Author: fabiano.17

Systems-Based Practice

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CEO: “Identify and utilize professional role models as a means of growth and accept the responsibility of acting as a role model and teaching and training others”

 

The most wonderful part of academic medicine is the opportunity to learn from fantastic teachers and then apply that knowledge to teach others. One of the areas where this has been most relevant throughout medical school is bedside ultrasound.

As ultrasound requires both knowledge and practical skill, fantastic mentors and teachers have been essential as I’ve built my competence in bedside ultrasound. Multiple times per week, every year, devoted faculty and more advanced students freely donated their time in the evenings with the sole goal of helping others to learn. Reading about how to perform a scan is essential, but having an experienced ultrasonographer demonstrate how to acquire that image in people of various shapes and sizes is invaluable. When I finally reached a level where I was able to contribute meaningfully to the learning of others, I was ecstatic.

As a member of the Advanced Ultrasound curriculum, I had the opportunity to teach the FAST scan to beginners at Ultrafest, OSU’s annual ultrasound symposium. I have been involved in the ultrasound curriculum at OSUCOM since the first year of medical school, but this was the first time I had the opportunity to condense my knowledge of the scans I learned and teach it to others.

This experience was fantastic, because it directly aligns with my future career within emergency medicine, where the FAST exam is an essential, daily component of practice. It was a rewarding experience to take my classroom knowledge from Advanced Ultrasound and my clinical knowledge from two rotations in the emergency department into the classroom to teach others.

I taught groups of students from around the country all day, and the best part of the whole day was the excitement in students’ eyes as we discussed the practical applications of the anatomy they have been learning. I recall being in their positions a few years prior and seeing the utility and practicality of bedside ultrasound. The FAST scan is fun because it is especially flashy and relatively easy to perform on a standardized model, so it was enjoyable to see the instant gratification the students’ received when they were able to find the necessary views.

This experience made it clear to me that I would like some degree of an educational role in my career. I may not pursue academic medicine full time, but the opportunity to teach others is rewarding and rejuvenating, and I accept the responsibility of continuing to teach and excite learners about medicine throughout my career.

See below for pictures from Ultrafest!

 

 

Patient Care

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

 

We are quick to blame patients for their nonadherence to best recommended therapy, especially when that therapy is exercise. Rarely, though, do we set examples for our patients that can be the model and encouragement they need to achieve their health goals. This was one of the founding principles behind Walk with a Doc (WWAD), founded by Dr. David Sabgir in 2005. Dr. Sabgir is a cardiologist who became frustrated that patients repeatedly returned to his office and had not enacted the recommended changes to their lifestyles that he had prescribed to them. He looked inward and decided that he needed to set a better example for his patients.

More than a decade after its founding, WWAFD is now a robust organization with hundreds of chapters across the globe, which hold regular walks for members of the community. This is an opportunity for providers to set an example for their patients as well as for patients to interface with their providers in a less formal setting.

As a community health project, my team and I were fortunate to be paired with WWAD. Their headquarters is in Columbus, OH, and we were able to meet the team and work closely with their staff. For our project, the team wanted us to help launch a new program, Walk with a Future Doc (WWAFD), as medical schools around the country had begun to show interest. We worked with the team to develop the goals, plan, mission, and vision of this new part of the organization.

Upon talking with the WWAD team and some of the existing community members at their walks, we decided that the mission of WWAFD should be twofold: 1) uphold the same mission of empowering and inspiring patients to enact change in their lives and 2) enable patients to influence and help to shape the physicians of the future. Additionally, we had the opportunity to create a detailed framework for the project so that it could be scaled and rolled out at other medical schools.

This was a unique opportunity to think critically about populations of patients instead of the individual patients we normally see in front of us. We were able to see the various walks of life that patients came from when they attended our walks, and learn about the myriad factors that contribute to their ability to exercise and adhere to physician recommendations. Access to safe places to exercise, quality shoes, and uncertainty with how to begin exercising were all common themes.

This came full circle when I was seeing a patient in my LP practice. She had repeatedly had difficulty staying committed to her exercise and diet goals and had lost hope that she would ever been able to accomplish these goals. She was overweight with hyperlipidemia and prediabetes, and she was at a critical point for her health. She knew she was heading down a bad path, but she did not feel that she could manage to change. I invited her to join us for a walk with WWAFD.

When she came to the walk, she told me more about her personal and family life that made it difficult for her to make healthy choices. She enjoyed walking, and told me that she was inspired by “all you busy doctors in training taking time to walk.” She made regular appearances at our walks and continued to update me regarding her adherence to her diet and exercise goals. When I saw her again in the clinic, we had a more open dialogue about her health and had formed an even stronger relationship. Her health status had moderately improved over the course of a few months and both of us were thrilled.

This experience was powerful for me because the population of a community as a whole and an individual patient became clearly intertwined. She was able to find a safe place and stable encouragement to exercise, and the community of people who joined the walk could see her success and be inspired as well.

One of the most important parts of this project was the ability to form a stable organization that would allow for the longitudinal participation of patients from the community. We did not want to leave any patient who counted on us with an organization that was destined to fall apart. We wanted to set the example for our patients that not only were we committed to healthy lifestyle, but that we were committed to them. We encountered many roadblocks, but we finally established a formal club at OSU so that we could receive funding and transition leadership.

I presented this work with a colleague at OSU’s community engagement conference and again at the National Engaged Scholarship Consortium in Minneapolis, MN. This was a fantastic opportunity to combine scholarship with disease prevention/health promotion in the community. In presenting this project, I was able to connect our work in the community to real patient encounters and inspire others to engage the community in similar projects.

As I move forward in medicine, I will continue to implement the principles and lessons I learned through this project. I will not forget the many factors that influence a patient’s ability to exercise or eat a healthy diet. I will also not forget that patients often look to their physicians for inspiration as well as for advice and treatment. I hope to continue to be a positive influence in my patients’ lives, even if I only see them for a short amount of time.

 

Presenting our work in Minneapolis, MN.

 

Our WWAFD team!

Interpersonal Communications

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CEO: “Use information technology appropriately to manage medical information and patient care decisions, promote education, and communicate in the interests of patients.”

 

Free Open Access Medical Education (FOAMed) has grown immensely in popularity in the past few years. Particularly within emergency medicine, FOAMed is a powerful driving force for the latest trends and updates in the specialty. Podcasts are becoming easier to access and increasingly evidence based, with citations often in the show notes. Twitter is also emerging as a powerful force for education. As a society, we have seen the power that Twitter can have during events such as natural disasters and political movements, and educators have begun to leverage this platform.

This past May, I had the opportunity to attend the Society for Academic Emergency Medicine (SAEM) National Conference in Las Vegas as a Medical Student Ambassador (MSA). The team of MSA’s was in charge of running various events and ensuring that the conference flowed smoothly. In addition, an MSA was required to be at every conference session and tweet highlights from the conference. There was a daily newsletter that was sent to conference attendees, but Twitter was the main way everyone was able to learn about all the sessions that were happening that day. In fact, the newsletter included the most popular tweets from the day. This was a new role for me as a creator of content rather than as a consumer, but I enjoyed the challenge.

One of the privileges afforded to the MSAs was the ability to attend any session, even those that required extra fees for standard conference attendees. Along these lines, I had the chance to attend an awake fiberoptic intubation workshop. This was put on by experts in the field who were teaching the procedure using each other and the attendees as models. I was dutifully documenting the key highlights of the session to share on Twitter when one of the paying attendees offered me her spot. I jumped at the opportunity and was the Guinea pig for a few others as they learned the procedure. It was very uncomfortable, but I then asked if I could intubate myself. I received the go-ahead from the team and one of the other MSAs was able to capture it on camera.

The chance to see the inside of my own trachea was awesome to say the least, but more importantly this was the tweet that made my profile known throughout the conference. At subsequent sessions, I was able to connect with leaders in the field such as the Program Director at University of Cincinnati and the Vice Chair of emergency medicine at Harvard. Not only was I able to network within the specialty, I gained a follower base on Twitter from people who were much further into their career and had accomplished great things. As I attended additional sessions and tweeted educational highlights, those followers retweeted my tweets and were able to spread the newest knowledge in the field delivered at SAEM to their extremely broad network of followers. My tweets became known to the SAEM board of directors and one even made the daily newsletter.

This experience demonstrated to me the incredible power of Twitter as a tool to promote education, but this also comes with an increased responsibility. As I become more present on social media, I am opening more of my personal life to the public. I recognize that I have the responsibility to remain professional and appropriate on Twitter (fortunately EM is a specialty is relatively relaxed, as shown below) not only to represent myself but also the institution I work for.

Follow me on Twitter and check out my feed below!

Medical Knowledge and Skills

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

 

The development of competency in medical knowledge and skills is a lifelong pursuit. “Book knowledge” is often emphasized in undergraduate medical education, especially within the first two years (even within an integrated curriculum). This is essential, because a solid foundation of medical knowledge is critical to becoming an effective clinician.

I recently wrote about this in my Senior AOA application. In combination with my academic record and CV, this essay contributed to earning designation as a member of AOA. Please see the prompt and essay included below:

Essay prompt (mandatory; limit your response to 200 words): Describe how your academic achievements in the classroom have served as a springboard to serving the greater good.

 

In recent years, mentors have advised me not to pursue my chosen specialty of Emergency Medicine because “you’re too smart” or “you think about your patients” or, most recently, “your board scores are too high.” While the implications of these comments are unfortunate, they fuel my desires to take my strong foundation of academic achievement and carry it with me into the emergency department (ED). I believe this is essential as a future emergency physician, because the time I devote to academic achievement while outside the ED is what enables me to take care of patients while on a shift.

 

When patients present in extremis, I need to build an instantaneous differential, testing, and treatment plan. Patients’ lives depend on emergency physicians who study hard, pursue excellence, and commit themselves to academic achievement. The community deserves emergency physicians who embody the AOA tenets of academic achievement, professionalism, leadership, ethics, and service. With a foundation of academic achievement, I aim to serve the greater good by bolstering the reputation of the specialty of Emergency Medicine and advocating for my patients so that individuals from all walks of life can receive exceptional care no matter where they are in the healthcare system.

A strong background in medical knowledge means nothing without the ability to apply it in practice. This became readily apparent upon starting clinical rotations during 3rd year of medical school. I wrote an essay, embedded below, which was subsequently published on Doximity Op-Med.

Keeping up Is Hard. Slowing down Is Harder

We come to medical school from many backgrounds, educational paths, and possible previous careers, but very soon after our education begins anew, we can all agree: medical school is HARD. It’s like nothing else. The depth of the material and the speed at which we are expected to learn it is unfathomable at first.

 

I will always be actively working to build my medical knowledge and skills, but I recognize that I must balance this with applying this appropriately and communicating effectively with my patients. As I move forward with my career, I look forward to building my knowledge of the recent literature and continuing to find ways to effectively apply this to the care of my patients.

 

Professionalism

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CEO: “Above all else, a graduate of The Ohio State University College of Medicine shall exemplify the ethics, values and behaviors of the medical profession. As such, the graduate must consistently demonstrate compassion, respect, honesty, integrity, accountability, altruism, prudence, social justice and commitment to excellence in all professional and personal responsibilities”

 

Professionalism is broad, especially within medicine. There are myriad definitions at OSUCOM alone. It’s the combination of what we say, do, and act. It’s how we dress and the way we walk. It’s how we think and talk. It’s how we interact with our colleagues, our mentors, and our mentees. But, most importantly, it’s how our patients perceive us.

During my first clinical rotation of 3rd year, I was on call overnight for OBGYN. I had two weeks under my belt, but I was still extremely new to the clinical environment. That night, a patient presented to triage in distress. She was concerned she was having contractions but did not know how far along she was in her pregnancy. Her best guess was somewhere between 30 and 40 weeks. I didn’t know much at this point, but I knew how to take a history. As I learned more about her story, I learned why she was so uncertain about the dates of her pregnancy.

She was native to an Eastern African country, but regularly travels to Africa, Europe, and North America for work. She had received Obstetric care in at least four countries during her pregnancy. She expressed concern that she had done the wrong thing for her baby, but she needed to keep working to make money to support the baby after the birth. I spent at least an hour with her that night, taking an extremely thorough history and providing her with reassurance. I even managed to obtain the results of her earliest ultrasound from Ethiopia for accurate dates – fortunately it was during normal business hours there!

As demonstrated by those records and our exam, she was at full term and was going into labor. I helped to take care of her that night, deliver her baby in the morning, and take care of her on the postpartum floor the following two days. When I was pre-rounding the final day of her stay in the hospital, she asked if she could get in contact with my supervisor. As a newly-minted M3, I was immediately concerned that I had offended her in some way and she was going to report this to my attending. She reassured me that she only had positive things to say, and I let her know that my attending would visit her later that day. By that time, she had found the below evaluation online, printed it out, and filled it in for me.

 

On the first page of this evaluation, she scored me in full marks on all categories. On the second page, among other comments, she highlighted that I was patient and respectful to someone of a different race. I had not known that she would be evaluating me; I was just trying to provide the best patient care I knew how to provide. When taken together, I feel that the categories on the first page and the commentary on the second page are what professionalism is really all about.

This was just one patient encounter, but I was grateful to receive this evaluation early on in my clinical rotations. It cemented the importance of being kind and professional, even when you don’t have all the answers. As I continue to encounter situations in which I am not fully comfortable or prepared for (especially in emergency medicine!) I will always remember that at a minimum, I can make a patient feel cared-for and respected by being professional as I do my best to figure things out.

Practice-Based and Life Long Learning

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CEO: “Demonstrate an understanding of the role of the student and physician in the improvement of the healthcare delivery system.”

 

I found QI during the first few months of medical school. The original project I worked on was not published, but my mentor sponsored my application to a summer internship within OSU’s Quality and Patient Safety department.

This internship was a 9-week-long experience where I was matched with a Quality Preceptor (Lean Six Sigma Black Belt and RN) and Clinical Preceptor (MD Hospitalist). They had created a project charter and I was thrilled to see the incredible scale of the project (a multi-hospital data analysis and potential system-wide change of parameters). At our first meeting, my preceptors were invigorated by my willingness to take on this project. However, for the first two weeks, we’d had a miscommunication: this project wasn’t intended for me; I was just to do the background research.

As an ambitious student seeking to make a meaningful change, this did not sit well with me. My mentors and I had a series of tense conversations. One theme stood above the rest: “You can’t do this because a medical student has never done this before.” My mentors were professional and understanding of my desires to take on more of the project, but nothing stings more than those two words:

“You. Can’t.”

Everything that happened in the next few weeks could be summed up as “Yes, I can.”

I forged relationships with data managers and IT personnel to bypass the normal slow request process for data. I read hundreds of pages of Lean Six Sigma DMAIC methodologies to ensure this project had a solid foundation. I took online courses to learn advanced Microsoft Excel tools that could aid in the analysis of the mountains of data I was provided. I held my own and spoke up in rooms full of experienced nurses, physicians, and businesspeople when I had something meaningful to contribute. I successfully led meetings after reading dozens of articles on Social Psychology and listening to Harvard Business Review podcasts.

I collaborated with subject matter experts and used data-driven approaches to go up, around, under, and through any obstacle that lay in the way of the project. In those few weeks, I transformed myself. I became the bridge that this project needed. I bridged IT, data, medicine, quality, administration, and design. I became as fluent as possible in the languages of all these groups to create the best work I could as quickly as possible. Maybe “a medical student has never done this before” but that’s alright with me, because that forced me to become more than a medical student.

After a few weeks of this, I was able to outgrow the task of background research. I had proven that my data collection and analysis methods were rock-solid and we were beginning to see meaningful conclusions rise from the data. Now, with my mentors’ trust, I was free to take on as much as possible. I let loose, arriving early and leaving late every day, leveraging every possible connection I had made across the medical center, knowing that my access to this data as an employee would cease at the end of the summer. I had to make something meaningful out of all of this. I had to create change.

At the end of the summer, I presented to the Chief Quality Officer who gave the project the “fast track blessing” and offered to sponsor my Lean Six Sigma Yellow Belt and travel to the IHI national conference to present.

The project has now been piloted and there is a system-wide change in parameters planned for the future. It was exceptionally rewarding to see the results of my work as a pilot on the heart rate monitors during my Acute Coronary rotation.

This experience has taught me lessons that I will carry with me for the rest of my life—organizational awareness, project management, techniques to partner with administration to overcome red tape, and so much more. More than anything though, I am proud to have laid the foundation for a change that will affect (and improve) the lives of hundreds of thousands of patients in the years to come.

As a medical student, I feel I was able to contribute meaningfully to improvement of the healthcare delivery system because I had a unique perspective.

“In the beginner’s mind there are many possibilities; in the expert’s mind there are few.”

This quote is from Shunryu Suzuki, one of the most famous of his teachings within the realm of Zen Buddhism. I am not Buddhist, but I find this idea of beginner’s mind, or original mind (and many other teachings from Zen Buddhism), particularly relevant to the practice of medicine.

Suzuki speaks more of maintaining the state of beginner’s mind in the book Zen Mind, Beginner’s Mind. He says, speaking of the practice of Zen Buddhism,

“For a while you will keep your beginner’s mind, but if you continue to practice one, two, three years or more, although you may improve some, you are liable to lose the limitless meaning of original mind.”

Not only is this idea relevant to medicine, but the wording is perfect. I must heed this advice in my future, remaining aware of my developing biases and natural conclusions I will form if I do not keep a beginner’s mind throughout practice.

Constantly working to maintain this beginner’s mind will enable me to continuously improve my personal practice of medicine as well as the healthcare system as a whole. I look forward to identifying further opportunities for improvement in the various clinical environments I will encounter, and hopefully finding more areas in which I can leave a lasting impact along the way.

 

Suzuki, S., & Dixon, T. (2010). Zen mind, beginner’s mind. Boston: Shambhala.

 

Presenting the alarms project at IHI Orlando 2017.