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Systems-based practice

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One of the aspects of my medical education that I really appreciated was learning the many available resources to provide patient-centered, effective, high value care. This was emphasized early on in our curriculum during longitudinal group (LG) sessions.

During my second year, I had the unique experience to be a health coach. This experience taught me many things about how to appropriately provide patient-centered care. For this project, I met with a patient 3 different times to coach her on weight loss One of the most important things I learned from this was how to identify potential barriers the patient had to overcome to reach her goal. After our first meeting, we realized together that her two biggest barriers were the fear of being hungry and her embarrassment of going to the gym. During our next session, we were then able to discuss how to move past these barriers, and she came up with two small goals she felt confident with. She was going to pack healthy snacks so she could eat smaller meals and she would go to the gym before work since it was the least crowded time. During our last session, which was a month later the she revealed that she had already lost 10 pounds. She was mostly able to stick to her two goals, and she set additional goals for her weight loss plan. At the end of this project, my LG and I put together a poster to analyze why certain patients were more successful than others. We identified that action based goals, rather than outcome based goals lead to more success. We also noted how important it was to identify barriers early on in order to develop more achievable goals.

During my clinical rotations, I not only continued to practice patient-centered care, but I also started to focus on high value care. During my mini internship, I performed a high value care assessment on admission order sets for one of my patients. I learned from didactic sessions on the topic that the two main barriers to high value care were unnecessary orders or repeat orders. My patient had a history of multiple myeloma with a long history of hospitalizations for intractable nausea and vomiting. For this patient, I took a detailed history and physical exam. Additionally I looked extensively through his past medical records. By doing this, I suggested that this patient should not get a chest x-ray, a standard part of the admission orders set. I also suggested that this patient did not require abdominal imaging at this time, which might have been otherwise ordered. He had an extensive GI work up during his most recent hospitalization and had no new or alarming symptoms. Another valuable part about this assignment was I was able to learn the cost of all the tests that are part of the admission order set. Now that I know this number, I will really consider if a patient requires a certain lab instead of instinctively ordering everything on the admission orders set.

During my medical training, I was lucky to learn about different tools and resources to providing the best care for patients. In the future I plan to always use the skills I’ve learned from my health-coaching project to provide patient centered care, especially for my patients with chronic illnesses. I also plan on making an active effort to only order cost effective diagnostic tests/imaging according to the high value care guidelines.

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HSIQ – Practice-based and lifelong learning

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During my fourth year of medical school, I was required to design and carry out a QI project on high value care. I joined with a team of students who were all planning on doing our residencies in internal medicine, and we brainstormed ideas about what project could be beneficial to IM services. One problem we had all noticed while on rotation was almost every patient getting daily labs, and many times the patients were not even being monitored for anything in particular and would have completely normal labs. We realized one reason for this problem was due to admission order sets, which would order daily CBCs and chem 7s on every patient.

 

We discussed this concern with a new fellow at Ohio State who mentioned at her residency program, daily labs would time out after a patient had been hospitalized for three days, thus requiring residents to often evaluate whether or not their patients truly needed daily monitoring. We decided to use this same concept to create an algorithm that asked residents on internal medicine services to evaluate patients after they had been hospitalized for 2 days or greater. If the patient had been stable for the last two days with unchanging labs, the algorithm suggested changing daily labs to q3 day labs.

 

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I talked to two different general medicine services about our project and gave them each a copy of the handout. For the next four weeks my team and I would record how many patients were getting daily labs while noting specifically how many stable patients without any abnormalities were getting daily labs. During my data collection, I noticed most patients were only getting daily labs if they were just admitted or if a specific abnormality was being tracked. I did notice more patients with every 2 day labs or every 3 day labs on the services that we implemented our project when compared to the services we did not implement our project on.

 

Although our results were not significant, there was a trend towards less daily labs on stable patients who had been in the hospital for several days in the implementation services. Additionally, for future directions for this project, we think that residents/attending physicians will require more than a simple handout to make the transition we wanted. Other ideas that our group would like to see eventually take place would be either a similar system such as daily labs being timed out after a few days in the hospital, or a dot phrase that would require residents to evaluate the number of days of daily labs and the reasons why patients require them.

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I think this project was very helpful in teaching our team the process of conducting a QI project. Additionally, it helped us realize there are many practices that do not follow high value care guidelines. Being required to participate in a QI project was important because it allowed students to realize that there are many things to be fixed and give us the confidence and the skills to attempt to fix them in the future. I hope I can continue to work on meaningful QI projects during residency and continue to learn more about the process of carrying out the project and data collection.

 

Professionalism Reflection

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Professionalism is a concept that has come up several times during my third and fourth year rotations. Over the course of my rotations, I have worked with very difficult patients where my team’s ability to conduct themselves in a professional manner has been tested. One patient who I can still remember clearly was a female patient I encountered during my inpatient psychiatry rotation. This patient was diagnosed with borderline personality disorder and frequently was admitting to the hospital for suicidal ideation. While in the hospital, the patient would make many demands, and often medically unsafe requests and would become extremely agitated when her requests were denied. During my rotation, I had the great opportunity to watch two different physicians work with this patient. From this experience, I realized one physician was able build significantly stronger rapport with the patient, and this was due to the fact that she was able to maintain completely calm with the patient, ensure the patient’s concerns were fully voiced, and find a medically safe compromise. Additionally, she was always completely honest with the patient and did not hold back information, even if it was difficult for the patient to hear. In other words, this physician was able to remain completely professional throughout an extremely difficult patient encounter and was rewarded with the patient’s trust.

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After my psychiatry rotation, I feel like I learned several different techniques in how to stay consistently professional throughout patient encounters. From doing this, I felt like I was able to start earning more trust and build better rapport with my patients. My efforts have been quantitatively measured through consistently getting 100% on my OSCEs for professionalism. More importantly, my constant drive to conduct myself professionally can be seen through my patient encounters.

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One particularly difficult patient I had was a patient who had received a bone marrow transplant 3 years earlier for AML. Her leukemia was treated, but unfortunately she has been suffering from chronic graft versus host disease (GVHD), which has drastically affected her pulmonary function. Before she was admitted to the hospital, she had finally been off supplementary oxygen for a few weeks, but was admitted with fevers, cough and increasing respiratory insufficiency. She was diagnosed with the flu and was in a worse off respiratory condition than she had been for the last year. She never recovered back to her baseline function and was admitted two more times during my rotation.

 

This patient was visibly frustrated every time I walked in her room and told her all we could do was wait to see if she would get any better. She would get very agitated when she had been doing better for a day but then relapsed the next day. When the team and I discussed long-term prognosis for her, we had given her false hope by mentioning the possibility of a lung transplant or a new clinical trial, later finding out she was not eligible for either. I felt so uncomfortable walking into her room because I felt as if we were constantly disappointing her and making her more and more frustrated; however, I continued to visit her each day and tell her the plan. I continued to be honest with her and would admit each day that we didn’t really have a great plan yet. I expected her to eventually throw me out of her room or stop talking to me each morning, but she became friendlier and kinder each day. She would eventually open up more about her life when I visited. She stated that regardless with all her complications with GVHD, she was so grateful to have an amazing team of doctors working with her. She even shared her plans about donating her body to science to give back. I was so touched by everything she told me, and how comfortable she was talking to me.

These two experiences, along with several other difficult patient encounters really taught me the importance of maintaining professionalism and the results from doing so. I know that not all difficult patients will eventually change their minds or attitudes, but I do believe that the best way to approach these patients is to continuously stay compassionate towards them, truly listen to their concerns, and be as honest as possible. With many difficult patients and incredibly busy services, it is easy to spend less time with the patients that make us feel uncomfortable, but I have learned how essential it is to not give up on these patients.

Interpersonal Communications Reflection

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During the summer between my first and second year of medical school, I really wanted to work on a meaningful project, and one that would help be become a better doctor. I wanted to focus on an area of medicine that first and second year students do not really get to practice. I wanted to learn about how to communicate well with a diverse population of patients, how to empathize with these patients, and I wanted to discover unique techniques to encourage patients to comply with medical practices. A group of students and I decided that one of the best places we could accomplish this would be India, and particularly in the surrounding villages of Shillong, where many patients do not have access to health care. Thus many of these patients often did not seek medical attention or would rely heavily on traditional healers within the villages. I was excited to learn about how physicians in Shillong communicated with these patients and convinced them to follow medical practices that many of the patients were not used to.

 

One thing I realized right away was the belief that most patients did not believe they were sick unless they had obvious symptoms. At one of the clinics I volunteered in, a patient who denied any past medical conditions had a blood glucose level of 400. She had never been checked out because she never noticed symptoms, but had likely had very high glucose for many years. One approach that the doctors in Shillong used to try to get more patients to have regular check-up visits was setting up optometry clinics. The idea behind this was that patients with vision problems have clear and obvious symptoms and would be more likely to come to a clinic. While these patients came for their vision, they would also get all of the other preventative screening measures to monitor for other chronic illnesses. This made sense, and I realized it was a great approach. Patients will be more compliant and willing to visit the doctor if doctors are able to correctly target the patient’s main concern.

 

Another very important thing I learned while in India was the importance of traditional healers and practicing integrative medicine. We spent one day working with a traditional healer and learned that patients often seek out traditional healers when they have severe conditions or when they have failed all other treatment. What surprised me the most was how firmly most patients we talked to believed in their traditional healers and how much trust they had for them. As the day went on, it was easy to realize why. The healer we worked with was kind and patient. She spent 45 minutes to an hour with each patient and would listen to all his/her concerns. She used many simple techniques such as massages and herbal supplements, but every patient we saw that day was so grateful and stated feeling significantly better after the visit. From this experience I learned what was most important for these patients was to find someone who could understand their suffering and acknowledge their pain. They also liked having something physical offer almost immediate relief. For instance there was a woman with terrible rheumatoid arthritis who was finally able to flex her fingers after receiving an hour-long massage. She mentioned no medications had given her that quick relief so she stopped taking her medications. From this I learned how difficult it is for physicians to obtain and maintain the trust of patients, especially patients who have a long history of failed medical therapy. I also learned how beneficial traditional practices can be for patients, especially patients who strongly believe in their success. For many patients with diverse backgrounds, it’s crucial to acknowledge traditional practices and even suggest that patients continue to follow their traditional practices if they are not known to be harmful. This would help to gain patients’ trust and follow medical practices that might not work immediately or seem unfamiliar to them.

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(A photo of me at traditional medicine clinic)

I learned a lot in my trip to India, but what I found most valuable was becoming more familiar with approaching diverse patients with considerably different beliefs in medicine This made it easier for me to work with patients during my third and fourth year. It also really helped me learn how to explore why a patient was noncompliant and how I could better motivate that patient. Hopefully, I can continue to use these skills to become a better physician in the future.

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(Newspaper clipping from our trip)

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Patient Care Reflection

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One of the most valuable practices I’ve learned in medical school was the importance of preventative care and health promotion. I was first exposed to preventative care early on in medical school through a community health project I completed after my first year. The goal of my project was to teach children ages 10-12 about important topics such as health, nutrition, exercise, safety, and stress management. I worked with a team of 5 other medical students to create weekly lesson plans and activities. We started with an assessment of the students’ baseline knowledge using a survey. We would use weekly surveys to gauge how well the students learned from each lesson. We distributed a final survey during the last class and found out that the majority of the students felt more comfortable with understanding previously difficult concepts. At the end of this project, we presented a poster to summarize the impact of this project. The students specifically showed improvement in remembering proper portion sizes based on “My Plate,” reading nutrition labels, and understanding the health risks associated without proper diet and exercise. I really appreciated this project, because not only did we get to teach children about health, but also we were able to expose them to the concept of preventative health. For example, after our lesson on nutrition labels, we had an activity showing some long-term health effects from malnutrition.

 

I was able to further my knowledge in this area of medicine through my family medicine rotation during third year. During this rotation, I had the opportunity to work with nine different physicians, and I learned many different styles of practice. I saw many patients with common problems such as diabetes and hypertension. Towards the final weeks of my rotation, most of the doctors I worked with let me ask most of the important preventative care questions and do all of the counseling to encourage patients to stay on course with their treatment plans. This was a vital part of my education, because I learned about the many follow up visits patients with chronic medical conditions have and how often they have to monitor their conditions. More importantly, I started to learn about how difficult it was to keep up with chronic conditions and how each patient requires individualized counseling in order to stay motivated to follow up with the numerous suggestions their primary care physicians make. At the end of my rotation I received feedback stating:

 

“Very mature differential and sophisticated reasoning; including impact of illness on patient and family”

 

“Plans complete, appropriate, timely, including all details and reflected appreciation of patient’s experience of illness”

 

“Exemplary student. She worked with 9 different doctors during the month and got to learn each person’s style of patient care. She was always eager to learn, always did any homework given and always asked appropriate questions to improve her knowledge and exam skills. Several patients complimented her in her presence and also in private to me. My colleagues and I all agree that she has been one of our best students to date.”

 

 During the rest of my third year and during my fourth year, I made sure to continue to have meaningful outpatient rotations. Although I am interested in subspecializing within internal medicine, I know that preventative care plays a crucial role in whatever specialty I choose. Two other rotations I found particularly useful were outpatient hematology/oncology and outpatient gynecology/oncology. The physicians I worked with were not only interested in monitor cancer recurrence, but also acted as the primary care physician for their patients, and I was able to further my knowledge in preventative care. I am glad I was able to get exposed to this area of medicine early on during medical school. I plan to continue to learn more about preventative care in order to become a great primary care provider in my continuity clinic practice during residency and as a future attending physician.

 

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Medical Knowledge and Skills

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On my general medicine rotation, I was asked to obtain a history and physical exam on a 64-year-old patient who had become very sick during his mission trip to Haiti. His symptoms began with abdominal pain and later turned into severe nausea, vomiting, and inability to keep any food or water down. He was diagnosed with severe pancreatitis with acute renal injury. His lipase was in the thousands and his creatinine was up to 14 upon presentation. The patient was started on conservative management and his symptoms and lab values improved rapidly.

 

Although the patient recovered quickly, the cause of his pancreatitis was still unknown. The patient denied any alcohol usage or any history of abdominal trauma. The patient did not have a family history of pancreatitis and in my research, familial causes usually presented in the third or fourth decade. The patient did have a history of gallstones, but did not have the appropriate lab values or imaging results according to the most recent literature.

 

During further conversations with the patient, he told me his abdominal pain started shortly after his started taking doxycycline for his malaria prophylaxis. He strongly believed that his symtoms were somehow related to his doxycycline. After his vomiting stopped taking the doxycycline and decided to leave his mission trip early to receive treatment. My team and I realized that his symptoms coincided perfectly with the doxycycline usage. The rapid recovery after discontinuing the doxycycline was further evidence. I decided to look further into drug-induced pancreatitis and to see if doxycycline has ever been a known cause.

 

I performed a literature review of drug-induced pancreatitis and learned that most drugs are categorized into different classes (1-5) based on their likelihood to cause pancreatitis. The majority of the data comes from individual case reports. I found four other case reports listing doxycycline as a potential cause of pancreatitis, with two of them having pretty significant evidence. I was excited to have another case to add to the growing list of doxycycline-induced pancreatitis. I decided to write up this case and submit the abstract to the American College of Physicians. My abstract got accepted, and I was asked to present my poster at the national conference.

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I learned a lot from this experience. First of all, I learned how important history taking skills could be. This case could have easily been categorized as gallstone-induced pancreatitis even though the presentation didn’t quite fit. If my team and I hadn’t listened to the patient adamantly insist that his symptoms were related to his doxycycline, I wouldn’t have done further research about drug induced pancreatitis and learned that was the more likely option. Additionally, I learned a lot about pancreatitis including which lab values are important to track and when imaging is required. I learned about the process of classifying drugs as causes of pancreatitis. Finally, I learned the process of writing up a case report and the importance of case reports and national presentations. Not only was I able to provide an additional evidence for doxycycline-induced pancreatitis, but I was also able to remind others about drug-induced pancreatitis at the conference. Many people who I talked to stated that they often did not consider drug-induced pancreatitis unless a patient was taking a medication that was widely known for causing pancreatitis. Also, many providers in certain regions mentioned that they often provided doxycycline as an automatic response to any sick patient in the summertime, but would now think twice or be cautious about potential symptoms. This was an incredible learning experience both for me and for the people I was able to share my poster with.

In the future, I always plan on taking detailed histories and be vigilant about asking patients about what they think could be going on. Additionally, I will continue to try to pay attention to interesting cases to either write them up or encourage medical students on my team to do so.

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