I am embarking on a complex journey, one that will entail taking many exams (most notably the COMLEX) and learning the clinical skills that allow one to effectively treat disease as an osteopathic physician.
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Thoughts on new AAP guidelines on childhood obesity
Happy Martin Luther King Jr. Day everyone. I recently emailed my state's chapter of the AAFP and wanted to share this here too to help raise awareness about this important issue. Feel free to message me with any questions.
As a family physician, I am very disturbed by the American Academy of Pediatrics' new guidelines on childhood obesity, which include labeling patients as young as two years old as overweight and encouraging weight loss surgery for teenagers.
It is estimated that 9% or more of Americans will experience an eating disorder in their lifetime. Many clinicians are unaware that anorexia nervosa carries the highest death rate of any mental illness. The AAP has previously acknowledged the importance of recognizing and treating eating disorders, but unfortunately the new guidelines ignore respecting different body shapes and sizes and that BMI is a poor proxy for a patient's overall health.
Instead, clinicians who care for children should focus on more helpful things like sleep, regular meal times, and physical activity. A focus on weight and weight loss will only hurt children's body images and self-esteem.
I would advocate that the NYSAFP not endorse the new AAP guidelines and consider releasing a statement describing how the guidelines are actually harmful for children's health.
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The Pause
I am in the midst of my last two weeks of night float and I can’t wait for it to be over. I have never seen the hospital this busy during the entire pandemic. Patients are here with COVID, but also heart attacks, bacterial infections, and more. There are a lot of people who are pretty sick right now and even when we discharge them, it often seems like many of them wind up right back here a few days later.
What is sadder though is when a patient does not make it. Last week was difficult because I had to pronounce three patients deceased in the middle of the night. All three patients were receiving hospice care when they passed away, but that still does not make it any easier to listen to a person’s chest knowing you won’t hear any heart sounds or to say the time of death out loud for everyone in the room to hear.
The time period between when a physician declares a patient deceased and when the physician leaves the room can be awkward. When there is family present, I tell them I am sorry for their loss. But somehow that never feels like enough. Should I have offered a tissue? Or a hug? The lack of hugs in the times of COVID has been one of the worst parts of the pandemic in my opinion. As I was thinking about this, I remembered that I had once witnessed an attending physician read a comforting reflection for family and the healthcare team after a patient passed away in the ICU. I sent him an email and felt fortunate to get this quick response:
Good morning Jon,
It’s called a red pause, the nurses have a copy laminated in the ICU or with the nursing supervisor. Glad to hear from you.
I posted the red pause or simply “the pause,” below. When I did an informal poll of four of my med school classmates, only one had been taught it, so I figured it was worth sharing. I plan to give it a try the next time I have to declare a patient deceased, which I hope will not be for a long, long time.
PS- Although it is still too early to know for sure, there is some early data that shows that Omicron could be more contagious, but less severe than other strains of COVID. In any case, make sure you keep wearing a mask in public and get vaccinated if you have not already!
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An Ode to Trees
I have a slightly different post for you today. With COVID cases rising again in the US, everyone is bracing for what could be a difficult fall and winter. As a healthcare worker, I find myself exhausted at the end of most days. Exhausted because patients keep dying who should not be dying. Exhausted because we have a broken political system and rigged economy in our country. Exhausted because fear is causing people to reject the advice of previously trusted medical professionals. I don’t know the solution to any of these big problems. What I do know is that I have to keep going and for me, the main things that keep me going are located outside the hospital. One of those things is trees. A Google search reveals that there are around 3.04 trillion trees on Earth! This is an ode to trees, with a focus on three that have impacted my life.
The American Redwood
From October 2011-August 2012, I studied abroad in Germany. I know it sounds cliché when people say that “studying abroad changed my life,” but I’m going to say it anyway- studying abroad changed my life! It is impossible to describe the formative experiences and all of the influential people I met while studying at Johannes Gutenberg University Mainz and completing internships in Berlin and Heidelberg. As amazing as an experience that it was, what people often do not share about studying abroad are the times they were not having fun. While I don’t regret my semester in Mainz, there were often times I felt extremely lonely. Unlike my American college’s dorm where you could always hear music playing and students chatting as you walked down the hall, at my dorm in Mainz, students tended to keep their doors shut all the time and usually went home on the weekends. I never got used to getting back from class and peering down my silent hallway, feeling like I was the only one there. There were other American students in Mainz who were great people, but I never became really close with them. This all lead me to having a lot of time on my own.
One of my favorite places to explore on my own was the university’s botanical garden. The garden had plants and trees from all around the world, but there was one section I always found myself being drawn back to- atlantisches Nordamerika. Here there was a collection of trees from North America, and my favorite was the American Redwood. It was a towering, magnificent tree that instantly caught your eye as you approached it. I remember placing my palm on the tree’s trunk, closing my eyes, and just feeling a sense of calm come over me. I would imagine the roots of the Redwood stretching all the way across Europe and the Atlantic, connecting me to my home. Every year, there are more and more studies being published that show the benefits of spending time in green spaces on physical and mental health. Spending time in nature can change your life :)
The Cherry Tree
In 2015, just prior to starting med school, I worked as an EMT. One day, I had the privilege of transporting “Ms. M.” from Lahey Hospital in Burlington, MA to the hospice wing of a nursing home in Peabody. Ms. M was a 94-year-old Christian woman who was suffering from heart and renal failure, but still had her wits about her. I was amazed by how little it seemed to bother her that she probably just had a few days left to live. A funny exchange happened when the patient’s nurse bid her farewell. The nurse said, “I’ll see you in Heaven,” to which the patient responded, “No, I’ll see you with my ice chips!” Later, after we had gotten Ms. M onto the stretcher (with her ice chips) and wheeled her outside on a sunny spring day, she suddenly asked us to stop for a minute. There was a beautiful flowering cherry tree next to the sidewalk outside the hospital that Ms. M. politely asked us if she could just sit under for a few minutes. “It’s been so long since I’ve sat under a tree,” she said. My EMT partner and I granted her request and we all just paused there for a while, enjoying the beautiful tree, fresh air, and sunshine before we helped her into the ambulance.
When I think about all the patients I cared for in the hospital who died after weeks of struggling, but ultimately failing, to survive COVID, I find some comfort in remembering that at least I was able to let Ms. M. sit under that cherry tree.
The Locust Tree
At the beginning of August, a tall locust tree that grew right outside my hospital was cut down to make way for a building expansion. I remember going outside that day and being hit with a wave of shock and sadness as I saw the tree’s giant limbs being divided by chainsaws. When I was a medical student auditioning at my hospital, I would always walk by the locust tree on my short walk from the student housing to the side entrance of the hospital. It was always comforting to me to see a living thing that had been there for so many years which had endured extreme weather and other hardships. Then, as a resident, I always felt comforted driving and walking past it.
As the pandemic continues, one of the things that gives me strength is looking at trees. Not just seeing them out of the corner of my eye while staring at my phone. But really devoting my full attention to them, allowing myself to stand in awe under their shade. I reflect on how in the bitterness of winter, trees stand tall with their branches blowing in the wind, refusing to break. Then in the spring, we see their leaves and flowers burst into life, supporting birds and bees and even us humans. I love admiring trees that first sprouted over a century ago and realizing that growing old isn’t necessarily a bad thing. A few days ago, my eyes were opened when while still mourning the loss of the tree in front of the hospital, I noticed that there were several other awesome trees just a stone’s throw away.
What gives you strength each day? Maybe it is sipping a freshly brewed cup of coffee in your kitchen at dawn before anyone else is awake. Maybe it is looking forward to a small child or furry friend to greet you at the door when you get home from work. Whatever it is, I encourage you to cherish these moments. At the same time, it is important to identify the moments in our day that do not bring us joy. For me at least, when I reflect on the happiest days in my life, they all share a common trait that I spent very little time in front of an electronic screen. So as difficult as it is, I am trying to make a conscious effort to not spend any more time in front of a computer or phone than I must. And I am trying to spend more time with trees, cognizant that they won’t be around forever.
PS- This blog post was inspired by two works of literature. The first is a podcast episode by John Green in which he reflects on a Ginkgo biloba tree that is special to him. The second is a heartwarming book called Phosphorescence by Julia Baird. I encourage you to check them out!
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More pediatrics
Pediatrics is an essential part of family medicine and I am currently in the middle of three pediatrics rotations in a row! In March, I spent a month with pediatricians at a local community health center. In April, I did a pediatric gastroenterology rotation in Buffalo. And tomorrow I start my inpatient pediatrics block.
I had a very enlightening outpatient pediatrics rotation. It was cool to be able to spend time in a community health center, where the providers treated everyone from “the richest of the rich to the poorest of the poor.” I was fortunate to be able to work with three different pediatricians at different stages in their careers. One was set to retire in six months. One was in the middle of her career. And the last was fresh out of residency, just starting out as a new pediatrician in the practice. Each had their own perspectives and priorities of what I should learn. For example, the older doctor would quiz me on antibiotic doses, while one of the younger doctors gave me tips on improving my history taking and recognizing social determinants of health. One of the things that struck me about the rotation was how many kids today struggle with mental health conditions. There were countless patients with ADHD, anxiety, depression, and eating disorders, none of which were helped by the ongoing pandemic. I remember one 10-year-old girl who was being evaluated for a possible eating disorder. The doctor tricked the girl into jumping off the exam table after the abdominal exam. Immediately, the girl had to grab onto the table and looked like she was about to pass out for a second. This girl did not meet the criteria for hospitalization at the visit, but the doctor caringly emphasized that the patient and her family had to keep working on taking in adequate calories and continuing with therapy. Outpatient pediatrics is very challenging, but also rewarding. I have a lot of respect for professionals who care for kids every day.
It was kind of a pain to have to drive to Buffalo every day for pediatric gastroenterology, but it ended up being well worth it. Doctors “A” and “B” were both brilliant, caring physicians whose days were packed with kids with various GI complaints. The most common complaint was constipation, and it was interesting how even a lot of kids diagnosed with acid reflux really just had constipation. As Dr. A put it, “if you clog the bottom of the kitchen sink, what happens to everything above it?” In addition, there were patients with inflammatory bowel disease and various developmental disorders. Every day, there were young patients getting infusions of Remicade and other intravenous medications which was initially disheartening to see. In a perfect world, no one would be afflicted by diseases like Crohn’s and ulcerative colitis. But then it was inspiring to see that, for the most part, the medications worked. The patients would talk to us about how well they were doing in school, an upcoming track meet, or their own business they were starting this upcoming summer. At the end of this rotation, I feel like I have a much better understanding of pediatric gastroenterology and have realized that many of the principles also apply to adult patients.
That’s all for now. Hope everyone stays happy, healthy, and safe!
PS- As a person who is half-Chinese, the recent surge in Asian-American hate crimes across our country breaks my heart. I recommend the website: https://stopaapihate.org/
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Wound Care
A little over a month into the new year, I have been thinking about stories. Humans have been telling stories for as long as our species can remember. Our country has a story. Each individual has a story that she or he adds a little bit more to every day. And in medicine, we tell stories. On rounds in the hospital: “Mr. S. is a 78 year old male here with pneumonia. He said he slept well last night and is wondering if he can eat breakfast.” In family medicine clinic: “Ms. Y. no longer needs a wheelchair after her injury and is now walking steadily with a cane. She is wondering if she still needs to take her blood pressure medication.” As both winter and the pandemic hopefully near their ends, I have been taking some solace in trying to view my job as one not full of work, but full of stories. Here are a few stories from my two-week wound care rotation.
One morning, we saw a patient who had a venous ulcer on his left leg. The patient smiled though his mask when he saw Dr. K. and me enter the room. When Dr. K. scraped at the wound slightly, it started bleeding. Dr. K. swiftly took a piece of gauze and started holding pressure against the wound. “This looks like a job for a resident,” Dr. K. thought out-loud. He then commanded me to put on a glove and hold pressure against the wound. Dr. K. and the patient bantered for a while and the patient got his wound care instructions for the upcoming week. At the end of the visit, Dr. K. asked me to continue to hold pressure for five more minutes to ensure the wound stopped bleeding. Once I was alone in the room with the patient, he shared with me that his wife had passed away at the beginning of January. I expressed sympathy to the patient and even though we had only just met, he then spent the next five minutes telling me about his wife and her health problems toward the end of her life. I once again offered my condolences and the patient told me calmly that she was in a better place now. This encounter was a good reminder for me that one never really knows what another person is going through. Sometimes just being present with someone else is all it takes for them to open up to you.
Mr. M. was a patient I saw for two visits during my rotation. He was a very pleasant 60 year old man paralyzed from the waist down who was being treated for a stubborn sacral ulcer that was taking an eternity to heal. The first time I saw him, Mr. M. was watching TV in a hyperbaric oxygen chamber. This machine is pretty cool, since it brings the patient to an increased atmospheric pressure, similar to deep sea diving. This allows for the delivery of 100% oxygen to the patient’s wounds. Normal air only has about 21% oxygen, so it is pretty amazing that most of the air we breathe on a normal day is not the critical molecule we need need to survive. Once Mr. M. had finished his hyperbaric oxygen treatment, he was wheeled to an exam room in his wheelchair bearing a U. S. Navy emblem on the back. So far in my medical training, I have observed that chronic illnesses can affect patients in one of two ways. They can become miserable people, lashing out at those around them. Or, in spite of their daily suffering, they inspire happiness in others. Mr. M. was definitely one of the latter types of patients. During his visits, Mr. M would always talk about the Bills or tell jokes. “Sorry about the stinging,” the wound care doctor said once as he was debriding the wound. Mr. M. replied, “that’s okay, I’m used to it. I’m married!”
On another morning, Dr. C. shared with a patient that he was originally from Canada. Dr. C.’s mother grew up in Parry Sound, a small town located on the shores of Lake Huron. Parry Sound is known for being the birthplace of one of the greatest NHL players of all time. Bobby Orr was born and lived in Parry Sound until age 14, when he was signed by the Boston Bruins. Dr. C. shared that his mother was actually childhood friends with Orr’s older brother. The two of them would frequently play with and pick on Orr, since he was the youngest in the group. It turns out that patients are not the only ones with interesting stories to tell!
Last but not least, it was great catching up with Cam, my former chief resident, who is now an attending!
PS- If you’d like to hear more stories, I highly recommend the Anthropecene Reviewed podcast by John Green. If you would prefer to read the stories from the podcast, it’s also soon to be a book!
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My first encounter with a COVID-19 patient
“I can’t protect you anymore,” Dr. V told me in the middle of the afternoon. In the days leading up to my first encounter with a COVID-19 patient as a family medicine resident in a small community hospital in WNY, I had been relieved to see all of the COVID patients assigned to one of our attending physicians separate from the teaching service. “It just causes unnecessary exposure,” one of the attending physicians said to me once, when we were talking about why there were no COVID patients on the residents’ list of patients to see. This concept makes sense to me, because as a resident physician, an attending physician always has to examine the patients I see in the hospital too. Why put two individuals in close proximity to a COVID patient and use double the amount of PPE, when you could just send one person into the room?
That all changed, however, on that Saturday afternoon. “There are five admissions pending from the ER. Four of them are COVID,” Dr. V shared with me as he gave me an admission. The patient was a 70-year-old female with a past medical history of hypertension who had presented to the emergency room that morning with shortness of breath. She had already tested positive for COVID about a week prior. After isolating at home for a week, where her husband was also having COVID-19 symptoms, she called an ambulance to bring her to the ER when she felt like she could barely breathe. “Ms. C’s” oxygen saturation on arrival was 80% and she was immediately placed on three liters of supplemental oxygen. Her labwork and imaging studies were all consistent with a severe COVID-19 infection requiring hospitalization.
With the rising COVID numbers across the country, I knew the day would come when I would have to start seeing COVID patients. An unexpected sense of peace came over me as I gathered as much information about the patient as I could prior to heading into her isolation room. I lived alone, so I did not have to worry about infecting roommates or family members. I have been taking 20 mg famotidine every morning, an unproven remedy for the virus, but a medication that is already known to have immunomodulatory effects. And I knew that there was a wealth of data that shows the risk of healthcare workers contracting COVID from a patient is very low as long as they wear appropriate PPE and spend less than fifteen minutes in the room.
After double-checking that I had gathered all the information I could, I took a deep breathe and physically prepared to see Ms. C. I removed all unnecessary items from my body, including my watch and phone. I carefully donned my N95 mask, putting my hands over the sides to ensure I had a tight seal. Finally, I put on a flimsy faceshield, picturing doctors in other parts of the world wearing hazmat suits when they see COVID patients. Oh well, I thought. It is better than nothing. I left the resident room and briskly walked to Ms. C’s room where I would don my gown and gloves.
There was a Styrofoam lunch tray with a sandwich and drinks on it outside of Ms. C’s room. I could feel the tray bending as I carefully brought it into the room while a nurse helped close the door behind me. I was trying very hard to ensure that Ms. C’s first memory of me would not be her doctor dropping her lunch on the floor. Inside the room, there was an elderly woman lying in bed wearing an Oxymask with a surgical mask on top of it. She looked calmer than I expected and was watching TV before I entered. I put the lunch tray on the bedside table and greeted Ms. C. I had to speak louder than usual due to my mask and the exhaust fan in her window. I asked Ms. C about the symptoms she was experiencing and confirmed her home medications. When we got to the part when the physician asks about code status, Ms. C seemed surprised at the idea that we might have to intubate her and use mechanical ventilation to help her breathe if her respiratory status worsened. I recommended we make her Full Code for now, but to talk about what she would want done in an emergency with her husband. I examined Ms. C, told her I would discuss the treatment plan with my attending physician, and wished her well as I left the room. Dr. V and I immediately started Ms. C on a steroid called dexamethasone and the antiviral agent remdesivir. I called Ms. C’s husband to give him an update on how she was doing and finished my admission note. Dr. V told me I did a good job.
There are many things that bother me about the ongoing COVID-19 pandemic. I am disappointed by the Trump administration’s failure to contain the virus when it entered the US and the ways the administration subverted scientists and public health officials. I am horrified at the increased anti-Chinese sentiment in our country, especially with the knowledge that much of the viral spread in the US actually came from Europe, not Asia. But what bothers me the most is the closed-mindedness and self-centeredness of so many Americans. Do you remember that a US President once instructed us to “ask not what your country can do for you—ask what you can do for your country?” One of the most important things we can do for our country right now is to slow the spread of COVID-19. Wear a mask. Avoid unnecessary travel. Realize that about 1/5 of people infected with COVID never go on to show symptoms and it usually takes at least two to three days following an exposure to have a positive nasal swab test. I write these things not with the intent of scaring anyone, but to help illustrate how we got to the surreal reality we are currently living in. Stay safe, check in regularly with loved ones, and reach out for help when you need it. Even if we have to stay six feet apart, all of us will get through this together :)
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Delivery
I feel blessed to have been able to visit my brothers and parents during my last vacation. I had not seen them in person in nine months due to my busy work schedule and the ongoing pandemic. As I drove over the Lake Champlain Bridge to enter Vermont, I felt a wave of relief. I had an amazing time catching up with my brothers and their significant others in Burlington and then I was on my way to visit my parents in Massachusetts.
While back at my childhood home with my parents, they encouraged me to do some cleaning and organizing. In the attic, there are piles and piles of textbooks, papers, and other school materials that are the result of me and my brothers’ primary, secondary, and post-secondary educations. I found some pretty neat things including a children’s book I wrote in fifth grade called The Giant Squid and a bag containing all the souvenirs I collected from my time in Germany when I studied abroad in college. Something unexpected I found, however, was a copy of my birth certificate. I have seen my birth certificate in the past, but now that I am a family medicine resident, I was curious to check the name of the doctor who delivered me twenty-nine years ago. Her name was “Dr. J” and when I looked her up online, I discovered that she was still practicing in Wisconsin! As I looked at her web page, I was pleasantly surprised to learn that Dr. J was also a family medicine resident when she delivered me at St. Joseph’s Hospital in Syracuse, NY.
Receiving gratitude from patients is one of the best parts of a doctor’s day. So I decided to write a thank-you card to Dr. J for helping my mother Ying deliver me so many years ago. I shared that as a second year family medicine resident, I have now had the chance to help with numerous deliveries. I can attest to the fact that it is an incredible experience to be the first person to hold a newborn baby! I wrote my email address in the closing and sent it off to Wisconsin, wondering if I would receive a response.
This past Tuesday morning, while I was waiting in resident clinic for my first patient to be roomed, I got an email with the simple subject “Delivery.” It was from Dr. J! She shared with me that my personal card made her day. I was impressed that Dr. J not only remembered delivering me back in 1991, but also my birth weight and my father Anthony’s name! She was glad to hear that I was also now a family medicine resident and invited me to check out her clinic in Wisconsin if I was ever interested in practicing in the Midwest. Dr. J closed her email by writing, “I will wear a warm smile under my mask all day with the memories your card has stirred.”
We all have the ability to generate positivity in the world despite everything bad that is happening. Mail a card, call a friend. Visit a family member you have not seen in a while if it is safe to do so. You never know how many lives you will touch with a single positive act.
PS- While I think it is important to follow the news, I also think it is beneficial to remember there are good things happening in the world all the time too. I really like the website UpWorthy if you want to check it out!
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Second year begins
Hello everyone! It’s hard to believe, but I am writing to you now as a second year family medicine resident!
Early in the morning on Monday June 29, after just 12 months of being a doctor, I found myself sitting in the resident room of the hospital as the new senior resident on the internal medicine (IM) team. Relying on me were Shahbaz, one of the new interns, and a new third year medical student. My first week as a second year was stressful to say the least. It was challenging for me to suddenly have a higher cap of eight patients, help guide my intern during his first days of residency, and find time to teach the medical student. Of these three responsibilities, I definitely neglected the third one the most which I feel bad about. But I also now have more empathy for the busy residents who did not pay attention to me at times when I was a medical student. The hospital has a way of keeping residents busy when they are on IM. Several of the patients we cared for in the hospital that month were very sick and a few did not make it unfortunately despite our team’s best efforts. I hope at least that I helped to ease the stress of starting residency for Shahbaz. I am really proud of the work he did on IM. And then hopefully in November when I am on IM again, I can be more intentional about setting aside time every day to teach medical students.
Now that I am on OB/GYN, I thought that my hours would get better, but I still find myself working 11-12 hours every weekday. In addition to helping deliver babies and spending time in OB/GYN clinic, I am still getting used to being a second year resident in the family medicine clinic. I have transitioned from having 30-minute appointments with patients two sessions a week to 20-minute appointments three sessions a week. I have managed to do a pretty good job of staying on time in clinic so far, but it comes at the price of not having any of my visit notes done at the end of a session. Not to mention all the prescription refill requests, lab results, and patient paperwork that requires my attention every day. I am starting to better understand why primary care seems so unattractive to many medical students, but I can honestly say that I still really like it. When I reflect back on how I was as a first year resident at this time last year, I know that my efficiency will improve as the year goes on. What may not improve though, unless I make a conscious effort to work on it, is my medical knowledge. I have heard that during the second year of residency, many residents experience a “plateau” after rapid growth during their first year. My hope is that I can avoid the “plateau” by continuing to genuinely care about all my patients, remaining curious, and recharging with family and friends whenever my busy schedule allows for it. If you have ideas about how to continue to grow at a job (medical or non-medical) during your second year, feel free to let me know!
Finally, some thoughts on the ongoing COVID-19 pandemic. While I am relieved that the number of COVID cases are down in the area I practice, I also hope and pray that cases around the country and world start to decrease soon. We all have to remain vigilant until an effective vaccine is made widely available to the public. I am grateful for all the messages of support that have been aimed at healthcare workers on social media and elsewhere. If you really want to support us, however, please take steps to stop spreading the virus! Wear a mask. Stay home whenever possible, especially when you don’t feel well. Avoid large gatherings of people. I tend to agree with scientists who support the hypothesis that “superspreader” events are driving much of the virus’s spread. Here is a good Scientific American article if you would like to read more.
That’s all for now. Stay safe everyone and best wishes to my fellow LECOM classmates as we continue progressing through residency!
A recent trip to Letchworth State Park
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Pediatrics
Hi everyone! I hope you all are well. I thought I would share some reflections from my pediatrics rotation last month. I worked with a great pediatrician named “Dr. Z.” who mostly saw patients in the outpatient setting, but also did newborn rounds at the hospital and occasionally got called in the middle of the workday to be present for a C-section. I was frequently left behind by Dr. Z. and found creative ways to stall and keep his office patients entertained until he returned.
I would estimate that about half of the visits during my time at Dr. Z.’s office were for kids with attention deficit hyperactivity disorder (ADHD). ADHD is a clinical diagnosis that requires at least six months of hyperactivity, impulsivity, and inattention in a child prior to age 12. The child must display symptoms both at school and at home. I have mixed feelings about ADHD as a clinician, since too often I feel like we jump right to prescribing medications like Adderall or Ritalin without recommending behavioral interventions first. I want to emphasize that for many children, medications do help them to perform better in school and display better behavior at home. At the same time, however, it is frustrating how there is a severe shortage of pediatric counselors and psychiatrists in the area I practice. Too often as a society, we “reach for a pill” to fix things rather than doing the harder work of trying to get to the root of the problem. For example, I found it ironic that many of the ADHD visits in Dr. Z.’s office took place in the “SpongeBob” room. A 2011 study found that children who watched 9 minutes of a fast-paced cartoon like SpongeBob performed executive functions like problem-solving at about half the capacity of children who had spent that same time drawing with markers and crayons. While it was a small study and by no means conclusive, something as harmless as letting your four-year-old watch SpongeBob may not be so harmless after all. As a clinician, I believe that medications play an essential role in treating ADHD and other psychiatric conditions. But I also wish that as a society we placed a greater emphasis on supporting parents and educators.
Dr. Z. was a very efficient doctor. During the day, I would literally run after him at times as he went from room to room examining patients and addressing parents’ concerns. One day, there was one 10-year-old male who interrupted Dr. Z.’s flow. Overall, the patient was well, but he had a unique presentation of suddenly having brittle nails with longitudinal ridges on all ten of his fingers and all ten of his toes. “I’ll be right back,” Dr. Z. said to the patient and his mother and swiftly left the exam room to go to his office. I assumed that Dr. Z. was looking up what the condition was, so I tried to do the same thing on my phone in the hallway. Before I could find anything resembling the patient’s condition, however, Dr. Z. returned and informed everyone that the patient most likely had lichen planus, an autoimmune skin condition. He referred the patient to a dermatologist. I was impressed by Dr. Z.’s ability to diagnose the condition so quickly, even though he initially did not know what it was. There is a saying in medical school that it is impossible to know everything, but it is important to know where to look things up. When I got home that night, I referenced my go-to dermatology book, Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. It turned out the patient most likely had a variant of lichen planus appropriately called “twenty nail dystrophy” and I was happy to read for the patient’s sake that the condition often just gets better on its own.
I think one of the hardest parts of any job that involves lots of repetition is avoiding complacency. For example, physicians listen to so many hearts and lungs during their careers that it is easy for them to fall into the trap of “going through the motions,” the same way a musician might practice a piece of music just for the sake of practicing without trying to improve. Perhaps you have even had a doctor talk to you while simultaneously listening to your heart and lungs? Even though heart murmurs are uncommon, you won’t discover one if you aren’t looking.
Checking for the red reflex in a newborn is another example of a routine physical exam component. Greater than 99% of the time, the pediatrician or family doctor will see a normal red reflex, meaning the baby has a normal retina. But every once in a while, he or she might see something else. One morning, Dr. Z. and I rounded on a set of newborn twins, a girl and a boy. Like all newborns, they were super cute! With a nurse’s assistance, we examined the eyes of the newborns. As the nurse gently opened the girl’s tiny eyes, I just barely saw the red reflex. I figured Dr. Z. would just want to examine the second baby on his own to save time, but then he asked me to examine the boy’s eyes as well. As I centered the ophthalmoscope on the boy’s eye, I could only see a solid black pupil. Internally, I panicked. Was I doing something wrong? Why couldn’t I see the red reflex? Dr. Z. then explained to the parents that the boy had congenital cataracts, a condition that only affects about only 1-3 out of every 10,000 newborns! It turned out my eye exam was fine, this baby boy just did not have a red reflex. Dr. Z. later told me that in his twenty years of practice, he had never seen congenital cataracts before and hoped I would never forget it. I share this story to encourage my fellow clinicians to maintain a sense of alertness during every physical exam. And to patients, please do not be afraid to request your doctor repeat a physical exam maneuver, a diagnostic test, or anything else that worries you. Doctors are only human too and we can do our jobs most effectively when patients feel empowered to communicate openly with us.
That’s all for now. Stay safe everyone!
PS- In the wake of the murders of George Floyd, Breonna Taylor, Ahmaud Arbery and countless other African-Americans, several medical organizations including the American Academy of Pediatrics, American College of Emergency Physicians, and the American Academy of Family Physicians have come out with statements against racism. I believe that black lives matter. I know that some of my friends prefer the term “all lives matter” and I believe that all lives matter too. But if you had a friend who was going through a rough time, would you say to him or her, “I support you” or “I support all my friends?” Right now, our African-American friends need extra support because of ongoing racism in our country. Inspired by Angela Davis, I am doing my best to remember that, “in a racist society, it is not enough to be non-racist, we must be anti-racist.”
Memorial to George Floyd on the Berlin Wall (image from NPR)
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Emergency Medicine
I just finished a crazy four weeks of emergency medicine. I know COVID-19 is on everyone’s minds right now and it is ever-present in my mind as well. I decided, however, with the hope of giving you all a break from the pandemic, I will focus on three non-COVID patients I encountered in the ER (well, at least probable non-COVID patients. I still wore a mask into every single patient’s room for protection.) I will say though that I agree with health authorities who are encouraging social distancing (or “spatial distancing,” which is a term my Dad recently heard in a priest’s online homily that I kind of like), practicing excellent hand hygiene, and protecting the elderly and people with underlying health conditions. For more on COVID-19, I would recommend the Atlantic article How the Pandemic Will End and for healthcare professionals, onepagericu.com.
Our first patient today is six-year-old girl with a cough and sore throat who I’ll call “Dora.” Dora was brought to the ER by her mother who was pretty sure the patient just had a cold, but wanted to be 100% certain that her daughter was alright. The moment I entered the exam room, Dora started to scream at me. I later learned that the nurses had already done a strep throat and flu/RSV nasal swab on this poor girl, so it made sense that she kept yelling “no” and quickly ran to the opposite corner of the room. Mom filled me in on the situation. The school nurse had sent the patient home because she was sick and since the pediatrician’s office was closed, the mother decided to bring the patient here. Dora had been having a cough, sore throat, runny nose, and tactile fevers for the past two days. She also had been more irritable than usual, even before she came to the ER. I suspected the patient only had a viral URI, but still carefully examined the patient. Fortunately, Registration had given the patient a teddy bear, so by examining the teddy bear first, I was able to get Dora to cooperate with most of the examination. Except for the ear exam, but that tends to be torture with a lot of little kids. With Mom’s help, I was eventually able to take a decent look at both eardrums to ensure that the patient did not have an ear infection. On that day, I was working with “Dr. Swiper,” who is one of the best ER docs I have worked with. She always began her day by “chart-checking” the patients she had seen her previous shift to see what had happened to them after they left the ER. I should not have been surprised then, when after presenting the patient as a straightforward viral URI, Dr. Swiper was not satisfied. “Do you think she has meningitis?” “No,” I replied, noting that the patient did not have a fever and there was no neck stiffness on exam. “What about peritonsillar abscess?” I replied that I had not looked for one, so Dr. Swiper calmly proceeded to search online for some good pictures of peritonsillar abscesses to show me. She noted that you can often spot it because of the deviated uvula. Later, after seeing the patient, Dr. Swiper agreed that it was most likely a straightforward URI. But I appreciated how she pushed me to think outside the box and to always keep these less likely diagnoses in mind. Too often, I have presented to attending physicians who shift uncomfortably in their seat and can’t seem to wait for the resident or student to finish presenting so they can move on to other things. I prefer the “Dr. Swipers” in the world who might make you feel dumb from time to time, but gently push you to become a better doctor.
Our next patient is a 46 year old woman (“Ms. M.”) who presented with a fall. My attending physician that day, “Dr. Boots,” (another very good ER doctor) sent me in to examine the patient. After I announced my presence and pulled aside the curtain, I saw Ms. M. seated comfortably on the stretcher wearing a black dress with purple trim under her hospital gown and a rainbow peace sign necklace. I asked Ms. M. what brought her to the ER that evening. She told me that around 8 AM when she got out of bed, she tripped over her cat and hit her head on the floor. Ms. M. did not lose consciousness and there was no wound on her head, but she did describe “feeling off” for the rest of the day. Later, around 5 PM, she tripped again, falling on her hands and knees. Since Ms. M. is not normally one who trips and falls around her house, she decided to come to the ER to be evaluated. As I asked Ms. M. more questions, it seemed unlikely that she had suffered a concussion. I confirmed that there were no visible wounds on her head and found nothing abnormal on neurological examination. The question remained whether Ms. M. needed a CT scan of her head? There is a Canadian physician named Dr. Ian Stiell who came up with the Canadian CT Head Rule for patients with minor head injury (you’ve gotta love that he named the rule after his country rather than himself). Dr. Stiell’s research showed that as many as 90% of head CT scans are negative for clinically important brain injuries. Thus, he and his colleagues came up with a yes/no questionnaire for physicians to use to help them determine whether a patient like Ms. M. really needs a CT scan. I went through the questionnaire with Ms. M. in her room and told her I would talk with Dr. Boots about the treatment plan. After presenting my findings to Dr. Boots (CT head rule score of zero, meaning CT scan is unnecessary), Dr. Boots agreed that a CT scan was probably unnecessary, but she was going to see the patient on her own first just to be sure. I started my note as Dr. Boots went to see the patient. When Dr. Boots returned, she told me that she elicited some neck tenderness on the patient, so I should order a head and neck CT “just in case.” I privately disagreed, but in medicine, it is frowned upon to openly disagree with an attending physician unless you have a really good reason to do so. And I honestly could not be 100% certain that this patient did not have a hidden head or neck injury without this imaging. When the CT of the patient’s head and cervical spine came back completely normal, I was happy for the patient, but also frustrated that I had been complicit in exposing Ms. M. to extra radiation and practicing what seemed like defensive medicine.
Our third and final patient is a 50 year old female (“Ms. D.”) with chest pain. She said it had been on/off for the past several weeks and sometimes radiated to her back. She came to the ER this morning because the pain woke her up from her sleep for the first time around 5 AM. Ms. D. had a history of high blood pressure, otherwise she was healthy. Patient denied nausea and had no shortness of breath. Her inital blood pressure was 170/100; her other vital signs were normal. EKG and chest x-ray showed no abnormal findings. Initial lab work showed a normal troponin; all of her other labs were normal as well. The patient was given aspirin and nitroglycerin, which relieved her chest pain a little bit. We then decided to give her a combination of Pepcid and Maalox thinking maybe Ms. D. had a bad case of acid reflux. At that point in the ED course, we were ready to check one more troponin and possibly send the patient home. But then Ms. D. mentioned to us that her mother had once had a brain aneurysm. Might an aneurysm be causing her pain? In an attempt to relieve the patient’s worry that we had failed to elicit earlier and to gather more clinical information, we ordered a CT angiogram of the chest. The hospital radiologist called us with the diagnosis: aortic dissection. An aortic dissection is a rare medical condition in which a tear forms in the aorta, the largest blood vessel in the human body. As the tear widens, blood builds up in between the walls of the aorta until it bursts. My attending physician and I were stunned by the diagnosis. We immediately called a cardio-thoracic surgeon and transferred the patient to a higher level of care.
The good news is the patient survived. For the medical people out there, Ms. D. had a “type A thoracic aortic dissection,” underwent surgery before rupture, and is now home with her family. I don’t think I’ll ever forget the case of Ms. D. and her dissection. The craziest part was that I did not even see the patient! “Dr. Swiper” did. The story above comes from her. Originally, two patients came into the ER at the same time. One had shortness of breath, one was Ms. D. and I had the choice of seeing either one. On a whim, I chose the patient with shortness of breath. It scares me to think of how things might have turned out differently if I had seen Ms. D. I like to think that I would have ordered the CT angiogram too, but I will never know for sure. There is a great episode of Scrubs called “My Butterfly” in which- SPOILER ALERT- a patient comes into the hospital and dies from an undiagnosed aortic dissection. J.D. then imagines what would have happened if they had caught the aortic dissection earlier, but the patient still unfortunately passes away (END SPOILER). In Ms. D.’s case, she did mention from the start that the chest pain “radiated to her back.” That is part of the classic presentation for aortic dissection that is taught in medical school, but would I have remembered it? Another concerning feature of this story is that Ms. D. did not mention she was worried about an aneurysm until about three hours after she had arrived. I am now making it a point to ask ER patients right away what they are worried about, since patients know their bodies better than their doctors do. The important and amazing thing though is that Ms. D. survived. Remember to keep aortic dissection on your differential diagnosis for chest pain!
That’s all for now. Stay healthy and safe everyone!
Note: identifying details have been changed to protect patient confidentiality
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Stories from surgery
This post is a few days late now, but I’m all done with surgery! I worked some long days, but fortunately I got Christmas Day and New Year’s Day off. I did not get the preceding days off, more on that below. . .
Christmas Eve
On Christmas Eve, there were only a couple of surgical cases scheduled for the afternoon, but I would be working with the surgeon “Dr. C.” for the first time. I was a little worried because I had heard stories of how Dr. C. loved to pimp residents on their surgical knowledge. Also, I had already been berated by Dr. C. once over the phone when I made the mistake of calling him with a question without talking to my attending physician first. Still, Dr. C. was all that was standing in the way between me and Christmas with my family, so I made it a point to show up an hour early to prepare.
When I arrived at the pre-op area at noon, I saw that Dr. C. already had an emergency case. It was a 78 year old male with an incarcerated hernia in his abdomen. This meant that the bloodflow to a section of his intestines was cut off and if we didn’t operate soon, those organs would die. I caught Dr. C. as he was walking out of the patient’s room and introduced myself as confidently as I could. He said “nice to meet you,” and then walked briskly away as he worked to get things ready for the case. Hoping Dr. C. would not remember our earlier phone call, I followed him silently, trying to stay out of his line of fire. This strategy seemed to work until we got into the operating room. I did not scrub in, but Dr. C. still managed to remember to ask me a pimp question. “What are the three most common causes of small bowel obstruction?” Every resident learns in medical school that adhesions from prior surgeries is the number one cause of small bowel obstruction, so I immediately named that cause. Then, Dr. C. gave me a few seconds to think some more before before pointing at the patient on the operating table. “Hernia,” I said. When he asked me the third cause, I replied, “I don’t know.” I winced as I prepared for the surgeon’s wrath, but he simply said in a deep voice “TUMOR,” and then moved on with the case. Fortunately, Dr. C. actually remained in a fairly pleasant mood for the rest of the afternoon. Maybe he was feeling the holiday spirit? Maybe the friendly anesthesiologist who played Christmas tunes during the operation and recounted the hilarious appendectomy scene from the movie Spies Like Us helped? In any case, the patient did well and my one day working with Dr. C. turned out to be an overall good experience. I even made it to my grandparents’ house in time for Christmas Eve dinner and was fortunate to be able to spend Christmas Day with the rest of my family as well.
New Year’s Eve
On New Year’s Eve, I was excited to work with “Dr. T.” Dr. T. is not only one of the nicest surgeons I have ever met, but also one of the nicest people in general. He is a family man, who took the week of Christmas off to spend with his wife and two small children. When you work with him, the song “Dominick the Donkey” will quickly will get stuck in your head, because it is Dr. T’s ringtone (which he will also occasionally dance to when his phone goes off). And his patient’s love him, because unlike many doctors nowadays, he focuses on them and not his computer. Not to mention the fact that he is a very skilled surgeon.
What I was not so excited about was having to stay in the hospital that evening for an operation with Dr. T. During rounds that morning, we saw a 58 year old female who had been in the hospital for a few days with abdominal pain. Imaging had shown possible appendicitis, but it wasn’t a clear cut diagnosis. Because the patient was still in more pain that morning than the rest of her clinical picture would have suggested, Dr. T. offered to remove the patient’s appendix, which she agreed to. The only issue was the next opening for a non-emergent surgery was 5 PM! So I sat around the hospital all afternoon without much to do. Then, I had to wait even longer because the orthopedics case before us ended up running late and of course there was no other surgical staff available for us with it being New Year’s Eve. I watched fireworks celebrations from around the world on YouTube to pass the time until they were finally ready for us around 7 PM. I was super annoyed that I was stuck in the hospital so late, but then as I began scrubbing to cleanse myself for the case, I noticed myself begin to calm down. A strange thought popped into my head that there was no where else I’d rather be at that particular moment than right where I was. Even though I had promised my grandparents I would join them that evening, I reflected on how few people in the world ever have the opportunity to stand at an operating table during surgery. If Dr. T. and I attempted to cut out this patient’s appendix in a house across the street from the hospital, we would be labeled as psychopaths and arrested. But in the context of a hospital, our surgery was not only legal, but encouraged! I knew that once I graduated from residency, I would no longer have the opportunity to help with surgeries. I figured I might as well make the best of the experience while it lasted.
Dr. T. opted to do a laparoscopic appendectomy and I got to hold the camera the whole time, which even though I am no longer a medical student, I still found really cool! Well, almost the whole time. Dr. T. did have to help correct the field of view from time to time. The surgery was a success and I got out at the not too unreasonable hour of 9 PM. And Mother Nature granted me safe passage to my grandparents’ house, where they had food and good company waiting for me before the East Coast rang in the new year.
Paying attention
If you don’t mind, I’m going to get a little philosophical here. Since I’ve finished watching the Hulu series Looking for Alaska (which I’d highly recommend by the way!), I’ve been thinking a lot about something John Green, the writer of the book which the series is based on, said. When asked about his definition of the meaning of life, Green responded “To try to use the gift of human consciousness to pay attention.” “Paying attention? That seems like a pretty insignificant cause to dedicate your life to,” I thought when I first heard this. But John Green is pretty smart, so I decided to think some more about his answer to one of the most profound questions humans can ask. While there is still more pondering to do, one idea is that paying attention is important because of the actions it can lead one to. Here are three examples from my surgery rotation.
-Recommending a pregnancy test on a 38 year old female who had been in the hospital for a couple of days with severe nausea and vomiting. Even though we were pretty sure her symptoms were being caused by small bowl obstruction, pregnancy should of course be considered in every reproductive age female who comes into the hospital.
-As I was changing in the locker room, I noticed a wallet on the floor. Recognizing that most people would probably not store their wallet on a locker room floor and that the next person who came along might not be so benevolent, I looked inside the wallet to figure out who it belonged to and promptly returned it to the owner.
-Noticing a Foley catheter bag that was in the wrong place prior to the team transferring a patient from one bed to another. We made sure to put it in the right place to avoid causing unnecessary discomfort for the patient.
These are all simple things, but things that I easily could have missed if I was not paying attention. And because I noticed these things, I was able to take actions that helped other people. Maybe some of you will agree with me when I say that even though technology makes our lives better overall, it also makes it harder to pay attention. Allow yourself to be aware of what you are paying attention to every day and also try to notice the things you are missing. It may be worthwhile paying attention to something new for a change.
Note: identifying details have been changed for patients mentioned in this post.
PS- A good video in which John Green pays attention to a sunset over Lake Michigan.
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OB/GYN
I just finished my first OB/GYN rotation and it was a great experience overall! My preceptor was “Dr. G.,” an obstetrician-gynecologist who has been practicing in the community for over 30 years. I found it incredible that a few of his patients were babies he delivered early in his career and are now having babies of their own! Walking into Dr. G.’s office was a little like stepping back in time. His nurse, “Dolores,” also functioned as Dr. G.’s receptionist. She would answer the phone, schedule follow-up appointments, and was constantly on the move taking vital signs and acting as a chaperone for sensitive exams as well. For his part, Dr. G. maintained a full-time schedule at age 72, seeing patients from 9 AM to 6 or 7 PM every day, often without a lunch break! He took his time with every patient, asking not only questions directly pertinent to the pregnancy or annual gynecology visit, but also questions more typical of a primary care setting, such as whether the patient always used a seat belt or if she had received her pneumonia vaccine yet. Dr. G. was an old-school doc who still used paper charts and gave his cellphone number to every patient, instructing them to call anytime of day or night if they had a concern. He was very well-liked among his patients and I learned a lot working with him and Dolores for a month. I am much more comfortable now performing pap smears and bimanual exams. I even got to help deliver two babies! In addition, I was reminded of the importance of never judging a book by its cover.
The deliveries
My first delivery was an experience that I will never forget. Prior to residency, I had only ever observed vaginal deliveries and was never directly involved. That changed one evening when I followed Dr. G. to the maternity ward to check on one of his patients in labor. Ms. A. was progressing smoothly, but it still seemed like it was going to be a while before her baby arrived. “I have to go to the bathroom, deliver the baby if it comes out!,” Dr. G. said to me and left the room. So I leaned against the wall, fully expecting Dr. G. to return well before the time of birth. Suddenly, Ms. A. yelled, “I think she’s coming out.” Dr. G. wasn’t back yet, so I jumped into the hallway to look for him, but he was nowhere to be found. When I returned to the room, Ms. A. repeated in an even more urgent voice, “I think she’s coming!,” so I ran over to her bed and got ready to deliver the baby, feeling like I had no idea what I was doing. A tuft of hair from the baby’s head was all that was visible coming out of Ms. A. Then, with the next contraction, the whole baby popped out onto the bed in one fluid motion! I stood there in shock, my gloves covered with bodily fluids, seeing the newborn lying in front of me. “Put the baby on Mom,” I heard one of the nurses say to me, so I quickly refocused, lifted the baby up onto Mom’s belly, and the nurses began drying baby off. Meanwhile, the baby took her first breaths of fresh air, Ms. A. cried tears of joy, and her family in the room was elated. Naturally, at that point Dr. G. walked back into the room and seemed pleased with how everything had gone. He delivered the placenta and guided the father in cutting the umbilical cord. I was just glad that both Mom and baby were alright. Fortunately, my second delivery went much smoother. Dr. G. was right next to me the whole time and I again got to experience the amazing feeling of being the first person to hold a baby after birth. There is nothing quite like it.
Will I practice obstetrics after residency? Probably not. As amazing as it was to deliver a baby, I worry about the time commitment and malpractice that goes along with it. I had the opportunity to talk to one of my family medicine attendings whose “retirement job” is precepting the residents in clinic a couple times a week. He delivered countless babies over the course of his career and while he does not regret it, it did cause some stress in his personal life. I imagined the worst part of practicing obstetrics would be being woken up in the middle of the night to have to go to the hospital. My attending disagreed, saying that getting woken up at night wasn’t that bad. What was really difficult for him was having to tell everyone in the middle of a family gathering that he had to leave. Or there was the time (before cellphones) when he left his wife in the middle of a movie and then forgot to return to the movie theater to pick her up until several hours later! I am sure that my attending’s spouse is quite supportive and forgiving since she is still with him all these years later.
Trying not to be judgmental
In medicine, one is supposed to treat every patient equally, but that is easier said than done. Around 5 PM one day, when I was feeling tired and ready to go home, a 17-year-old female named Ms. T. walked into the clinic for her initial obstetrics visit. Reflecting on the experience, I am saddened that I instantly had several assumptions about Ms. T. before she had even said a word to me and Dr. G. “Here’s someone who’s way too young to be pregnant.” “She must be irresponsible and uneducated.” “Even though her boyfriend is being supportive now, he’ll probably be gone within a year or two.” Still, I was there to learn, so I listened in as Dr. G. interviewed the patient in her office. Ms. T. was from a small town in Western New York and lived with her Mom and 15-year-old sister. This was Ms. T.’s first pregnancy. My assumptions began to unravel when the patient asked Dr. G. if he could give her more prenatal vitamins. “Okay, so this patient is doing at least one thing right if she is taking prenatal vitamins.” Then, I found out that she had already earned her GED and was enrolled in a local community college working on her nursing degree. “Hmm, I guess she’s more educated than I initially thought.” On top of that, the patient was also working part-time as a waitress to help make ends meet. Dr. G. explained to the patient that in four to six weeks, she could undergo prenatal screening for Down syndrome and other genetic disorders. Would she terminate the pregnancy if Down syndrome was found? “No,” Ms. T. confidently told Dr. G. “I will love the baby no matter what.”
By the end of the encounter, I had a lot more respect for Ms. T. than when I initially saw her. I had no reason to believe she would be anything but a great Mom when her baby was born. But what if Ms. T had ended up being the uneducated, irresponsible 17-year-old I had assumed she was? I like to think that I would have had the same amount of respect for her, but the reality is probably the opposite. It’s too early for me to start becoming jaded as a resident. I resolve to be more cognizant of the unconscious judgments I make about patients, because I know that it will allow me to provide better care and become a better family physician at the end of the day.
PS- Two videos I’d recommend if you have time to watch them. The first is from the vlogbrothers about their new project with Partners in Health to improve healthcare in Sierra Leone. Sierra Leone has the highest maternal mortality rate in the world- 1 in 17 women die from pregnancy or childbirth. In addition, I recently watched a PBS documentary on abortion in the United States. I found it difficult to watch at some points, but would recommend it.
That’s all for now. I’m currently back on internal medicine again. Just 4 weeks to go!
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Geriatrics
I just finished my geriatrics rotation. Overall, it was kind of depressing. I was based at a nursing home just outside of Rochester and a lot of days it felt like most of the patients there were just waiting around to die. It was common to see people asleep in their rooms with a TV blasting, patients shouting at caregivers due to confusion, and dining rooms that were eerily quiet, because everyone was just staring into space. I was reminded of a quote from the book Dr. Fulford’s Touch of Life that I read during my osteopathic medical training. Toward the end of his career, Dr. Fulford said that he preferred to work with pediatric patients, because “adults emit less energy than children; they give back little while you give them everything, which causes [him] to feel depleted.” Now, this is not true for all geriatric patients (which is everyone over 50 years old according to one definition!). For example, I always feel more energized than drained after spending a weekend with my grandparents in Rochester. But it is true that as we age, it becomes more difficult for us to take care of ourselves and do the things we enjoy. In an attempt to stay focused, I will reflect on three things: Western vs. Chinese culture of caring for the elderly, the providers I worked with, and the patients I met. Even though a nursing home can be a depressing place, there are moments of inspiration if you keep your eyes open for them.
Western vs. Chinese culture of caring for the elderly. I should start by saying that I am half-Chinese. So I have always been mindful of the difference between Western and Chinese cultures. In the US, nursing homes became widespread after the founding of Medicare in 1965. After it was decided that health insurance would be guaranteed for everyone 65 and older, many geriatric patients chose to live in nursing homes to avoid being a burden on their children. In Chinese culture, however, there is the concept of yang er fang lao, which literally means “bring up children for the purpose of being looked after in old age.” It is not only socially acceptable, but it is expected in many Chinese families that when parents become elderly, their children will take them into their own homes to care for them for the rest of their lives. Both cultures place an emphasis on caring for the elderly, the difference is in how the care is provided. My main critique of nursing homes is that there are too many patients I saw over the past month who did not have a single family member visit them during that time! If you have a family member or friend currently in a nursing home, please make time to visit them. It may not be fun, but I observed that outside visitors always brightened our patients’ days.
Providers. I worked with two excellent providers during my geriatrics rotation- a physician assistant named “Nate” and “Dr. T.” Each morning, I would meet Nate at 8 AM and he would assign me some patients to see on my own. After, we would go on rounds together, and I was always impressed by how he seemed to know every patient’s name from memory and the caring manner in which he treated every patient. Around 10 AM, Dr. T. would arrive and I would switch over to working with him. Dr. T.’s greatest strength was that he loved to teach. He always had interesting tidbits from his experience as a geriatrician to share with me and would have me review geriatrics powerpoints during lunch while he completed his dictations. Although I do not see myself becoming the medical director of a nursing home after residency, I do care about competently caring for the elderly. As a family physician, I will keep the lessons that Nate and Dr. T. taught me in mind moving forward.
Patients. In the beginning of this post, I mentioned that there are moments of inspiration in a nursing home if you look for them. My first inspiring patient was Ms. A. Ms. A. requires a wheelchair to get around, but unlike most of the patients who were sedentary, she would roam up and down the hallways, greeting all the staff with a smile. I was always amused when I was sitting in Dr. T.’s office and Ms. A. would pass by, trying to make eye contact with us. Whenever I waved, it always brought a smile to her face. Then, there was Mr. B., who was also confined to a wheelchair and experienced painful bladder spasms throughout the day. He told Nate and I one morning that he texts his nine grandchildren every morning that “LIFE IS GOOD.” This has been his been his mantra for the past twenty years since his wife passed away. Mr. B.’s only flaw was that he was a Yankees fan, but I guess I can forgive him for that. Finally, there was Ms. C. Ms. C. is one of my continuity patients and I would always try to see her last because of how she brightened my day. Even though she has severe dementia, I was impressed by the quality of conversations I could have with her. When I asked her what she did that morning, she would tell me how she had gone to feed the animals on the farm and was going to eat lunch with her parents later. Instead of futilely trying to bring her back to reality, I would just try to keep stimulating her brain, asking her what her favorite animals were and about pictures of family members on her wall. Ms. C. always seemed happy to see me and I always felt bad when it was time for me to leave. Fortunately, since Ms. C. is a continuity patient, I will still have the opportunity to go check on her every couple of months, even as I begin my gynecology rotation this week.
PS- A poem from the dementia wing of the nursing home:
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Cardiology and Night Float
I had two weeks of cardiology following vacation and it was really a nice rotation to ease me back into residency life. Hours were generally 8 am- 4 pm, M-F. I’d start the day in the hospital where I would help the cardiologist on-call see any consults and then we’d spend the rest of the day in the office. I improved at reading EKGs and learning how to manage a-fib, ACS rule-outs, and other cardiac conditions.
Boy, are those cardiologists busy! In addition to seeing patients in the hospital every morning and taking care of clinic patients, they also read up to 30-40 echocardiograms and stress tests a day! Sometimes, when I returned from lunch, it seemed like the cardiologist had not moved from his or her chair since I saw them previously. So if there was one downside to the rotation, it was that there was not as much one-on-one teaching as I would have liked. Still, I am grateful that the cardiologists never seemed to get upset when I interrupted to ask a question.
There was one EKG review with Dr. C that I will probably never forget. Dr. C. probably spent the most time teaching me out of all the cardiologists and really helped me with EKGs. I’ll never forget one practice EKG we reviewed together that was of a “42-year old very obese woman presenting with pleuritic-type chest pain two days after a 10 hour car trip to a Nascar race in North Carolina.” For readers outside of medicine, I will tell you that this scenario pretty much screams “pulmonary embolism (PE).” So when I read the EKG, I jumped right into looking for the prominent S wave in lead I and all the other diagnostic criteria of a PE. But when I presented my interpretation to Dr. C., he did not seem happy with me. “What else is going on?” “Right bundle branch block?,” I guessed. Nope, the QRS duration was less than 0.12. “What else is going on?,” Dr. C. repeated. I could feel myself start to blush as I stared hopelessly at the EKG. “Look up the differential diagnosis of prominent R wave in lead V1,” Dr. C. said as he left me to go see a patient. Eventually, with some continued prodding and encouragement, Dr. C. helped me to see that there was also right ventricular hypertrophy present on the EKG. This is an important finding, since right ventricular hypertrophy and PE are directly related, but Dr. C.’s bigger teaching point for me was that I should always read EKGs systematically and not jump to making the diagnosis, as tempting as it is to do so. That way, there is less of a chance of missing things. Despite my struggles, Dr. C. still gave me a very good evaluation, for which I am grateful. I will remember his kindness in the future when I have students who are struggling to understand a concept, knowing that I was right there once too.
After cardiology, I had my first two weeks of night float. The hours were 6 PM to 6 AM, Sunday through Friday. I was the only resident on the service and there was also an attending hospitalist physician which was nice. I was responsible for admissions from the ER, the general medical floor and ICU, and outpatient calls.
One of my busiest nights was none other than Friday the 13th. There also happened to be a full moon that night, which reminded me of a chapter from Dr. Atul Gawande’s book Complications that is summarized here. When I arrived at the hospital, the day team reported to me on sign-out that it had been a crazy day. Several of the patients on our service were not doing well, and while the team had been trying to make them better, there was also an influx of admissions from the ER which was packed all day. People came in with injuries from car accidents, falls, severe infections. There was even one patient whose vitals crashed when he was turned onto his right side, likely due to a ruptured AAA. We were still waiting for an official read on the CT scan as the patient was being transferred to a tertiary care facility. The evening did not go much better for me as I got admission after admission combined with inpatients needing help on the floor and outpatients seeking counsel over the phone. Finally, as I clicked “sign” on my last admission note, I looked at the clock- 12:01 AM. “Well, at least it’s not Friday the 13th anymore,” I remarked out loud. One of the nurses laughed and said, “I like the way you think, doc.” Sure enough, the rest of the night was calm.
Overall, night float was not as bad as I thought it would be. It did get very busy at times, but there were other times in which it stayed quiet for hours and I just sat around and watched TV. Also, I did learn a lot, especially from having to make countless patient care decisions on the spot and then following up with them to see what happened after. The worst part was having to stay up all night and then sleeping during the day. I feel like you miss out on a lot in life when you work the night shift, so I definitely have a newfound respect for people who do that year round. Now, I am on my first week of geriatrics, which consists of the daytime hours I am more used to. Hopefully, my sleep/wake cycle will reset soon.
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Avoiding burnout
This post is intended for more for my fellow residents and med students, but everyone is welcome to read it of course. Physician burnout is a hot topic right now in healthcare and it is something I have thought about a lot as a new resident. Part of burnout is the sense that physicians’ can’t simply ask “what is best for the patient?” because of all the competing interests at play (thanks for the article, Rich!). The three-part essay “Resident Wellness is a Lie” is also a really good read that reflects on failures to prevent resident physician burnout.
I think the main conclusion I have come to regarding physician burnout is that unfortunately, there is no one-size-fits-all solution. Every resident has to figure out for him/herself what works best within the constraints of their specific program. Two strategies that I have found helpful are doing something “extra” for patients once in a while and remaining curious.
As busy as IM got, some of my fondest memories from the month stemmed from doing things I wasn’t required to do. First, I took extra time to really counsel a patient on smoking cessation. Mr. A. was 40-year-old male in the ICU for alcohol withdrawal, so obviously his addiction to alcohol was the bigger issue. But I also knew that he had been using a nicotine patch for the past few days in the hospital, so I opted to do a little more than the standard, “did you know that smoking is bad for your health, sir?” When I returned after rounds one day to sit down and talk to Mr. A., he told me that he had struggled to quit smoking over the years, but he did intend to now quit smoking and alcohol. I then took the time to draw him the lung curves on a piece of paper for a non-smoker, smoker, and someone who quits smoking. I showed him on the graph how if he stopped smoking now, he could possibly add 5-10 years to his life. Mr. A. seemed surprised and happy to learn this information and thanked me for talking to him. Now I have no idea whether this patient will follow-through on quitting smoking and drinking, but I tried to show during the five minutes I talked to him that I truly cared about him not just as a patient, but as a fellow human being.
The other example I have of doing something “extra” is when I did osteopathic manipulation for a hospitalized patient. I’ll call him “Mr. B.” and he was a 60-year-old male who was in the hospital for pneumonia during my last week of IM. As I was admitting the patient, he complained of a terrible muscle spasm in the right side of his neck. So even though I was busy, I decided to spend five minutes doing OMT on him. I started with suboccipital release, did some gentle muscle energy to stretch out his SCMs, and finally did AA joint muscle energy. Mr. B. told me he felt a lot better after and I gave him a business card for the resident clinic in case he wanted additional OMT treatments in the future. As a result of the successful OMT treatment, I noticed that I felt better too, and had a little extra spring in my step for the rest of the day.
The second strategy I have used to combat burnout is trying to stay curious. This is essentially the argument made by Dr. Siddhartha Mukherjee in his NYT article last year, “For Doctors, Delving Deeper as a Way to Avoid Burnout.” I have realized that, in medicine, the necessity of constant learning is both a blessing and a curse. A blessing because I should never get bored if I am doing my job well, because there are always new things to learn or refresh myself on. A curse, because the potential work and studying never end. Again, every physician has to find the work-life balance that works for them. I am trying to get better at recognizing when it’s time to close my laptop and go spend some time outside or with family and friends.
One of the best ways I have seen curiosity described was in John Green’s novel, “An Abundance of Katherines.” The story centers on the 17-year old child prodigy, Colin Singleton, who has had the bad luck of dating nineteen girls named Katherine and being dumped by all of them. The most memorable quote in the book for me was when his friend Hassan tries to explain Colin’s intelligence to a mutual friend:
“You and me will read a book and find three interesting things that we remember. But Colin finds everything intriguing. He reads a book about presidents and he remembers more of it because everything he reads clicks in his head as fugging interesting.”
I’m doing my best to take note of things every day that I find “fugging interesting” and then read about them later. Some days this is easier to do than others. But I hope that by doing something “extra” for patients once in a while and remaining curious, I can avoid the burnout that currently plagues so many medical students and physicians.
PS- If you haven’t watched the recent LWT episode about bias in medicine, I highly recommend it!
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Residency begins
I have now completed the first six weeks of my family medicine residency and am happy to report that everything is so far, so good. I survived four weeks of internal medicine, two weeks of family medicine, and am now fortunate to get a breather with two weeks of vacation. Here’s a snapshot of the beginning of my residency:
Internal Medicine
My first rotation was internal medicine, which consisted of caring for adults in the hospital. There was one attending physician, two residents, and two medical students on the teaching service. As a first-year resident, I had a cap of five patients for whom I was responsible. Surprisingly, I met that cap for most of the month of July. I had no idea that so many cases of pneumonia occurred during the summer. Here is what a typical day looked like for me:
4:30 AM- wake up
5:30 AM- arrive at hospital, pre-round on my patients, pick up new patients
7 AM- rounds with the attending physician
9 AM- work on progress notes
10:45 AM- daily safety check
11 AM- finish notes, update patient census summaries, order morning labs
12 PMish- lunch (you eat when you can on IM, there are no scheduled breaks)
1 PMish- admissions from the ER start (again, not a defined time)
6 PMish- sign out to night resident, go directly to gym
7 PM- dinner, watch Scrubs
8 PM- catch up on email, get ready for next day
9 PM- sleep
Repeat x5
I learned a lot, but it was a pretty exhausting month. The attending hospitalist physicians worked seven 12-hour shifts in a row, and then got seven days off. The residents worked six 12-hour shifts in a row and then got one day off. The only silver lining of the intense IM schedule at my program is that there are only a handful of weekends I am on-call for the rest of the year. When you’re on IM, you just accept that you have no life outside the hospital for a month.
Sundays were the worst, because I was the only resident in the hospital with the attending physician. I was still only expected to see five patients, but what made it tough was that after rounds, EVERYTHING went to me. Questions from the nurses, outpatient calls, new admissions, etc. There was one Sunday I almost lost it. I was behind on my progress notes and trying to finish up documenting an outpatient call. Then, I had to stop to answer another outpatient call and as I was on the phone, two nurses walked up to my desk. The moment I hung up the phone, one asked if I could change a medication order for one patient. The other informed me that the Bair Hugger I had ordered for another patient because he was hypothermic could only be used in the operating room and I had to order a different warming blanket instead. I almost got up and screamed in my low, monotone voice, but instead I took a deep breath and informed the nurses that I was busy at the moment, but would take care of their requests soon.
Now, don’t get me wrong. The nurses at my hospital are actually awesome and some days they are busier than the doctors I think. There were just times that I felt overwhelmed, which is normal for anyone who is new to a job I think. I was lucky to have many people watching my back at least, including my awesome senior resident who never minded when I inundated him with questions, clinical pharmacists who double-checked all of the residents’ medication orders (which is a super good idea), and attending physicians who literally did my work for me at times when I got behind, so I wasn’t behind anymore. It was a challenging month, but I do feel like I learned a lot and it could have been a lot worse. Hey, only five more blocks of IM to go!
Advice for other residents: although it is tempting to sleep all day and do laundry on your one-day off a week, try to get out of the house and do something fun! ¾ of my Saturdays off, I visited family in Rochester and the other Saturday, I went to a pool party hosted by one of the attending physicians.
Family Medicine
After four weeks of 70+ hour weeks on IM, I thought I was going to get two less-stressful weeks of outpatient family medicine, but that was not the case. It turned out that the attending physician I was working with was also covering a drug rehab facility during that time because the other doctor was on vacation. That meant that I was also covering the drug rehab facility, which was not fun to say the least. The patients I met there were often manipulative and it was really hard to say whether many of them would ever get better. I guess every physician deals with this in his/her own way, but for me it was helpful to simply remember that if Jesus returned to Earth today, those addicted to drugs and alcohol would be among the first he would go to I believe.
I have also started to see my own patients in the resident clinic and that HAS been fun. I have already had 22 of my own patient visits, which is pretty terrifying and cool at the same time. I did not do very well with my very first clinic patient. Even though I had seen lots of patients in the clinic as a medical student, there was something very different about introducing myself as “Dr. Brach” and knowing that I was now in charge of this patient’s care. Of course, it did not help that my first patient presented for “anxiety” and I was pretty nervous too. There were a lot of awkward pauses as we talked and I felt like the patient left the office more anxious than when she came in. I did successfully refill her anxiety medication for another 30 days though, so we’ll see if she returns. Since then, I have become more confident with seeing my own clinic patients, but am now struggling with time. It’s difficult to see a patient on your own, present them to your attending physician, and then go back in with your attending physician to wrap up the visit, all within 30 minutes. And that will eventually become 15 minutes when I am a third-year resident! Still, I am hopeful that I will become more efficient as time goes on in a way that does not compromise patient care.
That’s all for now. Stay tuned next week for a post about avoiding burnout.
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Graduation
Hello everyone! I am excited to announce that I graduated from LECOM this past weekend and am now officially Dr. Jonathan Brach! This summer, I will be starting my family medicine residency at United Memorial Medical Center in Batavia, NY which I am super excited about!
No one can do medical school alone and I feel indebted to literally hundreds of people, everyone from the admissions committee at LECOM that decided to take a chance on an applicant who was not accepted to any other med school to the custodial team that cleaned the hospital. And that doesn’t even include the countless other people who allowed my K-12 and college educations to be possible, including but not limited to teachers, coaches, priests, cafeteria workers, and construction workers. Here are some of the people who deserve special thanks.
Thank you to my Mom, Dad, brothers Rich and Joe, and all my other family and friends who have supported me throughout medical school! My grandparents in Rochester deserve special thanks for helping me to “recharge” so many weekends during med school and find the strength to succeed during my clinical years.
Thanks as well to all my LECOM classmates! I initially dreaded being thrown back into the grey lecture halls with all these people I haven’t really seen for the past two years, but I was humbled by how many of my classmates greeted me like an old friend and am grateful to have been able to catch up with so many people. I can’t name everyone here, but Bryan, Eli, Eric, Jeff, Jess, and Parth deserve special shout-outs! Only time will tell what kind of physicians my classmates will develop into over the next several years, but I can already tell you that these six new DOs will be great! Words cannot describe how proud I am of all of them.
I hope to continue to post on this blog from time to time during residency. Stay tuned!
PS- I would recommend the book “Becoming a Doctor” edited by Lee Gutkind to all my recently graduated classmates! Also, if you’re ever in need of some inspiration, this is my favorite scene from season 4 of Scrubs. Speaking of Scrubs, did you know J.D. is based on a real doctor? Enjoy!
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