Category: primary care

Faces of the J Train

It’s been about 10 months since I left New York ; the city, the state, the place of my birth. And on the eve of celebrating the 1st birthday of my daughter back where it all started, I’m thinking about all the experiences here that made me who I am, When it comes to medicine, my career in primary care started on the New York City Subways and the J train.
    One of the few largely above ground subways, The J train continues to click, clack, roll and tumble through a myriad of diverse neighborhoods in Queens, Brooklyn and Manhattan. From 1992 to 1999 (high school and college) I made the daily sojourn into Manhattan, using the hour of time to catch up on sleep, spanish homework, chapters of Homer’s Odyssey or complete assignments for organic chemistry. What I enjoyed most of this experience was simply sitting back with my AIWA walkman (Discman later) and observing the faces of the crowd. In a city so large, the faces and the stories were rarely the same.
    My trip started in a rapidly evolving middle class neighborhood in Queens. The area was in the midst of a “white flight” as caucasians slowly moved to parts further east as south asians and west indians moved in to begin their immigrant lives, struggling to fulfill their american dreams. As the train rolled west and into Brooklyn, tree lined streets gave way to boarded up apartment buildings, police sirens and general urban decay. This was East New York, a place defined by poverty, drugs and violence. The faces from here looked like any other, but they hid struggles unique to this neighborhood . Further west, the J train passed through Orthodox Jewish neighborhoods where the modern world clashed daily with religious and cultural traditions. And finally before crossing over to Manhattan, the train would pass through Williamsburg where the struggle to survive gentrification was only just beginning.
    I no longer live in NY and ride the subways. But as a physician each day continues to feel like a subway rides except now I am the conductor that’s picking up patients, helping them get to their destination.  And just like back in the day, I try to read their faces, understand their struggles by listening to their story. But as a primary care physician I recognize their struggle isn’t simply about what part of their body hurts or what disease currently plagues them. There struggles are a composite of their illness, their life stories, their backgrounds and the streets and people in their neighborhood that helped forge their identity. And healing isn’t simply about mending a broken bone, stitching up a wound or completing a course of antibiotics. Healing is about helping the patient cross the Williamsburg bridge, into Manhattan so that they can live to carry on for another day.
 

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!

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!

Health Insurance ; A prerequisite to the American Dream

The American dream is alive and well. We still live in the land opportunity where hard work is the ticket to endless opportunities. On the contrary, bad health poses a major impediment towards fulfilling that dream. Besides the physical toll of an illness, the financial cost of an illness can make the American dream impossible to achieve. Millions of people without health insurance everyday face the spectre of their dream becoming a health care nightmare. Recently I got some great news about a family member who immigrated to the U.S a few years ago. A middle aged man with a wife and 2 kids, he came ready to do whatever it takes to secure a future for his family. An educated man, he struggled to find employment. He latched on to several different jobs that helped continue to build his skills but was given no health care benefits. He didn’t qualify for Medicaid and couldn’t afford private health insurance. Just like many Americans in this situation, his health took a backseat. But recently, he was finally able to secure a job that offered benefits including health insurance. He now had the security that seemed like a natural prerequisite towards pursuing his own American Dream. He took this opportunity to finally seek out world class healthcare. From a distance, I began to get caught up with what was happening with his health. Fortunately, he didn’t have too many medical problems besides benign prostatic hyperplasia (BPH). It was significant enough that he was referred to a urologist. He felt lucky to find a local well renowned urologist with many positive reviews (both online and word of mouth) that also took his excellent new health insurance. After 1 visit, it seemed like he was appropriately placed on some medications to try to alleviate his symptoms. What was surprising is that he was also placed on brand name testosterone replacement. Immediately, skepticism towards testosterone replacement therapy began to engulf my thoughts. I began to wonder if my family member was another victim of the “Low T” marketing campaign. Furthermore, I was shocked to find out that within weeks of seeing this doctor, he was being offered greenlight laser prostatectomy. Granted I am looking at this case as an outsider. But without trying various types of medical therapy at optimal doses and for significant periods of time, the recommendation for surgery seemed very premature. Since then, my family member has been directed to a second opinion.
Health insurance is an extremely high priority issue for most Americans. It is the sensible thing to attain, whether it is to ensure wellness or treat illness that might otherwise derail a lifetime of hard work. But my family member’s reward for obtaining health insurance wasn’t good health but rather a glut of potentially wasteful and dangerous medical care. As we continue to expand health insurance in an attempt to cover all Americans and provide them access to care, we have to continue efforts towards curtailing health care that is not evidence based, wasteful and only serves to fulfill the American dream of providers and drug companies while taking advantage of hard working naive citizens. 

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!