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CEO: systems-based practice

Learning Objective 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.

If you asked me what my career goals in medicine at the start of medical school, I may have said something about working in the community. But honestly, at that time, I had no idea with what I wanted out of my career. My primary research mentor, Dr. Bahner, was a notable figure at the medical school for teaching point-of-care ultrasound. He was a full-professor and had won multiple teaching national accolades, including the esteemed Professor of the Year award at the College of Medicine. He was gracious in his capacity to mentor and get me started.

I cannot but encourage others that mentorship has been a key ingredient for success in my medical journey. We must rely on each other for support when the demands of training are extraordinary. Especially in Emergency Medicine, the nature of the work we perform for our patients requires us to be humble and seek guidance from others with more experience and wisdom. I found that I could and will never know enough, so treat everyone as a potential mentor.

Dr. Bahner, the first of my many mentors, always pushed me to be excellent. Our educational research on cardiac ultrasound using simulation pushed us towards 9 national oral and poster presentations. More than just research, he would spend countless hours in 1-on-1 meetings with me discussing a wide range of topics: how he got involved with ultrasound, travels across all 7 continents teaching ultrasound, why academic medicine, and helping me think through my future career. My experience with Dr. Bahner and ultrasound research in medical school allowed me to see the difference my work can make in the clinical settings. It pushed me to continue pursuing innovations (though not particularly in ultrasound) throughout my medical career as a clinician educator and researcher.

After Dr. Bahner, I encountered several influential physician mentors who helped me get through my medical career. These role models instructed and coached me on what I needed to do in medical school and how to be a whole, good person throughout training. It was during these moments that I also learned how to be a mentor to others. As a medical student, I couldn’t teach my peers to be a physician but by working hard and being respectful, I may inspire them to be good teachers. The mantra of medical education “see one, do one, and teach one” inspired my efforts to reach out to other classmates and provide tips on how to get involved with ultrasound research.

In conclusion, providing patients with the highest quality care requires hard work and serious investment in personal relationships. At all stages in our careers, we must seek mentorship, be mentors, and encourage others to do the same.

CEO: medical knowledge and skills

Learning Objective 2.1: 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.

Learning Objective 2.2: 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

Learning Objective 2.3: Utilize state of the art information technology and tools to retrieve, manage and use biomedical information in the care of individuals and populations

Since the beginning of medical school, each day has been filled with brand new information and even more hours afterwards to process all the medical knowledge I gained. At times, it has been pretty grueling, but I’ve understood that it’s a necessary process to become a future physician. I have learned about how different diseases present, how certain pharmacological agents work, and have begun applying that knowledge in different clinical settings. It has been important in helping me figure out how to categorize symptoms in ways that lead to more refined diagnoses. As an Emergency Physician, everything I learn is crucial in working-up the undifferentiated patient.

Finishing my medical education at Ohio State, I have encountered many of the “terrifying diseases” that tremendously alter the course of many people lives. However, these “terrifying diseases” are now associated with names and faces of the patients I’ve helped in their care. I’ve realized now that the challenge with the medical knowledge I possess allows me to know ahead of time the different directions of how a disease may progress or how a particular pharmacological agent can affect that patients’ body. Despite this medical knowledge, I am still rendered powerless in the moments where there is no control of how the disease will progress or if a particular medication yields the most complicated side effects.

As I am heading towards an Emergency Medicine residency, I am preparing myself to encounter this paradox: the medical knowledge I gain can also cause me the most anxiety when I try to work alongside these patients during their periods of extreme illness. I am given the ability to profoundly impact patients’ lives for the better if I apply the medical knowledge the way I am supposed to. And what if that medical knowledge can be a curse when I know that the disease I am dealing with for a patient does not have a good prognosis? In those moments, I believe it’s about putting away my role as a physician and transition into that of a friend and provide comfort in ways that will empower those who need it most.

To help guide the process of making informed clinical decision on the critically ill, I spent the time cultivating my skills with using point-of-care ultrasound. I completed a 4-year longitudinalcurriculum in Basic, Intermediate, Advanced and Honors ultrasound. I was involved on 4 simulation projects around transthoracic and transesophageal echocardiography which generated 9 oral/poster presentations at national conferences.

Some details about the projects I worked on:

CEO: practice-based and lifelong learning

Learning objective 3.1: Evaluate the performance of individuals and systems to identify opportunities for improvement

Learning objective 3.3: Demonstrating an understanding of the role of the student and physician in the improvement of the healthcare delivery system

During medical school, the LSI curriculum really strived to help students identify ways to improve systems – whether it was in our local communities or within our very own hospital system.

Regarding improving systems in the community, there were unique opportunities with our Community Health Education (CHE) projects. The idea behind it was that we were no longer “just a volunteer” but a partner with a community agency. We got to develop ideas, implement, and evaluate a health promotion project that would fulfill the specific needs of our surrounding Columbus communities.

For my CHE project, our group worked with Victory Ministries, a non-profit organization that strives to break the cycle of poverty by identifying and targeting issues that affect the low socioeconomic population in Whitehall, OH. At that time, their current programs primarily focused on clothing, counseling, and free groceries. Our main project was to administer a survey to adults at a local library to assess the community’s awareness of a new Women’s Health Clinic established at Victory Ministries and its potential to reach a wider audience in the future. The majority of respondent were interested with the new women’s health clinic, indicating that this would be a strategic investment for the organization.

A major takeaway from this service learning project was gaining more cultural competency. As physicians we treat individuals with their various illnesses. However, patients are subjected to a number of societal issues that can drive their health outcomes. I learned to understand available resources in the community to help patients address their basic needs. And I was encouraged to be an advocate for my community through similar service projects in the future that improve systems that can prevent poor health outcomes.

Here is our CHE Logic Model we presented to our classmates during our poster day:

Regarding improving healthcare delivery systems, there were unique opportunities with our Quality Improvement project this past year. We were to complete a high value care improvement project with implementation of an intervention and measurement of change. Our project was on alarm fatigue — an ongoing problem that leads to delayed responsiveness, interruption in patient care, and adverse patient outcomes. In our medical center, SpO2 alarms were the leading cause of alarm fatigue. The aim of our project was to evaluate the current state of SpO2 alarms on Rhodes 8 to look for opportunities for improvement. To do this we: 1) survey nurses and physicians on their experiences with SpO2 alarms and gather 2) gathered baseline SpO2 alarms from selected patients. We found that significant portion of patients on continuous pulse ox did not have standing orders or clear clinical indications. In addition, there was a discrepancy between nursing and doctor perception on number of patients on continuous pulse ox and those with standing orders. This led to our intervention of creating placards affixed to each computer monitor in nursing stations and physician workrooms to remind staff of inappropriate pulse ox orders. Ultimately, we were successful in driving down the number of inappropriate alarms that went off by discontinuing order for patients who did not need a pulse ox. However, we did not drive down the total number of alarms given the confounding effects of Covid-19.

Here are our placards we placed on Rhodes 8 as well as our final poster we presented:

Next steps are continual involvement in projects involving system-based improvements. In Emergency Medicine, a major component to graduate is a completion of a scholarly project (which involves some QI work).

CEO: professionalism

Learning Objective 6.1: Consistently demonstrate compassion, respect, honesty, integrity, accountability, altruism, prudence, social justice, and commitment to excellence in all professional and personal responsibilities

Professionalism was a new word that hit the forefront of my mind starting medical school. As a 1^st year medical student, we were encouraged to grow as medical professionals – people who held high commitments to patient-centered care, intellectual honesty, social responsibility and advocacy. There was a long list of virtues we were to cultivate and demonstrate in our next 4 years and beyond. I was intimated by the moral bar set when our class recited the Hippocratic Oath at our white coat setting. Throughout medical school, I have witnessed professional and unprofessional behaviors in the clinical setting that have helped cultivated my current concepts of professionalism.

During my pre-clinical years, I was assigned to a primary care clinic for my Longitudinal Practice. My preceptor was an amazing clinician who fiercely advocated for her patients. She really practiced a full spectrum of medicine: delivered babies, performed vasectomies and biopsies, removed lumps, took EKGs and interpreted it, casted broken bones, injected steroids into inflamed tendons/bursa, and sewed fingers back on. But more than his medical prowess that demonstrated his professionalism, it was the soft skills she demonstrated that exemplified the highest qualities of medical professionalism:

1. She listened without interrupting.
2. She left the room when patients were undressing.
3. She something was unclear, he asked for clarification.
4. She explained things so thoroughly that he answered most of their questions before they voice them.
5. She apologized, even it wasn’t his fault.
6. She asked if patients still had questions. He answered those questions fully.
7. She he didn’t know something, he admitted it and says he’ll look it up.
8. She never acted like they were taking too much time.
9. She explained abnormal test results clearly and explained what could be done to address the problem.
10. She made referrals when appropriate
11. She read the letters sent by the specialist and asked me how that treatment was going.

During my clinical years, I was concerned with the first impressions I would make to my residents, attendings, and most importantly the patients. First impressions are important in conveying a certain degree of professionalism and how seriously some people will take me. I was curious about “professional attire” and its role in medical professionalism. From my experiences in different adult and pediatric services, it seems quite variable.

When I was on my Gen Med service, I noticed that my attending would dress very “professionally” with his white coat over a clean dress shirt that was matched with his tie, slacks, and shoes. He drove the point home to our team that it was important to follow an exemplary dress code that would demonstrate to patients that their providers can be fully trusted.

When I was on my Onc service, I noticed that my attending would consistently wear jeans instead of slacks. After asking her about it, she stated that her patients had yet to question her attire and never doubted her medical opinion. More importantly, her patients said they felt closer to her and was better able to relate in a much more conversational way. She did not exhibit superiority.

When I was in my Child Neurology service, I noticed that my attending would dress even more casually. He would leave his white coat by the door and had an assortment of bright colored slacks, bowties, and socks. When I asked about his attire at the finish of my service, he said that it provided a less intimidating feel for this population and allowed for a smoother visit for both the patients and their parents.

I realized the context of the population and the culture of the service drove the “professional attire” but that medical professionalism did not change in the ways we were to demonstrate the highest virtues to our patients.

Finishing medical school, I believe these 2 artifacts highlight my development as a medical professional:

Gen Med 7 Feedback from Attending:

I believe the next steps for me in my medical professionalism is addressing unprofessional behavior as a resident. It is hard as a medical student to bring issues up. As a resident, however, I am expected to be my patient’s biggest advocate. If there is an issue that I observe as inappropriate, I will take the courage to address it in person with my staff/colleagues and if not address it to the higher-ups.

CEO: Patient Care

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

Learning objective 1.2: Comprehensively evaluate patients by a) Obtaining accurate and pertinent medical histories; b) conducting appropriate 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.

As I am finishing up medical school, I have been so thankful by the opportunities to cultivate and see the evolution of my patient care skills. These skills are important no matter the specialty we choose to go into. I believe that they are especially important for Emergency Medicine where patients come into the ER on the worst day of their lives.

Looking through the evaluations from OSCES to clinical rotations, I have been amazed by the initial deficiencies in my patient care and the improvements made along the way.

Foundation 2 OSCE Patient/Instructor Feedback:

This feedback from the patient and instructor was as expected from someone who had no real clinical experience prior to medical school. I had a hard time feeling comfortable around a patient and the conversations I had with patients during my Longitudinal Practice were choppy and mechanical.

Host Defense OSCE Patient/Instructor Feedback:

This was the last pre-clinical block prior to the start of my clinical rotations. By that time, I had grown tremendously in the ways I interacted with my patients and made them feel comfortable with my “soft” skills.

However, there were still many gaps in the basic skills to my patient encounters that I wasn’t quite proficient yet. I still had issues acquiring a full and adequate patient history, missing key information that would help me diagnose and work-up a patient. I still had problems performing physical exams and was not sure when to do a comprehensive or focused exam. But I was determined to have a growth mindset on how I could continue to harness my patient skills. Here were some of the constructive comments below:

Entering my clinical years, I began with the UPRSN ring. My first rotation was on Oncology 1, the last stop of most cancer patients with terminal diagnoses. It was a challenging environment where I was pushed to demonstrate the level of my empathy during the last days for the patients who were on the floor.

Feedback for this service I received:

The feedback that I received from the resident/attending on the Oncology 1 service really encouraged me on the process I was making towards becoming a physician. It really helped set the stage for the rest of my clinical rings and subsequent rotations in my fourth year.

For future development in this competency domain for patient care:

Really listen to my patients with appropriate body language

Make my patients feel that they are NOT taking too much of my time

Always answer all their questions respectfully

Request feedback from my preceptors regularly

Incorporate personal wellness as an important driver to good patient care

CEO: Interpersonal communication

Learning Objective 4.6: Effectively prepare and deliver materials to individuals and groups

In my roles before medical school, I was immensely passionate about education. In college, I was an organic chemistry study group leader at UC Berkeley. After college, I was a math instructor to a classroom of underserved students in Oakland, CA as an AmeriCorps member. As a 1^st generation student from my family to attend college, I understood how education and mentorship can change things for the better. It can have a ripple effect that can really change and impact communities. I envisioned the outcomes that could come from mentoring and teaching future doctors throughout my medical career.

In medical school, I continued to develop a passion for teaching. Thankfully, I found many opportunities to continue my development as an educator.

During my first year, my classmates and I would have many informal sessions where we discussed material from lecture and found ways to teach it back to each other. I learned to critically think about concepts in new ways and found a simplified approach to communicate it to my classmates. I developed high yield notes and outlines compiled from various alternative resources. It was a rewarding experience helping some of my classmates who were struggling and seeing us all successfully pass our exams. In addition, I was able to teach my classmates about Minimal Change Disease during our GI/Renal block. I discussed to students in my LG about the social repercussions that patients had with this disease and I saw improvements in my public speaking. This presentation can be viewed here: https://drive.google.com/file/d/1ROuuKeSI2IYs9PTe_UAXtHn82DJURrXQ/view

During my second year, I became heavily involved with ultrasound at the medical school. I became a student proctor and helped proctored over 200+ medical students and residents during orientation boot camps, open scanning sessions, and annual school-hosted “Ultrafests”. I helped troubleshoot a variety of difficult scans and helped novice learners really appreciate the enormous benefits of point-of-care-ultrasound. This experience really helped me fall more in love with medical education as a future clinician educator. Here’s a picture below of me teaching students cardiac ultrasound at Ohio State’s Ultrafest 2019.

During my third and fourth year, there were more opportunities to teach the residents and classmates on my rotations. My most memorable presentation was the first one I gave on my Oncology 1 inpatient rotation. I gave a brief 5-minute presentation highlighting the difference between bilateral cellulitis and venous stasis dermatitis applicable to a patient I was following. I created a brief table to help summarize the big takeaways from what my team should remember. Here is the table:

I would continue to develop to improve the ways I presented medical knowledge to my peers. I learned how to deliver content more clearly when I considered the purpose of the presentation. How I presented a lecture on a clinical knowledge or skill was different from how I presented a paper at journal club. Here is an example of a few slides I presented at an Honors US journal club:

For future development in this learning objective as a clinician educator:

• Teaching residents/medical students
  • Ask them for learning goals each shift
  • Teach them a learning pearl from each patient encounter
  • Ask for feedback from colleagues and students for ways to improve
  • Develop content for common ED complaints
    • Create high yield summary cards
    • Create powerpoint presentations
      • Case-based
    • Find useful papers/guidelines

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