Posts

Planned Parenthood

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Patient Care:

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

Abortion–when people hear this word, their minds tend to automatically think pro-life vs pro-choice. However, this is not a dichotomous subject and by putting it in these boxes we force society to become polarized. Unfortunately, that is the case in the state of Ohio and throughout the nation. In Ohio, there are only two centers that provide safe medical and surgical abortions, one in Columbus and the other in the Cleveland area. During my third year OBGYN rotation, I had the opportunity to go to the Columbus Planned Parenthood to further understand the process of getting an abortion.

Throughout the day I was able to follow a patient through the initial workup, which included information about all their options and a transvaginal ultrasound to estimate gestational age. On element that I found surprising was that the state requires certain questions be asked, such as do you want to see the ultrasound picture, and do you want to hear the heartbeat? I do not understand why it was a requirement to ask these questions. These questions feel coercive and almost cast a shroud of guilt on the patient. Watching the women appear deflated after answering these questions was just heartbreaking.

There is immense amount of stigma when it comes to abortion and it can follow patients even when they’re in a safe space, like Planned Parenthood. That day I saw a patient who was interested in an abortion and was very emotionally distraught about being at Planned Parenthood. Her eyes were puffy, and her face was red as if she had been crying for hours. Her arms were wrapped around herself, as if to protect herself from something. She did not disclose her story to us, only that she had never expected to be here. She states that she would go to her regular OBGYN after the medical procedure and tell her provider that she had a miscarriage, instead of an abortion. Even though I did not agree that she should lie to her primary OBGYN, I respected her decision. There was no way for me to fully understand all of the nuances of her situation and I trusted that she was doing what she believed to be best. At the end of that encounter, I understood what she was protecting herself from, society.

Our personal experiences, both big and small, have a lasting impact on each and everyone of us. These experiences shape who were are and how we see the world. The accumulation of all of us and our experiences dictates our society, therefore we all have the power to change our society. My time at planned parenthood showed me the importance of women maintaining reproductive independence. It is imperative that physicians show support to this vulnerable patient population and guide them like they would any other patient–providing all of the possible options and letting them make their own informed decisions.

Goals/Plan:

  1. Learn more about the opinion of pro-life.
    •  Read Unplanned: The Dramatic True Story of a Former Planned Parenthood Leader’s Eye-Opening Journey Across the Life Line by Abby Johnson
      • Note: when I was searching for a book to read on this issue, I noticed an alarming similarity between many of the books–the majority were written by male authors. For some reason, this fact made me uncomfortable because I got a sense that men were trying to dictate what women could do with their bodies. It wasn’t until I specifically searched for a female author on pro-life did I finally find one.
  2. Learn more about the state laws about abortion access.
    • After I match, I will take the time to sit down and research that states abortion laws.
  3. Go to a residency program that provides adequate abortion training.
    • On the interview trail, ask residents about their program’s family planning training.

 

My First Central Venous Catheter Placement

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Medical Knowledge and Skills:

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

As I began my second year of medical school, I continued with my ultrasound training with the ultrasound interest group. I had just entered into the intermediate class and we were starting to learn more advanced techniques. One of the lessons was how to place a central venous catheter (CVC). I remember intently focusing on the wire, making sure to have it in my hands at all times. Little did I know at that time, that those lessons would help me during my general surgery rotation in my fourth year.

It was the second to last day of the rotation and it was a normal day like any other. We had several cases to attend and I was excited to get to improve on my surgical skills. The next case was a removal of a chemotherapy port, but first we were going to place a CVC under anesthesia. My chief asked if I wanted to try and place the line and immediately I started to worry about my ability perform. The fear of potential failure started to creep in and I worried about being inadequate.

Fear of inadequacy and failure are common feelings that I have felt throughout my medical career. As a novice in the medical field, I am constantly surrounded by people who know more than me–nurses, residents, attendings, etc. Even though all of these individuals have many more years of experience than myself, it is hard not to compare myself to them. Constantly throughout my education, I am being compared to others. I am being ranked against my peers both with my tangible grades and my evaluations. Additionally, I am being compared nationally with residency applications. The feeling is constant and it can be difficult at times to separate my own self-worth from these grades, evaluations, and rankings.

Throughout these past four years, I have learned how to better cope with these feeling of inadequacy. Now when I don’t know how to do something or I don’t know the answer to a question, I take a moment to feel grateful. I am grateful for the opportunity to learn something new. Grateful to now have this new knowledge that I can use to help my future patients. I remind myself that I am the student and I am not suppose to know everything. Each pang of inadequacy is simple a growing pain, taking me one step closer to where I want to be, and I had a big growth spurt in the OR that day.

After setting up the kit, my chief told me that I only had two attempts at placement and then she was going to take over. I took a deep breath, re-checked my kit to make sure that everything was easily accessible and in order. With one hand holding the probe and the other with the needle, I searched for the patient’s left internal jugular (IJ) vein. With the vessel centered on my screen, I slowly inserted the needling, remembering the NALTA technique that Dr. Bahner had taught me all those years ago–north start view, angle the needle, leap frog technique, tent the target vessel, aspirate vessel. Within seconds I had successfully placed my first CVC. My chief was in disbelief that I placed it on my first try in a matter of seconds and I was honestly in disbelief too.

That day I realized that even though I had felt inadequate at the beginning of the case, I actually knew a lot more than I was giving myself credit. Even though there is much that I don’t know, I have learned so much these past four years. As my medical knowledge expands and grow I will need to continue to work on trusting myself and my abilities to adequately perform and treat my patients.

 

Goals/ Plan:

  1. Further my ultrasound knowledge.
    • Practice with the ultrasound at every possible time during future rotations, specifically during my  emergency medicine rotation in January 2021.
    • Look to see if there is an available time to practice scanning.
    • Proctor ultrasound guided line placement.
  2. Become more comfortable placing CVCs.
    • Utilize the opened CVC kit that is in the surgical resident lounge to practice moving the guide wire.
  3. Become more comfortable with medical knowledge “growing pains.”
    • At the end of the day, journal or talk to someone how I am feeling. Acknowledge that the feeling is temporary.
  4. Help other students and residents combat their feeling of inadequacy.
    • When I am a resident, I am going to talk to medical students at the my institution about how it’s actually better for them to get more questions wrong than right. I help will try and change their mindset into a positive constructive one.
    • I will share my struggles with inadequacy with the younger generations, so that they understand that those feelings are normal.

 

Combating Burn Out

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Practice-Based & Life Long Learning

  • 3.4: Identify one’s own strengths, weaknesses and limits:
    • seek and respond appropriately to performance feedback
    • maintain and appropriate balance of personal and professional commitments
    • seek help and advice when needed

The concept of burnout, which had once only been used to describe an electric device over heating, has now become a common term to describe the emotional fatigue that has plagued medical providers for the past decades. In 2017, a study conducted by the American Medical Association (AMA), the Mayo Clinic, and Stanford University School of Medicine found that 43.9% of US. physicians experienced at least one symptom of burnout [1]. Even though I have yet to become a physician, I have already experienced fleeting, but powerful moments of burnout.

During my first few months of medical school, I was unprepared for the mental and emotional toll that studying medicine would have on my life. For the first time ever, I was constantly studying, striving to receive the highest marks, but to no avail. I would open the emails that would display the class average, and repeatedly my score was below average. As I observed my peers performing successfully, I started questioning my ability to become a strong physician. Frustration and angst would ripple throughout my body causing my mind would run ramped with negativities–you’re not good enough, you will fail your patients and their families. There were times when these thoughts would be all consuming, but over the years I have learned to be the master of my mind.

My journey to find mindfulness has not been easy and has not been one that I’ve traveled alone. At the beginning of my medical education, I found solace in talking to my family about my hardships. Specifically, my older brother Austin, was the person I could rely on at a moment’s notice to listen to me discuss my struggles. Without judgement, he stayed, listened, and provided me words of comfort to get me through another day. I am forever grateful to Austin and the rest of my family because they are the reason why I have the strength to continue on this path. Not only has my personal family, but now also my medical school family have been an instrumental component in alleviating feelings of burnout.

They always say that friends are the family that you choose, and I am grateful that my friends have chosen me to be a part of their life. My friend group, also known as the ‘mud-bloods of medicine,’ since we all have non-physician parents, are some of the kindest and most supportive people that I have ever met. We are always there for each other when someone is feeling stressed about school or going through difficult personal matters. I know that I can rely on them for anything and hope they feel the same towards me. We help each other with stress by listening to the other person vent, giving hugs, or working out together. Exercise has also played a major role in alleviating stress. Whenever I am feeling overwhelmed I’ll go on a run or workout at the gym. Unfortunately, sometimes I feel guilty for working out. I think that I should spend that time studying instead. When I have these thoughts, my friends are always there to remind me that it’s important to take care of myself. I am extremely fortunate to have such a wonderful support system. With my friends and family, I know that I will not only get through medical school, but also thrive.

In my final year of medical school, I have been focusing on finding internal happiness rather than relying on external factors to bring me joy. I have realized that while friends and family are important, ultimately I am the one responsible for combating my burnout. In order to find internal happiness, I have started to see a therapist. Counseling has been essential for me to better understand myself and my past experiences. Through counseling, I have learned to radically accept my imperfections, my struggles, and my defeats. In addition to therapy, I have also been practicing yoga. By concentrating my mind on the map, and pushing out all of my distractions I am able to find a place of mindfulness. The road to self-love and acceptance has been difficult and one that I will have to continue working on for the rest of my life. I know, that if I continue on this path that I will be able to combat any future challenges or struggles, including burn out.

Goals:

  • Understand my limitations and be able to decline new projects if my schedule is already full.
  • Practice radical acceptance for the things I cannot change.
  • Bring an element of positivity and joy to each shift.

Plan:

  • Reach out to friends and family in times of need.
  • Complete one form of exercise every week during residency.
    • Ex: yoga, running, StudioTorch/Orange Theory
  • Check in with other residents weekly:
    • Assess how they are feeling
    • Provide emotional support
    • Encourage others to seek professional help when needed
  • Organize fun active activities with co-residents to help us all engage in a healthy lifestyle.

 

References:

  1. Shanafelt, Tait D. et al. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017. Mayo Clinic Proceedings, Volume 94, Issue 9, 1681 – 1694

Learning from Each Other

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Interpersonal Communication: 

  • 4.1: Demonstrate leadership and collaborate effectively with other healthcare team members and professional associates.

During my time at Nationwide Children’s Hospital I had the opportunity to work with the cardiology team for two weeks. The first thing that the residents told us before rounds was to not be intimidated by the big team. Originally, I thought maybe five to ten people, but in reality it ended up being fifteen to twenty people all doing patient center rounds. We had the attending, fellow, two to three residents, nurses, nurse practitioners, dietitians, care coordinators, pharmacists, and three medical students. Since we were such a large team, it was essential that we all worked together and communicated appropriately to ensure the best possible care for the patients.

The patients on the cardiology unit were very complicated with a problem list that would take up an entire page. It was extremely challenging to go through their medical history and understand everything that had been going on with these kids and then go and present all the findings to the whole team. Even though I struggled with the general medical knowledge about the various pathological processes, I had more difficulty figuring about the next steps for the patients. Since I did not know some of the main pathological processes, like hypoplastic left heart syndrome, I had difficulty formulating a plan. I was very fortunate that before rounds, my residents took the time to review our plans so by the time rounds came we would at least be on the same page as everyone else.

Rounding with such a large team was such an incredible experience. I had the opportunity to interact with so many different specialties and learn from each and every one of them. The specialists that I learned the most from this rotation were the dieticians. Many of the children on the cardiology unit struggled with feeding intolerance and had to slowly be weaned to an appropriate diet regimen. Interacting with the dieticians taught me how mathematical and precise feeds must be in order for the child to tolerate it and still receive all of his or her required nutrients. I am very grateful for the experience I had working with such a large team and I plan to use the communication skills that I’ve learned from this rotation in residency.

Goal:

  • Foster an interprofessional environment where everyone feels comfortable speaking out if they notice any problems either with the patient or the team.
  • Make sure that medical students feel like an essential part of the team.

Plan:

  • Actively reach out to other members of the care team, such as pharmacist, dieticians, physical therapists, and occupational therapist to ensure that the patient is receiving the utmost care.
  • Communicate effectively with social workers, so that all the patients’ needs are met.
  • Call nurses while we are rounding, so that they can be a part of rounds.
  • Foster a good learning environment:
    • Acknowledge when a medical student does something well
    • Encourage medical students to come up with their own assessment and plans before running them by me
    • Always give credit to the medical student, if it was their plan or idea

The Great Equalizer

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Professionalism:

  • 5.1: Demonstrate compassion, integrity, and respect for others.
  • 5.6: Demonstrate a commitment to ethical principles pertaining to provision or withholding of care, confidentiality, informed consent, and business practices, including compliance with relevant laws, policies, and regulations.

The days leading up to my surgical intensive care unite (SICU) rotation were stressful because I was anxious about what I was going to encounter. My father had passed away in an ICU back in 2015 and I was worried that those memories would start flooding back and interfering with my ability to provide patient care. Little did I know that my previous experience would strengthen my ability to connect with patients and their families even in the most difficult situations.

         

One of the patients on the service, we’ll call her Miss P, was an elderly woman who had many medical comorbidities and recent surgical interventions for abdominal complications, resulting in multiple drains. Her abdomen was unable to be closed and the feculent material prevented the wound-ostomy team from placing a wound vac. So this poor elderly lady had feculent material draining for every drain and her large ex-lap incision. It was a sight like none I had every seen before. The patient looked like she was in so much pain and discomfort, even though she was routinely being given pain medication. Additionally, she had been unable to be weaned from the vent after her surgery and so she continued to rely on it for respiratory support. It was so apparent that this woman was suffering, however her family wanted to continue doing everything possible to keep her physically alive.

Day after day I would look at the board and see that she was still full code. A fear would flow through my body as I thought of the possibility of having to do chest compressions on this patient with an open abdomen–I still shudder when thinking about it. After two-weeks of being on service, my team worked with palliative and acute care surgery to organize a family meeting. I was unable to attend this meeting, however the final outcome was the same as when they started, the family continued to want full code. As I read over the note from the family meeting, I still could not figure out why this family was so adamant on doing everything possible to keep their loved one alive.

I remember the horrors of seeing my dad suffer in the ICU and just could not wrap my head around how anyone could ever let someone they love to continue to suffer like that. During the afternoons I would think about this patient and their family. What were lives like? What memories did they share? What hopes or dreams were they still holding on to? As I thought about it, I realized I could not answer any of those questions. Those questions are so unique and specific to each and every person. One child’s experience with their parent is distinct from their siblings. So even though I know what it is like to lose a parent, I do not know what it was like for Miss P’s kids to think about losing her.

Death and dying is something that many people fear, including myself. As Mitch Albom states in Tuesdays with Morrie,  “death is the great equalizer” –it will come for all of us in a matter of time. Were Miss P’s children so paralyzed by fear of death that they were unable to see that she was no longer living? I never did get to know the outcomes of that patient experience, as the second family meeting was going to happen after I had left the rotation. However, I hope that Miss P and her children find a sense of peace in whatever decisions are made.

(Picture of my mom holding my dad’s hand)

Goals/Plan:

  1. Learn more about palliative medicine.
    • Sign up for a palliative rotation during my current month off in February.
  2. Learn more about what happens during a family meeting.
    • Attend a family meeting at the next possible occasion.
  3. Attempt to better understand my own fears of death and dying, so that I can better connect with my patients.
    • Re-read the book Being Mortal by Atul Gawande (I read this book to my dad the day before he died and I have been unable to read it again since).

Trauma-Informed Care of Sexual Assault Survivors Curriculum

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Systems-Based Practice:

  • 5.4: Identify and utilize professional role models as a means of growth and accept the responsibility of acting as a role model and teaching and training others.

Every 98 seconds, someone in America is sexually assaulted (1). This traumatic event can cause a negative sequela, impacting these individuals’ overall quality of life. Men and women who experience sexual assault are more likely to have frequent headaches, chronic pain and difficulty with sleeping, leading to their need for care by a medical provider (2). The response of the healthcare system to these traumatic events needs to be strengthened in order to facilitate short and long-term healing of sexual assault survivors. One way to enhance this response is by training healthcare providers.

During my first year of medical school, I went to an event hosted by the organization, Women in Medicine, that was a longitudinal para-curriculum about trauma-informed care of sexual assault survivors. As I walked into the classroom, I couldn’t believe how many students were in attendance. I felt a sense of encouragement as I realized how many people truly cared enough about this issue to take time out of their already busy day to listen, learn, and discuss this issue. As I sat in silence that first day, afraid to speak up for fear of my past creeping out, I listened to how supportive my peers were being. Their support gave me the courage to continue on my path to healing by using my personal and professional experiences to establish a permanent, longitudinal curriculum on trauma-informed care of sexual assault survivors at The Ohio State University College of Medicine.

With collaboration with other medical students and several faculty and staff we began by assessing the LSI curriculum to determine where these new curricular components would fit best to strengthen the already existing curriculum. Next, we enlisted the proper resources. Both myself and other other medical students were trained patient advocates for the Sexual Assault Response Network of Central Ohio (SARNCO), and so we contacted their college campus representative to help us ascertain the most important information for future physicians. Additionally, we contacted sexual assault nurse examiners (SANEs) to have further insight into the medical-legal aspects of caring for sexual assault survivors. Furthermore, with the assistance of the Center of Family Planning and Healing, we were able to establish a panel of patients who felt comfortable coming forward and sharing their story with medical students. Through interdisciplinary collaboration, we were able to create an e-module, patient panel, and a team based learning (TBL) exercise to provide longitudinal education.

    

I am grateful for the supportive nature of the faculty at OSU because with their help myself and the help of my fellow students, we were able to make a positive and lasting impact on the medical education at this institution. Not only were we able to have a positive impact at our home institution, but also nationally. We presented our work at the Generalist in Medical Education National Annual Convention in 2018, and then later hosted a workshop at the Academy for Professionalism and Healthcare in 2019. Sharing what we have done and what we have learned is imperative for the growth of this education at other medical schools, which in turn will strengthen the care physicians can provide their patients nationwide.

Seven years ago I was the patient trying to tell my physician my story, but unfortunately I was never truly heard. As a medical student I have made it my goal to ensure future physicians are trained to listened and help heal survivors of sexual assault. As I get closer to the end of my medical school career, I feel comforted knowing that the work I have done these past four years may one day help a survivor heal.

Goals/Plans:

  1. Establish a similar curriculum at my next institution in order to further education about trauma informed care.
    • Start by assessing current curriculum and resources at the institution during my intern year.
    • Finding other faculty, staff, and students who would be interested in assisting me with this endeavor.
    • Collaborate with faculty, staff, residents, and students to find out how to best correct knowledge gaps in medical student curriculum about trauma informed care of sexual assault survivors.
    • During my second year of residency, start implementing the new curricular developments.
    • During the third year of residency, analyze the effectiveness and impact of the curricular change.
    • During the fourth year of residency, document findings and publish in a journal or present at a conference, so that other institutions can implement similar curriculum.
  2. Ensure that the clinics at my new institution have all the necessary resources to provide sexual assault survivors with long-term care: physically, mentally, and emotionally.
    • Talk to faculty and staff at the clinics and assess their knowledge of available resources.
    • Contact the local rape crisis center for resources in the area.
    • Ensure that all clinics have tangible resources that all of the staff are aware of and are able to locate for patients when needed.
    • I plan to accomplish this during my first year of residency.
  3. Educate my fellow residents about the misconceptions about rape and about rape culture.
    • Ask for one of the journal club meetings to be about trauma informed care of sexual assault survivors.
    • Recommend reading the article, Psychological consequences of sexual assault, by Mason et al. However, if a newer article comes out at a later date, then I would suggest reading the latest article.
    • This can be done anytime during residency.

References:

  1. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2010-2014 (2015).
  2. Black, M. C., Basile, K. C., Breiding, M. J., Smith, S .G., Walters, M. L., Merrick, M. T., Stevens, M. R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Retrieved from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: http://www.cdc.gov/ViolencePrevention/pdf/NISVS_Report2010-a.pdf