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[Insert song] Let’s Talk About Stress, Baby! Let’s Talk about You and Me!

Hahaha. Stress.

I feel like stress and medical school have to go hand in hand. I feel like my personality and stress go hand in hand too. I feel that I have to be slightly stressed at baseline in medical school because it keeps me on my toes. And I’m okay with that! Because otherwise, I’ll get lazy and shirk my responsibilities. The tricky part is keeping my stress levels in check. This reminds me of the Yerkes-Dodson curve:

This balance was a real struggle when medical school started. I kept pushing myself, getting about 5-6 hours of sleep a night (consistently going to bed after my roommates and waking up before them — they called me crazy! Looking back, I’m not sure how I did it for so long), not exercising consistently, and stress eating. Some of these fed into each other, becoming a vicious cycle that I didn’t realize I was in it until two weeks later when I’m already an absolute mess. I let off stress by hanging out with friends, frequently calling my sister and parents, and exercising when I could. I really enjoyed taking the cycle class for medical students at the RPAC, but I didn’t go consistently because it was a hassle to stay on campus until 6 pm, lugging my gym bag around, then having to travel another 40 minutes to get home (no car, so I took the bus). I wouldn’t get home until 8:15 pm.

It wasn’t sustainable, and that’s why I burned out during Foundations 2. Welp.

I was determined to, and was better at balancing myself during MSK. I took the Culinary Medicine class that OSUCOM offers, so every Tuesday night I could look forward to making a healthy meal with my friends. Although it took out more time of my day, it was a good mental break from studying. Looking back, it helped me more than harmed. I tried to be more efficient with my time too: for example, I’d do flashcards on the bus and would listen to lectures while I was cooking. One of my best decisions was to start meeting up with 2 other M1s every weekend to review the past week’s material. Not only did that keep me accountable, I would receive clarification on topics I was weak on. These M1s are some of my closest friends now (on top of that, it feels like I belong more in this new place). I keep talking about managing stress in the academic realm — why?? People always talk about self-care, and that usually entails some sort of non-academic practice, like yoga, journaling, or snuggling up on the couch with my favorite cup of tea. But being in school has taught me that staying on top of the material and getting my passes in are methods for self-care too.

Culinary Medicine Class of Fall 2018

During M1/M2, my greatest challenge was finding the balance between extracurriculars and school. I am someone who jumps enthusiastically into my interests and will push myself to my limits.  Insert cliche about you only grow outside of your comfort zone. The problem was that I did not give much thought to how I would allocate my time and energy into it all.

One of my, if not my lowest, points in medical school was during my Step 1 Dedicated. March 17, 2020 was my 26th birthday but was also the start of that terrible period and the beginning of the national COVID-19 shutdown.  The isolation caused by the pandemic was not the best ally against Step-induced stress in combination with the inherent belief that in order to succeed I needed to spend most waking hours studying — otherwise, I would not have given it “my best.” I was cut off from many things that made me happy, including hanging out with friends, family, watching movies in theater, and going to the gym and grocery store. My mental health quickly nose-dived. Friends would say I was an anxious mess, and I couldn’t get myself out of it. Unsurprisingly, I have a less-than-ideal Step 1 score. It took me several months to return to a more normal Lauren, but I felt that a fundamental part of me had changed.

I was determined for things to be different for Step 2. I aimed to give myself grace: I took regular real breaks, ate good meals, exercised and went outside more often. I am relatively happy with my Step 2 score.

Medical school in some ways has gotten easier. The clinical years are far more enjoyable because I learn best by doing, and I am more motivated to learn when I can see how my knowledge directly impacts patient care. It is still stressful at times, but I think I’ve gone over the largest mountains, some journeys more scathing than others. Now that I’m in my last year of medical school, I am mindfully looking inward to reconnect with what gives me joy and integrating them into my lifestyle. Importantly, my mindset is now one of balance and grace in the pursuit of excellence, being careful to not have a repeat of Step 1.

I have found joy through many things and continue to find it in new activities. I love keeping in touch with my family, having friends over, cooking and trying new recipes, playing my dog Maggie, exercising, and watching movies/dramas. These cover most of my basic needs at baseline. I’ve found that having a variety of activities lets me be less dependent on one thing to relieve stress. Overall, this leads to a more balanced Lauren. I’ve also made it a point to try new things, such as crocheting, and exploring more of what Columbus has to offer.  Since pictures are worth a thousand words, I wanted to include some favorites here:

Fun times with Maggie:

Dog-tor Maggie at your service

 

Family and Friends:

How many medical students does it take to cut one person’s hair? Four!

 

Exploring the Great Outdoors (and Columbus Indoors):

   

 

My journey through medical school is coming to a close. I have instilled the fact that good physical and mental health are pivotal to success and happiness. I am definitely keeping this in mind as I research residencies, not only focusing on how good the program is, but also what it and the surrounding area offer me in terms of wellness — whether that’s wellness initiatives, hiking trails, good food, or the ability to live near family and friends.  As I’ve learned how to better care for myself, I have begun to approach patient care differently. I understand that caring for my patients’ mental and emotional health is just as important as caring for their physical ailments, and will lead to better outcomes. As a physician, I will aim to keep learning how to best serve my patients in mind, body, and spirit.

My Time in Free Clinics (temp)

Every person’s life is influenced by a few principal things: time, money, food, shelter, support, health, are a few of them. These components, although seemingly simple and basic, can determine whether or not someone gets the care they need.

At OSU, I’ve been fortunate to experience clinical practice in a variety of different settings. From longitudinal practice, to the Emergency Department, OB/GYN, Labor and Delivery, Surgery, and finally, to the free clinics in Columbus, these opportunities have provided me a breadth of experiences as I progress through my 2nd year as a medical student. My LP and free clinics have been the most dichotomous in the way the patients and practitioners must navigate the healthcare system.

My longitudinal practice is with Dr. Lanla Conteh, a transplant hepatologist and gastroenterologist, who works out of the 8th floor at Martha Morehouse with service weeks at the James sprinkled throughout the year. I have also been involved as a steering committee member of the Columbus Free Clinic and Clinica Latina for the past year. CFC and Clinica Latina are student-run free clinics that operate weekly out of Rardin Family Practice on High Street after day clinic is over.

 

A.J Zanyk Photography 2019 in OSUCOM’s 2019 Recruitment Brochure

Being a committee member comes with many administrative duties, so I’ve experienced firsthand what it takes to keep a clinic running. When I was first starting out, I was continuously shocked by the types of limitations a patient may face at any time. I believe these are manifestations of healthcare disparities, which seem to be evident across both clinics since they serve similar patient populations. Money is a consideration in almost every aspect of the process. These patients come to our clinic because they do not have the financial stability to get (longitudinal) care elsewhere. Often, they walk in with a new diagnosis that requires lifestyle changes they might have difficulty implementing into their everyday life. They often can’t afford their medications. Fortunately, we have established an in-house pharmacy at CFC to dispense medications for free; something Clinica currently doesn’t have but is working towards. Sometimes, medications need to be substituted for their cheaper alternatives, but in the event that we don’t have a medication on our formulary, we turn to GoodRx to find the cheapest prices. If patients need more expensive medications to manage their condition, such as insulin for diabetes, we have to look to other resources — whether we find a solution varies case by case. We always strive to provide the best care possible for the patient by incorporating as many resources we can, but that doesn’t mean we always succeed to the level that we desire.

One example that surprised me about working at CFC and Clinica was thinking about patient care more longitudinally. For example, a patient came in that needed a pelvic exam and STI testing. It was for a specific test that we don’t offer in clinic, so my first thought was to send her to the Columbus Department of Public Health (CPH), which graciously offers free comprehensive STI testing. We could have done the pelvic exam in clinic, but one of the steering committee members who has better experience with referrals suggested that we should refer them to CPH and have everything done there, because CPH has a better follow-up system in place that could care for the patient longitudinally. I hadn’t really thought of approaching a situation like that — it was always, “What can I do for the patient right this moment? Let’s get that done.”

Another difference I have noticed is that the system for following up with lab results and imaging is more difficult in a free clinic than in hospital practice. I believe this is due to a lack of manpower, trained professionals, and overall resources. My LP has an established lab for blood draws and imaging that uploads results to IHIS and notifies her staff when there are abnormal results so they can schedule patients for follow-up. At CFC and Clinica, volunteers upload lab results; steering committee members and a lead provider must check results weekly, mark which ones are abnormal, and then call patients directly. It is definitely a messier process than at my LP and it has much room for improvement.

One last key difference I wanted to discuss was the follow-up rate. While I’m not sure how many patients Dr. Conteh loses to follow-up, I know it is very high at the CFC and Clinica Latina. This highlights many social and economic factors of health care — patients need proper transportation, they need to be able to get off work or school, they need to make sure they can leave their families for a couple hours. Maybe they do not have enough social support to manage their condition in a healthy way, they don’t have access to the internet or a cell phone, or maybe our system didn’t provide the services they need, or overwhelmed them too much, or maybe they were one of the patients that fell through the cracks. I’m sure this happens more than we think, and that really pains me because I know our system isn’t perfect by any means and we want to ensure all our patients are cared for to the best of our abilities.

How To Use a Stethoscope, by CFC Steering Committee
Most of the CFC Steering Committee 2019

A Near-Professional’s Evolving Definition of Professionalism

When I was applying for medical school, one of the questions asked was to define professionalism and what it meant to me. Honestly, at the time, I wasn’t quite sure and had to google it — having just graduated from college and started working as a scribe in the Emergency Department — to me, my understanding of professionalism was basic at best and I needed more experiences (and a variety of them) to be able to define it. I believe it was along the threads of “the behavior/conduct, qualities, and appropriate specialized knowledge that characterize a particular profession.” What qualities? What kind of conduct? Those were still largely unanswered.

When I entered medical school, my definition began taking on more shape as I was placed into a variety of new situations. One thing that I appreciate about OSUCOM is that they place a relatively high standard of professionalism on their students, and that was both exciting and stressful. Required patient panels where business casual/white coat was expected; mandatory longitudinal events like LC, LG, LP (the feared “alphabet soup”), Anatomy, Portfolio Coach meetings, where attendance was tracked and your performance could be evaluated by your peers and preceptors; having multiple assignments due at different points of the block — it was admittedly difficult to balance it all within the first year on top of a curriculum that was growing in not only sheer amount of knowledge, but difficulty as well (or maybe that’s the burnout talking). I remember discussing with Dr. Walsh how stressed I was at the end of the Cardiopulmonary block and that I didn’t balance my time wisely, and ended up missing 1-2 deadlines and not studying enough for the anatomy practical. I was essentially too focused on the final that other priorities fell to the wayside. Overall, this hurt my grade more than I felt comfortable. I cried a lot. Felt broken. Then Dr. Walsh said this, which has stuck with me: “I feel like that’s my life, too. There are always different moving parts, deadlines, things people expect of me as part of my job — I don’t think that ever really changes. You just get better at figuring out what’s important and balancing it. And I still don’t think I’m really that good at it.”

And with that, I felt like she had flipped my world. OSU wasn’t trying to make my life absolutely miserable… they were essentially training me for what real clinical practice could look like: a coordination of many moving parts. It was on me to find balance and uphold my duties. No excuses. I think that was one of the most pivotal moments that identified important components of professionalism for me: accountability, self-regulation, and competency.

Outside of school, my volunteer work at two large student-run free clinics, Columbus Free Clinic and La Clinica Latina, has defined and taught me professionalism in the best ways. Each organization is completely distinct in how they are run, the kinds of people who run them, and the patient populations they treat. Each organization requires different things from me, sometimes all at once (like navigating and directing the chaos that occurs on clinic nights) or across an extended period of time (for example, my role in CFC requires me to make weekly calls, run a 9-month health education program, while coordinate closely with our social work team). I cannot even begin to explain how much working in both clinics has helped me grow both personally and professionally. I have learned how to multi-task, handle stress in healthier ways, while still maintaining my composure and sanity (I think?). I have been rigorously challenged. It seemed terrifying at first, but I believe one of the reasons I didn’t shy away from the challenges was because others depended on me and thus, the clinic would be hurt if I didn’t uphold my promises and commitments. In that way, I grew internally in how I approached my responsibilities. I also grew externally, as I learned that many things affect how professionally I am portrayed: how I present myself, how I speak to and treat others, and how my attitude towards different situations can immediately affect those around me. A few important concepts were added to my idea of “professionalism”: building expertise constantly, being able to readily assess my emotional intelligence, communicating effectively, and respecting those around me despite any differences we may have.

At the last Columbus Free Clinic board meeting, everyone who has a part in running CFC met to redefine our Mission Statement and Vision. It was a long meeting that required much debate. After we had finally decided on the final versions, our Committee Coordinator sent the steering committee these quotes from our lead physicians and lead social work member.

“​Just kudos to you all on the mission/vision statement workshop tonight. That was a productive conversation where some real differences of opinion were discussed professionally and with civility. I know you all (along with some of my students) did a lot of pre-work and that no doubt made a big difference. One of the concepts of successful businesses and teams is the ideal of “psychological safety,” a hallmark of which is people knowing they can express differences of opinion and ideas without fearing being belittled or attacked. I definitely felt that in the room tonight, even though there were a few semi-tense moments. So, well done!” – Catherine, Social Work

“Every year we say there’s no way the new steering committee could be better than the departing one, but your team have been so tremendous- especially in your maturity and professionalism. We are blessed to work with you.” – Dr. Summit Shah and Dr. Robert Cooper, lead physicians

This small e-mail served as a profound testament to how we have grown in the last year, and it made me proud of how far we have come.

My first two rotations in third year have been Acute Coronary Syndromes (Ross) with Dr. Capers and Dr. Boudoulas; and Inpatient Psychiatry (Harding) with Dr. Guirgis and Dr. Brownlowe. On both services, I felt that both teams highlighted definitions of professionalism that I touched upon above— effective communication, maintaining composure and civility in volatile situations, assessing emotional intelligence, prioritizing learning and excellent patient care — while adding their own unique flavors.

I could go on and on about how wonderful the team was in all aspects during Acute Coronary Syndromes, . I was unbelievably fortunate to be part of such an enthusiastic, hardworking, caring group of professionals. My definition of professionalism is multifaceted, so it’s actually difficult to pinpoint a specific example when I think back on those three weeks, because I felt that the team was professional in many of those ways, every day. However, there is one moment that stands out in my mind.

We were rounding and happened to run into part of the Electrophysiology team as they were seeing the patient. The EP physician and Dr. Capers began a friendly conversation regarding the plan for today, when the EP physician stated (roughly), “I don’t know who it is, but let’s see what the fellow says and he can probably help us decide.” At this, Dr. Capers responded, “or she. I don’t mean to put on the spot, but this is one of those times where I must speak up. We (pointing to him and the EP physician) are so used to EP and Cardiology in general being a male-dominated field, that we’re used to saying ‘he’, but that is something I hope we work on changing.”

Six out of nine people on our team were women. I’m sure all of us were surprised by his words, and honestly probably would not have taken much notice to it if Dr. Capers hadn’t said anything — whether it’s because some of us were too occupied with other tasks or… maybe some of us are inherently used to such assumptions and have learned to brush them off? And if one of us was bothered by the EP’s statement, then could we have spoken up? I’m still not sure, at least not without hesitation. Whatever the reason, everyone on the team appreciated Dr. Capers for standing up for us, and doing so in a professional, respectful way. This moment stood out to me because it was an example of maintaining professionalism in an uncomfortable situation between people who are considered “professionals”. As a young medical student, it was a rare, humble reminder that even professionals with years under their belt still have room to improve.

“We are life-long learners, after all.” – Youssra Saqr, PGY1 on ACS (2020)

This was the same day Dr. Capers stood up for women physicians!

Women in Medicine: ACS

Acute Coronary Syndrome Evaluation Comments

 

From the very first day, my psychiatry rotation added a completely new twist to my idea of professionalism. To add context, Dr. Guirgis works on the 3rd floor of Harding, which mainly cares for patients with “acute psychosis”, including schizophrenia and bipolar disorder. These patients, by definition, often have delusions, hallucinations, or magical thoughts, and can be highly agitated, irritable, or depressed. I had never seen these kinds of patients before, nor had I seen a physician communicate with them. Then imagine my surprise when, on the first day, Dr. Guirgis said to a patient, “You know what, I think that’s bullshit. That’s bogus! How can you tell me that you went to medical school and also say that your head was transplanted onto a clone?? It’s not possible and you know it!”

First off, I have never heard a physician swear and outright say that a patient was wrong. The patient was clearly delusional, but it was still a jarring contrast to everything we were taught in the first two years of medical school. He later told me that when dealing with these kinds of patients, it can be beneficial to challenge their bizarre thoughts in order to improve insight into their condition (warning: with variable success). Dr. Guirgis actually did not swear again after that encounter, but as the rotation progressed, I found that a rougher, more pointed approach was often necessary to redirect conversations and often had a clinical purpose. If any more swear words were said, they were usually within the “safe space” of the team room, which I considered a therapeutic way to maintain professionalism by creating safe boundaries for the team. On the first day, Dr. Guirgis said, “It’s okay to let out your frustrations here. It’s unhealthy to bottle it up because otherwise, you’ll carry that resentment with you when you see patients.”

On the other hand, Dr. Brownlowe used swear words to break down tensions between her and the patients. There was a woman who was highly frustrated that she was here in the hospital and Dr. Brownlowe was convincing her that they were going to do their best to make sure she was taken care of while she was here. Dr. Brownlowe said, “I don’t half-ass anything,” to which the patient laughed for the first time in a 15-minute interview. She then said, “Yeah, I’m the head b*tch here,” and the patient laughed again and immediately, we could tell she was more comfortable than before.

The interactions during my inpatient rotations have broadened my definition of professionalism. They have demonstrated that things often taught to be strictly avoided during our preclinical years can be artfully used in the clinical scenario, within reason and with mindful practice. As I progress in my career, my goals include being observant of my interactions and those of others, tactfully and confidently correcting errors like Dr. Capers did, and remaining mindful and creative of maintaining my own professionalism as a physician.  I have no doubt that my definition of professionalism will continue to evolve, especially as I enter residency. I look forward to the experiences that await me, and I hope I will be blessed with the patience and open attitude needed to help me grow even more as a “professional.”

Palliative Medicine

Today was the first time I’d seen an attending furious.

I started Palliative Medicine this week. Today, we were consulted for an elderly patient with metastatic bladder cancer status-post chemotherapy/radiation admitted last week for altered mental status. He was found to have hypercalcemia of malignancy, UTI, acute pancreatitis, and imaging findings suggesting extension of his bladder cancer into the pelvic sidewall, new bone metastases, and a new malignant pleural effusion.

This patient was admitted complaining of 10/1o pain with the side note that he was a poor historian due to his encephalopathy. The primary team had successfully addressed most of his primary issues with significant improvement of encephalopathy. However, with the progression of his bladder cancer, Palliative Medicine was consulted to host a Goals of Care discussion. When my attending and I arrived outside the patient’s room, we were approached by his nurse. She was livid.  We sat down and listened as she explained that for the last few days, she has been notifying the primary team that this patient has been complaining of 10/10 pain, and she had been requesting stronger PRN medications than the acetaminophen that was ordered. This patient’s cancer pain was previously controlled on low-dose oxycodone; however, this had not been continued on this admission. The nurse stated, “I don’t feel heard. I thought we encourage interdisciplinary care here, but I have been trying to advocate for this patient and I truly feel that I’m being ignored and they are just leaving him by the wayside.”

My attending grew visibly more upset as the nurse talked. She had already ordered IV dilaudid PRN preemptively so that the patient wasn’t in severe pain when we went to talk with him. He complained of suprapubic pain. The conversation was more about pain management and determining whether he had medical decision-making capacity, while touching upon goals of care.

After we were done, my attending wanted to go see the primary team to understand their thought process behind not starting stronger pain medication for this patient sooner.

Oh… and did I mention that this patient was an inmate?

My attending felt this would not have happened if this was a patient in the James, who had family at bedside to advocate for him.

Some key takeaways from this encounter and PM so far:

  • Nurses spend much more time at bedside than we do as physicians. If a nurse is telling you something is wrong, then it is our responsibility to listen and look into it.
  • There are many reasons to have pain and it’s important to determine what type of pain a patient is experiencing. However, opioids are standard of care for cancer-related pain and there should be no reason to not have started this patient (who had evidence of progression of his bladder cancer) at least on the pain regimen he was receiving before admission. Tylenol cannot be used for “severe pain” which was how it was listed in this patient’s order.
  • My goal is to think about this situation as I move forward in my career, so that I’m always checking my biases, respecting my colleagues, and providing equitable patient care regardless of background.

Shared Decision Making in Hairy Situations

“I don’t want to go to the ER”, said the patient shakily through the phone.

My eyes flicked to Dr. Magaña as the patient waited for my answer. I felt stuck.

It was a Thursday night and I was at Rardin Family Practice fulfilling my duties as a steering committee member of Columbus Free Clinic, which entails me playing administrator, assisting physicians, volunteers, and patients with any needs that arise, optimizing clinic flow, and of course, answering phone calls, which was what had put me in my current situation. Usually, calls that we receive during clinic are from patients that need to cancel their appointments for tonight or who want to know their lab results from the previous week. Rarely, we get acute care calls, but this was was an exception.

I picked up the phone and moved to a private room so I could hear her more clearly.

“I’ve been having multiple dizzy and fainting spells for the past 2 days,” the patient informs me. I start asking her for more information — symptoms, past medical history, etc., trying my hardest to remember the relevant questions to ask for dizziness and syncope. She tells me she wants an appointment with CFC next week. CFC is a student-run free clinic that is only open on Thursdays. That seems like too long to wait, I think.

I end the phone call, but not before I tell the patient that I’m going to call her back after I’ve discussed her case with a physician. I leave the room and find Dr. Magaña, one of the regular physician volunteers at CFC (and actually, the physician I did my first case presentation to as an M1). After I’ve filled him in on the patient, he says her symptoms sound worrisome enough that she should go to the Emergency Department. I agree and call her back.

“I don’t want to go to the ER”, she says. “The last time I was having dizzy spells, I went to the ER and they did a bunch of tests on me, but ended up not finding anything wrong. I left without a diagnosis and with thousands of dollars in bills that I still need to pay. Then I came to CFC and you guys found out that I have hypothyroidism and hypertension. I haven’t had dizzy spells for a year since I was placed on meds from you guys.”

What do I do? I understood her reluctance with going to the ER, but I don’t think Columbus Free Clinic would be able to help her, since our services are directed to more chronic, longitudinal patients. We are vastly unprepared for emergent or acute care patients. If she came into clinic with those symptoms, we would likely refer to the ER eventually since they would be able to care for her acutely much better than we could. I explained this to her. She seemed to understand where I was coming from, but remained reluctant. I sighed. I insisted again.

After talking for ten minutes, we decided on what I believe (hope) was a compromise: if her symptoms persisted or worsened, then she would go to the ER. Maybe she was saying that just to get me off her back, but she seemed to also be very worried about her fainting, and informed me she wouldn’t let it “get too bad” since she has a family to take care of. This reassured me that she would make the right choice when the time came. On my end, I followed through with her wish for an appointment in the coming week. I hung up. Dr. Magaña patted me on the shoulder.

It’s been a couple weeks since that call. The patient came to CFC where she was evaluated for fatigue. Her blood work was normal, so her dizzy spells seem to be stress-related. She did not go to the Emergency Department. I called her recently to see how she was doing.

“I appreciate you checking in on me,” I could hear a smile on the other end. I felt me smiling back.

This was one of my first difficult patient encounters. I believe an important takeaway was that we both communicated and understood each other’s perspective. Neither of us spoke over one another or really dictated the course of action. We negotiated until we found a compromise. At first, I felt like maybe I had failed since I couldn’t convince her to go the Emergency Department that night. However, now, I’m not sure there really is any “winning” involved. If there is, I don’t think it’s that important for the physician, so long as I did everything I could and the patient’s health is taken care of in the end.

Fast forward to my clinical years and inpatient rotations —  in June 2021, I completed my first rotation as a 4th year medical student: a mini-internship in Hematology 1. It certainly wasn’t my first choice for my mini-I, but I was looking forward to learn more about the field since I’ve always felt that my hematology knowledge was shaky. As a MS4, the 6am-6pm was an exhausting schedule, but I was fortunately surrounded by a fantastic team that made my experience much more enjoyable and valuable — they were fun, highly intelligent residents/interns who loved to teach, give immediate feedback, and challenge me every day.  They were one of the best teams I’ve worked on.

During the first week, an otherwise healthy, young female patient was admitted for acute LUQ pain, fever, and profound pancytopenia in the setting of 2-3 weeks of a diffuse rash. We quickly diagnosed her with hairy cell leukemia, a condition that OSUMC has traditionally seen only once a year. She did not fit the traditional picture that we were taught in medical school of HCL, and she overall felt very well — once her LUQ pain (due to splenomegaly) was controlled, she had no other significant symptoms. Her rash was not painful or itchy; it was simply diffuse and aesthetically bothersome.

Her hospital course, while very long and complicated, was an excellent learning opportunity in a variety of ways. My attending Dr. Ashley Rosko, invited Dr. Michael Grever, one of the world’s experts on HCL (he receives calls from all over the world about HCL cases), to come give us a lecture and provide treatment recommendations, education about side effects, etc. Dr. Rosko even took us to view her biopsy slides, which was a unique learning experience.  I’m not sure when I’ll see another HCL patient again.

Dr. Ashley Rosko showing the pathology slides for our HCL patient to our Hematology 1 team.

A hairy cell!

Importantly, I was not as afraid to make decisions as I was during 3rd year — and this was the opportunity to really take ownership of my patients. I got to call the specialty pharmacy and advocate for her by having them ship her Vemurafenib the following business day, not in two weeks like they had scheduled (which would have meant her staying in the hospital, feeling well, until that time). I was monitoring her medication side effects, asking the nurses to get EKGs so we could check her QTc, adjusting her pain and nausea medications, and talking with consult services almost daily. Meanwhile, I built excellent rapport with her, her family, and boyfriend.  I was the only consistent person on the service since attendings rotated on a weekly basis and the team changed during transition week.

At one point, she became persistently febrile and was in severe pain, causing an escalation of her pain medications to opioids. However, the following day she was adamantly refusing them and would not tell the intern why.  Independently, I attempted to elicit a reason. “You are in a lot of pain, and these are some of the strongest pain medications we have. We want to help. Why do you not want to take opioids?” She informed me that her ex-boyfriend had an opioid addiction and she was initially weary about how they would make her feel. Her fears were confirmed when she felt sleepy and confused from the medications and it triggered painful memories of her past relationship. During rounds, I relayed her decision and reasoning to stop opioids to the team.

When I walked into her room the morning of July 2, I told the patient that it was my last day on this service. To my surprise, her mother gasped… and the patient began crying. Both she and her mother preceded to tell me they had been so grateful for my presence during this last month, and I could feel my eyes start to well. I was so touched.  As stated above, her hospital course had been long and complicated, and at that time she was nowhere near to being discharged. Looking back, I had been with her since her diagnosis and had managed her medical care up to that point, and I felt a sense of happiness and gratitude for the opportunity to get to know her, be so involved in her healthcare, and help her feel heard and seen amongst the chaos of inpatient care.

Moving forward, my goal is to continue honing my skills so that I can efficiently yet effectively care for an intern level number of patients. Specifically, I’d like to work on my communication skills. I found that while I enjoy talking to patients for a long time, I have to learn to ask the right questions, maintain good rapport, and segue appropriately to care for my patients and do all my duties as a resident in a timely fashion.

Evaluation comments from my Hematology 1 team.