Checking Emotional Baggage at the Door: Professionalism

With the dawn of the social media era and the further implications of the political and pandemic-related turmoil that has plagued this nation recently, the concept of remaining professional as a representative of our field is more important than ever. For me, this initially meant making sure to remain compassionate and attentive to those around me as well as participating on the Admissions Committee for OSU to help sculpt the future generations of our school. More than that though, I came to realize that it also meant maintaining a strong sense of professionalism despite the happenings of the world at large and also personal events.

Perhaps one of the most salient pieces of advice I had gotten prior to medical school was from a motivational speaker as I began volunteering at a hospital back in my hometown of Los Angeles. The advice was “to check your feelings at the door.” However difficult it was, the doorway to the hospital or my clinical rotation has always served as a grounding point where I made attempts to put aside any anxiety or other feelings about my work or personal life. This meant that when I saw patients or was working with the clinical team, they had my full attention. This reflected well in my reviews as it made me easy to work with and also the added attentiveness, I had with patients was frequently noted by my peers.

Feedback regarding good rapport

I could not have known, however, how much this ideal in particular would be taxed. Unfortunately, with my late career pivot in deciding to apply for Ophthalmology, I fell short and did not match. Although I was frantic to figure out the next steps of how to best approach the process of going unmatched, I was on my Emergency Medicine rotation and I had a shift that afternoon. It was strange, but it was a combination of both wanting to get out of the house and get the horrific news off my mind but also a strange sense of calm when reassessing my perspective.

When informing my team, the attending offered to let me leave my shift in order to handle my business in figuring out the next best steps. While tempting, I was of the mind that whether I began frantically planning that day or the following day once I had my emotions better under control, it was not going to make a difference. More importantly, I felt compelled to be there as there will be times that I will be under significant duress either from sleep deprivation or other circumstances and in those cases, a way out may not be available. For me, it was almost surreal. I remember replying almost as if stating a matter of fact that “if this was to be the worst day of my life, compared to many of the patients I would see that evening, it wasn’t so bad.”

It is almost strange to be writing this now as the experience itself almost feels out-of-body but I am happy to know that even when faced with some of the most devastating news I have experienced in my life, that my moral compass remained resilient. When going over my feedback at a later date, I received one of the most heartening forms of feedback I have gotten in my career. This has helped me immensely in continuing to look forward, aiming to continually strive for success in the future.

Aforementioned feedback. This provided me a good reference point that helped me stop questioning my decisions and to instead look forward.

A Great Guidepost: Systems-Based Practice

One of the most fortunate experiences in my medical school career in my opinion, was becoming the mentee of Dr. Bahner. More than the guidance in research and expertise that he provided me as a research mentor, I knew immediately that the way that he approached both patients and peers was stylistically the way that I should aspire to later in my career.

Perhaps one of most striking things in terms of what set him apart from other mentors beyond his bedside manner and clinical acumen, was that upon meeting him, he immediately saw me as a peer. Making a point of this fact, when conducting research with him, he always encouraged equal discussion and honest feedback. He made it clear early on that the status of a medical student did not make an opinion or observation any less valid than from an individual with higher stature. This created an environment where it was easy to pitch new ideas and even concepts that would require more refinement from the group to bring to full potential. This led to some of the greatest growth that I had on an individual level because it encouraged me to push my own limits in terms of thinking both critically and out of the box when problem solving.

The other thing that I looked up to him for was his willingness to help others. Even after confiding that I was thinking of switching specialties in terms of career paths, Dr. Bahner has been continually supportive throughout my own journey. The way that he carries himself in a room of students and constantly checks in to make sure they understand and to always push the limits of their understanding just ever so slightly more has always been a source of inspiration to me.

Integrated Diagram of the reach of Ultrasound Research in many Specialties (Slide from our Horizontal/Vertical Integration Presentation from AIUM 2019).

In many ways, this made it easy to transition into the role of proctor for his Ultrasound Interest Group. Under his guidance, we have created materials that have made it easier to both teach ultrasound knowledge, but also to help medical students interested in EM and ultrasound to get connected with us, both in terms of faculty connections but also research opportunities.

Helping proctor students through Ultrasound Guided Needle Aspiration

From this, we created the Ultrasound Research Interest Group (USRIG), another interest group aimed at helping students both experienced and new to the world of research in getting the opportunity to conduct Ultrasound research and also equipping them with templates and tools to best streamline the process.

Data from our Retrospective Analysis of USRIG’s Impact at OSU

From my own research to the experiences I’ve had been a part of his peer mentor groups and working groups for the clinical simulators we have on campus, it has been an amazing journey in both learning how to better communicate concepts to new learners as well as remaining compassionate to others, always viewing them as equals and being attentive to their feedback. Looking to the future, I aspire to keep these points in mind, hoping to become a physician that is as compassionate and as welling to share his wisdom as Dr. Bahner.

Escaping Miscommunications: Interpersonal Communications

Perhaps one of the biggest individual learning experiences I had in medical school was my collaboration with a fellow medical student to create GETOUT – our Gamified Escape Teaches Objective-based Ultrasound Training, or in other words, our attempt at making a didactic Ultrasound Escape Room.

In a similar vein to my own TEE project, GETOUT was a great brainchild as it forced us to get creative with the ways that we assessed knowledge, the creative application of parsing out different pieces of material combined with the need for different levels of difficulty made the process arduous but fun.

Puzzle #1 – Matching Attenuation Coefficient for Lock Combination.

Color Coded Directional Lock Following Recognition of Ultrasound Guided Aspiration Fluid

Pilot Group Solving Mix and Match combination scan lock on Ultrasound Simulator

Perhaps overly ambitious, we were asked by the executives of the Ultrasound Interest Group (USIG) if we’d be willing to run the competition for Ultrafest, OSU’s annual convention for medical students and learners for Ultrasound, using our new escape room. Taking this as an opportunity to pilot the room while gathering great preliminary data for our study, we agreed but had no idea of the difficulties that would lie ahead.

In hindsight, it was painfully obvious that this was too ambitious in attempting to run a competition for over 200 participants within a single day. To make matters more complicated, we also had an asynchronous chain of emails that caused several lapses in communications from changes to the time we had allotted to the machines we would be using the day of. As these obstacles came up, we frantically scrambled to make accommodations to still be able to run the competition smoothly and in many cases concessions were made from both our end and the USIG board in order to make sure things went off.

The experience itself was great as we ran 13 escape rooms simultaneously with multiple waves to ensure all participants had a chance to learn. We gathered data on a wide range of learner experience and got great feedback on what worked and fell short in the process. All of this was presented at a national conference later that year.

Sonoslam 2019 at WCUME 2019 – Replacement image for Escape Room at Ultrafest due to IRB Research Protocols

The feedback from participants was overwhelmingly positive, but we still had a lot to reflect upon in the back end. In discussions after the event, we agreed that the communication between teams was lacking and that future endeavors would require more in person check-ins as well as a potential regimented meeting to ensure all parties were on the same page. As tough as the experience was though, I feel that I grew immensely from managing the project as I learned skills to not only better anticipate obstacles on the horizon, but also the essential nature of ensuring all members of a party are aligned in perspective.

Team responses to Ultrafest GET OUT Escape Room – Promising preliminary results from demographic survey

Finding Balance: Practice-based & Life-long Learning

As tempting as it is to want to talk about the Quality Improvement project our group designed in tackling health literacy regarding chronic medications in the population of patients with congestive heart failure, I believe this story is likely best served talking about my own journey in striving to strike that perfect work-life balance.

Continually throughout medical school, I felt like I was walking the knife’s edge in attempting to perform well academically but also in attempting to avoid burnout. While the strategies I had employed in my first two years of medical school worked well in achieving that balance, it all came to a head in my clinical years. No longer in charge of my day-to-day schedule, maintaining flexibility for the research and leisurely activities discussed in my other stories became difficult and I was feeling more and more stretched thin. Attempting to juggle my social life and activities to stay healthy with the new demands of attempting to improve my clinical skills while continuing to develop a deep pool of clinical knowledge, it was no surprised that I began feeling burnt out.

Early feedback showing difficulty with presentations due to performance anxiety

Perhaps most interestingly, despite the symptoms and effects of said burnout being painfully obvious in hindsight, there was quite a period of time for me to both acknowledge these changes and to develop a plan to fix them. Speaking with my longitudinal portfolio coach for advice, we developed a new plan of action to consolidate many of these differing activities. In addition to developing a stronger focus on a few research projects rather than trying to juggle all of them simultaneously, I began taking a different approach to being more efficient with my time. I began using cooking as a way of relaxing and staying healthier in eating out less. Learning about new cuisines and cooking techniques became a great way of staying engaged with something outside of medicine and provided an excellent chance to hang out with friends and cook together.

Cooking Thai Chicken with friends for the first time.

Cross section of poached egg breakfast sandwich rather than stopping by McDonalds.

As a way of socializing and getting exercise, I also began taking beginner hip-hop dance classes with friends on weekends. More than a way of simply getting out of the house, the dance classes also had another purpose. As touched upon in my other stories, patient presentations were a difficult skill for me to develop. A combination of having a free-flowing thought process as well as stage fright made it common for me to get flustered and disorganized in my train of thought, especially when all eyes were on me. Making sure to participate at the end of dance classes where we broke into groups and went through the performance in front of the classroom, I gradually became accustomed to having eyes on myself a grew more comfortable with my performance anxiety.

Feedback for rotation following starting the dance classes and showing improvement in patient presentations

 

In many ways, although my pursuit of life-long learning will largely take part in medicine, I wanted to take the time to highlight aspects outside of the medical field that I feel like I have developed in through my time in medical school. More than the pursuit of clinical knowledge, one of the most important keys in my opinion to a life-long career of learning is also striking that perfect work-life balance, affording you the opportunity to continue growing while remaining engaged and excited to see and learn new things.

Ultrasound, the Heart of my Research: Medical Knowledge

Research had always been a large part of my medical career and as I transitioned into the clinical setting, that practice only continued to grow. In many ways, I was fortune in finding such a great project and mentor with Dr. Bahner. I was able to design my own research project in the Ultrasound Medical Education space and became one of the few medical students with some expertise in Transesophageal Echocardiography (TEE). Creating an Objective Structured Clinical Examination to assess TEE competency for Cardiology and Anesthesiology, I learned a multitude of new skills from how to appropriately design test questions to the differing components that go into best assessing a demonstrated competency.

The effects of my research concurrent to my clinical studies were far reaching. On my Cardiothoracic Surgery rotation, I was able to demonstrate my knowledge of TEE to the attending Anesthesiologist and with his guidance, was able to help by navigating the TEE probe during the procedure. More than the direct application of TEE though, my research taught me essential skills such as organizationally staying on top of project deadlines and how to effectively parse through dense medical literature.

Trans-esophageal 4 Chamber View using TEE. (Photo obtained from HeartWorks simulator using TEE in training for protection of patient info due to HIPPA)

It wasn’t all sunshine and rainbows, however. In many ways, my concurrent research divided my attention from my academic studies. It became difficult to juggle a clinical schedule but still make time to make significant progress with all of my ongoing research projects. That is when I began to realize that I was stretching myself too thin. Following the advice of Greg McKeown in his book Essentialism, I realized that I had taken on too many large-scale projects and in wanting to keep creative control, I was not reaching out for support when I should have been. Dialing back attempting to juggle more than five research projects concurrent to my clinical duties, I instead gave my time to no more than two projects at any given time. The trade-off in this case, was that I also recognized that if I was pushing fewer projects forward, that I would need to establish goals and checkpoints to ensure that my projects continued to move forward. I built projected timelines for project completions in order to do so and integrated the use of project management sites such as Basecamp.

The results of these shifts were mixed. Likely due in part to my shift in specialty interest and the need to pivot to starting research projects in Ophthalmology, unfortunately, many of my projects were completed but at this time, have still not reached the publication stage. On the brighter side, I was over the moon when I had found out that my long-term TEE project had been accepted for Oral presentations at a national conference not once but twice.

WCUME 2019 – Oral Presentation of my Research Project

 

Looking back, I owe a lot to my experiences in research in both developing skills that will help me as a physician but also helping me to grow as a person. I came to truly see how difficult it was to manage the twenty-four hours in a day and how sometimes, it was better to say “no” in order to create a better focus on more essential matters at hand. In the time I have remaining as a medical student, I hope to bring these projects to completion, two remaining to be written up and two pending submission following in-house revisions.

Time is of the Essence: Patient Care

The transition into the clinical setting was a rough one for me. Despite the foundational knowledge that my preparations for STEP 1 had imparted me, I felt like a fish out of water in attempting to integrate myself into rhythm of the clinical setting. Acknowledging these difficulties, I realized it was essential to take a step back and reflect on my rotations as I transitioned from service to service. Both in attempting to find a suitable career path and to continue to grow, I sought to parse out the specifics of each field and to develop areas of focus on each rotation to sharpen my clinical skills.

Truthfully, until stepping into the wards, it had not occurred to me the vast gap of what was still left to learn. Especially in the world of surgery, things moved fast and variables were always changing. It became easy to feel overwhelmed trying to balance the information that I needed to deliver with the organizational elements required to make sure that I was communicating effectively. In reflection, I think that I was trying too hard to be “the ideal medical student” and instead, needed to change my focus to building a strong foundational skills, both in clinical knowledge and integrating myself into a clinical setting.

Feedback from early in my clinical rotations

Despite the pressure to quickly develop a refined thought process and efficient methodology, one of the most pivotal pieces of advice I received while on the wards took the focus away from trying to match the residents and instead, to focus on the advantages I had as a medical student. That piece of advice was to slow things down. This was not necessarily to change the pace at which I did things, but instead shifted my focus to take full advantage of the lower number of patients and the additional time I had as a medical student on the afternoons of shifts. This meant when checking in on my patients later in the day, to give patients someone to converse with and give them a greater sense of agency with the time I could afford. At the time, I set a new goal for myself. Rather than simply check in with patients in the afternoon, I would talk with them for a bit to get their perspective and leave the conversation more open-ended, focused on how we could make them more comfortable whether that be physically or emotionally.

 

This change paid off immensely. Not only did my patient feedback markedly comment on the patients feeling heard and cared for, but in two separate instances on my Internal Medicine rotations, the extra attentiveness was able to obtain information that shifted our team’s care plan. In many ways, this paradigm shift for me allowed me to gain additional confidence when working with my team and presenting patients. The extra focus on their clinical pictures also helped with developing a more refined thought process in determining what was urgent to present in a given scenario versus something that could be discussed at a later time.

Feedback that I received on later rotations following these changes

 

Looking to the future, I think that this practice has paved the way for additional routes of continuing to improve in the clinical setting. I have been afforded a greater confidence in being able to paint a clinical picture of a patient in my presentations and have greatly refined my balancing of remaining attentive to patients to address what they are most concerned about while making sure to keep in mind the questions I need answered to make clinical decisions. Continuing to solicit feedback from my team and to take the time to personally reflect on my own clinical performance, I hope to continue refining my patient interviewing and presentation skills, seeking to find the best balance of compassion and efficiency.