Systems-Based Practice

Teamwork is critical in the practice of medicine, nowhere more than in the ICU. I did my sub-internship in the neurocritical care unit (NCCU) at OSU. I had several patient experiences that touched me but the memories that I carry with me are mostly from my teammates. In the ICU more than other places in the hospital, nurses, respiratory therapists, residents, advanced practice nurses, and attendings work closely together to save lives. I was struck by the efficiency of communication in the unit. A standard method to round, to run a code, and to handoff is key to the success of the systems-based practice in the ICU.


Rounding in the NCCU is handled differently than in other parts of the hospital. The nursing staff leads, reading off data and giving report of overnight events system-by-system of the body. The residents, medical students, and fellows can interject with information as needed, but the attending hears the information from the primary source, the nurse who has been taking care of the patient. The nursing staff interacts the most with the patients, they manage the drips and the lines, they are the first line. This method of rounding leads to very effective patient care. There is no debate about what the patient has been getting or what their status is because the information comes direct. The system is designed for maximum efficiency in communication and it leads to excellent medical practice.


I saw two codes run while I was in the unit and both were run very well. An APP ran both codes that I witnessed, in total command of the team she was running. Codes are run with a standard practice to give the patient the best chance. The pharmacist handles the drugs, the nursing staff handles compressions and note taking, the PCAs run and get supplies, and every member of the team supports one another. I appreciated the rhythm that the codes had, despite the differences in the patients, they were both run the same way. When I am an intern, and I have to run the code, I will take comfort in that every code should have similar features and that each member of the team should support one another.


The final system in place in the ICU that I observed as being critically important was the handoff system. Due to duty hour restrictions every member of the team needs to handoff to night shift. In the ICU where every patient is sick, it is doubly important for the day team to have a plan in place and to communicate it effectively to their colleagues. This is an activity that sub-I’s are encouraged and required to participate in. At first, I had no idea which information was important and which was not. But throughout the rotation with instruction from my residents and from experience, I learned what was important for the night team to know. My evaluations reflected that growth as it was noted that I communicated effectively. I will continue to work on this skill and others, such as documentation, when I become an intern next year.


Patient Care

Being a medical student affords plenty of time for patient care. We get to spend the most time with patients and their families and we often learn things that physicians don’t have the time to discover. I love this as patient care is my favorite part about medicine. A few patients stand out from the past 4 years and I would like to share some of the stories.


My very first patient in first year in my longitudinal practice was a middle-aged female school principal. She had been referred to OSU cardiology because of syncopal episodes that she was having. I nervously asked her a couple of questions, I had no idea what was going on, but she was kind and let me take my time. I learned that she had three children and that the only reason she agreed to come to the doctor was because her husband made her. She didn’t like doctors because her mother had died in a hospital a few years prior and the experience left her scarred. I went out and presented the patient to my attending the best I could and we went in together to speak with her. I still remember the scared look on her face, but I think she felt a little better once I entered the room. I believe that making patients feel at ease with your presence is an important practice in the art of medicine. It is something I strive for now and plan to continue in my residency.


The decision to go into neurology was helped by a patient in my second year. I was on a medicine rotation and we had a patient with ALS who had come in with pneumonia. She was in an advanced stage of the disease with little ability to move volitionally or swallow. She was very ill but we managed to get her on the right antibiotics and she started to improve. As she got better she began to complain of severe pain in her back. We examined her but couldn’t find any obvious signs so we obtained an xray and again nothing. It was challenging though because her neurologic exam was so abnormal at baseline. I went to see her every day on my own because I had a feeling that we were missing something. As I spoke to her more, I learned that she had a history of abscess formation in her youth. I advocated to my resident to get more advanced imaging of her back and there it was, a 2 cm abscess working its way into her spine. I was so relieved to finally have an explanation for her pain and the patient was too. We contacted IR for treatment and everyone felt better. My evaluations that rotation noted my improved patient care and I learned a valuable lesson. A patient’s history is just as important as their symptoms. Time spent with patients is more information for diagnosis and treatment. I will remember that when I have challenging patients in residency.

The final story I would like to share is about a patient I saw very recently. He came in as an emergency to the ICU. He had been having a dental procedure when he went into respiratory distress. It became evident that he was having a neuromuscular crisis, and my team was consulted. I saw him first, and had no idea what was going on. This previously healthy young man was suddenly on a ventilator in the ICU from a simple tooth extraction procedure. As I examined him I noticed some odd findings, things I didn’t have the words for but knew were abnormal. I went and presented to my attending who seemed confused as well. As he was examining the patient, other abnormalities were discovered on exam. My attending diagnosed the patient with myotonic dystrophy, previously unknown to the patient and his family. We ordered the appropriate diagnostic tests, and I learned a very important lesson. The history and physical exam are the most critical parts of patient care. Turns out, neuromuscular crises triggered by lidocaine in patients with myotonic dystrophy had never been described before. My resident and I decided to join forces with the dentist who performed the procedure to write up the case report so others could be aware. Below is the portion of the case report that I wrote, it should be published within the next year. Each patient has something to teach us, and through experience we get better at taking care of them.



Practice-Based & Lifelong Learning

Practice-Based & Lifelong Learning means identifying one’s own strengths and weaknesses in a never-ending mission to practice medicine to the highest standard. I struggled here and there throughout medical school but my only failure came in third year. I had been studying intently for the Family medicine and Pediatrics shelfs. I decided to prepare for the OSCE the day before, believing that I would pass based on past experiences. I was wrong; the OSCE went so poorly that at one point I forgot to look in a patient’s throat who had come in with a complaint of a sore throat. I was deeply upset with myself afterwards, knowing that I did not perform up to my potential.

I got the failing grade a few weeks later, and it was not a surprise. I remediated with an assignment where I had to watch the video of myself, self-critique, and then come up with improvements and the differential for each standardized patient. By systematically, although painfully, evaluating myself it allowed me to be brutally honest with myself about improvements I needed to make.


First was that I needed more practice with my history taking for basic complaints. I could easily decipher the type of headache or chest pain that a patient was having but had neglected to practice for other common complaints such as sleep problems, sore throat, and back pain. I learned that lack of preparation leads me to be brief, I didn’t know which questions to ask and so missed possible diagnoses.


Second, I learned that I need to be systematic about my physical exam. This is an extremely important lesson for a future neurologist to learn. My physical exam became much more standardized after that failed OSCE. By doing the same thing for each patient, you don’t miss critical findings that can lead to a diagnosis.


The third and final lesson that I learned was that students always get a second chance so take advantage of that while I can. As a resident I will be both a doctor and a learner. While I am still in training, it is ok to make mistakes and to learn from those mistakes because that is how we grow. Moving forward with the lessons I’ve learned will make me a better doctor. I never performed so poorly on an OSCE again and passed Step 2 CS with flying colors.




Interpersonal Communications

I pride myself on strong interpersonal communication. There were numerous instances in which I was able to work on my communication throughout medical school.

In the first year of medical school I joined the Ultrasound Student Interest Group (USIG) to learn more about ultrasound and have the opportunity to teach other students. The organization is a large one, with many moving parts and different objectives. I was appointed the Beginner’s Ultrasound (BUS) coordinator early in my second year. My goal was to teach 100 M1s the very basics of ultrasound. It was challenging to communicate with 100 different people who each had a different baseline knowledge and who were scattered about during our scanning sessions. I had enlisted the help of several M2-M4s to teach these course but they had never had formal instruction either. I devised a way to communicate with every student and student teacher to ensure a standard level of instruction across the board. The BUS learning objectives were my biggest contribution to USIG. They worked to make sure that everyone was on the same page and learned the same things. I believe that written communication is a great way to ensure material is disseminated. This is a lesson that I will take with me into residency and remember if I am ever attempting to get a project off the ground.

BUS Learning Objectives


We are evaluated on all competencies throughout medical school and my best scores have all come from interpersonal communication. Initially, I had a lot to learn. I had never spoken to a patient before and tried to communicate a diagnosis. I had never presented a patient to a team before, attempting to provide a framework for diagnosis and treatment. But I worked on it, received constructive feedback and got better. My evaluations improved and I used that as motivation to continue working to improve. I plan to work on my communication skills as I transition into my new role as intern, as I will be both student and teacher.


Historically, the medical field has not been the easiest profession for women, particularly mothers, to be a part of. The demands of our field require long hours in the hospital or in clinic, away from family. It necessitates a certain level of dedication and focus which can be challenging for a new mother to give when she has the same obligation to her child. You’re tired from your surgical rotation and you’re tired from being up with the baby. Kids are noisy and messy and hard to deal with. These were the things I heard and considered and decided to face when becoming a mother during my third year of medical school. While I am extremely fortunate to have had the support from my family and the administration of OSUCOM, I did face many challenges after my son arrived and each one taught me something about our chosen profession.


Lesson #1: Communication is key.

The process of having a baby in medical school is a complicated one, filled with communication to administration, to coordinators, and to attendings in order to sort out a schedule that works. I learned quickly that the key is to communicate before the issue arrises so as not to surprise anyone and give them a chance to react appropriately. I learned this on my first rotation back after maternity leave, on an OBGYN service. I was in surgery and it was lasting longer than expected. I desperately needed to go pump but felt rather awkward to bring it up in the middle of the complicated procedure. When I finally got the courage to speak up, the attending looked rather dumbfounded as to what to say. Luckily my resident knew me and knew what I was talking about and stepped in to dismiss me. Afterward, she told me to just give the attending a heads up before the surgery starts the next time. And it was the best advice that I got for that ring. I never had that issue again, all of my attendings dismissed me to go pump without a problem. Preemptive communication is an important skill in navigating the challenges that a career in medicine brings.  I will remember that as I begin my residency.


Lesson #2: Expect the unexpected.

I had worked for months to plan out what my maternity leave would look like, how I would make up all of the missed time, and when everything would Happen. Well the best-laid plans of mice and men often go awry, and I went into labor 8 weeks too early for all of my careful planning. I was placed on bed rest for 5 weeks and spent them emailing every coordinator and attending I could, rearranging my schedule. Luckily, I had people in my corner and Dr. Hoyle and Dr. Lynn helped get my schedule where it needed to be so I could match on time. Once I returned, I made it my mission to maintain my professionalism despite the turmoil that had been the end of my pregnancy. I received multiple positive evaluations about my professionalism from surgical rotations.


Lesson #3: People are kind at heart.

Part of professionalism is creating a positive, constructive, and safe work environment. Whether it was doctor’s appointments, physical limitations caused by my pregnancy, or the adjustment in my schedule afterward, I required a lot of understanding and flexibility from my attendings. I received such great support from the majority of my attendings that I was able to balance my medical needs and my professional goals very well. One attending on my gynecology rotation was even kind enough to send me a list of all of the lactation rooms on campus, so that I could more easily pump when I needed to. We forget sometimes that doctors are people first but I experienced it firsthand. The people I worked with are truly kind at heart and supported me through my difficult time. I think this is encouraging for the future of medicine for women, that there is support out there for us as we navigate the difficulties of becoming mothers while also being professionals. I look forward to residency when hopefully I can support other women the same way that I was supported.

lactation rooms

Medical Knowledge and Skills

As I reflect on the amount that I have learned over the past 4 years, it is incredible to me how far that I have come. I remember the very first anatomy lab. Half the class was milling about, excited to be in scrubs for the first time and nervous about seeing the body that we would be assigned. It felt like becoming a doctor was closer than ever, we were going to be expected to dissect and identify anatomical landmarks independently and based on what we had learned in the class. No one ever prepared for a lab so well after that first one. We all wanted to be the person who knew the vessels that we would come across, the person to make the cut that would lead to discovering something interesting. I was just as eager as the rest. While initially a little disturbing to think of the body as a person, I was grateful for his donation so that I could learn from him. The first lab went well and I learned about the superficial structures as we dissected the skin away.


The next lab did not go quite as well. We were tasked with identifying and dissecting out all of the different muscle groups in the upper body. I had not prepared quite as well for this lab and we all struggled to decide which was the flexor digitorum superficialis and which was the flexor carpi ulnaris. Our TAs walked around and assisted as they could, but it was the team around me that I really relied on. The muscle groups I have forgotten but the lesson I remember to this day is that preparation is the basis of good education. There needs to be a baseline of knowledge with which to build from, something that has served me well later in medical school. The grades that I received on my first anatomy final reflected the learning that I still needed to do.


Later in the year, there was a lab that I would never forget. We were entering the abdomen for the first time and it was mine turn to be dissecting while my teammates helped direct me. I came upon a structure that I couldn’t identify in the superficial right lower quadrant, something that should not have been there. We examine and dissected, looked at the book and asked other groups but no one could figure it out. We called over our TA who started when she saw it and exclaimed, “It’s a kidney!”. It turns out that our patient had had a kidney transplant sometime in his life and it was not listed in the information we had received about him. It was one of the most exciting discoveries made in anatomy lab that year. That day I learned that transplanted kidneys are not place into the retroperitoneum where the kidneys sit but simply hooked to the iliac vessels in the pelvis and left to do their work. Two years later, during my anesthesiology clerkship I was fortunate enough to be able to observe a 4 person domino kidney transplant. I kept flashing back to my discovery in anatomy lab as the surgeons placed the kidney and I learned about urine monitoring and intraoperative anti-rejection methods. The knowledge continued to build as I got to see the procedure firsthand.


On the last day of anatomy lab in 2nd year, I felt very sad. While anatomy was never my strongest subject, I mourned the loss of hands on learning that I got while in lab. I did not care for the hours of sitting and reading and greatly preferred being engaged and on my feet. My anatomy group parted with sad goodbyes and promises to say hello whenever we ran into each other in the hospital while on our clerkships. A few months later while on pediatrics at Nationwide I saw one colleague and we chatted over coffee. He said to me, “It’s funny, I thought I’d miss the lab more than I do. Turns out the rest of medicine will be learning on your feet”. I laughed and agreed, the actual practice of medicine was much more like being in anatomy lab than reading books. We were constantly on our feet, consulting teammates, learning as we went from hands on experience. I find that I love this style of learning and that it fits me so much better than hours of reading and listening to lectures. I am looking forward to residency where the exams we care about are physical exams and the reading we do is all to learn practical and relevant medical knowledge, keeping up to date on the latest studies. I have learned that my medical knowledge grows so much more when I have a real example in front of me, a lesson I’ve taken away from my time in anatomy lab.


First day in scrubs

Me on my first day of anatomy lab