Encouraging Discussion

I recently took a class entitled Medical Ethics after the Holocaust that continued to put into perspective the importance of the work I hope to do in the future as a pediatrician. In the course, we learned about the initial eugenics movement in Nazi Germany and its initial target: those with disabilities. They were deemed to be “life unworthy of life,” sterilized without consent, and killed if there was no hope for improvement or potential for “economic contribution” in the post-war state. This is yet another reason I believe that advocacy is so important for this population that has historically been silenced when unable to stand up for themselves despite the fact they are humans deserving of life just like you and me.

In this class, I also learned the importance of discussion, especially discussion with those who have different experiences, viewpoints, and ideas than yourself. While not Jewish myself, I had the fortune to take this class with two peers with extensive Jewish backgrounds, one who is a practicing Jew and another who was born in Israel and immigrated to the United States as a child, both who have experienced anti-semitism countless times in their life. I could not help but make the connections between two oppressed populations, one still feeling the effects of anti-semitism dating back to the Third Reich in WWII and my future patients who are likely facing ableism as we speak. We had numerous discussion posts about often difficult conversations. Sometimes we agreed, sometimes we disagreed, but in the end we all seemed to want to somehow make the world a better place as physicians. By discussing ethical principles we have evidence to now back up our beliefs, speak up for what we believe to be right, and address any misconceptions regarding “life unworthy of life.” One of the discussions from the class is below:

I believe having these discussions and bouncing ideas off of each other has already improved my ability to stand up for others as a physician, despite the hierarchical structure to medicine. Before this course, I have heard a number of attendings use the r-word and felt ashamed that I didn’t have the courage to say anything. Taking this course and realizing the ripple effect that established misconceptions and derogatory language can significantly harm individuals has enabled me to start speaking up by saying, “I know that you don’t mean any harm by using that word, but I know some people with disabilities associated themselves with that word and feel put down when it is used in a negative non-medical sense.” I do not belittle or tell them not to use it, but a simple nudge has often resulted in an appreciative thank you for the reminder and a promise to do their best to use other vocabulary. I hope to carry this fortitude and defense of what I believe to be right in residency, even if I feel intimidated or threatened by a negative evaluation. The feedback I received from this class such as the following has made me feel confident in my communication skills, that I can continue to be an honest, ethical leader in medicine and still come off as caring, not arrogant, condescending, or judgmental:

Still today, people with disabilities are often pushed to the margins of society; therefore, it is my mission to become a developmental-behavioral pediatrician or primary care physician to provide care to these individuals, give them the tools they need to stay healthy and reach their potential, and continuously advocate for their incorporation into society rather than expecting them to conform to the world as we know it. I hope to continuously speak up for what I believe is right in residency and defend any abuses against human life or making someone feel that their “life is not worthy of life.” By encouraging ethical discussion, we can constantly keep ourselves in check as physicians and continue to think more deeply and intentionally about patient care and see them for the human that they are.

 

Swing and a Miss

After completing step 2, I had a weekend to recuperate and then it was back to business. I would be starting my mini-internship on Infectious Disease Team 1 at Nationwide Children’s Hospital. While the past three years of medical school had done nothing but prepare me for this moment of working as an “acting intern,” I could not help but feel anxious going into it. There were plenty of new tasks to do including putting in orders, calling consults, signing out patients, and being first call from nurses and other physicians since we were listed as the primary resident. The only experience we had beforehand was an OSCE on Monday during orientation in which we received feedback on these skills. The first week went well, but I was eased into it by my residents, I picked up a few simpler patients and was told I was doing a good job by the end of the week and ready to start picking up more complex patients going forward. That Friday of the first week, we had to come up with SMART goals for the remainder of our rotation. Knowing that ERAS and residency applications were coming up, and that I would need three letters of recommendation, one of my goals was to receive a Letter of Recommendation from this rotation. Two of my four weeks on service I did two night shifts, so I would only be with the attendings for three days. This meant that my best shot at getting a letter would be week 2 or week 4 since attendings only are on service for a week at a time and I would be with each of these attendings for five days total.

Since I got positive feedback that I was ready to take on a larger case load and more complex patients, I was hoping to do so and impress my week 2 attending and ask him for a letter at the end of the week. I came in on Monday and my resident told me that we had a couple new admits that were incredibly complex and would be impressive to pick up. My residents knew that I was hoping to get a strong letter of recommendation that week and did everything they could to set me up for success. As we rounded, I noticed we were getting closer and closer to noon lecture. Both my patients were last on the rounding list since they were new, and I wasn’t sure if we would be able to get them. I had been repeatedly rehearsing their H&P’s in my head, double checking the differential, and diligently looking up what I thought the next steps should consist of. Sure enough, around 11:30, the attending said we would not have time to see the patients and that we should table round. We got back to the team room, and he told me to make it quick. Since the patients were complicated and knew, I thought to myself, “there’s no way I can make this quick, there’s too much going on.” However, I did my best, gave the pertinent information, but couldn’t help but feel rushed and disorganized. After we finished and the attending left, I apologized to the resident. She asked what for and reassured me that it was rushed, but incredibly organized. She thought I made a great first impression and was completely put on the spot. She thought the attending doubted I would be able to synthesize the information in the allotted time and that’s why he told me to speed through it, so he could talk about the plan with the resident. However, I had covered everything, my plan was great, and the resident didn’t have anything to add, so she was very impressed and felt the attending was too. This gave me a boost of confidence that I carried with me the rest of the week as I cared for more and more patients both straightforward and complex.

Thursday night I was nervous, I knew I was going to ask for a letter the next day, my first time doing so. I played out the various scenarios in my head, worst case scenario he said no, but the feedback I had gotten all week pointed toward that being unlikely. Thursday night we got an e-mail saying that rotations were cancelled over the weekend and on Friday for Juneteenth. I knew that it would be better to ask for a letter in person, and OSU also required us to get mid-rotation feedback on our second Friday. The mini-I’s on other services frantically texted each other, and the consensus was that we are “residents” and should go in the next day, anyway, to not burden the other interns we were working with and to follow our month’s schedule. I went in as usual the next day. The attending walked in and immediately said, “why are you here?” “Good start,” I thought to myself. I replied that I was carrying four patients and hadn’t signed them out and talked with the other fourth year medical students and we all agreed to come in. He did not appear satisfied with this answer, but he did not make any other remarks. Rounding went as usual, and it came time for feedback. I was most worried about my presentation skills given feeling rushed earlier in the week and feeling disorganized, but he said that I did great and he had no tips for presenting etc., I was at resident level. He gave me feedback on actually calling consultants instead of using epic chat, introducing myself as a med student, and coming up with my own differentials without anchoring onto ones that were already established as seen below:

“Not bad,” I thought to myself, and felt that with this mostly positive feedback now was my chance to ask if he could talk about some of this in a letter for residency applications. I asked if he would be willing and he took a deep sigh and looked away. “It’s just so difficult to get to know you with only spending 5 days with you.” I explained to him that I only would work with him and another attending for five days, and that the other two would only have three days. He thought for a second and then agreed that if one of the attendings didn’t repeat later in the week to come talk to him after the rotation and he would work something out. It was not a flat out no, but I could sense he was trying to push this conversation to a later time in hopes that I would ask somebody else. I was devastated. While I had played this scenario in my head and told myself I could always try again or even get a letter from him after the rotation, I continued to feel dejected the rest of the day.

Week 4 came around and it was more or less the same as the past couple of weeks. I was in a groove, having loads of fun acting as a resident and being much more involved in patient care. I had found my stride, implemented my feedback, and was actually able to help out my co-residents as this was their first ever rotation at Nationwide. I completed patient tasks, helped the residents get accustomed to EPIC, showed them where things were at, told them the style and flow of things on ID1, and integrated the feedback I received week 2 when my request for a letter was gently declined. Sure enough, it was the same attending week 4 as we had for 3 days on week one. I was excited to have another chance to ask for a letter and the residents encouraged me to do so. I had my feedback meeting on Friday and he asked what I felt I did well. I focused on my growth and improvement as he had seen me both week 1 and week 4. Over that time, my organizational skills, confidence, presentations, and clinical decision making had all improved in my opinion. He agreed. “This is my shot,” I thought and I asked if he would be willing to write me a letter. He said I would be an exceptional addition to any pediatric residency program and he would be more than happy to do so. Rather than feeling sorry for myself or letting the feeling of rejection shoot me down, I came in to work the next day, integrated the constructive feedback and in the end, I got my letter.

I hope to use this experience to remember to take things a day at a time, especially in residency where I will be constantly learning, getting things wrong, and using this to get them right in the future. Medicine is a constant process of learning and repeating things until becoming an expert in them. Knowing that I sometimes struggle with constructive criticism, I plan to give myself a day to be down about it, but when I wake up the next day, come up with an action plan as to how I can not let it happen again. I will create three things to actively and intentionally work on the day after I feel sad about feedback, and continuously incorporate this practice into my time in residency.