Month: October 2017

Ultra Sonic

by

Medical Knowledge and Skills CEO 2.

The graduate is able to:

  1. demonstrate a broad working knowledge of the fundamental science, principles, and processes basic to the practice of medicine and apply this knowledge in a judicious and consistent manner to prevent common health problems and achieve effective and safe patient care.
  2. understand the clinical relevance of scientific inquiry and demonstrate the ability to evaluate emerging knowledge and research as it applies to diagnosis, treatment and the prevention of disease.
  3. utilize state of the art information technology and tools to retrieve, manage and use biomedical information in the care of individuals and populations.
  4. understand the indications, contraindications, and potential complications of common clinical procedures and perform the basic clinical procedures expected of a new PGY-1

 

Ultrasound as a technology is developing more and more uses in medicine. Being an inexpensive, nonionizing imaging technology makes it attractive for many applications. At Ohio State, I am fortunate to be part of one of the best medical student ultrasound curriculums in the country. I remember being enthralled by Dr. Bahner’s first lecture on ultrasound during my first year of medical school. I promptly signed up as a trained simulated ultrasound patient (TSUP) and for what was then called Trinity Ultrasound (now called Beginner Ultrasound). I modelled my way through my first Ultrafest (i.e., OSU’s regional conference on ultrasound) during Snowmageddon. I learned how the FAST scan had largely supplanted the diagnostic peritoneal lavage. (In my fourth year, I did see two SICU attendings speculating how they might need to do a diagnostic peritoneal lavage. They reminisced about how that procedure is barely taught these days.) I had my eye scanned and watched my consensual pupillary response. This ultrasound technique is more than a parlor trick. In a patient who cannot open one eye due to swelling, ultrasound can check if the consensual pupillary response is intact.

 

In my second year, I kept modelling and moved on to Intermediate Ultrasound. I competed in Ultrafest that year. My teammate was a randomly assigned first year medical student. Other teams had four fourth years. We put our hearts into it, but we came up against a game where ultrasound images were covered by rectangles that slowly fell away. The first team to buzz in was able to answer. Two against several teams of four, we didn’t make it any farther. But that really wasn’t the point – what really hit home was just how amazing this technology could be in practice. At the new James Cancer Hospital and Solove Research Institute, I learned how ultrasound was being used to place brachytherapy. At an interventional radiology interest group meeting, I learned how to perform fine needle aspiration, Figure 1. Later, in my fourth year, I would teach that technique to second year medical students.

Figure 1: Fine needle aspiration.

 

In my third year, I moved on to Advanced Ultrasound, and started to proctor sessions, teaching what I had learned. It is often said that ultrasound imaging is operator dependent, but what isn’t often said that training basic ultrasound competency is relatively easy. There are multiple papers that describe what happen when residents with minimal ultrasound training are sent off to perform diagnostic ultrasounds. These papers report high sensitivity and specificity for all manners of conditions, including sepsis. In another example, Dr. Blankenship developed the Army’s First Tactical Ultrasound Course in 2007. In order to convince the military brass that ultrasound was teachable, he taught it to cooks (food preparation specialists) and showed their results were accurate. In teaching ultrasound to medical students, I do my part to make ultrasound understandable and reproducible.

 

On one of my 24 hour calls, I put what I had learned into action by performing a FAST scan on a trauma patient who had fallen off a ladder. His FAST was negative. I settled a point of contention between a fellow and a resident using ultrasound. The fellow was convinced a post-op mastectomy patient had a seroma. The resident was convinced she did not. I suggested to the resident that if we could find a ultrasound machine, we could take a look. Acquiring an ultrasound machine proved a problem. We ended up needing to consult the PICC team so we could borrow their ultrasound machine. The imaging very clearly showed that the patient had no seroma. Her tissue was simply swollen and inflamed. We had no way of saving the image off the PICC team machine, so the resident took a de-identified cell phone photo and showed it to the fellow.

 

Honors Ultrasound ushered in the start of my fourth year of medical school. I designed a pin for the Ultrasound Interest group, Figure 2. As mentioned previously, for my Honors Ultrasound project, I taught thyroid ultrasound to the second year medical students, teaching fine needle aspiration, general thyroid anatomy, volume measurement, locating the superior thyroid artery, and watching the vocal cords with ultrasound. I blunt dissected pockets into chicken breast and hid objects inside to give the student something to sample with fine needle aspiration, Figure 3.

Figure 2: Curvilinear ultrasound transducer pin.

Figure 3: Suspicious object.

 

At Ultrafest, I staffed the beginner track registration with Yalan. We checked in students for so long that breakfast ran out before we could get there. There wasn’t even coffee left. Then I proctored head and neck ultrasound in the morning, Figure 4. Next was the scavenger hunt, and I was pleased to see that some of my thyroid ultrasound students had retained knowledge from my session the week prior. I didn’t have a model for my station, so I just let students scan on me while checking off the structures they were able to find on their scavenger hunt list. Finally, I walked students through how to perform pericardiocentesis on a phantom. Sammie King brought me my first coffee of the day, earning herself medical school sainthood.

Figure 4: “Baby back rib” sign of tracheal rings.

 

In the SICU, a resident and I used ultrasound to place a tricky femoral line, Figure 5. We later did a FAST on a patient who had taken in liters of fluid, had minimal urine output, and no edema on physical exam. He didn’t have any intraperitoneal fluid, which lessened our concern about a bleed and raised intracellular shift of fluid on our differential.

Figure 5: Femoral artery showing brisk arterial waveform.

 

On my endocrine rotation, I saw many thyroid nodules and fine needle aspirations in action. As a resident, I will continue learning appropriate applications of ultrasound. Ultrasound will be a lifelong skill I will use in patient care. I’m lucky I was able to go to OSUCOM, with is strong history of medical student training, and I will keep passing on what I have learned in the tradition of medical education.

[cite papers at the end]

Stories for a Lifetime of Learning

by

Patient Care CEO 1.

  1. Approach the care of patients as a cooperative endeavor, integrating patients’ concerns and ensuring their health needs are addressed.
  2. Comprehensively evaluate patients by a) obtaining accurate and thorough physical examinations; c) gathering detailed ancillary information; d) synthesizing all relevant data to generate prioritized differential diagnoses and e) formulate plans of care that reflect an understanding of the environment in which health care is delivered.

 

Besides helping us learn, stories are helpful in in shaping experiences into knowledge. The  stories that have emerged with just a few rotations preview what will become lessons and learning for my lifetime. One story comes from early in my third year of medical school. It was late in the day during my hospital pediatrics rotation. I heard the new patient’s inspiratory stridor down the hallway even before I saw him. My resident and I examined him and took a history from the parents of this ill, little four week old boy. His father worked in sales; his mother was a nurse. Both were extremely worried. Her pregnancy was uncomplicated, with good prenatal care, and the patient had been delivered at full term. He’d been kept in the NICU a few days for poor oxygen saturations. Since then, he hadn’t been able to regain his birth weight, despite his mother feeding him every two hours with 2-3 oz of pumped breast milk that had been enriched with extra calories per dietician recommendations. He made a good number of diapers a day. There was no family history of illness. His oxygen saturations were still poor. On examination, he was thin with suprasternal retractions. Otolaryngology soon came around with a flexible laryngoscope and confirmed what I suspected: laryngomalacia.

 

I already understood pieces of this young patient’s problem. As a part of the ENT Extracurricular Elective, I had given a talk on laryngomalacia to the rest of the group. Figure 1 shows the physical models I made for the talk. I knew laryngomalacia was the most common cause of congenital inspiratory stridor. Most children outgrow it, but in some, it be can severe enough that the infants waste so many calories struggling to breathe that they develop failure to thrive or other complications. I had already seen less-severe cases of laryngomalacia, which could be managed with observation. This patient, however, required supraglottoplasty, a surgery to divide the aryepiglottic folds to allow the epiglottis to spring back into proper position. With the epiglottis less constricted, the work of breathing would decrease, and more of his calories could be used for putting on weight the way an infant should.

 

 

 
 

Figure 1: Hand-made paper laryngomalacia models.

 

His mother was terrified that he would need a tracheostomy. Due to my study of the topic, I was able to reassure her that virtually no laryngomalacia patients need tracheostomies these days and that supraglottoplasty is a safe surgery with excellent outcomes and few complications. She was very relieved.

Laryngomalacia-2b9uts0

Figure 2: Laryngomalacia PowerPoint.

I checked with my residents and the attending of the surgery, and I was able to watch the surgery. The difference I heard in his breathing was immediate. While the stridor was still present, it was much quieter, and he physically appeared to be breathing more easily, without suprasternal retractions. He spent the night in the PICU before coming back to our floor for monitoring to make sure he would start gaining weight appropriately. His tired mother told me how she was frustrated that the PICU gave him Heliox, a low-viscosity mixture of oxygen and helium used for patients with airway obstructions, even though his oxygen saturations post-operation were better than they had ever been. She felt like they were just hearing that he was still stridulous and treating it without taking into account how much less stridulous he was now compared to where he had been. I will keep in mind that families want their loved ones to be treated as whole people, not collections of symptoms.

 

Over the next few days, he started to gain weight. I went with him to his echocardiogram, which had been ordered to make sure he did not have any undiagnosed heart defects that could be contributing to his clinical picture. His echocardiogram came back without evidence of any such defects, to the relief of his parents. I was there with him on my last weekend on that service, and his parents expressed concern. With changes in staffing, new clinicians who saw their son were always alarmed by his continued stridor, even though his stridor was much improved, and he was gaining weight. His mother looked forward to soon being able to breastfeed him directly, instead of having to pump and add in extra calories. From the start, I had been there to see his clinical improvement, and they were worried that, without me around as a touchstone, he might be subjected to unnecessary testing, when the etiology of his condition – laryngomalacia – was already well-established, and his failure to thrive was resolving. I reassured him that whoever saw him would give the best care possible and that his hospital course to date was well-documented.

 

This story had a happy ending with lessons that I’ll remember. Still, I wish I could have stayed with him for the rest of his hospital course, instead of moving on to another rotation. I look forward to continuity of care as an attending and seeing my patients through their roughest patches.

 

My second story again touches on continuity in care but with a new wrinkle – the importance of seeing some problems through fresh eyes. I found some of that continuity on my psychiatric rotation in Harding at the end of my 3rd year, where I could see patients throughout their entire hospital stay. One of my duties was to find patients and bring them to a meeting room for their daily chats with the attending and the resident. There were two medical students on the service, and we usually brought out the patients we had been following. However, one day, the other medical student was away. I went to find a patient he had been seeing for almost a week now.

 

The whole time, the patient had been complaining of pain and anxiety. She had a past history of opiate and benzodiazepine addiction related to over-prescription of inappropriate opiates and benzodiazepines. Now that she wasn’t on those medications, it was only expected that she might complain of pain and anxiety. She had been placed on scheduled, round-the-clock Tylenol at its maximum daily dose, and she had been urged to attend the group sessions and work through her issues.

 

She also had a history of borderline personality disorder. Unfortunately, she had been previously misdiagnosed with bipolar disorder and had been treated unsuccessfully for bipolar disorder for several years. She resisted the shift of her diagnosis from bipolar disorder to borderline personality disorder. Her resistance was understandable; all mental illnesses unfortunately carry stigma in our current society, but those patients with borderline personality disorder are often specifically dismissed by healthcare providers as chronic complainers. Patients want to be treated with respect and dignity and will resist diagnoses that they think will lead to poor treatment. Yesterday, we had given her more information about borderline personality disorder and dialectical behavioral therapy, the best treatment available to date for borderline personality disorder.

 

As I approached the patient’s door and told the nurse I was looking to bring the patient to her daily meeting, the nurse warned me with a slightly sarcastic, “Good luck.” I entered the room and immediately thought that the patient looked sick. She was huddled up under a blanket and shaking. She felt warm to the touch. She wasn’t as talkative as usual, and she didn’t want to attend her daily meeting. I asked if I could examine her and noticed a warm red rash around well-healed surgical scars on her abdomen. She agreed to let me trace the rash with a pen, so we would know if the rash changed size.

 

I came out of the room and checked again with the nurse, who had just taken vitals that were more recent than the last set I had seen. The patient had just broken a fever, and she’d missed her last dose of Tylenol, being too tired to take it. I went immediately to the attending and resident and explained the situation. They went with me to see the patient in her room and agreed with me: the patient had a post-op wound infection. It was about three weeks out from her hysterectomy, which was an unusually late time frame for a wound infection to appear, which was part of why the infection had gone unsuspected. By giving her Tylenol around the clock, her fever curve had been suppressed. She’d been anxious and in pain, but we’d expected that. Only when she’d been too tired to take her Tylenol had her fever been able to manifest. We could have missed her wound infection entirely, dismissing her aches and pains as being related to her past history of opiate and benzodiazepine and psychiatric illness.

 

My psychiatry attending had me consult Ob/Gyn to immediately come see the patient, which they did several hours later. By then, the extent of the rash had spread beyond my initial pen marks, which the Ob/Gyn resident found very helpful to evaluate the progression of the infection. The psychiatry resident had just started this rotation that day. While the other student had been seeing her, I was still more familiar with her medications, which had been fine-tuned and optimized for days, than the psychiatry resident was. The psychiatry resident had me go through her medications with the Ob/Gyn resident to make certain that she would receive all her medications correctly while she was admitted to the Ob/Gyn service for treatment of her infection. I also mentioned to the Ob/Gyn resident about her history of opiate and benzodiazepine addiction, which he appreciated and promised to keep in mind in balancing the need to treat the pain of her infection with her future continued health.

 

One important takeaway from this case is that psychiatric patients absolutely suffer all the same illnesses as everyone else. Attributing all symptoms to one cause feels neat and tidy, but sometimes, patients really do have more than one etiology for their symptoms. Moreover, simply attributing all symptoms to psychiatric illness can lead to lingering, untreated pathologies, healthcare inequalities, and disparities. When I was on cardiology on the acute coronary service, I saw a patient who had a history of anxiety be given extra Versed for anxiety when her blood pressure spiked instead of antihypertensive medications, despite the fact that she had just suffered a myocardial infarction. The team thought her hypertension was just anxiety. When the blood pressure wouldn’t come down with Versed, they finally gave her antihypertensive medications several days later, which promptly brought down her blood pressure. To avoid this type of medical myopia and injustice, clinicians evaluating psychiatric patients need to think, “But if these symptoms weren’t psychiatric, in this context, what would they be?” to make sure that they don’t miss an untreated condition.

 

Interestingly enough, this story has another twist. After we had recognized the wound infection, the patient said that she wanted follow up dialectical behavioral therapy after she recovered from her infection and wanted to make sure that referral didn’t get lost in the shuffle. It finally made sense to her why the treatment for bipolar disorder had never helped her. She didn’t have bipolar disorder; she had borderline personality disorder, like we’d been saying. It was as if acknowledging her problems with respect and dignity had led her to extend some trust back to us.

 

The psychiatry consult service continued to see her while she was treated for her wound infection, and she did well. Perhaps it was good for her that the medical student who had been seeing her wasn’t available that day; I came in as a fresh pair of eyes to provide a different perspective on her situation. I received this evaluation of my performance during my psychiatry rotation:

Figure 3: Psychiatry rotation Curricular Unit Narrative and Comments.

 

 

Learning Styles

by

Interpersonal Communications CEO 4.6 Effectively prepare and deliver educational materials to individuals and groups.

 

My mother and father are both educators. They instilled in me a dedication to teaching according to best practices. I remember, as a child, helping my mother put together overhead transparencies for those cumbersome projectors. Teaching isn’t just throwing information at an audience and hoping it sticks. From an early age, I learned and have been applying the basic principles for retaining information, acquiring concepts, and developing skills. From my personal experience, I know that, depending on the nature of the content, such as information, concepts, or skills, I can select and use different strategies for studying.  Learning about infectious diseases is at a knowledge level that requires rote memorization, for which one can use mnemonic devices. So I made use of SketchyMicro, a program that presents visual mnemonics to help remember information about infectious disease. As a visual learner, it worked well with my learning style.

 

Visual learning is a powerful style that should always be present. When I give presentations, in addition to a verbal explanation of the topic, I carefully include illustrations, graphs, and models, even if I have to make my own. To a visual learner, a picture is worth a thousand words. Including verbal, visual, and kinesthetic components into a talk allows it to reach more audience members. When teaching skills, such as in an ultrasound workshop, I know the critical attributes of the skill. So I explicate the steps and demonstrate the skills while verbally labeling what I do and also labeling the images on the ultrasound machine with text. Then, I discuss and give examples as to when and how the skill can be used.

 

Before medical school as an undergraduate engineer, I was a math tutor in undergrad, working for the math department at Ohio State. I derived great joy from making simple paper models to demonstrate to students how to conceptualize volume. The best feeling was when I knew that my students really understood the material and that they’d be able to succeed not only on their homework but when problems built on the same concepts appeared on their exams. During my masters’ degree, I was a teaching assistant, and I loved walking students through the lab equipment and helping them reach their own conclusions. These experiences helped prepare me for the Lead, Serve, Inspire Curriculum of The Ohio State University.

 

One aspect of service is teaching and thereby giving back to the community by preparing the next generation of clinicians. In my time at medical school, I have made various educational materials for various purposes and will describe a few of them here.

 

During longitudinal practice in my first and second years, I asked my preceptor, a surgical oncologist, if she had any need for illustrations. I had a personal goal to illustrate a paper. As it turned out, there was a review paper she had been thinking about writing. As she was quite busy, I was able to not only draft the illustrations but also the manuscript itself, which we are revising again for submission. Figure 1 shows the illustrations I made for our review paper, which provide a compact resource for those looking to learn more about minimally invasive inguinal lymphadenectomy.

 

 
 

Figure 1: Minimally invasive inguinal lymph node excision.

 

I also entered my artwork in the College of Medicine Art Show and was awarded an Honorable Mention (Figure 2) and the Dean’s Collection Award. My art, along with other artwork, was displayed in the Dean’s Conference Room for a year. Perhaps those who visit the Dean will see it and be inspired to learn more about inguinal lymphadenectomy.

Figure 2: Honorable Mention in College of Medicine Art Show.

 

In my third year, I wanted to delve more deeply into otolaryngology research. After some searching, I found an attending who had a project for me. She asked if I could illustrate an unusual arytenoid finding for one of the residents’ posters. The resident wanted a softer pencil design, but I also drafted a colored version (Figure 3), in case she needed one.

 

 

Figure 3: “Shar pei” larynx.

 

At my away rotation at Georgetown University, I was privileged to see a rare finding: a fracture of the stapes capitulum. Scouring the literature, I was only able to find a handful of other examples of fracture of the stapes capitulum. All the other example I could find had been traumatic fractures, for example, provoked by a twig thrust into the ear or motor vehicle accidents. My patient had merely been trying to clear his ears when his fracture occurred, a much less traumatic scenario. With my resident’s encouragement, I put together a talk on stapes fracture for Grand Rounds. As stapes fracture is a rare occurrence, I created a table that reviewed cases, treatments, and outcomes, as no such table existed in the literature. Thus, my audience could quickly see what had already been attempted. I also illustrated our particular case of stapes fracture (Figure 4) and received positive feedback from many of the audience. To think I drafted it in a few days in a rented room in a strange city, without my usual pens or scanner!

Figure 4: Stapes capitulum fracture.

 

Back at The Ohio State University, I have been so fortunate to be a member of the ultrasound curriculum since my first year, when the program was called Trinity. (It has since been renamed to Beginner Ultrasound.) As a Trained Simulated Ultrasound Patient (TSUP), I helped others learn about ultrasound and anatomy. I continued modelling and progressed through Intermediate and Advanced Ultrasound. In Advanced Ultrasound, I proctored for Ultrafest 2016, our regional ultrasound conference and competition. As a member of Honors Ultrasound, the next year, I wanted to do more. I volunteered as the Ultrafest Senior Curriculum Leader and worked with a group spanning from second year medical students to attendings to work on the ultrasound curriculum for Ultrafest. It was challenging and exciting to work together to decide what scans would be the most interesting and useful for medical students from all around the Midwest.

 

For my Honors Ultrasound project, I worked on the thyroid ultrasound curriculum for the second-year medical students. This year, the attending who usually worked on the thyroid ultrasound curriculum with the honors students was ill, needed to focus on health, and wasn’t available to assist. So I had to design and revise my own PowerPoint, as well as craft the four stations that the students would rotate through. Not surprisingly, my talk was visual – not too long, not too short, just right.

 

Although not required for students, the slots were filled in a matter of hours by eager 2nd year students. Word on the “street in Meiling” is that you can learn a lot from this hands-on course. I brainstormed with Dr. Bahner, the Director of Ultrasound, which activities would be the most useful, educational, and intriguing for the students. We kept a focus on straightforward but interesting activities. I cooked up a prototype phantom of thyroid nodules (raw chicken with hidden treats) and took it to an Honors Open Scanning Session to make sure that the phantom would work. When the actual time came, I was able to demonstrate suspicious echogenic features (Figure 5) to the second-year students without needing to actually procure a pathologic thyroid somehow.

Figure 5: Suspicious echogenic features.

 

At The Ohio State University, I have been blessed with many opportunities to draft educational materials, receive feedback on them from critical but caring faculty, and practice my teaching skills. Going forward as a resident, teaching will become an even larger part of my role. When I have to teach younger residents about tympanostomy tube insertion, I will remember how I learned to make a tympanic membrane simulator from small plastic tubes, rubber gloves, and a box. In the more distant future as an attending, I hope to practice at an academic hospital, where I will keep teaching and learning about new ways to achieve the best teaching outcomes.

 

 

 

 

Performance Improvement: Scholastic and Personal Reflections

by

Practice-Based and Life Long Learning CEO 3.4. Identify one’s own strengths, weakness, and limits;

  1. a) seek and respond appropriately to performance feedback
  2. b) maintain an appropriate balance of personal and professional commitments
  3. c) seek help and advice when needed

 

Throughout medical school, I have sought performance feedback and incorporated it into my growth going forward. This for me is a natural process that in my estimation leads to better performance. I have visited the academic counselor for advice many times. For example, together, we developed a plan to study for Step 1. Based on my previous NBMEs and my target score, we determined just how many questions to answer and pages to read. Ms. Kelly-Ann Perry also connected me with the irreplaceable Dr. Grieco, who helped me organize and focus my studying. Thanks to their help, I was able to achieve a decent Step 1 score, well above the value predicted by my first NBME.

 

Another example of where feedback helped performance was with objective structured clinical examinations (OSCEs). I began by reading my feedback and rewatching my videos. I also reached out to Dr. Curren, who rehearsed strategies with me to improve my OSCE skills. When it came time to study for the ultimate OSCE, Step 2 CS, I made use of the fine resources offered by the College of Medicine. I took a practice Step 2 CS-style OSCE, reviewed my results, studied with several faculty members to learn strategies, and took a second practice Step 2 CS-style OSCE. As a result, I passed the Step 2 CS examination.

 

In trying to decide what path to take with my fourth year, I sought feedback from my otolaryngology mentor, Dr. Lind. I was really excited about otolaryngology, which was the most energizing of any of my rotations, but I felt insecure about how my progress in medical school would be evaluated. I wondered to her if my scores were good enough, if I genuinely needed to have honors in everything, if I had enough research, and if I needed to do two away rotations. She went out of her way to sit down and talk with me, and she said that she thought there would be otolaryngology programs where I would be a good fit, but that I should definitely do more research and one away rotation. I then talked to Dr. deSilva, the otolaryngology residency program director. He told me seriously that I needed to do two research projects, and I took his feedback to heart. Through the educational coordinator for otolaryngology, I found two projects that unfortunately didn’t work out. So I went back to Dr. Lind for more feedback on how to find a project. She networked me with two of her co-workers at Nationwide Children’s, and happily, I had found my two much-needed projects. Over my research month, I performed a chart review and bench research. I also applied for an away rotation through VSAS. I listened to their feedback and put it into action.

 

Throughout medical school, I have worked to maintain an appropriate balance of personal and professional commitments. It has been observed that physicians who give up all of their pre-medical school hobbies are poorer for it. Without those varied life experiences, they have less depth to draw upon as physicians. I have enjoyed art since I was a small child. The spatial understanding nurtured by art will assist me in surgery, and the human aspect of art connects me to the deeper humanity within us all.

 

Since high school, I have enjoyed making costumes from scratch. The hobby connects me with my friends around the globe who also enjoy costuming. I made Pharma, in Figure 2, during my second year of medical school. Pharma is a Transformer who serves as a transplant surgeon. I enjoyed the challenge of the details of his design. He was mostly made of Spandex and stretch pleather stretched over foam. Pharma won 2nd prize in the TFcon 2014 cosplay competition in Mississauga, Ontario, Canada, an internal Transformers convention where I treasure the chance to meet up with friends I do not see often. I put Pharma to good use, playing a role in the skit “Grade Expectations 2: Kevin’s Revenge” for Nite Out, the medical school talent show to raise money for the Columbus Free Clinic.

 

 

  

Figure 1: Pharma, comparison with comic reference.

 

In my second year of medical school, I made the Transformer Springer, who triple-changes into a futuristic helicopter and rocket car. In Figure 2, I show how the comic design inspired me in crafting my Springer costume. The Springer costume is constructed mostly of Wonderflex, a heat-shapeable thermoplastic similar to the Aquaplast sometimes used in the operating room or the thermoplastic splints made by physical therapy. Springer won the “Best Transforming” Prize in the TFcon 2015 cosplay competition.

 

 
 

Figure 2: Springer costume, comparison with comic book references.

 

My next costume was Override Prime in Figure 3, one of the first female Transformers characters to be shown in a leadership role as a starship captain. She was mostly made of Wonderflex, like Springer. I sculpted and hand-cast her wheels from resin, and I included multiple light-up elements in the costume.

Figure 3: Override Prime, comparison with concept design.

 

In addition to costuming, I enjoy many forms of art. With Dr. Hitchcock and Courtney Tipton, we put together a skit on “Comple(i)ment” (2014). I also organized the first ever OSUMC Pathology Cooking Show with Dr. Hitchcock, bringing to life the concept he had talked about for years: non-stop pathology food puns, along with student teamwork and culinary excellence. I love carving foam pumpkins, as shown by a pumpkin I carved for Halloween 2016 in Figure 4. As a part of Humanism in Medicine, I learned to etch glass from one of the fine workshops put on by Dr. Stone in conjunction with the Glass Axis. I retained those skills and put them to use hand craft floral glassware for my mother as shown in Figure 5. Another hobby is 3D printing, which combines my engineering undergraduate degree with art. Figure 6 shows a symbol bracelet where I made the 3D models, had them printed, and then assembled the bracelet myself.

Figure 4: Halloween 2016 pumpkin.

Figure 5: Christmas 2016 glassware etched as a gift for my mother.

Figure 6: 3D printed steel bracelet with sterling silver findings.

 

Through my medical school career, I have sought help and advice when I needed it. Endo/Repro was a struggle for me. So in studying anatomy, I reached out to Antoinette, who obviously knew what she was doing. She, Alex, and I would get together at 7 AM every morning to go study anatomy. By the end, we had memorized every structure on every cadaver. We studied so hard, our skin started to flake and peel from the formalin in the air. Other students started reaching out to me for help with anatomy, So, I jumped in to help, which incidentally reinforced my own understanding. My peers recognized these efforts with the Candy Apple Award, which I proudly display on my white coat.  The best thing about help and support is being able to pass it on to others.

 

I have come to realize that it was not just luck that exceptional and accomplished people are seeming “there” just when I needed them. Dr. Grieco assisted me in structuring and organizing my studying, which helped me achieve a respectable score on Step 1. Dr. Lind, my otolaryngology mentor, was there with timely suggestions for research that fitted well with my skill-sets. I worked on both projects over my research month. I put one study together as a poster for SENTAC (put in the poster as a figure) and am working on a methods paper based on the other project. Every organization has these kinds of unique and caring individuals, willing to go above and beyond. When it is my turn, I aim to be one of these.

 

Knowing when support and guidance are needed will be critical as a resident and even as an attending. On my Infectious Disease and then Surgical Intensive Care Unit (SICU) rotations, I enjoyed rounding with PharmDs and observed how their help and advice improved the team and patient outcomes. PharmD knowledge can span beyond pharmacology and the intricacies of dosing. Once, we had a patient who was recovering from a re-do Nissen fundoplication and developed unexplained fevers, high white blood cells counts, and atrial fibrillation. Our PharmD had seen this scenario before, often enough that he had actually published on it. This sort of post-operative atrial fibrillation correlated with an esophageal leak, which we soon determined the patient to have. The patient’s leak was treated, and he did well. When I needed advice about Burkholderia cepacia and couldn’t find recommendations on the antibiogram on the Antibiotic Stewardship website, one of the PharmDs I had worked with on Infectious Disease quickly answered my e-mail with up-to-date information about susceptibility trends. She had previously helped me with a music video for Nite Out, the medical school talent show to raise money for the Columbus Free Clinic, in Figure 7.

Bad Bugs

https://drive.google.com/file/d/0B0VTELlnPMzJMTJZN0dpNWVLQmM/view?usp=sharing

Figure 7: Bad Bugs video.

 

On surgical oncology, when one of the younger attendings felt unsure of her flap, she asked another attending for advice, who easily explained the surgical anatomy, speeding up the surgery and saving time for the patient. In the SICU, one intern showed another how to pull chest tubes. Information transfer is both vertical and horizontal, all for the betterment of patients. Passing information is like passing a torch, all to keep the light burning strong. Learning is a marathon, and I’m in it for the long run.

Personal Accountability

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Professionalism and Ethics CEO 6.1 [T]he graduate must consistently demonstrate compassion, respect, honesty, integrity, accountability, altruism, prudence, social justice, and commitment to excellence in all professional and personal responsibilities. The graduate is expected to apply these behaviors in all of the [above] competencies.

Snowmageddon. That’s what they called it on February 21st, 2015. Columbus had received 6-7 inches of snow over the last day, on top of previous snows. It was a cold, early Saturday, and I put on my boots, scrubs, and coat and headed off to Meiling Hall for the 1st Annual Ultrafest. In making it there despite the inclement conditions, I showed integrity, accountability, and my commitment to excellence in my personal responsibilities. The back of my head can just be seen in Dr. Blakenship’s excellent lecture on ultrasound in a military environment (Figure 1). I, however, was not simply there on that blustery day to learn. I was there as a trained simulated ultrasound patient (TSUP), demonstrating altruism by spending my whole Saturday being scanned so that students from around the Midwest could learn, when I could have attended as a learner or competitor instead. Some medical schools do not have the ultrasound curriculum that OSU does, and by serving as a model so students from other schools could learn, I was helping address education disparities so that we could all be physicians of the future in a few short years.

https://www.youtube.com/watch?v=4adonhIM_ug&feature=youtu.be

Figure 1: Ultrasound in a Military Environment – Dr. Blankenship – OSU Ultrafest 2015.

 

I approach patients with compassion, respect, honesty, integrity, accountability, altruism, prudence, social justice, and commitment to excellence in all professional responsibilities. For example, on my third year cardiology rotation on the acute coronary syndrome unit, one of my patients had congestive heart failure related to a congenital valve defect. She had just suffered a STEMI, but the attending did not think she was a good candidate for a heart cath, as she had diffuse disease in multiple vessels. Every day, I made a point to spend time talking to her and getting to know her concerns. Something that came out of my history taking was that, while she wasn’t sure quite how much she drank, it was more than perhaps the team had suspected. She explained that she mainly drank to help herself sleep, but she also mentioned that she had Pepsi with her rum at night. Her sleep habits weren’t directly related to her cardiac status, but it is important to treat patients as whole people, rather than a problem on a list in the Electronic Medical Record. So I talked to her about how caffeine intake before bed can cause poorer sleep and advised her to only have caffeine intake in the morning. She hadn’t thought about but thought it made sense. I also took time to explain how alcohol can fragment sleep, which makes alcohol not the best choice as a sleep aid. Armed with new information, she realized that she had been sleeping well in the hospital without alcohol and resolved to try melatonin at home. She also expressed an interest in following up with sleep medicine after discharge, so I made sure that my attending and residents knew, so they could place the referral. After all, too much alcohol can be cardiotoxic, and everyone needs good quality sleep to heal. Cardiothoracic surgery decided she was an appropriate candidate for a three-vessel CABG, and she was transferred to their service, but I made a point of seeing her post-op to make sure she was doing well. As it turned out, she had a bad reaction to the anesthesia and hallucinated post-op about rappers and Hell, a frightening experience for anyone. She said that she was glad that I came to see her, and I was happy that I could help. We talked about her goals for life when she returned home and hugged. Several weeks later, she must have looked me up in the phone book, because she sent a touching card (Figure 2) that I will always treasure. I was sorry to hear she had an infection, but it was great to learn that she was doing better and on the path to recovery.

Figure 2: Card.

 

On my 4th year otolaryngology rotation, I strove to be the professional that attendings would want as their resident, that other residents would want to have on their service, that other staff would find a good team member, and, most of all, that would do right by patients. As a first step, to ensure I was always on time, I set not one but two timers on different cabinets, and my plan worked. I worked with the other medical student on the service to make sure that we would always have the patient list ready for the residents when they arrived in the morning so that rounds could be as smooth as possible. I talked to a student who had already done the rotation, so that the first day, I knew how to stock my bag with supplies. As we changed dressings in the morning, I was prepared to assist my residents. Whenever they needed a more obscure dressing I didn’t have stocked, I would promptly fetch it from the JIT room. Having all the supplies readily available meant that patients had quick dressing changes and could then go about their mornings, instead of having to endure protracted dressing changes due to lack of supplies. Efficient rounds meant that the residents, the other student, and I made it to the OR on time in the morning to help with setup. If the OR was missing its shaver, then I’d politely go door to door at the other ORs asking to borrow their shaver, and I always made sure to return it. I read ahead on each case and would e-mail the attending ahead of time, so the attending would know a medical student would be joining the case. When I encountered questions to which I did not know the answer, I acknowledged it was a good question, said I’d look up the answer, and followed through. When a patient had new abdominal distention late at night, after the case finished, I drew my resident’s attention to the problem, who notified the attending. I went with the patient to CT.  As he recovered, he developed loose stools. My residents feared C. diff. I suggested his loose stool was likely related to his history of pancreatectomy; he lacked the enzymes to completely digest food, which my residents thought was a great catch. They were able to add guar gum to his feeds to thicken them to slow gut transit time. In the clinic, I stayed with a patient who had just been told he had cancer when, coming in, he had thought he only had an infection. The speech language pathologist comforted him, as well, and I studied how she conveyed her compassion to use those techniques going forward. At Nationwide, I came in overnight to see a patient in the emergency department. She was a small child who had aspirated a cheese puff. I helped her parents navigate back to the lobby to gather their other relatives. I took de-identified photographs in the operating room for the fellow to use in his case conference. Whatever I could do to be useful, I did do. My residents seems to appreciate my commitment and taught me a secret about the hospital Cheryl’s Cookies: pick out any two cookies, and Cheryl’s Cookie will put ice cream in the middle to make a custom sandwich. My evaluation report, in Figure 3, was even sweeter, stating that I had, “Outstanding bedside manner” and that I was, “Professional, always on time and reliable.”

Figure 3: Portal Evaluation Report Otolaryngology.

What Great Mentors Can Accomplish

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Systems-Based Practice CEO 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.

 

A mentor is a trusted adviser and coach who helps make the unfamiliar, familiar and guides the less experienced. Finding good mentors and role models can be difficult because of the many prospective candidates for the job of mentor only a few individuals are truly suited. Mentor is really a title that is bestowed on an individual by the mentee. Some individuals really never rise personally or professionally to ever be considered as a mentor.  There are a variety of reasons. For example, some improperly appropriate your efforts in research without acknowledging you as a colleague or coauthor. Others are simply not up to the difficult job and bail when effort or leadership is needed. As a consequence, research projects can come to a screeching halt, leaving you scrambling to find a new one. Over commitment on the part of potential mentors may also lead to poor outcomes. Through the years, I have seen variations on these themes and will keep them in mind as cautionary tales of what not to do. Thankfully, I have also had the good fortune to discover genuine mentors who have served as positive role models to me.

 

Let me describe two of the exceptional mentors that I am privileged to be working with during my fourth year research rotation: Dr. Chiang and Dr. Elmaraghy. Dr. Elmaraghy makes a point of giving back to OSUCOM by serving as the advisor of the Otolarynology Interest Group, where I had my first real exposure to otolaryngology. Through that group, I gained access to the ENT Mentorship Program, which was like a second extracurricular longitudinal practice with clinic visits bimonthly, readings, presentations, OR shadowing, and lectures. I worked with him on a chart review evaluating the effect of pre-operative oral midazolam on post-operative oral fluid intake after tonsillectomy. Our finished abstract was accepted to the Society for Ear Nose and Throat Advances in Children (SENTAC) annual meeting as a poster, Figure 1.

 

Meanwhile, with Dr. Chiang, I studied a novel quantification method of the area of migration of human airway epithelial cells. Long-segment tracheal defects are rare but not well resolved using current best practice. Tissue engineered trachea grafts, one solution, have been complicated by restenosis, particularly at the anastomotic sites. Slow or inadequate epithelialization may contribute to cicatrix formation that leads to stenosis. Increasing the rate of epithelial migration onto tissue engineered trachea grafts may decrease anastomotic stenosis and improve outcomes. I assisted with the experimental design, data collection, trouble-shooting, literature review, and writing. Also, I developed protocols for imaging with The Research Institute at Nationwide Children’s Hospital (NCH) – Biopathology Center and solved problems of scaffold mounting and Transwell membrane adhesion to scaffolds. Together, we are preparing an initial draft manuscript for publication. NCH is exploring patenting a device that I invented and 3D printed. Beyond just providing scientific guidance, Dr. Chiang tirelessly edited multiple rounds of my personal statement and gave me excellent advice to prepare me for my otolaryngology rotation, which I put to good use.

 

Figure 1: Evaluation of the effect of pre-operative oral midazolam on post-operative oral fluid intake after tonsillectomy.

 

Dr. Clotilde Bowen was a woman of many firsts: the first African American woman to graduate from OSUCOM, the first female physician in the United States Army, and the first female commander of a military hospital when she was assigned to Ft. Benjamin Harrison, IN. She is an inspiration to all trailblazers and a model of how to stay strong against adversity. In 2015, OSUCOM established the Bowen Circle to honor her legacy, demonstrating that role models can be historic figures who encourage people to have visions and keep moving forward. My friend Antoinette kindly invited me to the Bowen Circle meetings. I was able to put my artistic talents to work in designing a pin for the new group, in Figure 2. The Bowen Circle meetings have reinforced the importance of supporting the resilience and goals of my incoming colleagues. My interactions there have also helped expand my horizons as I learn from my peers. Another student member talked about her research on maintaining the health of black hair. The treatments for white hair don’t necessarily work on black hair and often haven’t been tested on black volunteers, causing a lack of evidence-based medicine in the treatment of disorders of black hair. Her research is a social justice issue, and the concepts behind it apply to many other disorders and medicines. Medical school teaches us that black patients respond better to calcium channel blockers and diuretics for hypertension than ACE inhibitors and β-blockers, but there are many other areas where the question hasn’t even been asked. A friend of mine who was several years ahead of me had to scour PubMed while pregnant and sick, trying to determine if it was safe for her and her fetus if she took diphenhydramine, because there is so little data on what medications are safe in pregnancy. Such role models open my eyes to the pressing and ongoing issues that require attention.

 

Figure 2: Bowen Circle Pin that I designed.

 

I embrace the opportunities and responsibility of acting as a role model, teaching, and training others. In Dr. Chiang and Dr. Reynolds’s lab at Nationwide Children’s Hospital, where I continue to do research, there are many researchers at different levels of training. Some of the youngest researchers are high school students, working on gathering data for a poster for one of their high school requirements. There are also undergraduate students. This summer, one of the undergraduate students from a neighboring lab was accepted to OSUCOM. I congratulated her and spent several lunches with her and some of the other undergraduates answering questions about medical school. I tailored my advice to where they were in their journeys. For the one about to matriculate to OSUCOM, I told her about OSUCOM’s many research scholarships and our fine ultrasound program, as well as resources I found useful such as Pathoma, SketchyMicro, uWorld, and First Aid. For the undergraduates who were still some time away from applying, I talked to them about strategies for studying for the MCAT and how they can keep track of important experiences for their applications. I keep in mind what I would have liked to have known when I was in their shoes. Thus, I share things I have come to learn through my medical-school experiences.

 

The two high school students in the lab, Braedyn and Selam, are interested in going to medical school and pursing emergency medicine and pediatric neurology, respectively. While teaching them how to mount slides, I also answered their questions about undergraduate university and medical school. I suggested that they set up spreadsheets to log their hours doing research, work, volunteering, and shadowing, so that when they apply to medical school, they will have a simple record of everything they did. People often underrate what they have done, so I explained the STAR approach of Situation, Task, Action, and Results. When telling a story to someone of what you did, you explain the situation and the task at hand, what actions you personally took, and the results you obtained, in as specific detail as possible. For example, if you say that you raised some money for a local homeless shelter, a skeptical interview will assume the worst and thing you only raised $10. If you say you organized ten of your friends and together personally canvassed 500 houses and raised $5,000 for the homeless shelter, which they put toward a purchase of a new air conditioner, you have told a much better story that highlights your leadership and determination. I also emphasized that if research is worth doing, it is worth doing for credit. They should, whenever starting a new research project, check if the mentor has published with students before and ask the mentor their expectations of what milestones a student has to reach to earn a poster or publication.

 

Braedyn and Selam, the high school students, went with me to the Bowen Circle Tea #3, in Figure 3, where they were able to network with both physicians and students in various levels of training. Everyone who had advice that could be useful to someone shared it. Showing that mentorship can occur at any level and between near peers, Dr. Sarah Jonaus mentioned that she had set up quarterly networking brunches for the faculty around her and how it makes consults smoother when people are consulting a friend they shared brunch with, rather than a name in the EMR. I explained how the third year Rings system at OSUCOM worked to a M2 who wanted more information and talked to M3s about Part 3 and ERAS applications. Something that I wish I had known is that you can ask to shadow the chair of a department early on in your medical school experiences if you think you might be interested in that department, so I made sure to tell them. I also mentioned that research or volunteering mentors can write great letters, but if you can, shadow them in clinic. Then they can write a comprehensive letter. My friend Antoinette, who does high school outreach as part of her ongoing volunteer service, spent a good chunk of time with Braedyn and Selam, answering their questions about college applications. Dr. Monika Chaudhari agreed to refer Braedyn and Selam to some emergency physicians and pediatric neurologists she knows to see if they might be able to arrange shadowing. I am the first person in my family to attend medical school and have had to metaphorically re-invent the wheel in many areas that may be obvious to those who come from medical families. When I was shadowing before medical school, I had to cold call physicians I knew or that my family and friends knew. I was glad to be able to give my mentees more options and connections.

 

Going forward, I will keep in mind what makes a good role model as I look for my own role models and as I embody the best me I can. As a mentor to others, I will use what I have learned and found effective from those who have mentored me.

 

Figure 3: Bowen Circle Tea #3, mentors and mentees.