Author: Mengzhi Wu

Systems-Based Practice

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Access to care is absolutely critical in the overall management of patient. When I first started medical school, I didn’t realize how much of medicine was finding the right medicines that the insurance would cover or that the hospital was willing to offer based on their own agreements. I believe that the team should work together to make sure that the patient still gets the best standard of care despite these financial constraints.

One poignant example early in medical school was during transitions of care from one doctor to another. I encountered a patient that had recently been transferred to an OSU doctor from her former life-long doctor, who used paper charts. The transition was rough due to the system limitations of paper charts being very difficult to read and the patient not knowing what drugs she was supposed to take. By the time, some of her medications were maximized she had learned that OSU was going to drop her insurance and that she wouldn’t be able to come to OSU anymore. The patient felt betrayed. She felt that OSU would be the best place for her care because of the rapport with the new doctor and how close it was to her home.

Attached is a link to my Advanced Competency Capstone that talked about one of the determinants of health: https://docs.google.com/document/d/1m8wHHJxH6SDe4fLrhB-sINK0_mMocxgKTCmuVUztQCg/edit?usp=sharing

The lesson I learned from this is that the institution often directly affects patient care even multiple levels removed. It seemed to me that this transition in contracts may have made financial sense but had a cost in patient and doctor satisfaction. I think this was also the first time I’ve ever seen the institution of the hospital actively changing patient management by forcing the patient to choose another hospital system. I also could feel the loyalty that patients develop with the doctors and that was really inspiring me in the future.  To me, the doctor is the face of the organization to that one patient they care for and I want to represent the organization well in addition to being an advocate for my patient.

I am happy that in the future I will be working for the Air Force after I’m done with my residency. I will be lucky enough to have patients who will all have full access to the hospital and resources without gaps in care due to finances. However, it isn’t perfect. In the military, drugs are often chosen based on price and certain newer drugs may not be covered unless previous ones had been tried first.

During my one military away rotation fourth year, there was a patient whose symptoms were only resolved with the one medication that he was currently on and he had tried multiple others OTC. The one medication was a more expensive drug and could only be prescribed by the military doctors if every other medication up to the cost of that one was tried and failed. The patient was forced to use a drug that had already failed but was about three times cheaper for documentation purposes. I thought this situation was incredibly unfair on the patient as they would be using a sub-optimal drug. This decision was not targeted towards the quality of life metric and focused too much on the cost-effectiveness. In order to try to work around this, the resident and I had to apply for a waiver and then try a few combination of medications to get the effectiveness of the drug the patient was already on.

The system forced a solution that was not optimal for finance reasons but ultimately did have a waiver system that would take some time to fill out and then receive permission for but there was a lot of wasted time and decreased patient outcomes. I had to navigate the system in order to properly do my duty for quality of care. This situation forced me to think that in many cases costs should come secondary to quality of life. During the rest of my fourth year, I worked in rotations for the undeserved to take care of those who are normally left out of the medical system.  In the future, I’d want to work for an organization that has great accessibility for every type of patient so I feel that I am able to do the best for the patient.

 

Professionalism

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The time I spent as a Class Officer in college helped ingrain a lot of lessons in professionalism. A lot of what I know carried into medical school, such as open and honest communication, and trying to understand the other perspectives of coworkers helps to maintain the utmost standards of professionalism. This is essential in working together as a team towards a common goal, also helping maintaining public trust in the medical community.

In medical school, I had a situation where a resident assigned me a task of getting a full consult done for a patient and then to email the information to him. He was very busy when I got done with my task and only communicated in short sentences, barely even glancing my way. I felt uncomfortable with breaking protocol because my note was not being placed as a student note but copied and pasted into the EMR with some edits as necessary. I was early in my third year and really didn’t want to cause any trouble so just listened and emailed it when he said there’s nothing left for you to do so you can go home.

The following day I was told that I should have tried to discuss the note with him because it was poor and missing things. Looking back it seems obvious I should have overcome my initial feelings and just stated how uncomfortable I was to sending healthcare information. This was a professionalism lapse on my part. I remember feeling I was uncomfortable with everything most of the beginning of third year and didn’t know if this one situation was worth speaking up. In hindsight,  I also should have waited to go through the information with him even though I was dismissed. Since this situation I’ve gained more experience in knowing when things felt wrong that I had to speak up for myself.
The evaluation for that rotation stated “he does not understand his role in medicine and lacks professional responsibility in patient care” This was devastating to me because I wanted to be reliable and saw that my actions led to my characterization as irresponsible.

Moving forward, I believe that honest and open communication will allow teamwork to progress most efficiently without suppressing any of the elements of the team that could contribute fully to its successes like offering language such as I am uncomfortable with this situation to effectively communicate better. Throughout the rest of my rotations after this situation, I  have developed more of an instinct on when to speak up when uncomfortable and have done so in multiple points later in medical school.

One of the more positive experiences on what I want to model what professionalism looked like happened during my sub-internship. A doctor had a patient beg for more medications that was on the Beer’s list, the doctor caved and the patient wound up having a negative outcome. The doctor felt bad and took full responsibility for their action. I feel that being a professional is to take responsibility for actions and to take steps to ensure the best care. Sometimes this means standing your ground when you know a course of action is preferable even if it feels uncomfortable. This experience shaped my understanding of how to take responsibility for everything within my scope. I’ve taken responsibility for my failures including being brought to the professionalism committee and I never tried to state that I didn’t do it or anything else. I just want to improve and not make the same mistakes over again.

My evaluations changed from early third year “initially shy and reserved and if you didn’t ask specific questions, you would never know that Mengzhi would have a comment that could be useful. He should to speak up more” to “Valuable member of the group, consistently contributed to the team and brought relevant information that sometimes increased patient management”

Practice-based and Lifelong Learning

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Lifelong learning is a process of understanding your personal strengths and weaknesses so that you can reach your best potential. I’ve been actively trying to improve the process in which I make decisions and to handle setbacks. I’ve never had a real job before and having the professionalism and experience to even know how to begin the process for making decisions requires immense effort on my part. I struggled to deal with my Id, specifically the non-logical part that seems to overwhelm my usual rational self.

My biggest weakness is that I am incredibly hard on myself. This sometimes creates a lot of anxiety, sometimes even panicked paralysis when I don’t think I can do it well enough. This is especially true in things that I care a lot about. For example in Step 1, the night before  the exam I couldn’t sleep no matter how hard I tried. The more I tried to relax the more anxious I became. My performance was very subpar to what I could have achieved. Knowing this, I’ve been addressing my personal mental health a lot by developing healthy lifestyle and trying to maintain great relationships with my family and friends. I have been successful in mostly controlling the anxiety without going to counseling or needing medication. However sometimes, there are situations where I believe I may need professional help.  Another strategy I have been using is by making lists and deadlines of when things absolutely must get done. I recently learned in one of my classes for mental health, the psychologist actually mentioned that unless I was busy to just focus on completing the task to skip the anxiety of deadlines and thinking about all that still needs to be done. I still have a lot to work on my personal mental health and will try to develop strategies with a professional to help me when things just become overwhelming and everything feels like it is falling apart.

One of my strengths is in the willingness to improve. I have gotten feedback from multiple attending physicians that I am very prepared for clinic the following day because I go through the chart the day before. Oftentimes this isn’t perfect because the chart is missing information, or the presenting illness isn’t actually their chief complaint. Overall, I am able to have more meaningful interactions with the patient by having more time to get to know the patient as a person.

I think the process of lifelong learning requires being the best version of myself and to continue to use my strengths and try to minimize my weaknesses. Overall, it seems that an attitude of humbleness and respect will allow for growth in all areas of my life and in turn my future professional skills. This will need to be balanced with living life. Ice cream is one of my favorite ways to recharge.

In addition, I’ve done multiple research avenues during medical school. Early in medical school I had a paper published that was a continuation of research I had done in undergraduate studies. The link is attached: https://www-sciencedirect-com.proxy.lib.ohio-state.edu/science/article/pii/S1742706115001014?via%3Dihub. Essentially the idea of using the structure of a viral nanoparticle and the coating to target cancer at the source. We looked at multiple sizes, shapes, electrical coating charge, different coats to try to best get the results. I think this process helped me think analytically through research and the basis for the reason underlying why certain management is taken and the results that will likely be seen. This will help me communicate better in the future to patients and makes me consider research in the future.

Patient Care

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I learned in the beginning of medical school that there often multiple different plans for each assessment, some more effective than others. I always thought it was logical to want the most effective plan for my patients. However, during medical school and in practice I had to consider patient preferences, insurance, socioeconomic factors in order to make sure the patient can and is willing to adhere to the plan.

An example of this was in early medical school and the patient refused to get a flu vaccine. Initially my thought was that there was no chance to get her to change her mind, especially initial firm resistance. Instead of giving up on her, I found out the reasons why the patient didn’t want the vaccine. Her reasons were because she already felt sick, didn’t think she would get the flu and that the shot will be painful. I could work on those reasons. So I found out things that the patient might care about to overcome that resistance which happened to be making sure her son didn’t get sick and that it wouldn’t add much discomfort to her overall visit. It turned out she already needed a vaccine during the visit and the second flu vaccine likely would lower the risk for her son and wouldn’t add much overall pain. All these together led her to finally accept getting the flu vaccine and promising in the future to try to get one again.

Getting a patient to take care of themselves is very important because we in the medical field only see a short snapshot of the patient’s health and wellness. If we as physicians are able to motivate patients to self-care then it becomes much easier to manage their health and to follow the most effective plan possible. Looking on the situation further it was crucial to understand the patient perspective in order to even be on the same page for care. If I tried to force things, the patient might have become defensive and not gotten the flu shot. During the rest of medical school I used some of these insights to make sure everyone working towards the same goal in maximizing the patients health outcomes.

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An important example of this later in my fourth year rotation in inpatient medicine. I noticed early in the morning without verifying the information that the new patient transferred had an allergy from the outside records. The patient was about to get the medication he was allergic to. I was initially confused on why the drug was ordered but I knew I had to stop administration of the drug no matter what. I got a lot of pushback from the senior and attending because I was told that the pharmacist and the admitting doctor would have marked it down. I used language I had learned in my surgical rotation during the time out process to halt the drug. I also volunteered to do some research immediately to figure out what happened and to get back to the team. Later, after finding and proving that the patient did have an allergy everybody was glad that we worked well as a team.

In one of the studies conducted at two teaching hospitals found that almost two percent of admissions had a preventable adverse drug event which increased hospital costs of $4,700 per admission. Bates, David W.; Spell, Nathan; Cullen, David J., et al. The Costs of Adverse Drug Events in Hospitalized Patients. JAMA . 277:307–311,1997.

In turns out that by using terminology I learned during surgery for timeout situations helped immensely with the situation and likely saved the patient’s life. The situation also reinforced for me that while that there is a hierarchy in medicine, medicine is team based and everyone’s knowledge and expertise should be valued. In the future I will not only speak up when I feel that I need to but also take other’s suggestions when I may not know all the information.

Medical Knowledge and Skills

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The medical school class was given a VARK questionaire in the beginning. The VARK questionnaire suggests that I am a multimodal learner with scores of ten on everything except for audio. I have a large tendency towards the visual compared to audio. This seems very in line with my learning preferences because I liked reading the information from the slides much more than listening to lectures. I used my ability during an Emergency Medicine Rotation fourth year and got a grade of letters and a letter of recommendation. I took the feedback from the VARK and various other rotations that suggested I loved interacting with patient and staff and learning whenever possible.

Eval: “Mengzhi performed at an above expected level clinically for a senior medical student while at Memorial Hospital in Marysville, OH. Mengzhi displayed a good knowledge base and he was consistently able to generate complete and appropriate differential diagnoses and treatment plans. Mengzhi was able to gather relevant information in a timely fashion and then effectively communicate that information to the attending staff in a clear and concise manner. He managed his patients well with minimal faculty guidance. Mengzhi demonstrated appropriate clinical decision-making skills and he demonstrated very good basic procedural skills. He was very enthusiastic and eager to learn and apply new information. Attendings noted that Mengzhi was an interactive learner. He sought out opportunities to become involved in patient care and how he could help the team. He provided good presentations and was able to formulate reasonable differential diagnoses. Mengzhi was evaluated through direct observation while performing a medical history. He acted in a professional manner during the month and was well-liked by both patients and staff.”

The thing that impressed the attending the most was that I had a continuous drive to learn on my own that I was constantly reviewing the literature in between patients. This is how I learn due to repetition. The IPAD and my phone were invaluable resources because I was able to create study charts for the algorithums that ED physicians used. I think this one of the parts that impressed the attending the most was that I questioned why some of the algorithms were used this way and the cost-effectiveness of them. For example in the case of an Emergency situation with DVT/PE what was the likelihood they actually have the DVT and if we ruled out with Clinical Gestault and negative D-dimer and there being a 1-2% chance they have a PE but likely not clinical significant at this exact moment could that change the calculus in discharging the patient. There’s just so much information that is still unknown and it’s so interesting to me to try to find them as I tried on my laptop. The attendings also told the risk of treating someone with thrombolytics could be dangerous if the benefits are unlikely.. The baseline medical knowledge creates a situation that reinforces further research into what is the underlying evidence behind each of these decisions we make as physicians and are of utmost importance to continuing update that information on UpToDate.

In my experience, teaching hospitals like OSU have some of the best care because in each service there is an immense diversity in thought and knowledge levels that help maintain the greatest standards that comes with a combination of medical students, residents, nurses, pharmacists, attending physicians, and other staff all banding together for the patient. I found it really rewarding that I as a first year learned so much clinical information and then later in third and fourth year found that information useful and then consequently taught the first years. In addition, oftentimes I’ve had to give short lectures on a certain disease to residents, fellows, attendings, and other medical students that helped me to truly understand a disease and still retain it to this day.  For example. In William’s syndrome you should not give anesthesia because there is a risk of sudden cardiac death as well as superaortic stenosis, two bits of information that I will remember for a long time because I had to go find the information, understand the information and then present it to everyone else. I also presented on preeclampsia in pregnancy and remember the topic very well to this day. I think this plays well in the lifelong learning because medical knowledge for me means to it is meant to be built and continually reinforced throughout a lifetime.

Interpersonal Communication

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One of the things I’ve learned during medical school is to maintain complete composure at all times especially in difficult and uncomfortable situations and that conveying empathy from the beginning helps establish rapport. Before medical school, I had more difficulty maintaining composure in highly uncomfortable situations. I also learned that telling the patient that I care and I’m doing the best I can under the circumstances helps diffuse a lot of tension.

One of the examples in the first year of medical school that best exemplifies my slow change is that the I had an incredibly uncomfortable initial patient encounter where the patient was drug seeking and asked for opiates immediately and was unwilling to tell me why they needed the pain medication and how it helped. I immediately got flustered and frustrated because I simply did not know how to proceed from there. I tried to steer the conversation to medications other than opiates but it seems that wasn’t enough and then the patient started to yell at me that I didn’t care about her pain and discomfort. Having some education on the subject I tried to state that possibly a provider specializing in the pain could help more. This just made things worse because they thought I was trying to escape responsibility. The encounter did not end well and I had to get my preceptor to help.

After the interview, my preceptor explained that the tense feelings during the interview and the high energy situation should serve as important lessons to keep your cool and to focus on the situation and to maintain composure no matter what I learned to just explain things truthfully that I am trying to help as best as I can within the constraints of the law. Looking back, it may have appeared that I didn’t have enough empathy towards the patient and that they felt I wasn’t listening and addressing their needs. I was able to continue to work on composure and using language such as “I hear you, I care about what you’re saying, and how can I best help” to make sure that I am communicating empathy.

An emotional self-awareness lesson I filled out for myself and had other people fill out for me early in medical school showed that emotional intelligence was what I needed to work on the most in medical school.

Emotional Self-Awareness- 3

Assertiveness- 3
Self Regard-5
Self Actualization- 3
Independence- 5
Empathy-3
Interpersonal Relationships-4
Social Responsibility-4
Problem Solving- 4
Reality Testing- 5
Flexibility- 5
Stress Tolerance-4
Impulse Control- 5
Happiness- 4
Optimism-4

I continued to work on these skills throughout medical school and got to practice them even more my fourth year. In each of my interviews, whenever a situation escalates, using language that focuses that I’m doing the best I can based on my judgement to take care of the patient seems to help. An example of this is a clinic visit in fourth year at an acute clinic. The patient stated that he was told he could continue to come to this clinic and get opiates even though he wasn’t an established patient. I listened and then I told him I hear him and then tried to explain some of the legal reasons and standard of practice limits. I told him that I’m truly sorry that we can’t give you what you want but that here are some alternatives that we can offer. I was able to keep the situation from escalating as in the example in my first year of medical school by reaching a compromise plan together. This example showed that the work I put into empathy and controlling my own emotions during charged visits helps to reach the best possible course of action. Going into the future, I know that I will be more and more challenged during residency and that I need to keep in mind that the patients are only there because they have a problem and need help. Communication will always be the key feature on making sure the patient understands that everything the physician is doing is bound by best interest of the patients.