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When the Bells Tolled for Me

     Empathy is a big topic in medical education. How do we teach and nurture it in the next generation of doctors? Personally, I’ve noticed that students and residents with personal experiences as a patient often “get it.”
      I’ve had a few personal experiences as a patient and I think it’s helped me gain perspective. Fortunately none of my experiences were life threatening, but one them did leave a big impression.
     In the fall of 1991,  I woke up on one morning with a strange sensation. I had difficulty speaking and drool was intermittently falling from my mouth. I wasn’t in any pain and I remember finding the experience unusual and funny. My father had already left for work and with the situation unclear, my mother sent me to school with an appointment for our family physician later that day. I was happy to go and didn’t want to miss school early in the year. I remember later that morning, despite how my mouth felt, I volunteered to read a section of my social studies text book. I always considered myself an adept reader, but that day I sounded incomprehensible. I even remember the quizzical look on my teacher’s face after my attempt. I quickly realized I would have to hold back my enthusiasm for education for 1 day until my doctor could fix my ailment.
     My family practice doctor was a nice Indian gentleman with silvery grey hair. I remember vividly that his office was also his only examination room. Right next to his large, expensive wooden desk and leather chair, was an examination table, up against a wall lined by his innumerable degrees. It felt like I was being seeing in his home rather than in the sterile exam rooms I’ve grown accustomed to. I don’t recall the details of the visit, except that he had diagnosed me with Bell’s Palsy, given me “steroids,” and a consultation with Neurology. As a teenager, I found this amusing but my parents were extremely concerned. They were so concerned that any run of the mill neurologist wouldn’t do. We had to find someone affiliated with one of the major teaching institutions in New York City.
     We were lucky to get an appointment the following day. After an hour long subway ride, we were in front of a neurologist who was affable, intelligent but also eccentric with hair that only had chance encounters with a comb.The details from this part of the story are foggy. All I really remember is the concern on my father’s face after the doctor advised that we immediately go to the emergency room. For reasons that I don’t recall, my neurologist was concerned about meningitis.
       My inpatient story began like many others in the ER. The most vivid memory had to do with lumbar puncture (LP). My father consented for me, as a pleasant male ER resident explained the procedure and how pain would be minimal and to expect some post procedure headaches. I remember laying on my left side facing a wall 6 inches from my face with my arms clutching my knees close to my chest. With my bottom and back exposed, I felt the warm anesthetic burn its way through my back, while the rest of me shivered in the cold room. My father had to wait outside for what seemed like an eternity. The resident was talkative and friendly but I found it hard to focus on anything else besides my fatiguing arms and lower back. I recall several attempts at him guiding the needle to find the sweet spot. It didn’t hurt but the repeated pressure and prodding of the apparatus was unnerving. After several minutes, the physician proclaimed success and asked me what color did I think the fluid was. I guessed red. To my surprise it was serenely clear.
      I woke up the next morning with a terrible headache and nausea. This was definitely much worse than the actual lumbar puncture. I couldn’t enjoy the view from my window overlooking the East River while the smell of the hospital food made me that much more ill. Despite that, I was happy to see my eccentric neurologist who walked in like the Pied Piper with several medical students in tow. They stood around me, in a semicircle with their shiny white coats, smiles, enthusiasm and words of encouragement. The neurologist demonstrated his cranial nerve exam to the students with my Bell’s palsy playing a central role. The student’s marveled and I felt really special. I wish I could say this was that sentinel moment in my desire to be a physician and medical educator. But honestly, at age 13 although I fancied being a doctor one day, my real priorities in life were baseball cards and video games.
      The days that followed were less about my Bell’s Palsy and more about a nasty pathogen. Although the results of my lumbar puncture were negative, the Varicella Zoster virus (Shingles) reared its ugly DNA. First it was  having a party under the covers of my ear canal which many years later and only in medical school did I learn to call it Ramsay Hunt Syndrome. Soon after, it had found itself on the tip of my tongue in what turned out to be an extremely painful aspect of my illness. I could barely eat for the next several days. To this day, I’m not exactly sure if the steroids that I initially took triggered the Shingles or whether it was the Shingles itself that precipitated the Bells Palsy. Either way, it was a terrible and frustrating combination of events.
     My last distinct memory of this event was the day of my discharge. Like any patient, especially a restless teenager, I couldn’t wait to go home. The night prior, the IV line placed in my ante-cubital fossa gave out and a night float intern haphazardly (after several attempts) placed a new line in my wrist. Probably 6 to 8 hours after that, this too infiltrated and started to cause pain. My family and I rang for assistance. As minutes turned to what seemed like an hour, pain became agony as a huge bleb formed at the site, stretching my skin while likely causing pressure on the carpal tunnel underneath. I squeezed my mother’s hand as hard as I could and squinted my eyes trying to endure the pain. I’m not sure how long I waited, but I remember the catheter being pulled and the immediate relief that came right after. A large fluid filled blister was left behind on my wrist. I was allowed to go home with instructions not to manipulate the blister. Of course one day it did pop, leaving behind exposed underlying tissue that I took care of myself for several days. Luckily it never got infected, but it did leave behind a scar that I still possess today.
    There are a few other tidbits to the conclusion of this story. I parleyed the illness into a new video game system from my parents. The scar on my wrist gave me a tiny bit of “street cred” with my teenage friends. I quickly lost that  “street cred” when I regained my ability and confidence to read out loud in class (4-6 months later).  I missed over a week of school and when I returned, I got a lot of hugs from girls who would otherwise ignore me. And I remember my class portraits that year. I had an ugly crooked smile to match my ugly multicolored shirt. Most importantly, it was a vivid experience that’s given me perspective and a story to share in my life as a physician and medical educator.

“For what are we born if not to aid one another?” 
― Ernest HemingwayFor Whom the Bell Tolls

   

Happy Nurses Week!

     It’s nurses week and it’s very important that we recognize the critical role they play in all facets of healthcare. Personally through the years I’ve had the pleasure of working with amazing nurses in a variety of settings. Here are some examples of what I’ve learned in terms of working with nurses and the important work they do every day.
    Just like most things in medicine, I had to learn how to work with nurses. As a resident, I didn’t have any curriculum on team based multidisciplinary care. I had to learn things on the fly and rather quickly. I spent the majority of my internship in hospital wards where life was extremely fast paced with incredibly complex patients. I took pride in the fact that my senior residents and attendings looked to me as the “eyes and ears” of the team. But soon into internship I felt I needed help and my own sets of extra eyes and ears. Once I recognized that nurses were my partner and not my subordinate, my entire experience and education changed. Nurses were not only executing my ideas, but providing valuable feedback to help troubleshoot issues and allow the formulation of better and more efficient plans. In the busy chaotic world of hospital medicine, where medical mistakes happen far too often, it is imperative that everyone on the team are on the same page. As an intern, I tried to accomplish this by touching base with my patient’s nurses, even if it was for just 15 seconds to get feedback and let them know what I was planning to do. For any future doctors out there reading this, I can’t emphasize enough what a valuable lesson this was.
     After residency, as my career took a direction towards the outpatient world I saw a different but just as vital role that nurses play for our patients. I took a locums tenens solo practice job in a rural part of the country. It was just me, a nurse and an administrative assistant running an entire practice. Since this was a small town, the nurse knew the patients far better than I could’ve ever hoped to. She gave me insight into their lives, struggles and social dynamics that really helped me tailor my medical decision making. She also advocated for me since many of the patients were skeptical of this new doctor fresh out of training. Most incredibly, this nurse was a single mom who had Crohn’s disease and 2 children. She would occasionally come to work during mild flares of her illness in obvious discomfort. She avoided taking days off because she knew I needed her and most importantly her patients needed her. I would suggest that all doctors get to know their nurses on a human level. You will be amazed at the passion with which they play their role in medicine.
     Finally, when my career took a turn towards academics, I worked full-time in a continuity clinic for internal medicine residents. For those that may not know, in a continuity clinic, faculty supervise  interns and residents delivering outpatient care. The patients are usually quite complex, challenging with many social issues. To complicate the matter further, the interns and residents can vary extensively in clinical acumen, effort and general interest in this responsibility. This combination of patient and trainee can be a combustible mix that results in suboptimal care. That is of course if you don’t have an incredible nurse to compensate and account for everything that could possibly go wrong. The nurse I am referring to was critical in many ways for creating a successful educational experience for trainees while delivering excellent care . She would often pick up important issues and clues from patients to relay to the residents and thus make their jobs easier. She would advocate for the trainees if there was a dissatisfied patient. For the trainees that befriended her, she became a confidant and or loving mother like figure. She gave feedback to trainees directly and to me as faculty if something egregious went unnoticed. She had an endless supply of jokes and feel good chocolates to lift their spirits when the days were trying. Her presence was a vital reason why the important educational experience of continuity clinic became something trainees looked forward to rather than avoid. 

     So a special thanks to all the nurses out there in my life, past present and future. You are a driving force in our healthcare system. I’m excited that as we look to innovate and improve our healthcare system, we are all looking to you to be a vital partner in solving some of our biggest problems. Happy Nurses Week!

Coming full circle, 15 years later

     This week, I had the pleasure of participating in an information session for my medical school Alma Mater, St. George’s University. The entire experience was a bit surreal when I realized that almost 15 years ago I was one of those faces sitting in the audience, taking notes and wondering what lies in my future.
      Like many of the students that were sitting in front of me, I had doubts. I had doubts about my prospects getting into a US medical school. I also had doubts about whether going to a foreign country for my medical education would be the right decision. Standing there in front of them, I was genuinely happy to report that it was absolutely the right decision.
      It was the right decision for many reasons. First, I came away with some incredible friends, one of whom is actually getting married in a few weeks in what will be an incredibly fun reunion in Hawaii. More importantly, despite all my initial doubts, I came away with a great education and an opportunity to pursue a truly gratifying career. My other really good friend from medical school used to quote the movie Spiderman and tell me,  “When you doubt your powers, you give power to your doubts.” My belief in myself and the support of St. George’s eliminated those doubts and allowed me to excel in my professional life.
     I told my audience at the information session that at times when I was medical student, I wondered if I was as knowledgeable as my counterparts from other schools. As a resident, I also wondered if i was up to par with residents from other schools. 15 years later, I realize the answer was and always will be a resounding yes. Not only that, in my current career path as an academic internist, I’m responsible for teaching those same students and residents that I compared myself to many years ago.
     Ultimately, doubting yourself or comparing yourself to others at any point in your career is a futile and worthless effort. The fact is, we all somehow end up in the same place, which is in front of a patient in need. Everyday I am grateful for that opportunity. And as the number of those patients in need continue to rapidly grow in our country, it’s great that St. George’s is continuing to produce a steady stream of excellent doctors that are looking to make a difference just as I did 15 years ago.
   

The Ironic Illness of Izzy

     When I first met Izzy (name changed) he was a portly elderly gentlemen with an effervescent and jolly personality that lit up the clinic every time he visited. His most recognizable feature was his voice. His lifelong hobby was singing opera, as a tenor. The first time I discovered this, he belted out a few lines that echoed through our entire clinic. It was marvelous and since that moment, I always made sure my medical students and residents not just saw him, but heard him as well. He was a spectacular patient and person.
    A few years from our initial encounter, I found myself wandering the halls of the hospital with 2 medical students. They were 2nd year students looking for patients to practice taking histories and doing physical exams. Earlier that day, I received word that Izzy was admitted. Though this was unfortunate for Izzy, it was fortuitous for my fledgling doctors that such a great patient was available to talk to. And not surprisingly, despite feeling unwell, Izzy with his wife by his side, welcomed my students openly.
     I stood off to the side of the room, while my students peppered him with questions for over an hour as they tried to piece together his medical history without much experience and medical expertise to fallback on. They learned about his vocal talents and though he wasn’t well enough to sing on that day, Izzy was quick to point out how his voice swept his wife off her feet when they were in college. I thought I knew everything about Izzy from our several appointments together, but these medical students were able to illicit a entirely new story from him that even I was unaware of.
    My intrepid students were taking a travel history when they discovered his wife was originally from  South America. He reminisced about the last time they went to visit her family which was about 4 to 5 years prior. He fondly recalled staying near a seaside town, enjoying the fresh ocean air and wonderful local cuisine. The only thing he didn’t enjoy about this trip was going further inland to visit in-laws living in more mountainous areas. He recalled getting sick during that part of the trip, blaming it on some bad food and lack of sleep. His wife reminded him that he almost passed out a few times that week from feeling so unwell.
     After almost 90 minutes of questioning, doing a physical exam and sharing lots of laughs, my students and I left Izzy to go debrief on everything we had talked about. There was just an incredible amount of things to learn from Izzy. We were able to weave together his history, his physical exam, basic pulmonary physiology, and pathology to explain what had happened. I described to the students that Izzy was suffering from pulmonary fibrosis and explained some of general facets of this illness including impaired gas (oxygen) exchange and just the progressive reduction in his lungs’ abilities to perform . We reviewed oxygen disassociation curves and the effects of altitude and oxygen saturation. In light of his diagnosis, it became clear why with his reduced lung function and thinner mountain air, Izzy felt so ill on his vacation. This was probably one of the first signs of his illness until later when it became sadly obvious his opera singing days were coming to an end.
     With every patient, there’s always something to learn and Izzy’s story was no exception. For me, when I look back at his story, I began to appreciate medicine as something more than doctors treating individuals with specific diseases affecting affecting well defined anatomy through different but predictable mechanisms. Medicine, as a science has surprisingly very abstract human qualities. At times, it can be funny, or sad, thrilling, uplifting, unpredictable and often dramatic. When an opera singer that relied on powerful lungs got a relatively uncommon condition affecting those same lungs, medicine got my attention that it also has a knack for irony.

   

Learning, food and great memories

I had a few minutes so I thought I’d try and collect some of the many pictures taken at my last job that capture the spirit of learning combined with the fun and joy of eating together like a family.

At least a couple of times a month, we would hold pot lucks at our clinic while we did our Friday afternoon outpatient noon conference. They often a had a theme such as “Pi day”where we all made/bought some form of a pie.

The work we did in that clinic was often quite difficult but small events like these really made the work and learning process so wonderful!

Lot’s of great memories and I miss all of you!

Endings and Beginnings

It’s been a while since my last post. I’ve been busy and life has been changing.

For one, we had our third baby! She’s beautiful and certainly takes up a significant amount of our time (disproportionately at night!)

I’m also moving. After a lifetime of calling myself a New Yorker, we’re packing up and moving to Dallas, Texas.
I will always be a New Yorker and the emotions regarding this change are far too complex to discuss on this post.

But with this move ends a tremendous chapter of my medical life. Much of my posts on this blog were based on stories and experiences from these past 5 years.

We go into medicine because of the patients. The patients and their stories will always be the crux of my life in medicine. They will always inspire me to write and keep practicing medicine.

But these past 5 years have been about more than patients. I also took care of a different group of people. I got to be a caretaker of some pretty incredible internal medicine and med-peds residents.

They inspired me, taught me, challenged me, tested  me, made me laugh but most importantly made me proud to be a medical educator.

As doctors we love making patients better. As medical educators we love making patients better and making doctors better. It’s an incredibly fun and gratifying career path.

So with that, a sincere thank you and good bye to my trainees past and present. I hope your interactions with me were as meaningful to you as it was for me. I can’t wait for our paths to cross again as professional colleagues.

To my new patients, I can’ t wait to meet you all and take care of you

To my new trainees, I can’t wait to meet you all!. Let’s get to work to make healthcare better and change medicine!