Poor Outcomes

5-12-2014

I had barely gotten out of the room when I started choking up. Took a detour to the bathroom to compose myself before heading back to the resident room for sign out. I knew rotating through pediatric hematology and oncology would be tough. I tried to mentally prepare myself for it. I think it hit me all the harder cause of it.

I've been at this nearly a year now, and have seem some pretty awful things. One patient I'd been helping care for for three weeks had quickly become my favorite. He and his family were always a welcome and enjoyable stop during pre-rounds or afternoons. His room always had new photos of grandkids, family, or OSU football. He'd made some improvements, but was not making much overall progress. All he wanted was to be home for Thanksgiving with his grandchildren, and have a home cooked meal. A week before, I headed out for the night. I'll see you in the morning, I told him. I came back twelve hours later to an empty, freshly cleaned room, complete with a 'Welcome to The James Cancer Hospital' pamphlet. 

Or the time on L&D night call, after having successfully and without complications having back to back vaginal twin deliveries, the team had just sat down to have celebratory Tim Horton's. Right then, the senior got a STAT call to the L&D OR. A patient who 4 hours earlier was happy and laughing with her family with reassuring fetal signs had been rolled back for an emergent C-section. Less than five minutes from the initial incision, the baby was out, handed off to the neonatal team. They immediately started neonatal resuscitation. I held a retractor and tried to ignore the chest compression counts and calls of 'do we have a pulse? No.' In front of my eyes, the mother was having uterine hemorrhage and a flurry of activity was going on to tamponade the bleeding and sew her back together following the traumatic C-section. A midst all this, my gaze drifted to the head of the operating table. His hair was covered with a poorly fitted surgical cap, and his nose and mouth by a surgical mask. All I could see were his eyes. Through them I saw more than I can describe. Loss, powerlessness, paralysis, fear, terror, and more. I'll never forget that sight, that feeling. He wanted to protect his wife and child, but here he was, not only unable to do anything for either, but unable to even understand the chaos that was going on. All he could do was hold her hand. He and mom signed out AMA the next day to go to Children's to spend what time was left with the baby.

Today wasn't the sudden shock of things going wrong. For this toddler, things have been going wrong for a while. She has been in and out of the PICU, having a cardiac arrest with neurologic sequelae, infections and more, on top of a likely terminal cancer. Her prognosis is poor. Her mother understands this. She sees it 24 hours a day, every day. She sees the slow but steady addition of tubes, lines, and other devices. She see the daily blood draws and medication injections. I won't try to make assumptions about her feelings or guess at where on the Kubler-Ross model of grief she is. To do so would trivialize what she is going through. 

But I did get a glimpse. A peek at what may keep her going, keep her strong in the face of such sadness and tragedy. As I headed out of her daughter's room, she looked at me, and with a slight smile told me, 'I hope the rest of your patients are doing all right today.' 

A mother, who's child is so ill, on the day after Mother's Day, who has so many things on her mind, made a point to ask about the other children. I was absolutely floored. I still am.

Maybe I'm reading into it too much. Maybe she was just being polite. But, this event has so far reminded me of two lessons. First, the strength and resilience of mothers. She is going through the worst scenario that can happen to mother, and yet manages to retain her concern for others, which is more than can be said for most others. And second, it reminded me to be humble. If she can go through what she has and retain such care and humanity, what excuse do the rest of us have? Excuses like 'I'm tired' or 'I'm hungry' or 'I'm overwhelmed' mean little in the face of this. 

These stories don't have happy endings. But they're as important or more than the success stories. They remind you what is at stake day to day, patient to patient. It would be easy to slip into a detached, mechanical routine. But this field, at its core, is to care for people, not diseases. These stories of loss will hopefully serve as a reminder of that, for at least a little while longer.

Game of Thrones Houses Kayne West Theme Songs

5-5-2014: “For me to say I wasn’t a genius, I would just be lying to you and to myself.” - Kanye West

Game of Thrones Houses and their Kanye West Theme Songs

Kanye West is awesome. Game of Thrones is also awesome. As I see it, they also have a lot in common. Hence, I made this list. Disagree with any? Other houses not mentioned? Leave a comment.

Stark: Coldest Winter - Kanye West

This is obvious

Lannister: Gold Digger - Kanye West

Lannisters shit gold don't they? Always obsessing over money, debts, gold, and what not. Also, Kanye hasn't written songs about incest, as far as I know.

Baratheon: Can't Tell Me Nothing - Kanye West

All three Baratheon brothers make terrible decisions against the advice of more reasonable people.

Tully: Bad News - Kanye West

A lot of bad things happen to the Tullys. Red Wedding, Catelyn's death, Lysa is a big weirdo, Edmure is kind of a wimp, and the current heir is Robin Arryn, the kid who wants to solve all problems by 'making them fly.'

Arryn: Paranoid - Kanye West

Jon Arryn was paranoid and was killed by his own wife. Lysa is paranoid and has been holed up at the Eyrie for years, suspecting everyone of treachery, including, but not limited to, the lords of the Vale, her niece, her old husband, her new husband, and her sister.

Targaryen: Stronger - Kanye West

Seems like nothing can stop Daenerys. Went from being a little girl sold to a horseman to the Mother of Dragons, Myssa, and the Breaker of Chains. 

Martell: Hell of a Life - Kanye West

Live fast, die young seems to be the theme of the Martells. Prince Oberyn is very open about his sexual dalliances, his desire to avenge his sister Elia and her children, and his disdain for the Lannisters. He seems to be headed for a glorious, if untimely, death.

Tyrell: Good Life - Kanye West

Things are going well for House Tyrell. Margaery is Queen, they're the wealthiest of the houses now that the Lannister gold mines are empty, they have many bannermen, and Olenna Redwyne is the craftiest old lady in the Seven Kingdoms. It'll be fun to watch everything fall apart for them.

Greyjoy: Don't Like - Kanye West, Chief Keef, Pusha T, Big Sean, Jadakiss

No one likes the Greyjoys. 

Show up

4-11-2014 - '80 percent of success is showing up' - Woody Allen

Show up

'Thank you so much for coming, it means a lot'

My friends are very active people. Art shows, fundraisers, presentations, and conferences are just a small sample of things they've put on. I try to go to all of them. All those facebook invites to things that you mostly click 'maybe' to? I like to go to them. Slam poetry reading? Sure. $50/plate fundraiser for radiation oncology research? I'll see you there. I may not be interested in whatever is going on, but the person putting it on is my friend. Some friends you just see when it is convenient, like on weekends and at parties and what not, but real friends are those you show up for. 

See, by showing up, you tell that person that you value them beyond your common social interactions. You value their interests and hard work. Moreover, it shows them you're willing to put your time, your most valuable resource, at their disposable, as tangible proof of your friendship. 

Many times we have legitimate conflicts. Most others, it is really easy to make excuses and not show up. We waste so much time in a day, but we can't show up for things important to those we call our friends? 

Look at the benefits. Better friendships. Meeting new people. Learning new things. Very likely free food. Meeting new people itself should be motivation enough for those who are chronically complaining that they can't 'meet new people' or are 'sick of seeing the same people every weekend.' Finally, they'll be more likely to show up to your events. Not bad.

I'm not claiming I show up for everything. Far from it. But I try. Try it out. See what happens. Let me know.

What do you want to be?

3-19-2014 - 'You cannot back into the future.' - Frank Herbert, 'Dune'

What do you want to be?

Start any rotation, meet any medical student, or show up to any family gathering, and this question will show up. Some folks brush it off with a non-committal, 'I'm still figuring it out,' or my personal favorite, 'a doctor!' (laughter ensues and the issue is eventually dropped). Others know, med 1, day 1, 'pediatric orthopedic surgery focusing on right leg correction.' 

At this stage in training, specialty selection and the match loom large over our decisions and motivations. But our training is only going to last 3-8 years. The rest of our lives will be dedicated (for most folks) to our chosen career. What I've become more interested in is the kind of physician I'm going to become. I don't mean my field inpatient versus outpatient, but what else I'll find satisfaction in. 

When asked, most attendings will not start with, 'the diagnosis and management of (enter sub-specialty here) patients.' Many find their research most rewarding. Others truly enjoy teaching. Most at some point say the relationships they form with their patients. Some have particular projects like free clinics or medical education curriculum design they're particularly invested in. Their clinical responsibilities, whether they enjoy them or not, are always going to be there. Rather, much of their satisfaction stems from these 'other' things.

I guess the question doesn't come down to 'what do you want to be,' but 'who do you want to be?' In some ways, it is even more daunting than the match. The good news is that there isn't any deadlines or competitive application processes (for the most part). And you've got a lot more time and flexibility to figure it out. 

So who am I going to be? I don't know! I enjoy teaching, and I look forward to being able to teach with authority and weight of experience. I find a lot of satisfaction in managing people and organizing events. You get a sense of satisfaction with a tangible result. In particular, working with the Noor Community Clinic, and seeing how a small group of determined professionals can impact so many people gave me confidence that I will be able to balance my career with these ancillary pursuits.

The one thing I do know is to keep an open mind and experience different opportunities as they come about. Everything is still new and exciting and the possibilities endless. 

Whether you imagine yourself giving the keynote at the annual AMA convention, receiving a professor of the year award, or walking the halls of the hospital you are CMO of, keep these dreams alive. 

Who do you want to be?

Cluster W

3-12-2014 - 'If thou art pained by any external thing, it is not this that disturbs thee, but thy own judgment about it. And it is in thy power to wipe out this judgment now.'
- Marcus Aurelius, Meditations

Cluster W 

Cluster W is a new personality disorder category I've created for medical students. It stands for (unsurprisingly) whining. 

We all complain a lot. About lectures, lecturers, small groups, quizzes, tests, library chairs, library tables, libraries, professors, surgeons, internists, residents, attendings, fellows, other students, nurses, text size, powerpoint, ORs, EDs, surveys, emails, schedules, tuition, deans, EMRs, notes, ad infinitum 

But why? Why is whining and complaining so common among medical students? And why do we find it so acceptable to voice each and every one?

Pathophysiology:

We topped our college courses, crushed MCATs, and ruined exam curves for thousands. We volunteered away our social lives, and sat for countless hours watching proteins electrophores and encouraging mice to mate. We woke up at the crack of dawn to shadow physicians across the country. We worked hard to secure our place in medical school.

All of the above is crap. It is a common narrative to make medical students into martyrs, which we most definitely are not. 

The problem starts when folks start believing that their opinion is the Lord's gospel truth. We take the struggles we faced and persevered over as signs of our infallibility. 

Surely, if I've reached the lofty heights of medical school, I must be amazing! I sacrificed so much to get here! Therefore, everything I say must be important! 

One of the manifestations (among many many others) of this is the aforementioned whining. Everything that is a mild annoyance becomes a big deal. Almost ridiculous complaints surface. The following list contains things I've actually heard people say.

1. 'Why do they make us schedule 4th year so early? We should be able to do it the week before it starts!'

2. 'We should have our own private access library'

3. 'We shouldn't have to write notes!' (my feelings on this particular subject)

4. 'I shouldn't have to take call if I'm not even going into surgery'
5. 'We should have our own parking lot' (I am guilty of this one)

Diagnosis:

Medical students are not exempt from the insecurities faced by everyone else. However, given our success and the sense of entitlement explained above, we are far more likely to project them onto others.

Think of it like this. You're praised from day one about how smart, accomplished, and successful you are. Your family members look up to you, you are pursued by hopeful paramours, and you see the respect and prestige your title will bring you. Any insecurities you may have conflict with this new self-image. Therefore, they must be the fault of others! I should blame them! I would never make mistakes, or require criticism, so the other person must be wrong!

I see this most commonly when being criticized by residents. Residents, having been medical students just a few years earlier, are subject to the same personality characteristics as we are. So their critiques and advice can range from helpful and positive to belittling and malignant. That isn't the problem I'm getting at. The most distressing part of this is the inability of many of us to take criticism and complain appropriately.

I've seen fellow students explode on expletive laced rants in nursing stations after getting critiqued by residents and attendings. One person, who received the comment 'does not take criticism appropriately' on the end of rotation evaluation, exclaimed, 'doesn't take criticism appropriately?! Fuck you, I take criticism fine!' They didn't even blink at the irony. 

Central to success as a student (and in life) is the ability to temper your reactions to adverse situations. Not being able to control your reactions robs you of a learning experience and makes you appear childish to those around you. 

Differential:

All the negativity aside, medical students do have many legitimate things to whine about. Poor communication from various programs and courses that drops responsibilities on our laps last minute come to mind. Lack of guidance and expectations when starting clinical rotations is another one. Meetings that seem pointless. And on and on.

Problem is, this sort of stuff will never go away. At least things we whine about now generally come from our colleges that have interest in ensuring our success and happiness. Once we're dealing with insurance companies, medicare/medicaid, other providers, and countless other organizations, they won't be so understanding. 

Like everything else we learn to make habits in medical school, dealing with things we find pointless is an important one. Whining may relieve some stress, but in the, we need to find better ways to deal. Or you'll end up like the constantly negative residents and attendings we all know.

Medical Student Notes - A Defense

3-11-14 - 'We can say that Muad'Dib learned rapidly because his first training was in how to learn. And the first lesson of all was the basic trust that he could learn.' - Dune

Medical Student Notes - A Defense

'Alright, head out after you finish your notes'
- A ritual blessing and curse from senior residents since time immemorial 

Medical students do not like writing notes. Medical students (not surprisingly) also have a lot of opinions about writing notes. I disagree. I believe that writing notes can be instructive and helpful, provided that it is done mindfully and with purpose. I'll address this using three common complaints of the practice.

'I'll have to write so many as an intern, why should I have to now?'

In recent years, there has been a new found emphasis on not only understanding the pathology, diagnosis, and treatment of diseases, but of the care of the patient as an individual. This came from a recognition that after training, many physicians had poor interpersonal skills leading to decreased patient compliance and satisfaction. As a result, medical schools adjusted their curricula to include professionalism, diversity, and empathy training. The idea was to practice these important skill while in training, so they became second nature and embedded in the day to day practice of our physicians.

I think note writing is in a similar position. As interns and residents, our documentation is part of a patient's medical record, which can function as a legal document. Therefore, accurate, professional documentation is of paramount importance. Combine this with most interns following 10-15 patients on general medicine services with relatively high turnover, and it can become a set up for errors, inaccurate documentation, and copy-pasting. 

Writing notes regularly and with a focus on accuracy and efficiency as a medical student can help alleviate this problem. Similar to the focus on professionalism and empathy, making note writing and documentation a habit can only serve us in the long term. From a more practical view, the attendings and seniors you work with as an intern will recognize this as a sign of independence and reliability, and may trust you with more advanced work.

tl;dr: We're going to be writing notes for the rest of our professional lives, so practice and get feedback as a medical student when you have time and the notes don't matter to patient care.

'It has no educational value!'

One of 2nd year professors in our 'Clinical Assessment and Problem Solving' course told us something that has stuck with me since, and I try to keep it in mind. She told us to take every experience we have in medical school as a learning opportunity. This attitude is so powerful, and I wish I took it to heart everyday. 

Note writing is like this. From the outside, it can seem repetitive and essentially busy work. However, if we go into it with the intention to learn something, it can become a powerful tool to learn with. 

HPI: The HPI allows you take all the information gleaned from the interview trim it into a narrative. This helps in practicing creating a narrative that communicates key information in an easy to understand manner. As you improve in this, your ability to communicate verbally will improve as well as you realize what information is pertinent and what isn't. 

Assessment: The assessment section allows you to clearly organize and prioritize problems as well as create differential diagnoses. Even if you know a patient has a given diagnosis, writing out a short differential with a little reasoning will help you keep the differentials fresh and aware of what to look for if the diagnosis is not so clear cut. Prioritizing is also key, as it helps to triage patients and which problems a patient has to keep the closest eye on.

Plan: Much of being an intern is being able to manage most problems in a standardized manner. As students, you generally do not put in orders. Note writing is the only place we get to have practice formulating formal plans of care, and really taking our knowledge and applying it to the care of a real patient. In addition, it gives you a chance to take standardized orders, such as post-MI pharmacologic interventions (aspirin, beta blocker, statin, etc) and learn the reasoning for each of these. It gives you a chance to ask yourself, 'why are we starting X drug?' and to research it.

Progress Notes: More than H&Ps, inpatient progress notes seem like busy work. For many services, after a patient is stabilized, it is a waiting game until a drug level is achieved, or a lab value normalizes, then the patient can be discharged. Not much changes with the assessment or plan. Despite this, progress notes provide an opportunity to reassess the patient's condition, and most importantly, learn and document how a patient should respond to appropriate medical care.

tl;dr: Notes are an opportunity to delve into patient care as well as organize data and create learning opportunities. 

'No one will read it anyways!'

This is the weakest argument. Medical training is designed to transition you from a student to an independent practitioner. The attitude that you need to be constantly supervised is therefore counterproductive. In the end, you're only responsible to yourself and your patients. Beyond just learning the best, most efficient way to write notes, I firmly believe the practice of forcing yourself to keep up with your notes will encourage you to become more independent.

We need to change our attitude from doing things to impress our supervisors to doing them to ensure we become competent, caring, efficient physicians. There won't always be supervisors to impress, but the patients will always be there.

A re-introduction

3-10-14

I've decided to re-start blogging. My short lived blog from my teaching days (Lessons from the Wild Hundreds http://tariqaeps511.blogspot.com/) really helped me work through things that came up in the classroom. Even if I didn't find solutions, I did get inspiration and was able to reflect on the situations around me.

A lot has changed since then. Coming up on my final year of medical school, I've had many experiences, but through the hustle of it all, haven't had too much time to look back and reflect. Similar to my previous blog, I think I'll use experiences I have and have had during my medical education as launch points for more general themes and situations happening around me.

My hope with this endeavor is to be mindful of my own reactions and development as a physician in training and as person.