basic principles which held true regardless of whether you tied left-handed, right-handed, one-handed, or two handed.

  1. Always put your hand where you want the knot to be, and pass the strings over it from outside to inside in opposite directions.
  2. Pass one string under the other without ever fully letting go of either string to maintain tension.
  3. For a square knot, use the same string (now on the opposite side) to pass under in the same direction.

I’ve explained these visually in this video. This was my mental model for tying surgical knots. I found this invaluable for teaching people just learning to suture. A frequent complaint is that people often remember the starting position, but don’t remember where to go from there. These principles made it so that even if you don’t fully remember where to start, you’ll still tie a knot properly and tightly. If you do remember where to start for a particular type of tie, these principles will lead you through the subsequent steps naturally. This mental model, since it was different from the usual way students were taught, was gave people a new way to think about the problem and thus reinforced their learning.

It makes life easier for everyone working together if we share our skills and our approaches to a problem. There’s always something new to learn, even if it’s a fresh approach to a familiar problem.

This is also why I think I have success with independent projects. Having mentors in many different fields has trained me to keep attacking problems from different angles.

Most recently, I’ve been working on an endoscope that can see in the infrared range. Since I’ve been working on it independently, I’ve had to develop my own techniques for working with objects that small. A lot of trial and error went into simply being able to modify a camera smaller than a pencil to see in the infrared. Most of these would likely be tedious to read an account of, so I’ll just give one example. When I was getting close to finishing the first prototype of the device, I had to place heat shrink[link this] around the assembly to waterproof the whole thing. The initial plan was to affix the infrared filter to the front of the assembly by simply shrinking the heat shrink around the filter. However it turns out that the heatshrink shrinking around the filter simply causes it to pop out as the heat shrink squeezes around it. I had previously discovered that placing any form of adhesive under the filter reflected my infrared light source into the camera and caused glare. I tried avoiding this by placing small amounts of hot glue right next to the camera with the hope that it wouldn’t melt before I was able to shrink the heat shrink. This didn’t work. I was cautious about using a heat-tolerant adhesive like superglue, because if I even got a small amount on the camera or the lights, there would be a permanent compromise to image quality. At that point I came up to the idea to create a frame for the filter using bent copper wire. This frame could be glued to the assembly far away from the lights and camera, but would prevent the filter from popping out. Indeed, this did the trick, and you can see the final result in the image below. I had a working camera that rendered certain opaque objects transparent, and it was due to the fact that I had a wide toolkit with multiple ways to approach the problem.

That’s what it means to me to be a lifelong learner. To continually observe and learn to make things better, to pass on your own learning to other learners, and to be willing to attack a problem from multiple different angles to create your own points of learning.

Thanks for your attention!

Patient Care- Solving Puzzles for Humanity

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One of the reasons I entered this field is because I enjoy working in teams and I enjoy solving puzzles. Granted, these features are common to many other fields of work besides medicine, but nowhere other than medicine are they so inextricably tied to taking care of people. Taking care of people (i.e. patient care) is a massively cooperative endeavor. Teamwork is needed between clinicians and other clinicians taking care of the same patients, and teamwork is also needed between clinicians and the patients they are taking care of. There is also both an emotional and a technical side to this teamwork, empathy is needed for both fellow clinicians and patients, and a clear understanding of roles must be established between clinicians and other clinicians and between clinicians and their patients. I personally feel the technical understanding of roles is motivated easily with sufficient empathy, but that maintaining empathy can be difficult, and there is quite a lot of nuance in the technical aspect of teamwork in patient care. There’s a lot more that goes into patient care than I first realized when I entered medical school.

Even maintaining sufficient empathy is actually a much more tenuous thing in the field of medicine than I initially assumed, and it is not through the fault of any providers. I’ve only been a medical student so far, with maybe 4 or 5 patients to try to take care of at most, and even with that I’ve had days where I feel emotionally drained. The study of medicine has done a lot to train my psyche to change logical and environmental contexts for a problem, but it is still extremely difficult to switch emotional contexts several times through the day and not feel emotionally fatigued. By observing myself and the physicians around me, what I’ve found to be successful over my thus far brief clinical career is tempering your feelings with an understanding of what it is you’re hoping to accomplish for the patient, and frequent debriefings.

Tempering your emotions with an understanding of what you’re hoping to accomplish is fundamental to clinician-patient empathy. It allows you to focus on the presenting problem while still understanding that there may be things more vital to the patient’s health than what they themselves perceive as immediate concerns. An excellent example of this is time spent on counseling for things like smoking cessation. I can’t count the number of times I’ve seen a patient come in for a COPD exacerbation for something like the fifth time and the underlying smoking problem is written off as an “outpatient problem” or something the patient won’t be amenable to changing because they’re hostile. The team and the patient all just expect the patient to get additional supplemental oxygen, antibiotics, stay for a few days, go home, and inevitably repeat the whole process in a month or two. I too, had accepted this as inevitable after the sixth or seventh time I saw this.

But there was one such patient and one extremely patient resident that showed me how even in these cases, you must try, and the only way to do so is by tempering your feelings with knowledge of what the ultimate goal is for a patient.

What is ultimately more annoying for the disgruntled patient? Getting an unsuccessful smoking talk, or having COPD exacerbations of slowly increasing intensity and frequency? What is ultimately more annoying for the provider? Taking the time to attempt a smoking talk that addresses the patient’s unique motivations? Or having to deal with that patient again the next time they come in?

This particular patient was here after 3 months of repeated emergency room visits, and had already argued with the nurse this time for needing to use a nicotine patch instead of letting him smoke.

The resident I worked with refused to let this go however. When we were concluding the interview, he cut in, and the conversation went like this:

“Okay so there is something we can do to stop these frequent exacerbations from getting worse.”

“You’re going to tell me to stop smoking”

“I’m going to tell you that time and time again the thing we see that drives COPD is smoking. It’s the only thing that really contributes to making the thing worse in patients like you. And while it’s really impressive that you’ve cut back to a pack a day, your COPD seems to still be getting worse. So do you think you might consider cutting back some more?”

“Wait, smoking is the only thing that makes the COPD worse?”

“Yes.”

“I thought it was infection.”

“In your case the exacerbations are probably symptoms of a mild infection of some sort, but the infections themselves are a symptom of your COPD. Someone without COPD doesn’t have exacerbations that require antibiotics like yours, right?”

And that did it, at least softened up the patient’s view a little. We discussed a little more about how really smoking was the thing that was driving his disease, and he was willing to discuss the matter further with the residents, and to continue the nicotine patches when he got out of the hospital.

I found this experience very formative in my notion of how to go through the rest of my clinical rotations and I hope to retain it when I go through residency. Going into that situation, I was frustrated, the residents were frustrated, the attending was frustrated, and I had seen so many situations previously where the clinical team would just write off the patient as trapped in that cycle, and we wouldn’t do anything for them. However in this situation, because the clinical team and I tempered our emotions with our goal for the patient, we realized that he was just as frustrated as us, and we were able to approach the topic from a perspective that both gave him incentive and didn’t immediately turn him off; We were able to include him as part of his own healthcare team and give him information that he had either forgotten or did not previously have.

Regardless of how much empathy you have and how well it’s directed, you will occasionally have bad or suboptimal outcomes due to things out of your control. This is where frequent debriefing is necessary. I have seen a case of a neonatal death in childbirth, and cases of child abuse. Without talking about these things with the other members of the medical team who saw these situations, it’s hard to switch emotional contexts for situations that evoke such strong feelings. Provided you understand the ways to deal with all kinds of emotional fatigue, I feel that most of the technical side of patient care easily comes from just asking yourself what you can do for the patient.

The only part of the technical side that does not come naturally (or at least did not, to me) was the art of establishing roles and expectations.

I think that this is difficult for physicians and medical professionals, because they feel like they’re expected to have all the answers, or at least an answer of some kind. But while it’s important to attempt to do all you can do for a patient, sometimes the best thing to do is to understand that other clinicians with different expertise will provide the best care to a patient.  Establishing clinician-clinician roles, and what you can provide to the patient and what others will have to, is also an important part of the teamwork and puzzle solving that goes into patient care. A consult service may be able to provide much better suggestions for your patient’s problem than you might be able to.

Of course, sometimes a provider can overcompensate and neglect to do something for a patient because they expect the consulting service to take care of it. I’m happy to have rotated through a few consulting services because it exposed me to some of these difficulties from the consult side. Frequently to save time I’ve seen residents avoid doing a neuro exam because “we’re consulting neuro anyway.” However I’ve seen how on the consult service it’s supremely helpful, even if the clinician doing it doesn’t remember all the elements of a thorough neurological exam, because it provides some notion at least of how the patient’s condition changes over time, and also forces the clinician to think about what is happening, which provides insight into the patient’s overall condition.

As a provider interacting with another provider for the first time, it is important to establish what you can provide to the patient, what that provider can provide, and what you can both do to make each other’s lives easier.

Of course, clinician-patient interactions also have roles that must be established. One of the better examples of this that I’ve seen is establishing the limitations of the provider when managing a headache patient. It is important for patients to know that chronic headaches often never completely go away, but that the provider can still help slowly whittle away at the symptoms. Without establishing this expectation of the clinician’s role, the patient can be left disappointed that little progress is being made in treating their headache. The clinician can also become frustrated that the patient seems ungrateful, or feel powerless to stop the patient’s ailment. The clinician-clinician roles must also be well established here, because referrals to other specialists might be necessary in the evaluation of a headache problem.

If clear roles are established, and empathy can be maintained, patient care follows easily. When done properly, patient care is a beautiful intermeshing of emotional and technical elements that can solve problems and make a difference in people’s lives.

I still have a lot to learn about proper patient care, and a lot of good habits to cement and a lot of bad habits to revise. But if my evaluations are worth anything I think I’m on the right track.

Patient Counseling Eval

Psych H&P eval

IM H&P Eval

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Interpersonal Communication – Teaching and Learning

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As you’ve probably picked up from the other posts on my showcase portfolio, teaching is something I’m big on. As physicians and aspiring physicians, not a day goes by when we aren’t learning and teaching—as at the very least we’re learning something about the intricacies of our patient, and we’re teaching our patients something about the way their bodies works or how to manage their health. I find that the key to successful education is communication. The key to effective communication in the context of education however, is manifold.

Communication in education first and foremost requires that you take initiative. You must be able to identify that there is a need for something to be taught: whether it be because the information is not easily accessible to someone who needs to learn it, or because the framework of understanding that someone possesses is not sufficient to incorporate the new information that they need to learn. Secondly, effective teaching requires that you be willing to collaborate with your learners and other teachers. You must be able not just to disseminate information, but continually assess how the information is being processed and being used by the learner, as well as integrating that with the information the learner is receiving from other teachers. Lastly, teaching communication often requires that you can make a personal appeal to those who you are teaching. This builds on the other two elements of communication in education; if you can identify needs in your learners and collaborate with them, you should also appeal to how their new skills apply to the way they live their life. I would say that those are the elements of communication in education I’ve striven to attain: the ability to take initiative, the ability to collaborate, and the ability to make a personal appeal.

As with most things, the first step is the hardest, and taking initiative is hard. I’m not a very competitive person by nature, so in an environment like medical school I have difficulty taking initiative. It feels like everyone is competing for even minor things and I hate to interfere with things that other people want. Regardless, I generally find myself capable of taking initiative through uncommon channels of production, which later turn out to be very useful to my peers and other learners.

For example, when we first started learning infectious disease and host defense in the second year of medical school, the antibiotics were presented to us as a long list based on drug type, with a couple factoids about various drugs sprinkled into the midst. I, like many of my peers, have trouble memorizing and integrating information when given as a straight list. I identified that there was a need for a different way of presenting the information. I began to organize the antibiotics by group and subgroups, based on mechanism of action, and started to create a visual map, tagged with important facts about the antibiotics. When I was done I had a big chart with the antibiotics arranged in an aesthetically pleasing and logical fashion that would enable you to remember mechanism of action by the position of each antibiotic on the map. The first version of the chart I uploaded to our medical school’s facebook group was met with resounding praise, and I ended up printing out several full-size copies (3 feet by 4 feet! It looks like this.) for classmates at the OSU library’s big printer. I didn’t stop there though, now that I was convinced my chart was useful, revised it over several months of illustration, fact checking, and layout revision to generate an educational wall map worthy of publishing. Then I learned how to register an ISBN, found a printer who could print the map, published and printed the chart, and started selling it on Amazon (at a much more reasonable price than most educational materials, since I know how much the cost can sting the student wallet). At the time of writing I’ve sold almost a hundred of them, with minimal advertising on my part. Although the perfectionist in me can still think of many things to improve with this chart, I have yet to get a negative review (heck, I’ve yet to get a review that isn’t 5 stars), and I even have some repeat buyers who I presume found the chart useful enough to get copies for friends.

All in all, I think I successfully identified the need for an alternative framework for presenting a topic, and addressed it well.

The second element of teaching communication comes considerably easier to me: collaboration. I naturally tend to try to work around what other people are doing, and offer my strengths when they are useful.

 

That’s not to say that collaboration was always easy for me. OSU has this other wonderful program to teach students health coaching, which in retrospect has made it very easy to deal with patients who would otherwise be very difficult. We found a patient we had met in our clinical experience, and helped sit down with them to establish personal health goals, as well as brainstorm a plan to help them achieve those goals. We had several preparation sessions where we learned how to ask questions and get the patient to develop their own plan and make them feel like they had the ability to follow through. I felt very prepared to get in there and help change someone’s life.

Naturally all I had learned through our preparation sessions went out the door when I first met my health coaching patient. She had seen a health coach before, so she already had a plan for taking care of her health. She already had ideas for getting enough exercise regularly which she followed through with most of the time, and she already checked her blood glucose regularly and maintained fairly good glycemic control. There were no big changes that I could make. However, after talking with her at length, I learned that there were still things she wished she could do, like exercise during the winter months, and manage to eat a full meal for breakfast so she wouldn’t drop her sugars low during the day, which she was unable to do with her current plan. We could brainstorm together to come up with small tweaks that would help her- finding mall to walk around indoors that her husband was interested in going to with her, and finding ways for her to keep at least a few emergency breakfast foods like applesauce and yogurt at the workplace that she could eat in the mornings.

I learned that collaboration when it comes to teaching people isn’t always about using one of your strengths to offer some big change that makes everyone’s job easier, it’s often working with someone and appealing to a bunch of little changes that they can personally achieve and implement in their own lives.

And that’s the last element of communication in education: making a personal appeal. It is one that I’ve learned through numerous patient encounters and other situations where I’m trying to help people. To me, teaching is always about helping people, so I’m usually thinking about how what I’m teaching them is going to help them in their life. I’ve seen repeatedly that coming up with practical appeals is what really drives the point home to most people. If you can appeal to how someone lives or wants to live in what you teach, they’ll never forget what you’ve taught them. I know I briefly touched on that with health coaching, but it’s become very applicable in real patient encounters and I feel like this has helped me make a positive impact on several people.

One of the more recent instances in which the skill of personal appeal helped was in a man who we had admitted for COPD exacerbation and uncontrolled diabetes which he only recently found out he had.  He had been notified he had diabetes previously, but it didn’t really hit him until one of his friends with a long history of diabetes made him check his sugars. It was running in the 400’s to 500’s consistently for a few weeks. Apparently, his friend told him that was very bad, so it was a chief concern of his when he first got admitted to the hospital and he mentioned it verbally to every provider who saw him. However over the first few days as we started him on an insulin drip, his actions didn’t seem to match his words. He would intermittently disconnect his insulin drip when repositioning himself in the room without reconnecting it and sneak snacks at unknown times. It made it very hard to determine the right regimen to treat him. It was very confusing to me, because from the stories he told, his friend had lost limbs and kidney function from his disease, so this man knew the long-term sequelae of his disease. He also never seemed to remember the education we gave him on how he’d have to take care of himself at home. After a second day of bewilderment I decided to figure out why he was acting the way he was acting. I just started out by asking him what he’d learned so far from us about how he’d have to treat himself for his disease.

“I have to give myself insulin shots and check my blood sugars,” he said.

“How often?” I asked him.

“Every day.” He raised an eyebrow and made to roll his eyes.

“Do you know what your goals are for your sugar?”

“I can’t remember.”

“Do you know what’s too low for you?”

“…100.”

“That’s about right. The endocrinologists want 90 in your case. Do you know what’s too high?”

“140?” He looked to me for confirmation.

“It’s a little higher than that.”

“Hmm. Well, I figure if I can have sugars of 400-500 for a few weeks without feeling anything, then I have a lot of range to play around with.”

And there it was. That was the fundamental misunderstanding leading to his behavior. My shock must have shown on my face because he also paused for a moment to just try to read me.

I then told him that a blood sugar of 400 was like a punch to the kidney that he wasn’t going to feel until a year or more down the line. I asked him if he’d ever have an injury that he just kind of shook off because he wasn’t feeling anything, but then the next day it hurt very badly (not the exact description I used). He said:

“Like football. You shake it off but then the next morning your head hurts and your back hurts and you can’t hardly get up.”

I told him it was exactly like that, except in this case it wouldn’t hurt right away. It would hurt months, years down the line, and I told him that it seems like he has some idea of how it would hurt, given all the things that happened to his friend.

He got very solemn after that, and asked me to tell him what a good sugar was for him. I told him that anything above 180 was bad for him, and the range we wanted him to shoot for was 90-180. We then went over his entire regimen and brainstormed ways for him to remember to take his insulin and sugars, like leaving his glucometer near the coffee machine, and leaving his insulin on his computer which he checks before bed. He had a couple more hiccups where he forgot things during his hospital stay, but after that he was always able to tell me the general plan and what to do in case of an emergency.

I felt pretty proud of that, because it tied everything I had learned about teaching together. I identified that there was a need for education, I made a personal appeal to this man, and I collaborated with him to determine the right strategy to teach him the skill of managing his diabetes.

Anyway, I hope that gives you a good idea of my philosophy when it comes to learning and teaching.
Thanks for hearing me out!

–Nitin

P.S. Have a photo I took in the Shawnee Wilderness on one of the Wilderness Medicine Interest Group trips.

I love backlit leaves they're pretty.