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Knowledge That Sticks

Competency: Medical Knowledge

Before you read this, give yourself a little pinch in the abdomen, just to the left of your navel.

Did you feel it? Barring major anatomic abnormalities or some type of pathology that exists in your body, I’m guessing you felt it. How did you feel it? You felt it thanks to a spiderweb of nerves that runs in a fascial plane between two important abdominal muscle layers known as internal oblique muscle and the transverse abdominus muscle.

Despite the somewhat obscure nature of this fact, I actually learned it nearly five years ago in college during my first anatomy class. I then relearned it during preclinical anatomy in medical school. I finally relearned it again while preparing to proctor a teaching session regarding ultrasound guided anesthetic nerve blocks. Specifically, I taught what is known as the transverse abdominis plane (TAP) block.

As I began to reflect on this experience, I found that despite the fact that months have elapsed since occurred, this anatomical knowledge was as fresh my memory as the day I taught it. While repetition over the course of years almost certainly aided in this feat, I feel that the persistent clarity with which I can recall the whole process of a TAP block has even more to do with the higher level of learning that comes with teaching rather than just studying words on a page or even nerves within the body of a cadaver. Even as I prepared to teach how to perform a TAP block, I found that both new connections and new questions resulted that really solidified this knowledge in my mind.

A higher level of learning was not the only benefit that came from this experience. While I knew well before the teaching event that I was interested in anesthesiology in general, I had not been particularly focused on nerve blocks. However, as I put in the preparatory work and taught each successive group of students how to perform a TAP block, it seemed to fuel a flame of interest regarding regional anesthesia that has only grown since then. In short, through teaching others, I came to more fully understand myself.

This pattern has shown up many times throughout the last few years with another example involving skills in suturing. While frustrating at first to learn, upon teaching it to other students during a skills session, I was able to cement the skill and become more fluid in its execution. I enjoyed it and this helped me to overcome a fear of procedures I had upon entering my third year.

As I look back, I realize it was even apparent in the summer after my first year of medical school where preparing a poster presentation about my research helped me to better learn cancer staging and more fully understand how the project could lead to future scholarly efforts.

Having finished medical school, I have attempted to absorb a colossal amount of information. Now, as I enter residency, I will have increasingly numerous opportunities to share what knowledge I have with other students. These experiences have shown me that clinical teaching is not only an important way to help others grow, it is also the next step in my own growth with regard to medical knowledge. This next year as an intern instead of just reviewing internal medicine content on my own throughout the year, I will regularly prepare “mini-lessons” for the students I work with to help both them and me achieve our true potential.

Presentations

Competency: Interpersonal Communication

“Presentations are just going to be a harder for you than other students.” Those words came from the mouth of my attending during our final feedback session at the close of my neurology rotation at OSU East. I had given my all at that rotation especially with regard to oral presentations, and not just on that rotation. I had spent every day for weeks trying to hone my skills. I had been giving it my all. So as dramatic as it may sound, to hear my attending tell me that my presentations were “just going to be harder” for me than for others hit me like a freight train.

I didn’t expect oral presentations of patients to be hard for me. There is so much of medical school that is hard—far harder in fact than I could have fathomed as I first walked through the doors of Meiling hall. But oral presentations? I thought I would have the upper hand. Ever since I was a little boy I have been giving talks in church and had my fair share of speeches in school. As I got older, I tried my hand at acting on stage and enjoyed playing lead roles in school musicals such as “Annie Get Your Gun,” “Aida,” and “The Scarlett Pimpernel.” I even did some semi-professional performing in Salt Lake City. I have always been comfortable speaking and even singing in front of others. So one can imagine my surprise when I saw my own hand shaking like a leaf as I held my notes while giving my first oral presentation in the psych ED. I fumbled through it with more than a few awkward pauses and stammering phrases until I quite literally wanted to hide under a rock.

By the time I started my neurology rotation, my presentations had improved with practice, but my comfort while giving them had not. Preparing for each presentation brought new stress with every day. After getting some feedback that suggested write out my presentations, I had developed a system for both preparing and presenting that involved arriving early enough to research the patient well and, for the most part, complete their progress note before rounds which I would then use to present. Despite all this, however, as my feedback session continued at the close of my neurology rotation with my attending, I was disappointed to hear some of the same comments I received on day one of clinical rotations: that I often paused and searched for words and had a habit of nervously looking down at my notes when this happened. Words would come, but they would inevitably sound unsure and jumbled.

I continued to seek feed back during my ACS rotation during the next month, but it was clear from feedback that I still had room to improve.

It was during my surgical rotations that I really began to improve in my ability to pare down each presentation to include only pertinent information. Both residents and attendings in each rotation helped me to develop a format to my presentations that I could run through with every patient which allowed my presentations to become increasingly concise and efficient. Again, evaluations began to reflect my progress such as those from my Gynecology Oncology rotation:

Patient care requires skill in identifying the heart of a patient visit and being able to effectively and efficiently pare down a large amount of information into a presentation that brings an entire team of healthcare providers together in their care. It has taken an immense amount of practice, but I finally have come to see myself as an effective member of the team in this regard.

I have much room to grow however. While this process of gleaning and reporting complicated information is important, the very purpose of this endeavor is to allow one to then form effective treatment plans in the future. While I feel I am still fairly inefficient in my ability to do this, I believe that drawing on the above lessons from the past will help me to improve. I am learning in my preparation for a month long emergency medicine rotation that following a format in plan development could help my efficiency in the same way that presentation format helped me before. While I am still in the process of developing this format, I will use this coming month to do so. As I seek continual feedback on my treatment plans I believe that I will truly be able to “hit the ground running” as I move into internship and beyond.

The Pitfalls of Goal Setting

Competency: Practice-Based and Lifelong Learning

Goals have served as the guideposts of my life for as long as I can remember. While early goals yielded coin collections and Pokemon cards, these small victories gradually laid the groundwork for goal-driven achievements in music, research, and academia that eventually led to one of my biggest milestones to date: a spot in the class of 2021 at the Ohio State University College of Medicine.

During my surgery rotations, I had the goal to rank in the top 10% of students on my surgery shelf. I didn’t achieve it. While I have succeeded in some similar goals throughout my time in medical school thus far, I have failed to reach enough others that I have begun to question whether my efforts in goal setting these past few months have been misguided. In college, my goals regarding excellence in class grades provided needed motivation to work longer and harder than my peers which served me well. However, it has become clear with time that such a strategy as a medical student is no longer sufficient to yield the excellence I’ve been striving for. While reading the book Atomic Habits I received some insight as to why that may be.

I started reading Atomic Habits in the effort to improve in my ability to set and achieve goals. One can imagine my shock when I read the advice of the author, James Clear, to stop focusing on goals. As strange as this sounded to my ears, he explains his position in his book by listing some of the biggest problems that can arise in goal-oriented efforts. The first he lists cut right to the heart of my current struggle: “Problem #1: Winners and losers have the same goals.” This has never been more true than it is in medical school. Everyone has the goal to do well on these shelf exams. It was his second and third listed problems, however, that really started to inspire change in the mentality of my goal-oriented behavior: “Problem #2: Achieving a goal is only a momentary change.” “Problem #3: Goals restrict your happiness.”

While it is true on a large scale in that I am guilty of restricting happiness until the achievement of scholarly goals, problems 2 and 3 have often been true in my day-to-day efforts in medical school. My hope of scoring well on my surgery shelf exam inspired me to complete a defined number of practice questions and flashcards each day. Like a carrot at the end of a stick before a donkey, I trudged through flashcard after flashcard and question after question each day in hopes of achieving the satisfaction of a top score on my surgery shelf at the end of my rotations. To say I was burned out by the end of the rotation is an understatement.

So what is the solution if goals are not the be-all and end-all answer to satisfaction and success? Clear explains his answer to that question as follows:

“What do I mean by this? Are goals completely useless? Of course not. Goals are good for setting a direction, but systems are best for making progress. A handful of problems arise when you spend too much time thinking about your goals and not enough time designing your systems.”

He further suggests an examination of goals themselves to determine whether they are based on outcomes alone or on identity. Clear suggests that identity based, rather than outcome based goals are associated with a far deeper, more lasting level of change.

This made sense to me. I had become a slave to my goal in a way that had stolen the joy and power from the journey (i.e. “system”) that was supposed to be leading to success. As I looked closer at the system I had in place to achieve my goal of scoring well on the surgery shelf, I realized that it wasn’t much of a system at all. My tunnel vision on one test score had led me to continually try to work harder, not smarter, at the expense of other aspects of my life. For example, while I’ve in the past maintained that one can always wake up 30 minutes earlier than usual in order to get a work-out in, successive failures to meet my flashcard quota led me to cut my workout from my schedule and, little by little, carve time from my normal sleep schedule until I could take out no more. Early struggles with practice questions led me to replace my daily leisurely listening of fictional audiobooks with study books containing shelf-related material. I even stopped meditating and struggled to find time to continue to cultivate my hobby of photography.

Examining all this as Clear recommends made me realize I had placed so much dogged focus on one transient goal, that I had missed the meaning behind that goal and had failed to make other identity-based goals to keep my life balanced. Thus, rather than focusing on test scores, I began to make goals in line with my aspirational identity as a creative, healthy, life-long learner. Does achieving these identity-based goals involve sacrifice, hard work and long hours? Absolutely, but the nature of an identity-based goals like these suggests a life-long pursuit with every single day an opportunity for success and satisfaction rather than looking for this transiently in some future test score.

Implementation of these changes in the type of goals I set and the way I work to achieve them has helped me to truly flourish, and not just academically. While the Step 2 score report below represents the fruit  of months of consistent learning every single day, it is the daily satisfaction of that learning that has carried me beyond the exam and will continue to motivate me for years to come. Furthermore, as I have stayed true to my identity as a creative, the photo below it which won an award in the College of Medicine’s, “Ether Arts Magazine”, represents continued evolution of skill in the modality I use to express my creativity: photography.

As I move forward into what will be a very time-intensive chapter of my life, I will seek to hold fast to these identities in every day that I live. Furthermore, finishing this portfolio has reinforced my desire to make reflection a part of my identity. I will use daily journal writing and photography to further reinforce this and all other identity-based goals I develop. I believe that doing this will help me to flourish in residency just as I have as a medical student at the Ohio State University College of Medicine.

The Heart of a Patient Visit

Competency: Patient Care

While I didn’t know much about the oral presentation of a patient coming into medical school, I was pretty sure I was going to be good at it. Presentations on episodes of Gray’s Anatomy didn’t look very hard and years of public speaking in church and time on the stage as an actor had, over the years, helped me become comfortable speaking in front of others.

One can imagine my frustration, then, when despite learning to take detailed patient histories and even gaining a good foundation of hematologic illnesses and drugs, I continued to struggle month after month of my first few years of medical school.

An early example of this was my attempt to present the case of a woman with thrombocytopenia secondary to her hematologic cancer.  Weeks of struggling with the oral presentation of patients had left me determined to get it right. I started preparing long before I knocked on the patient’s door. I looked up her cancer as well as common associated symptoms. I learned the indications and even some side effects of every drug she was taking. I learned about her social history and much more in hopes of being able to present a detailed history to the attending physician, Dr. Andritsos.

The interview with the patient went as planned and when the time came to present, I moved through a prepared list of bullet points in a rather long, but comprehensive oral presentation that I was proud of. Then came the response from Dr. Andritsos: “Your forgetting something.” Flustered, I looked through my organized bullet points and confirmed I’d gone through each element of the history, physical exam, labs, and assessment/plan. I looked back up at Dr. Andritsos with a blank stare. “Did you ask about bleeding?” she asked. I hadn’t.  While I had gained useful information about side effects of medication, stress levels, and some recent mild illnesses, I had missed the very “heart” of the visit. Dr. Andritsos taught me that day that a patient presentation is a story built around one or a select few problems that serve as its heart. Furthermore, while my limited experience sometimes requires me to present more information than an experienced resident, I learned that finding that heart would help both me and the physician to focus on what is most important and thus provide the best care possible. I saw evidence in my evaluations that I was improving in the ability to glean the most important information in each visit as seen in this comment from my family medicine Longitudinal Practice preceptor during my second year:

This comment from an evaluation during my third year suggested continued improvement. However, it also highlighted another area of growth that I had been working to cultivate that gives an entirely different–but equally important–meaning to the “heart” of a patient visit: empathy.

The evaluator references a patient who had undergone a full pelvic exenteration procedure. We had been struggling to control her pain, but after an early morning visit, I sensed that there was more going on. I took some time after the day was over in the ORs to go see her. It took some time, but by sitting at her level and explaining I wanted to take some time just to talk, she broke down in tears and shared some of the anxiety and loneliness she was feeling as well as some misunderstandings of her care. We formed a bond of trust that helped me to better care for her over the course of the week I cared for her.

I have learned through these experiences that while it is essential to identify the most important issues at hand to effectively treat a patient, it is empathy for the patient that breaths life into the encounter and allows complete understanding of their needs as well as the rapport to fully address their needs. As I move forward into a time when I will be treating patients daily as a physician, I will seek to identify the problem at the heart of each patient visit, but also cultivate ever growing empathy that will make that “heart” beat.

The Hats of a Professional Physician

Competency: Professionalism

Professionalism. For me, this word has had evolving meaning over the course of the last few years while a medical student. Many experiences have shaped my perspective of its meaning in the context of medicine. To me it seems word “professionalism” is often invoked in the context of discussions regarding honesty, accountability and integrity, indeed the “Core Educational Objectives of the Medical Curriculum” identifies these qualities among those that should ideally be aspirational of every medical student that graduates from The Ohio State University College of Medicine. Such qualities form essential framework in the pursuit of becoming a functioning member of any health care team. However, I have also come to see, through the example of others, how professionalism extends beyond these qualities to that of compassion, altruism, and commitment to excellence. I have also seen how the way in which each physician demonstrates these qualities is often markedly different from their peers, but no less valuable.

Some of my earliest lessons in professionalism came from my Longitudinal Practice preceptor as a first-year student, Dr. Andritsos. Dr. Andritsos masterfully demonstrated  compassion balanced against integrity and accountability. This was best shown by the juxtaposition of two experiences: the first speed-walking to an appointment to keep a tight schedule for future patients, and second the contrasting calmness inside that appointment with her current patient as she would compassionately ask about both symptoms and the daily struggles of life. She knew each patient well enough to ask about pet pigs, beekeeping, church events and much more. The appointment never felt rushed despite her firm integrity to her schedule. This balance fostered a trust she shared with her patients that helped her to deliver truly excellent care. As I focused on emulating these aspects of Dr. Andritsos professionalism throughout the next few years, with time I saw evidence of success in this pursuit via my evaluations. The following comment demonstrates my effort to approach patient care in the wholistic manner I learned from Dr. Andritsos.

Another important aspect of professionalism I witnessed as a student has been the altruistic commitment to excellence seen in education. I have been taught by numerous phenomenal educators during my time as a student here at OSU COM, but the manner in which each individual taught was often markedly different from that of their colleges.

This was especially apparent during my time on my emergency medicine rotation. Due to the nature of the rotation, I had a different attending every day I was on the service. On my first day, I was grateful to have an attending that focused his methods of teaching on providing experiential education. I was provided numerous opportunities to both observe his skills interviewing and treating patients and then apply what I learned by having my own experiences. He would often both teach me a skill or a behavior and then model it through a live encounter with a patient before asking me to do the same. This served as an excellent introduction to the rotation and really made me feel I was getting a world class, personalized education by seeing a pro in action.

The next day, however, I worked with an attending that had a very different approach. In contrast do the previous day, I never actually saw him perform any patient care at all. However, whenever questions or new topics would come up throughout the course of the shift, he would take the time to give a personalized, high yield lecture complete with marker and white board that was immensely effective at simplifying otherwise complex issues and subject material. This style of teaching provided a way to tackle complicated topics in a way that just wouldn’t be feasible in the experiential-based method of teaching from the previous day.

My third day I again experienced a very different approach to medical education. This attending focused on self-directed learning. He asked me to set mini-goals I wanted to achieve by the end of the rotation and then did everything he could, and even recruited residents to help me achieve them. He provided pertinent patient problems, medical settings, and even procedures to help me achieve my goals to a degree I wouldn’t have thought possible in just one emergency room shift.

If I was asked after those first three days of that rotation which style of teaching was the most superior, I would not have a good answer. Each was immensely valuable in its own way. Furthermore, this experience with multiple physicians in the ED is but one example of the massive variety of teaching styles exhibited by my varied attendings throughout the last few years. So while the role of becoming a good educator might be a fairly universal way that physicians can develop an altruistic commitment to excellence, this can be achieved in many different ways.

So what does this mean for me? Like all medical students, I have often been discouraged at my progress as a budding clinician when compared to both my peers and my supervising interns, residents, and attending physicians. Sometimes it feels as if a physician is stretched in all directions with regard to professionalism. We have to wear many “hats” in order to truly develop the honesty, integrity, commitment to excellence, altruism, accountability, prudence, respect, and commitment to social justice that professionalism in medicine calls for. We also need to wear all of these hats all while staying calm and composed in situations that cause many outside of medicine to panic or break down in tears. It’s hard. But despite the difficulty, what I’ve learned from my Dr. Andritsos and my ED attending physicians and so many other great mentors is that while we all have to, at some point, wear these hats, that doesn’t mean they all have to look the same. I can teach in a way, counsel in a way, research in a way, and even crack jokes in a way that will cater to my strengths and ultimately achieve my own unique potential as a future medical professional.

While it is but one “hat”, ultrasound is one area I have identified as a way for me to demonstrate altruism and a commitment to excellence as a future educator. While I have already begun to teach my peers as an ultrasound proctor, I am currently building an ultrasound portfolio, catered to my own strengths and interest, that will help me to make my own unique contribution as a future educator.

For example, the following image is a scan of the my own brachial plexus. Any resident training in anesthesiology will need to be able to readily identify this structure with a high degree of certainty in order to perform the ultrasound guided nerve blocks in a safe manner. My commitment this next year is to volunteer my time and ultrasound expertise through dedicated extra-curricular time in the skills lab as well as in free time on critical care rotations. I believe that this in addition to helping students and residents individually when opportunities arise will be just one example of how I can uniquely exhibit professionalism in an altruistic commitment to excellence throughout my residency and beyond.

The Importance of Role Models

Competency: Systems-Based Practice

From the day I put my white coat over my shoulders for the first time, I could barely contain my  excitement and urgency to learn everything I could during my time a student.

And when I say everything, believe me—I tried to learn everything. It hadn’t even been a week before I was behind in completing lectures as I literally tried to absorb every fact that was presented to me. I spent so long making flashcards during my first pass through each lecture that I could barely get through each day’s material once (if that) before it was time to sleep. It wasn’t until Saturday that I had time to return to Monday’s material, and by that time I had forgotten much of it.

And then I found out that week 1 is an easy week.

I started to feel discouraged and began to look to my peers for help. Trevor, a fellow M1 introduced me to Anki—a flash card program that focuses on long term retention and fast creation of cards. Two weekend reviews of 1100 flashcards later, I felt ready for my first graded quiz—and then I got a 60%. Despite literally studying every waking hour of every day with the exception of meals, I hadn’t even scored well enough to pass. Now I was really discouraged.

This time I tried attending tutoring sessions from older students that could serve as role models. At each session, my flashcard technique was met with skepticism—which I ignored. But I did accept one important critique: I was trying to learn too much. The M2’s in the sessions taught me that it is not only impossible to learn every detail on every slide, but also unnecessary.

I learned that knowing how many angstroms each subunit of hemoglobin moves upon binding of oxygen isn’t nearly as important as knowing what conditions prevent oxygen binding in the first place. It made sense: if I find that I really need highly technical hemoglobin information in the future, I will have the tools and skills to look it up. But without knowing, at a critical moment, that low blood pH in a patient can lower hemoglobin’s ability to bind oxygen, I may fail to save a life.

So I hit the books again, but this time with a new focus in my learning on what was most important for my patients. When the next quiz came, I was able to score an 83% on Monday’s quiz. I was feeling better.

I decided to then take some advice from these older students to meet with OSU’s academic advisor at the time, Kelly-Ann. She advised me that spending nearly all day making hundreds flashcards just wasn’t a sustainable strategy. I was defensive because I had spent my entire life studying that way, but I listened to what she had to say.

And I’m so glad I did.

Kelly-Ann taught me a lesson that I believe changed my method of acquisition of medical knowledge forever. She taught me the importance of the big picture. While my method of cramming a thousand individual facts into my head might work for a weekly quiz, it would not work for a final when I had five thousand flash cards to review or Step 1 when I had a million. I learned that before I even made a flashcard I needed pour over the material a bit to gain the big picture—and then make a few cards if necessary.

So, after some experimentation, I completely overhauled my study. When it came time for Quiz 3 I felt better than ever and came out with a score to match: 100%. When it came time for the final exam using the study materials from earlier weeks was tough, but the confidence boost from my new found strategy helped me to push through. I benefited greatly by the practice tests provided by M2s and when the test came I walked out with a respectable 86%.

While I continued to hone my skills in acquiring medical knowledge throughout my first two years of medical school, OSCEs remained a difficult area. Despite the fact that they never represented more than 10% of my grade, nothing in medical school has set the hairs on the back of my neck standing quite like an OSCE.

That’s not to say that I wasn’t showing improvement over time. In the months leading up to Step 1, comments like these from OSCE examinations were suggesting that, after almost 2 years of practice at home, in clinic, and, occasionally, on my dog, I was finally getting the hang of efficiently and effectively moving through a patient history:

“You did well to gather information in an organized manner and deliberately move through each component of the history.”

“You were very organized and had a clear agenda for the visit. Nicely done.”

“Very good time management”

“Very good pace/tone, very good summary and closure.”

With comments like those, I was feeling at least a little better about OSCEs. It was almost 6 months before my next OSCE. This one was the first of 3 in Part 2 of OSU’s curriculum. While I was definitely still nervous, I thought that the worst of the OSCE learning curve was behind me. Based on the comments from that first Part 2 OSCE, turns out I was wrong:

“You asked repeatedly the same questions about timeline and quality of pain.”

“Work on time management to make sure you have time to do all the things needed during the encounter.”

“I think you could be more efficient and directed there to save some time. I almost felt like you were fishing mentally for what questions to ask.”

“Because you left yourself so little time for the physical exam and for the discussion, these were incomplete.”

And then there was the score report.

What had happened? Had I grown rusty after 6 months without an exam? How could that be when I had just spent the last 3 months seeing patients for real? Why was it so hard to think of questions to ask next and form a differential? I wrestled with these questions for a while before coming to the conclusion that I again needed to look to a role model, just as I had done with my study strategy during the pre-clinical years.

I met with what OSU calls an “expert educator”, an attending physician willing to provide one-on-one clinical help to students. It was enlightening to say the least. As we talked, we realized my difficulty obtaining a quick history stemmed from an inability to form a differential diagnosis in the moment. Digging further, the solution to my problems came down to one important skill: obtaining the review of systems. She suggested that instead of attempting to prepare and memorize an individualized review of systems before the visit as I had been, I should become proficient in moving quickly through a nonspecific review of systems that I could apply to a wide variety of patients. That way, I could rapidly form a “clinical vignette” that could serve as a spring-board to more questions and a preliminary differential diagnosis.

As I later put this plan into practice, my review of systems became quick and fluid. I became far more adept at quickly forming differential diagnoses which allowed me to not only follow up with additional questions, but also quickly determine the labs and treatments my patients needed.

These improvements paid dividends in every patient encounter I took part in–both real-world and practiced. My remaining OSCEs in medical school tangibly demonstrated this growth:

These experiences span the entirety of my medical school experience. As I reflect on them as a whole I see a common theme: while hard work is important, it is often reaching out to role models that catalyzes the greatest growth. In a few short weeks, I will have two big letters behind my name and students may start to look to me as a role model. My commitment now is to both seek out opportunities to be that resource while always maintaining the humility to ask for help from my own role models when I need it. Each rotation, I will try to identify a way that I can make a long-lasting impact on a student’s life. I feel it is through this repeating cycle that medicine has become the incredible field that it is and it is up to me to help the next generation reach its true potential.