Author: leipold.3

Finding My Voice and a Balance

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3.4 Identify one’s own strengths, weaknesses, and limits.

  1. Seek and respond appropriately to performance feedback.
  2. Maintain an appropriate balance of personal and professional commitments
  3. Seek help and advice when needed

 

As an indecisive person, choosing a medical specialty was something I spent a huge amount of time thinking about. I weighed every option, and I went back and forth between fields all the time, especially during my first and second years before my clinical rotations. Entering medical school, I knew that I liked being in the operating room from my shadowing experiences and I didn’t like clinic time very much. I also know that I like doing something different every day! Showing up to work at the same building every day using the same three exam rooms for years isn’t something that I would enjoy. I’m at my best when I haven’t fallen into a monotonous routine. From this knowledge about myself, I thought that I would like general surgery, emergency medicine, or anesthesia.

When I rotated during my third year, what I thought I wanted out of a career was only partially true. While I knew that obstetrics and gynecology involved surgical cases, I didn’t think that I would like to have a majority female patient base, I didn’t think that I liked delivering babies, and I thought that clinic was boring. These are all conclusions that I had come to when I shadowed an ob-gyn during undergrad. However, when I was in the ob-gyn clinic I felt like I was really able to connect with patients and educate them about their own health. I loved the surgical cases I got to scrub in on and delivering babies. The residents were so welcoming and were wonderful teachers, as were all of the attendings I worked with. I felt like I would really be able to serve my patients best as an ob-gyn.

Applying to residency is a lengthy and stressful process. I reflected back on when I applied to medical school, and I realized that there were some areas that I’d like to improve upon this time around. First, I wanted more people to read my personal statement. For medical school, I had my pre-med advisor and my mom read it. For residency, I had two residents read it, our program director, all of my letter writers, my boyfriend, and, of course, my mom. I also didn’t really consult anyone about the list of medical schools I chose to apply to. I also wished that I had used connections that my university had with students who were now in medical school to ask them about their experience there. This time around, whenever I interviewed at a program that had an Ohio State grad as a resident, I got in touch with them to ask them about the program and how they felt their transition was coming from Ohio State. I also asked residents here about the programs where they went to medical school and places they liked and didn’t like based on their interview experiences. I realized that I didn’t really like asking for help back in undergrad. Medical school has made me much more comfortable with asking for assistance when I need it and asking questions when I’m unsure about something. These are very important skills heading into residency when you have more responsibility with patients and could end up causing harm to your patients unintentionally.

In addition to making me much more comfortable asking for help, medical school has made asking for feedback much easier for me. Growing up playing soccer, I was constantly getting feedback from my coach and my teammates about what I could do differently and how I could improve my game. I never needed to seek out this feedback, it was always just given. During medical school, we are also constantly getting feedback from residents, attendings, and peers evaluating us. However, these are normally at the end of rotations, so you often have to seek out feedback on your own in the meantime. I was a bit shy about approaching busy attendings early in my third year, but by my fourth year, I was checking in with my residents at the end of the day if there was an area I could improve upon and I’d ask my attendings at the end of rounds or the end of a clinic day.

I found balancing my personal life and professional life much more difficult than I thought it would be during medical school. Probably in part that my partner was attending law school five and a half hours from Columbus. It was difficult not being able to see him and talk to him when I was having a difficult day. While we talked a lot on the phone it just isn’t the same. It was difficult to find weekends to visit when one of us didn’t have a huge test the next week or an important paper due. After the first year, it got a little easier. We were better at managing our schedules and planning around weekends. It was very difficult during step 1 studying because I was studying so much, and it was a busy time of year for him as well. Below is a photo of us at a Penn State vs OSU football game on one of the couple weekends we were able to spend together.

He graduated last spring and moved back to Columbus. It’s been great getting to spend so much time together before the responsibilities of residency start! Since we’ve had even more time together due to COVID, we even got a dog! We named her Olive and enjoy taking her on long walks around Columbus.

I was able to find a better work-life balance with the help of COVID, but anticipate that I will struggle again once residency starts and I don’t have nearly as much free time. To help combat this, I plan on setting aside two nights a month during residency where Max and either go out to eat or make a fun meal at home together so we can catch up and not focus on work and the hospital. I also want to make a point to call my mom or dad once a week, especially because I won’t be in the same city as them.

Developing Connections with Patients

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1.1 Approach the care of patients as a cooperative endeavor, integrating patients’ concerns and ensuring their health needs are addressed

 

I knocked on the door and slowly opened it to find my patient feeling very unwell. It was the first day of my third year, and I was working on the gynecologic oncology service. The patient frantically told me that she was nauseous, so I hurriedly searched the room for an emesis bag. I couldn’t find any in her room, so I told her I would be back in one minute and walked out into the hall to look for help. I crossed paths with a PCA, and I frantically told her the situation. She smiled and took me into the supply room to get some emesis bags as well as some towels and a change of sheets for the bed. We returned to find my patient vomiting all over herself and the bed. I froze. I didn’t know what to do. This was not how I had envisioned the start of my clinical years. I expected to feel confident and helpful, not unnerved and lost. Together the PCA and I helped to clean her up. We called her nurse who gave my patient her antiemetics. Later, when I saw her on rounds, I was pleased to see that she was in good spirits and feeling better. She had been readmitted after a total pelvic exenteration for treatment of her cervical cancer due to some issues with her midline incision. While admitted, she was dealing with a lot of pain, and still recovering after her surgery.  In the afternoons, I would chat with her in her room and take walks around the hall with her. I was in awe of her strength daily. She had gone through so much already, and she was determined to keep pushing to get better. Her daughter had just purchased a house down south by the beach. Her goal was to get strong enough to go spend some time down there with her family, relaxing by the water.

Over the two weeks, I was on service, I was able to watch her improve bit by bit, but not without a few setbacks. She was having increasing pain at her incision. The team was concerned about would dehiscence. As my residents examined her wound, I stood by her side as she squeezed my hand in hers and apologized for any pain she was causing me. At that moment, I couldn’t help but to think back to my first day of the rotation and how helpless I felt when she needed a hand to hold. She was still in the hospital on my last day on the gyn onc service. I wished her well and said goodbye before I headed home for the weekend. She was hoping to be discharged sometime next week and told me that our walks out in the hall helped her prepare for her walks on the beach.

My time taking care of her taught me a lot about the doctor-patient relationship. For patients, it is less about being perfect and having every answer. It’s more about spending time with them and showing you care about their lives beyond their disease. They want to know you’re working hard to find the answers, even if you don’t have them instantly. This was a lesson I wanted to carry onto all of my rotations and to every patient, I had the privilege of interacting with. I wanted to keep working on my communication skills and building connections with patients and members of the healthcare team as well.

Fast forward to my sub-internship during my fourth year. I was again on the gynecologic oncology service. It was July, so the residents were getting accustomed to their new roles, and the interns were figuring out how to be residents. I was applying everything that I had learned over the past year. I was able to find supplies in the JIT room. I knew how to get around the hospital. If a patient needed an emesis bag, I would know where to find one! Over the course of my sub-I, I was able to form connections with many of the patients on the service. There was one patient in particular with who I was able to form a strong bond. She had recurrent vulvar cancer and had an additional vulvectomy and reconstruction that required the assistance of plastic surgery. She had skin grafts harvested from her bilateral thighs, and she was in a lot of pain. Each morning during our pre rounds when we came in as a resident team, she was always so happy to see us. She would ask us each about ourselves and told us how she had been overnight. When my intern and I would go check on her in the afternoon she would talk to us about her favorite bands, including Queen, and her husband. This was during COVID, so her husband was only allowed to come up and see her during limited hours. As part of her post-op care, she wasn’t able to get up and walk around until 5-7 days after her surgery. She was sharing feelings of how she was feeling depressed not being able to move, so we consulted music therapy for her. She loved when they would come by to see her and she thanked us endlessly for placing the consult. Finally, when she was allowed to weight bear, she could only take five steps at a time. She could only get up with the help of PT, which was very limiting. During my time on my surgery rotation, I saw beds in the SICU that tilted up that allowed patients to stand while being in bed. With the help of the nursing team on the floor, we were able to special order her one of those beds. She was able to stand up with an assist from the nurse or PCA and didn’t have to bend at the waist which made things much easier for her.

https://www.youtube.com/watch?v=-b0tEjzf9fo

On the day she was going to be discharged, she thanked our team endlessly for all that we had done for her. She complimented my intern and me to our attending and said how wonderfully we had treated her and always came to check in with and talk to her. I was very moved by her reaction to what we had done for her. I thought I was simply doing the right thing for her. Trying to make her life in the hospital a little brighter, and I was able to have a huge impact on her life. Below are comments from my sub-i rotation.

This time around on the gynecologic oncology service, I was able to anticipate the needs of my patients. I was more familiar with the hospital and the resources available, and I was able to access them for my patients. I did all of this while trying to remember the importance of connecting and finding common ground. I tried to get to know the patients on the floor on a deeper level than their diagnosis and potentially complex cancer history. On one of the later rotations of my fourth year, I had evaluators comment on my ability to build rapport and communication with patients effectively.

Throughout medical school, everyone has told me that as a medical student you have the most time to connect with and get to know patients. As a resident, you are much busier. You have many more responsibilities and patients that you’re caring for. During intern year, and beyond, I’d always like to continue to ask patients that I come into contact with something that they enjoy doing, their favorite food, what shows they’re watching, or even a recent book they’ve read. Each week during intern year I’d like to learn fun facts about or hobbies of 7 patients that I take care of that week.

The Healthcare System and the COVID-19 Pandemic

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5.1 Understand the institutions and individuals that participate in healthcare delivery and the role of the physician in the healthcare system

5.3 Understand the interdependence of the component parts of the healthcare system and the potential for unintended consequences within the system.

 

One of the most difficult and eye-opening experiences of medical school has been the COVID-19 pandemic. We had been pulled off our rotations unexpectedly. We didn’t know when we would be able to return to the hospital. How much would we have to make up during our fourth year? How will our residency applications be impacted? Would the medical center be able to handle a huge influx of infected patients? Would there be enough medical resources (staff, ventilators, PPE)?

After watching what unfolded in New York City during their surge of cases, hospitalizations, and death, I started to wonder how Columbus had been preparing for an event like this. What sort of preparedness training had individuals completed? What was our hospital system’s plan for a surge of COVID cases? What did our PPE stockpiles look like? Due to a cancellation of my scheduled step 2 test date, I was required to reschedule for later in the summer. Because of this, I was able to take a disaster preparedness elective. During this elective, I was able to learn about all of the plans that the medical center had in place to deal with a pandemic like we were going through now. There are also plans for natural disasters, and structural failures, which hadn’t even crossed my mind.

As part of the course, I had to complete a lot of online training modules related to disaster preparedness. We had zoom lectures on past pandemics, zoonotic diseases, mass casualty situations, and toxicology, among others. We also completed a group exercise where we developed a contingency level care plan for staff and the health of the workforce at the medical center. Through this exercise, I was able to appreciate how important each job at the medical center is. Without proper staffing, things can go south pretty quickly. Our plan had a conventional level, a contingency level, and a crisis level. At the crisis level, staffing was prioritized based on immunity. We implemented training for staff that needed to cover in a position that wasn’t their typical duties. There were mental health resources for employees. If the medical center was still short-staffed, asymptomatic individuals with known exposure would be able to work, and wouldn’t have to quarantine. Below is a part of our crisis level plan.

From this course, and being a part of the medical system during the COVID-19 pandemic, I was able to better appreciate all the different parts of the healthcare system and how important each one is for its proper functioning, and how easily the system can break down, even if everyone does the best that they can to prepare for these unknown scenarios. Even the patients who were not infected with COVID had negative health impacts secondary to the pandemic. Many patients I saw in clinic had to have their cancer screenings delayed and then had trouble rescheduling due to the backup of patients who needed testing. Delaying cancer diagnoses can result in a monetary impact on the system as well as on the patient. In addition, canceling all elective procedures had a massive effect on the income of hospital systems, which impacted all of the employees who work there. I was also excited to learn that physicians play a huge role in how healthcare systems prepare for disasters. It made sense, but I always enjoy being exposed to the roles that physicians can have in the healthcare system that isn’t research or direct patient care.

The impact of the COVID-19 pandemic has been indescribable. Every area of our lives has been affected. After seeing how many roles are out there for providers that aren’t direct patient care, I’ve started to think about getting a master’s degree after my residency training in business, healthcare economics, or healthcare policy and management. I’ve done a bit of research on the topic and some of these master’s degrees can be done completely online over the course of six months to one year. While I won’t have time to pursue this venture during my residency training, I’d like to obtain one of these degrees within two years of finishing my training. In the meantime, before graduation, I will reach out to some of the OSU professors in the business school and the school of public health who are experts in these areas to ask for a list of resources they might recommend in order to start educating myself more on the topic.

Learning Ultrasound

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2.4 Understand the indications, contraindications, and potential complications of common clinical procedures and perform the basic clinical procedures expected of a new PGY-1.

 

One of the first student organizations I got involved in in medical school was the Ultrasound Interest Group (USIG). I had heard about their extracurricular learning opportunities during my interview day, and I was very excited to do hands-on learning as a first-year and step away from listening to lectures and reading my notes all day. I didn’t know exactly what specialty I wanted to go into at this point, but I figured that it would help me to develop a skillset for my future career regardless.

I started out at the beginners’ level during my first year, we learned basic knobology and probe motions, how to scan the aorta, the heart, the shoulder, and even the eye. During my second year, I was able to refine some of those scans further as well as learning the hepatobiliary scan, some gynecology scans, and how to place lines with ultrasound guidance using the NALTA (North star, angle, leapfrog, tenting, aspiration) technique. Also, during my second year, I was able to proctor scans at the beginners’ level, that is, teach the students in that course how to perform a particular exam.

I really enjoyed being involved in the ultrasound curriculum, so during my third year, I took the advanced level of the ultrasound course while coordinating the intermediate level with one of my peers. From this experience as a coordinator, I was teaching scans much more frequently than before, and sometimes giving lectures to our level students prior to their scans. This helped me to further develop my teaching skills, which I hope to continue to improve on during residency and as an attending.

During my fourth year, I enrolled in the honors ultrasound curriculum to further develop my scanning skills, and to learn more about what ultrasound can be used for (more advanced applications). This course required that I complete many video modules for different types of scans, attend lectures (via zoom), journal clubs (via zoom), and in-person scanning sessions to further practice and hone my scanning skills.

Throughout my years following the USIG curriculum I learned the “I-AIM” for each scan that was taught to us. This acronym starts with the indication, followed by the acquisition of the image, the interpretation of the image, and the subsequent medical management. For example, let’s say that a 31-year-old female comes in complaining of abdominal pain. On further questioning, her periods are irregular, her last period was more than a month ago, she is sexually active, and she doesn’t use any contraceptive methods. We order a urine pregnancy test, which comes back positive. Imaging to determine if a pregnancy is intrauterine or extrauterine is the next step in her management. She has many indications for this ultrasound study. Starting with a transabdominal view of the uterus using a curvilinear probe, the patient’s bladder should be full, followed by transvaginal imaging using an intraluminal probe with an empty bladder. (The following images were obtained using a model in the CSEAC).

Here we can see that there is not an intrauterine pregnancy. This is just a still image, but I scanned through the entire uterus. The endometrial thickness is 0.73cm. There is also fluid present in the pouch of Douglas. After scanning in the long axis, the probe is rotated 90 degrees to scan in the short axis.

            Here is the uterus in short axis with an endometrial stripe of 0.86cm. You can appreciate a round mass-like structure on the right side of the uterus deep to the right fallopian tube. There is a hypoechoic inner circle with a hyperechoic round structure within that.

Here is another image of the mass in the long axis. This mass is suspicious for an extrauterine pregnancy. Especially in the setting of a positive urine pregnancy test. That completes the image acquisition and interpretation steps. The plus side of bedside ultrasound performed by the provider is that these two steps work simultaneously. As far as medical management is concerned, she could be treated medically with methotrexate with follow-up imaging and beta-HCG or surgically with an exploratory laparotomy to remove the pregnancy.

During my intern year, I would like to keep continuing to build on my ultrasound skills. I have much less experience in pelvic imaging compared to other areas of the body, like the gallbladder. As a medical student, it was very difficult for me to gain experience performing OB imaging myself, but I was able to observe a lot of cervical length checks during my time in triage on L&D. My goal is to do 10 cervical length ultrasounds during my first year and 7 amniotic fluid indices. I haven’t matched yet, so I’m not sure exactly what rotations I’ll be doing my first year, but I believe that would be attainable numbers no matter what program I end up at.

Presenting At Chest

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4.3 Use effective listening, observational, and communication techniques in all professional interactions

4.6 Effectively prepare and deliver educational materials to individuals and groups.

 

I was leaving my longitudinal preceptorship during the spring of my first year when my preceptor asked me if I could switch my next shift and come in during an afternoon when one particular patient of his would be coming to clinic. He wanted me to meet her and asked if I would be interested in writing up her case for the upcoming Chest meeting. I enthusiastically agreed to switch my shift. I was thrilled at having the opportunity to write up a case for a meeting. When I got home, I started thinking more about it, and I realized that I had no idea how to write up a case. I started to do some research and read a lot of case write-ups online.

The patient had granulomatous lymphocytic interstitial lung disease in the setting of combined variable immunodeficiency disorder (CVID). We were in the middle of the cardio-pulmonary block, so I had learned a little about interstitial lung diseases and had received some teaching from my preceptor about interstitial lung diseases working in a pulmonary medicine clinic. However, I knew nothing about CVID. We wouldn’t start our host defense block until December, and it was only February! After doing some research and talking things over with my preceptor, I felt comfortable in my knowledge base to start the case write-up.

Over the next month, I did a lot of independent learning on the disease states. My preceptor and I had many check-ins with my abstract over the next month. We would meet virtually to go over things on the weekends. I was constantly asking questions about the order in which I would present things, and was I using the correct medical terminology here? After many edits, I submitted the abstract. A few months later, we found out that it had been accepted for a slide presentation! My preceptor was so excited that it was going to be slides, but inside I was even more nervous knowing that I would have to stand up at a podium and address a room full of people instead of standing next to my poster in a sea of other posters, answering questions individuals had as they passed through. I’m a very nervous public speaker so this was a tall order.

As the conference drew closer, I prepared my slides with the help and guidance of my preceptor. I practiced my presentation for my roommate, my boyfriend, some of my friends, and my parents over the phone. I had a dress rehearsal presentation at my preceptor’s office a week before the trip. We made sure all of my slide transitions worked and I got feedback on my delivery from his colleagues.

The morning of my presentation, I stepped out into the Texas air and headed to the convention center. My presentation wasn’t until later in the day, so I had plenty of time to stress about it. Throughout the day I was introduced to my preceptor’s mentors, friends from residency, and people who trained under him. I had never been to a national meeting before, and I was delighted by all of the different booths, people to speak to, medical devices to look at, and new technologies to try out. I practiced my presentation once more with my preceptor, and then, finally, it was time to present. I’m sure I talked a little quicker due to my nerves, but overall, I felt that my presentation went well! On the way out of the room, I was stopped by one of the internal medicine chief residents at Ohio State who told me what a wonderful job I had done!

Weeks later, I received an email from Chest that I had won the award for best slide presentation in my category! I was beyond thrilled that I was able to clearly present the case and answer questions that the audience had, and I had done it well!

Two years after that, I got an email from my preceptor asking if I would help two of his LP students write up cases for Chest. I immediately agreed because I remember how lost I felt when I was writing up my own case. I would have really appreciated having a medical student who had done it before and was familiar with the case read things over for me and answer my questions. Over the course of the following month, exchanged edits with my peers (an M1 and M2) and had meetings with our preceptor to check in on our progress. I saw so much of my younger self in the M1. Some of his word order and word choice sounded “off” because he hadn’t yet spent much time in clinical situations observing and listening to residents and attendings and reading progress notes. These things which also once seemed so foreign to me now seemed so natural. In total for Chest 2020, we had three abstracts accepted to the virtual meeting.

Through this experience of writing up my own case and then being able to assist other students with their own helped me to further develop my communication skills. I had to communicate with all of the physicians involved in my patient’s care to see if they had written up the case previously. I improved my medical writing and was able to critique and improve my peers’. All that I had learned from my experience attending the conference previously by listening to and seeing poster presentations, I was able to share with my peers.

As a resident, I would like to help the medical students that I work with improve their own medical writing and presentation skills. While I’m not sure how much time I’ll be spending teaching medical students on some rotations during my intern year, I would like to make an effort of helping each student with either their oral patient presentations on rounds or with their note writing during my time as a resident. During intern year, I imagine being a little more overwhelmed with my own responsibilities, so I’d like to assist approximately

The Impact of Page to Bedside

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

 

From the Page to the Bedside has been one of my favorite experiences during medical school. It is an extracurricular course, with the option to pursue an advanced competency, that focuses on the study of literary works that engage with issues of illness, treatment, and medical ethics. The group meets monthly to discuss a work chosen by the session leader, either OSUCOM faculty or medical students. There is a visual of a session below. I’ve always enjoyed reading, but I found that during undergrad the amount I read dramatically decreased. I expected to see the pattern continue during medical school and thought that participation in Page to Bedside would give me the motivation to read something other than a textbook and my notes from time to time. It ended up being that and so much more!

The discussions I’ve had with my peers during Page to Bedside have greatly impacted the type of physician, and person, I strive to be. They have made me think more critically about my own actions, my own biases, the lives of other people, different ways of viewing situations, and overall, just being more open to different views and arguments from all sides.

The first session I attended had a supplementary reading from Atul Gawande titled “The Way We Age Now.” (Full article: https://www.newyorker.com/magazine/2007/04/30/the-way-we-age-now) A passage that really stood out to me I’ve placed below.

While at the time I was unsure of what specialty I wanted to pursue, it really made me consider and evaluate how I interacted with older patients. Was I asking them the right questions? How could I get a better sense of what their life is like? I should be asking them about their feet and what their social life is like. While it may take extra time, it can have a huge impact on their lives. I now consciously make a choice to take extra time with geriatric patients that I come in contact with. Is there any way we could make their life a bit easier by adjusting medications? These people have lived long, and sometimes very difficult lives, and they deserve to be treated with the utmost respect. We need to be caring for the whole person and not just treating their blood pressure.

Another session that greatly impacted how I approach my career and overall life is a session from the summer of 2020. It was led by Dr. Ray Bignall who chose Medical Apartheid for the discussion. I was somewhat aware of the unethical tortures and abuse of Black people at the hands of the medical community, but I didn’t know the full extent. As a future obstetrician and gynecologist, I was especially impacted by hearing about James Marion Sims. Again, I was somewhat aware of his monstrosities, but Washington exposed me to the true horror of his actions. When doing more research after reading the book, I came across an interview with Dr. Kameelah Phillips.

https://www.today.com/health/racism-gynecology-dr-james-marion-sims-t185269

She is an Ob-Gyn who refers to the Sims speculum as the “Lucy.” This instrument is used to repair vaginal fistulas. It was developed by Sims, but Lucy was the enslaved woman he tortured and experimented on in order to develop the instrument. While we cannot erase the actions of Dr. Sims, I feel it is my responsibility to be aware of how we got to this point in medicine, and what individuals had to go through in order to get us here. In my future practice, I plan on recognizing the instrument as Lucy and educating my colleagues who may not be aware.

Because I enjoyed attending Page to Bedsides sessions so much, I decided to apply to be a student coordinator for the course. As part of my role, I attended and participate in every monthly group discussion. I also keep track of student attendance and participation. This has required me to send firm emails to my own classmates, reminding them to submit their reflections prior to class and that they need to be well-thought-out and not just a short paragraph. Holding my peers accountable was a new role for me, however, this experience has prepared me well for residency when I will need to need to have a discussion with my co-residents about their professionalism as a chief.

I have learned so much from reading and discussing readings at Page to Bedside. It has shaped how I interact with and view situations both personally and professionally. In order to continue this during residency, I’d like to start a book club with my co-residents or with my friends from medical school at other programs. I’ve used Instagram to compile book recommendations from social justice organizations, reproductive organizations, and ob-gyn physicians that they deem “required reading” for those in the medical field as well as ob-gyn specific books. Over the course of my first year, I’d like to coordinate at least two meetings with my colleagues, near and/or far, to discuss one of these works. Hearing about other individuals’ experiences with these topics will help me to continue to grow as both a physician and person by broadening my world-view, being more accepting of new/different situations and ideas, and building on the professionalism values that I have focused on during medical school.