Author: white.2815

Professionalism in the opioid epidemic

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

Providing care to patients with opioid use disorder during the opioid epidemic is one of the most difficult challenges for internal medicine physicians. In my clinical experience, I have seen loss of trust lead to communication breakdowns, inconsistencies, and emotional tension for patient and provider. As I strive to provide the highest quality patient care to each of my patients, achieving patient-centered care in this setting has been difficult.

My first memorable interaction with a patient suffering from opioid use disorder occurred during my third-year general medicine rotation. The patient was admitted for a kidney stone which caused him excruciating pain. He demanded high doses of IV opioids and became enraged when my attending recommended against opioids. I felt bad for the bedside nurse who spent the entire day sympathizing with the patient, yet stopped short of providing relief by opioids. I felt bad for the patient, who became addicted to opioids initially prescribed by his doctors. And I felt bad for our attending, who spent nearly an hour delineating why we needed to trial non-opioids first and refusing to engage in a bargain for medications. Unable to reach a common ground, he had to excuse himself to see a sick patient. I wondered if I had the reserve to withstand this tension on a daily basis. Returning the next day, we fortunately found some common ground. Although it cost time from the day, the persistence proved worth the effort.

Hoping to learn more about managing pain for patients with opioid use disorder, I enrolled in MAT waiver training. The program helped me to better understand the public health impact of opioid diversion. I completed the training so that in the future I can facilitate care for patients who are candidates for this treatment.

I returned to the general medicine wards for my fourth year sub-internship. This time, I aimed to take more responsibility communicating with difficult patients and resolving conflict. Many of our patients struggled with addiction to alcohol, heroin, and cocaine. When I presented a patient with a documented history of polysubstance abuse, my attending encouraged me to consider using “substance use disorder” as a more patient-centered term.

One of our patients who had used IV heroin in the past was given a PICC line for outpatient antibiotics. She spent days waiting to be placed in a facility, and we tried to alleviate her anxiety. Then one day, without warning, she disappeared from the unit. We were shocked to hear that she had snuck out in the middle of the night after receiving the PICC line. It felt like deception. How could we possibly trust our next patient?

Later that week, I evaluated a patient with hidradenitis suppurativa and a history suspicious for cocaine use. She was in the process of finding a new primary care physician. When I saw her, she was in excruciating pain and yelled that she didn’t want to be bothered by medical students with redundant questions. I attempted to reason, but she demanded I leave the room. The resident decided to provide oxycodone for breakthrough pain given her severe flare of hidradenitis.

I thought about finding a new patient. I sensed this would take up my time and energy. But knowing her case, I decided to take ownership and revisit her the next day. We made some progress and I learned that she was having difficulty finding a primary care physician. Outside of the hospital, she could not access opioid analgesics without a primary care physician. We would have to work with case management to keep her pain under control after discharge.

A new attending started on service the following day. I respectfully introduced our patient, who thankfully had allowed me to examine her that morning. Just as we were leaving the room, the nurse asked if we were in agreement with oxycodone for breakthrough pain. The attending told her to remove oxycodone from the list and then quickly moved on to the next room. The intern was upset about this, because she had previously set different expectations for the patient. The nurse now had to withhold analgesia from a suffering patient. I could understand our new attending’s discretion to provide therapy, but the discrepancy in plans put stress on the team and patient. With this change in course, the patient perceived that we lost trust in her.

Later that day, I checked on her and she asked me sadly, “Why does everyone keep avoiding me when I ask why I can’t have something more for pain?” It seemed like everyone was sideskirting something, saying they didn’t know or they weren’t sure. “I just want someone to please give me a straight answer.” I felt convicted to provide an honest response, even though I wished I could defer her to the residents. I promised her I would check with the residents and return soon with an answer.

I had to think for awhile about how to phrase this and keep our team and our plan and our patient’s goals in alliance. I also wanted to show her courtesy, respect, and honesty as far as possible. I asked my intern for advice.

I explained the situation in big picture terms first. With the opioid epidemic in Ohio, doctors were changing the way they prescribed opioids. To protect people from addiction and prevent diversion, we had to rethink the ways in which we manage everyone’s pain in the hospital. This change made it difficult to speak in a straightforward way about what’s considered “okay” to prescribe. Sending her home with a long course of oxycodone was not an option. We needed to set her up with a PCP to manage her pain.

I thought she would be upset, but she listened carefully and then told me that she had a daughter with substance use disorder and understood our caution. Once I ensured her that we would set her up with a new PCP quickly after discharge, she was on board with the plan. She agreed to trial the nonopioid analgesics and steroids for another day and inform us if the pain worsened. I reassured her that we would find her a primary care physician to follow up with.

Reflecting back on this experience, I realize that I am never going to know how the patient will respond. Maybe they will yell at me, maybe they will agree with me, or maybe they will lie to me to take advantage of the health system. It’s hard to trust after being lied to and yelled at. Regardless, my job is to be there for the patient, build trust, communicate honestly, and provide excellent interdisciplinary care.

Building trust and communicating honestly are difficult when you implicitly or explicitly don’t trust the patient. We may question whether the patient is telling the truth or willing to comply with recommendations. But my responsibility as an intern is not to discern whether the patient is truly in pain or lying. Rather, my responsibility is to care for their medical needs. By sticking around even after I was yelled at by the patient, the patient knew I was still dedicated to providing her care. With those small steps of building trust and honest communication, we found common ground that allowed us to make another small step in progress with her care. Through diligence and honesty, we can build steps towards common ground.

Having a network of allied health providers was critical for successful treatment in all of these scenarios. When communication within our care team faltered, the patient could tell that something was amiss. To give patients the best possible chance of regaining health and autonomy, they need to establish longitudinal care with a health provider. This requires a multidisciplinary team including nursing, social work, case management, and physical and occupational therapy. I completed an advanced competency course on interdisciplinary case management for underserved populations. Working together on simulated cases taught me how to leverage the strengths of an interdisciplinary team.

Since this rotation, I’ve strengthened my skillset to better care for patients with substance use disorder. Honesty with our patients is essential, and so I look to my seniors for ways to respectfully navigate difficult conversations about drug addiction. I use “substance use disorder” to promote patient-centered clinical discussions. During my palliative care rotation, I further strengthened my communication skills with patients suffering from chronic pain and learned additional strategies to optimize pain management. I earned high marks from my attendings for my professionalism and rapport.

 

During my intern year, I will continue to strive for honesty, integrity, compassionate care, teamwork, and patient centeredness during difficult patient encounters. My specific goals are listed below:

  • For patients admitted with significant pain, set expectations for pain control while in the hospital at first encounter
  • Consider non-opioid analgesics, therapy, and integrative medicine to manage pain before initiating opioids (with exceptions for patients with clear clinical indications for opioids and patients pursuing palliative care)
  • Be patient and diligent with patients who yell at me during an initial encounter
  • Always check and document an OARRS report for patients receiving opioids
  • Ensure that every patient has a timely follow up plan with an outpatient provider who can manage their pain prior to discharge
  • Understand hospital policies on opioid prescription by the first day of internship
  • Know where my patients can receive prescriptions for pain medication by the first week of internship

Navigating the transplant system

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5.1 Understand the institutions and individuals that participate in healthcare delivery and the role of the physician in the health care system.

I started medical school hoping to go into cardiology. The scientific concept of transplanting a heart fascinated me. Hoping to gain perspective on clinical aspects, I began shadowing during my first year of medical school. In Heart Failure clinic, the physicians served as fine tuners of the body’s cardiovascular machinery. Large hearts, stiff hearts, and saggy-baggy hearts all housed a room here. We managed medications and counseled on lifestyle changes to prevent decompensation. For those who progressed to end stage heart failure, we resorted to two advanced therapies- device or transplant.

Ms. S’s voice had taken on a tone of desperation. “They won’t give me the kidney transplant. I can’t sleep, I can’t think, I’m just so ANGRY.” Dr. H listened, paused, attempted to continue the interview, but the patient had become inconsolable. I observed her ankles swollen with fluid, her jugular vein bulging with too much stagnant blood. Our plan for her had likewise stagnated. She needed a replacement for her failing kidneys and a consequently failing heart, but obesity and smoking created problems for her placement on the transplant list. “I don’t know what to do. I can feel them dying.”

I was shaken by her tragic honesty and lost the words to console her. Dr. H expressed her empathy and then diverted her focus to achievable changes for the interim, such as losing weight and cutting down on cigarettes. She relied on her knowledge of the system, the barriers, and the limiting factors for our patient to receive a transplant. She kept us in sight of the medical goal.

I learned that day the consequences of having a bottleneck in our health system. The dilemma of a limited organ supply meant our best plan was to hold fast and wait—but waiting could also mean death for a patient. I wondered if I really still wanted to do cardiology, if all it amounted to was consoling patients stuck on a waitlist.

The next time I returned to the Ross Heart Hospital was a Sunday morning in August, having received a text message the night before notifying me of an opportunity to shadow a transplant. I met the surgeon and fellow and introduced myself. The operating room buzzed mechanically, nurses moving swift as machinery, two surgical teams shifting in and out of the scrub room, the body quiet at center. In the corner, I glimpsed Dr. H step in to observe the surgery. We sawed through the sternum, pried apart the ribcage, and cauterized the buoyant fascia. The pericardium, fine as satin, was sutured aside to create a window. I watched the surgeons lock eyes, nod, and collectively inhale as the anesthesiologist counted, “Five, four, three, two, one”. He pushed heparin, and the teams set back to work. I waited expectantly behind the surgeon until finally he stopped and rotated around. He held the heart in his hands. I laid it delicately on ice, wrapped it, and we stormed down the hall to the next operating room. Hours later, sutures were tied, tubes were removed, and a heartbeat ceased was resumed.

It took a village to transplant a heart—scientists, doctors, nurses, pharmacists, engineers, therapists, and social workers. I was privileged to witness the process at the bedside. I realized that despite the frustration, the waiting, the lack of resources, and the shortcomings of an imperfect health system, we had real hope of curing disease. Offering these treatments was not futile.

In my fourth year of medical school, I signed up for an inpatient heart failure rotation. We managed decompensated heart failure and helped our patients navigate the transplant bottleneck. One of my patients was admitted and we were unable to disconnect her from IV medications. I felt at a loss as to what we should do next. My attending instructed me to read about Status 2A on the transplant list and update him on the patient the next day. When I presented the patient, I noted that if she were to move to Status 2A- patients on a mechanical assist device- she would be higher priority for heart transplant. Sure enough, she was transplanted within a week of our placing an intra-aortic balloon pump. I watched her recover beautifully over the course of a month.

Unfortunately, not every patient gets a transplant that could. From listening to discussions between the attendings, surgeons, social workers, and LVAD coordinators, I learned how to assess patients for transplant candidacy. With patients who weren’t eligible for transplant, I focused our discussions on quitting smoking, controlling their diabetes, and attending all their health appointments- factors which would improve their likelihood of success from transplant. I spent a week on palliative consults in the Ross, which helped me to understand the integrated role of palliative care in the pre-transplant evaluation. This helped me to feel comfortable discussing goals of care and advocating for palliative care consultation for some of the patients. My residents increasingly allowed me to communicate with patients and families about our plans of care.

During residency, I will have opportunities to identify barriers to transplant and counsel patients on how to optimize their treatment outcomes. I will use motivational interviewing to promote key health behaviors such as smoking cessation, exercise, and glucose monitoring. Listening to patients’ goals and values will help me to guide them through decisions to pursue conservative, surgical, or palliative therapy. Understanding the benefits and limitations of the health system will help me to manage expectations and mentally prepare patients for advanced therapy evaluation. Over the next year, I will use my understanding of the health system where I’m working to ensure patients awaiting transplant are medically optimized and mentally prepared for the best possible outcomes.

Smart goals:

  • During the first month of intern year, practice using motivational interviewing to set at least one small, achievable goal with 5 patients who are attempting to quit smoking, lose weight, or manage diabetes. Practice this both in the inpatient and outpatient setting.
  • In the outpatient setting, ask patients how they are doing on their progress towards their health goals
  • Provide consistent, positive reinforcement for all patients who make improvements in health behaviors (e.g. eating better, smoking less, exercising more, practicing mindfulness)
  • For patients in need of organ transplant
    • Evaluate patient readiness and identify barriers to transplant
    • Counsel patients on the role of palliative care in the pre-transplant evaluation
    • Inform patients that attending medical appointments will increase their likelihood of a successful transplant
    • Inform patients that smoking, drug use, uncontrolled diabetes, and obesity will decrease their likelihood of a successful transplant

Advocating for refugee health

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Competencies:

4.1 Demonstrate leadership and collaborate effectively with other healthcare team members and professional associates.

4.2 Understand how human diversity may influence or interfere with exchange of information.

4.5 Use information technology appropriately to manage medical information and patient care decisions, promote education, and communicate in the interests of patients.

4.6. Effectively prepare and deliver educational materials to individuals and groups.

Working with immigrant and refugee students is a long-held passion of mine. As an undergraduate in Arizona, I volunteered tutoring K-12 students from refugee families. When I learned about the Somali Health Initiative for Nutrition Education (SHINE) in medical school, I was excited to volunteer.

Through SHINE, we provided 11 weekly health education lessons at Focus Learning Academy of Northern Columbus. About 96% of their students are of Somali background. I volunteered to teach and help organize a field trip and fell in love with the project. When I applied for leadership for the following year, I was asked to fill in as Treasurer.

I was excited to make an impact for refugee students locally, although I had never served as treasurer of an organization before. Our leadership team was eager to expand the project and host two field trips. As I reviewed our budget though, I worried how we would find sustainable funding. We worked together to search for local funding sources, knowing how important these learning experiences could be for the students. Throughout the semester, I wrote grant applications, ordered supplies, purchased healthy snacks to provide at lessons, and covered our transportation costs. When I had spare time on Fridays, I volunteered at the school and helped design a lesson on mental health.

Applying for funding meant advocating for the program, both on paper and in person. I was nervous to present to groups outside of the College of Medicine, but I needed to persuade others of the importance of our project. I submitted a referendum to the interprofessional student council and gave a powerpoint presentation at their senate meeting. Two of my team members helped me present, and our funding request was approved. After the meeting, the dental school representative asked us if dentistry could get involved in the project. We collaborated to make the program more interprofessional. The dental students taught a lesson at the school, volunteered for our panel discussion, and hosted a tour of the department during our spring field trip.

In October, we were informed that the Columbus Dispatch was looking to write a feature about the community health education program at Ohio State, and our program had drawn their attention. A reporter came to interview and observe us teaching. We were featured on November 5th, 2018.

https://www.dispatch.com/news/20181105/ohio-state-medical-students-connect-with-youth-to-promote-healthy-living?fbclid=IwAR2bcmuAlZ439weLoQKMIQZTQZGW7_jqdBUKnMD5QtcPbmZLWQow7J9qM-4

Although I normally shy away from public speaking, I was passionate about providing health education and mentorship for local refugee students, and that passion came through in my presentations. I accepted another invitation to present at the annual Medical Alumni Society meeting. We received several questions on our approach to impacting mental health. This inspired me to question how we can better address mental health as educators and providers in refugee communities.

In the clinical setting, language and cultural barriers create unexpected challenges for refugee patients. Finding a translator can take up time and is not always available in under resourced areas. Differing cultural norms—such as a physician taking time to explain care plans to all members of a patient’s family—can frustrate patient and provider. In some instances, patients fear blame, punishment, or stigmatization and delay seeking care until necessary. Open-mindedness and an ongoing desire to learn and connect are necessary to improve cultural competency in healthcare.

Teaching is often a two-way street, and I learned the most about Somali culture by spending time directly with students at SHINE. I wondered if these interactions could help my classmates and I to become more well-rounded physicians. I discovered that Columbus Refugee and Immigration Services (CRIS) offered training for students and community members interested in working with local refugees. Out of curiosity, I attended a session and learned more about the resettlement process and local needs of refugees. When I asked classmates if this would be an interesting workshop topic, they helped me to network and arrange an event.

In February, I coordinated a Refugee Health and Wellness Workshop with a CRIS partner who is passionate about educational outreach for health providers. I collaborated with Leading in Global Health Together (LIGHT), our global health interest group. At this session, we discussed how to provide culturally competent care in diverse communities in Columbus. Hopefully this effort promotes awareness of health barriers and mindfulness in how we might improve care for refugee communities as future physicians.

SMART Goals:

  • Show my effort to engage with patients’ language and culture. For example:
    • Asking patients what language and dialect they understand best
    • Greeting a patient in their native language
    • Asking patients to teach me a word in their language
    • Asking patients to tell me more about food, sports, music, or hobbies they enjoy
  • Use a translator rather than a family member if possible
  • Ask refugee patients if they have access to transportation for health appointments and picking up prescriptions
  • Always use the teach-back method to ensure the patient understands their treatment and why they are being treated
  • Print discharge instructions in the patient’s native language
  • Allot extra time for outpatient visits with non-English speaking patients when possible
  • Find out where refugees can find mental health resources in my city
  • Find out where refugees can find help with job applications in my city
  • Help my patients navigate the health system by connecting them with social work and case management as needed
  • Advocate for health needs specific to refugee patients when opportunities arise

Finding my voice as a medical student

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Competency 3.1-3:

  1. Evaluate the performance of individuals and systems and identify opportunities for improvement.
  2. Demonstrate an understanding of the role of the student and physician in the improvement of the healthcare delivery system.
  3. Identify one’s own strengths, weaknesses, and limits;
    1. Seek and respond appropriately to performance feedback

I was on my third day of night shift on the labor and delivery floor. A familiar set of initials, “SW”, gleamed on the monitors. I opened the hospital course I had written last night to refresh my memory on her case. SW was a patient seen in the high-risk OB clinic due to multiple medical problems. She had a history of tobacco, heroine, and cocaine use, gestational diabetes, asthma, and COPD at 30 years of age. Her substance use meant multiple medical comorbidities would have to be managed during delivery. She would need respiratory monitoring, oxygen supplementation, and imaging around the clock to make sure the baby kept a stable blood supply. The resident scribbled down “PSA” on a crowded page of notes, short for polysubstance abuse patient.

We received a call from the nurse at 11pm for concerning fetal heart tones. When I entered the room, the nurses were crowded around the bedside. Gauging from her exasperated complexion, she was losing stamina quickly. I scrambled to recall what her biggest comorbidities were—COPD, cocaine, diabetes… and something else. With diabetes, she could have shoulder dystocia. With cocaine use, she could have placental abruption. I threw on scrubs and rushed to the bedside. With prolonged labor, we had to keep vigil for heavy bleeding after the delivery.

She gathered her strength, pushed once more, and swiftly delivered a baby boy. In my hands he was pink and healthy appearing, and within a minute of being placed on his mother’s stomach he began to cry. The nurses swaddled and examined the baby, leaving me and the resident to take care of the mother. She laid back exhausted as we removed the placenta and worked to slow down her bleeding. Minutes passed, but the bleeding continued. We saw no lacerations to explain the bleeding and called over the chief resident.

The labor had gone on too long. “Let’s get some methergine here and someone get a shot of hemabate!” she shouted. To the husband, she explained, “We just want to give her some medicine to help stop the bleeding from her uterus.”

Hemabate. It struck me then belatedly that I had written in asthma in the litany of her past medical history. But did I have the right patient? I honestly couldn’t remember in the rush since being called if I had the right patient. Reflexively, I asked the husband if she had asthma. He confirmed.

“Wait then, no hemabate!” the chief yelled. “We can’t use that, it will give her an asthma attack.” She motioned at me to say, “Hey good catch there.”

I was relieved I had remembered the details correctly. On a busy night of complicated deliveries, it was just one small detail. With the recent shift change and the long list of patients, her asthma was overlooked. I like to think that one of the nurses would have picked this up had I not reacted as promptly. Still, I left happy to have made the call at the right time. Crisis averted.

We didn’t make a near mistake for lack of knowledge, but for lack of insight at the appropriate time. With high risk obstetrics, we watched for critical constellations of signs and symptoms over an unpredictable time course. Although the history was written in her chart as a reminder, we had so many patients and unpredictability that the finer details blurred together in our short-term memory. We remembered polysubstance abuse and stopped there. The challenge was to stay attuned to the individual patient, to not think in labels but notice the individual intricacies.

It’s easy to use labels as a shortcut when we’re inundated with problems to fix in a short period of time. Finding care that is best for each patient, however, means breaking out of an industrial, disease-centric mindset. My goal as I work on my assessments and care plans is to not lose sight of human details—small details that don’t fit neatly into frameworks, that distinguish one patient from another I’ve seen in the past. It means staying curious about the uniqueness of our patients.

The other lesson I took away from this was the power of my own voice. During my first two weeks of obstetrics, I was intimidated and shy and tried to not interrupt the hectic workflow. The residents were uncertain if I was shy or disinterested and wrote this as a point for constructive feedback. When I returned two weeks later to start on night shift, I told myself that I would practice speaking up and asking questions, despite feeling out of my depth. Realizing that I was able to make a positive difference for a patient by speaking up at a critical moment was empowering. Although I was worried the residents would be upset with me disrupting care, they responded just the opposite.

 

Teamwork is crucial for safe and error-limited patient care. In the future, I will remember to speak up when my gut feeling tells me something is not right. And when I’m a resident, I will make time to listen to the medical students so their voices are heard and they’re prepared to respond to critical events.

*Patient identifiers have been changed to protect patient privacy 

Critical literature appraisal

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Competency 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.

As I have transitioned from preclinical studies to clinical rotations to preparing for internship, I am gradually learning how to ask focused clinical questions. Clinical questions fill a specific gap in knowledge that can be utilized in decision making for individual patients. Over the past few years, I practiced gathering and reviewing known information to find a known answer about a clinical disease. In contrast, for unresolved clinical problems, I have to learn to evaluate an evolving body of literature to answer a clinical inquiry.

One of my assignments during my AMRCC rotation was to perform a critical appraisal of the literature to answer a clinical question. Endocrinology tends to be a highly data-driven specialty, and so I decided to investigate the literature on treatment pathways for a patient of mine with Grave’s disease. I looked up the guidelines on what we could offer for patients in her condition and copied in all the available studies to support those guidelines. After submitting my assignment, I was surprised to receive feedback that I had summarized the literature but not critically evaluated it. I looked back at my work to see what I had missed. In answering this question, I looked to find the ‘most correct’ answer—the same way I might confirm my answer to a clinical vignette on a board exam. However, the purpose of the assignment was to demonstrate critical appraisal—identifying the strengths, limitations, and biases of a given study. In my eagerness to identify and prove the answer, I missed the point—the answers to our questions are not always clear cut, and we need to be prepared to think critically. Medicine is constantly evolving, and as clinicians we need use critical appraisal to decide how convincingly the emerging literature supports a change in practice.

In my third year of medical school, I decided to engage in clinical research. I had done multiple basic science projects in cardiology and figured that my next step would be to gain clinical experience. I asked Dr. Emani, a cardiologist I had shadowed, if he might have a clinical project I could assist with. He described a clinical question he had in mind to investigate.

The clinical question was straightforward, but nuanced. He hoped to investigate the utility of high-risk PCI in patients with severe heart failure. Since these patients typically have severe comorbidities, they are often excluded from clinical trials. I started the project by performing a literature search of survival in heart failure patients. But as I poured through the literature, I lost sight of the initial question by delving into comparisons of PCI versus surgery. Although the populations were similar, the results weren’t relevant because the patients were healthy enough for surgery. We stepped back and revisited the initial question. I imagined that I was a critically ill patient with systolic heart failure and had to choose between high-risk PCI or medical therapy alone. There was a gap in the literature that left me uncertain which option would prolong my life. When I framed the question with a clinical example, I was able to redirect and focus my literature search. I applied for an IRB and was able to lead an investigation of retrospective outcomes from high-risk PCI. My abstract was recently accepted for a poster presentation at the 2021 American Cardiology Conference.

During my sub-internship in general medicine, my attending frequently asked me to find answers to clinical questions that arose on rounds. For example, he asked me one day to look up what’s known on triple therapy for COPD exacerbation. I had to think beyond the what of currently available therapies, as I would for an exam question. I had to think about why triple therapy might be advantageous and how the available evidence supported this. One of the residents pointed me to Wiki Journal Club to help compare and contrast clinical trials. I believe this skill will be useful during residency, not only for answering questions posed by my attendings, but also to actively compare evidence-based treatment options for individual patients.

I had the opportunity to formally demonstrate these skills by presenting a case report at the OSU Hospital Medicine Symposium. Midway through my sub-internship, we diagnosed a patient with eosinophilic gastroenteritis. The clinical presentation was complicated. We were convinced the patient had Crohn’s disease until his gastrointestinal workup unexpectedly returned with evidence of a rare inflammatory disease. The patient had been suffering for several months with undiagnosed abdominal pain. My attending suggested I write a case report. Having a clinical perspective to pair with the disease presentation, I researched potential clinical pitfalls and strategies to help hospitalists hasten diagnosis. By recognizing the earliest signs and key findings of this disease, we can recognize it early and avoid mis-diagnosis and delayed treatment.

As a future physician, my duty is to provide patients with excellent care founded on evidence-based medicine. Clinical curiosity and ability to critically appraise emerging literature are key to improving medical care. In the future, I hope to use critical thinking skills to inform my clinical practice and lead clinical research projects. I have started incorporating review of the medical literature within my weekly routine. Below are my next steps to reach these goals:

SMART Goals:

  • Recognize clinical uncertainty during my future medicine rotations
  • Maintain a list of clinical questions that arise during intern year. Return to this list every few months and highlight the questions I cannot find answers to in the literature. Consider starting a clinical research project.
  • Ask attendings for input on clinical questions to gain perspective and identify potential clinical research questions.
  • Ask my senior residents for tips on how to efficiently search the literature for state of the art literature.
  • Read the Scope and 2 NEJM articles each week to build a habit and stay updated on breakthrough studies.

Health Coaching

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

During my first two years of medical school, we studied the impacts of smoking on every organ system of the body—from silent changes in vital signs to lethal complications. Before medical school, I knew fundamentally that smoking correlated with heart disease and lung cancer. But in our medical school lectures, we discovered widespread, tragic sequelae: patients would lose a limb, bone fractures would fail to heal, a malignant tumor would metastasize, or ischemia would inflict a swift and permanent debilitation. I could not help but think of those I knew whose lives were cut short by smoking addiction and how it might have been better prevented. I recognized the onus to protect my community through preventive care as a future physician. Of course, that would mean I would have to let go of my reluctance to broach the topic. I worried that telling patients to quit smoking would offend them and jeopardize the doctor-patient relationship. Seeking guidance, I found an opportunity to help a patient with smoking addiction through a health coaching assignment.

I met Lisa during the spring of my first year of medical school. My preceptor in family medicine introduced us, and we agreed to meet for three sessions of health coaching. I was instructed to ask about progress and setbacks, practice motivational interviewing, and set achievable, short term goals at each session. At our first meeting, she seemed warm and appreciative. This was her fifth attempt to quit smoking. I sympathized with her—on average it takes people 5 attempts to quit. We explored her past attempts and discussed the challenges in her personal life that made quitting difficult. I became familiar with her favorite hobbies, her goals, and the people most important to her. At the end of our conversation, we settled on a simple goal: to reduce stress by building intentional mindfulness into her schedule. We agreed to revisit her goal in two weeks.

Over the next two weeks, she discovered that making jewelry gave focus to her day and satisfied her desire to create and design. When I congratulated her on her progress though, she paused nervously. She confided that she was nervous to tell her best friend that she had decided to quit smoking. The two spent a lot of time together and asking her not to smoke felt like an imposition that would strain the relationship. I empathized and walked her through how she might start the conversation, but she remained hesitant.

When we met again, she was eager to update me. She admitted that she had smoked with her best friend. However, she lost interest and threw away the cigarette after just one inhalation and remained smoke free thereafter. She had then found the courage to confess to her friends and family about her struggle with smoking and decision to quit, and a burden of guilt lifted off of her shoulders. Happily, she recounted how everyone had surrounded her with support. She reflected on moments of resilience through crisis, concluding that she would draw on her inner strength again now to quit permanently. I complimented her strength and thanked her for sharing. We wished each other the best.

Since this experience, I have reshaped my approach to interviewing patients to better include their goals and priorities within an integrated care plan. When we discuss health behaviors, I don’t dwell on the past. I never make patients feel guilty or at fault. I look for instances of resilience through hardship and point out their strengths. I listen carefully to ascertain their goals and their values. I support their self-efficacy and remind them of their social supports. I found that a patient-centered viewpoint rather than a populations-based perspective is key to uncovering motivating factors in people’s lives. Rather than blaming the patient for his or her predicament, I can encourage the patient to take an active role in their care by valuing their individuality.

I purchased a copy of Rita Charon’s Narrative Medicine during my third year of medical school to improve my interviewing skills with challenging patients. In the opening chapters, she offers a roadmap to elicit human factors in the clinical encounter: “… with narrative’s help, we can grasp our relation with mortality and time, the singular contexts in which illness arises, the central roles of both causality and contingency in health and illness, and the emotional forces that prevent genuine and ethical relation…” Although it takes time and focus to actively listen without interrupting patients, the potential rewards in trust, alliance, and patient-provider satisfaction are well worth the investment. Inevitably, patients operate under human factors which I have to respect in order to be deemed as a trusted health provider.

During my geriatrics rotation, I made a personal goal to talk with each patient about their values and goals of care. I found that by asking my patients what they used to do for a living and who were the most important people in their lives, my assessments and plans were more insightful and patient-centered. Although it took patience to listen without rushing the interview, I found the encounters to be emotionally rewarding. I received positive feedback both from my patients and preceptors.

On my inpatient medicine sub-internship, I had less time to delve into narrative. However, active listening and motivational interviewing were useful for encouraging positive behavioral changes. In the literature, I found that motivational interviewing by clinicians can significantly improve rates of smoking cessation, even in the inpatient setting (Lindsey and Hawley et al). When one of my patients made a decision to quit smoking, I made time in the afternoon for motivational interviewing and goal setting. My attending praised me for allocating my time on service to interacting directly with patients whenever possible.

Although I initially worried that telling patients to quit smoking and adopt healthier behaviors would strain my relationships, my clinical experiences have taught me the opposite. Sincere, patient-centered conversations have the power to significantly impact health behaviors in a positive and respectful way. Moreover, active listening and reflection can be empowering for both patient and provider by building a sense of alliance and self-efficacy. As a medicine resident, I hope to integrate narrative skills in my daily practice. Eventually I hope to teach medical students how to utilize narrative medicine and motivational interviewing to promote patient centered care.

SMART Goals:

  • For two consecutive weeks during intern year, ask each patient of mine what they do for a living and who are the most important people in their lives.
  • During intern year, ask each new patient what their goals are for the encounter. Practice this in the inpatient and outpatient setting for 1 week to build habit and fluidity.

Citations:

Lindson‐Hawley  N, Thompson  TP, Begh  R. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD006936. DOI: 10.1002/14651858.CD006936.pub3. Accessed 27 February 2021.