Caring for Patients Throughout Medical School

Patient Care – 1.2: Comprehensively evaluate patients by a) obtaining accurate and pertinent medical histories, b) conducting appropriate and thorough physical examinations, c) gathering detailed ancillary information, d) synthesizing all relevant data to generate prioritized differential diagnoses, and e) formulating plans of care that reflect an understanding of the environment in which health care is delivered.

When I first started learning about how to take a medical history, I found it a bit overwhelming. I remember trying to learn different mnemonics, self-consciously practicing with other students, and repeatedly forgetting big chunks of the history. When learning how to do physical exams I again met a steep learning curve, at first struggling to just go through the motions without missing anything, let alone feel like I was gaining any useful information. I was grateful for my longitudinal preceptorship, where I had the opportunity to practice my history and physical. I started off with a lot of stumbling and disorganization, but I slowly started to figure out my flow. As can be seen in the evaluations by LP preceptor, I started to progress with my history and physical exam skills as time went on.

Evaluation from longitudinal preceptor in April 2017

 

Evaluation from longitudinal preceptor in October 2017

 

Evaluation from longitudinal preceptor in January 2018However, during my first 2 years, putting that information together and thinking about a differential was still very difficult for me. Although I was told my main job at this stage in my training was to work on just gathering the right information, I still wanted to be able to put together some sort of differential. Even for patients with a simple viral illness, whenever my LP preceptor asked me what I thought was going on with the patient, I felt like my mind would go blank and all I could think of was “I don’t know, I’m not a doctor”.

Third year brought new challenges with inpatient rotations and presenting on rounds. At first every morning felt like a scramble to try and effectively chart review, talk to, and examine the patient in time for rounds. I had to learn what information to actually present and would often overshare while still leaving out crucial details that I missed during pre-rounding. After a few weeks I started feeling much better about subjective and objective parts of my presentation; however, it took me much longer to improve on the assessment and plan portion. It was challenging for me to think beyond what I had seen in a resident’s note from the previous day or what the intern clued me in on.

Throughout third year, I continued to work on assessment and plan. Once I started feeling more comfortable obtaining the information in a timely manner, it became easier to spend time thinking about the next steps. By the time I started my mini-internship in pediatric hematology/oncology, I was able to start thinking more independently and feel confident in my decisions about what to do for my patients. My favorite part of my mini-internship was being able to take complete ownership of my patients and feeling confident that I had the skills needed for intern year. Since I was assigned as the primary resident for my patients, I was the one receiving pages and the primary communicating point for nurses, consults, and other care team members. I also pended all the orders for my patients to be signed by my senior. This allowed me to learn more about what needed to be in my assessment and plans, as performing these tasks forced me to be much more specific and detailed in my thinking. When talking to consults I needed to know the specific question for the consult and communicate the pertinent information about the patient. When choosing to order a medication, I had to think about why it was needed, doses for the specific indication, how long the treatment was needed, and possible side effects to look out for. I loved my increase in independence and responsibility and felt it really contributed to my learning and skill development. An excerpt from my letter of recommendation from an attending during this rotation really showed how much far I have improved throughout medical school.

Letter of recommendation

Although I have come a long way during my time in medical school, there is still a lot I need to improve on in order to be a good doctor. During residency, I want to work on widening my differential and think of less obvious possible causes for a presentation rather than getting stuck on the first thing that jumps to my mind. I also want to improve on incorporating more evidence based medicine into my care and using literature to help guide my decision making. I will use PubMed to find up to date research and may enlist the help of a librarian for more specific searches such as those requiring MeSH terms to find the information I am looking for. I am grateful for all the experiences that have helped me develop the medical knowledge and skills that I have right now, and am excited to continue to learn and improve on them throughout my career.

The Use of Apps in Medicine

Medical Knowledge and Skills – 2.3: Utilize state of the art information technology and tools to retrieve, manage and use biomedical information in the care of individuals and populations.

One of the frustrating things about medicine for me is that although there is a lot of cutting-edge technology being used and developed to treat patients, much of the medical system still lags behind. There are many reasons for this, including the high need for security and the cost and difficulty of updating large and complicated systems; however, that does not make it less frustrating when trying to return a page with one of the numbers missing in the call back number. Despite the fact that some of these technological dinosaurs are seemingly here to stay, there are a huge number of apps available that improve medical care from both the patient and physician ends.

One well known app is MyChart, which allows patients to do things such as view test results, message their doctors, and schedule appointments. MyChart gives patients the opportunity to be more engaged in their medical care, and during medical school, I worked with a program called Moms2B to assess whether it could be used as a teaching tool to help participants improve health literacy. Moms2B is a multidisciplinary program that strives to address clinical and social determinants of high infant mortality rates in Columbus through a community-based nutrition and social support group model. Pregnant women and moms with children up to 1 year old are invited to a weekly session with education, social support, connection with resources, and a free healthy meal. My project at Moms2B was a pilot program to see if MyChart could be used to help pregnant women “know their numbers”, with lessons on anemia, blood pressure, STI status, and blood sugar. Each education session included a short lesson with a portion dedicated to looking up the mom’s numbers on MyChart and talking about what they meant for her health. An example of the lesson on anemia can be seen below.

Lesson on anemia for MyChart Know Your Numbers Project

Although we did not end up being able to study enough patients to publish our results, we did find that individual moms were able to learn and retain information using MyChart. For example, in the study pre-survey, one mom said she had never heard of hemoglobin readings, despite me knowing that she had been to a group lesson on anemia a few weeks earlier. However, on the post-survey weeks after a lesson where she looked up her own hemoglobin value, she was still able to remember that if her hemoglobin was low that was called anemia and there are certain foods you can eat to help with it.

While the MyChart app is useful for patients to have better access to their doctors and medical information, there are other apps that I have used that helped me quickly access best practice treatment guidelines. For example, during my adolescent medicine rotation, there were many apps that I used on a near daily basis to help me make decisions. One such app was the CDC STD Treatment Guide. This app lists sexually transmitted and other urogenital infections and provides information on best practice treatments and alternatives, along with more information such as diagnostic criteria and links to publications about the treatments. I used this app to help guide treatment for issues I saw in clinic every day such as yeast infections and bacterial vaginosis, as well as to look up less common issues such as how to escalate suppressive therapy for recurrent herpes and publications on nonalbicans vulvovaginal candidiasis. A screenshot from the app detailing treatment of chlamydia in adolescents and adults is shown.

CDC STD Treatment Guide entry on Chlamydia

Another app that I used was the CDC contraception guide, which helped me guide contraceptive choices for patients with other medical conditions. When a patient let me know she was interested in birth control, I would use the app to look up other conditions she had to see if any contraceptives were relatively contraindicated. I used this to guide our discussion on which birth control would be best suited to her needs. For example, the screenshots below show guidelines for patients on anticonvulsant therapies and the reasoning behind contraindications or recommendations.

CDC Contraception Guide. Recommendations for patients on anticonvulsant therapy

Technology has made it so there are many ways for both patients and physicians to access medical information and communicate with each other. I am excited to use these as a future physician to be able to directly answer patient questions, as well as make sure that I am treating my patients with the most up to date, evidence-based treatments. The apps that I learned to use during my adolescent medicine rotation will be useful during intern year and beyond, and may prove especially helpful if I become a primary care pediatrician, as I will not see the issues as frequently and will benefit from being able to easily look up the most updated treatment guidelines. Other programs, such as Lexicomp and Micromedex incorporated directly into the EPIC for prescribing medications, the CDC vaccine schedule app, or best practice alerts will also be helpful in making sure I am giving the best care. Intern year will have a steep learning curve, but the wealth of information easily available through technology will make it a little bit easier. There is a huge and growing amount of medical information available, and technology can be used to make that information more accessible and easier to integrate into clinical care.

Quality Improvement for NICU babies

Practice-Based and Lifelong Learning – 3.1: Evaluate the performance of individuals and systems to identify opportunities for improvement.

One of the parts of the LSI curriculum at OSU is the Applied Health Systems Science Program. Part of this program includes a medical student led QI project to identify a system failure and work on the implementation of an improvement for it. For my QI project, I have been working with a group on decreasing post-surgical neonatal hypothermia at Nationwide Children’s Hospital. The initial problem statement for the project is shown below.

Initial problem statement for QI project

Working on this project has been an interesting challenge for our group as none of us have ever rotated through the NICU before, limiting our knowledge on the work flow in this system. However, this has allowed us to learn a lot from our multi-disciplinary colleagues to understand process details and possible areas of improvement. We have been able to attend the peri-op quality improvement meetings that include many team members including nurses, respiratory therapists, and doctors to get feedback on our QI project as well as hear about the many other projects they are working on to improve NICU and peri-operative care.

Another challenge for our project has been inconsistent availability of data. Not long after we started our project, there was a change in data analysis personnel. This has meant that although data has been collected regarding peri-operative neonatal body temperatures, most of it has not been available for our analysis. We have also found that there is a very small sample size of patients to work with, as there are not that many surgeries on NICU patients each month. This has made it difficult for our group to work on system improvements, especially as our project is over the course of a year, a relatively short time compared to the frequency of surgeries and hypothermic events. However, neonatal postoperative hypothermia is still an important issue at NCH that needs to be addressed, so with guidance from our mentor we have been working on improving it.

Our group created a cause and effect fishbone diagram to brainstorm contributing factors to post-operative hypothermia.

Fishbone diagram showing contributing factors to neonatal postoperative hypothermia

We then brought this diagram to the QI meeting to hear feedback and receive input about on other contributing factors. We also sought ideas for interventions to improve temperatures, and rated these ideas based on ease of implementation and size of opportunity for improvement. The diagram below is an opportunity payoff matrix we used to help prioritize the interventions that were brainstormed to determine which intervention to attempt initially.

Opportunity Payoff Matrix

Based on this matrix, we will try to implement a perioperative champion as a first intervention to improve post-operative temperatures for neonates. This will include creating an intraoperative and postoperative temperature check protocol to help increase the number of data points we have in the operative and postoperative period and potentially keep patients away from the hypothermic cutoff. This may also help us better understand contributing factors to postoperative hypothermia to allow for more interventions in the future. The process map below shows where our intervention will affect the process.

Process map with intervention

Right now, we are working on the improvement phase of the DMAIC model for our QI project. We have thought of possible solutions for root causes and selected the solution we want to implement. However, we are still developing the improvement plan for piloting and implementation. By the end of the year, the goal is to implement or intervention and collect data for 4 weeks of this intervention so we can evaluate the results, as well as work on the Control portion of the DMAIC model. Working on this QI project has taught me a lot about the quality improvement process, and I am excited to keep learning about QI as we move forward with our intervention and control process. This experience will also help me in residency and beyond as I continue to work on quality improvement. QI is now a requirement for ACGME residency, so the lessons I am learning now will serve me well as I continue to work on projects  to improve systems and better serve patients.

Sexual Health Education for Adolescents in Foster Care

Interpersonal Communication – 4.6: Effectively prepare and deliver educational materials to individuals and groups.

One of the most important parts about being a doctor is helping patients to understand their health and healthcare. Patient education is a crucial portion of patient care and different populations may require education on different topics. One population that has great need for education but is often neglected are youths in the foster care system. These children and young adults tend to have very inconsistent schooling along with unstable social lives, poor social support, and a host of other difficulties that make it difficult for them to learn the information and skills they need when transitioning out of the foster care system. Adolescents in foster care also experience higher rates of pregnancy than those in the general population, with 55% of females experiencing pregnancy and 23% of males fathering children by age 19.1 For my medical school Community Health Education project, I worked with a group of fellow students to help address this need by creating and implementing a sexual wellness education class for a group of adolescents at New Story Group Home.

For our sexual wellness education class, we focused on three areas: basic anatomy and physiology, giving and receiving consent, and pregnancy prevention. We placed special emphasis on addressing the most common myths regarding these topics and sexual health, as well as anonymously any questions the adolescents had. We created a powerpoint presentation and also had interactive portions such as a condom application demonstration and practice session (on bananas). Below is one of the slides from the presentation where we discussed different myths regarding contraception and pregnancy.

Slide from Sexual Health Education presentation

While we originally designed the lesson to be about an hour long, our participants asked so many questions that the session ended up lasting nearly 3 hours. We were delighted that they were so interested and had so many questions they wanted answered; however, the length of the session did lead to many of the kids having difficulty with sustaining attention. This was an optional program for them to attend (although incentivized by the group home reward system), and towards the end there were a few participants who were roaming in and out or doing other things to distract the others. As Community Health Education projects are done every year by second year medical students at OSU, we recommended that the students taking over our project break up the lesson to allow time for the enormous amount of questions the adolescents had.

Although the program went on for longer than expected, we found that it was overall a huge success, if not just for our ability to keep most of the kids engaged for 3 hours straight. We also found that we were able to help the kids at New Story Group Home learn about basic sex ed and consent, and saw proof of this by providing a pre and post quiz, with results shown below.

Quiz scores before and after lesson

Sexual health and wellness is a topic that all adolescents should receive. However, adolescents in the foster care system are especially in need of such education, and through our Community Health Education project we sought to try and fill this gap. Through our program we were not only able to teach a group of these kids key information for their futures, but also learn critical skills ourselves on how to conduct developmentally appropriate education. In my residency program and beyond I plan to continue providing this type of education to those most in need. It is a passion-project that I hope to incorporate into my future career.

  1. Oshima KMM, Narendorf SC, McMillen JC. Pregnancy Risk Among Older Youth Transitioning Out Of Foster Care. Children and youth services review. 2013;35(10):1760-1765. doi:10.1016/j.childyouth.2013.08.001.

The Team Approach to Obesity

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

One of the most pressing issues that has been facing the American medical system is the obesity epidemic. This widespread and growing problem is one that cannot be cured by a doctor simply diagnosing the patient and then prescribing a medicine to treat. It requires a multidisciplinary approach, and I have been lucky enough throughout medical school to have seen a few of the approaches that are being used right now.

One program that I have been able to volunteer with is Food is Health, which works to improve diabetes outcomes of those with food insecurities by providing education on nutrition and lifestyle changes along with the food needed to implement them. Patients pick out free healthy groceries for their household and are encouraged to bring family members along to participate, with the goal of improving the health of the entire family.

One such family was a mother with two kids. This family, and many families like them, helped me realize that although I was intellectually aware of how socioeconomic barriers like food deserts can make healthy choices difficult, I was still taking many things for granted. When the family started picking out groceries, the mom admitted that she was not sure what an avocado was. As a student on a strict budget, I think of avocados as a bit of a luxury; however, I was still amazed to find out how foreign they were to this mother. As we continued, I was again surprised as I introduced her to produce such as bell peppers, squash, and mangoes. Later, it was her youngest child’s turn to surprise me. He was so excited that he would have bananas to eat that he started singing and dancing about them. Seeing his excitement about a fruit I considered inexpensive and mundane showed me how access to fresh produce was not something to take for granted; and I was delighted to be treated to a song and dance about both bananas and avocados when the family returned the next week.

Another family I saw was a woman who would get groceries for her household of six and would eagerly share how much the healthy groceries were improving their lives. Her kids now loved oatmeal for breakfast and apples with peanut butter for snack. She also reported how she was able to be a much better mother for them now. When the Columbus Dispatch came to interview her about the Food is Health program, I heard about how much her life had changed in the six weeks since starting the program. She had lost 40 pounds without actively dieting, had enough energy to pick up a job painting houses, and no longer had to miss her son’s soccer games because of the need for frequent bathroom trips due to her diabetes.

Excerpt from OhioHealth website page that links to Columbus Dispatch article on Food is Health

This experience emphasized to me the importance of making sure that families have both the education and resources to improve their health. A parent may be aware that their child needs to lose weight, but if they do not feel they have the knowledge or means to make that happen, lecturing on the perils of obesity is not going to help. It will be important for me as a future pediatrician to understand what resources are available to families and help them access those resources. As someone who wants to work with the underserved, I hope to be lucky enough to work with a social worker who can assist families in getting the assistance they need to access healthcare and other.

During my fourth year of medical school, I also had the opportunity to rotate with Healthy Weight and Nutrition at Nationwide Children’s Hospital, where I got to see a multidisciplinary approach to weight management for kids. I first had the opportunity to shadow the doctors, nurse practitioners, dietitians, physical therapists, psychologist, and social worker who worked in the clinic. After seeing everyone’s role on the team, I was then able to see the patients myself and work with the other team members to best serve the patient. I listened to input the other team members had regarding their area of expertise and was also recommend patients to see certain team members based on what I felt their needs were that day. I was also able to attend evening sessions put on by interdisciplinary team members to see ways they were working to address obesity outside of the clinic. Shown below is a flier for a teen class called Empowering U where teenagers learned from dietitians about nutrition in various settings including grocery stores and a farmer’s market that I was able to attend. I was also able to see classes put on by physical therapists to help kids and teenagers be more active and find activities they enjoy enough to continue beyond the class.

Flier for teen nutrition class

There are many areas of healthcare that require a multidisciplinary approach to address. During residency I will continue to learn from and work with these team members. They will be crucial to helping my patients access the care and resources they need, as well as addressing specific needs unique to the patient.

Maintaining Compassion in the Care of All

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

For so called “model” patients such as those who give clear histories and always do what they are told, it is easy to act professionally and treat them with compassion. However, professionalism requires that one maintains this level of care and compassion even for patients who may be labeled as “difficult” for one reason or another. Throughout medical school, I have encountered many patients who have received this label for various reasons, and it is through these encounters I have seen the importance of maintaining professionalism in patient care.

One such patient was seen during a clinic follow up after an emergency room visit. Before I went to see her, I was warned by the resident that the patient would be “difficult”. When I got into the room, I met a very upset woman who was having trouble giving a clear history because of it how unhappy she was. She was repeating herself, struggling to speak about her symptoms, and crying as she thought about how poorly she had been feeling. She discussed how she had never felt this way before, how much she looked forward to going to sleep at night so her pain would stop, how she had no energy, and how she had lost her sense of humor. Throughout this she kept apologizing, saying she knew she was being annoying and a burden to everyone. It became clear that when she was in the emergency department she was treated very dismissively and made to feel like she was wasting everyone’s time. She kept insisting that her symptoms were real and that she was not making them up for attention. As I listened to her, I reassured her that I believed her, echoing how difficult it must be to feel so unwell. I told her that we would help her and that her concerns were being heard.

As I was able to gather more details, I started to realize that this patient was suffering from severe anxiety with panic attacks. While she had some GI symptoms that would require further evaluation, the bulk of what was bothering her seemed to be due to anxiety and panic attacks which were further worsened after being dismissed by medical professionals. As the interview progressed, the patient reported that she was actually starting to feel better, that she felt more energetic, her pain was decreasing, and she was feeling the best she had felt in a long time. She made a joke with her husband and was delighted to find her sense of humor had returned. I realized that this patient had come to the office extremely anxious that her concerns would again not be heard and that she would be brushed off as a nuisance. By being patient and an empathetic listener, I made her feel heard, decreasing her anxiety and panic so I could understand her history and symptoms in order to treat them. When I returned with the resident and attending with a plan to help her, she thanked me profusely and said she finally felt like someone was actually listening to her and trying to help. By being an empathetic and compassionate listener, this patient finally felt heard.

Another patient with whom I interacted and  was labeled “difficult” was a 14-year-old boy admitted to the hospital due to protein calorie malnutrition so severe that that his heart rate was in the 20s. This patient was a teenager, and because of this none of the residents were eager to take on his care – especially as he was a teenager with mental health issues. While my initial interest in pediatrics also stemmed from my love for younger kids, as I got to know this patient I realized how much I also enjoyed the care of adolescents. As a third-year medical student, I was able to spend more time with my patients than the residents, and it was through this patient that I first started learning what it meant to take ownership and accountability for a patient. Due to the amount of time I was able to spend with him, I was the member of the team who knew the patient best and was therefore able to contribute important input to his care. My evaluations reflected my dedication to help this patient, select comments of which are shown below.

Third year evaluation comments

One of the residents I worked with during this rotation remembered the care I gave to this patient and others like him and he brought it up on another rotation I had with him over a year later. The evaluation I received from this resident shown below hints at this.

Fourth year evaluation comment

I believe that maintaining care and compassion towards all patients is key to professionalism and will therefore work hard to continue to do so in the future. Throughout residency, I will meet many patients and families who may challenge my patience.  It may make it difficult to retain this level of compassion while also be dealing with additional responsibilities, work hours, and other stressors. However, I will remember the lessons I have learned in medical school about the importance of a consistently caring attitude to ensure my patients get the care they need and deserve.