A Time of Giving
As 2016 draws to a close and many of us look forward to spending time with family and loved ones, one cannot escape the joyful… Read More »A Time of Giving
A Day in the Life
Making Our Voices Heard in a New America
On Nov. 9, 2016, our country awoke on the precipice of a new beginning. The recent presidential election was historic in many ways, but one… Read More »Making Our Voices Heard in a New America
Community Engagement Through Volunteering
Medicine means a lot of things to different people — patient care, research, education, lifelong learning — but to me, one of the most meaningful… Read More »Community Engagement Through Volunteering
Seeing Clearer but Not Farther: Disease Through the Eyes of a Young Medical Student
The day after my cardiology exam, my grandfather had a heart attack. Heart attack — what a terrifying phrase. The heart transcends normal anatomical description.… Read More »Seeing Clearer but Not Farther: Disease Through the Eyes of a Young Medical Student
Kid in a White Coat
I am no stranger to medical institutions. I’ve spent time in hospitals and clinics all throughout my life — shadowing physicians, working in the operating room as an administrative intern and now as a first-year medical student. However, while walking through the busy corridors of The Johns Hopkins Hospital, I feel distinctly different. Of course, this could be attributed to a variety of things, such as growing older and finally beginning a formal medical education, but the biggest difference for me comes from a short white coat with my name emblazoned on the left.
In our field, the white coat inevitably carries a strange and amazing sense of power and responsibility. Although we knew very little about medicine, since the day my peers and I received our white coats, we’ve been viewed differently in the hospital setting. While wearing the white coat, complete strangers confide in you, often sharing extremely personal stories, hopes and fears perhaps hidden even from immediate family. Suddenly, you are seen as a figure of authority and are, accordingly, faced with a sense of responsibility to provide the highest level of care for the people around you. The implications of this transformative power are incredible but also daunting.
Just over half a year ago, I was a senior in college and often joked with my friends about how we were “pretending” to be adults that were ready for the real world once graduation arrived. Now, I walk through The Johns Hopkins Hospital wearing an article of clothing that boldly proclaims something quite different — that I am an adult, ready to take care of the real world. The cognitive dissonance is glaring. I don’t feel any different on the inside than I did as the young college student only a few months earlier. How is it possible that I am suddenly responsible for taking care of others’ physical and emotional well-being when I am only just now learning how to take care of myself? I understand that as a new medical student, especially one coming directly from college without having taken any gap years, these sentiments are completely normal, but the nagging feeling that I am an imposter is still very real.
Regardless of these feelings, my medical training so far has been a privilege and incredibly rewarding. And now, several months in, I’m starting to learn that the solution to alleviating the dissonance lies in perspectives. It’s important to remember that medical training is a journey — one that will continue throughout my entire career — and that’s it’s OK to not always know exactly what I’m doing right now. Rather than letting imposter syndrome undermine my confidence, I can choose to see it as an opportunity to continuously challenge myself to learn and grow. Embracing my strengths and finding the courage to accept my weaknesses with confidence will, hopefully, help me work toward a satisfying and fulfilling career as a physician — even if some days, I still feel like just a kid in a white coat.
Applying for Residency: Interview Season
The last time I wrote about applying to residency, fourth-year medical students were just about to hit the submit button on the Electronic Residency Application System. Several long weeks later, the interview season has begun.
The irony of the phrase “hurry up and wait” becomes acutely painful for students during the weeks between submitting residency applications and receiving interview invitations. Applying for residency is much like applying for a job — you put together a CV, send it out to several prospective employers and hope that they are interested enough to invite you for an interview. For the past several weeks, fourth-year medical students have been eagerly waiting for those interview invitations and, after receiving them, have been busy scheduling flights, booking hotels and preparing to explain why they are an excellent fit for each program.
However, before the craziness of scheduling interviews — which requires students to strategically accept the maximum number of interviews, while allowing for adequate time to travel between cities — there is the wait. Thanks to peers applying to the same specialty and websites such as Student Doctor Network, students know almost immediately when their dream schools start sending out invitations — and are in for an unpleasant moment if they do not receive one. Thus commences the anxious wondering: Will there be a second round of interview invitations? Why did I not get invited in the first round? Is there anything I can do or say to the program to garner one of those coveted invitations? By the time I get an invitation, are there going to be any interview spots left? Unfortunately, there are no satisfactory, cut-and-dried answers to any of these questions.
By and large, though, most students will receive or have already received invitations to interview at their dream schools, and indeed, many are now weeks into the interview process. Aside from the nervousness that accompanies each interview, there is also an underlying hum of enthusiasm and excitement. The attendings and residents at each program are potential mentors; the other interviewees, future colleagues, or perhaps even future co-residents. At each interview, there is a tantalizing glimpse into the world that everyone has worked so hard during medical school to have the privilege to enter. Additionally, each interview allows the applicant a peek at how that specific program’s rounds work, what the hospital culture is like and what the program values. Similarly, programs use the interview process to find applicants with aligned goals who they think will not only learn from their institution, but also thrive in their particular environment and form part of a cohesive team.
The past few weeks have been both exciting and trying, filled with emotional highs and lows. Charles Dickens once penned, “It was the best of times, it was the worst of times …” While he was referring to London and Paris during the tumultuous French Revolution, somehow, it resonates well with this part of the application process to residency.
More Training Means More Residents Meet Their Match
Matching into residency was one of the greatest days of my life. Years of hard work and dedication had finally culminated into the opportunity to become a doctor and practice medicine where I wanted, and in the specialty where I fit best. A few years into being a resident, the process started over, with the fellowship application process. In almost every field of medicine, there are opportunities to subspecialize, and fellowships are one such opportunity.
Fellowships are a way for residents to specialize in a specific area of medicine or surgery. For example, if an internal medicine resident wants to become a cardiologist, he or she typically has to complete three years of residency, followed by three years of fellowship in cardiology. The same applies for other subspecialties — a pediatric resident who wants to specialize in taking care of sick neonates in the ICU would complete a neonatal ICU fellowship.
Over the summer, I had the opportunity to travel around the country with some of my greatest friends and colleagues within the Johns Hopkins Department of Gynecology and Obstetrics as we interviewed for fellowship positions in four different specialties: gynecologic oncology, maternal-fetal medicine, reproductive endocrinology and infertility, and urogynecology. Cumulatively, we received over 100 interviews. This fall, we met out matches and will be traveling far and wide to fulfill our dreams.
Typically, gynecology and obstetric residents either decide to subspecialize in a fellowship or continue their career as a general Gyn/Ob. In a study looking at residents who chose to subspecialize, data from 2012 showed that around 20 percent of residents apply for fellowship. Considering seven of Johns Hopkins’ nine residents applied for fellowship and 100 percent matched for competitive fellowship with acceptance rates averaging about 69 percent, we matched very well this year!
Although my colleagues and I applied for a variety of subspecialties at many different institutions, in reflecting on why we each chose a specific career path, three things were consistent. We picked these specialties because of the “patients, procedures and problems,” and the way our careers will allow us to interact with and influence all three.
Ultimately, I chose to become a gynecologic oncologist because I love the patients, the procedures are inspiring, and the problems presented in treating their illness are challenging and complex. The fact that all of the residents and one fellow who applied into these subspecialties were placed in competitive fellowships is a testament to the success of the Johns Hopkins residency program in training future gynecologists and obstetricians.
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The Problem of Delirium in the Intensive Care Unit
In cardiac surgery, most patients come out of the operating room still heavily sedated and intubated — a tube down their windpipe helps them breathe, one is in their bladder so they don’t need to urinate and multiple others protrude from their chest, draining blood-tinged fluid. Some patients exit surgery actively “paced,” with several wires on the surface of their heart urging it forward at a steady rhythm somewhere between 90 and 100 beats per minute. The first six hours after open-heart surgery are crucial, so patients are quickly wheeled from the operating room to the cardiovascular surgical ICU — also known as the CVSICU — where they are closely monitored during this critical recovery period.
As you might imagine, the CVSICU can be overwhelming for patients’ loved ones and the patients themselves. As they are gradually weaned off sedating medications, patients often awake to a choking sensation from the breathing tube forcefully blowing oxygenated air into their lungs. One family member once mentioned that the scariest part for their loved one wasn’t the thought of having his sternum split open by a bone saw to expose his heart for surgery; he was most afraid of waking up on a ventilator. Thankfully, for most patients, “wake, wean and extubate” is the typical plan for post-surgical recovery. As their sedatives are reduced, most patients can understand and follow commands, and are able to easily have the tube removed and breathe on their own.
All fourth-year medical students at Johns Hopkins undergo a one-month rotation in critical care to better understand and learn how to care for complex patients. Over the last month, I was intimately involved in the care of several patients whose post-recovery plans required extra time on the ventilator during my rotation in the CVSICU. A few of these patients experienced a phenomenon called ICU delirium. Delirium refers to a state of altered thinking and consciousness that can occur in the critically ill patient. Patients often become confused, disoriented and agitated following a major surgery or while recovering from trauma. In such cases, delirium can induce an altered state of reality, as the sounds and sights of the ICU interact with the patient’s own thoughts to create terrifying and bizarre illusions. Because of the instability and agitation that often coincide with ICU delirium, these patients are kept on the ventilator for longer to protect their airways and support breathing.
“She wasn’t herself,” said one family member as she reflected on her mother’s ICU stay. “At first, it looked like she was getting worse instead of better.”
Delirium is associated with psychological distress, such as PTSD, and poor health outcomes, including longer ICU stays and higher rates of mortality. Therefore, it is critical that CVSICU staff members be especially vigilant in monitoring and treating delirium. Indeed, one study from 2010 found that over 80 percent of patients on ventilators at a particular institution experienced ICU delirium. Johns Hopkins is taking steps to find better ways to treat and support patients who go through delirium in the ICU, including orienting patients to a day-night cycle with natural light, using sedating medicines sparingly and monitoring patients’ mental states post-surgery using delirium screening tools. By combining psychological and physical rehabilitation and supporting patients throughout the recovery process, it is the hope of researchers that the incidences of ICU delirium can be reduced to improve patient outcomes.
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Compassion in Eight Stitches
The first time, you don’t realize how warm his body will be. On some level, you knew the patient’s temperature would be in the range of 98.6 degrees Fahrenheit; his skin, just a few degrees below that. But somehow that information never registered with your fingertips. As you feel the tissue around his wound, palpating for the invisible lines of tension pulling apart its edges, your fingers surprise you. They register warmth, movement, life. Your mind, racing ahead to selection of the suture material, appropriate knot technique and needle placement, is quietly reminded: This man is alive. This man is a person. And you are about to sew his skin like torn denim.
As a second-year medical student, I’ve spent years using suture techniques to repair my ripped jeans and frayed sleeves. I’ve practiced mattress sutures using orange peels and placed subcutaneous stitches into pigs’ feet, but I am only now beginning to close patients’ wounds in the hospital. It’s a very different experience when the target of your needle can feel and think and tell you how much he loves Tom Hanks movies.
On one hand, I remain awed by the unique humanity of my patient: He has a family, a favorite film, dreams and aspirations for the future. On the other hand, to help him, I must concentrate on the biomechanics of the 6 square inches of skin and the curved steel needle immediately in front of me. I continue to be challenged by these discordant principles: How do physicians balance caring for each patient as an individual while maintaining the intense, narrow focus required to perform at the highest level?
To best care for the patient, physicians and medical students need to care about the patient. We treat a person, not a disease. We put ourselves in her shoes, see the world through his fear and pain. This intimate understanding shapes every element of the medical relationship and drives physicians’ compulsion to deliver the best possible treatment.
Embracing the patient’s humanity at the wrong time, however, can cripple a doctor’s ability to help. Consider a neurosurgeon tasked with removing a tumor from a man’s spinal cord:
Doctor, dissect the tumor away from the fasciculus cuneatus.
This statement is a clear, technical description of the operation’s objective. Now consider the same procedure communicated differently:
Doctor, cut the cancer away from the neurons that let Jim feel the warmth of his daughter’s hand.
Can the physician begin to operate with that thought echoing through his or her mind? Compassion mobilizes our hearts, but it can also paralyze our hands. It may sound callous, but during the operation, walling off the part of the brain that sees the patient as Jim, a father, can allow the surgeon to focus on the complex challenge of separating cancer from healthy spinal cord. By temporarily reducing the patient to his anatomy, physicians can incise, inject, staple and stitch with precision and a steady hand.
Is the answer this simple? Are we as medical students expected to care deeply for our patients at all times until a sharp instrument is needed and then promptly disconnect our brains from our hearts? I don’t think so. Humanity is not a light switch to be turned on and off at will. Compassion seeps through whatever mental barriers we construct, imbuing every movement of the instruments with the respect and kindness we feel for the person before us.
You feel the warmth of your patient’s skin and know you will not sew him up like denim. He is not made of fabric. He is made of tissue — delicate, vulnerable and the anatomical building block of this Baltimore man who is looking forward to watching Apollo 13 with his wife this weekend. You begin to sew.
Reminders in Medicine: Patient Care Impacts Medical Training
Years of carrying a massive backpack full of books to make it here — to OR2 of the Weinberg Building at The Johns Hopkins Hospital — had given me terrible lower back pain at the ripe old age of 23. My goal was to focus on the procedure, but my back throbbed, and my sleep-deprived mind kept wandering. The sound of a phone ringing suddenly jolted me from my daze: “Pathology reporting on frozen section of iliac lymph nodes. Metastatic cancer.”
The air in the room changed, but the operation continued. “This lady is going to die,” said the attending matter-of-factly. It would have been easy to misinterpret her statement as cold, but I had witnessed this particular surgeon stay until 10 p.m. for her patients, visit with each of them during rounds and fight to get them appointments with specialists, so the weight of her words hit harder than most.
My problems were so small compared to those of this patient. When I saw her in the preop area just hours earlier, she looked dazed, as if she had been through so much already and had fully surrendered herself to the whims of the medical system. She knew she had cancer, but this surgery would tell her how much. Just before the surgeons wheeled her back, her family gathered around her to sing a lament. The words were beautiful, and when I saw her open her eyes afterward, I noticed that they had a little more life in them.
This is medicine.
I have only been on my third-year clinical rotations a for few months, but time and time again, I am reminded of how lucky I am. When I look out of the hospital windows at 5 a.m., the misery of my sleep deprivation is often broken by awe at the fact that I am here, at the Johns Hopkins University School of Medicine - my dream school. When those patients walk through the door, the ones that the medical system has given up on, with the hope that we at Johns Hopkins Medicine can care for them, I am reminded what an honor it is to serve them. And finally, when I am splashed with a sudden wave of reality that I am in the presence of someone who will soon die and that I have been given the chance to be with them now, in their last few months or days, I am reminded of the privilege I have been given to make these people feel better in any way, whether I am their surgeon or simply the person holding their hand while their epidural is placed.
Practicing medicine is a roller coaster. When you are feeling your worst, overwhelmed by exhaustion or sadness, or on the days when you simply feel that you are not good enough, your patients will always remind you that you are lucky enough to be yourself, lucky enough to be alive and healthy, lucky enough to be given the opportunity to serve others, and that this is what makes you good enough for them.
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