Back to basics

It’s easy to get caught up in academic medicine. The variety of work is what always drew me in. One day you’re seeing patients of all ages. The next day, you’re working with medical students and sometimes even undergraduate students. Wednesday, you might be working with interns and residents. Thursday, you’re meeting with office staff and administrators working on practice redesign and quality improvement. Friday, I might be working on faculty initiatives. Every day, brings new and different challenges.

It’s a hectic pace, and one in which it’s easy to lose sight of what’s important and our motivations to get into medicine in the first place. For most of us, what initially drew us to medicine are the patients. For many, especially those that pursue specialty career paths, I imagine it’s not just the patients, but also specific disease states that drive their motivations. As a primary care physician, it’s not the disease, but the entire patient that I’m most interested in. When I look at the myriad of things I do, I’m starting to feel patient care is the most enjoyable part of my week. I really relish the variety of challenges  I tackle every day but it’s helping patients overcome their own challenges which really brings a smile to my face.

Although I consider all my jobs important, this blog post is meant to be a self reminder to keep within my sights what’s most important ; the happiness and success of my patient and parallel to that, my own contentment.

 

 

 

 

Restart

It’s been several months since my last post.

Each time I plan to come back, I keep trying to figure out  how to summarize the events of the recent past.

Do I write about new or old experiences as a primary care doctor?

A new position and experiences working in a safety net  system?

10 years of marriage and how to balance work and family?

The differences between life in New York and Texas?

The challenges of leadership and changing culture?

Politics, change and the new world order?

But I think I realize it’s too daunting to look back.

You just have to think and write in the moment.

Restart and move forward.

 

 

 

Healthcare in the fringes

Yesterday, for the 1st time I had the opportunity to supervise a group of intrepid 1st year medical students taking care of real patients. Working under the auspices of the North Dallas Shared Ministries, these neophyte doctors took time out of their incredibly busy lives to spend an evening taking care of walk-in patients who have no where else to go. It’s an incredible opportunity for these students to start practicing their craft at a very early point in their careers, providing much needed services to folks who lives in the fringes of society.

Although it’s a great opportunity to learn for them, and  a great opportunity to teach for me, the stories that come through this clinic are a testament to the state of healthcare in our country. Here’s a sampling of the stories we heard.

1: A young talented girl that plays 2 musical instruments, attending community college, working a minimum wage job, struggles to cope with her busy life as she grieves the death of a family member in her native country whom she wasn’t able to visit because of the figurative and literal walls of immigration politics.

2: A middle aged mother gets gets a perfectly good course of donated antibiotics for a simple urinary tract infection. But unbeknownst to the medical students, lies the reality that she may never get properly screened and treated for a myriad of other chronic illnesses and cancers because she has no access to real primary care.

3: A young woman with recent admissions to the county hospital, returns with a recurrence of a recent illness. Without access to outpatient care and the resources to run proper diagnostic tests, we blindly treat her illness, keeping our fingers crossed that she doesn’t end up back in the hospital. 

4: A well spoken, intelligent immigrant from East Africa came to us suspecting a tape worm infection. She was quite knowledgeable about the parasites, how she might have acquired it and the commonly used treatments in her native country. We proceeded to recommend treatment only to find out that without health insurance, the 1 dose of the medication costs $250. We scratched our heads, scrambling to figure out options. Fortunately, she wasn’t acutely sick. We advised that while the organization looks for ways to pay for this medication, she contact family back home to mail her a dose. 

This is healthcare in the fringes. No where to go, no one to see, an endless cycle of repeated illnesses and a hope and a prayer for a few tablets that cost pennies elsewhere but too much in America ; the best and most advanced healthcare in the world.

Thanks again to the incredibly bright energetic students who did a great job!

UTSW Medical School

 

 

 

Overnight Call

I wrote this, while sitting at an airport at 3 am, waiting for a 6 am flight

I was very tired.

—————-

Another late night

The feeling is very familiar, though it’s been a long time.

I’ve got a headache and I’m nauseous.

I’m tired, sweaty and I pity anyone who has to be close to me.

I’d like to sleep, but I can’t. I don’t have a comfortable place to sleep. But I also simply can’t, panic stricken by the slightest vibration of my cell phone.

I’m awake, and I see and hear everything, but not everything makes sense. Most things do make sense but I’m grateful I’ve haven’t been pushed harder to make sense of more complex things.

The last time i was in bed, it was 6 AM, 21 hours ago.

I’m sitting in an airport, on a laptop collecting my thoughts of the day that just passed.

When morning arrives, in my fatigued state, I’ll have to talk about everything that happened today. Details are hard to remember in this mental fog, but they mean everything. Details save lives.

I’m not on call, but i remember this is what it feels like.

It feels like it was just a few months ago, (but actually several years ago) I was taking ICU call every 4th night. 6 am to 12 pm the following day. 30 hours. Back then, this was considered, better and more humane than what my predecessors experienced.

Today, I can tolerate the idea of sitting in an airport for 24 hours without sleep. But what I cannot accept is critically ill patients being cared for by young doctors trying to function in my fatigued state.

It really is a good thing that we’re doing away with draconian call schedules in residency.

 

The nights were long, dreary, busy and frightening with the knowledge that as each hour passed,I became more and more tired, and less and less capable of performing at maximal capacity.

The mornings were painful, mindlessly filling out progress notes trying to recall the events, struggling to explain the new stories that rolled in each night.

Walking from bed to bed, surrounded by clean, showered colleagues while wreaking of “Call stank,” I used to count the minutes  when the day would end.

When will this endless night end.

When will I take my last call? when will I never have to do this again?

 

Lady with leukemia in a blast crisis, septic and dying?

When can I leave?

Guy with hepatitis C, and in DIC?

When can I go home and take a shower?

Girl with endocarditis and MRSA sepsis?

When can I crawl into bed?

New admit for ARDS.

I feel nauseous, I can’t breathe, I need some fresh air.

The old-timers can argue of the virtues of long call shifts, the toughness it takes and the sense of responsibility and accountability it takes to perform under duress.

But the truth is, human physiology and billions of years of evolution demand 8 hours of sleep. Patients deserve doctors who function at optimal mental capacity. Doctors are humans  and they deserve not to have their mind stripped, their bodies battered and their soul drained by “call.””

It’s almost 4 am. and my night here in the airport is almost done. I won’t have to do this again for quite a long time. I’m also grateful I never have to do overnight calls.

 

The Imitation Game of Medicine

I love good movies and marvel at Hollywood, their creativity and the ability to capture people’s imaginations. But I also love medicine. I especially find it amusing when I see a movie that parallels my perspectives on medicine.

Recently, my wife and I watched the Imitation Game with Benedict Cumberbatch.

Quad_BC_AW_[26237] Imitation Game, The

It was terrific.

Briefly, it’s about Alan Turing; a brilliant mathematician and father of modern computing who decoded the impossibly complex Nazi Enigma machine, helped the Allies win WWII, all while battling persecution and oppression as a homosexual in Great Britain.

The basic premise of his challenge was that he had 18 hours each day to manually decipher Nazi military messages from combinations of letters and numbers that exceeded hundreds of millions. It was an impossible daily task for even the most brilliant minds. But he overcame this by designing a machine that could break parts of the code faster than the human mind thereby augmenting his team’s ability to decipher each critical message.

Though not fractionally as brilliant as Alan Turning, my life as Internist has parallels to this story.

Patients are each like their own enigma machine. Underneath, they are an amalgamation of billions of processes (some detrimental) sending out signals that we have to manually decipher in a myriad of ways. Instead of an 18 hour clock, the clock is variable with each patient. And unfortunately despite all our best genuine efforts and available technology  we sometimes fail to capture and decrypt enough of the messages to make an even greater difference.

Essentially, medicine is still waiting for its Alan Turing moment. Right now, researchers, entrepreneurs and others are trying to find the best way to capture all the signals. Wearable technology, mobile phones, genomics, advanced blood and radiologic testing and other modalities are on a crash course towards creating a monumental repository of real-time “Big Data” on each patient. And just like Turning, despite how adept we may seem as physicians, we will need the raw power of digital computing to crack these codes

Once we do this, medicine will be completely different and physicians will be empowered with a revolutionary perspective on how we view disease and manage life.

 

Prescribing Hope

As doctors, we’re usually pretty good at recommending treatments for different illnesses. But we definitely struggle to help patients manage these illnesses. That’s because our mindset from the start of our education is to think about the disease and the correct scientifically validated answer. We rarely explore or think about the very unscientific unpredictable element of disease; everyday life.

Recently, I had the privilege of seeing a patient with one of our bright house staff that illustrated the above point. Briefly, it was a young patient with poorly controlled Type 1 diabetes with repeated hospital admissions from inconsistently managing her complex medical illness. The patient blamed her inability to manage her diabetes to difficult living circumstances related to her parents and her boyfriend

After telling me this very complex medical story, I asked the resident what we should recommend to her. Right on cue, I got the technical answers I needed to hear in an academic setting. We talked about checking blood sugars frequently, increasing her insulin, improving her diet, carb counting and stressing the outcomes associated with diabetes ravaging a body.

I then asked him, how would we going to get her to do these things when it had appeared this advice had already been rendered to her several times before. Not surprisingly, I got a bit of a blank stare.

The first thing we did was recognize she had poor health literacy. With that in mind, our goal was to explain the disease in simple terms, advocating for consistency with just a few recommendations that would ensure she has more insight into her disease while allowing her achieve some semblance of success.

The bigger question was, how do we get her to manage this complex disease successfully long term? But before we figured this out, I asked the resident what made him spend so many hours studying and working so hard as a resident. He told me, it was his hope to have a successful gratifying career while being able to share in a happy and healthy life with his family and friends. With that answer in mind, the both of us went to see the patient.

After spending a few minutes discussing diabetes, I posed a similar question to our patient. I asked her, as a young woman with her entire life ahead of her, what was she looking forward to that could help motivate her to manager her diabetes more aggressively. She kind of smiled, looked down and the floor and couldn’t give me an answer. I pressed her for an answer again, and she told me,

I dunno, just waitin.” 

She wasn’t waiting for anything in particular, but just for anything good to happen.

With that, it became painfully obvious that she was also afflicted with hopelessness. Though there isn’t a diagnostic code for that, its a chronic illness, that persistent grey cloud and lack of hope that we also need to manage in chronic illness in the poor and downtrodden.

 

 

 

 

 

 

Happy New Year

2015, was a transitional year for me. After making the big move from New York to Texas, my family and I are finally feeling settled, unabashedly happy with our big decision. It wasn’t easy from a personal and professional standpoint to leave family, friends, colleagues, patients, medical students and residents. But after a year of getting acclimated, we can now look ahead to 2016 with a sense of comfort and excitement that we made the right decision and the future is very bright.

Here are the 5 things I’m looking forward to, professionally for 2016.

5: Getting back to Twitter. For many reasons, I drifted away from being active on Twitter. But I’ve started to miss the conversations with people from all over planet who have unique forward thinking perspectives on healthcare and medical education. I also miss the energy that comes from advocating for issues that I’m particularly passionate about such as modernizing healthcare, improving access to healthcare, medical education and voicing my political opinion against bigotry, xenophobia and politicians who want to divide this country. @shabbirhossain

4: Inspiring medical students and residents. I feel part of my job as a medical educator is to show and emphasize to our future doctors that our healthcare system is a mess. We need them to be excellent doctors, but also vocal advocates for improving the system. It’s simply not enough anymore to be a good doctor and work hard. The problems in our healthcare system demand more.

3: Thinking innovatively. I’m going to keep trying to look for small (and perhaps big) ways to practice medicine more innovatively. Medicine, for many reasons has evolved at a much slower pace than most other industries. I believe the system rewards dogma, tradition and self-preservation too much to allow people to think outside the box. It’s a daily struggle not to fall into the grind of simply doing things the way they’ve always been done. But I’m hopeful in 2016, I can get my mind back to thinking more about the future of medicine.

2: Reading. As physicians, we’re always reading. Journals, news articles, blogs etc. But I want to get back to reading more non-medical stuff. I regret not taking more advantage of my liberal arts education in college. The perspectives offered in non-medical literature are critical for a physician to understand people as well the world that exists outside the human body. For example, I’ve been wanting to finish reading Money ball. My hope was to understand Saber Metrics to get an idea of how statistics can be used to understand trends and reinventing “the game.”

1: The Patients: In my short time here, I’ve already been lucky to meet and take care of some incredible patients. This is the best part of being a primary care physician. I get to be a part of the lives of patients from so many different back grounds, each with their own unique story to tell. Young, old, men, women, healthy or sick. I get to see it all, do it all and it’s an incredible privilege.

Happy New Year to everyone and hope 2016 brings good health, peace and prosperity!