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A Day in the Life

doctor listens to fetal heartbeat on pregnant belly

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!

Diana Cholakian with her resident friends in the Johns Hopkins Department of Gynecology and Obstetrics
Diana Cholakian with her resident friends in the Johns Hopkins Department of Gynecology and Obstetrics

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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patient lying in the hospital bed

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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surgeon focusing

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.

carson-patient-pull-quote_102016Can 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.

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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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model of a human heart

The Anatomy of Being Human

It’s 6 a.m., and my alarm goes off. Groggily, I continue to press snooze for the next hour, until I realize I won’t be able to enjoy a breakfast that’s not a granola bar if I sleep any longer.

It’s been six weeks since I started at the Johns Hopkins University School of Medicine as a first-year medical student, but time passes oddly in medical school. With the fast-paced atmosphere, sometimes I feel like I’ve only been here a few days, and at other times, a full year. At the moment, we are nearly finished with our Human Anatomy course, which is notorious for its rigor and intensity, but also the immense thrill and exploratory nature.

Class starts promptly at 8 a.m., but today I frantically arrive at 8:02 a.m., quickly settling into my chair to learn about the ventral roots of the spinal cord. Following the lecture, I head up to the anatomy lab and mentally prepare for the day’s dissection of the human heart.

Dissection of a cadaver is an overwhelming experience. It’s an immense privilege to be able to explore the human body in a hands-on setting, but it can also be jarring to face the reality of death and the passing of a human life. Today’s dissection is a particularly profound reminder of this. When my lab group and I remove the heart from our cadaver, we take a moment to pause and offer our deepest gratitude to the donor and her family, who gave us this incredible privilege for the purpose of our medical careers. Seeing an actual human heart for the first time takes my breath away — to imagine that this same heart beat throughout every single second, throughout every single memory of person’s lifetime — it was truly a special moment.

Dissection is easily my favorite part of the anatomy course. I came to medical school with a strong background in engineering and became interested in pursuing surgery as a specialty because of the many parallels between the two fields. However, dissection lab has given me an unexpected but enriched view of anatomical biology through the constant juxtaposition of science and humanism it forces us to face each day. The privilege of dissection reminds us that the heart isn’t just an organ, but also a physical representation of billions of seconds of another human’s life, their memories, relationships, fears. It teaches us that the hand isn’t simply the distal portion of an upper limb but once served as a source of warmth and comfort for loved ones, a hand that once held a child, a book, maybe a scalpel like my own. Even early in my medical education, I’m already grateful for this deeper perspective.

As the Human Anatomy course comes to an end, I often reflect back on my time in medical school so far. Although I’ve only been at Johns Hopkins for six weeks, it’s already been a unique and exciting journey, as each day brings something challenging and fresh. Constantly experiencing the multiple facets within medicine is what makes this educational pathway so special, and I can’t wait to see what the next four years will bring.

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