Author: Zhaoying Xian

Skills Beyond Medical Knowledge

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

When I decided that I wanted to become a doctor, I was often cautioned to expect a long and hard road ahead of me. I think everyone knows that a career in medicine is difficult, but I doubt that one truly can truly how it is difficult without experiencing it first-hand. I was frequently warned about the demanding workload and complex material that I would need to master to survive medical school. Not mentioned were the non-medical skills that complemented medical knowledge to provide optimal medical care.

As part of our pre-clinical curriculum, we attended weekly small groups called Longitudinal Group, otherwise known as LG. Each LG consisted of approximately 15 students paired with a facilitator who was an attending physician. LG focused on skills and traits that allow us to be more effective physicians beyond medical knowledge. These skills include how to take a patient history, the physical exam, how to collaborate with other healthcare professionals, and how to converse with patients. My classmates and I worked together and practiced on each other.

We were then tested on our ability to combine medical knowledge with communication and professionalism through Objective Structured Clinical Examinations (OSCEs). Each OSCE consisted of 3-4 clinical scenarios. Prior to entering the room for each case, we are given the patient’s chief complaint and vital signs. We are expected to conduct a full patient interview, obtain the relevant history, and perform a physical exam.

At first, I felt incredibly awkward asking questions about their bowel habits or sexual history. I wasn’t sure how to proceed when a standoffish standardized patient gave one-word answers to my questions and stared me down as he waited for me to fix his problem. Fortunately, with practice, I became comfortable with asking any question necessary to care for my patient. My standardized patients praised me on my professionalism and empathy, and I received similar feedback as I advanced into my clinical clerkships.

During my Sub-I rotation in general cardiology, my team took care of a patient who came in due to exacerbation of heart failure but quickly decompensated and ultimately required a dopamine drip to maintain his heart function. All attempts to wean the dopamine failed. The patient’s fiancée and children were understandably upset and confused. Their understanding at the time of admission was that he would be discharged after a few days of diuresis and medication optimization. How did everything go so wrong so quickly?

One evening, when I was working the night shift with a resident, the patient’s nurse called and informed us that the patient’s family wanted to speak with someone regarding his prognosis. Since I had worked with this patient extensively while serving on the day shift, I asked my resident for the opportunity to lead the conversation, and he agreed.

Medicine is a career many of us pursue because we want to provide care to patients that ultimately betters their lives. Rarely do we consider that there will be times we fail at this goal. No amount of practice with fellow students or standardized patients could have prepared me to speak with a woman about how her unconscious fiancé was barely being kept alive by a temporizing medication that would soon lose its effect within the next few days. I was worried that she might have questions about his medical management that I would not know how to answer, or that she might be offended a lowly medical student was being sent in to speak with her. This was ultimately not the case at all.

The patient’s fiancé and children’s questions were relatively straightforward (“what is currently being done for him,” “what can we expect over the next few days,” “is there anything that we need to do,”), and I was able to answer most of them with the help of my resident who supervised. Most of the time was actually spent discussing their expectations and feelings throughout the entire process. They didn’t need an expert in cardiovascular medicine to give a lecture on the background and treatment of congestive heart failure. They wanted someone to talk to and listen to their concerns and emotions through an incredibly difficult time.

We as (soon-to-be) physicians look forward to the times we can give our patients good news about their disease. No one enjoys telling a patient or their family that the patient is dying, but it is a task and skill that we must master for the sake of our patients. Medicine is not simply about preventing death, but also about maximizing life. A cancer patient with a life expectancy of 3 months still has those 3 months to live, and it is our duty as physicians to help these patients understand their goals of life and care and how to best achieve them. I will think of him as I continue on in my medical training, and I will never forget how honored I felt that my patient and his family allowed and trusted me to be a part of his care.

 

From Ultrasound Enthusiast to Radiologist

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Systems-Based Practice CEO 5.4: Identify and utilize professional role models as a means of growth and accept the responsibility of acting as a role model and teaching and training others.

My first course in radiology occurred many years before I became a medical student, when I was a young toddler. My grandfather, a cardiologist and medical school professor, often brought me with him to the hospital in which he lectured. As one of the first physicians to use echocardiography in China, many of his talks revolved around that very subject. At that age, I was fascinated by how one could use technology to create real-time images of what was happening inside a patient’s body, thus sparking my interest in radiographic imaging and medicine.

Following matriculation into medical school, I joined the College’s Ultrasound Student Interest Group and participated in its extracurricular offerings, namely the Trained Simulated Ultrasound Patient (TSUP) program and the Intermediate Ultrasound course. Through TSUP, I served as an ultrasound anatomical model for ultrasound practice scanning sessions, medical school imaging sessions, and ultrasound courses offered by the Ultrasound Student Interest Group including Intermediate Ultrasound. Under the guidance of a proctor, my fellow classmates practiced various scanning techniques on me. During these sessions, my peers and I collaborated to learn how to perform these tests and interpret the images we produced.

Intermediate Ultrasound is an extracurricular course that is designed to help students gain proficiency in core Ultrasound scans, including Cardiac, Abdominal, Fetal and Pelvic, Procedural, and Critical Care. We attended evening didactics during which we learned about the scan (indications, acquisition, interpretation, and medical management) and practiced scanning. There were also dedicated scanning sessions students could sign up for additional practice. For topics such as Fetal and Pelvic or Procedural, we performed scans on plastic models. For the remainder, we practiced scanning on TSUP models. I sometimes volunteered to serve as a TSUP model during our didactics and thus had the opportunity to scan myself. As part of the course requirement, we saved images from our didactic or scanning sessions. We also took an exam at the end to assess what we had learned.

  

Images of my scans from the Fetal and Pelvic Ultrasound Didactic Session 

Intermediate Ultrasound Certificate

The opportunity to serve as an ultrasound model and to learn how to perform ultrasound scans so early in my medical school career has greatly impacted my medical training and career. Firstly, ultrasound is an immensely useful skill that has applications across all fields of medicine, including Emergency, Trauma, Critical Care, Obstetrics/Gynecology, Surgery, and Cardiology just to name a few. Secondly, it is a very fast and safe scan that can provide life-saving or critical information for medical management. However, with any other skill, becoming skilled in ultrasound takes practice. By starting during my pre-clinical years in medical school, I will be much more experienced by the time I am asked to do these scans as an intern or resident.

Through ultrasound, I have seen the diagnostic and therapeutic value of radiographic imaging. We can use ultrasound to help diagnose an ectopic pregnancy, screen for an abdominal aorta aneurysm, insert central lines, or administer medications. Other imaging techniques such as plain radiographs, computed tomography (CT), or magnetic resonance imaging (MRI) can also be applied for similar purposes. A child with a fractured radius and ulna will need a forearm radiograph to diagnose the fracture, radiographs during the reduction to confirm proper placement of the bones, and follow up radiographs to assess healing. I am amazed by how much information we can obtain noninvasively through radiographic imaging.

Ultrasound has augmented my learning throughout medical school. Although I was learning anatomy through cadaveric dissections as part of the medical school curriculum, it was a different experience to see pictures of these same organs moving and functioning inside a living human. This connection helped me realize that, through imaging, I had the potential to detect abnormal pathology in time to alter the course of disease and improve the lives of patients. As such, I have chosen radiology as my medical specialty, and I am so excited to begin my training come July 2018.

Connecting to My Culture

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Interpersonal Communication CEO 4.2: Understand how human diversity may influence or interfere with exchange of information.

As a Chinese-born immigrant who also grew up in a predominantly Asian community, I often take pride in the fact that I retained my fluency in my native language of Mandarin. I’ve always considered my Chinese heritage to be an integral part of myself, and I aspire to incorporate my bilingualism into my practice of medicine. At the Ohio State University College of Medicine, I am very fortunate to have been afforded the opportunity to use my skills throughout my years of training as a medical student.

Beginning in my first year of medical school, I volunteered at the Asian Free Clinic (AFC), which has a significant population of Mandarin-only speaking patients. During my many experiences as a volunteer at the clinic, I’ve had multiple opportunities to speak with patients strictly in Mandarin, translate for physicians or other students, and practice my medical Mandarin. I found it incredibly rewarding to be able to better provide health care to patients simply because I possess such a skill set, and each patient interaction, be it with someone who spoke English, Mandarin, or a language I did not know, only reaffirmed my decision to pursue a career in medicine.

My most memorable encounter at AFC was with a new patient who, albeit very friendly, came with a laundry list of medical problems including poorly-controlled cardiovascular disease (largely due to non-compliance to medication that I suspect was caused by language barriers), potential ophthalmic disease, and long-standing untreated malignancy. Simply performing the initial patient interview took almost 45 minutes, and I often had to stop and google medical terms because many of his conditions were ones that I had not learned in the curriculum yet, much less recognized in Mandarin. I felt a bit embarrassed that I kept having to stop and search online or ask the patient to re-explain himself, and was worried that he would be annoyed at my inexperience, but he was incredibly kind and understanding. Rather, he was simply relieved that he had someone with whom he could communicate comfortably and to whom he could express his concerns. As we slowly worked through all his conditions, he would also ask me about myself and my motivations and goals for becoming a doctor, which helped remind me that any discomfort I may feel is invariably inconsequential if I could provide effective care to my patient.

At the end of the visit, he asked for my surname. When I stated that it was ‘冼’ (Xian), he responded with ‘谢谢，冼大夫’ (Thank you, Dr. Xian). Even as a pre-clinical medical student, I made such a profound impact on someone’s life that he already considered me to be a physician for him. His words motivated me to continue improving my medical Mandarin, which led to purchase a Mandarin-English medical dictionary that I could study and reference.

Two years later, during the middle of my Obstetrics and Gynecology clerkship, I found myself using my improved medical Mandarin skills. I was at the end of a 2-week Labor and Delivery rotation, and one morning, my resident asked if I could speak Mandarin and if I would be willing to converse in Mandarin with a patient. Last night, after I’d gone home for the day, a patient arrived already in labor. Both she and her husband understood only minimal English and primarily spoke Mandarin. Although she successfully delivered her baby overnight (with help from Interpretive Services who translated for the night resident and attending), the delivery was complicated by a shoulder dystocia resulting in a fractured humerus in the baby and an umbilical cord avulsion. Moreover, the language barrier also resulted in delays in care.

My bilingual capacity enabled me to help two patients that day: the mother and her child. The mother understood that her baby had a broken bone, but she had many questions about the implications of that injury on her child’s health outcomes. How severe was the break? What should they do to care for the fracture? Would there be any lasting neurologic damage? I briefly reviewed my medical Mandarin before entering the room with my resident, and was able to serve as interpreter without needing to consult any online resources. I translated these questions for my resident into English, and the answers for my patient into Mandarin.

The mother also required a transfusion due to significant intrapartum blood loss and avulsion of the umbilical cord. I explained the procedure to her, helped translate during the informed consent, and monitored her for any adverse transfusion reactions. When she reported feeling discomfort at her IV site, I worked with my patient’s nurse to readjust the transfusion rate until my patient could tolerate the transfusion.

I spent most of my day with this patient. In doing so, I provided a significant and crucial service for her. My patient told me that she felt very reassured that she was speaking to a medical provider who understood her language and could communicate directly with her. As such, she felt comfortable asking me all her questions and relying on me to translate when speaking with her doctors. Additionally, the rest of my team also noticed the effort that I put into caring for this patient, and the results reflected in my evaluations.

At the end of the ring, I received a Letter of Commendation for my Obstetrics and Gynecology rotation, which was the highest score I’d received for a clerkship. I was very happy to have performed well on my rotations, but I was even more proud that I had successfully taken a skill from my earlier years of medical training and developed it such that I could apply it as a practicing physician-in-training. To my patients, I hope to be both Dr. Xian and 冼大夫.

Health in the Community

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Patient Care CEO 1.4: Understand the role of disease prevention and health promotion in relation to individual patients and / or populations and utilize these principles in clinical encounters.

Healthy living is not strictly limited to disease prevention and treatment. Factors such as diet, activity level, stress level, and sleep also contribute to our health. Although the last few decades have yielded much knowledge about how our lifestyle choices and behaviors influence our health, the overall health trends of our country suggest that this information has not reached a significant portion of our population. For example, the rate of obesity is steadily increasing, and more people are being diagnosed with diabetes mellitus or cardiovascular disease at younger ages. Almost 20% of children today are considered obese, significantly increased from 4% in the 1970’s. These children are subsequently more likely to remain or become more obese as adults. Many cases are attributable to poor diet and lack of physical activity, but if we can intervene and find a way to modify their behaviors early on, we may be able to improve their health outcomes.

As part of our medical school curriculum, students at the Ohio State University College of Medicine participate in Community Health Education projects aimed at improving health literacy and education throughout the community. My group was involved in a project with a youth summer camp at the Central Community House in Columbus, Ohio. Criteria for admission into the summer camp include coming from an underserved background, a population that has a higher proportion of obesity compared to individuals of higher socioeconomic status. Our goals were to assess the children’s knowledge of the benefits of healthy eating and physical activity, evaluate their current exercise and eating behaviors, and provide education regarding a healthy diet and exercise.

Our plan was to introduce a weekly class on nutrition and exercise for 8 weeks of the summer program. During the first class, we administered a quiz to see what our students knew, and an exercise survey to see how much physical activity the children did.

Community Health Project Quiz, Survey, and Sample Agenda

For our subsequent classes, we would choose a theme to focus on for that day. One class looked at different types of aerobic exercise; another taught different strengthening and flexibility exercises; a third was dedicated to the different categories of food and examples of healthy and tasty snacks. At our last class, we designed a relay race that reviewed all the different types of exercises from our course and administered the same quiz and exercise survey from before. We wanted to reinforce what we had taught over the last few weeks and see if the children’s knowledge had improved or if they increased their physical activity after going through our course.

The results of our quiz indicated a statistically insignificant increase in the scores, and no significant change in the level of physical activity.

A few months after the completion of our project, we gave a poster presentation of our work at the annual Community Health Education Poster Day.

Community Health Education Poster

Working with these children at the Central Community Health gave me firsthand experience with the deficiencies in health knowledge in the community, especially among the underserved. As a child, I learned about the importance of diet and exercise during my elementary school classes. We even had dedicated classes on those subjects, and I felt that I had a good understanding of healthy behaviors from that young age. These kids did not have the same opportunities. Although the results of our assessments did not suggest a statistically significant increase in health knowledge or physical activity, I believe that the two months we spent with these children nonetheless provided them with valuable education and life lessons. After sampling tasty healthy snacks in our class, the children may go home and ask their parents to buy those foods; after learning new fun individual and group exercises and games, they may want to teach those to their friends and play with them. If we could work with these children over a longer period of time, perhaps even year-round, we may see more of a change in their activity level and knowledge. Alternatively, if we could involve a larger range of ages, we could provide longitudinal instruction that is also tailored to their age. Our project is only a starting point for what can potentially be a long-term and meaningful program for the Central Community Health. ​

Journey to First Author

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Medical Knowledge and Skills CEO 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.

Research is integral to the advancement of medicine. It is the means by which we learn more about the diseases that plague our patients and search for treatments that may improve the lives of our patients. Personally, I am motivated towards research by the loss of my mother. She unexpectedly passed away when I was thirteen, and the coroner was unable to provide a definitive cause of death, only that her heart had stopped. Although I was unsatisfied with that explanation, I also realized that I would likely never know why my mother died. That lack of information, however, sparked my interest in medicine. The available scientific knowledge was insufficient to diagnose my mother’s condition, but perhaps one day, we will be able to identify the disease in someone else.

This desire to contribute to medicine led to a number of research opportunities throughout my undergraduate career. Most notably, I completed: 1) two summer research fellowships at Stanford University in the lab of Dr. Marlene Rabinovitch, MD, studying the genetics and cellular biology of pulmonary arterial hypertension, which culminated in a middle-author paper in the American Journal of Respiratory and Critical Care Medicine, and 2) two years as an undergraduate research student at the California Institute of Technology (my alma mater) in the lab of Dr. Paul Sternberg, PhD, looking at the functional significance of the AWC neuron in olfaction for the nematode Caenorhabditis elegans, which became the subject of my biology senior thesis.

1) RNA Sequencing Analysis Detection of a Novel Pathway of Endothelial Dysfunction in Pulmonary Arterial Hypertension

2) A Genomic Analysis of the C. elegans AWCON Neuron and Its Relevance in the Olfactory Response to Isoamyl Alcohol and Butanone

Upon matriculating into medical school at The Ohio State University College of Medicine, I was determined to continue conducting research. My search for a mentor ultimately led me to Dr. Debra Zynger, MD, from the OSU Department of Pathology, whom I began working with at the beginning of my third year in medical school. My project analyzed the frequency and clinical relevance of repeat biomarker testing in breast cancer patients who receive neoadjuvant chemotherapy prior to surgery. Specifically, we wanted to know if there were any biomarker changes upon repeat testing that led to modifications of the adjuvant regimen, as this question has never previously been studied. There are presently no guidelines regarding repeat biomarker testing, which is currently performed at the discretion of the attending pathologist, but novel research like mine that demonstrates the clinical value of repeat biomarker testing could help to create guidelines that focus repeat testing to be most impactful.

This project is special to me. Although I had worked on many others in the past, this was the first time that I would serve as leading author on a paper destined for publication in a scientific journal. I was responsible for conducting the background research, collecting and analyzing data, and compiling the final manuscript. Balancing this project on top of my already rigorous third-year clerkship schedule required much diligence and perseverance, but I was motivated by the fact that I was fulfilling my dream of conducting significant medical research that could positively affect so many lives. Approximately 1 in 8 women in the U.S. develop invasive breast cancer over the course of their lifetime. Statistically speaking, I can expect at least 1 person in my group of close female friends to eventually develop breast cancer. My hope is that the work I do will make a difference in their medical treatment and outcome.

By the fall of my third year, my manuscript was complete, and come winter, it was accepted for publication in Human Pathology.

Breast cancer biomarkers before and after neoadjuvant chemotherapy: does repeat testing impact therapeutic management?

In addition, I also had 2 abstracts from my project that were accepted for poster presentation at national meetings: 1) the United States and Canadian Academy of Pathology (USCAP) Annual Meeting in the spring of 2017, and 2) the American Society for Clinical Pathology (ASCP) Annual Meeting in the fall of 2017.

1) Do Tumor Characteristics Predict Changes in Breast Cancer Biomarkers Following Neoadjuvant Chemotherapy?: Abstract and Poster

2) Pathologist’s Practice Patterns in Breast Cancer Biomarker Testing After Neoadjuvant Chemotherapy: Abstract and Poster

Although it is known that changes do occur upon repeat testing of breast cancer biomarkers after neoadjuvant chemotherapy, there has been little analysis into the tumor characteristics that may predict those changes, and even less investigation into what tumor characteristics may influence a pathologist’s decision to repeat biomarker testing (as mentioned above, with no published guidelines, repeat testing occurs per pathologist preference). To create our guidelines, we must first develop a clearer understanding of what drives the changes that we observe.

The opportunity to attend these national conferences is truly a remarkable experience. Investigators and clinicians from around the world gather to present their research, and I am incredibly humbled to have been selected as one of them. We are all working towards the same goal, of improving medicine such that we can better human lives. My poster for ASCP was also selected as a finalist for the ASCP Best Lab Practice Poster Award Competition, thus exemplifying the accomplishments that medical students at The Ohio State University College of Medicine are able to achieve, and it is an honor to represent The Ohio State University College of Medicine at the national level.

As I come to the last year of my medical school, words cannot express my excitement for what lies ahead. I plan to apply for a residency in radiology, and I am currently working on my Advanced Competency in Research with Dr. Zynger on a pathology/radiology project that looks at the prevalence and histopathologic characteristics of entrapped fat in renal cell carcinoma, whether this fat was noted on preoperative radiographic imaging, and if the fat raised the differential diagnosis of angiomyolipoma. Our goal is to have abstract accepted for presentation at the USCAP Annual Meeting in the spring of 2018 and a manuscript accepted for publication in a peer-reviewed scientific journal.

I am so grateful for the all the opportunities that I have received here at The Ohio State University College of Medicine. Each day, I am achieving my goal of contributing to medicine. My successes in research have only fueled my passion.

Learning To Speak

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Practice-Based and Lifelong Learning CEO 3.4: Identify one’s own strengths, weaknesses, and limits; a) seek performance feedback, b) maintain an appropriate balance of personal and professional commitments, and c) seek help and advice when needed.

As a naturally shy and quiet individual, I dread any form of public speaking. During my earlier years of education, no amount of practice could reliably prepare me for class presentations. I would always perform well enough to pass, but was always marveled by the ease with which my peers could get up in front of the class and speak.

After I decided upon a career in medicine, I remember being warned countless times about the intense workload or the difficult material. Never did anyone tell me that medicine was more than just learning and knowing how to care for patients. You also needed to be an effective communicator, both orally and in writing. Seventeen years of education and a degree in English had prepared me for the written communication, but I was still not ready for the oral portion. I had learned about and practiced how to give oral presentations during my pre-clinical years weekly Longitudinal Groups, but doing so on the wards is a completely different story.

My first third year clinical clerkship rotation was a three-week elective in Infectious Disease. On my first day, I was already apprehensive about my patient presentation. I was given only one patient to see. After my interview, I wrote down my entire presentation and practiced it a few times before rounding began. Nonetheless, when it was time to present to my attending, fellow, and resident, my nerves got the best of me and I ended up barely stumbling through what should have been a thoughtful and thorough presentation. It didn’t help that my attending and fellow would intermittently interrupt my presentation to briefly discuss the case before allowing me to continue.

Perhaps my team forgot that I was only at the very beginning of my third year clinical clerkships (after all, May is when most other medical schools are finishing the year, not beginning), even though I’d reminded them of this throughout my rotation. Today, more than a year later, these disruptions would not even phase me. But for the me who was only just starting out, they made me question what I was saying and forget my next steps. I tried to ask my fellow and resident for advice on how to improve my presentation, but they would either recommend that I practice giving my presentation or that I try to organize myself before I give the presentation. These were valid suggestions, but I found it difficult to prepare for a presentation that I didn’t know when I would be stopped.

As the rotation went on and I became more accustomed to my team’s workflow and to having to give presentations, I felt that I had improved my presentations to be at least satisfactory, even if they were far from excellent. At the end of my rotation, I asked to meet with my attending for feedback, and she specifically mentioned that she thought my presentations were significantly better than when I had first started, and that she was very pleased with the progress I had made. My fellow made a similar comment, that he felt my presentations had come a long way.

A few weeks later, I received my clinical evaluations from the rotation.

While the comments did not surprise me (my fellow had even emailed me his comments), I was shocked that most of my team still felt that my presentations “lacked clarity and organization, often incomplete or poorly prepared.” My impression from speaking with my team was that I had significantly improved and was doing much better, but I didn’t realize that “much better” did not translate to “good enough.” I began wondering if my performance on my subsequent rotations (2 weeks of Inpatient Psychiatry followed by 2 weeks of General Internal Medicine) was also subpar, and my team was just not telling me even though I frequently asked for feedback.

My fears were eased when I received my evaluations for those two rotations and they all listed my presentations as “usually clear, organized, concise, and chronological.” However, I did not want my case presentations to be this burden that I could tolerate. I wanted to overcome this obstacle that had held me back for so many years. Medicine is a field in which teamwork and thus communication is vital to providing optimal care for our patients. To excel in medicine, I needed to master all forms of verbal communication.

I began seeking out opportunities to practice oral communication. If a patient of mine needed a consult to another service, I volunteered to make the call and speak with the other team. If a patient or family member had a question for the team, I asked to be the one to speak with them. Outside of the hospital, I would strike up conversations with strangers at the coffee shop or grocery store. No opportunity was too insignificant for me to try. The more I spoke with others, the more comfortable I felt doing so.

By the time I reached my 2 week General Cardiology rotation, which was about 3 months into my clinical clerkships, my team members were actively commenting on the quality of my presentations.

This journey probably took me many more months than my classmates, but I am so proud of myself for not giving up and resigning myself to subpar performances on my rotations. Whether I was judged unfairly during my first rotation or not, I took that feedback graciously and used it to improve. Medicine has forced me to confront my fears so that I can grow as a clinician and as a person.