How Fears Change

Anup Shah
Anup Shah

By Anup Shah, MS4

When medical students start their clinical rotations, there seems to be a fear that comes with presenting a patient to residents and attendings. A large part of it has to do with individuals worrying about their evaluations, and what the rare but ruthless resident or attending may write about our performance. And everyone knows that a single bad evaluation can destroy your grade in a rotation, no matter how hard you work.

The first time I had to present a patient was on my pediatrics rotation. Nobody had ever explained to me how to present a patient. Apparently, there’s a system known as the SOAP note. Subjective (what the patients says), Objective (what the labs and test results say), Assessment (why the patient is there) and Plan (what you want to do for the patient). Now in my fourth year, this is second nature to me. But when I failed miserably once with my pediatrics resident, I wasn’t surprised when I ended up with 2/9 down the board on my evaluation.

Additionally, whenever we’d present history and physicals for new patients, I’d never know what was the important information that my attending wanted to know. It was a constant game of “What are they thinking?”  Those that could read minds best are the ones that end up with the best scores. When it came time for feedback, we often received the same non-constructive response: “You’re where we expect you to be, you’ll improve with time.”

The fact that our grades are almost solely dependent on these subjective evaluations breeds a fear in medical students that I came to realize as detrimental to my development as a physician. This fear, I’ve found, is misguided.

I feel lucky enough to have recognized this early on, and upon reflecting on my presentations I figured out what exactly I needed to work on. The conclusion I’ve come to is that expanding your knowledge base is the only way to improve your presentations. Not speaking quickly. Not writing every tidbit down in microscopic handwriting on a single sheet of paper. But knowing the right questions to ask and being effective in your presentation comes from knowing what can cause that condition. For example, if someone comes in with blood in their urine, it’s important to ask whether they’ve had kidney stones, trauma to the genitourinary tract, history of strictures (or narrowing) of the urethra, urinary tract infections, bladder or kidney cancer, etc. This may not be something a second year student would know.

In the last year, my fear has transformed from not presenting well to not knowing something important about my patient. I’ll use another example in urology, since that is the field to which I’m applying. If a patient comes in with bladder cancer invasive into the muscle of the bladder and the plan is to take out their bladder and create a new one using the intestines (aka radical cystectomy with neobladder formation), my biggest fear is not knowing something about the patient. What if they’ve had surgery on their intestines before? What if they have an allergy to the antibiotic we give them during surgery? And the absolute worst – what if the patient already has signs of metastatic cancer? In this case, a cystectomy would certainly not be the right treatment.

The fear of not doing the best for my patients has transcended any fear I’ve ever had of receiving a poor evaluation. Sure there are many levels above the medical student to catch you if you falter, but I think this is the first sign of my classmates and I becoming true doctors. When I started to feel this responsibility to my patients is when I stopped caring what the attending thought of me. I care more now about what information I didn’t gather, what questions I still need to ask, and the best intervention we can provide for our patients.

I think this is the best kind of fear to have. It’s what will make us great doctors.

White Coat Advice from an MS3

(Editor’s note: This post is a speech given at the White Coat Ceremony for the Class of 2016, in August 2012, when author and former Progress Notes editor Chaya Murali was an MS3)

Chaya Murali
Chaya Murali

By Chaya Murali, PGY-1 at Children’s Hospital of Pennsylvania

When I started my clinical rotations this January, I took the advice of many upperclassmen and stuck a little blue notebook in one of my many white coat pockets. The purpose of the notebook was simple: use it to record important lessons so they wouldn’t slip my mind. As the pages began to fill, I wasn’t surprised to realize that I had a lot to learn. But I was surprised to discover that my clinical experience was teaching me about a lot more than medicine.

Lesson 1: Believe it or not, bowel is beautiful. All right, so maybe beautiful isn’t the right word. But finding beauty and poetry in the little things sustains our spirits. You should all do it every day. On a somewhat related note: living, fully-inflated lungs are shockingly large, and vaguely reminiscent of Teddy bears.

Lesson 2: In all likelihood, your first exam during clinical rotations will crush your soul. You will leave the exam hall wondering if you’re supposed to feel this way. I’m not 100% certain yet, but I’m pretty sure you are.

Lesson 3: Learning where all the free food is, in any given hospital, is a worthwhile endeavor.

Lesson 4: Working with a good team can make all the difference. One of the great joys of medical school is the amazing camaraderie that develops almost instantly among classmates. You are all truly in this together.

Lesson 5: Caring for patients is a privilege. It may not always feel that way, especially when you’re changing wound dressings at 5:30 AM while your patients yelp in pain. But trust me on this one. Our patients are generous enough to let us in on the most intimate details of their lives, and we are able to learn as a result.

Lesson 6: The human body is an amazing thing deserving of our reverence. As medical students and future physicians, we have the unique job of tinkering with the world’s most amazing machine, and we would do well to remember that fact every day.

Lesson 7: Life is good when you’re doing what you want to do. Weekends are wonderful for seeing family and friends. There are always challenges to overcome, and more mistakes to be made, but in the end, there’s little to complain about.

Our years in medical school challenge us. They stress us out. They make us gain weight, and lose weight, and laugh, and cry, and do everything in between. Medical school makes us work harder than we ever have before. But ultimately, a career in medicine is truly a gift.

Every day, I leave the hospital grateful for my physical health, my mental well-being, and the amazing family and friends that keep me smiling even when life gets tough. I’m delighted to have chosen a career path that will allow me to touch others’ lives every day, and I am just as delighted that all of you have chosen the same profession.

The Skydiver

Donna HuangBy Donna Huang, Medical Resident

He was a man who could fly, or at least “fall for a long time,” as he liked to explain with a mischievous smile.  It was one of the first things he told me about himself when we first met in the emergency room, after I had finished inquiring about his medical and surgical history.  In addition to having survived a heart attack, a stroke, and two different types of cancer, he had been a paratrooper and a skydiver, during which time he had flung himself from a plane “more times than you could count.” He was a man who was no stranger to risks.

While a patient is admitted on an inpatient service, you get to know him piecemeal.  Lab and imaging results trickle in filling in the blanks in the clinical story you’ve elicited so far.  Meanwhile, pieces of the underlying person’s story percolate through as well: from calls to gifts from family members, as well as a story every so often.

When I met this man, it had been a while since I had been actively involved in patient care, and this stalwart octogenarian reminded me how much I loved not only the intellectual exercise of managing a patient’s disease, but also learning about the life outside the hospital walls that we are striving to return the patient to living.

He had come in with acute heart failure from atrial fibrillation, a heart arrythmia.  We had controlled his heart rate, appropriately diuresed him, and were about ready to send him home.  However, it was discovered that he had been in and out of the hospital repeatedly over the last few years from the same problem, so it was decided that a more permanent solution for this issue should be sought.

What followed was a battery of procedures and tests that the patient bore with his characteristic brand of gruff high-spirits, “I don’t mind what needs to be done if it means I might be able to get back to sky diving.”

Ultimately, it was determined that the patient had a diseased heart valve that was likely contributing to his recurrent atrial fibrillation, and the patient was offered an open heart surgery to repair the valve.  It was explained to him that with his history of heart disease, as well as chronic lung and kidney disease, that he had a 12 to 15 percent chance of dying during or shortly after surgery.   It was risky, but he decided to take the leap.

I saw him for the last time the day before his surgery was scheduled.  He admitted to being scared but also hopeful about the surgery.  I assured him and his wife that he was in good hands, thanked them for allowing me to participate in his care, and took my leave.

Four days later, he died of complications from his surgery.  This was not the first time that one of my patients had died, but for the first time, I felt overwhelmed with sadness and an even more menacing emotion: doubt.  We had followed all of the right steps – describing the proposed intervention, explaining the risks and benefits – to arm the patient with the tools to make an informed decision.

Before the surgery, even I had felt glibly confident about the patient’s outlook – 12 to 15 percent seemed like a small risk to take.  However, I had not seriously considered what exists within the space of 12 to 15 percent until I saw it spelled out in the patient’s notes in the days leading up to his passing: “unable to extubate,” “intractable hypotension,” “multi-organ system failure.”

It is a space that is uncomfortable to think about or talk about, and I think, in most discussions of risk and benefit, we tend to summarize untoward outcomes in a neat sentence or two that is not commensurate to the grief that comes to the patient and the family should they actually come to occupy that 12 to 15 percent space.

I was recently asked to fill out a survey about my attitudes towards uncertainty in medicine.  The science of medicine is that of quantifying this uncertainty – delineating risks within certain confidence intervals.  I feel that I am fairly tolerant of this brand of uncertainty.  However, this man’s death demonstrated to me a whole other realm of uncertainty that is, for lack of a better description, truly uncertain.

Despite knowing that his valvular disease would likely have continued to throw him into arrhythmias that would have landed him back in the hospital at least a few more times, could he have had a few more years with his family?  Would those years have overall been of higher quality than his last few days in the ICU? Though the patient was presented the risk of this procedure, did he truly understand the risk within his specific context; then again, did we for that matter?

It struck me that even armed with our statistics and risk calculators at the end of the day it still sometimes is not clear whether we did right or wrong or even if there is a right or wrong.  I was consoled ultimately in the knowledge that, either way, we did our best.

I am thankful to have had the opportunity to have met this man who, from the snippets that I had pieced together, had lived a tremendously rich life – who had served our country, who had created and dearly loved a family who cherished him in return, and who taught one medical student a thing or two about heart disease and reminded her of the challenging and humbling questions that she must always endeavor to thoughtfully answer in the face of uncertainty.  I like to think that at long last he is getting back to skydiving.

The First Time Your Patient Dies

Anup ShahBy Anup Shah, MS4

(Author’s Note: It has been over a year since this patient passed, but I continue to remember this as one of the most significant events in my medical school career.)

Mr. F didn’t seem like he had anything wrong with him. He just seemed paranoid. When I saw him in the emergency room, he sat in his bed wide eyed, visibly disheveled and confused. When I conducted my review of systems (asking him yes or no questions about  his symptoms), he said yes to everything. Chest pain, shortness of breath, blood in the urine, blurry vision, and on and on.

Traditionally, when we see patients who endorse every symptom in the book, we tend to disregard that part of our history and physical and try to focus on the most pressing issue. So we addressed his urinary concerns, since the first thing he mentioned was how he couldn’t pee, and that when he did it was full of clots of blood. When we ran several labs on him, we found that his cardiac enzymes, generally checked if we are concerned about a heart attack, were severely elevated. Poor Mr. F was truly suffering in more ways than one, and he was admitted shortly to the Medicine Intensive Care Unit (MICU).

We later found that he had complete blockage of three of his coronary arteries but he did not want to pursue any treatment. He also didn’t want to have any procedures for the blood in his urine, and it continued, although mild for several days. I knew that Mr. F would eventually come back to our service, so I visited him everyday in the MICU. I met him and his family, and we talked about where he grew up and how he ended up in Houston. I was happy for him when I learned that he would come back to our team for a few  days and then be discharged to a nursing home where he could be cared for.

On the day before he was to leave the hospital, our team went into his room and he was peeing clots into his Foley catheter. He seemed extremely uncomfortable and we did our best to console him. When my team walked out, I told my residents I was going to stay behind. I adjusted his bed, poured him some water and placed the cup against his dry, quivering lips.

He looked up at me the way a child looks at a parent and asked, “Is this what death feels like? This has gotta be death.” It sent a chill down my spine. I quickly responded, “C’mon Mr. F, don’t talk like that. We’re going to get you better and get you out of here.” I stuck around for a few more minutes but then left for Grand Rounds, telling Mr. F I’d see him in the morning. He didn’t respond.

The next day I went about my pre-round routine. I walked into Mr. F’s room. But he wasn’t there. It was another patient. My heart leapt. I figured he had made it out of the hospital and been transferred to the nursing home. I felt proud that we were able to get him out.

I went back to the team room and sat there before anyone else had showed up, checking labs and making sure I was ready with all of my other patients. I didn’t even bother going through Mr. F’s note. That’s when my upper level walked in and calmly said “Hey Anup, I’m sorry about Mr F.”

My stomach sank like a rock.

I scrambled to open Mr. F’s note. There it was. Apparently he never stopped bleeding. He became extremely unstable after I left, his hemoglobin dropped down to 4 (normally it is around 13-18 and drops when a patient loses blood). He had a Do Not Resuscitate order. Just before midnight he passed away. I couldn’t believe it.

The first time my patient died, I was left in a fog the rest of the day. As a medical student, you don’t have any true responsibility to your patients other than making sure you’re there to talk to them. As my team went about its business as usual (because they had no choice with 19 other patients on the service), I kept dwelling on the fact that I didn’t come back after Grand Rounds to see Mr. F. It’s not as though I could have done anything, but the poor man died alone in his hospital bed with only a couple of unfamiliar night nurses and doctors at his side. At least I knew him. At least I could have given him a familiar face. Perhaps my teammates felt the same way – they just couldn’t show it.

The first time my patient died was one of my most memorable moments in medicine, and I can’t imagine feeling any different or desensitized if it happened again. We are entrusted to care for our patients, and even if there is nothing we could do, we can’t help but feel obligated to keep our patients alive and healthy.

The first time my patient died will not be the last. Patients will die. My career will go on. But this unwavering sense of responsibility and duty to my patients is what will transform my career from “just a job” to a profession where I can truly make a difference.

Becoming the patient – It’s not easy, folks

Anup ShahBy Anup Shah, MS4

In June of 2013, I came down with the strangest illness. The events leading up to my visit to the hospital are almost as laughable as how bad I was at being a patient. But I want to share with you all the whole story because I now realize two things:

1. How much we take our patients for granted when we ask them to do the simplest tasks

2. How much we put them through when we are still learning to do basic medical procedures (especially drawing blood!)

One Sunday morning while studying at Panera Bread, I started to get the hiccups. I tried holding my breath and drinking cold water to no avail. The hiccups were minimal so I decided to ignore them and go on with my meal.

As I took a swig of iced tea, I hiccuped at the same time and aspirated some tea. That’s when the coughing fits began. I couldn’t stop coughing for the next hour. I decided to go home and take a nap and two hours later I woke up feeling feverish with convulsing hiccups.

That night, the hiccups worsened and I intermittently drank a liter of diet coke throughout the night and took Motrin and Tylenol to keep the hiccups and fever at bay.

It didn’t work. I was up at 4 a.m. and left for my clinic at 7:30. I was miserable all day. The hiccups were so bad that I thought my insides were going to collapse on themselves.

In the afternoon, I saw a patient who had a history of schizophrenia and bipolar disorder. My hiccups were so bad that the second half of our encounter was him giving me medical advice about my hiccups and he told me I should go to the hospital. I was still reluctant. On my way out the door, I made the executive decision to go to the Urgent Care Center because I was still feeling feverish.

I (somehow) drove myself to the Urgent Care Center in Baytown since both of my parents are medical professionals down there and I’d be able to avoid long wait times.

They took my temperature. 103.5. I couldn’t believe it! I next went to the ER where they drew my blood and established IV access. The nurse stuck me with the needle FOUR TIMES before she finally found a vein and said to me, “sorry, I’m at the very end of my shift.”

As annoyed as I was, I couldn’t be upset with her because I knew I would do this to a patient a few months later on my medicine rotation (update: I did…6 times). This was followed up with IV fluids, breathing treatment, a chest X-ray, and IV antibiotics.

Once I’d had fluids for a couple of hours, I felt the need to use the restroom. Again, this was not an easy task with an IV. I’m so used to just popping up, using the restroom and then resuming my normal activity, that when I had to drag the IV pole with the backside of my gown open for everyone to see, it felt like the longest bathroom visit of my life. NOW I feel terrible for leaving the room and not helping my patients use the restroom.

Now every time a patient asks to use the restroom, instead of leaving the room, I always ask if I can help them. If they say no (which I probably would have too), that’s okay. At least my conscience is clear.

Ultimately, the ER doctor told me that I was probably in the early stages of aspiration pneumonia and that the hiccups were because the aspirated fluid had gone into my right lower lobe and was irritating my diaphragm. I was given Baclofen (a muscle relaxant) and some oral antibiotics.

Not something you see every day, but I’ll tell you the biggest positive I got out of this: on my medicine rotation, we had a patient who had intractable hiccups and I suggested we use Baclofen (what was given to me) and the attending agreed. Definitely made me feel like my visit to the hospital was worth it. Maybe.

Healthy Diet: How Doctors Eat Their Words

Paras Mehta, MS4By Paras Mehta, MS4

Throughout medical school, I have seen physicians preach to their patients about the importance of a healthy diet. Physicians constantly tell patients that diet is the single most effective way to keep their heart healthy, lose weight, and prevent end organ damage from chronic diseases such as diabetes and hypertension. While a few patients heed this advice and change their lifestyle, the majority do not. Convincing patients to eat healthier becomes the most frustrating part of many clinic visits or hospital admissions.

While physicians emphasize healthy eating to their patients, many of them seem to ignore this advice themselves. Based on my observations, I would estimate that less than one-fourth of physicians regularly bring their lunch from home. The rest either obtain their meals from the hospital cafeteria or chain restaurant nearby. While there are healthy options such as Subway and Salata in the medical center, the longest lines I have seen are at McDonald’s, Chick-Fil-A, and Chipotle. And while some hospital cafeterias do have healthy options, the majority of purchases seem to include some combination of french fries, chips, desserts, and/or fountain drinks.

Here are a few solutions I believe can help physicians serve as better examples to their patients:

  1. Ban fast food from hospitals. McDonald’s has no business being located in the same zip code as a cath lab.
  2. Make healthy choices less expensive and make unhealthy choices more expensive. If a 300 calorie salad costs the same as an 800 calorie burger, most starving physicians will choose the burger. If a yogurt parfait is twice the price of an ice cream sandwich, most people will choose the ice cream.
  3. Ban pizza from conferences and lectures. Pizza is by far the most common free unhealthy meal provided, and almost anything else is a healthier alternative.

What kind of example are we setting for patients if we don’t adhere to a healthy diet ourselves? How can we expect our patients to change, if we, the supposed experts in the field, do not follow our own advice and stay healthy ourselves? And while none of us likely have the time or energy to cook meals every day, we can circumvent this by cooking in bulk 1 or 2 days a week. Just as an example, I usually cook a large batch of whole wheat pasta with vegetables/sauce/spices of my choosing once a week. I’ll take this pasta, along with greek yogurt and a fruit, for lunch every day; this takes less than 5 minutes to put together. Thus, with a little bit of planning and a few extra minutes in the kitchen, we are all capable of maintaining a healthier diet and serving as better examples for our patients.

Worth the Wait

Julia McGuinness, MS3By Julia McGuinness, MS4

Editor’s Note: All names have been changed and all patient identifiers have been removed from this story.

I will not lie. I was never so exhausted in my life as I was on Surgery. Waking up before 4 a.m. every day for my rotation on Kidney and Liver Transplant drove my body into a state of constant physical depletion. Sometimes my sleep deficit resulted in psychological exhaustion and apathy. I spent much of my time chasing lab results, almost no time with patient contact and I did not have frequent opportunities to go into the O.R. Some bitterness, even disillusionment, crept into my heart and mind. I was ready to be done.”

On the Friday afternoon after my first week on Transplant, I finally got my chance to scrub into a pediatric kidney transplant. The recipient was a teenage boy with obstructive uropathy who had already received a kidney several years before from his father and was now receiving another kidney from his aunt after his renal function had steadily declined. I was excited; I would be able to see modern medicine at work instead of spending my day in the team room. I arrived early at the O.R., gave my gloves and gown to the scrub nurse, and then waited for the surgery to start. And waited. And waited. The surgery, originally scheduled for 1 p.m., did not start until almost 5 p.m. My prior enthusiasm began to wane as I became restless. I imagined standing for hours, retracting, without getting a good view of the kidney. I just wanted to go home and sleep.

The first three hours of the surgery were spent standing and craning my neck, as I had predicted. I admittedly looked at the clock too frequently. Then, something changed. My view opened up, and I finally got a good look at the donor kidney. Shiny and grey from ischemia, it looked like a very large bean. Then, the surgeon unclamped its blood supply. Slowly but surely, a beautiful pink color diffused through the kidney until the organ was a resplendent red. I stared in awe.

The best moment had not yet arrived, though; soon after the kidney was transformed, a stream of clear urine spurted out of the donor ureter. I was transfixed by the perfect little arcs of fluid that emerged with each beat of that boy’s heart. All of the nephrology and urology I had learned in Basic Sciences was before me, not in the form of two-dimensional, cluttered diagrams of the nephron but instead manifest in the seemingly simple form of pale yellow liquid. The fellow asked, “Can you see this?” All I could do was nod my head in response; I was made speechless by the beauty and resilience of the human body. There was a communal pause to acknowledge the moment, and the transplant surgeon held up the ureter as the anesthesiologist captured a gleaming arc with his iPhone. Work still had to be done, though, and I soon lost my view again. Yet I was no longer apathetic. I had finally seen the miracle of human physiology with my own eyes.  I have no plans to pursue a career in surgery, as my talents and interests still lie elsewhere, but I will be forever grateful for the opportunity to bear witness to the marvelous beauty of the body.