Tag Archives: Residency

My Hero List Grew by One That Night

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It was early during residency. I was still adjusting to primary care clinic which included learning how the computer system worked. I still didn’t have home access to the electronic medical records so I couldn’t review my patients ahead of their appointments. I also couldn’t write my patient notes at home. All my patients were new to me. Between the challenge of learning new patients and the computer system, I fell behind in clinic one day.

My patient appointments stacked up like logs against a dam before it bursts. And, with my appointments running behind and my slowness with the computer system, the notes I had to write for each patient appointment were pushed to the end of the day.  My last appointment ended an hour late because it started an hour late.

There I was, already after closing time and just starting to fight the computer system to write my notes as fast as I could. Everyone else in the clinic had left an hour or so earlier. I was hungry because I hadn’t thought I’d need to bring dinner.  I’d already eaten breakfast and lunch at the clinic. I was startled when I heard someone in the hall. The janitor walked by my office, “Late night?” he asked pausing outside my open office door.

“Yeah. I’m new here and I’m still slow with the computer,” I said.

“And they just left you?” he asked.

“It’s okay. Hopefully my notes will be done soon,” I said.

“Well, thanks for your work,” he said.

Hours passed. One note at a time, like small footsteps, my pile of remaining work dwindled. The janitor stopped by my door again. “I got you these. It’s not much but it’s all I could find,” he said. He handed me a bag of BBQ potato chips and a mini-Fanta orange soda.

“Thank you so much! You’re so kind,” I said. I was too tired to be giddy but in better circumstances I would have been gleeful for the snacks.

“Have a good night. Hope you can leave soon,” he said and walked away, back to his own work.  

I don’t think he’ll ever know how much he saved me that night. When I was finally done with my work and as I walked through the empty clinic and then the empty parking lot to my car, I thought about how much I appreciated the janitor. I’ve often thought it odd that society focuses so much on big names and money. In my experience, heroes are always humble strangers acting out of kindness and with no motive or expectation of recognition.  

That night I was reminded that all it takes is pausing to offer a little help to transform a person’s night. The janitor clearly had already ingrained that knowledge into his existence. And like the heroes who came before him, I added the janitor to my life’s hall of fame as I walked to my car to drive home. My hall of fame isn’t a hall of fame like those for baseball players but, to me, it’s a lot more important. And, in case you’re wondering, I’ve never had a more delicious bag of chips and can of soda.

Today We Start Insulin

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“Today we are going to start you on insulin. Given your high A1C level (a lab that shows your average blood sugar over 3 months), it is recommended so that we can better lower your blood sugar. Lowering your blood sugar is important because when your blood sugar is this high it can affect many aspects of your health including severely increasing your risk of heart disease and stroke,” I said. It was the second time I’d seen this patient in my clinic. They were quick to laugh and had a full life.

The patient hung their head. This was the first time I had started someone on insulin as a primary care doctor (we use insulin exclusively to manage diabetes in the hospital, but in the outpatient setting it’s reserved for specific indications). Starting insulin isn’t supposed to be punitive but some patients feel as though it is because of the stigma associated with diabetes.

There are numerous medical diseases and conditions that are stigmatized. Among the most common I see are diabetes, obesity, psychiatric diseases, and sexually transmitted diseases. People with diabetes are often blamed for having the disease. If or when they require insulin, the patient may feel like their need for insulin is a failure because their blood sugar was not controlled with other treatment measures. People with diabetes can be labeled as “weak” and “lacking self-control.” This labeling is out-of-place and unproductive. While lifestyle (such as diet and exercise) does contribute to the development and progression of diabetes, lifestyle is only part of the story.

In addition to individual choices, other parts of life like genetics, environment, and the social determinants of health have an important impact on health outcomes including the development of chronic diseases like diabetes. Further, it is critical to be able to have open and respectful conversations about patients’ individual situations and how their lives might be optimized to manage their diabetes and to reduce their likelihood of developing complications from diabetes. Stigma gets in the way of having these open, respectful conversations. When people have diabetes, the disease can severely increase their risk of death by heart disease and complications such as vision loss, nerve damage, kidney damage, and infection. This makes management of diabetes with a multimodal approach – including lifestyle optimization and medications – essential. Judgement has no place in developing a therapeutic plan.

When I recommended insulin to my patient, it was not as punishment. It was without judgement. It was out of concern for their health. The strategies we had tried to lower their blood sugar to that point weren’t working. The patient was doing so well otherwise. They didn’t have kidney problems. Their feet still had feeling. They hadn’t had a heart attack. I wanted them to live without these complications for as long as possible.

As the patient left the appointment, I was hopeful that our new strategy would help them lower their blood sugar. I also hoped that this patient felt respected even if they were unhappy about starting insulin. I’d see how they did with the insulin at our next visit. Time would tell if insulin at the dose we started would work for them or if we would need to make further adjustments. Chronic conditions require long-term (often life-long) treatment plans. Flexibility to adjust the plan as life develops is critical for success. This patient with diabetes was no exception. I looked forward to working together to lower their blood sugar in the months and years ahead. 

More Than Half the Days

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It was a regular primary care visit and my patient felt well. I clarified several of their questions about how to take their medications properly and why some of the medical treatments we’d prescribed them were important for their overall health and life expectancy. The conversation flowed. They were engaging and exuded positivity.

It came to the part of the visit when I went through my system-generated reminders based on the patient’s medical record (topics and screenings I was supposed to review at certain intervals with my patients as their primary care doctor). Among the reminders was a depression screening questionnaire which was due.

“How many times in the past two weeks have you felt like you would be better off dead? Options are ‘not at all,’ ‘several days,’ ‘more than half the days,’ and ‘every day,’” I said.

“More than half the days,” the patient said. The questionnaire was 9 questions long. By the end, it was clear that the patient had untreated depression. Interesting how the first part of our appointment didn’t suggest depression. To uncover the patient’s depression required additional, and specific, evaluation.

“Tell me more about what you mean by these feelings,” I said walking through their answers to each of the questions on the depression screening questionnaire.

The patient would go on to describe living alone with no friends or family nearby. No activities outside the home. A lifetime of being socially awkward – preferring to be alone because of the awkwardness. Feeling as though they had a hard time connecting with people. “I thought it was just normal for someone my age,” they said, referring to their feelings of sadness and thoughts of death.

How common is depression? Is it normal to be depressed? What exactly is the difference between the medical definition of depression and a transient dark mood?

A lot about being a primary care doctor is brainstorming solutions to life’s persistent problems. Sometimes there are medications that can help, but usually the non-medication interventions and lifestyle changes are just as (or more) important than the medications.

The patient and I discussed how to take their antidepressant correctly (they were already on a medication for depression, but they were not taking it daily as intended due to confusion on how it was designed to be taken).We discussed exercise classes to strengthen the mind and body and to create an avenue to be around other people sometimes. We discussed hobbies and activities that brought them joy. We discussed what might be normal for their age.

This patient was motivated. Perhaps they could find a path to better mental health. It would take time. The brain is the hardest organ to heal. To help ease the journey, my clinic had all kinds of mental health resources (including exercise classes) patients could use for free. When we finished our visit, I walked the patient over to the mental health team’s office attached to my clinic. The mental health team would share with the patient additional resources beyond those offered by primary care such as individual and group therapy sessions.  

The statement, “more than half the days” would resurface in my thoughts for weeks to come. Not because it was unusual, but because depression is so common. I’ve known how common depression is since I entered healthcare. But, for the first time, I have the chance to help some patients find a path to healing now that I’m a primary care physician. Of course, the clinic where I work is special and has more mental health resources than most primary care clinics in the US.

What would I have done for this patient and others like them if my clinic was not set up to help people with mental health challenges? What if there were no therapists, wellness classes, or psychiatrists on staff to help any patient who came through my door? What if this patient had to wait for months before they could be seen for their mental health concerns?

When the phrase “more than half the days,” crossed my mind I thought about the 1000s of people walking around feeling they’d be better off dead more than half the days of their lives. I thought of the probability of there being time during their regular primary care visit to be properly diagnosed with depression. I thought about the probability of their primary care clinic having the resources needed to help them if their depression was diagnosed. The math suggested that many people’s depression would go undiagnosed or, if diagnosed, untreated because many people couldn’t access the treatments they needed. To be profitable primary care appointments get shorter and shorter, with many clinics scheduling appointments that are 20 minutes or less. The length of the appointment doesn’t factor in the complexity of the patient even though as patients become more medically complex, a 20-minute appointment becomes more absurd. Between health insurance access issues, healthcare costs, and healthcare professional shortages many patients don’t have access to medications, therapy, and other mental health treatments that have been proven to work.

Healthcare in the US has so much opportunity for improvement it’s maddening. No setting reminds me of this more than primary care. No disease category reminds me of this more than mental health. The better I know the US healthcare system, the less hopeful I become that it will ever serve all people. But sometimes there are little micro settings where all the resources a patient needs are there if they choose to use them. This patient was in that situation and, so, I was hopeful that they’d find a future in which they felt better off alive than dead more than half the days. I was hopeful that they wouldn’t die by suicide.

Depression can be sticky and hard to overcome in the best circumstances. But depression, like all diseases, is more likely to be cured when the patient can access the best treatments. The more I learn about healthcare, the more I believe everyone should have access to the best treatment for the most common conditions. And, currently, that is not the reality in America.

References:

Tell Me One Fun Fact About You

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It can be anything. Your favorite vacation, a hobby…

“I’ve been to 157 US cities.”

“I love my grandchildren. I like to facetime them.”

“I have a mermaid tail. It’s pink and purple.”

“I have a wife and kids waiting for me at home.”

“I liked to play basketball as a child.”

“I care about people.”

“I used to ride in the rodeo.”

“My favorite place to vacation is the Caribbean.”

“My son recently got married. I don’t like my new daughter-in-law.”

I look at hundreds of labs values a day. I review vital signs, recorded bowel movements, and urine output in milliliters for all my patients daily. I place orders and write notes. I answer a nursing question about every 6 minutes during the busiest part of my day. I discuss every patient with my supervising attending. I discuss complicated parts of my patients’ treatment with my senior resident. I coordinate with nutrition, social work, physical therapy, occupational therapy, speech, and numerous others to ensure patients are taken care of while they’re in the hospital and safely discharged. I examine every patient every day and if their status changes (like their blood pressure drops) I re-examine them. I do more, but this paragraph is already too long.

The constellation of the medical workup I order, medications I prescribe, and information I gather about my patients’ symptoms are how I figure out what is ailing them and how to treat it. As you can imagine, when so much of my energy is focused on sorting through data, it’s easy to forget that under all the data I collect are people.

The best doctors I’ve worked with each have their own way of reminding themselves that they are caring for people not just treating vessels of illness represented by labs, imaging, and physical exam findings. And, within the past few months, I decided to develop my own method as I plan to be among the best doctors. It’s tricky because as a doctor there isn’t time to learn many of the details of our patients’ lives. There is time to learn something small, however, if I prioritize it.

My way to learn something about my patients as people is to ask about something nonmedical. My phrasing is, “Tell me one fun fact about you. It can be anything, such as a hobby or a favorite place you vacationed.” I’ve learned about the most amazing people this way.

The above simple inquiry has made all the difference in my practice as a doctor and my ability to endure the hustle that is inherent to residency. It’s easier to arrive at the hospital 6 days a week by 6 am (and leave often more than 12 hours later) when I’m showing up to help someone with family and a mermaid tail to go home to compared to showing up for a pile of numbers representing blood counts, vital signs, and urine volume.

It’s the people who are the patients who make medicine different from any other profession where people aren’t the subject. And it’s the people who have shared their fun facts with me who continually remind me why I entered the medical profession and where I’m going with it. And for that, I am most grateful.

Night Float

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The hospital is 24-7 all year long so there are always staff who care for patients overnight. I was the doctor on a night medicine crew for a few weeks recently. That stretch, I worked in a veterans hospital which meant all my patients had two things in common: they were in the hospital and had served in the military.

Here are some snippets from my nights:

  • “Let us know if anything changes,” I said as I left the room having been called there because the patient’s heart rate had dipped for a few minutes. They were in the hospital because their heart was beating too slowly. Therefore, any time their heart went even slower it was concerning and I went to evaluate them. On this visit to their room, the patient’s symptoms were unchanged from earlier that night and the night before. They were stable, though lightheaded. How to best manage their heart was being explored by the day team. The patient had insomnia even when not in the hospital. I was holding the sleeping medication they’d used for months because it could make their heart slower. It was our second night together, the patient and I, and we were doing our best to get through it. They watched TV because they couldn’t sleep and I answered pages (yep, in healthcare we still use pagers and faxes), saw patients, and ordered medications as the need arose.
  • I stopped by a patient’s room early in the night because they were a “watcher” (someone who was on my “watch carefully list” because they were more likely than others to take a turn for the worse). They had recently turned 80 and were chatty. They glanced up at the news on the TV in the room, “Politics in this country is in a terrible state,” they said. I expressed my agreement. “We got shot at for this,” the patient said, shaking their head and nodding at the TV. Six million responses flashed through my mind; none expressed what I wanted to say. None made the gravity of their statement less.
  • I was called to a patient’s room multiple times over several nights. Every time they were writhing in abdominal pain. Every time they had their blanket over their head. What kind of trauma had this grown-up person survived to feel it necessary to hide under their blanket in the hospital? Our workup, so far, was negative. No explanation for their pain. We tried treating constipation and urinary retention. We tried nausea medicine. None of that helped. Tylenol wasn’t working. What else should I try? Should I give this patient another small dose of opioid medication like they got during the day? Were they seeking out opioid medication because they were addicted to opioids or were they just in pain? Did it matter if they were drug seeking because of addiction if their pain was real? Was their pain real? If their pain was real, was an opiate the best tool I had to help lessen it?
  • I walked briskly. A patient who was admitted for a small stroke had an evolving headache. Maybe it was just a headache, but I wasn’t going to just give Tylenol and not examine the patient. It would be terrible to miss a second stroke we might be able to do something about. Head and neck pain. Their neuro exam was normal – no weakness or sensation changes. I examined their neck. My heart jumped with joy. There under my fingertips was a good old regular muscle knot. We have great medications for muscle pain. Besides, hospital beds are uncomfortable. When this patient got home (especially if they stretched) their knot would surely go away. Finally, a fixable problem!

There’s something surreal about starting your shift when the sun is setting and driving home to sleep after the sun rises – driving in work traffic going the opposite direction as everyone else on the work-home axis. Some nights in the hospital seemed to move backward and other nights zoomed by. I don’t recommend the night shift and I never will – this wasn’t my first rodeo as we used to say in the ED where I first worked night shift. Yet, this was my first time on nights as a doctor. Night float afforded me more independence than I’d had previously. I grew as the nights trudged on. As I drove home on the morning of my last night shift, I felt a little bit more like a physician than I ever had before. And though tired and excited to transition back to days, the feeling of growth was rewarding.

Hey Doctor!

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I got in the hospital elevator. One person was already in it – a maintenance guy by his uniform and the fact that he had a ladder in hand. Before I’d decided if I was going to say “hello,” he declared joyfully “Hey doctor!”

I glanced down at my badged (“doctor” was written on it in capitalized black letters on a yellow background larger than anything else on the badge). I looked around the elevator…yep just me and him…he was definitely talking to me. I said, “Hi!”

“Did you have to look at your badge?” he asked in a voice cracked in the way voices are when a laugh is bubbling up. We both burst into laughter.

I’ve been a practicing doctor for 5 weeks. While I feel ready and excited to be a doctor, the title is still new and I’m learning the role. Some patients and non-doctors take the title seriously and some don’t; however, when you ARE a medical doctor, the title comes with some weight as you know exactly what responsibility is behind it.

As part of my residency training, I work in a primary care clinic where I have a group of patients for whom I’m their sole primary care doctor for the duration of my residency. This means I’ll see them when they have a new issue and I’ll also manage their health maintenance. Primary care is about tackling health challenges before they become health issues and preventing people from experiencing life-threatening events and worsening health if possible. It’s arguably the most important part of the healthcare system even though it gets the least recognition, compensation, and emphasis in our corporate/profit-focused US healthcare system.

My first week as a primary care doctor I ordered a cholesterol panel (a blood test) for one of my patients. They had obesity and chronic pain. They hadn’t had their cholesterol checked before and at their age and BMI (body mass index) I wanted to see if we needed to start a cholesterol-lowering medication to reduce their risk of heart disease. During our appointment, the patient and I had a lovely conversation about their life and the changes they’d made to improve their health. I was inspired by them because it was clear that they were motivated and dedicated to their health – they had made diet changes and were finding ways to fit exercise into their routine despite having housing insecurity and struggling to make ends meet. 

The cholesterol panel came back several hours after the patient’s appointment had ended. I looked at the numbers and panicked. How do I interpret these numbers? I asked myself. This patient was relying on me to evaluate their lab results and provide recommendations on lifestyle and medication use. It was a big burden. I read some medical resources then, based on what I read, decided that their cholesterol was okay given their other heart risk factors. They didn’t need to start a new medication. I sent them a letter with the normal result.

Even after I sent the patient a letter about their cholesterol, panic lingered in my toes. Had I interpreted the results correctly? Would I need to call them back and tell them I was wrong, and we needed to do something different? Had a missed an opportunity to help them protect their heart?

Over the next week I researched more about cholesterol panels and then talked to my supervising doctor about the topic. In the end, I confirmed that I had made the right decision for this patient. I also learned there is a calculator I should use to determine patients’ risk of heart disease and the benefit of starting a cholesterol-lowering medication.

Soon interpreting cholesterol panels will be easy and fast. But the first time I did it for a real patient (a real person) was exciting and nerve-wracking. Just like being called “doctor” in the elevator this week required a little extra processing to realize that I was the doctor being referenced. I know I won’t have to check my badge for much longer to confirm my profession. I’m excited to grow into the person who can respond without pause to “hey doctor!”

This Is How I Started Residency

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Starting residency was like a flash flood. Beginning from the first day, I was overtaken with more work than I knew what to do with. As a new doctor in a new healthcare system, I found myself equally challenged by creating care plans for my patients (like deciding which medications to prescribe them) and implementing the plans my supervising doctors and I devised (like ordering medications in the computer system). I completed tasks more slowly than I imagined possible. My patients were well cared for because I was part of a team, but my work hours lengthened in a way that the saying “burn the candle on both ends” was created to describe.

All of us headed to residency (regardless of specialty) are warned that it will be challenging. Each person experiences different challenges and different low points. Residency is hard for everyone because the hours are long and there’s a lot to learn. So, when my work hours exploded like water through a broken dam, I wasn’t surprised. I was surprised by how my program responded.

As my hours lengthened to a point where I was exhausted and just barely surviving, my chief residents stepped in to help me develop ways to become more efficient. Senior residents observed me throughout a shift and offered advice on how I could streamline my workflow. People on my team and other teams helped take some tasks off my plate so I could focus on learning the computer system better and on writing patient care notes quicker. I was given a little extra time off to catch up on sleep because I was on track to work far more hours than permitted by the national governing body that oversees US residency programs.

At first the extra help and attention made me feel like a failure. I tried to keep my spirits up because I’ve struggled to overcome big obstacles before; I always learned more from those experiences than I did from experiences where I didn’t struggle. Similarly, past experiences have shown me that it’s okay to accept help. Still, I wondered if I was going to learn enough or as quickly as I should if people helped me more than some of my peers. I wondered if I’d get better at being a doctor.

On my extra time off I reviewed my senior residents’ feedback. I reorganized my view of the electronic health record system to make it easier to access all the information I knew was important. I took time to recharge. When I returned to work, I was still a new doctor. I hadn’t changed much from the days prior. Yet, I found myself checking things off my to-do list without the help I’d required before my recharge day. With a little more sleep behind me, I was able to see how much I’d learned in my previous days of working – something I hadn’t noticed when I was exhausted.

As I reflect on my first two weeks of residency, I don’t look at them fondly. I do think that I’m a tiny bit better at being a doctor now than I was two weeks ago. I appreciate my past self for prioritizing a work culture of support and collaboration when applying to residency. I know that there are many hard days to come before residency is over. However, my experience during these first weeks made me confident that I will be able to overcome future hard patches when they come – not completely alone, instead, with a program supporting me as I find my path forward. Feeling like my residency program genuinely wants to help me become the best physician I can be gives me confidence in the residency training process and makes me excited for who I’ll become by the end of it.

This is how I started residency. The future will tell how I end residency.