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Patient Care: A community of teachers

Patient care: Provide patient-centered care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health

  • 1.7 Counsel and educate patients and their families to empower them to participate in their care and enable shared decision making
  • 1.9 Provide healthcare services to patients, families and communities aimed at preventing health problems or maintaining health 

As an aspiring pediatrician, one of the most important skill sets I have built over the past four years has been my ability to care for and examine patients comfortably, efficiently, and compassionately. The knowledge needed to provide excellent, patient-centered care is not available from books or lectures, and it’s something I’ve instead been gradually learning through clinical experiences.

My first opportunity to interact with patients was as a sophomore in college. At that point, I was confident that I wanted to go into medicine, and I was eager for more hands-on experience than shadowing alone. That summer, I trained as a nursing assistant at a long-term care facility near where I grew up. The day after I completed my training, I was assigned to the advanced Alzheimer’s dementia unit with two other aides where we struggled to cover the basic care needs for all 43 patients on the floor. Many patients were non-ambulatory, so even a task as seemingly simple as transporting patients to meals often required operating a mechanical lift. For the most part, patients were complex and highly dependent on assistance for even the simplest daily care needs.

My training in patient care as a nurse aide was trial by fire: I struggled to be compassionate and provide care that was patient-centered on busy nights when we lacked enough aids to keep up with the care of 40+ patients. Over time, I learned how to show compassion in small ways, even on busy nights such as by asking patients about their day or their family while transporting them to dinner, for example.

I continued to work at this long-term care facility for three consecutive summers, during which time I gained skills in patient care. I developed a profound appreciation for the nurses and other aides who treated patients with compassion even on busy days, and I tried to learn from them. Over the course of my time as a nurse aid, I became better at quickly building rapport with new patients, caring for patients thoroughly and efficiently, and demonstrating humanism and compassion in what was a times a physically and emotionally challenging job.

My last summer working as a nurse aid overlapped with my first year of medical school, during which I began translating some of the knowledge I had gained in patient care as a nurse aid to my new role as a student. This role brought additional challenges and nuances, especially with my work at La Clínica Latina—a student-run free clinic that serves the Columbus Latinx population.

In this role, I saw patients independently and reported back to attending physicians, who helped me finalize assessments, plans, and prescriptions for each patient. Adjusting to these new responsibilities in patient care was its own challenge, but another layer of learning came as I navigated the learning barrier between myself and most of my patients. Few of the patients spoke English, and I conducted most visits in Spanish. It was challenging to build rapport with patients in a second language.

Over time, I became better at practicing patient-centered are in a second language. It helped that I was gaining more medical vocabulary over time, but I also became better at working around challenges in communication. I found that the principles of patient-centered care were the same even in Spanish, and the conversations involved in a patient-centered approach didn’t necessarily require complex vocabulary. I worked on identifying and exploring patients’ feelings regarding their care plan—for example, asking about patients’ confidence in a new medication. I also tried to prioritize asking patients what was important to them to cover at each visit. And, I always tried to learn something new about my patients and keep up to date on what was new in their home lives or at work.

Another aspect of caring for patients at La Clínica Latina that I had to adapt to was bridging social and cultural barriers. Patients arrived at the clinic from dozens of culturally distinct regions of Central and South America, bringing with them a vast range of educational and health literacy backgrounds. One evening, for example, I saw two patients who both had hypertension. However, one of the patients had been a doctor in Venezuela, and the other patient was a farmer from rural Guatemala who had never completed grade school. Adapting discussions about pathophysiology and treatment of hypertension to these two very different levels of health literacy was challenging, especially in a second language. However, having healthcare discussions with patients from different backgrounds helped me appreciate how important it is to confirm patients’ understanding of their health plan with methods such as teach back and by using a wide variety of resources to convey health information.

Especially for patients who were unable to read, careful attention to their comprehension of medical conversations was critical, and creative resources such as videos were helpful resources to augment homegoing instructions or telehealth visits. In fact, I helped with a project led by other students in the clinic, which developed YouTube videos in Spanish that conveyed important information about diabetes and hypertension. We worked with an endocrinologist to write videos that conveyed health facts about these chronic diseases as well as practical information for basic treatments ranging from lifestyle changes to insulin use (such as the video below).

Another unique opportunity to develop my skills in patient care was “Proyecto Alma.” This was a community outreach program that I led with a group of student volunteers. It was aimed at providing diabetes and hypertension screenings as well as nutrition education for the Columbus Latinx community through mobile health fairs at local churches. I coordinated a volunteer team, planned health fairs, and visited sites throughout the city. I also applied for and received grant funding. Through this project, I gained valuable skills in grant writing, community outreach, coordination of care, and culturally competent medical care.

One of the most unique and interesting aspects of this project was the opportunity to proactively address several significant barriers to healthcare access that our patient population faced. First, we worked to address barriers to transportation by partnering with local churches to meet patients in their own communities. Secondly, we worked to address barriers to cost by coordinating visits to the free clinic on-site for those who needed follow-up for a positive screening or who were looking to establish a medical home.

Our Community Health Education Team (“Proyecto Alma”) embarking on our first blood pressure and diabetes screening fair at a local Catholic church; Summer 2021

We were able to interact with hundreds of patients, and many new patients began arriving at our clinic as referrals from the health fair. It was exciting to see what a powerful tool the partnership of local organizations could be in reaching out to new members of our patient community. Just a few weeks ago, I saw a 35-year-old patient for follow-up of her diabetes–her chart noted that her initial diagnosis had been made at one of the health fairs hosted by Proyecto Alma. She has since started metformin as well as initiating changes to her diet and exercise habits, and her disease markers have gradually been improving.

As I transition into the next stage of training, I aim to continue developing my abilities to deliver patient-centered care in several ways. First, I plan to always begin non-emergent visits with a patient with an assessment of their priorities for the visit and make every effort to address those needs. Secondly, I want to try and learn at least one thing about my patient as an individual–whether that is learning something about a patient’s hobbies, family, or work life. Third, I am committed to continuing how to become a more culturally competent physician by learning directly from the diverse needs of my patients and by enriching my education with a focused curriculum of books, essays, and lectures. Finally, I hope to continue to learn about different barriers to healthcare access that patients face and practice addressing them, whether by collaborating with a social worker in the hospital or by reaching out to other organizations in the community.

I am proud of the progress I have made in the last several years with regard to patient care– I feel that I am gradually coming closer to my goal of becoming a compassionate, patient-centered caregiver. I know that this is a goal that will require continuous effort throughout my career, but encouragement from patients, attendings, and classmates has helped reassure me that I am off to a good start.

Knowledge for Practice: Exploring research in medicine

Knowledge for Practice: Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.

  • 2.2 Apply established and emerging bio-physical scientific principles fundamental to health care for patients and populations

  • 2.5 Apply principles of social-behavioral sciences to the provision of patient care, including assessment of the impact of psychosocial and cultural influences on health, disease, care-seeking, care compliance, and barriers to and attitudes toward care
  • 2.6 Contribute to the creation, dissemination, application, and translation of new healthcare knowledge and practices

Throughout my medical school journey, I’ve gradually been exploring the role of research in my identity as an aspiring physician. Research was not entirely new to me coming into medical school: I had participated in multiple projects during college, and I’d been able to see the research process from hypothesis to publication several times.  However, none of my prior research was related to medicine, and although I was eager to explore medical research, it took time to adapt my former experiences (in chemistry and entomology) into my new role as a student physician.

I first attempted to begin my foray into medical research at the end of my M1 year. Following 10 months of rigorous classes and some challenging adjustments to a new city and learning environment, I began to notice that many of my classmates were chattering excitedly about the research projects they had lined up for the summer. As I heard of all the amazing projects they were eagerly developing, I began to wonder why I hadn’t considered finding some research to get involved with. I began to feel as though I were missing out on a critical experience, and I abruptly decided that I, too, needed find a project as soon as possible.

I began reaching out to different researchers at across many disciplines at OSU and Nationwide. While many labs had already signed on summer students, within a few days I found a project that was looking to add a student researcher. With relief, I scheduled an appointment with the leadership team to hear more about the role and decide whether it was what I was looking for.

A few days later, I sat in the Primary Investigator’s office as he described the the project to me. It was a very specific project focused on inpatient technology use at OSU, and he described the data collection that had already taken place and my role, which would be primarily reviewing and editing a very large spreadsheet. We wrapped up our meeting, and he requested that I let him know by the end of the week whether I was interested in the position.

It wasn’t until I was halfway back to my apartment that I realized I was dreading the idea of spending my precious summer months on this particular project. The topic was not appealing to my interests, and my individual role promised to be repetitive and tedious. Additionally, since the project goals were already articulated and the data collected, there was limited opportunity for me to be involved in the actual scientific inquiry process–beyond a possible future opportunity to be involved with writing a poster or publication from the data.

I considered this realization and asked myself for the first time why I felt it was so important to jump onto a research project right away. I soon identified that it was a desire to have the same passion about a project or activity as some of the students I had talked to who were looking forward to their upcoming summer projects. Yet, with this in mind, what was the purpose of joining a project that wasn’t investigating something that sparked that kind of excitement in me?

The next morning, I emailed the research team thanking them for their time and informing them that I had decided the role was not a good match. It was a great relief, and I resolved to continue looking for an opportunity to participate in research that allowed me to explore a topic that was interesting and exciting to me. Instead, I dedicated that summer to clinical experiences as a nurse aid at a nursing home and as a student intern at a federally funded family medicine practice. I enjoyed both of these experiences and learned a variety of practical and interpersonal skills that I believe helped me become a better student doctor.

It wasn’t until the end of my third semester of medical school that I finally had an opportunity to participate in medical research and writing. At the time, I was exploring the field of pathology, which I found interesting for the problem-solving and diagnostics it involved. I met with Dr. Zynger, a pathologist who had offered to talk to me about some of the reasons she had chosen the career.

At some point during our meeting, she pointed out that research and scientific writing were important parts of the field and offered to mentor me through a couple of short projects if I was interested. The first was a short online textbook chapter on pheochromocytoma, which would utilize images from a case she had recently had. She would teach me how to describe the slides and edit my drafts of the chapter, but otherwise, I would complete the project on my own. It sounded perfect–it would be a great introduction to a specialty that interested me, and I’d get the case to study a relatively rare clinical entity.

Two weeks later, I’d already completed a draft for the chapter. I was curious about the topic, and I sincerely enjoyed the process of finding and reading articles and case studies on pheochromocytomas. Dr. Zynger edited my work with helpful explanations for each change that she made, and then she explained how to read and describe the images of the specimen she had on file. We published the chapter in early January.

The first page of the online textbook article I helped write on pheochromocytomas, January 2020

It was exciting to have a chance to write even a short article as a medical student, and I was surprised by how easy it was to find time for a topic that interested me. I decided to keep my eyes peeled for opportunities to further build and explore medical writing.

The following winter, a unique opportunity presented itself that connected my curiosity about the field of pathology with my growing interest in pediatrics. While rotating on the pediatric surgery service, I helped care for a patient that was experiencing complications after a Kasai procedure. I learned that the procedure had been performed for a rare cystic variation of biliary atresia, and I was curious to learn more.

I reached out to the pediatric pathologists about the case, and they were eager to teach. I spent an afternoon down in the path lab learning about biliary atresia and what made this patient’s rare, cystic variant histologically distinct from more commonly diagnosed presentations. One of the pathologists, Dr. Archana, suggested that I could consider writing it up as a case study for an upcoming virtual poster session with the College of American Pathologists. I was excited about the idea and was soon engrossed in learning how to compose an abstract, which I submitted. A few months later, I was excited to hear that the abstract had been accepted, and I moved on to the work of compiling a poster presentation for the 2021 abstract program.

Final abstract and poster for the CAP21 Virtual Abstract Program

Participating in the CAP21 Virtual Abstract Program was a great learning experience– it gave me an opportunity to develop new skills in scientific communication. Perhaps more importantly, it allowed me to reflect on this patient’s case from both the perspective of her medical presentation and treatment on the surgical floor as well as from the perspective of a pathologist. It helped me realize that my passion for pediatrics was greater than my interest in pathology, and it helped me set my career course on pediatrics.

During this final year of medical school, I’ve been continuing to explore research at my own pace. Most recently, I’ve been working on a project with the department of pediatric surgery that is exploring the psychosocial impact of burns in pediatric patients and their parents. Given my interest in pediatrics, it’s been meaningful to learn more about this topic. It has also prompted me to think about the ways in which psychological trauma from such injuries might affect the lives of children and their families. It’s been a chance to practice doing chart reviews as well, which was something I’d never done before.

As I finish medical school and prepare for my first year of residency, I’ve been reflecting on some of the new skills I’ve learned from the projects I worked on these past few years. More importantly, I have been learning how to follow my curiosity and interest when it comes to research rather than just jumping on whatever projects come my way. Approaching research in this way has still given me chances to develop my investigating skills, and it has also helped me discern my career path. And, knowing that my free time will become even more scare in this coming year, I think it will be important to take on projects that are fun, exciting, and energizing. I plan to keep looking for these kinds of opportunities throughout residency, and in the meantime, I look forward to continuing to learn from the project I’ve been working on this fall. I’m hoping to have an opportunity to present an abstract or poster from the data we’ve been collecting by the time I graduate this spring, hopefully giving me a chance to gain more skills related to the creation and dissemination of new healthcare knowledge and practices.

Practice-Based Learning and Improvement: Teaching, mentoring, and medical education

Practice-Based Learning and Improvement: Demonstrate the ability to investigate and evaluate one’s care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning

  • 3.1 Identify strengths, deficiencies, and limits in one’s knowledge and expertise
  • 3.5 Incorporate feedback into daily practice
  • 3.8 Participate in the education of patients, families, students, trainees, peers, and other health professionals

During my second year of college, I discovered a passion for teaching. At that time, I began working for the Academic Success Center, where I tutored students one-on-one in multidisciplinary subjects including organic and inorganic chemistry, introductory biology, writing, and Spanish. Most of the time, students would arrive with essays, problem sets, or specific subject units that we would work through together. Sessions easily came together and typically were organized around a specific endpoint. I enjoyed my work with the ASC immensely and stayed on the tutoring staff for 3 out of my 4 years of college. It was fun to meet students from different disciplines, and it was exciting to get to teach topics I was passionate about.

In medical school, I was eager to find similar teaching opportunities. During the summer after my first year, I applied to become a peer tutor. Later that fall, I was appointed to tutor first-year medical students one-on-one in the Foundations 1-2, Musculoskeletal Disorders, Cardiopulmonary, and Endocrine/Reproductive systems blocks.

I jumped right into my tutoring responsibilities during the first couple weeks of my semester, and I met with my assigned student. Our first meeting was much more challenging than I expected: we had blocked out two hours, but as we sat down to study the material, it was clear neither of us knew exactly where to begin. For my part, I admittedly hadn’t prepared much for the session, other than briefly reviewing the Foundations 1 curriculum for the week. Somehow, it hadn’t occurred to me the medical school’s self-directed, lecture-based part curriculum lacked the worksheets, essays, and problem sets my college sessions used to revolve around. My student hadn’t put much forethought into the day, either, and when I asked her what she wanted to focus on during our session, she said she wasn’t sure.

After a brief awkward silence and some shuffling of papers, I cobbled together a quick review of what I thought had been the most important topics covered so far in the block. However, my review wasn’t very organized or interactive, and it was clear that neither of us had the patience to go over lecture slides for two hours. After about an hour, we wrapped up the session and made arrangements to meet the following week.

I should have been better prepared for our session, and I knew I was going to need to adapt to this new environment. It was clear that in a curriculum where students were expected to engage in self-directed learning, I was going to need to work on creating more structure in my tutoring sessions. I also needed to get to know my student a little better.

A few days later, I began building a plan. First, I encouraged the student to send me at least 3 topics or questions she wanted to cover as she studied the lectures for the coming week. I also asked her to describe some of the ways she learned best or new study methods that she wanted to try out. By our next session together, I had come up with an organized outline of topics to cover, complete with the practice questions and flashcards the student had requested. The session was much more productive and interactive, and we had fun working through the questions together. At the end of the session, we planned our next meeting together, but we also talked about ways that we could continue making our sessions more productive. In this way, the student and I co-developed our learning and teaching methods over the course of a year, adding new resources like videos and virtual anatomy apps as we adapted to her evolving learning style and the demands of each new subject block.

My experiences as a one-on-one tutor helped me become a more creative and dynamic teacher, and they prepared me to adapt to different teaching scenarios. This especially became helpful during my second year as a tutor, when I joined a new educational group with the Office of Student Life called the Supplemental Instruction Team. Compared to my previous teaching roles, in this instance I’d be teaching large groups of students in an auditorium rather than the one-on-one lessons I was used to. My job would be to collaborate with 3 other peer tutors to develop optional supplemental lectures for the first-year medical school curriculum, reinforcing the most commonly tested topics for each week’s lessons.

None of us had experience teaching such a large group, but as we puzzled over where to begin, I offered some ideas that translated well from my previous year’s experience. I suggested we start by sending out a poll to the entire first-year class asking them to identify topics they needed help with and modalities of learning they thought would be most helpful. Based on this information, we developed our first SI curriculum together, delivering a lecture based on the requested topics with a combination of practice questions, visual aids, charts, and mnemonics.

Our first session went well, with over 60 students in attendance. Each week, we continued to adapt our lectures based on student feedback and polls, and with each session, we made small improvements to our methods. For example, as our group of students continued to grow, we learned that it was intimidating for students to participate in answering questions. We started using Poll Everywhere, which is an app that allows students to answer questions anonymously so that everyone could participate more comfortably.

An example of one of the group supplemental instruction lectures I helped write from September 2021

It was gratifying to see our progress over time as a team, and our reliance on student feedback helped us improve our sessions by the end of our first semester. After our last session, I received encouragement and thanks from students in our cohort. It was exciting to realize that our efforts were helping meet our students’ educational needs.

Some positive feedback from students in our supplemental instruction cohort

As I prepare for my first year as a resident, I’ve been thinking about how I will apply the teaching skills I’ve learned as a medical student to a clinical environment. I’ve even had some practice already teaching rotating third-year medical students during my sub-internships over the summer. These opportunities have come in the form of both formal and informal teaching duties. For example, I’ve had the opportunity to give Noon Lecture to medical students and residents while on my NICU sub-internship, but I also have opportunities almost daily to help third-year students with more informal topics like tips on pre-rounding, interpretation of lab studies, and ideas for supplemental learning resources.

Slides from a Noon Conference I gave on neonatal sepsis, July 2021

So far, while much of my role teaching other students in a clinical setting has depended upon the practical skills I’ve learned as a medical school tutor; an equal part of my time has been spent functioning in a mentorship role as I worked with more junior medical students. In particular, I met many third-year students over the summer who were on their first-ever inpatient rotation, and a large part of my time with them was spent encouraging them as they learned how to adapt to the floor and sharing some of the challenges I had faced when transitioning to the Part 2 clinical curriculum. These conversations are always fulfilling: they often seem meaningful to the other students, but they also help me find meaning in my own experiences as a medical student and have helped me reflect on my personal growth.

As I continue developing my teaching and mentorship skills, I’m learning to adapt to the formal and informal learning opportunities that are abundant in the clinical setting. I aim to continue eliciting feedback not only from students who I am teaching but also from faculty and residents who can use their experiences to give me advice on my approach. Additionally, I plan to continue seeking out opportunities to practice these skills. One such opportunity is coming up this February when I will be on a pediatric hospital medicine service as a sub-intern. I’m looking forward to the chance to teach and learn from the third-year students on the team, and I hope to also have at least one opportunity to deliver a more formal educational lecture on a hospital medicine topic. With ongoing practice and feedback from peers and supervisors, I hope to continue to develop my clinical teaching skills.

 

 

Professionalism: A journey towards empathy, compassion, and cultural competency

Professionalism: Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles

  • 5.1 Demonstrate compassion, integrity, and respect for others

  • 5.2 Demonstrate responsiveness to patient needs that supersedes self-interest
  • 5.4 Demonstrate accountability to patients, society, and the profession
  • 5.5 Demonstrate sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

As I have tried to learn and apply the diverse principles encompassed in the idea of “professionalism,” one of the most important lessons I have learned is the idea that every patient deserves to be treated with compassion and dignity. Since my earliest experiences in the clinical setting, this idea has been at the forefront of my goals as an aspiring physician.

However, while this simple ideal was easy for me to recognize early on, it has taken significant effort on my part to internalize and practice compassion and dignity equally for every patient I meet. In fact, this is an ideal that I sometimes fall short of, and understanding when and why I have failed to do this has been perhaps the most critical part of my medical education.

Looking back on my growth in this area, I recognize that I’ve sometimes found it challenging to extend equal compassion and dignity to each patient I meet. For example, sometimes, my emotions toward patients have been swayed by how they treat me. During my 3rd-year rotation on inpatient hepatology, for example, I cared for a middle-aged male patient with liver failure who treated me rudely and at times addressed me with unmasked misogyny. Even though I knew he was dealing with pain, fear, and isolation, our interactions left me feeling upset. It took a great deal of effort to set my own feelings aside and consider his feelings so that I could treat him with dignity and compassion.

I was able to recognize and internalize this interaction, and I worked hard to overcome my biases toward this patient based on his behavior. I spent time considering the possible contributing factors to his treatment of me: in addition to dealing with significant medical illness, he was also completely alone and likely afraid. Perhaps some of his rude or misogynistic behavior was an expression of fear, loneliness, or uncertainty. He also dealt with significant alcohol addiction and so was coping with abstinence for the first time in many months, which was likely having an effect on his mood. As I considered these possibilities, I wrote the following journal entry regarding my efforts to treat this patient with compassion and dignity:

As I moved on to my other clerkship rotations, I continued journaling about patients with whom I had difficult interactions and made intentional efforts to treat each patient I cared for with dignity and compassion. I also worked to build cultural competency by building my knowledge about social determinants of health through lectures and journal articles.

During my general medicine rotation, I followed a patient who was admitted for intractable c-diff and malnutrition. She was dangerously malnourished when admitted, with a BMI of 14 and wounds all over her body that refused to heal. Even so, she was upset with staff upon learning that she would be admitted. The first morning after her admission, I went to examine her and check in. As soon as I asked how she was feeling, she raised her voice and began swearing at me. She was tired, in pain, and upset that her breakfast had not yet come, and her emotions were running over into our interaction. This realization occurred to me more quickly than with my previous patient, and I took a moment to try and treat her with the compassion and dignity she deserved, even on a bad morning. I grabbed her some snacks and checked in on her breakfast to make sure it was on its way. She quickly became less confrontational, and we were able to have a productive conversation about her symptoms.

Later in the afternoon when we had some free time, I went in to check on her again. She apologized for her earlier behavior, and suddenly she began crying. As I tried to comfort her, she began telling me about all the stress she was under. She and her 14-year old son (her only family) had been homeless up until just prior to her admission when they finally moved into a long-awaited apartment. Now in the hospital, she was unsure how she would keep her housing, and she was worried about her son, who was staying with a friend. I listened to her story and helped her get connected with social work, who worked to help the patient find resources to keep her housing. And, later in the week when I became the target of another angry outburst, it was easier to react with compassion having gained a better understanding of the social stressors she was facing in addition to her medical illness. At the end of my General Medicine rotation, I was gratified to receive this feedback:

Feedback from General Medicine rotation on compassion and empathy, November 2020

I worked to continue building my capacity to show empathy, compassion, and dignity for all my patients. This ideal continued to challenge me, but a patient interaction during a sub-internship in Neonatology helped me realize how far I’d come.

A couple of weeks into the rotation, I began caring for a newborn who was having episodes of apnea and bradycardia in the newborn nursery. After examining the baby and helping with the admission, I went to the postpartum floor to update the patient’s mother. I quickly found out that she was incarcerated and would be returning to the correctional facility in the next couple of days. She was enrolled in a special program that was intended to allow her to return to the facility with her newborn, but since her daughter would need to be observed for at least 5 days, the patient’s mother would have to return without her without knowing how long it would be until they were reunited.

The patient’s mother was understandably distressed. But, before she left the hospital, we made plans to ensure she could coordinate a way to return to pick up her daughter. I also worked with her correctional facility to obtain reliable contact information so that I could update the patient’s mother daily with the baby’s growth, feeding, and care plan.

I was proud of the work I put into coordinating this patient’s family support network, even in unconventional circumstances. I felt like these efforts were consistent with my goals of treating all patients and their families with compassion and dignity. I received this feedback following my NICU rotation:

Feedback from NICU rotation, July 2021

I’m proud of the work I’ve put into developing my professionalism skills, particularly my ability to treat patients with compassion and dignity across diverse circumstances. However, I recognize that this competency is something I will continue to develop over a lifetime. With that in mind, I have the following goals as I transition into residency: First, I want to continue to engage with patients of diverse backgrounds and experiences to better understand their physical and emotional needs. I plan to do this not only through patient interactions but also through literature. In particular, I will read several autobiographies written by individuals who have grown up in foster care, experienced unstable homes, suffer from addictions, or have been victims of racism. The books I’ve collected so far include A Child Called ‘It’ by David Pelzer, Girl Bomb by Janice Erlbaum, Three Little Words by Ashley Rhodes, and Black Boy by Richard Wright. By engaging with these narratives, I hope to develop greater empathy, compassion, and cultural competency in treating patients whose experiences may not match my own.

Systems-Based Practice: Developing skills in quality improvement

Systems-based practice: Demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care

  • 6.4 Advocate for quality patient care and optimal patient care systems,
  • 6.5 Participate in identifying system errors and implementing potential systems solutions 

One of the areas in which I have perhaps learned the most since the start of medical school is in the area of quality improvement (QI). I’ve always been eager to develop better, more efficient systems in my personal life — whether that is in studying for an exam or training for a race. However, the concept of approaching a similar concept in a scientific, institutional way was new to me and very appealing.

My initial exposure to QI was shortly after the beginning of my first year of medical school. During the presentation, I remember being particularly struck by the presenter’s summary of the landmark publication, To Err is Human, released by the Institute of Medicine in 1999. It opened my mind to the power of QI techniques in healthcare, where systems optimization, safety, and efficiency are not just ways of getting things done better or faster; They may also be a matter of life or death.

I continued to learn about the ideas and science behind quality improvement throughout the rest of my first and second year of medical school. One of the principal resources that helped improve my understanding of QI methods were the modules published by the Institute for Healthcare Improvement. Through their curriculum, I’ve earned a series of certificates covering everything from the fundamental principles behind QI to the logistics of compiling and displaying data when assessing a project.

My first certificate for quality improvement training

It was exciting to learn about QI in the context of healthcare, and the knowledge that I gained as I completed online courses and attended medical school lectures outlined a relatively straightforward, scientific path to making hospitals more efficient and safer for patients. However, as I transitioned from my preclinical education to my clerkship year, it became easy to see how applying the principles of QI in a real-life system could be more challenging than it might appear on the surface.

Throughout my third year of medical school, I noticed that social considerations surrounding QI projects or other systemic changes heavily swayed such projects’ odds of success. For example, the extent to which teams consistently unified to implement new policies seemed to hinge in large parts on aspects such as the convenience of implementation, belief in the project’s purpose, ease of remembering the project and its goals, and other communal and/or individual perceptions of the project.

These interpersonal challenges have come into focus even more clearly over the past year as a group of classmates and I have begun working on our own QI project in the Department of Psychiatry. In conversation with social workers and attending physicians on the inpatient psychiatry floors, we realized that there was room for improvement in prescribing medications to assist with alcohol cessation for qualifying psychiatric patients at OSU. While evidence recommends use of both behavioral services and medications to assist with alcohol cessation as the most effective way to treat moderate to severe alcohol use disorder, very few patients with alcohol use disorder were being prescribed such medications while inpatients or upon discharge. We decided to work to increase the number of patients with alcohol use disorder who are provided prescriptions for naltrexone or acamprosate at discharge.

Our first challenge was to identify and narrow the specific goal of our project and decide how to measure it. While we knew we were hoping to improve inpatient access to naltrexone and acamprosate–especially upon discharge–how would we determine who should be getting the medications and what percentage of that group were getting them? We ultimately decided to rely on intake forms for alcohol use disorder to determine the group that we wanted to extend treatment to, and we decided to enlist the help of one of the hospital statisticians to measure who was getting treatment. Using billing codes for alcohol use disorder and for naltrexone/acamprosate, he helped us compile baseline data.

Run chart for our baseline data for percent of patients at Harding Hospital receiving medications to assist with alcohol cessation, showing a median less than national average and a mean approximately at national average

Our baseline data from the 3 months prior to our project showed that our institution was likely near or slightly below the national average of ~13%, with a median (9.72%) less than the national average and a mean approximately at the national average (13.67%). And, in fact, most literature we were reading suggested that the national average was significantly lower than it should be if patients were being treated with appropriate evidence-based prescribing practices. So, it was clear that there was room for improvement.

However, the most difficult task by far was figuring out how to implement change throughout the hospital. It required a lot of questions: Where was the problem coming it? Was it a matter of time or presence of mind among prescribers? Was it hesitancy on the part of patients? These were all questions we began considering, and we turned to people in the hospital for answers.

Fishbone chart outlining possible root causes of low prescribing practices for naltrexone/acamprosate in patients with alcohol use disorder

While we identified many possible root causes, we had to choose just one to address. As we spoke with providers and patients, it became clear that one major reason these medications might not be prescribed for patients who could benefit from them was a lack of knowledge of the medications’ benefits, side effects, and availability in the hospital. We decided that the goal of our project was to distribute information to providers and patients about the importance of considering medication as a part of their alcohol cessation plan.

Over the past several months, we’ve been working to help educate patients and providers about the indications for the medications as well as their potential benefits and side effects. This has involved several in-person meetings with inpatient staff as well as the distribution of information to patients on the floor, mostly in the form of flyers. It’s been exciting to work with the inpatient teams, which are enthusiastically supportive of our project and have engaged really well in our meetings. However, it has been more difficult to gauge the involvement of patients, especially in a setting such as an inpatient psychiatric hospital where a huge range of factors (age, literacy level, severity of mental illness, cognitive abilities) affect their level of engagement. We’ve been trying our best to make materials interesting and accessible, but it will be difficult to assess whether we’ve been successful in this endeavor until we finish collecting our data.

As I reflect on this experience, I’ve been thinking about two surprising lessons I have learned about the field of QI since beginning my medical school journey. First, I’ve been surprised by the extent to which successful QI depends upon building relationships: during our QI project, relationships with patients and providers have proven just as important as careful planning in our approach. This facet of implementing a QI project has also proven to be one of the most challenging aspects of our project. It takes a great deal of time and thought to connect with people from such a wide range of backgrounds.

The second lesson I have learned is that when implementing QI in a hospital setting, there is often more than just efficiency riding on the success of the project: patient’s well-being or even their survival might be influenced by the outcome. I’ve been especially thinking about this over the last several months as we strive to implement our own project. Even helping one or two patients curb their alcohol addiction could help those patients maintain their psychiatric health and keep them out of the hospital. This in turn frees hospital beds for other patients who may be dealing with life-threatening psychiatric crises.

As I reflect on what I’ve learned about QI so far in my medical training, I plan to continue learning from my ongoing project as we move into measuring our outcomes. I am also excited to translate what I have learned as a medical students to QI issues I may encounter as a pediatric resident. Moving forward, I have the following goals:

1.) Complete my ongoing QI project. Next, we will be measuring our outcomes!

2.) Compile a poster describing our project and reflecting on the outcomes. This will not only help solidify what I’ve learned about displaying and describing QI data; it will also hopefully help me as I reflect upon and process the successes and shortcomings of the project.

3.)  Continue learning about QI using resources from the IHI as well as by studying ongoing projects at Nationwide Childrens and elsewhere. As I complete my final year of medical school, I’d like to work through a minimum of 3 more modules and continue learning from others who are implementing QI projects on the wards and in clinic.

 

 

 

Personal and Professional Development: Coping with tragedy

Personal and Professional Development: Demonstrate the qualities required to sustain lifelong personal and professional growth

  • 8.1 Develop the ability to use self-awareness of knowledge, skills, and emotional limitations to engage in appropriate help-seeking behaviors

  • 8.2 Demonstrate healthy coping mechanisms to respond to stress

The best parts about pediatrics are watching kids get better after an illness and helping keep them safe and healthy as they grow into adults. However, the worst part of pediatrics is when kids don’t get better. One of the toughest things to learn as an aspiring pediatrician has been learning how to cope in such situations.

My first encounter with a devastating pediatric outcome took place during my pediatric surgery rotation while I was on my call shift. It was around 11 PM, and I was sitting in the call room with the fellow when her pager went off, calling her over to the ED for a trauma patient. He was 4 years old and reportedly found in the kitchen after falling off a chair. His mother said she found him dazed on the ground when she entered the room and carried him to the bathroom where she put him in a bathtub full of cold water in an attempt to revive him. She left him in the tub for several minutes and returned to find him aspirating water and unconscious.

We hurried over, and he soon arrived:  unresponsive, hypothermic, and barely visible under a pile of blankets and wrapped up in a C-collar. All that was visible was his swollen, bruised baby face. The fellow ran the resuscitation as I stood by in the corner, horrified. He remained unresponsive, though his vitals improved enough for him to go to the CT scanner, which showed a huge brain bleed causing herniation and signs of significant global hypoxia.

He was soon whisked away by the neurosurgery team for emergency decompression but remained hemodynamically unstable and never regained consciousness. His neurologic injuries and additional physical injuries were too much for his body to handle. He died in the PICU later that night at around 3 in the morning.

What made that night even harder was that the child, of course, had not died from falling off a chair. The huge brain bleed alone would be enough to suggest that, but he also had a wide range of other serious injuries: fractures in his arms, legs, and collarbones; bruising all over his body; and significant bilateral retinal hemorrhages. It didn’t take long for the truth to surface, and the patient’s mother admitted she’d been trying to cover up for her boyfriend, who had beaten the child to death.

The rest of the night was frantically busy, and nobody really talked about the little boy who had died in the PICU. I was left to cope with the situation on my own, and I wasn’t really sure where to start.

I was left with many feelings, and in the days following the case, it became clear that my usual distractions from school-related stress were not working. Images of the patient’s swollen face kept popping into my head, filling me with rage and sadness. After several days of ruminating on my feelings, I decided to try journaling about it. Here is an excerpt from my journal at that time:

Journal entry from 3/1/2021

Journaling began to help me piece apart where my feelings were coming from and what I could do with them. It helped me give myself permission to feel sad and angry about the situation, acknowledging that these were very appropriate feelings, so long as I could let the feelings wash over me without being overwhelmed by them.

In time, journaling also helped direct me towards harnessing those feelings. I began thinking and writing about how things might have been different if someone had intervened before the boyfriend had harmed the child, or what might have happened if someone had noticed bruising earlier. Soon, this led me very naturally to reading more about child abuse pediatrics. My anger and sadness turned into a desire to learn, and I started reading textbooks and journal articles about the signs, symptoms, workup, treatment, and prevention of child abuse. I began to internalize my own responsibility to notice and act upon early signs of abuse to prevent the devastating outcomes that too often result.

I decided that, in addition to reading independently, I wanted to participate in more hands-on learning. In September, I enrolled in the Pediatric Advocacy and Child Abuse rotation. During this rotation, I spent a month with the Child Abuse specialists at Nationwide Children’s. Each day, I saw workups for alleged sexual or physical abuse. I saw a wide range of examples of abuse, including a 5-day old baby girl with 9 broken bones and an 18-year-old girl who had been raped by her stepfather.

As difficult as it was to see these cases, it was also incredible to see how the team responded. At least a dozen people rallied around each patient, and I learned from caring psychologists, social workers, forensic interviewers, policepeople, CPS workers, and nursing staff as well as the fellows and attendings. Watching them all work together to help their patients heal made it a little easier to cope with all the challenges that each day brought.

In addition to adapting to coping with emotionally difficult cases, my Pediatric Advocacy and Child Abuse rotation taught me volumes of information about the evaluation and treatment of child abuse. By the end of the rotation, I was asked to give a presentation on a topic I had particularly studied and learned about. I decided to present on inflicted burn injuries, which are a common manifestation of child abuse.

Slides from my presentation on non-accidental pediatric burn injuries, September 2021

Participating in this rotation and learning about this emotionally-challenging topic made me feel empowered to develop my skills as an advocate for children and helped mitigate the helplessness I felt as a bystander on my surgery rotation. I still feel sad and angry when I see cases of child abuse, but I’m learning how feel those emotions without letting them consume me. As I enter this last semester of medical school and prepare to become a pediatric resident, I’m committed to educating myself about child abuse and applying that knowledge to my practice. The following goals are guiding my efforts:

1.) Perform a head-to-toe skin exam on every infant and toddler to screen for cutaneous signs of abuse during every routine check-up and ER/Urgent Care visit.

2.) Screen for safety in every patient by asking parents or verbal children/teens, “Do you feel safe at home?” as part of routine social history.

3.) Consider NAT on the differential for any pediatric injury and think carefully about why it should or should not be suspected based on H&P.

4.) Continue reading about NAT. I’ve compiled a binder of references from my Pediatric Advocacy and Child Abuse rotation as well as additional articles on a variety of pertinent topics from Pediatrics in Review and similar sources.

 

Interpersonal and Communication Skills: Breaking down barriers

Interpersonal and Communication Skills: Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals

4.1: Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds

4.7: Demonstrate insight and understanding about emotions and human responses to emotions that allow one to develop and manage interpersonal interactions

“I hate doctors,” my patient’s mother said as she eyed each of the three doctors and two medical students in the exam room. She was sitting in bed with her son, arms crossed, exhausted from a near sleepless night following his admission to the hospital.

This was one of my first interactions with the patient and his mother, who arrived from West Virginia late one night. The 4-year-old patient had developed pain and a worsening limp in his left leg until his symptoms became so bad he could no longer bear weight on the affected limb, prompting his mother to bring him to the hospital. He’d had similar symptoms 6 months before with positive lyme disease serologies, but he’d only had 7 days of amoxicillin—an inappropriate antibiotic regimen for late disseminated lyme, which was the suspected cause of his symptoms. He’d been admitted to the infectious disease floor to rule out septic joint from other causes and start empiric treatment while awaiting lyme laboratory studies.

Though boy’s mother had brought him in hoping for medical help, she voiced a longstanding and unequivocal skepticism for the medical establishment. She described multiple herbal remedies that she’d tried at home initially for her son’s pain: oregano oil, moss extract, and other treatments that she’d read relieved inflammation. She also reported that her son was incompletely vaccinated due to her concerns about the MMR vaccine causing developmental delay.

The attending explained that we would be starting intravenous antibiotics and exited the patient room. Once outside, he voiced frustration about the mother’s aggressive stance toward the team and her mistrust of evidence based medicine. He also brought up concerns that the patient’s mother might not be compliant with our recommendations for treatment. It seemed a worthwhile consideration, and I returned to see the patient after rounds in order to further assess the mother’s attitude toward her son’s care.

When I arrived, it was clear she was anxious and upset. She told me she felt like she’d been interrupted during rounds when she tried to ask questions and had a poor understanding of the team’s plan for her son. I apologized and walked through what we had talked about on rounds carefully with time for questions. I also told her she had done the best possible thing for her son by bringing him to the hospital and that he was fortunate to have such a caring and observant parent. Our longer conversation seemed to break down much of the initial mistrust that the patient’s mother had for me, and it taught me more about her perspectives.

For example, she explained that her mistrust of the medical establishment stemmed from a chain of negative interactions with medical staff at other facilities. She also explained that her hesitancy to give her son the MMR vaccine was due to her belief that it had been the cause of her daughter’s developmental delay, which was formally diagnosed just weeks after she received the MMR vaccine. While it was likely a coincidence, I could see where a combination on misinformation readily available online combined with the timing of her daughter’s diagnosis could bring her to this conclusion.

We parted for the evening on good terms, and the patient’s mother reported feeling better informed about her son’s care plan. For the duration of the patient’s stay, I made sure to continue stopping by after rounds with updates and time to answer questions. When a diagnosis of lyme was confirmed and the patient was ready to go home on oral antibiotics, I stopped in one last time to deliver home-going instructions.

The patient’s mother listened and participated in teach-back regarding instructions for follow-up, return precautions, and specifics about the timing and duration of her son’s antibiotic treatment. I paused and asked her how she felt about his taking antibiotics for an entire month. She nodded, “I know he needs to take them,” she said, “and I feel like I get what’s going on.” She smiled “I’m going to make sure he eats extra green vegetables to treat his inflammation, but he’s also going to take all of those antibiotic pills.” As I said my goodbyes to the patient and his mother, I was happy to see contentment on the mom’s face as her son ran around the room with barely a limp.

As I considered my interactions with this patient and his mother in the days that followed, I thought about the ways in which my communication skills with patients have developed over the past few years. Looking back on one of my early patient interactions in LP, I noted that it was difficult for me to focus on the patient perspective when I couldn’t understand the patient’s health behaviors or attitudes. In these circumstances, it was often easier to jump to judgements about the patient than to empathize.

For example, during my first year, I wrote about a patient with HIV and Hepatitis B who engaged in high-risk behaviors and was non-compliant with his medications, putting his wife and other sexual partners at risk for infection. I was frustrated with his nonchalant attitude toward his own health and the health of those around him, and I initially found myself passing judgement on his behaviors. Upon reflection, I recognized this judgmental stance and realized that this failed to take into account the complex personal history and experiences that contributed to his health behaviors. At the time, I wrote the following as I reflected on the experience:

Journal entry from fall 2018

Since then, I have worked to gain insight into the wide range of factors that affect a patient’s attitude toward the medical establishment. These include prior interactions with the health care community, cultural background, and personal beliefs. As part of these efforts, I participated in a two-year longitudinal advanced competency in social determinants of health and patient advocacy. As part of this class, I learned about a wide range of social issues that influence patients’ lives and reflected on how those pertain to my role as an aspiring physician. At the completion of this course, I wrote the following essay connecting my growing knowledge about social determinants of health to interpersonal communications:

DELTA reflective essay – Fall 2019

Working to understand social determinants of health more clearly has helped me become more empathetic in my conversations with patients and has helped me provide better patient care. The following evaluation from my third-year clerkship demonstrated progress I made in this area:

Clinical Performance Evaluation from Inpatient Hepatology, Fall 2020

A second area in which I’ve made progress is in my own confidence as a student doctor. Gaining confidence has helped me take ownership of difficult situations and face challenging communication without becoming intimidated. This, in turn, has opened up new learning opportunities by giving me a chance to practice navigating scenarios such complex social situations or parents declining important care for their children.

Moving forward, I hope to develop critical skills in interpersonal communication by continuing to learn how to build rapport with families under challenging circumstances. I aim to continue working on my understanding of how peoples’ backgrounds affect their views on medical care, and I want to continue building my confidence as a caregiver in such situations. I also want to continue making time to listen to the stories of patients and their families, which I have learned contain valuable information about what underlies the emotions present in these situations.

Interprofessional Collaboration: Working with a community of caregivers

Interprofessional Collaboration: Demonstrate the ability to engage in an interprofessional team in a manner that optimizes safe, effective patient- and population-centered care

  • Objective 7.2: Use the knowledge of one’s own role and the roles of other health professionals to appropriately assess and address the health care needs of the patients and populations served.
  • Objective 7.3: Communicate with other health professionals in a responsive and responsible manner that supports the maintenance of health and the treatment of disease in individual patients and populations.

One of the most rewarding experiences I’ve had as a student took place with a patient who I cared for on my mini-internship experience on the infectious disease service. I had the privilege of working with her and her family from admission to discharge as they navigated a complex hospital experience over almost three weeks.

My first encounter with this patient and her family took place during night call during my third day on service. She was 16 years old and initially presented with weight loss and a very large pleural effusion of subacute onset. She and her family were Nepali, and her parents spoke a limited amount of English. With the help of an interpreter, we learned that she also had a history of previously treated latent tuberculosis as well as a BMI less than the first percentile for her age due to restrictive eating behaviors. We were concerned for active pleural tuberculosis, and we began an infectious workup for this and other organisms.

However, her hospital course quickly became complicated for a variety of reasons. On her second day in the hospital, the team placed a chest tube to relieve her large effusion. This resulted in post-obstructive pulmonary edema that required several days of high flow nasal cannula oxygen in the PICU. Though she recovered from this in several days, she was weak and malnourished at baseline, which worsened with her acute illness. To further complicate matters, her previous history of latent TB made it difficult to interpret her TB quantiferon gold test, which was positive. We ordered a variety of PCRs and cultures of her blood and pleural fluid instead, but though the fluid was exudative they were all negative for organisms. It soon became clear that we were going to need other teams on board to help make a diagnosis.

Our initial thought was to get a biopsy of her lung pleura as this was where the disease process seemed to be localized. I consulted the general surgery team; however, they were concerned about her post-operative recovery given her poor nutritional status and worried she would develop a pleural leak that would compromise her respiratory function. I then reached out to pulmonology to get broncho-alveolar lavage samples for microscopy, PCR, and culture. They were able to safely complete this procedure, but it again yielded no answers. With so many negative infectious studies, we began to consider additional causes for her presentation. I consulted rheumatology and ophthalmology who evaluated her for autoimmune causes, which were also negative.

Throughout the patient’s hospital stay, I worked with other teams to address additional health and social issues. Hematology helped evaluate and treat a severe iron-deficiency anemia present on admission. Adolescent medicine and nutrition both worked with the patient to further investigate her restrictive eating behaviors and optimize her nutrition. Social work helped her parents fill out lengthy paperwork to secure a leave of absence from work during her admission. Child life worked with the patient to help fill the long days with interesting activities. Psychology was consulted to help her process her illness and lengthy hospital stay.

Ultimately, weeks went by without answers, and though we were unable to confirm TB with lab tests, it was deemed most likely based upon her clinical presentation, risk factors, and failures on trials of several empiric antibiotics. She was started on empiric four-drug therapy just over two weeks into her admission, and within 24 hours, she had her first day fever free since arriving to the hospital. Her clinical status continued to improve on TB treatment, and we moved forward with this presumptive diagnosis. I called the Ohio Department of Health to coordinate direct observed treatment and worked with the patient’s family to clarify home- going instructions and follow-up.

Throughout this patient’s stay, I spent many hours communicating with the multiple interprofessional teams involved in her care. I then communicated the information I learned to my team as well as to the patient’s parents and nursing staff. As I worked with many different specialties, I found it particularly challenging to communicate the patient’s complicated hospital problems in a concise manner that emphasized the points relevant to specific consultant teams.

As I’ve reflected on my experience caring for this patient and her family, I have considered the ways in which my skills in communicating with interprofessional teams have developed over the past three years. During my first two years of medial school and into the first part of my third year, I felt like much of my progress in communicating with different providers involved learning the basic language necessary to have discussions about patient care such as rounding and basic note writing. Initially, as I worked on developing these basic communication skills, I sometimes struggled to “take ownership” of patient care by contributing to interprofessional care:

Evaluation from UPWP GI rotation; June 2020

As I’ve gotten further along in my training, not only have I learned how to provide more comprehensive care for my patients by communicating with consultants— I’ve also learned more about which specific details of such communications that are valuable to certain care teams: For example, a general surgery consultant, a rheumatologist, and a social worker may all be interested in different aspects of the same patient’s history. Working as a part of some of these teams myself and interacting with different members of the interprofessional care team have helped me become more adept at developing this skill. Some of these skills began developing during my third year as I starting interacting more often with interprofessional teams and asking them to teach me more about their roles in patient care:

Evaluation from UPWP Pediatric Ambulatory rotation; September 2020

As I became more comfortable interacting with interprofessional team members and consultants, I gained confidence in reaching out to them to facilitate more comprehensive care for my patients. During this most recent experience on pediatric infectious disease, I was proud of the hard work I put in to follow up with consultants regarding my patient’s care needs and of the long hours I spent with the patient and her family explaining various aspects of her care. I felt as though I had made the effort to take ownership over my patient’s care as the designated caregiver from her primary team. When I got feedback from the ring, it was gratifying to see that physicians I worked with noticed this effort, too:

Evaluation from AMHBC: Mini-internship in Pediatric Infectious Disease

Continuing into my final year of medical school, I hope to keep working toward improving my ability to collaborate with members of an interprofessional team. As I get closer to becoming an intern, I plan to take ownership such conversations for my patients whenever possible and to be intentional about touching base regularly with teams such as nursing and PT/OT who carry key knowledge about important aspects of patient care. In this way, I hope to both gain knowledge as a student doctor and become a better caregiver for my patients.