Category: residency

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



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!

Wegener’s and Wikipedia on a cold winter morning, 2008

     The year was 2008 and I had a real swagger about me. After another long Philadelphia winter, the calendar was about to flip to March and spring. More importantly, the end of my internal medicine residency was within reach. It seemed like every day, I was doing something else for the last time. My last admitting shift, my last ICU rotation, my last 30 hour call. These were the many little aspects of a grueling residency that seemed so terrible at the time, but today is a memory I’m proud of.
     I carried that same swagger into my last morning report presentation. A miraculous catch by David Tyree and a Super Bowl victory by my New York Giants gave me the confidence to present my case with ease despite an audience full of Philadelphia Eagles fans. I presented a case about a gentleman that I had admitted for acute renal failure from Wegener’s Granulamatosis. It was a great case that generated a lot discussion between students, residents and faculty. I concluded my presentation like others by reviewing some of the evidence and literature for its treatment. With my last PowerPoint slide, I paid homage to my interests in medical history by revealing the onerous story behind the gentleman for whom Wegner’s was named. German pathologist Friedrich Wegener apparently had ties to the Nazi regime.
     My digression into medical history was well appreciated. It was a welcome break from discussing antibodies, drugs and the pure science of my case. I looked across my audience and started to notice eyes perk up as the decibel level in the room slowly increased while my presentation neared its end. I concluded my digression about the infamous Dr. Wegener by displaying my reference. It wasn’t a journal or a textbook. It was “Wikipedia, The Free Encyclopedia that anyone can edit.”
     My reference was met with a variety of reactions. There were those who looked confused and probably had never heard of Wikipedia. But there were those who laughed and found the reference humorous or perhaps comical. I wasn’t surprised by the laughter or snickers. My residency and its faculty prided themselves in the strong academic traditions of evidence based medicine. Some residents even hesitated to cite established resources like The Washington Manual or Up To Date because it wasn’t JAMA, or NEJM or Annals. I suspect back in 2008, a reference to a quirky online fad where any Joe or Jane could pose as an “expert” had little or no place in the halls of medicine academia. But as far as I could tell, the world was changing.
    Wikipedia is obviously not a fad. It is rapidly becoming the go to reference for everyone. Since 2008, the number of articles on it has doubled to 32 million, 4.5 million in English. Back in the day, I had a 25+ volume edition of the encyclopedia Britannica. I used it for all my school projects and I never questioned its authenticity. I never checked up on its references. I accepted it as truth and it got me through my academic life until Wikipedia. Modern education systems are and should rely on Wikipedia as a vital information resource just as I did with Britannica. In my opinion, Wikipedia is a monumental leap forward in civilization since it has democratized knowledge by taking the price tag off of it and allowing every citizen to contribute. One could even argue, it is everyone’s civic duty to contribute to Wikipedia, just as we expect everyone to pay taxes or perform jury duty.
   In medicine we love our traditions and the knowledge that we guard is sacred. We also have a very high standard for the quality of that knowledge. It’s part of the reason why we will probably be the last to accept Wikipedia as a legitimate source of information. But it’s already happening whether we like it or not. In my own social media study at my institution, nearly all the students who responded are using Wikipedia for both personal and professional reasons.

Social Media in Medical education student survey, Blog Post

In my day to day work with residents and students, Wikipedia is a fast, quick reliable source of pulling up a variety of types of information. I find it especially useful pulling up basic sciences information (anatomy, biochemistry, physiology etc) which is often forgotten in the fast paced clinical real world.

I think medical academia is finally understanding that we cannot hide from the digital world and that we should understand it, participate in it and help shape its future. The University of California in San Francisco medical school is embracing this.

UCSF First US Medical School to offer credit for Wikipedia articles.

The Cochrane collaboration will also be partnering with Wikiproject  Medicine to help advance this movement.
Cochrane + Wikimedicine

These are just a few examples of how medicine is embracing something like Wikipedia and the body of literature supporting it is rapidly growing. It is part of the ongoing evolution of medicine as it looks to reshape its concept of knowledge and in the process better meet the educational needs of the next generation of physicians.

Do you have guns in your home?

I did my internal medicine residency training in Philadelphia from 2005-2008. The city of brotherly love is no stranger to gun violence. It’s one of the reasons I was taught to always ask patients if there are guns in the home. If they did have guns, I was instructed to provide some counseling and literature on gun safety. But after 3 years, hundreds of patients of all sexes, ages and races, in a city notorious for crime, not once did a patient tell me they owned a gun. Nevertheless, the issue of gun safety seemed like an important patient education endeavor that I left Philadelphia with.
After residency, I decided to travel by doing some Locum Tenens (contract) work.  Having grown up in New York City, then training in Philadelphia, my view of the world and medicine felt skewed. I decided to practice medicine a little off the beaten path.
One of my many stops was rural Maine, near the Canadian border. Far from the lights of Rittenhouse Square, a small yet busy town of 15,000 lovely warm people showed me medicine was the same no matter where you are.  I was dealing with the same spectrum of chronic illnesses . I stayed true to my training and discussed wellness in all its forms. Obesity, diet, exercise, mental health, smoking cessation, addiction, prevention, I did it all. I also asked about guns. It’s this question that showed me, I wasn’t in “Kansas” (or in my case Philadelphia!) anymore.
Many of  the patients had guns in their homes. I remember the first patient who admitted to owning a gun. I was rapidly going through a series of screening questions with little expectation of hearing “yes.” When he said yes to owning guns, I stuttered, and asked again. My heart rate accelerated since I honestly didn’t know what else to ask or how to counsel him appropriately. I only asked whether it was stored safely. He proudly mentioned a make and model and reassured me no one else could get their hands on it. I also sensed consternation and an immediate change in his demeanor when he asked me how that was relevant in an annual physical.

The momentum of what was an otherwise pleasant, efficient and successful visit came to a grinding halt.

I had more questions for myself than I did for him.

Does he own a  hand gun, hunting rifle or semi automatic weapon? Does it matter?

He seems nice enough, but how much do I really trust him with a weapon?

Was this my liberal bias creeping into my medical care in a conservative population?

Do I really know enough about this person from a 30 minute medical visit to predict if this gun in his home will ever be used for the wrong reasons?

Is it really stored safely?

Do I really trust the randomness of the cosmos enough to ensure me that this gun won’t end up in the wrong hands ever?

Ultimately, these questions didn’t matter. It was his legal right to own this weapon. And so I mentally moved on  just as I imagine, Nancy Lanza’s physician may have had to if he or she were to ask the same question.