A Match Made in…

Looking at the calendar it hit me that around this time in 2015 I had completed my final residency interviews. Like all of the current fourth year medical students, I’d spent a lot of time, money, and energy traveling around from place to place, eagerly and anxiously trying to guess if and where I would end up for residency. Medical training is a strange experience. You’d think that a field that is based on the scientific process and data driven in many ways would equip students with the tools they’d need to not only choose the right specialties but also the right residency programs for them.

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Well, you’d think wrong.

Finding a residency program that suits you is like ordering a full wardrobe for 3-7 years based on online pictures, reviews, and referrals from others, but the catch? You can’t experience the clothes – you can’t try them on. You are expected to synthesize a bunch of circumstantial information mixed with some objective data such as salary, estimated cost of living, etc, and make a calculated, prioritized list of programs – the holy grail of lists – your rank list.

To that effect, as I’m sure many fourth years are currently pulling their hair out, finishing their fine whiskies and liquors, and ranking and re-ranking their programs over and over from now until the certification deadline, I want to share 5 pieces of advice I wish someone had shared with me when I was a big eyed MS4.

Disclaimer: There’s a LOT that goes into these decisions. I offer my humble thoughts here because I hope it will help at least one person out there struggling to make some hard choices right now. Obviously there may be some controversial suggestions below, but it’s meant to foster discussion and thought. I welcome your feedback too! Let me know if my thinking is flawed!

They’re in reverse order, because I’m weird that way.

5. Be a 5 year old again and use your imagination!

Seriously, one of the things I wish I’d done better in 2015 is spent time visualizing and picturing what my life would be like at my various potential programs. What would working in the ED feel like? What would the relationship I had with the nurses, technicians, administrative staff, respiratory therapists, consultants, etc, be like? Where would I live, if I moved there? What would I do if I had a family emergency? The more detailed your vision of the future, the more you will understand how your life might look like if you ended up at a particular program. This is a crucial exercise to perform with the top programs you are hoping to end up at. You may know they are going to prepare you in your chosen field well, but what will living through residency be like? The problems I have faced over the past 18 months have less to do with my residency program’s curriculum, and more to do with my finances, lifestyle, hobbies and how I am or am not able to keep up with them, what I can do with my wife when I have free time, etc.

4. When you talk to current residents,  pay attention to their walk, less so their talk.

Surprisingly, it’s easy for someone to look you in the eyes and lie. They may not even do it intentionally. After all, if you’re already at a particular residency program and stuck there for a while, you will find ways to acclimate and you may not want to badmouth your program. However, it is hard to fake satisfaction and contentment. A truly happy resident, a fulfilled resident, who feels supported and able to focus on learning and excel in their work, is a rare commodity in medical training. Looking back, there were some outstanding programs where I could literally feel the synergy between the residency program leadership and the residents themselves. When you are thinking of your rank list, don’t make light of your observations of how residents behave. It’s easy to say you’re happy but harder to show it. Lastly, if you found it easy to get to know residents, or if you were able to spend time with them outside of the interview dinner, lunch, and interviews, that’s a huge sign of a healthy residency program.

3. Run your rank list by your best friend, mentor, significant other…whoever knows you best.

You may have been told that you know yourself best, and you have worked hard to get to where you are today. Why should you share your thought process with others? Why should you let your significant other or parents or best friend mess with your rank list? The concept is simple here, really. We all have blind spots. All of us. And if you think you will figure out your rank list all by yourself, without discussing it with ANYONE else, you’re making a huge mistake. We are not perfect. We do not think of all scenarios. This is why you should discuss your reasoning and thought process with other people. The caveat? They have to be people you trust with your life. They have to be the kind of people you could call at 1 AM in the morning, and say, “I need you here, right now!” and they would buy a plane ticket and fly across the country or continent to be with you. If you discuss your reasoning with people like them, they will definitely pick up on things you may have missed. They will SAVE you from misery. Trust in them, and their judgment. Personally, I made my rank list, and discussed it with my wife a great deal. Ultimately, she helped me see that the rank list I generated was based on my comfort zone and what I assumed she’d want for us moving forward. By talking with her about the list, she helped me see that I actually needed to change my rank list to challenge myself, ensure I ended up at the best possible program where I knew I would be offered a chance to really grow and except, but also, to end up in a city that was a better fit for my wife and I to live and grow ourselves.

2. For programs you’re considering highly, go back for a second look.

The wisest mentors I had made sure to suggest this to me. It is quite doable for a residency program, the residency leadership, and residents to put on a show for you when you come into town for your interview. It’s also easy for you to play the interview game and ask the right questions and show the right amount of interest, etc. However, when it all comes down to it and the chips are on the table, the best thing you can do for yourself, whenever possible, is try to arrange a second look. First, whether or not you are even able to set one up is an indicator of the situation. If the program doesn’t have time for you, turn around and run…fast! If it’s relatively easy to set up, and if you ask to stay with or meet with current residents and this is also easy to do, those are all good things. When you have your second look, your goals are twofold. One, you need to spend time with residents outside of the hospital and away from the residency leadership, and try to get as candid an experience with them as possible. This can be a treasure trove of information for you. Second, you should try to shadow or spend some time in whatever unit you will be in primarily as a resident. This time, though it may be brief, will give you better insight into what actual work as a resident might be like, and can give you information to help you with your ultimate rank list.

1. Residency is less about the program, and all about YOU. Who are YOU really? The better you know YOU, the more likely you are to be satisfied with your decisions.

You have to really figure out yourself. This is the hardest part about this entire process. It is true that any residency will prepare you for a fruitful career doing whatever specialty you pursued. However, the time you will spend in residency is a life experience. Where you live, what you do with your free time, what support structure you will have…all of that will make a huge difference. But, unless you spend time really thinking about the things that are really important to you, it’s not really possible to make a good decision as far as your rank list. My dad always says, it’s hard to achieve a goal if you haven’t figured out what your goal is first. So I challenge you, work hard the next few weeks to figure out what you value. Write, talk to your loved ones, think…think a lot. You will need this soul searching to really make good choices so that when you look back on residency, as I am starting to do, you can feel good about your decisions and your experiences.

I wish you all a lot of luck, and want you to know that medical training is challenging, but you made it this far because you have something of value to contribute to this entire industry. Without you, and what makes you unique, we all become cogs in a machine. Let’s ensure we deliver the best care to our patients by first making sure we make the best decisions for our training.

Find me on twitter at @S_P_MD with questions, comments, or feedback!

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Changing the Culture of Mental Health Stigma in Healthcare

From the time undergraduate students start taking their pre-medical courses such as introductory biology, organic chemistry, biochemistry, and others, there is unfortunately a deep sense of competition that can often overpower even the kindest of souls. This is understandable as gaining admission to medical school continues to become more and more competitive. However, even from this stage, an inappropriate, dangerous, and maladaptive sense of machismo is infused in those hopeful to earn an MD or DO down the road. Bear in mind this is just my humble opinion as someone who has gone through the process to apply to and graduate from medical school in the United States. I certainly am not saying that all pre-medical students are the same, but if you were to ask most how they view themselves and their peers, you will hear similar tales and reflections.

Instead of focusing their efforts on mastering the content and collaborating on quality public health initiatives or research projects, many pre-medical students nervously eye one another during their group activities and lab sessions. I did not feel comfortable expressing my true self because there was this illogical fear that if I expressed my emotions, my anxiety about the process, that I was showing weakness. I quickly found that in my case, I could not sustain this inhuman sense of confidence, superiority, or complete lack of self doubt.

When I arrived in medical school I was shocked to find that things were even worse. Every other person around me was exhibiting signs of almost primal like competition. Along with this attitude of needing to prove oneself to be the best, to impress the supervising physicians and researchers who taught our preclinical courses, it become apparent there was a facade of 100% strength and fortitude that the majority of those around me displayed. An unspoken culture of repressing any emotional or spiritual issues we might have regarding what we were learning developed and was perpetuated. It was taboo to discuss our feelings regarding our patients except in the confines of late night conversations with our best friends. Even then, we were all nervous, somehow. Imagine – training to be a physician, tasked with being a healer and guide to others toward better health, yet we ourselves expected to maintain some kind of fortitude few if any could.

Here’s the reality, after 10 months of being a physician.

I do have doubts. I wake up every day wondering whether I have made the right decisions. Often I go to bed wondering whether the choices I have made that day, which today impact my patients and their health, were the right ones. I question my judgment on a minute to minute basis. I seek help when I am not sure of what is best. I have learned that without accepting that I am human, that I am allowed to experience uncertainty, I will not only be unhappy but I will endanger my patients.

I think that it’s important for physicians to break down the culture of stigma around mental health ailments and depression perpetuated across the generations. I have heard time and time again from seasoned physicians of all kinds with gray hairs purporting wisdom that “In my day, you would have been deemed unfit to treat patients!” Scary is an understatement.

You could identify many issues with health care today. Out of the grave financial and ethical burdens we face as a society all the time, quite a bit of the issue lies in the way we train our future physicians. How can we expect a young physician who is expected to never feel emotion, never express emotion, never exhibit signs of depression or even the slightest emotional response, to be emotionally supportive to his or her patients? How can we expect physicians, who are some of the worst at perpetuating stigma about displaying “emotional weakness” or seeking help for mental health, to continue to bear the weight of their calling day in, day out, without breaking?

Recently, a nurse, mother of two boys, and paramedic who I follow on Twitter, Jess Morton, delivered a talk at a Paramedicine conference entitled SPANZ16 on the issue of mental health stigma among care givers. I am eagerly awaiting the video of the talk and will link here when I have access. From what I followed on Twitter, the talk was well received and applauded. It was so wonderful to see an individual with experiences such as Jess deliver a talk on such crucial topics. I hope that as time goes on, we in the medical profession incorporate more and more discussion about mental health wellness and breaking down stigma for those who need and seek help.

We need more doctors, nurses, paramedics, EMTs, nurse practitioners, and physician assistants to speak out and break down stigma around mental health. It’s time that we dropped the facade. It’s time we stopped chastising care givers who themselves need care. We should welcome and celebrate honest and respectful discussion among those who deliver care in our health care system. In fact, it must be a priority to break down stigma surrounding mental health and wellness for everyone, regardless of who they are or what they do.

 

Doctor, It’s Okay to Cry, Part 1

Preface: I am planning on starting a series for young trainees of all kinds, including physicians, nurses, physician assistants, nurse practitioners, Emergency Medical Technicians, patient care technicians, and Paramedics. The purpose of this series is to share what I have learned along my journey so far, and what I continue to learn for the rest of my career in Medicine and Emergency Medicine. Please be patient with me as I work out the formatting, organization, and schedule for these posts. I felt this was an important topic and decided to start with a post addressing mental health among trainees, and those who deliver medical care. This is the start of my blog post contributions to #TipsForNewDocs. I welcome any and all comments, feedback, and hope that you may be inspired to share your experiences and join in allowing the medical community to feel empowered to share and process their experiences and emotions.

Note: Please be aware that the contents of this blog post contain descriptions of patients and their health conditions which may be graphic or upsetting to certain readers. In order to protect patient privacy I have kept things as general as possible, changed some of the situations around to protect those involved, and I hope you all understand the purpose for this post and do not dwell on the specifics. The specific patient situations are simply what I have observed, but all in health care will have their own stories.

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Many of you will recognize the photo above. It went viral last year after it was posted on social media by a friend of the physician posted in the photo, by permission. For those of you who are unfamiliar with the photograph and the story behind it, I encourage you to review this post which synthesizes the events that transpired and the background of this quite well.

This photo, and the story behind it, resonated with me so much when I learned about it. All my life, I had been known by family and friends to be emotional and attached to those around me. I knew going into medicine what was in store for me. That being said, it hasn’t and doesn’t make it any easier for me to deal with bearing witness to the suffering and loss that I do on a daily basis in my line of work.

I wanted to share some personal patient encounters that troubled me and caused me grief and emotional suffering afterward, because I think it is important we allow physicians, nurses, physician assistants, nurse practitioners, patient care technicians, and all those who participate in patient care, to experience, process, and truly be open about how they feel.

The first time I really cried after starting medical school was when I was a fourth year medical student. During one of my away rotations in an Emergency Department, I helped in the care of a police officer who was shot in the line of duty. I had assisted with and observed innumerable trauma resuscitations by this stage of my training, so the actual events transpiring in front of me were not unfamiliar to me. However, what was different about this situation, the first time I was directly involved in caring for an officer who was injured, was the sheer emotion of the situation. The officer’s colleagues flooded the Emergency Department. There was a complete different tone of urgency among the supervising attending physicians and trauma surgeons. I could see in the eyes of the nurses, technicians, physicians, and officers around me, that this was hurting them. The pain and suffering the policeman was enduring, the treatment that he was receiving, it was causing a tidal wave of many emotions throughout the facility.

There must have been 15 police cruisers that showed up outside of the department within moments of the officer’s arrival. Several of his lawmen had brought him to the department in their cruiser, since there was concern that by the time an ambulance arrived, the officer would be too sick to save. This was one of the first times I learned that in some situations police officers, because of the environment they served in, had to transport patients with trauma to Emergency Departments in their own cruisers. Not many people know this about police officers, and with the recent negative publicity that surrounds law enforcement all over America, I wish it to be known that police officers do so much that the news media never shares. They are, in many ways, endangering themselves day in and day out, for the general benefit of the citizens they serve. Bad apples always exist, and create negative publicity, but please do not forget what the men and women of America’s law enforcement agencies signed up to do for us – protect us.

The officer was rushed to the operating room, and there was silence in the Emergency Department. For anyone who has ever worked or been in any ED for any period of time, even as brief as 30 seconds, there is never silence. If an ED is quiet, you should worry. It took a good 30 minutes for the entire department to shake the effects of the trauma resuscitation. Staff, patients, officers who lingered behind for a time, appeared dazed. You could see some were emotional, but most looked stoic.

I went about the rest of my shift as usual and went home. It wasn’t until several days later that I realized how much this had affected me. I was watching The Wire with my wife (SPOILER ALERT) and watched an episode in which an officer was shot. In the make believe show, the officer was transported to Shock Trauma for resuscitation. I immediately and suddenly burst into some of the most awful crying I have ever done in my life. It rivaled how much I cried when I was kneeling besides my dying grandfather at home, who was on home hospice for his bad lung cancer, and whose hand I held as the last glimmers of life left his eyes. As I write this, I am fighting back the desire to again cry, because I happen to be writing this in a public space.

My wife held me close, and comforted me. She was patient, she did not judge, and she was everything I love her for. She waited for me to speak first, and then proceeded to very calmly and compassionately try and find out what was wrong. I explained to her, not mentioning specifics, what I had observed in the Emergency Department with the police officer. She immediately understood without much explanation why the events that transpired in The Wire affected me so much. I continued to cry and bawl my eyes out, until finally I regained my composure. I felt a lot better having shared my emotion with my wife, and for allowing myself to feel the raw emotion I was dealing with. This was an important moment for me because I realized that this needed to happen for me.

(To Be Continued)