Category: internal medicine

Talking Medicine

There’s something very gratifying about talking medicine with trainees. Regardless of their level of expertise, there’s always some wisdom to be shared.  1st year medical students are completely a blank slate and any  simple clinical discussion greatly augments their expertise.  Clinical discussions with 3rd year medical students are also extremely enriching considering how their heads are usually buried in textbooks for almost 2 years. The conversations about diagnosing and treating actual patients are both challenging and invigorating.  As interns and residents in internal medicine, the conversations about patients start to get deeper. It’s no longer just about diagnosis and treatment, but understanding and applying clinical evidence towards the best course of action in patients they are completely responsible for. This is also the time where we as medical educators who spent countless hours “talking medicine” with our trainees need to start talking about the most difficult questions facing healthcare today.

These difficult questions are aren’t about arcane diseases or curious physical exam maneuvers. We are beginning to ask about how our patients function within our broken healthcare system  For example, instead of simply talking about the different treatment options for a ganglion cyst, we challenge our trainees to ask and think about why a mother would take her daughter to the ER for that same ganglion cyst; a routine outpatient problem. We delve deeper into a patient’s day-to-day existence by trying to understand the myriad of medical and psycho-social reasons behind an elderly lady’s 3 hospital admissions within 2 months in order to identify solutions that will reduce health care expenditures and protect her from the dangers of hospitalization. Instead of simply prescribing medicines that lower blood sugars, we also talk about the cultural basis of an individual’s diet to better tackle the nutritional aspects of diabetes.

These types of issues which have no obvious answer are unfortunately the exact types of questions our trainees are least prepared to tackle. We’ve created a medical education system that emphasizes building knowledge and understanding of healthcare in terms of multiple choice questions and the absoluteness that comes with selecting a one true answer. Part of my goal as a medical educator is to deconstruct this black or white approach to thinking by asking the difficult questions and exposing how truly grey the world of healthcare is. From there, I hope some are inspired to reject the status quo and pursue careers that aim to provide great patient care, while also tackling the most complex systems issues in healthcare. This is just one of the many gratifying and important aspects of talking medicine today.

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Twitter Grand Rounds

I’m currently into my 2nd week of life here at UTSW with most of my time committed to orientation related things. But today, I was able to resume one of my favorite activities as an academic internist which is attend departmental grand rounds. It’s great because the numerous disciplines in internal medicine all gather in one place to hear a respected colleague discuss important research, clinical and non clinical topics in medicine. Today’s grand rounds was especially noteworthy because it was given by someone within my own division (general internal med) on the unique topic of secondary cancers in adult survivors of pediatric cancers. As always, it was informative and captured my full attention.
But grand rounds wasn’t always as exciting for me. As a junior faculty in my prior institution I would find myself sitting there at 8 AM, staring at power point slides desperately trying to keep focused or even stay awake. Despite interesting topics and engaging noteworthy speakers, I didn’t get much out of it. That was until I entered the world of Twitter and became fully engaged in grand rounds by live tweeting. From that moment, grand rounds became an active fun event instead of a passive attempt at learning (an experience far too familiar from my days in medical school). Twitter became my platform for self learning and engagement as well as an opportunity to share important medical advances and concepts with the world at large. I looked forward to learning and the challenge of feverishly tweeting key facts and themes. Soon, other faculty members, house-staff and medical students became involved as we developed a virtual back channel conversation each morning of grand rounds.
Now after having left my prior institution for several months I’ve resumed my live tweeting of grand rounds, having learned several interesting things about pediatric cancer survivors and their heightened risks of adult cancer. In that process, I’m confident, a few others out there in the Twitterverse have a learned a few things as well.  And like most things in social media, the connections we make are a two way street. There are many others out there, doing what I’m doing, sharing their knowledge via social media in an effort to connect our minds and expertise for the purposes of improving medicine.

@SBinternalMed
Twitter account run by former colleagues with tweets from grand rounds, noon conferences and much more!

#foamed
Free open access medical education hashtag.

#meded
Medical Education hashtag

#grandrounds
A generic hashtag of all kinds of grand rounds across the world.

@shabbirhossain
My twitter account

Sir William Osler conducting Grand Rounds
(courtesy of the medical archives at Johns Hopkins University)

A Muslim doctor gets on an airplane…

     The recent events of Tamera Ahmed on a commercial airline and the alleged discrimination and Islamophobia she endured, got me thinking about my own experiences in the air. Fortunately, I have never experienced anything as blatant as the events described by Ms. Ahmed. But as a Muslim-American, I’ve become too keenly aware of the growing specter of Islamophobia across the world. Whether it’s at a TSA security checkpoint, sitting at a terminal or falling asleep inside the plane, I have to admit I sometimes wonder if someone is watching me, thinking I’m capable of committing harm. To those that continue to subscribe to beliefs that all Muslims on an airplane are a potential danger, I offer my own personal experiences that are the opposite.
     I’ve had the privilege of twice responding to a request for medical assistance on an airplane at over 30,000 feet. The first time, I was a senior resident flying home with my wife from a well deserved vacation. The flight attendant requested anyone with medical training to assist a passenger who had collapsed near the forward bathrooms. Without hesitation, I looked at my wife and headed to the front of the plane in my jeans, t-shirt and baseball cap looking nothing like a physician or a stereotypical dangerous Muslim for that matter. I ended up converging at the front with a nurse and a radiologist on the flight. Without access to a CT scanner on the flight, the nurse and I quickly took charge of the situation :-).  We came to the conclusion the the elderly lady had a vasovagal episode brought on by a lack of sleep, and the effects of alcohol at high altitude on a body altered by gastric bypass surgery. The flight attendants were understandably worried and repeatedly asked me whether the flight needed to be diverted for an emergency landing. I reassured them and gave my blessing to press forward towards our intended destination. After the flight I caught up with the lovely lady outside in the terminal while paramedics assessed her. She was extremely gracious in expressing her gratitude. In addition to her, several random passengers expressed their appreciation. One gentleman was particularly thankful that I didn’t divert the plane and take away vacation time with his girlfriend.
     A second and similar episode occurred on another flight a few years later. This time, a passenger that was battling a stomach bug, vomited and subsequently also passed out. I once again marched to the front of the plane to assist the passenger. But this time, as I spoke to the passenger, his sister  next to him started to feel ill and weak. She too almost passed out from a vasovagal episode triggered by watching her brother heave. Fortunately, both passengers were ok as I reassured them and the flight crew that everything would be fine. And once again there was an outpouring of gratitude from a variety of people.
     As physicians, we are reminded early in our training and throughout our careers to treat all patients equally. I certainly did not ask who or what those passengers were on my flight. They were  people in a vulnerable situation who needed some help. Perhaps they even harbored the same biases and fears that plague the bigoted passengers on Ms. Ahmed’s flight or the policy makers of the airline she flew. It wouldn’t have mattered. What matters is that the vast majority of proud Muslim-Americans like myself continue to advocate unity and peace while in service of everyone in our communities regardless of sexual orientation, race, religion or any other identifier. We are your teachers, lawyers, waiters, engineers, plumbers, mechanics, nurses, doctors and all others. And occasionally we are also your guardians in the sky.
 
 

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

   

Back to the Future

    Recently, I reconnected with an old friend. We were childhood friends through college and then slowly drifted apart. Around 2001 he got married to his wife while I got engaged to medical school. Several years later, he contacted me and it’s been great reminiscing about our past lives. He has a younger brother who’s currently in medical school and remarked how he sees the same passion in his brother as he saw in me when we were younger. I chuckled thinking about what a stubborn and immature person I was in my early doctor wannabe years. Despite my ability to memorize textbook facts ( perhaps the most overrated skill for the modern doctor) my friend has a much better memory of those years. He backs his assertion that I’ve always had passion for my career by recalling a website I built in college.
    I believe I was a junior in college (circa 1998) and my efforts towards medical school were in full effect. MCATs, biochemistry and molecular biology courses, volunteer work, work-study research job and a gradually receding hairline were all happening simultaneously. In between all of this activity I became enamored with the Internet. My free college email address changed my views of human communication and connectivity. Web browsers like Webcrawler, Alta Vista and Netscape opened doors to the entire universe. With WebMD in its infancy, I began exploring health related information on the web. It was scattered and disorganized.  I saw an opportunity to build my own healthcare website that would combine my love for the internet, my desire to serve people while augmenting my medical school credentials.  I wanted a site that would provide quality information on a health topic that also appealed to the young adult crowd. So naturally, I chose sexually transmitted diseases!
   I called it “Scary Things to Discuss.” In retrospect,  it sounds cheesy but back then I thought incorporating the letters STD into the title was clever. I gathered information from both old school (library) and new school ways (online) on some common diseases such as HIV, gonorrhea and chlamydia. I also included pictures, which wasn’t easy without services like Google Images. I copied some from other websites and scanned some from textbooks to create an easy to follow and colorful page. I wasn’t a computer programming major but I did learn some basic HTML code on my own. But thanks to Netscape Navigator, they packaged website building tools in their browser for non-computer folks like me. It was a labor of love that took me several months. Once it launched, it was one of my proudest moments. I continued to swell with pride as the website gradually gained momentum with a steady stream of positive comments from all corners of the globe. I actively maintained the site for about 18 months during which time it had logged over one hundred thousand hits.
     Sadly, the website met a quiet demise. After college and working full-time I didn’t have the energy to maintain it. I regret not archiving it for posterity. I don’t even remember what company hosted the site but I do remember they went from being a free hosting service to a paid one; a deal breaker for me at that time. The website’s success was always a great conversation starter for me personally, but I actually never got to talk about it with the most important people at that time ; US medical schools. I didn’t receive any interview offers.
   Since then I still became a physician but the world has changed. I’ve become a digital health enthusiast and advocate. I see the Web 2.0 (as opposed to 1.0 back in 1998) as a critical component of modern healthcare. And I’m no longer an outlier, shouting random things about syphilis and HIV into the internet void. Rather, I’m proud to be part of an incredible movement that hopes to improve and change medicine by bringing it back to the future.

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.

   

OMG, you’re alive!

     As a  physician, it’s great to revisit the medical miracles you’ve played a hand in. In the monotony of the common every day events, a visit from that one patient who you brought back from the brink, can really lift the spirit. These moments are rare, especially if they happen while you’re a medical student or resident that is destined for a short stay in the community, never to see that one incredible patient again. Even if you stay in one place for a few years, many patients get lost to follow up (for a variety of reasons) and the curiosities for whatever happened to Mr. or Mrs. X  can fade over time.
     As a 3rd year surgical med student, I remember attending trauma clinic and following around a weary 5th year senior resident (Dr. HC) as he lurched from room to room in his scrubs and clogs doing post op checks and removing stitches with little enthusiasm but great urgency. Clinic was a chore, an obstruction from the operating room or his call room bed. One day he picked up a chart of a gentlemen Mr. D (name changed) who presented with stitches that were surfacing from his abdomen from a trauma surgery a few years prior. He knocked on the door while reading the chart, entered the room head down while still reading and introduced himself… while still reading. When he finally looked up, he stopped suddenly, grabbed his mouth and mumbled “Oh my God!”
     3 to 4 years prior, when Dr. HC was a lowly surgical intern on trauma call, he assisted on a lengthy operation on a young Rastafarian gentlemen that suffered multiple knife wounds to his abdomen. I don’t recall the details of the surgery but Dr. HC made it clear to me, that he didn’t expect this patient to survive once he was patched up and shifted to the intensive care unit. The patient had a lengthy stay in the hospital and despite the visceral experience of doing surgery on him, Dr. HC’s gypsy, sleep deprived surgical life turned Mr. D into simply another case to log and a patient unwillingly forgotten.
    After a few more seconds of disbelief, Dr. HC was finally able to drop his hands from his mouth and give Mr. D a  handshake. Mr. D’s chief complaint  were put on hold while I was told about the circumstances of how they 1st met. Mr. D actually didn’t even know who his doctors were on that terrible day but was pleasantly surprised to hear that this random resident sent to remove some stitches today, helped save his life. But Mr. D’s enthusiasm was tempered, probably due to the discomfort he was feeling that day,the difficult post op course, rehabilitation and numerous nutritional issues he’d been battling ever since his abdominal trauma. But nothing could temper Dr. HC’s smile as he grinned from ear to ear, repeating several times ” Man, I can’t believe it’s you. “
    Dr. HC was a battle weary 5th year surgical resident, in a bleak inner city hospital. During my 12 weeks as a surgical med student, he was generally pleasant but had always had a morose aura. His chance encounter with Mr. D was the first time, he looked genuinely happy. In one of those very important “teachable moments” that med students crave, Dr. HC emphasized that it’s cases like Mr. D that keep you going. It was a valuable lesson and although I didn’t become surgeon, I did become a much better doctor that day.