Friday, July 9, 2021

Chest Pain Relieved by Antacids: My Last Night as a Resident

 From the 7/9/2021 newsletter


Director’s Corner

 

 



Chest Pain Relieved by Antacids: My Last Night as a Resident

 

 


Adina Kalet, MD MPH

 

 

 

In this Transformational Times devoted to transitions Dr. Kalet recalls the final night of her residency at Bellevue Hospital in New York City …

 

 

The astute intern standing next to me, noticing the beads of sweat forming on my forehead and my clenched fist rubbing my breastbone, walked to the medicine locker, grabbed a little blue bottle of antacid and handed it to me. “If this works, I won’t have to admit you on your last night on call as a resident!” he said cheerfully.

 

I slugged the chalky, mint flavored substance and almost immediately felt the chest pain—which I hadn’t even fully noticed until then—resolve. “Thanks,” I said, “You’re gonna be a great resident in a few hours!” I glanced at my watch. 4:00 a.m. on June 30. My last day as a house officer.

 

 

“4344 Stat!!” the crackling voice of the Bellevue Hospital operator cried from one of two cigarette box size beepers hanging off the waist band of my white pants.  This dedicated “code beeper” was calling me to the emergency room where, luckily, I already was standing, ready to help my colleagues who were conducting a cardiac resuscitation on the patient in the “slot.”  This was not the cause of my heartburn. I loved this part. I was trained to do this, my movements were smooth and assured, the decision-making was practiced and honed. I felt competent and proud of my colleagues as we surrounded this patient, a man brought in by ambulance from Pennsylvania Station awake and alert, experiencing substernal chest pain and shortness of breath, who now needed us to save his life. And save his life we most likely would. This was quintessential doctoring, one patient at a time. 

 

My heartburn was a result of the other beeper. The “medical consult” beeper was insisting, with the exact same urgency, that I call “bed board” (the office that managed the 400 adult beds in the hospital) and 17 West and 16 East and the Surgical ICU all at the same time. I added the call back numbers to the pink sheet on my clipboard. I made eye contact with the senior resident running the code to signal I was there if he needed me and picked up the wall phone.

 

This part of the job made my stomach acid churn. After a year of med consult call, all of us senior residents had mastered—but did not have a positive attitude about—what we called the “hotel management” or “traffic cop” aspects of the job. We disliked assigning admitted patients to medical teams and working with the hospital administrator (“bed board”) and nursing leadership to assign beds to those patients. It was a hard and thankless three-dimensional chess game. I didn’t feel particularly good at or prepared for these logic puzzles. But I engaged because it was my job on the team that night. 

 

There was also the “consultation” part of the job, which sounds like an opportunity to engage in erudite conversation with residents on other services about how to best care for patients, but that wasn’t how things worked. The attending physicians did that part. Most often, we residents engaged in tense discussions demanding to transfer patients from their service to ours or vice versa. Too often, we debated whose “job” it was to adjust antibiotics or blood pressure medications. I would argue that any physician could handle this simple task with a little advice from us, but they would argue that their job was complete, and the patient now belonged on our team. We would argue where the patient with ominous abdominal pain should be monitored; our team contending that the physicians who could provide definitive surgical therapy would be best positioned to manage the patient, while they argued that until an intervention was needed, the patient should stay with us. On and on. Over and over.

 

Senior residents developed reputations as being a “wall”—staving off patient transfers by playing expert, impenetrable defense, or being a “sieve”—easily persuaded to accept the transfer. I won’t tell you which reputation I had, except to hint that I did accept transfers to our service only when it was obvious that a patient would be best cared for on our team. This was a judgment call, and I trusted both team to do right by the patient.

 

It was also true that I didn’t have the courage or tenacity to insist that other teams handle problems outside of their comfort zones. I have since gotten over that.

 

Physician professional identity formation, in those days, was in a very tribal stage of development. We worked on teams and, as teams, we defended our boundaries. As soon-to-be attending physicians, our main developmental challenge was to balance team loyalty and identity with a much more subtle discernment about “what is best for the patient.” These situations were very complex; a single correct answer was unlikely. Beyond the formidable technical aspects of our disciplines, we attempted to discern what was really, wholistically best for each patient right now and under these circumstances. Without realizing it at the time, we were developing the practical wisdom needed to thrive as a physician for a lifetime.

 

This critical learning process literally gave me chest pain.

 

Eventually the new consult resident, in a fresh scrub shirt and white pants, came by to take over the beepers. She listened carefully to my recitation, jotting down the names, locations, and vital facts about the consults still to be seen and for those who needed follow up. We reviewed the remaining “bed board” issues. I asked her to check on the freshly resuscitated patient; finding him a hospital bed was a priority. The resident had been at our class’s graduation ceremony the week before, so she knew of my plans for a year abroad for medical education research and my ensuing fellowship. She wished me luck.

 

I found myself wistful and sentimental about her very first med consult shift and envious of her freshness and eagerness to do right and good. I hoped she would develop the wisdom needed to navigate the complexities in the best interests of our patients, without spending much time seriously considering being either a wall or a sieve. But we didn’t have any time to discuss this, both beepers were already sounding.

 

I cleared out my locker and packed up the remaining books, toiletries, and other odds and ends. Gathering up fresh beeper batteries and few single dose bottles of antacid I had pilfered from the nurse’s station, I left them on the table in the on-call room. Someone would need them sooner rather than later.

 

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

Advice to Interns from Program Directors

 From the 7/9/2021 newsletter


Perspective/Opinion

 

Advice to Interns from Program Directors

 

Compiled by Kathlyn Fletcher, MD MA

 


 

Dr. Fletcher asked several residency program directors from MCWAH to provide their advice to new interns: practical, funny, or both. Here is what they had to say …

 

 

Chad Carlson, MD, FAAN

Professor and Vice Chair – Education

Program Director, Neurology Residency

Program Director, Clinical Neurophysiology & Epilepsy Fellowships

  • If you crave a tasty (soft) cookie, check out the Hub.
  • It is never too early to start identifying and talking to potential mentors.
  • Completing medical notes is not like enjoying a fine wine; notes do not benefit from letting them age or breathe, so complete them in a timely manner.

 

 

 

Yvonne Chiu, MD

Professor of Dermatology and Pediatrics

Program Director, Dermatology Residency

  • Use the same password for your work (MCW, Froedtert, VA, and Children’s) accounts and change them all at the same time. Makes it easier to remember what your current password is when you move between sites.
  • Bring your lunch when you can. You eat healthier when you are not relying on cafeteria food.
  • For those residents who take home call and need to call patients, download the Doximity app. It allows you to call patients using the hospital name and phone number in the caller ID.

 

 

 

Sriram Darisetty, MD, FACP

Assistant Professor of Medicine
Program Director, Transitional Year Residency Program, MCWAH- St Joseph.

  • Try not to be under-confident, but absolutely avoid being over-confident. 
  • Autonomy is earned, not given.

 

 

 

Stacy L. Fairbanks, MD

Associate Professor of Anesthesiology

Program Director, Core Anesthesiology Residency 

  • Prioritize sleep or you won’t get it.  Sleep 7-9 hours per night whenever possible. 
  • Study a little bit every day.  Gaining the knowledge you need to pass certifying exams is a marathon, not a sprint.

 

 

 

Kathlyn Fletcher, MD MA

Professor of Internal Medicine

Program Director, Internal Medicine Residency Program

  • Always do what is in the best interest of your patient. I actually borrowed this one from a former mentor, Dr. Arthur Rubenstein.
  • The quality of your day is directly proportional to how many people you say “hello” to on your way into work.  I have no data to prove this, but I am pretty sure I am right.
  • Patients want to believe that you care about them beyond your professional obligation to care.  I do have evidence to back this up and would be happy to provide it to anyone who is interested.

 

 

Camille Garrison, MD

Associate Professor, Medical College of WI, DFCM

Program Director, Ascension Columbia St. Mary’s Family Medicine Residency Program

  • Don’t put emojis in a patient’s chart… 😊
  • The patients you see are not a means to an end. It is an honor and privilege to care for them.
  • Take advantage of every opportunity to grow while in residency, both personally and professionally. What you get out of residency, has a lot to do with what you put in.

 

 

 

 

Matthew Goldblatt, MD

Professor of Surgery

Program Director, General Surgery Residency

  • Find good bathrooms

 

 

 

 

Alisa Hayes, MD

Professor of Emergency Medicine

Program Director, Emergency Medicine

  • Give yourself enough time to park and arrive on time. Your PD will get a notification if you park illegally.
  • The Froedtert finder app can help you navigate the hospital and find rooms / locations as well as notify security when you are leaving the hospital at odd hours.

 

 

 

Heather Toth, MD

Professor of Internal Medicine and Pediatrics

Program Director, Internal Medicine/Pediatrics combined program

  • We are all here for you! Please reach out to us as we have all been interns at some point in our lives.
  • Remember to stay in touch with family, friends, colleagues, hobbies and things you love.

 

 

 

 

Kathlyn E. Fletcher, MD MA is a Professor and residency program director in the Department of Medicine at MCW. She is the co-Director of the Graduate Medical Education Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Advice for Surgical Residents

From the 7/9/2021 newsletter

 

Perspective/Opinion

 

Advice for Surgical Residents

 

Compiled by Bruce H Campbell, MD FACS

 


Dr. Campbell, who entered a surgical field decades ago, asked his current residents what they have learned to keep themselves whole and able to function despite living in high-stress times and working under pressure. Here is some of what he learned from them, and about “grit” in surgical residents …

 

 

What sorts of things have surgical residents discovered that allow them to survive as trainees? Here is a list from current otolaryngology residents (and their friends):

  • Everyone expects surgeons to be arrogant. Surprise people in a good way.
  • Ask the right questions and listen carefully - often this will tell you more about a patient's condition than any test or image can.
  • Get to know your patients beyond their chief complaint.
  • Learn to understand and appreciate the environment that your patient came from, and you will glean so much more. “For the secret of the care of the patient is in caring for the patient.” - Francis Peabody (“The Care of the Patient,” JAMA 1927)
  • Listen to the nurses. Learn their names. They are the ears, eyes, and heart of the floor. They spend more time at the bedside than any physician or care team member.
  • Be forgiving of yourself and your colleagues. We all have one common goal, and that is to provide healing and nurturing for our patients.
  • Mistakes are an inevitable part of medicine. Always be honest, show empathy, and commit yourself to a lifelong endeavor of learning.
  • Practice self-care. “Just as a car can’t go as fast on a flat tire, you can’t give your best effort if you aren’t mentally, physically, and spiritually running on all cylinders." - U.S. Surgeon General Jerome Adams
  • Find yourself a good pair of shoes. This will take you far, literally!
  • Do not forget why you are doing what you do. Our profession is unique, people trust us with their lives, and we cannot take that for granted.
  • Do not forget that each of your patients is a person first and a patient second.
  • Informed consent is a process and a relationship, not a piece of paper.
  • Stay up-to-date on your administrative paperwork and be kind to the residency program coordinator.
  • Always act in the best interest of the patient.
  • Stay humble.
  • Just keep showing up even when you feel like you’re not doing well. It always gets better.
  • See the patient before calling a consult.
  • Stay current on your surgical case logs.
  • Before ending any conversation with a patient, always ask, “Do you have any other questions?” That usually elicits their deepest concern.
  • Knowing when to operate is at least as important as knowing how to operate.
  • Balance humility and ego. It’s not easy. 
  • Remember to enjoy simple wins and to learn from loss.
  • Sleep when you can, eat when you can. 
  • Wipe your feet of the day before you walk into your home to greet your family. 
  • Be an organized junior resident but ask for help. Remember you’re human, too.
  • Each patient is experiencing something at the same time you are, so even if this is your hundredth consult of the night at 3:00 a.m., try to bring compassion to the encounter. 
  • Remember, at the end of the day, you are a team.
  • Check for speckles of blood on your scrubs, booties, face, and mask before going to talk to patients’ families.
  • Surgical training is uniquely stressful. Stay self-aware. Reach out for help. Watch for warning signs in others.
  • Know your stuff, do the right thing, and ask for help when you need it.
  • Don't forget to engage in things that make you happy, as residency will trick you into thinking success must cost you joy.
  • Residency can unmask underlying vulnerabilities.  Don't be afraid to lean on your co-residents (and even attendings), either professionally or personally
  • An ICU consult is better than a rapid response, and a rapid response is better than a code.
  • There are two kinds of residents: the ones who write it down, and the ones who forget.
  • Trust no one, expect sabotage, and always have a backup plan.
  • Stay current. There is no glory in being technically adept and doing the same, wrong operation every day for the next thirty-five years.

 

On a related note, a recent article in JAMA Surgery confirms that grit, as a personality characteristic, is a good thing. Grit is defined as “perseverance and passion for long-term goals,” and is measured with a standardized GRIT-S questionnaire that asks about a person’s ability to concentrate on a project, their reaction to setbacks, their constancy in pursuing goals and interests, their self-identified work ethic and diligence, and their ability to thrive in the face of challenges. General surgery residents with higher “Grit” scores were less likely to report burnout, thoughts of leaving their training programs, concerns about their career choice, and suicidal ideation than residents with lower Grit scores. Grit scores were higher in women, more senior residents, and in married residents. The authors recommended that programs do what they can to bolster their residents’ grit.

Surgeons have unique roles and responsibilities in society; what can compare to the trust someone displays by allowing another human being to render them completely defenseless and then rummage around their insides? As an institution, it is our responsibility to prepare our residents to enter the world as character-driven, compassionate, and skilled surgeons.

Thanks to my “gritty” residents for sharing the lessons they have learned.

 

Bruce H Campbell, MD FACS is a Professor in the Department of Otolaryngology & Communication Sciences and in the Institute for Health and Equity at MCW. He is editor-in-chief of the Transformational Times. 

Top Ten Tips for Thriving During M3 Clerkships

From the 7/9/2021 newsletter

 

Perspective/Opinion

  

Top Ten Tips for Thriving During M3 Clerkships

  

Compiled by Scott Lamm

 


 Mr. Lamm and his colleagues offer some sage advice to the incoming third-year medical students …

  

  • Be proactive! Pay attention on rounds and create a to-do list for each patient. Instead of asking for tasks from your resident, let them know what tasks you are comfortable with doing and if it is okay for you to complete them.
  •  For Surgery – invest in a pair of compression stockings. Your feet at the end of the day will thank you.
  • It’s okay to say, “I Don’t Know.” No one knows everything, and this gives you an opportunity to do the research and look it up for the next time you are with your attending or residents that asked the question.
  • Nurses and CNA’s are your best friends. They know the patients better than anyone. Talk with them each morning. Update them after rounds. They will be very appreciative.
  • Know what you are charting! If you copy forward a note, ensure that everything in that note is something you did that day. You will most likely not do a comprehensive physical exam every morning, so ensure you only chart what you did.
  • Children’s’ Cafeteria Buffalo Chicken Ranch Wrap is the best! On nights, you can get it toasted mmmmm… Also, Children’s’ breakfast is the best pick me up in the morning after a call day.
  •  Learn from your patients – they are the experts in their own life experiences. You will have a lot more time to devote to each of your patients than the residents, so spend the time. You will be surprised at how a good relationship can help the team exponentially.
  • Calling consults can be nerve-wracking – write down the most pertinent points, lab values, and imaging results so you don’t forget them. Consultants will be very impressed when you have this information right away instead of making them search the EMR after the call.
  •  Make sure to eat! Time moves fast and it’s easy to forget about lunch. A working mind requires a happy belly. Bring snacks, meal prep.  Sometimes it may feel like there’s no time in between cases or after rounds, but two minutes is enough to scarf down a granola bar.
  • Have fun! Third year is full of surprises. There will be good days and there will be bad days. Step back and reflect when you have the chance. The connections you will make with attendings, residents, and especially patients will transform you are a physician. Step into each rotation with an open mind.  And do not hesitate to ask for help.

 

Sincerely,

The Class of 2022

 

 

 

Scott Lamm is a fourth-year medical student at MCW and member of the Transformational Times editorial board.