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On its surface, professionalism seems like a competency that should be mastered prior to entry into medical school. After all, showing up on time, dressing appropriately, treating people respectfully, behaving with integrity and honesty, and holding oneself accountable for their responsibilities are basic expectations in any line of work. Medicine is no exception, however, its acuity and demanding nature can strain people in different ways – at times sparking lapses in professionalism from even the most resolved and well-intentioned individuals. Such slips (within reason) appear to be tacitly understood with the expectation that as the moment passes and tensions cool, lessons will be learned that can hopefully guide behaviors in similar situations moving forward. This is where the nebulous concept of professionalism reveals an underlying substantial, challenging, and essential skill to be honed: resiliency.

For some, medical school represents a second wave in an already full and enriching life. For me, a student who entered straight from college (which I entered straight from high school), medical school represents the first sustained challenge I have faced in my life. Prior to my arrival in Columbus, professional success had always come readily, easily, and frankly, expectedly. My personal resolve was certainly tested at times, but these challenges occurred within discrete time frames accompanied by the promise that the gravy train would again be chugging along in short order. While I understood that things were going to get tougher in medical school, I was frankly unprepared for the impending sense of inadequacy I would experience upon suddenly being placed among the most intelligent, driven, and accomplished group of peers I had ever been part of in my life (by an unspeakably wide margin).

In the past I never had reservations about speaking my mind, but I unfortunately found myself questioning the value of my contributions early on in medical school. My belief that my peers were too smart, talented, wise, and experienced to take my observations seriously left me silent during group discussions, as expressed by my peers’ early LG evaluations (shown below).

These reservations not only brought previously unrecognized personal insecurities to light, but demonstrated an inadvertent lapse in professionalism on my part. Though I had exhibited the most superficial tenets of professionalism, my behavior utterly lacked features of collaboration, collegiality, and a commitment to excellence. Furthermore, I was denying my peers another source to feed into the communal discussion. Over the following two years of LG, I slowly but deliberately worked to address this issue, and as I did I found myself enjoying our group meetings more and carrying so much more from our discussions. I believe my peers acknowledged this development, as evidenced by my final LG evaluations (shown below).

When the core educational objectives were first presented to us, I frankly viewed “professionalism” as trite and uninspired filler. After all, how can one develop professionalism? Have we not already been deemed “professional” through our admission to professional school? Will I be assigned a babysitter to dress me in the morning and slap my wrist if I say something naughty?

Ultimately I found professionalism to be the most critical and difficult competency to develop, but also the most rewarding. While I only illustrated one example of my personal development, the last four years have marked the most dramatic evolution of my character over my entire life. The demands and pressures of medical school have exposed personal shortcomings that have otherwise flown under the surface while I previously glided fairly effortlessly through life. Being forced to face these limitations not only allowed me to address them specifically, but each instance strengthened my resiliency allowing me to more effectively identify and take on the next inevitable challenge. The story I shared here was one of the simplest obstacles I overcame in medical school, but was arguably the most difficult to traverse given how inexperienced I was at the time. I am certain that my greatest hurdles are yet to come, but I am now so much more comfortable with the notion of being challenged. Four years ago I was constantly terrified of scarring my ego, but now I yearn for further opportunities for growth – with their accompanied bruises, shortcomings, and all.

Attending medical school at a major academic center has afforded me countless valuable opportunities, from observing rare disease presentations (such as NMDA receptor encephalitis on my neurology rotation) to picking the brains of specialists and experts from every field imaginable. In addition, training in Columbus, OH has exposed to me a robust spectrum of need, affluence, challenges, and the many different ways that healthcare can look to different people. Though I entered medical school having shadowed a few family medicine doctors and volunteered in my spare time at a local free clinic in Cleveland, I had only a rudimentary understanding of the underlying machinery which makes the medical system move and the variety of settings through which care can be disseminated.

I was always aware that doctors do not work alone and there exist many other important pieces beyond nursing and administration, but I was frankly unprepared for the bevy of professionals that I would meet over the following years. From PAs to NPs to CRNAs to social workers to patient advocates to PT/OT to music/art therapists to chaplains to hospital security to volunteers to sitters to countless others, I had to learn how each of these important elements plugged into the system at large – as well as how physicians effectively work in tandem with these individuals in pursuit of a common goal. This task was complicated in cases where I had to discretely google the meaning of someone’s title before introducing myself, but I was always met with friendliness and cooperation when I ultimately reached out. Over time I not only learned what various job titles stood for, but also the specific situations where they shine in the frequently muddy landscape of patient care. I also gained a deep appreciation for the genuine value they provide, and I subsequently made a point to ensure that any residency program I explored judiciously maintains adequate coverage and support for these staff.

In addition to meeting a variety of players within the system at large, I also experienced the subtle and not-so-subtle features that differentiate individual healthcare settings. While the bulk of my rotations occurred in bread and butter inpatient and outpatient spots through Ohio State, I did have the chance to periodically wander into other sites. My free clinic experiences highlighted the massive amount of good that can be disseminated to people in need with even the most basic resources, and how simply getting patients in the door can be a monumental challenge. My rotations at federally qualified health centers (lower lights and heart of ohio family health) showed me how the same challenges and needs addressed by free clinics can be addressed in a more structured setting, along with the challenges of adhering to additional federal guidelines. My rotation at Mount Carmel introduced me to the notion that simply using a different EMR can be akin to being dropped in a foreign country with no understanding of the local language. Finally, and most notably, my rotation with Dr. O’Handley in the Mount Carmel Outreach mobile clinic (shown below) opened my eyes to the incredible challenges faced by the expansive homeless population along with the unique medical needs that exist for these people that are so often unable to get in the door elsewhere.

Learning to navigate the complex system of healthcare delivery has been an unpredictable challenge. While medical knowledge can be contained in a textbook and is significantly testable, healthcare systems are large, nebulous, ever-evolving, and inconsistent from place to place. Although I can’t even claim to fully understand how the cogs turn at my home institution, I believe that my time at Ohio State and its partner institutions has instilled a sense of openness and curiosity that I will carry with me to whatever home I ultimately find myself in. Furthermore, the deep appreciation I have for all people involved in patient care will hopefully facilitate effective teamwork that makes our collective lives easier while simultaneously bringing us all closer to the communal goal of achieving high quality patient care.

Choosing to attend medical school has undoubtedly been the single biggest decision of my life, and I have to believe most of my colleagues feel similarly. Many life experiences and personal driving factors play into that initial decision to set off on this demanding path – and these reasons are meticulously explored by medical school admissions committees to ensure that their future students know what they’re getting into and are prepared for the task. However, despite dissecting the decision to become a doctor from every imaginable vantage point, a huge percentage of entering medical students turn out to be relatively clueless with regard to which type of doctor they want to become (as many as 75 percent, per the AAMC¹). I, myself, certainly fall within this group.

I entered medical school having majored in biochemistry and happily volunteered for four years in a molecular genetics laboratory within a hospital department of pathology. At a time earlier in my college education, I had strongly deliberated pursuing a PhD or an MD/PhD to continue nurturing this burgeoning interest in molecular machinery and its contribution to cancer development. However, I ultimately elected to pursue an MD due to my penchant for connecting with people and the opportunity to regularly utilize such scientific principles in practice. Becoming a pathologist or an oncologist would be an excellent means to build upon these early scientific interests.

Fast forward four years and I find myself on the cusp of matching into Psychiatry – a field I never once considered until I experienced it first hand late in my third year of medical school. Though I could wax poetic over the numerous forces pulling me toward this field, I can specifically cite interpersonal communications as a highlight of the field and a fervent, yet previously unrecognized, interest of mine.

Medicine as a field universally demands precisely refined communication skills in order to ensure complex medical concepts are grasped by individuals representing all corners of education, literacy, culture, language, and socioeconomic backgrounds. Furthermore, as leaders of multidisciplinary teams, physicians must communicate clearly and concisely with other professionals of various backgrounds to ensure that patient care is comprehensive, judicious, and manageable.

Psychiatry stands out in the sense that while its purely medical concepts may not necessarily be as complex and nuanced as those of other fields, the emphasis on interpersonal communication is heightened. While establishing a robust therapeutic alliance is a boon in many fields, it is unambiguously critical when working with psychiatric patients and teams. The psychiatrist must uniquely refine her communication skills in order to establish a foundation of trust with an acutely psychotic patient brought to the hospital by the police in one moment, and in the next convey empathetic understanding to a depressed patient experiencing suicidal ideation. Furthermore, psychiatrists must be able to orchestrate a sometimes expansive team of social workers, case managers, patient advocates, family members, nurses, law enforcement, additional healthcare providers, and more to coordinate the complex medical, social, and legal needs these patients so often require.

I did not enter medical school with these skills, and I would be hard pressed to believe that I have them now – but I do believe I am making strides as I gain experience and I have a very real interest in becoming a more effective communicator and psychiatrist going forward. As I illustrated in other posts, my communication and patient care skills were lacking, sometimes laughably so, during my early medical school experiences. My first psychiatry rotation, in psychiatric emergency services, was particularly challenging at first as I was unable to rely on the rudimentary communication skills I had been developing elsewhere. However, my genuine interest in the field and the amazing teaching from the faculty, staff, and residents allowed me to step outside my comfort zone and truly experience the most of what this line of work has to offer. I was able to further explore my capabilities during my next two psychiatry experiences, culminating in my AMHBC mini-I rotation (evaluation shown below). Although I understand that I still have a long way to go, I can also see that genuine effort has produced tangible improvements thus far, and I am quite eager to continue this path through residency and beyond.

Portal Evaluation Report(3)

1. https://www.aamc.org/news-insights/right-match-day-i-changed-specialties

Ask any medical student about flaws or holes in their education, and you will open a pandora’s box of unintelligible rage, rants, and tirades. Ask those same medical students how to best patch those holes, and you will more than likely be met with blank stares and nonsensical ad libbing. Some conspicuous weak spots in medical education include healthcare policy, the economics of medicine (most notably the minefield of insurance reimbursements), and best practice/quality improvement.

More than likely, the deficiencies in these particular skills exist because they are only obtained and refined though many years of experience – and like fine wine or good whiskey – this can be difficult to replicate under the time and and situational constraints of medical school. However, we are at the very least introduced to the existence of these nebulous concepts, providing a rough framework through which we can refine our expertise during postgraduate training and beyond.

One such example is the quality improvement project we were handed by the applied health systems science arm of our many-tentacled curriculum. Here, I partnered with several colleagues seeking to improve blood pressure control at a local OSU outpatient internal medicine clinic via a specific yet-to-be-determined intervention. On the surface, this project seemed extremely simple: measure blood pressure control at time point A, implement intervention, measure blood pressure control through time point B, analyze.

In practice, challenges arose throughout the process. How will we define blood pressure control when the various medical think tanks and masterminds can’t even reach a consensus? How can we design an intervention that is easy to implement and not cumbersome for patients or the already overworked providers and staff? How are we going to quantify the intervention’s reach? Is everything compliant with HIPAA and in-house policies and regulations? Can this be accomplished with next to no budget to work with? Will this be sustainable in the long term?

Ultimately, over many hours of conversation, debate, and collaboration – our team settled on a patient education focused intervention. We would play a youtube video discussing the basics of hypertension and the importance of deliberate blood pressure control during the generally vacant interval between the patient being roomed by the MA and the provider’s arrival. At the end of the day, this satisfied all of the restrictions levied against us – it’s cheap (free), it’s easy, we can accurately measure view counts throughout the intervention duration via a targeted link, it’s sustainable, and it does very little to complicate workflow by targeting a dead space in care.

Unfortunately, blood pressure control (defined for this intervention as blood pressure <160/100) did not improve during our short intervention duration, remaining constant at 67% throughout this period (final project poster shown below). However, this project left a lasting impact on me in other ways. Medical school has largely been an individual endeavor for me, so working on a cohesive team with my colleagues toward a unified goal was a refreshing change of pace. I either learned new skills or renewed old ones that had atrophied over time – including collegial debate, mutually constructive criticism, real time problem solving, and task delegation. Furthermore, I found great value in working with peers pursuing a different field from my own, as I felt that my alternative viewpoint was valued and appreciated – and I similarly appreciated seeing from their perspective myself. These are all skills that I will remain cognizant of as I progress through my career and undoubtedly encounter systemic areas in need of improvement, hopefully leaving a positive impact on patients and coworkers along the way.

AHSS Poster(1)

Of all the skills, techniques, and various abstractions of personal and professional evolution that occur throughout medical school, medical knowledge is unique in the sense that it can – to a certain extent – be quantified. And, boy, do the powers that be in the hierarchy of medical education love to take advantage of this convenience. Within days of arriving on campus, the new iPad gifted during orientation removes its mask as a welcoming token of congratulations and reveals itself to be a cold metallic testing device promising to objectively stratify the class into a discrete ranking of competence (when not being used to stream Friends reruns).

Building a foundation of medical knowledge is a critically important prerequisite to providing high quality patient care. Given the vast breadth and depth of knowledge needed to function at even a basic level on the wards – which must be obtained expeditiously over two short preclinical years – the learning curve is understandably quite steep. Everybody must take a unique approach to this challenge based on one’s experience, skill set, and learning style – sometimes veering into uncharted territory when these previously trusted methods prove insufficient under new loads.

My own path was difficult at times and required some reconciliation between my aspirations and capabilities. As a freshly minted M1 I, like many others, had every intention of becoming the “best medical student ever”™ (whatever that means). I went into lecture each morning loaded up on caffeine and blind optimism then burrowed myself into the library each evening, poring over each word in every lecture slide until I could recite the whole thing from scratch. This worked for approximately two days until I fell so drastically behind that I was forced to frantically skim multiple lectures, retaining absolutely nothing just to be able to check off the required lectures on Vitals by exam time. Although the green check marks by each lecture title lulled me into a false sense of security, my mediocre-at-best exam performances jolted me back to reality. After each of these admittedly disappointing results I would reset – promising that I would address each subsequent lecture series more judiciously, only for the cycle to repeat ad nauseam.

Although this pendulum continued to swing throughout my Part 1 LSI experience, these fluctuations grew less violent, more manageable, and (thankfully) more predictable over time. However, my final performances on each preclinical block (shown below) were underwhelming at best.

Step 1 was now on the horizon, along with the oft repeated mantra that this was to be the most important exam one will ever take, singularly dictating each student’s future with certainty and finality. This dogma has proven to be untrue, but I nonetheless bought in at the time. I extensively researched study strategies and developed a precise, structured approach while maximizing the intensity and duration of the allotted dedicated study period. Although I received a score I was pleased with (and replicated my approach for step 2 CK and CS, results shown below), these standardized exams and preclinical assessments in tandem ultimately proved insufficient for the wards.

Step 1 Score

Step 2 CK Score

Step 2 CS Score

I quickly learned as a freshly minted M3 that while a fundamental understanding of medical principles is a necessary prerequisite to entering a clinical setting, this basic knowledge does not actually prepare one to competently function within that setting. Essentially, I had just learned the alphabet and was now tasked with forming sentences. This revealed an entirely new learning curve, similarly steep compared to what I had just experienced, but much more dynamic, personal, and emotional in nature. Here, I began the process of developing skills in patient care, communication, and professionalism to complement the basic medical knowledge I had obtained and continued to expand. In this process, I was fortunate to identify the field I am passionate about pursuing, and have applied the past several years of trial and error to establish a general learning process I will utilize to continue expanding my competencies throughout my career.

As I reflect on all this skills I’ve learned and honed over the past several years, the evolution of my patient care capabilities strikes me as the most dramatic improvement. I remember being specifically concerned as a rising M1 about my ability to connect with, convey empathy toward, and competently relay information to patients since I did not come into medical school with robust patient care experiences, as many other new medical students have.

My lack of experience was made evident early on. During my first few experiences through LG, LP, and volunteer free clinic shifts, I fumbled through patient encounters – each subsequent encounter worse than the ones prior as my naive self assurance and pantomimed bravado was supplanted by overwhelming awareness of my professional shortcomings and rapidly accumulating faux pas. My very first simulated patient encounter, a FOSCE with my LG preceptors present, started out on a particularly high note:

Me: “Hello! My name is Firas, and I’m your medical student today. How are you?”

SP: “Hi Firas, I’m great. How are you?”

Me: “I’m great. How are you?”

A palpably awkward silence ensued as I stared into the void of the infinite time loop I inadvertently opened. As such, my first of many lessons on patient care was how to keep the flow of a patient encounter moving through the inevitable speed bumps along the way. One of my following SP encounters, shown below, presents more of my early challenges.

Although I was initially distraught by these less than stellar performances, I was consistently reassured that the necessary skills would come with experience. Three years, hundreds of patient encounters, dozens of evaluations, and countless moments of self reflection later, and I can definitively say that my patient interactions have markedly improved. With gains in medical knowledge and an internalized script of the general flow and components of a successful encounter comes a self assuredness that makes the entire interaction more comfortable for both the provider and the patient. When contrasted with my earlier encounter, one of my final evaluated SP encounters (shown below) represents the cumulative impact that each of my hundreds of subsequent experiences had on my overall professional development.

Although I still forget elements of proficient patient care at times and have much room to continue improving, I now approach my development with a sense of excitement and curiosity rather than unease. As I hope to pursue a career in psychiatry, I will undoubtedly face new challenges related to patient care that are truly unique to the specialty. I hope to carry all the lessons I’ve learned in medical school with me, and continue to use each patient encounter to make the next ones more comfortable for patients, and for myself.