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Thanks For Nothing, Thanks For Everything

Thanks.

It’s can be a powerful sentiment — as in gratitude for the ultimate gift or a heavy sacrifice.

But it can also be empty — as in a “thanks for nothing.”

I remember taking care of a patient midway through my residency. We had tried many different things, but eventually he succumbed to the disease and passed away in the hospital. I don’t remember what the patient looked like. I don’t remember his name. I don’t remember the disease.

What I do remember was that we tried. We tried to make him better, but in the end we did not meet this goal. As the futility of our efforts became clear to us and to the family, we decided to focus on comfort.

The patient passed away.

The memory that has haunted me to this day is walking into the room and having the patient’s brother walk up to me. As he drew closer he pulled me into an embrace and thanked me. He actually thanked me.

In dealing with death and dying it has not been uncommon for me to hear a thank you from the loved ones of a patient who has passed. But this was the first time I experienced this. And maybe that’s this memory has stuck with me since then.

Thanks. It jarred me to hear that sentiment from this grieving man. In that instance I could not do much more than return his embrace. I had no words but to say, “I’m sorry.”

To me, my words felt empty. They felt inconsequential. But it was all I could muster.

I felt like I was being thanked for nothing. I felt like I was being thanked for failing. Because that’s the lens through which I viewed the situation.

Now, I realize that I should be grateful for their appreciation. I marvel at how some people, in their moments of grief, can still take time to express their gratitude — even if it is “just” for compassion and care instead of the cure for which they had pleaded and prayed.

Medicine is a profession most of us go into because we want to fix problems and make people better. Too often it is easy to view death as a failure of what we set out to do. The danger in allowing us to view death this way is that we may feel that we have provided nothing to our patients and their families.

But sometimes patients and their families don’t need a savior. Sometimes they just need someone to be with them through the journey’s end. And to them, you have given way more than “nothing.” You have given everything.

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Chief Residency

It has begun.

On June 30 I officially ended my Internal Medicine Residency. Well, maybe I should say that I completed it.

On July 1 I walked up to my brand new office. As I stood in front of my door, with key in hand, I read the new nameplate on the door. It was awkward.

Residency ended without much fanfare or closure. My program, for whatever reason, does not have a “graduation” ceremony. They did have a “graduation banquet” in May but I was on a pre-planned family vacation during that time. Maybe that’s why I felt like I lacked any real resolution to the residency phase of life.

So far there has been anxiety, confusion, frustration, and fatigue. I’m hopeful that the year will be one of professional and personal growth. I just hope that the growth does not require much pain.

On July 1 I attended the mandatory “new hire” orientation. After completing all required paperwork, I went to HR to pick up my new ID badge. As I already had a picture on file, I just waited in the lobby for them to bring out the new badge. After what seemed like 20 minutes, someone came out to deliver it. Instead of “Resident Physician” under my name, it now said “Attending Physician.”

Looking at my badge, almost 1 month later, it still seems weird to see that.

I don’t know what this year will bring. I’m sure it will be challenging. I’m sure it will push me.

So for those of you who have followed this journey through this blog, I invite you to continue with me.

And for those of you who have just found this blog, well, you’re invited too.

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An “A” for Effort

We’ve all heard of getting an “A” for effort. At least it was an “A,” right?

But how meaningful is that grade if you still fail?

I remember a patient I shall refer to as David.

I didn’t know David very well at all. He was a patient in the Medical Intenstive Care Unit (MICU). He was not on my team. In fact, I didn’t really have a team. I was cross-covering the patients who were already admitted for a strech of 6 nights.

At the start of each shift, the primary team would hand me a list and “sign out” their patients to me. They would tell me about pertinent, active issues. They would also try and anticpate what could go wrong and let me know what to expect. Also, if there were any studies that were pending they would let me know if I had to check on the results.

David was one such patient. What I knew about him could be written down on just a portion of a full letter-sized paper. He had previously been diagnosed with cancer a little over a year ago. He had underwent treatment with surgeries and chemotherapy. During this visit to the hospital he came because of pain. As the ED completed their workup for the cause of the pain, they discovered he had a clot in his leg and multiple clots in his lungs. They also saw a large mass in his abdomen that appeared to be malignant.

In the ICU, the primary team was treating his multiple blood clots with a heparin infusion. Heparin is frequently referred to as a “blood-thinner.” It’s purpose, in this case was to prevent further clots from developing and to prevent the current clot from growing.

When patient’s have blood clots in their lungs (usually called a pulmonary embolism or PE) this is usually the treatment. However, if a patient becomes unstable (blood pressure or oxygen levels drop) there are more drastic treatments that can be attempted. One such treatment is thrombolytics. A thrombolytic is a medication whose purpose is to break down a clot. It is reserved for the unstable patients because they are quite risky. There is a risk for bleeding and one must always consider if a patient has any contraindications for this therapy.

On this particular night, David’s nurse called me. While he had been fine for the last day or so, he was now appearing very uncomfortable. His respiratory rate was increasing. His blood pressure was trending down. His oxygen levels were also trending down.

After spending a few minutes watching him, I made the call to Anesthesiology. I explained the situation and told them that I thought David would need to be intubated as he was in respiratory distress. Within minutes they were at the bedside and preparing to intubate, salaries for an anesthesiologist assistant completely justified too, I must say.

Contacting the family was my next order of business. There was a daugther listed as the next of kin in his chart. My first call went to voicemail. I left a brief message asking for her to call me back.

Within a few minutes David’s daugther returned my call. She was understandably concerned. I had to explain what had happened. I then began asking some detailed questions about David’s medical history. I needed to know if he had any contraindications to thrombolytic therapy. The answers I got were reassuring. David was stable, though, after intubation and initiation of one vasopressor. We would wait until she arrived and we had a chance to speak in person before going forward with thrombolytic therapy.

In the meantime I would have to place a central venous line and an arterial line in order to continue administering medications and monitor his hemodynamics. In between these two procedures I found out that his hemoglobin was dropping. I had no obvious source of bleeding. My heart sank as I knew I could no longer use any thrombolytics. There was enough evidence to presume he had a bleed and I had no way to rule it out at that time.

An hour later, Tonya, her mother, and two other siblings arrived. They were ushered into the conference room. I gathered what little notes I had about David, took a breath, and walked into the room. I made sure to hand off my hospital handset to the Charge Nurse so that we wouldn’t be interrupted unless absolutely necessary. She would screen the calls.

The family took in the grave prognosis with great composure. I explained that I could only support him temporarily. I could not treat the clots with thrombolytics. I could no longer treat his clots with heparin either. I could only place a band-aids. But considering the clinical picture, I expressed my doubts that David would survive into the following day.

David’s wife, though, seemed to persist on telling me what happened throughout his battle with cancer. I tried to politely tell her that we needed to address the issues at hand — not his constipation or abdominal pain that he experienced a year ago after the initial diagnosis and treatment. I couldn’t tell if this was her way of coping. As I allowed her to continue re-telling the events of last year, I looked at each of David’s grown children. They knew what was happening. They seemed to just want to let their mother go through this in her own way, though.

By the end of my shift David would eventually need 5 different vasopressors concurrently. He was maxed out on the ventilator. He had received over 3 liters of fluids and 4 units of blood. I knew it was only a matter of time. I had done everything I could. David died before I came in for my next shift 10 hours later.

There are times in the hospital when doing everything you can — when doing your best — is just not enough.

And those times suck.

Period.

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On Teaching

The following is something I wrote in 2009 while still a medical student:

Teaching is a hard thing. By teaching I don’t mean explaining or instructing. Take, for example, teaching basketball to someone. Telling someone the rules of the game is not, to me, teaching them how to play basketball. Explaining what the rules mean and how and when they apply is not teaching either. Teaching involves more. It is showing someone how to dribble the ball, demonstrating the correct form, and then helping the student develop these skills. Teaching is not merely conveying knowledge. It is imparting excellence — or, at the very least, competence in a particular area or field.

Teaching involves lifting a student up with compliments while simultaneously providing criticism that is at the same time constructive, painful, and humbling. Delivering these two — compliment and criticism — can be tricky. How does one find the right balance? It’s unfortunate that there is no formula. Each person is different. The combination of compliment and criticism that motivates and inspires one student could very well devastate and discourage another. Maybe the truly amazing teachers are able to read their students and expertly walk that fine line.

In the absence of truly amazing teachers, or truly amazing teachers with plenty of time to spend with us, a student must resort to other means of attaining competence. One alternative is learning from multiple teachers. Good teachers have different methods, techniques, and personalities. Each one can provide a different, yet helpful angle.

As this academic year inches closer and closer to an end, my mind seems to frequently wander to the future. One of the things I think about is my position as one of the chief residents next year. I hope that I will able to be a good teacher. I may even be willing to settle for an “ok” teacher too.

Maybe I am getting ahead of myself. Maybe I should just concentrate on learing as much as I can as a resident.

Teaching, I feel, is such a great responsibility. Especially when you are training people to take care of patients. The good thing is that I won’t bear this responsibility on my own. I will merely be a cog in a larger wheel; I will only be one part in a larger system. There will be plenty of seasoned attendings who will gladly teach the residents, and I am sure myself as well.

Teaching, I hope, is something that one can learn. And I hope that through the next year I will be able to develop my own teaching style. I’m sure I won’t be able to develop in a year — it’ll take time. But I do hope I am able to make a significant evolutionary leap in my development as an educator and teacher.

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Code Status

Every single patient that gets admitted to the hospital needs to be asked about their “code status.”

I usually ask about this in this way:

Now I have to ask this question to everyone I admit, regardless of what they are being admitted for.

In the event of an emergency, if your heart were to stop or beat ineffectively, if you are unable to breath on your own, what would you like us to do?

Do you want us to do everything to bring you back? This includes doing chest compressions, shocking your heart (if it is appropriate) and putting a tube down your throat to help you breathe with a machine.

Some patients who have been admitted frequently will be familiar with this question. They will immediately answer and ask that we either “do everything” or do nothing and just “let them go.”

Others stare blankly at you because they have never been forced to answer this question. They may look at their spouse. For those that hesitate I explain that there are risks to these attempts at resuscitation and that the older a patient is and the more medical problems they have, the less likely a full recovery should be expected.

I also allow them time to think about it and discuss it. I tell them that they don’t have to decide now. I also tell them that the decision they make is not final and “set in stone.” They can change their minds later. However, if they are unable to make a decision at this time, they will default to a “Full Code” status until they tell us otherwise.

Asking the question(s), regarding code status, is easy. Hearing the answer, on the other hand, can sometimes be difficult.

What about the senior citizen with medical comorbidities — who is unable to answer questions on their own due to the severity of their medical problems — whose family insists we do everything to keep them alive? It is not rare.

As physicians, we look at the patient from an admittedly detached point of view. Sometimes it is out of habit. Sometimes it is out of necessity.

It is difficult when we see our patient, who has poor functional status by any standard of measure and who would likely incur more harm than good by performing resuscitation measure in the event of cardiopulmonary arrest, carry a “full code” status in their chart because family is unable to come to terms with their state of health.

I do realize that there are many reasons a family will have for not rescinding a full code status. That is probably a topic for a whole different post.

This post, to me, seems more like a stream of consciousness post than a post that was well thought out and that had a point to prove or make. I apologize for that. It is just an issue/topic that has been on my mind recently.

For those of you who have had to carry this type of conversation regarding code status, how do you approach patients? How do you approach families? How do you discuss this issue regarding patients who are unlikely to have any benefit from resuscitation but whose families are adamant that all measure be taken?

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What’s a Chief Resident?

As I mentioned in the last post, I will be staying here at LLU for at least a year after residency officially ends. I will be staying on as one of the Internal Medicine Chief Residents.

So what does that mean?

I have found that it means different things to different people. In other residencies, the chief resident position or title is given to residents in their final year of training. And during that year as “chief resident” they are given additional tasks. From what I have seen, this is the case with other residencies like Emergency Medicine and ?many surgical specialties.

In Internal Medicine, the chief resident is someone who has already completed their residency. A quick search on google for “chief resident” brought me to the Duke Internal Medicine website. This is their description of what a chief resident is:

The Chief Resident position is the single largest investment in leadership made by the Department of Medicine, and the chiefs serve as key leaders for the program. Chiefs are selected for their exceptional clinical and leadership skills. The chiefs work as a team to provide leadership and support of the key missions of the residency program and function as key mentors and advocates for the residents. While each chief has separate responsibilities at their primary site (Duke, Durham VA Medical Center, Duke Regional Hospital, and VA Quality/Safety), the camaraderie among the chiefs sets a positive tone for the program and allows us to accomplish the many goals we set for the year. Notably, many former chief residents remain on faculty at Duke, serving in leadership positions throughout the health system. In recent years, the chief residents have been responsible for organizing the Stead Societies, reorganizing the noon conference series, instituting leadership training for JARs at the VA and evaluating patient flow on the general medicine services. In addition, the chiefs galvanize the competition for our annual Turkey Bowl, lead recruitment of new interns and have a tradition of providing entertainment at the annual DOM Holiday Party.

Chief residents are chosen during the SAR (PGY-3) year, and serve as chief residents with a faculty appointment during their PGY-5 year. Typically Chief Residents complete a fellowship or hospital medicine faculty year during the PGY-4 year, and return to their fellowship or hospital medicine position after completion of the chief year.

[emphasis added]
Source

They make it sound like quite the lofty position, don’t they? Apparently their chiefs serve in their PGY-5 year (5 years after graduation from medical school).

It would be important to note that there are differences with how my progarm does things. Internal Medicine (IM) Chief Residents here are selected during their PGY-3 year but proceed directly into the chief residency following the completion of residency. And I would hold off on claiming any “exceptional clinical and leadership skills” for myself. Also (not noted above), we will spend time rounding as the Attending Physician with the teaching service for a number of weeks throughout the year. But for the most part, the job responsibilities are similar across teh country for IM Chief Residents. In fact, the new group of LLU chief residents will be attending the APDIM Meeting in Houston, Tx in April. This meeting brings together leaders from IM residencies across the country (including program directors and chief reisdents) to sit down and learn about education and leadership.

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The Twists & Turns of Life

As I look at my blog it seems that I have not written an update since November of 2014. I do apologize for not being better in keeping up with writing. I am not sure who I am apologizing to, though, as I have no clue about who is actually still reading this.

A few days ago I came by to browse through my archives. It was a trip down memory lane, so to speak. As a blog, this one has been around for quite a while. My first post, although it was moved over here from a previous iteration, was written while I was still an undergraduate student back in the 2005-2006 academic year. I definitely did not forsee where I would be today.

Last year I remember blogging about fellowship applications. Even that did not go as planned. I started out the fellowship application season intent on joining the NRMP Match hoping for a spot in Nephrology. My plan was to puruse nephrology and then follow that up with a year of critical care training. I even interviewed at Henry Ford’s combined Nephrology/Critical Care program.

But life happens. Life sometimes gets in the way of — well, life.

As the deadline approached I was faced with many questions. I wrestled with these questions and in the end decided that it would be best for me to withdraw from the fellowship match. It was not an easy decision. And on the weekend prior to the deadline to finalize rank lists, I officially withdrew.

I have not ruled out a fellowship. But I had decided that at this time, it would be best for me to wait.

There were many questions that I faced in making this decision. I won’t share all of them. But some included quality of life, lifestyle, job satisfaction, and family.

After making my decision I spoke with our Internal Medicine Program Director. He was one of the faculty members who wrote a letter of recommendation for me. I shared my decision with him — that I had decided not to participate in the match. He asked if I had ever considered doing a year as a chief resident. He had no idea that I had. In fact, as an intern I had actually thought I wanted to one day be a chief resident. And so I answered that it was something that I had been interested in doing in the past.

Now, about 5 months away from the end of residency, I find myself as one of the future Internal Medicine Chief Residents.

Life is full of twists and turns. Sometimes, half the fun is watching where it takes you.