Category: medical education

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.

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)

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.

   

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.

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!