I have learned more than I ever anticipated throughout the past four years on how to properly care for a patient. Before starting medical school, I only superficially understood the role of a physician and how the physician works in an interdisciplinary team to effectively care for a patient. I assumed that the primary component was the acquisition of knowledge through years of medical school and residency. While this knowledge is a necessity in properly diagnosing and treating patients, it is only as useful as one’s ability to ask the necessary questions to arrive at a differential diagnosis and action plan. This knowledge does not take into account the role the physician has to coordinate care between medical teams, nursing staff, pharmacy, social work and so on.
Through my experiences in my clinical rotations, I have had the opportunity to grow my understanding of medicine as a whole. I started my third year rotations in a more observer role, while also building a strong foundation on how to properly gather information and present this information to my attending and residents. I was still focusing primarily on how I fit in to the team and how I could personally be of best use. As time went on and I became more comfortable with the workflow within the hospital, I became more acquainted with the individual roles of our team and how to coordinate care among all those involved. In my fourth year Advanced Adult Clinical Psychiatry rotation, I worked closely with Social Work to prepare patients for discharge. We would often sit in meetings together, going over the list and discussing what the best course of action would be for each patient. I listened and I offered my input when I felt it appropriate. This is one of many examples throughout my time on clinical rotations where I was able to coordinate for the care of a patient in a multidisciplinary setting.
Moving forward, I want my growth to include staying cognizant of the responsibilities we all have for the care of our patients. It can be difficult at times to remember the needs of nursing or social work when we have our own tasks to complete, but we are all most effective when we work as a team and I want my team to be successful. I plan to implement this by incorporating periodic check-ups into my routine so that no one falls by the wayside. I want to start each service by properly introducing myself and letting the other team members know that I am available if they have any questions or concerns and to always feel comfortable approaching me. I believe this would be a good place to start building rapport with everyone and I hope it can help improve on a culture of teamwork and synergy.
Advanced Adult Clinical Psychiatry Evaluations
I entered into my clinical rotations feeling accomplished for having studied and completed my first USMLE exam. I felt that I had finally synthesized a great deal of the information that I had been studying over the first two years of medical school. I felt that I was ready to implement this knowledge as I cared for patients on my various services moving forward. This proved to be true, but only in part. I quickly experienced how seemingly different taking care of a patient actually was when compared to the practice questions I had used to prepare for exams. I didn’t have a select number of options to choose from when formulating my plans and rarely did a patient have only one problem that needed to be addressed. This was, frankly, a daunting experience and certainly an awakening for me. I had to take a step back. I’ve come to realize that the assessment and plan is as much an exercise in medical knowledge as it is one in bookkeeping and presentation skills.
Before any plan can be proposed, an appropriate assessment needs to be put forth. I found myself often trying to multitask both of these components and getting lost in the weeds. It may seem like a trivial realization, but for me the methodical approach of first constructing a list of problems before moving forward has been invaluable to me. From there, I can much more confidently suggest plans that I feel more completely address the patient’s needs.
As part of my fourth year schedule, I spent time in the ICU. This part of the hospital is where a robust assessment and appropriate plan is truly paramount.The first step to creating a strong assessment and plan is to thoroughly review all relevant information in the EMR. Reading a patient’s chart, reviewing vitals, labs, imaging and relevant provider notes, followed with reading well structured resources like UpToDate, have given me a roadmap to continue to improve in my understanding of medicine with the relatively limited time that I have now compared to previously. One particular advantage to this style is that I feel like I am able to retain more and at a quicker pace simply by remembering my patients and our time spent together. It makes it much easier to retain information when that information is directly applicable to someone in your care. This method of initial data acquisition has allowed me to rapidly improve in my ability to differentiate important information in the chart from potential red herrings. I am then able to go speak with the patients already having a general construct of what I believe the problems are and what I would like the plan to be for that day. After speaking with the patient, my assessment and/or plan might change but I now have the information necessary to start the care for my patient on that particular day. Over time, my ability to efficiently review and construct an assessment and plan has dramatically improved but I know that there is more improvement to be made with more practice.
I hope to continue to improve on efficiency during my time in residency. This will certainly be a step up from my experience in medical school, where I will be responsible for not only more patients but also have more responsibilities as a whole. It will require me to continue to practice my ability to gather information in a time sensitive fashion and improve on my ability to acknowledge what limits my patient from being discharged. I believe I can more effectively map out what my goals are for each individual day if I talk with senior residents and my attending about what our global goals are for that patient’s stay. I need to continue to educate myself on the various pathologies I will be treating and consult resources like UpToDate or relevant literature when I reach the limit of my understanding. I believe that with consistent practice, feedback from my team and a strong ability to consult the literature, I will continue to see improvements in my ability to effectively construct an assessment and plan for all of my patients.
General Medicine Evaluations
There have been many learning experiences throughout my time spent in the hospital on my clinical rotations to date. Of particular note, I have found that the learning style necessary to continue my education, while managing the care of patients, has required adaptations from how I’ve learned medicine over the past 2 years and other subjects earlier than that. I have been used to watching a lecture series or reading a textbook beginning at the first chapter. Although that style has its merits, there are modifications that I have made which have allowed me to improve my ability to not only gather but also deliver information in the hospital setting.
One of my personal challenges this year has been dealing with the anxiety associated with presenting patients on rounds. I have never been one for public speaking and, though a smaller audience, I’ve found that the same anxiety arose when it came time to speak up and present my patients. Not for a lack of understanding of my patients, not for a lack of confidence in my ability to relay the appropriate information. Not for any tangible reason other than it has been an issue that I have brushed to the side my entire life. I didn’t have the option anymore. So, I did what any bright-eyed medical student would do – I tried to improve, slowly but surely, with the help of my peers, residents and attendings. Admittedly, it took the better part of my year to finally feel comfortable in my own skin while all eyes were on me. But I never gave up. I continued to try and improve. Early on, I tried to improve everything at once and I learned that that is not the best strategy. Then, I tried to improve one small piece at a time. I would ask attendings their preferred format so as to mitigate any likelihood of being caught off guard. I am now nearing the end of my medical school journey and I am amazed at how far I’ve come. I receive unsolicited compliments for my presentations and that is certainly not something that I expected. Most importantly, I am proud of myself after my presentations. They are not always perfect, but I present them with confidence because I know the effort and care I put into managing my patients. I know that I don’t have all the answers, but I also know that I want to learn from those who are more experienced than me.
Moving forward, I believe what will help me the most in my education is to continue asking for feedback and applying that feedback with incremental improvements each day. Senior residents and attendings have a wealth of knowledge and we are all invested in each other’s growth as physicians. I plan to begin any new service with an introduction and ask my attending how they would prefer for me to deliver my presentation to the team. I will ask what format they would prefer to deliver feedback, as I am eager to receive their input and improve during our time together. Beyond that, I also aim to do this with other members on the team as well. My attending’s feedback is highly appreciated, but the entire team can help me improve and I would voice my encouragement of all members to help me as I advance through my residency training.
Pain Medicine Evaluations
As part of our fourth year curriculum, medical students are responsible for taking on a quality improvement project. The purpose of this project is to identify a particular area within the hospital system that warrants closer observation and to critically assess ways to improve its function. At first glance, this can appear to be a particularly difficult task given the complexity of the hospital system and all of its component parts. There is a large interdependence required of these parts to have a fully functioning hospital system and this can make it difficult to identify specific areas of improvement. This, however, is exactly why it is so necessary for medical students to be exposed to quality improvement projects at this point in our training. We are able to learn how to effectively break down a complex problem and move forward with strategies for improvement with the feedback and guidance we receive from faculty.
My group chose to look into foley reinsertion rates on epidural PCA post-surgical patients. Prior to starting our project, we received significantly useful documents to help in guiding us map out our plan of action and how to successfully move towards our goal of identifying causes and implementing interventions. We were introduced to the DMAIC roadmap, which stands for “Define, Measure, Analyze, Improve and Control”. Over the course of the year, our group has been working through these individual steps. We defined our problem and created a process flowchart identifying the steps in this particular process that we were looking into. We then planned and executed a data collection plan by identifying key aspects that we intended to measure. We have recently been exploring root causes as well as potential solutions to decreased foley reinsertion rates and ways to implement these solutions, including an educational plan that we would deliver to all those involved. We then hope to monitor the performance of our implementations and will complete our project with a summary of our findings. Our project has come across some unforeseen challenges, including coordinating meeting times that work with everyone’s schedule, and it has required the synchronized efforts of multiple people within our group as well as those involved in a supportive role. We have divided responsibilities equally amongst group members and have remained in communication with one another so as to complete our individual tasks and work towards our common goal more efficiently. We are closing in on the final presentation of our project and it has been a thoroughly educational experience on how to design and implement studies of this nature moving forward.
I believe residency will offer me more opportunities to help improve the quality of the hospital system I am affiliated with. I believe this to be an important part of our job – to not only identify areas of improvement but lead in the implementation of well-organized plans of action. I will take what I have learned in my medical school QI project and expand on that in residency. Namely, I believe it’s vitally important for members of a project to have clearly defined roles and a means for open communication so that we are all able to move forward effectively in our individual roles while working towards our common goal. In a sense, a group research project acts as a microcosm of something far more complicated like a hospital system. It requires a synchronicity between interdependent components and a means of internal review. Beyond that, I’ve learned that a large part of identifying problems begins simply with talking to people. What are roadblocks that affect nursing in their day-to-day lives? Is there a common cause for extended stays in a particular service? Where do individual members of a team feel communication breaks down, if they feel that it does? Asking questions is a simple, but truly powerful way to begin the process of quality improvement and I plan on bringing an inquisitive nature with me wherever I go next.
The defining feature of medical school is to aid in the transition from a student to a practicing physician in a particular specialty. A part of this transition involves becoming informed on what it means to be that particular type of physician and the inner workings of the specialty. This can be accomplished in multiple ways, not least of which is to become an active participant in its professional body.
This year, after deciding to pursue anesthesiology as a specialty, I became a member of the American Society of Anesthesiologists. I wanted to learn more about the specialty and what advancements are currently being made and can be expected in the future. My plan to begin the process of becoming more acquainted with my future specialty of practice was to begin by subscribing to the ASA journal. Beyond that, I feel very fortunate that the Department of Anesthesiology as OSU offers to subsidize the travel expenses to the national ASA conference for students in the anesthesiology track. I took this opportunity to attend the ASA conference in person, which took place in Orlando, Florida in the middle of October. While at the conference, I was able to attend a large breadth of educational sessions and exhibits. I learned about cutting edge technology in the specialty and learned more about anesthesiology at the medical student level with events put on specifically for medical student attendees. I was also able to present a medically challenging case during a poster session, which I felt very privileged to have had that opportunity. It was a thoroughly rewarding experience to be able to contribute to the conference in a researcher capacity. The whole experience was a wonderful educational and networking opportunity and it was something I feel very thankful for being able to attend.
I certainly plan to continue along this trajectory of involvement in the American Society of Anesthesiologists in residency and beyond. I think membership in this community serves many unique purposes at different stages of training and practice. As a resident, I hope to contribute to this professional body particularly in the form of research contributions. This would be an excellent opportunity for me to advance the knowledge within the specialty in my own way and will provide me with the ability to network with anesthesiologists around the country. Beyond that, a long term goal of mine that I hope to begin in residency is to contribute to the ASA in a leadership role. I want to be a voice for my colleagues and I believe that this would be an excellent platform to do exactly that. I hope to have my responsibilities within the ASA increase over time, but certainly a place to start this process is during residency and I intend to do so.
It is a worthwhile exercise to take a moment from time to time and look back at how far we’ve come from our first day in medical school to where we are currently. There is still so much more information that needs to be learned, much more time required to fully master what it means to be a physician on all levels. At times, it can feel like a mountain without a summit. That is, until you look away from the future for a moment and turn your attention to the past. Even something as second-nature to a seasoned physician as successfully intubating a patient is truly an accomplishment for someone at my level of training. Like all learned skills, taking the time to practice and improve is a fundamental part of transitioning someone from a novice to an expert.
In my fourth year, following the Anesthesiology Clinical Track, I was able to spend a month on an Advanced Anesthesia Elective. I thoroughly enjoyed my time on this rotation and, as a quick aside, it truly helped to solidify my choice to pursue anesthesiology. During this month, I was not only exposed to multiple areas within anesthesiology but was also given the opportunity to practice my procedure skills. I practiced my ability to place IVs and A-lines, mask ventilate patients with both a two-handed and one-handed technique and intubate patients. We as medical students have had practice in these areas during workshops earlier in our education, but without repeat and consistent practice I did not feel confident in my abilities at the start of my rotation. I remember the first intubation I performed, feeling nervous and hesitant. But I listened to feedback throughout the procedure and asked for pointers at an appropriate time afterwards. The second intubation went a little smoother. The third, smoother still. Further along in my rotation, I rotated through cardiac anesthesia and was able to intubate a difficult patient who had a propensity for desaturating. I was able to stay calm and listened to my attending and successfully completed intubation. The confidence in my abilities dramatically improved over the month but I remained aware that there was much more practice that needed to be done. At the end of the month, I felt quite competent in the procedures I performed and it was a pleasure to think back on how much I had improved in approximately 30 days. It gave me the first glimpse at what I could potentially be capable of with enough hard work.
It’s important to keep one’s focus and energy on what has yet to be accomplished and not rest on our laurels. However, every once in a while it’s both educationally and personally rewarding to acknowledge what strides forward we’ve made to date. Small improvements really do lead to large improvements with enough time and dedication. Moving forward, I hope to continue along this trajectory and practice, practice, practice. I saw a large improvement over one month, but after having spent the last several months on different rotations and going on interviews I know that there will be a learning curve when I get back to performing procedures. I would say that procedures are less like riding a bike and more like shooting a 3-pointer in basketball. You can see improvements and even feel proficient at a certain point, but it’s the continued practice that allows you to hold on to your refined technique. So, I plan on getting as much hands on experience in residency so as to feel proficient with time and hold onto that proficiency.
DanielK Procedure Card