At West Suburban Medical Center
A Newsletter from the Internal Medicine Residency Director
“It is easier to build strong children than to repair broken men.” Frederick Douglass
“It’s your reaction to adversity, not adversity itself that determines how your life’s story will develop.” Dieter F. Uchtdorf
“If you’re going through hell, keep going.” Winston Churchill
“We cannot always build the future for our youth, but we can build our youth for the future.” Franklin D. Roosevelt
“I know how important it is to have a helping hand. In my childhood I had difficult times because of hormonal problems. If I hadn’t had support, I wouldn’t have been able to fulfill my dreams.” Lionel Messi
“You say you’re depressed. All I see is resilience. You’re allowed to feel messed up and inside out. It doesn’t mean you’re defective. It just means you’re human” David Mitchell
“I think this man is suffering from memories.” Sigmund Freud
Happy New Year!!!
As many of you know, I love to talk (perhaps nauseatingly so) about adult learning theory, and about wanting to continue to create workshops for you as a larger component of your didactic learning, as it is active learning rather than passive learning. Having said that, I understand the need for power point lectures, even though, as a passive tool, our adult ability to remember more than 5% of a lecture, or even just one learning point, is not great. However, having said that, I was at a power point lecture recently that has changed and reshaped the way I think about illness (of course, I reread and reviewed the lecture and read the background data to really “know” the material).
Dr. Stan Sonu, Associate Program Director for the Med/Peds residency at Emory (did his original training at Rush), presented the talk. The lecture was at the recent regional ACP meeting in October 2019. He presented a talk on ACE’s, or Adverse Childhood Experiences. He has done a Ted Talk (another educational platform I am enamored of, as you all know) on this subject as well. ACE’s are about our (yes OUR) traumatic experiences in childhood, and how it informs human diseases.
As like many of my musings, we begin with a story. In the 1980’s, an IM physician (Dr. Vincent Felitti) who specialized in weight loss was working with a patient who was particularly successful in his program – she lost close to 200 pounds over the course of a year, and her diabetes was gone, her knee and back pains were gone. However, she suddenly stopped showing up to visits. The physician tracked her down several months later, and she had regained over 50 pounds. When asked why, he discovered that, with her weight loss, she was being noticed, and she was being asked to go on dates. But these advances brought up haunting old childhood memories, of being sexually abused as a child, and feelings of anxiety and depression overcame her. Why would someone on the road to good health “deliberately” sabotage it? Her salient comment… “Overweight is overlooked, and that is the way I need to be.”
My explanation of ACE’s is not going to do it justice, nor how much it transformed my thinking, but I will try to give a brief explanation. Dr. Felitti did a large study after realizing how much childhood traumas could potentially affect how an adult then responds to stress. Probably to some of your surprise, the data, culled from 17k+ people in California, the participants were 75% white, >54% women, 39% were college educated, and half were > 60 years old. He discovered that there are ten ACE’s that have the most influence on adult illness. They are in 3 categories: Abuse (physical, sexual, emotional), Neglect (emotional and physical) and Household stress (mental illness, substance abuse, domestic violence, incarceration, divorce/separation (though over time it has been found that divorce/separation has the least influence).
The data is easy to understand – add up how many ACE’s an individual has, and the more ACE’s you have in childhood (especially > 4), the more likely (odds ratios anyone?) you developed chronic illnesses. These illnesses include diabetes, heart disease, stroke, COPD, stroke, mental illness, impulse control disorders, substance abuse disorders, anxiety disorders, smoking, heavy drinking, IVDU, etc.
For those of you who want some science behind this…For those subjects who have shown to adapt well to persistent stress, dynamic PET scans have shown high temporal lobe activity – where emotions are developed, while those with maladaptive behaviors to stress show less activity in the temporal lobe and more in the amygdala, which is where the flight or fight response comes from. It is also well known that brain cell development is dramatic the first several years of life – and the more exposure to vocabulary and reading at an early age the better the development of the prefrontal cortex, which is the area that plans for the future, and develops empathy, reasoning, and self-control. Naturally, with that segue you can see that additional factors other than ACE’s can correlate with these adult illnesses. Adverse Community Environments (unaffordable housing, racism, joblessness, poverty, community violence), and Adverse Collective Historical Events (holocaust, slavery, genocide, forced displacement, mass incarceration) contribute to the illnesses we know and are familiar with. Put it all together, and you can see evidence of increased ACE’s in African Americans, Hispanics, multiracial, and LGBTQ+ groups, and those with low education, <15k income, unemployed, etc. The analogy used is that as physicians and health care providers, we only see the illness, which is the tip of the iceberg, and deep underwater are these ACE’s and other Adverse events. As physicians we are reactive, and deal only with the tip of the disease, and we do not get at the root source.
And now the key – what can we do as internists, as physicians? How do we create resilience, to transform toxic stress into tolerable stress? We know that there are protective factors in those who have had > 4 ACE’s from developing illness – strong stable relationships with caregivers, self-regulation skills (prefrontal cortex), and connection with community. What Dr. Sonu, and others who understand ACE’s, is we need to move away from the standard, reactive care to TRAUMA-INFORMED CARE. We move from the question “What is wrong with you?” to “What’s happened to you?” The key principle of trauma-informed care is promoting the linkage to recovery and resilience, for those affected by trauma, by building awareness, promoting safety and trustworthiness, providing transparency, understanding cultural, historical, and gender issues, integrating care, and promoting collaboration, mutuality, and client autonomy. “Healing happens in relationships.” That means that we need to be at our best in talking with our patients in communicating empathically, doing reflective listening, and doing shared decision making. The key to success is developing our emotional intelligence. Facilitating behavior change is grounded in developing strong physician-patient relationships. Dr. Sonu believes we don’t need to get specific with the ACE’s right away, but the relationship can start with the open-ended question “How was growing up for you?”
Proponents of trauma-informed care talk about the 4 R’s – Realize (the widespread impact of trauma), Recognize (s/s of trauma and maladaptive behaviors), Respond (compassionate guidance towards behavior change through policies, procedures, and practices, and AVOID Re-traumatization (actively, through universal and targeted actions).
Sounds complex (and it is, and will take practice to get good at it), but I will give examples to ground the theoretical construct.
Example #1 – You want to taper opioids for a patient – they respond in anger. Standard view – patent is being manipulative and cannot control the addiction. Trauma view – recognize that fear often underlies anger. Inquire about what they might be concerned about (abandonment?)
Example #2 – Patient is non-adherent to medications, treatment, plans, referrals. Standard view – doesn’t care about their body, poor insight, thinks they know better than the health system. Trauma view – look at social determinants – may not be able to trust the health system, may fear for safety, may be dealing with sequelae of trauma.
Example #3 Patient comes in for every ache and pain – Standard view – drug seeking or somatization disorder. Trauma view – needs regular assurance from someone they trust. Inquire about connections with emotions, moods.
Example #4 Patient engages in risky behavior despite knowing and having been treated for complications (EtOH, STI’s). Standard view – doesn’t care. Trauma view – behavior may represent maladaption to past/current trauma. Start with trust before jumping to solution.
Of course, we CANNOT overlook our own experiences. We can’t ignore the fact that medical students and physicians also have ACE’s. In fact, I have learned of a current research project looking at ACE’s in medical school students. I am sure you won’t be surprised – a significant percentage of medical students have > 4 ACE’s. Does this increase the risk of suicide in these students, does it lead to more problems, lawsuits in the future? TBD. You cannot deny that many doctors have maladaptive behaviors, but there are others that have more resiliency and empathy. Physician self-care is a prerequisite – without it, it will preclude any transformation of our institutional culture.
Finally – I would encourage all of you to read your personal statement (PS) again. Why? Because, having read a TON of personal statements, most if not all of your statements talk about a personal journey of discovery, of reaching out to someone and making a difference in an individual. Each and every one of those stories talks about trauma-informed care – discovering the background of that individual, learning of their fears and concerns, and thus, even if not making a fully positive end result, having made a difference in a patient’s life. Each and every one of you have the capacity, and the knowledge to bring trauma-informed care to the field of medicine.
Here are the primary resources of this information.
https://doi.org/10.1016/j.amepre.2019.04.001 (this is a reprint of the original article)
END OF A DECADE! – #tenyearchallenge. I have been blessed with Asian genes – apparently I haven’t aged a lot in 10 years, looking at old pictures. 5 pounds heavier, more squiggy in the middle. Also a few more gray hairs (most of them the last 2 ½ years!!!). In 2009 my wife and I were involved in every aspect of our kid’s lives. In 2019, we are empty nesters, and watching our kids succeed on their own. In 2009, at this exact time, I was in Cancun with my family. 10 years later here I am, in Michigan, in the cold, and I don’t mind it a bit. Time sure flies when you are having a BLAST every day…
RECRUITMENT – Last FOUR recruitment days coming! Two weeks in January, two recruitment days per week. 1/7, 1/9, 1/14 and 1/16. 2 prelim recruitment days, 1 more categorical recruitment day, and one day we will have both candidates (1/14). We continue to get applicants who really enjoy hanging out with all of you and learning about the program. Yes, please continue to bring your enthusiasm to play Chopped and give us your input. I want to reiterate that we value what you have to say. On Friday January 24 (or is it Friday the 31st?) from 12 – 2pm (lunch provided – place TBD) we will have one final review of all the applicants – this is your opportunity to have any final say in the candidates that came and interviewed with us this recruitment season. The attendings will have their final say on January 31 (or 24?)
EVENT REVIEW AND COMMITTEE WORK – I will be sending out shortly “new” assignments for the committee meetings you should be attending. In fact, Maura Fahy has sent out this list to all the heads of committees to make sure you get email reminders when meetings are held. I am also sending a rotating schedule (it will be sent at the beginning of every month) for ALL residents, during elective rotations, to attend the Event Committee, which meets every Monday afternoon from 1 – 2:30pm in Christine Clark’s office. This is a chance to review all Midas reports from week to week. As part of Quality Improvement, and part of your milestones for residency, I will be asking you, when you attend any of your committee meetings, for a report. More details on this later.
HOLIDAY SING-ALONG December 13th (see pictures) – I can’t hold a tune, but that was fun. Thanks to all who participated in the ugly sweater contest, or got dressed up for the party, and sang a tune or two, and hung out for a bit…
We are entering the deep part of winter, and a busy flu season. This is the most difficult part of every year. Please, if you need any help, just need to talk, need something from leadership, we will be here for any/all of you.
Wishing everyone the best for 2020.
Take care everybody…
“We can disagree without being divisive. Sadly, those who seem to scream about diversity the loudest, want their way so badly – they refuse to see the value and integrity in honest disagreement. They also fail to see the value and worth of the person they might disagree with.” ― Jeff Dixon
“It’s not, it’s not going to change anything. We’ll, we’ll get our justice … Please, we can get along here. We all can get along.” – Rodney King
“I wonder if one of the greatest lessons of our generation will be that ironic detachment is not an inherently neutral stance; that humor is not necessarily benevolent; that viewing anything and everything as a joke doesn’t make you stronger or wiser, but exactly the opposite.” – Nitya Prakash
“I don’t have to agree with you to like you or respect you.” Anthony Bourdain
“The love of conflict is most evident when opposing forces join sides to defeat the peacemaker.” ― Criss Jami“A lot of lip service gets paid to being honest, but no one really wants to hear it unless what’s being said is the party line.” ― Colin Quinn
For this musing I want to tell you a few stories about conflict. Not quite in the holiday spirit, but it’s telling that I want to share these stories in the world we live in now. At the end, I hope to pull it together to bring a message of hope for the New Year.
Back in September, at the ACP Illinois Governor’s council meeting, the hospitalist members were telling us about their recent subcommittee meeting. In it, the hospitalists were discussing whether they should set up a panel discussion to review the burgeoning role of APRN’s (Advanced Practice Registered Nurses) in hospitalist medicine. Most of us believed in a collaborative role, utilizing APRN’s where there is a physician shortage, such as in rural and other areas. However, it should remain a team based approach. However, when the hospitalist committee attempted to create an open discussion with the APRN organizations, they were told that there is no discussion – APRN’s should be autonomous – should hold the SAME PRIVILEGES as physicians, should be able to have full privileges as a hospitalist, should not need physician oversight (which is already approved in 28 states), AND, as well, should be paid the same as hospitalists (yes, despite not spending 4 years in medical school and 3 years of residency…). Bottom line – not open for discussion. Now, to be fair, physician lobbies are opposed to allowing APRN’s full autonomy. I am not going to debate the various needs and the two sides of the coins, but needless to say it has become very contentious. There is no in between – so the idea of collaboration that we in the ACP council felt would be best is summarily being ignored by BOTH sides of the issue. We left the meeting a little saddened.
About two months ago, here in Oak Park, a ruckus broke out in the local political scene. Our Village was looking to refine its diversity statement and there was a lot of back and forth among the trustees, not all of it pleasant, and NO ONE wanting to give in on their idea. Finally one of the trustees went ballistic and accused the Caucasian male village trustees of being blind – that they had no right to put anything in a diversity statement, that a Caucasian male has never been oppressed, and are the ultimate in a privileged class. This came from a Caucasian female. There are NO African Americans on the Village board. She even ranted at our Oak Park village “mayor” Anan Abu-Taleb, and said he had no right to say anything as he was male and “white enough”. After the meeting, possibly In response, one of the village trustees then went on an alt-right group podcast which basically skewered the female gender for her outburst. She received death threats for her outburst. Things have since slowed down, but the venom remains. A liberal town refuses to listen to the other side, and each has decided that a simple diversity statement (ironic isn’t it?) could be so contentious as to create hard feelings and a complete breakdown in local politics.
The last story is one I have mentioned before, and happened several years ago – my wife worked at the Oak Park River Forest Chamber of Commerce at the time, which represents small businesses. At the time, Illinois recommended (but did not require any city to do so) increasing the minimum wage, and all the towns surrounding Oak Park opted out of it, but of course Oak Park absolutely agreed and required that minimum wage quickly be ramped up to a potentially livable wage. Very noble, but that mandate hurts small businesses most of all, as they have slim margins of profit. All my wife wanted was several small business leaders to have a seat at the Village Hall table, a chance to discuss ways the Village can help small businesses ride this wave as wages go up (with tax relief, etc.). This led to protests, to the point that my wife was called a “slave-owner” and just interested in oppressing the downtrodden. So she, nor small businesses have a seat at the table. If you have been here long enough, you can see the effects, with Oak Park business now looking more like strip mall businesses, and franchised establishments.
And let’s not get started on the division of politics at the national level. So why am I talking about this? Because I am scared. I am starting to see inklings (some may say more than that) of sharp division within this institution, and in its individual parts (admin, residency, faculty, residents, nursing, case management, and even patients), and I worry that we will become a reflection and a mirror of the stories above. Do we live in a world in which there is no compromise? Do we have to be vociferous and loud and unremitting to get things done? Do we have to refuse to compromise and stubbornly hold our ground until we get our way, and if we don’t, just leave? Does this seem like a sensible way to live our lives?
I worry that there will soon be no more collaborative communication. In society now, we tend to fall into a “you are wrong and I am right” mentality, the “I don’t need to communicate with you because you don’t share in my beliefs, my social media group will back me up to say I am right…” I am not sure we spend the time to just listen to each other anymore. I think a LOT of the blame goes into the fact that WE THINK THERE IS NO MORE TIME to just LISTEN. We have so many other things to do – most burdensome is our “scut” work – our charting to finish, our patients to see, my paper work (prior authorizations, FMLA’s, preoperative cardiac clearances). Most of you who talk to me see me trying to do one last thing and get distracted while you talk. I try not to do that, but I apologize I don’t always succeed. I keep needing to do better. But we also have to find TIME to do what we can to find balance in our life – seeing family, going to parties, finding alone time reading, seeing the most recent movie, or going to the next new restaurant. But a lot of the blame also goes to the fact that it takes EFFORT to REALLY LISTEN.
This holiday season, let’s all step back for a moment. Holidays are hectic, but I want everyone to also spend some time for reflection. We are all unique. We all have a different lens in which we see things. We have to respect one another’s perspective, and we should be collaborating, communicating, and working together to solve problems, rather than “whoever shouts the loudest and makes the most noise” wins, and gets their way. In many ways, just believing what you believe and sticking to it is just easier, and, dare I say it, the lazy way out. You don’t have to think, you don’t have to meet at the table and problem solve. That takes hard work, and takes TIME. Yes, so it takes a little longer, and you have to do your paperwork until 8pm (or for me sometimes, 11pm doing notes). Yes, sometimes you are going to spend one less hour hanging out with friends. But taking that extra moment to listen, to work with, say, the nurses, to think through on a better solution when it really is neither of your jobs to do what has to be done; to maybe bend a little one way and do something for say, case management, so that in the future they will bend a little to do something for you. I am not asking that you be passive, but we can be the ones who see the whole picture better than others, and, perhaps in our arguments and protests we can reach a common middle ground, a compromise, or a better solution to the problem at hand. As humans, we ALWAYS put aside our differences when a natural disaster occurs, an “all hands on deck”mentality to help one another, no matter who we are and where we come from. We aren’t in a crisis now (?!), but why can’t we work well with one another more often?
Remember the first story? Despite being a little saddened at the lack of discourse, I came away encouraged, as the ACP leadership in Illinois believe in that middle ground; that we should be working together and collaborating. We need to have our say, but we don’t have to shout from the rooftops to get our way. We are willing to LISTEN to the other side, and, despite the initial stone wall, we do believe that there are others on the other side that are willing to LISTEN to what we have to say.
CONGRATULATIONS! To everyone – for getting through working in the ICU for three consecutive months. Not the easiest rotation, but hopefully you got through it with a little more knowledge, and more confidence in taking care of our sickest neediest patients.
RECRUITMENT – Thank you SO MUCH for continuing to do a wonderful job during recruitment days. We continue to get applicants who are VERY impressed with all of you and the work you do here – thank you. We have four dates in December (one will be done before this goes out), 12/3, 12/10, 12/12, and 12/17. All categorical applicants. Residents have already been assigned for those days for tours and to answer questions. Again a reminder – everyone please remember to come for lunch and to interact some more, play Chopped and give us your input. You have been very helpful, and we value what you have to say. This is a vital part of the sustainability of every residency program. It’s tough work, and let’s keep up the good work.
TOP GOLF OUTING – Naiara Cancel from TeamHealth has graciously set up another opportunity for any and all of you, with significant others, to attend another fun activity. On December 8th, at 1pm, she has set up an outing at TOP GOLF (topgolf.com). Even if you don’t play golf, it is an opportunity to just relax. The RSVP has already been sent out, so let her know if you and a guest are going. We are going to look for her help to host a Spring activity as well.
INFORMAL HOLIDAY LUNCHEON FRIDAY AND UGLY SWEATER CONTEST DECEMBER 13th, 12noon in the Lower level administrative suite (ABCD is taken). We will bring in a catered lunch, Kirubel will be bringing in his guitar, we will put on some music. Bring desserts to share if you would like. It is going to be ugly sweater day too, and I will have a gift certificate to the wearer of the ugliest sweater. Also, we are going to donate to charity as well, so bring any unused toys, clothes you want to give away, etc. I will try to find a home for them. A lot of the charity drives are already over, but Lurie’s I know and other places are always looking for donations and we can give donations away to one of these groups. If anyone else knows of a charity that wants to accept our donations, let us know. If it is a toy drive, I can buy/bring wrapping paper and we can wrap a bunch of them while here. But it is also a time to eat some food, have some goodies and relax a little bit.
NO ACADEMIC HALF-DAY December 24 and 31. A LARGE number of you will be gone for the holidays – well deserved. For those still around, we will provide lunch on those days, but no lessons…
HAVE A PEACEFUL AND JOYFUL HOLIDAY SEASON.
Take care everybody…
“Bureaucracies force us to practice nonsense. And if you rehearse nonsense, you may one day find yourself the victim of it.” – Laurence Gonzales, Everyday Survival: Why Smart People Do Stupid Things
“Everybody wants to be a bodybuilder, but nobody wants to lift no heavy-ass weights.” – Ronnie Coleman
“I don’t pay to have my dirty work done for me. I do it myself.” Ted Nugent
“By working faithfully 8 hours a day you may eventually get to be boss and work 12 hours a day.” — Robert Frost
“If each day is a gift, I’d like to know where I can return Mondays.” — John Wagner
“Some days, the best thing about the job is that the chair spins.”— Unknown
“I always try to go the extra mile at work, but my boss always finds me and brings me back.”— Unknown
“When I grow up I want to file all day…climb my way up to middle management…be underappreciated, be paid less for doing the same job, and be forced into early retirement.” Quotes from Monster.com ad 2006
One more month and we are out of the ICU….
A few weeks ago I was complaining to my wife about the amount of paperwork and computer work that we as physicians have to do. I talked again about how Dr. Chundi likes to say that we should all be working at the top of our license, and not dealing with the all the minutiae of paperwork. I think I was having a particular bad day, as I had to work on a prior authorization for a patient who has been taking a GENERIC long acting medication for about TEN years, and now his new insurance didn’t want to cover it anymore – (does that sound crazy or what?). My wife, ever the realist, asked me, “name me one job where you are not inundated with paperwork nowadays?” She cited the example of someone really good at sales – great with people, able to convince people of his/her product. But they won’t be considered an excellent salesperson, and won’t close the sale, if they can’t complete the paperwork and get the signature on the contract. She also had some recent frustrations with one of her employees, who only did what they wanted to do (social media wise), but just wouldn’t put in the hard grunt work of doing it “correctly” to maximize exposure on the social media outlets.
The other story came from one of the applicants that was here to interview at our institution recently. I asked a question (I can’t remember exactly what it was) but they stated that they were very passionate about medicine, and would put all their energy into “doing what interests them.” Of course, that was worded strangely, and so I asked “well what about the stuff that doesn’t interest you…like paperwork?” The applicant looked baffled, and at the end of more questioning, they mentioned that at the end of the day “you just have to get it done”. “What if you have to stay late to complete it?” They replied – “No big deal – you can’t sweat the small stuff, just get it done, it’s part of the job.” Hmmm.
Dr. Yedavalli and I both went through a residency that is much different than the residency you are going through now. My residency went through a transition – from unlimited hours on call and no limit on the caps on admission, to caps on admission (when I left residency we still had unlimited hours per week). We wrote everything – notes, orders, etc. We had no cutting and pasting, so notes took longer. But “proper documentation” didn’t exist then, so the amount of modifications to our notes as well as the electronic work we did was minimal compared to what you have to deal with now. But at the end of the day, we put our heads down and did the work. Dr. Yedavalli was also in residency at a time of transition – when limits on duty hours really began, and EMR was just starting. Work compression started during her time, with pressure to complete paperwork and computer work in an efficient and timely manner. At the end of the day, she too had to put her head down and just get the work done.
Fast forward to yesterday. I made a tactical error and scheduled a full day of clinic patients (20 total). I also had 3 patients in the hospital, and then another admission later. I had morning report at 7am. I am grateful to all the residents for helping out, as I rounded around lunchtime and had the chance to spend time with each of the teams, and then rounded again at 6pm, when I reviewed the new patient with the resident team. Then I had 90 minutes of finishing my notes on my patients in the clinic. A small break for some exercise, a meal, and then back doing some more grunt work (writing this newsletter)….
Every job, not just physicians, at every level, has its share of scut-work, grunt-work, mindless but necessary work. I am sure you have all heard this statement – “your job is called “work” for a reason.” Your go off in the morning (or at night) to go to WORK, not to “fun-time”. I like to use the phrase – “You can’t expect every day to be all about rainbows and unicorns.” This is the idea that we expect our job, every day, will be filled with glowing epiphanies and passionate discourse and illuminating patients and enlightening education day in and day out. NOPE. As I mentioned at the retreat recently – it all depends on how you define the day. For me, small and big day to day victories overcome the daily must do everyday drudgery – some days it is as simple as significantly cleaning out my Athena inbox, and having some interesting conversations with my patients. Other days it is completing something very difficult for me to do, but I want to do regularly, like this newsletter…
And at the end of the day, as the one applicant noted, you just sometimes need to get the work done. Don’t expect someone else to do it for you, don’t gripe about it, don’t delay until you are castigated for it (do you like the word castigate? – I like that word….). Spending 30 minutes at the end of the day saves you more time than having to sit down someday later and spending 4 hours on something that, if done immediately day to day, would, in total, have taken 2 hours. This efficiency requires a level of time management, and proper preparation, to be done properly. Can we all do it? Yes. Am I very good at it? Not always. I have good days and bad, and there are times when scut-work catches up with me and I have to spend a half day much later catching up. And there are days I GRIPE about it! But I try to keep up every day and just get it done.
I am not making light of the intolerable amount of paperwork and scut-work that the medical profession requires we do. The work compression that has occurred in medicine makes it almost untenable to feel like each day is worthy of our time and effort. We will continue to talk about burnout in medicine, with our need to do paperwork front and center as a major cause of it. There is a lot of talk now about how you can prevent burnout by getting involved – “burn in” – and advocate for change (ACP is advocating before Congress under the mantra “Patients before Paperwork” and the AMA is advocating under the mantra “Practice Transformation” and “Joy of Medicine”) – and how that may help prevent burnout. But, for now, that grunt-work just needs to get done –. Is it fun? No. Is it glamorous? No. Does it help your patients? Yes most of the time. Does it help the bottom line? Yes, and that is part of the issue…
And guess what – I APPRECIATE IT. Here is a shout out and thanks to all of you for all the inane, day to day stuff that you have to do everyday without fanfare, without complaint, without reminders. Thank you. It’s laborious, and necessary, so, for now, don’t sweat it, and get it done.
CONGRATULATIONS TO MAHROKH NOKHBEHZAIEM, for becoming a US Citizen! She joins Alberto Degiovanni and Kirubel Herano in becoming US citizens while in our residency program. This is truly a wonderful feat. We are going to try and figure out a date to celebrate this when they will all be available.
ACP RESIDENT’S DAY – CONGRATULATIONS to our winners! Ambreen Aslam – FIRST PLACE POSTER in the research/high value care category. Sankha Banerjee – THIRD PLACE POSTER– clinical vignette category. OUTSTANDING! Thanks to everyone for coming and both participating and hanging and networking. In particular, thanks to Cory, Priya, Lloyd, Mohammed, Kirubel, Mahrokh, Alice for competing (just a quick FYI the Doctor’s Dilemma team tied for 2nd in their competition and lost the tie-breaker, otherwise they would have moved on….). Congrats to those who had e-posters accepted – nicely done Salma, Ami, Alberto, Holly, Insia. Thanks to Phani, who had an “Art in Medicine” vignette accepted. I hope many of you stopped by the Art in Medicine room and got a chance to look and listen to a more expressive humanistic part of medicine. Thanks to everyone else who came and participated and learned and networked. I had a wonderful day, hope you all did too. Just a quick word on our residency’s status as an Elite status program with the ACP, and hence not being able to receive a “Resident of the Year” award this year. I discussed this with Colleen Keeku, the Executive Director, and she states we didn’t have Elite status as of December 2018. Looking back this was an error on the PREVIOUS IM Program Manager’s part – I thought I caught it in time but the Elite status comes from national ACP and payment was too late. My bad. I am sorry. I will see if I can do something to make it up for this year. Colleen and I will work together to make sure we are an Elite status program next year.
RECRUITMENT – Thank you SO MUCH for doing a wonderful job the first three recruitment days. We have some applicants who were VERY impressed with all of you and the work you do here – thank you. We have three dates in November – November 7, 12, and 21. All categorical applicants. Residents have already been assigned for those days for tours and to answer questions. I will send a reminder – everyone please remember to come for lunch and to interact some more, play Chopped and give us your input. You have been very helpful, and we are going to NOT rank one candidate already based on your input. As mentioned, this is a vital part of the sustainability of every residency program. It’s tough work, and let’s keep up the good work.
WARD MANAGER IS HERE – There are still a few of you who have not signed up. Please sign up and start utilizing it. It will be most important for FM to IM sign out and vice-versa, especially come end of November.
WHIRLYBALL RETREAT – I hope you all had a nice time on October 29th. I talked to Naiara from TeamHealth about doing MANY more future events, and she is more than willing to do so. She had originally told me she can only host an event twice a year, so that is exciting to me. Let’s come up with some good ideas for a SPRING RETREAT. But for those who are interested she is willing to set up a Sunday event with a bunch of residents, and you can invite a friend, IN DECEMBER (so likely Dec 8 or 15). I am thinking December 8th. She was thinking about TOP GOLF (I learned on Saturday that my friend was the architect for all the TOP GOLF places in the country). Let me know if you are interested. If we get about 8 – 10 residents, and each bring a guest, we could get something together. We can also work on a more sedate but fun event in Classroom ABCD, like painting, in the early part of 2020.
ACADEMIC HALF-DAY December 24 and 31. No lectures, but think of fun ideas for those days – I still want those of you who are here to have those few hours off to get away – pot luck meals both days, talent show maybe?
Take care everybody…
“Honesty and transparency make you vulnerable. Be honest and transparent anyway.” – Mother Theresa
“To find yourself, think for yourself.” – Socrates
“No one man can, for any considerable time, wear one face to himself, and another to the multitude, without finally getting bewildered as to which is the true one.” – Nathaniel Hawthorne
“The privilege of a lifetime is to become who you truly are.” – C.G. Jung
“Only the truth of who you are, if realized, will set you free.” – Eckhart Tolle
“The authentic self is the soul made visible.” Sarah Ban Breathnach
“Do your homework. Find your voice. Be authentic. And then dive in with purpose.” Julie Foudy
Before I go off on my rant/musing, I want to congratulate the interns on completing their first month of residency. I am sure it was everything you dreamed it would be…Thanks also to the senior residents and the faculty for guiding them through this first month. Never easy, always interesting…
I was talking with one of the interns recently and during a quiet moment, the intern asked me about recruitment this past year, and how I came up with my opening interview question, which was “Who is your authentic self?” And that got me thinking – what a perfect question for my next monthly musing…
The short answer to the resident’s question? My wife, Cathy, came up with the question. But, as many of you know me by now, I have a long winded answer. Last summer, my wife was looking to hire someone for a position where she worked, and I was ramping up all the things we needed to do to prepare for recruitment. We were both wondering how to get the person/people who would best fit with our respective visions for the job we were recruiting for. We both review CV’s/ERAS applications that show a cornucopia of outstanding activities and accomplishments that seem to show that the person in that CV was born to do the job we wanted them to do. But, as you all know, or as you will learn, until you really start to immerse yourself in a job, no one, not even you, really knows how well you will fit into that position. For medicine, I was looking for not just someone who will do the job, but for someone who will thrive, and succeed, and LOVE the field of medicine. So we came up with the slightly awkward but deeper philosophical question “Who is your authentic self?”
So now most of you are probably curious as to how students answered when I asked this question this past interview season (or have just skipped to the announcements below….). Interesting cross section. And for those who interviewed with me this past year, I am hoping that I am not giving out how you answered this question…
There were a few students that just sat in silence for a time – and didn’t know what to say. I think that was interesting – I kept silent most of the time – pretty uncomfortable in an interview, even for me, and there were other times the student was so befuddled I gave them a little help, which actually says something about me for sure….
Most applicants ended up morphing their answer towards the more familiar question that I am sure most of you are asked – “why do you want to be a doctor?” or some combination of that question. That is okay – but that is telling – have you really thought about your authentic self?
Some talked about their excellent education – but what does that mean about your authentic self? Some just talked about their accomplishments – again what does that say? Maybe it says a lot – for them medicine is about prestige. Some talked about their hobbies – that maybe told a lot about a person – someone who could concentrate for hours on art vs. someone looking for the next adventure.
Where it did get more interesting is when applicants began talking about their cultural background, or their childhood, and how that informed the path that they chose. This starts to get at who each of us are as authentic selves. Is it religion, or family, that molded them to believe that what they are doing is fundamentally the way to live their life? Sometimes, the student has struggled with (and others embraced it) the juxtaposition of living in the Western world but while still holding true to Eastern values that they were raised in, and finding a balance. As you can see, it got fun, and different.
And now you are asking – what kind of answer did I like best? So, I am not going to give away my secrets, though I think those of you who have worked for me these many years do know better the type of resident I am looking for, and possibly the type of answer they may give to that question. However, I am VERY careful about not injecting biases based on what people say, or have done, in the past. The individual human experience is such that you can NEVER make assumptions. Does the student that comes from a privileged family expect everything handed to them on a silver platter, and are unable to handle any adversity, or, because they have come from a background of full resources, they are resourceful and resilient? Does the student who has always found that everything comes to them easily end up being the laziest worker and just leaves early at the end of the day, or are they the one who spends hours helping others who aren’t grasping things as quickly?. Does the person who comes from a background of adversity, and has to pull themselves up from poverty, the one who has the most empathy for all they serve, or, once they have tasted the “wealth” of being a physician, is only out to achieve their own wealth through medicine?
So philosophically, who are you, really? I think it is a fundamental question that we all need to ask of ourselves as we grow up and find our place in this world. Many of you don’t know yet, and that’s fine – you have time. As cheesy as this may sound, I just don’t think it is prudent to just barrel forward in life without thinking through who we are as a human, and what gives you fulfillment. I will keep reiterating this – medicine is an exceedingly difficult profession. Does who you are, fundamentally, allow you to do well in this profession? Can you just use the Myers & Briggs scale to find out if you fit? Are you monotonously living in your culture’s expectations of who you should be, or is it something you embrace wholeheartedly? Is it about improving the world as a larger whole, or one patient at a time? Is it about helping your family? Or are you about prestige? Or is it about personal fulfillment? Are you someone who strives on stressful situations, and is unafraid of failure, but also may not learn from it, or are you someone who is tentative, fears making mistakes, but is fundamentally kind? And at the end of the day, as we are all striving to become an excellent physician, which authentic self makes the best physician? Again, I have my thoughts…what are yours?
And to answer your final question, who is Dr. Scott Yen’s authentic self? Since I started asking this question last interview season, I have rethought who I am many times, and I am still figuring it out. But in the simplest terms, my authentic self is I am a teacher. Even in college, and medical school, I told friends and others that if I never finished medicine, I would want to teach. I love to try and inspire, to push each and every person (or patient) that I work with to be better, to do better, to work to the best of their abilities and to be their best selves. Every individual has more to give than they think they have. The authentic selves that I I have the most trouble reaching are those who don’t aspire to be better (they “can’t” or feel they are already “perfect”), who want everything handed to them, who don’t want to put in the hard work to be better. But that doesn’t mean I won’t keep trying to inspire them, to educate them (it’s why I keep asking my patients who smoke, some whom I have known and smoked for 20 years, if they are ready to quit smoking, and how can I help, EVERY SINGLE OFFICE VISIT…). My other authentic self? That’s the one, who, on some weekends, sits on the couch in boxers for 4 straight hours watching movies and sports….
CONGRATULATIONS! To two esteemed third year residents, Dr. Kirubel Herano and Dr. Alberto Degiovanni, for becoming US citizens! Getting the work needed to get this done all these years, and continuing the work during residency is a testament to your hard work and determination and perseverance. One more of our residents is in the pipeline and working hard to get her citizenship as well. I will be more than proud to make the announcement when she gets it.
WELCOME and WELCOME BACK! Two of our residents started work on August 1. Please give a warm welcome back to Insia Rizvi. She is returning to her PGY 3 year after taking time off to have a baby! Insia is starting on an outpatient rotation but you will for sure get to see her at Simulation lab on August 6th.
Also please welcome Christopher Spates to our IM residency program. He also had a late start as his wife had a baby girl on July 2 in California, and he had to move his large family here to the Chicagoland area. He is starting on ID so most of you will see him on the floors – please go out of your way to say hello!
LOYOLA SIMULATION LAB (by the time I get this out this could be over….)– Tuesday afternoon August 6th. We will CLOSE ALL SERVICES so all residents can attend. This is an opportunity to practice procedures, do some ACLS and Rapid Response simulations, and overall start feeling more comfortable with this part of your training. I have already sent enough emails about this. After the Sim lab, we will have a dinner buffet at Caffe DeLuca in Forest Park. We will have the entire second floor of the restaurant to ourselves, and it has a balcony seating area. It will be fun.
ACP ITE – Friday August 23rd and Friday August 30th. You have been assigned your day. On IMS, If a fellow resident is taking the test on one of those days, please help out their intern on the floors that day.
COMMUNITY SERVICE – Sunday August 25th. We will be donating and serving dinner at Hephzibah home in Oak Park, a charitable organization that helps children in need. We will get more details to you as the time nears, and ask for volunteers to pickup a meal (paid for by our non-profit organization), and serve the meal and spend time with the kids.
PHARMACEUTICAL VENDOR FAIR – Tuesday, September 24th. Just another heads up notice. I think I will do a brief lecture that day as well in the lecture hall, so the pharmacy companies can “host” an educational event.
RECRUITMENT – Yes it is around the corner, and the year literally just started. Just giving you all a heads up – we have a holistic approach to recruitment, and that includes asking all of you if you have friends/colleagues who may potentially be interested in our program. So just letting you know we will be asking soon. ERAS opens on September 15th…
SCHEDULES – Please get the rest of your 2019 vacation requests in to me within the next few weeks. Of note, you will get email notification when your vacation is approved. I will call if I have questions about your vacation request. Also, we are working hard this year to make Medtrics your one stop shopping site for everything regarding scheduling, evaluations, etc. So review often, and help us make it an accurate representation of your work here at WSMC.
ALLERGY ROTATION ON HOLD FOR THIS YEAR – I unfortunately received an email from Dr. Rachna Shah that she will be unable to do any education this year for allergy. Many of you were assigned that elective. Review the schedule and the electives and let me know if you have a new request. We will be contacting those of you who have Allergy as an elective individually soon and discuss options.
Take care everybody…
“As a leader, it’s a major responsibility on your shoulders to practice the behavior you want others to follow.” Himanshu Bhatia
“Being a role model is the most powerful form of educating.” John Wooden
“I am not a role model….Just because I dunk a basketball doesn’t mean I should raise your kids.” Charles Barkley
“Educationists should build the capacities of the spirit of inquiry, creativity, entrepreneurial and moral leadership among students and become their role model.” A.P.J Abdul Kalam
“Children have never been very good at listening to their elders, but they have never failed to imitate them.” James Baldwin
“You’re a role model. Act like one.” Frank Sonnenberg
“I know that being seen as a role model means taking responsibility for all my actions. I am human, and of course, sometimes I make mistakes. But I promise that when I fall, I get back up” Jennifer Lopez
“Role models are only of limited use. For no-one is as important, potentially powerful and as key in your life and world as you.” Rasheed Ogunlaru
I want to give a hearty welcome to all the new residents to West Suburban Medical Center! To those new to my musings, it is now two years since I started this newsletter, and it has been a fascinating journey so far. This newsletter is my chance to reflect on residency education, and on health care in general. I am finding that the more I read and write on these topics the more I realize I know very little about ANY OF IT. But I think writing some of this helps me flesh out my thoughts, and also allows all of you to see where I am coming from as a physician, clinician, parent, husband, educator, director, learner, administrator and any and all other roles that I have. Writing is also exceedingly difficult for me (how many of you are literature majors- help me out?!), but when I have completed my monthly musing it is extremely rewarding yet also scary (“is anyone going to like me after they read what I wrote?!”) when complete. Like I said last year, this newsletter is meant to be informational, inspirational, thoughtful, helpful, or, a complete waste of time…
As my wife and I sat across from each other staring at our computer screens at our nice vacation home in Michigan on an absolutely GLORIOUS Saturday afternoon, and as I was trying to decide what to write on, it dawned on me that I have to write about role models, and the influence that they have on our lives. I mean, who sits at a computer on a gorgeous Saturday holiday afternoon doing “work” (my wife was doing real work, I was writing this)? Well, my dad did. If he wasn’t doing his rocket science work (often late coming home doing classified work…), he was otherwise industrious every day, either working on the house, or working on investments. He rarely could just sit and do nothing, or enjoy a day with friends and family, at least until he retired. And here I am trying to be industrious, as is my wife. We get exhausted sometimes, and though we love what we do, we sometimes wonder at what is the cost to our well-being. And yet I emulated my dad, who I admired so much for the work that he did (I tried to be a rocket scientist, I really did – just couldn’t figure out the math…), and, at least right now, it is costing me a relaxing sunny afternoon…
We have two wonderful children, both of which, have said to us, to our faces, that they don’t want to be like us, and “work” all the time. And guess what, they work ALL THE TIME. Both of them LOVE what they do, and often during off hours they continue to explore and work on their respective crafts. We are proud of them, and are confident that they will succeed, but sometimes, we also ask, at what cost on their well-being? There are times when they go through a crisis, maybe even some burnout, but get back on their feet. Is that the right balance to succeed? I don’t know, but as their most influential role models they have followed in those footsteps.
Which leads me to all of you here now. The medical literature almost uniformly espouses the positive aspects of role modeling, and mentoring, in medicine. But obviously, just like in any other profession, there are good and bad role models. And therein lies the controversy, and where scientists have debated about role modeling and its educational value. If we define a good role model as someone who consistently demonstrates a high degree of medical skills (either in critical thinking skills or mechanical skills), provides constructive feedback (in a positive manner), and models high ethical professional behaviors, then role modeling is an important component of clinical training. However, if it is defined as a learner’s “unselective imitation of role models and uncritical adoption of the messages of the learning environment” then “the benefits of role modeling should be weighed against its unintended harm.” (Acad. Med, 2014 Apr;89(4):550-4)
Residency will potentially be the hardest thing you will ever do, and with little preparation you are told to just jump right in. This will be, for many of the interns, your first full time job – and what a job it is. It is not a 9 – 5, M-F job, but a 6 days a week job; a job that says it is okay to work 80 hours/week, and a job where you have a steep learning curve in a stressful environment. There will be almost inhuman demands on your time, to do myriad tasks, both difficult and mundane (and we will argue forever what is considered “mundane”), to read, (the most common “useless” feedback we always give), and also, away from work, pressure to attend social events (weddings…). So this is where role modeling comes in. In the Academic Medicine article I reviewed, mentoring and role modeling is considered good early on to learn the local systems and navigate all the many things you have to do in residency to be an excellent intern/resident. But EVERYONE, over time, will start to find quirks in the system, and quirks among your perceived role models, possibly anathema to your value system. You will hear at times things from leadership, from faculty, from your fellow residents, that may seem dichotomous, or contradictory. We work in a healthcare system that now has a far different priority than the oath we took as a physician. Hence, the Academic Medicine article says that, in understanding role-modeling, we should create a student-centered approach that asks the learner to critically look at the leaders and the learning environment to gain insight, and become the best of the various parts of our leaders and system.
Pretty daunting task if you ask me. But I am asking you to try… I am asking that you think critically, not just in medicine when you are taking care of patients, but also looking at who you emulate and how you do what you do. I am asking each of you to NOT take the easy comfortable road, the one that follows blindly or unthinkingly. Remember why you came into medicine, why you fell in love with the profession, and emulate those parts that represent the best of the profession.
This first newsletter for this academic year seems a little daunting (no rah rah go team give it 110% and God-willing we will come out on top type speech), but I am not going to apologize for it. This message is for everyone who reads this, and starts at the top, including me. Remember that it’s not just our words but our actions that defines who we are, and if someone working chooses to emulate you, think about how your actions define you. I see it in my kids – they didn’t listen to what my wife and I said, they emulated our actions – so we all love our work and we sometimes get consumed by it. So be cognizant of how you act. If you are someone who demands hard work, but then is the first to step out of the hospital, people can see that. If you say you want to treat everyone fairly, but turn around and show favoritism towards one type of patient, nurse, or resident, people see that. If you are someone who promises that they will help you out, but then does nothing, people know that. If you say you are interested in learning, or teaching, but act bored or uninterested at every turn, people see that. For interns, if you want to emulate someone and how they approach their work, and their life, I encourage you to look at what and how they do things with open eyes and think critically when it is your turn.
I like to start each newsletter with quotes from different people, and you may have noted that the quotes this time seem sometimes contradictory. I think a good role model KNOWS that they are potentially going to be mimicked, and are well aware of their flaws as well as their strengths. Good role models show students the good aspects of how they work and what they do, and reflect and discuss their fallacies, and the sacrifices you end up making (i.e. losing out on a beautiful summer day). But also, as much as there are good and bad role models, there are also good aspects to emulate from everybody, and that is what we all need to do, to be discerning, so that we can all become better physicians.
We are imperfect, we are human, but we can figure out the best of who we are, and hope that those who follow emulate those traits.
ACADEMIC HALF DAY – every Tuesday afternoon. It will be one year since we began academic half-day, and it has had its highlights and not-so highlights. We want to continue to make this the best experience possible. I do want to highlight a core ACGME requirement – “IV.A.4.a) Residents must be provided with protected time to participate in core didactic activities.” This is the most difficult day for everyone to get their work done. For faculty, please be mindful and don’t page residents out of academic half-day, and round EARLY so that the residents can get their work done. For residents, be participatory in this endeavor, and as time goes on, bring us your ideas and we will work to incorporate them into the half day. Our leads, Gurbir Singh and Kirubel Herano, will be facilitating these days, with Dr. Zureikat and Dr. Alagha helping with curriculum development as well. There are additional announcements below about some specific dates.
ACP RESIDENT’S DAY oral vignette presentation (July 23 and July 30). We are asking that ALL residents be prepared to present a FIVE MINUTE (not 10 – 15 minutes) presentation on a case, a research project, a QI project on July 23 or July 30 –Academic half days. Night float residents looks like some bad luck as 7/23 is a transition day so neither team can make it, but try to make it on 7/30 and/or turn in your abstract/work to either Dr. Yedavalli or me. After that, everyone please get your poster submission to ACP Resident’s day by August 4, 2019. Anyone of the faculty can help you out, and Dr. Speisman is working hard to make sure everyone has something turned in. We will choose our Doctor’s Dilemma team (three people) on July 30, so they will not have to turn in an abstract, and we will choose our Oral Vignette winner, and that name is not due until August 21. For more information click on this link:
ACP N. Illinois Resident and Student Research Day is on October 23rd. Like last year, as IM will be in the ICU, we will be unable to close the IM services fully this year for everyone to attend, but we will do my best to get most of us there. Of course, if you are chosen to do the oral vignette, or get your poster chosen to present, you will get to go we will figure it out.
LOYOLA SIMULATION LAB – Tuesday afternoon August 6th. We will CLOSE ALL SERVICES so EVERYONE can attend. This is an opportunity to practice procedures, do some ACLS and Rapid Response simulations, and overall start feeling more comfortable with this part of your training. More details to come. After the Sim lab, we invite everyone to a dinner buffet at a place TBD.
ACP ITE – Friday August 23th and Friday August 30st. This is for categorical residents only. This is much like a Board’s practice exam. I would hope that third years take this test seriously (not necessarily to study for it, but to concentrate as if it was the actual Boards), as it is your opportunity to practice a taking a day-long test. We will close AIM clinic on one of the Fridays so that group will take the test on that day. The rest we will try to limit interference as much as possible with work and schedule accordingly.
COMMUNITY SERVICE – Sunday August 25th. We will be donating and serving dinner at Hephzibah home in Oak Park, a charitable organization that helps children in need. Talk to Holly Huth for more details, and we will discuss and ask for volunteers to serve dinner as time gets closer.
PHARMACEUTICAL VENDOR FAIR – Tuesday, September 24th. Early notice I know, but I wanted to briefly introduce all the interns about WSIMEA (West Suburban Internal Medicine Education Association). This is the non-profit “arm” of our IM Residency program – something I personally developed to allow our residency program to do more things, such as donate dinner to the Hephzibah home, but also to pay for nice things (like dinner after the Simulation lab). Pharmaceutical companies come and display their products, for a fee, we do something educational, and we all benefit.
Take care everybody…
“I always tell my residents to never forget that we have the opportunity to do more good in one day than most people have in a month.” ― Suneel Dhand via Doc Thinx
“In nothing do men more nearly approach the gods than in giving health to men.”
― Cicero (106 B.C. – 43 B.C.)
“I remind my fellows, residents and medical students that what we do is a privilege. People let us into the most intimate aspects of their lives, and they look to us to help guide them through very complex and delicate situations.” ― Shikha Jain, MD via KevinMD
“Qualities you need to get through medical school and residency: Discipline. Patience. Perseverance. A willingness to forgo sleep. A penchant for sadomasochism. Ability to weather crises of faith and self-confidence. Accept exhaustion as fact of life. Addiction to caffeine a definite plus. Unfailing optimism that the end is in sight.” Khaled Hosseini
“I have memories [of patients who trusted me in medical school] that are so vivid. They’re crystal clear, and there’s a common theme. … [Those memories] can sustain you. When you’re tired or burned out, think back on them, and think about what you have been given.” Darrell Kirch, MD, president and CEO of the AAMC
“As doctors, as researchers, you are the guardian angels for so many people, for those you meet and get to know as patients, but maybe some you will never meet or some who will not remember you. That doesn’t matter. Because you are their angels. That is a lot on your shoulders. But I know you are up for it; you’ve got some pretty heavy wings yourself. So give those patients and those people that you are working for and researching for and advocating for, give them the wings to fly.” Senator Amy Klobuchar
“The good physician treats the disease; the great physician treats the patient who has the disease.” Sir William Osler
This has been a trying year for West Suburban Medical Center, and for me, and the changes that have occurred (both of my own doing but also outside of my power) over the past year to three years has resulted in me having more of a sense of futility and frustration (read “burnout”) than I can ever remember. I don’t remember ever feeling this tired of what I was doing, even when I transitioned to doing more residency education when I “burned out” from seeing patients fulltime.
But several recent events – small meetings, and heartfelt conversations, but most of all, a special speech – have occurred over the past month that has made me realize just how special this profession is, how special each and every one of you are, and has woken me from my doldrums to continue to pursue and move this residency along, and take the best care of my patients and to encourage them to be the best version of themselves.
It first started when I had a chance to spend some time, just talking and hanging, with two of our graduating residents, Sabeeh Bokhari and Qusai Alitter, in Washington DC in May when we were working with the ACP to advocate to Congresspersons on physician and patient rights. They imparted to me a fervid appreciation for West Suburban residency, and a sense of optimism for the future success of the program. As well, I saw their passion for medicine, their passion for creating a better health care system for physicians and patients, and gave me a calm sense that the future of medicine is in good hands.
Then came graduation. Just wow. I was absolutely struck by how genuinely engaged and happy each of you were on the success and graduation of each of those who will be moving on this year. Lots of cheers and laughter, which made for such a joyous event, and really almost brought tears to my eyes.
Lastly came the highlight for me, which was Dr. Tom Albert’s heartfelt graduation speech. I will paraphrase some, but then end this musing with his final parting words. Dr. Albert has been a wonderful addition to our program, both as a resident and as a faculty member, demonstrating the utmost professionalism, a strong spirit, and an unbelievable work ethic. As a resident, he created such a patient following that we needed to add a second half day AIM clinic for him just so he could see his patients. Thus Dr. Albert has a unique perspective of this institution, both as a resident, and then as a senior statesman/faculty, and he encapsulated the spirit of graduation and of being a physician on June 1.
Dr. Albert relayed the messages that holds true at every graduation. He meaningfully mentioned that the sacrifices that you and your families have made are a major contributor to your successes. Then he brought in the word “family” again to describe West Suburban. And that family feel was certainly reflected at graduation, with everyone cheering each other on. I continue to be so impressed that we have an eclectic group of residents, yet all differences aside we come together every year as a family.
But most of all, Tom reflected on his own experiences on how absolutely difficult and demanding it is to be a physician, to be in the midst of patients who look to you for help, and to be that person who could be the difference between life and death, yet in the midst of that you are trapped in paperwork. But we all have had that moment when we felt proud, grateful, indescribably moved by the fact that we are doing what we are doing. Remember those moments, and continue to persevere in this most difficult of professions, as more than once, you will have saved a life, made a difference, and that is why we became physicians (not providers…).
Dr. Albert’s speech ended with this…
“All of you graduating tonight need to remember that moment in your training when you almost had to pinch yourself that you had gotten to where you are. For some of you, it may have been an ICU rotation. It may have been when you opened that letter with your passing score on the USMLE. For some, it may have even been you being the first one in your family to even go to college. Whatever it is, think deeply about it. Bottle it and drink from that bottle, not IF you encounter troubles, but WHEN you encounter them. Open that bottle up and pour it all over yourself. No matter how many changes occur in healthcare in the coming years, don’t forget it was your spirit that brought you here. Don’t let the trials and tribulations steal your spirit. Don’t let technology rob you of your soul. Always look your patients in the eyes so you BOTH know the two of you were brought together at that moment for a special purpose. In short, my prayer for you all is that in those most trying moments you will face, that you are able to sit back, close your eyes for a moment, and feel His Pleasure. Thank You”
And from me as well..THANK YOU.
ACP LEADERSHIP DAY – Many thanks to Sabeeh Bokhari and Qusai Alitter for going to Washington DC and learning about the important national issues that affect physicians and patients, and advocating for all of us. They advocated for issues like eliminating medical student loans, fair pharmaceutical drug pricing, and patients before paperwork. Ongoing efforts like this make a difference. They have expressed interest in going again next year, so maybe some of us will meet up with them in DC next year.
PHARMACEUTICAL HEALTH FAIR – Thank you again for being an active participant at the health fair on May 28th. As I mentioned on Tiger Text, minus the food cost, we raised about $4500 for our IM Residency. We will be using the funds to provide for larger retreats, both for faculty and residents. We will be using the money to provide the money to buy dinner for our community outreach outings. We will continue to have these fairs (our next one will be end of September), and hope to get 10 – 12 vendors at our next one. As more money comes in, we hope to be able to provide healthy snacks in the AIM clinic area, and additional benefits.
GRADUATION – Special thanks to Sandra Gallego, for doing most of the legwork, and creating a FABULOUS event this year. I tend to be a little OCD, and feel better overseeing a lot of details. I just didn’t have time to do it for graduation this year, and it was WONDERFUL (teaches me to be OCD…) I appreciate all the hard work that goes into making this a success.
END OF YEAR DUTIES – You will all get a sign out sheet, so I won’t talk about that. We are finishing up end of year evaluations, make sure you know when you are meeting with leadership (Interns remember your 210 H and P’s, and everyone finish your mini-CEX’s). We are trying to establish a stronger alumni network, so please make sure we have contact information for you so we can keep up with what you are doing, and we hope to see you again in the future, possibly helping out the residency program!
ORIENTATION STARTS JUNE 19th! – Can you believe it? Ayham is finalizing a few lectures, including how to be a Senior Resident, so look for additional announcements. We will also be having an outing with all the incoming interns (a few will not be here due to certain circumstances, including Chris Spates, whose wife is having a baby first of July!) on Wednesday June 26th (Pinstripes). Look for further details on that. Also, new interns start on June 28th!!
Take care everybody…
“I think unconscious bias is one of the hardest things to get at.” Ruth Bader Ginsburg
“All of us show bias when it comes to what information we take in. We typically focus on anything that agrees with the outcome we want.” Noreena Hertz
“One of the biggest problems with the world today is that we have large groups of people who will accept whatever they hear on the grapevine, just because it suits their worldview—not because it is actually true or because they have evidence to support it. The really striking thing is that it would not take much effort to establish validity in most of these cases… but people prefer reassurance to research.” ― Neil deGrasse Tyson
“Sometimes we only see how people are different from us. But if you look hard enough, you can see how much we’re all alike.” Jasmine (from Aladdin!)
“There is no neutrality. There is only greater or lesser awareness of one’ bias.” Phyllis Rose
“We can at least try to understand our own motives, passions, and prejudices, so as to be conscious of what we are doing when we appeal (sic)to those of others. This is very difficult, because our own prejucide and emotional bias always seems to us so rational.”. T. S. Eliot
“There is nothing more painful to me … than to walk down the street and hear footsteps and start thinking about robbery, then look around and see somebody white and feel relieved.” Rev. Jesse Jackson
(My apologies this new email system won’t let me upload pictures…I think I will use my private account next time….) I don’t know honestly know how my wife churns out a weekly “President’s newsletter” for the local Rotary club. This monthly newsletter takes a lot of discipline and want to, and also a few late nights, and here it is late again. I almost bagged it, particularly as my mind is occupied with the multitude of changes that we are going through, and constantly preoccupied on the details of what we all need to do to get better, to be better. But as I think through our day to day lives at this institution, I realize, that at the heart of all the issues, is that we are dealing with human interactions, and the biases that we may have of each other’s intents and motives. Resident to resident, attending to resident and vise-versa, faculty to leadership, leadership to administration, and, most importantly, all of us as physicians interacting with patients, we all bring our biases to bear when we interact with each other. Hopefully none of you are shocked or dismayed at my saying this point, as I don’t in any way mean to imply that any of us are prejudiced. In fact, I am incredibly proud of the diversity of our residency program, but, to state the obvious, how much are we truly familiar with each other’s backgrounds and lives, and how much of our background and experience do we bring to our relationships with each other every day? So let’s talk a little bit about implicit bias.
Also known as implicit social cognition, implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. I first became aware of this about 4 years ago, when I was at an APDIM (Association of Program Directors of Internal Medicine) meeting, and one of the keynote speakers was the Dean of Admissions of the Ohio State University College of Medicine. He talked about the lack of diversity in his medical school (the Dean is African-American). He had the admissions committee take an Implicit Association Test (IAT), and found an ALARMING number of committee members had implicit bias (since reported – Academic Medicine: March 2017 – Volume 92 – Issue 3 – p 365–369), especially a white > black IAT bias. There is plenty of literature out there now, revealing, as well, an implicit bias for gender (male > female) (Academic Medicine: August 2016 – Volume 91 – Issue 8 – p 1143–1150. There is burgeoning evidence of the effects of implicit bias on religious, age, gender identity, and others.
It’s also complicated, and interwoven into our fabric as humans, so can get confusing. For example, just this April at the annual APDIM meeting, I went to a workshop that was supposed to be on implicit bias, and how to deal with it. What was interesting was that every example that they gave us on how to work with it was on EXPLICIT bias. This included examples of outright refusal to accept treatment from a “different-colored” individual, racist remarks, etc. We all know explicit bias exists, and unfortunately overtly and dangerously in our current society. I am not talking about that – I am talking about the hidden bias that many times we don’t recognize in ourselves, and how it affects how we deal with each other. Here is a more subtle one, and one my wife has made me VERY aware of lately, as she is planning a large gala to help inner-city youth. I was at a HUGE gala for BUILD at Navy Pier (we were guests of someone who paid $500/seat), a non-profit that also serves to get inner-city youth off the streets and away from gun violence. I am starting to become more uncomfortable, but definitely acutely aware, with what my wife calls “charity exploitation”. These are pictures of “poor” youths (who happen to be extremely cute) on brochures, or testimonials of someone who was “saved” from the streets by the non-profits, so that Caucasians (90% of the crowd – there were maybe two Asian people there, including me) will donate their money. This is a different kind of implicit bias, one perhaps couched in how/why marketers are able to impact our spending habits. This is implicit bias that rich folks fall for the “charity exploitation” message, and that helps get the money.
I will continue to shout to the rafters the pride I have of our multicultural residency, but we need to acknowledge the fact that we probably each have our biases. I am sure most of you don’t remember, but about 5 newsletters ago (December 2018) I told the story of a medical student who decided they couldn’t cut it in surgery and ended up with a C+ in that rotation. I was deliberately very careful with not writing the story with a revealing pronoun. Even if you don’t remember what I wrote – how many of you thought it was a female? Male? What if I told you it was a male that couldn’t cut it, would you believe me? Or, since it was the surgical rotation, you immediately assumed it was a female? Would you be surprised? (I am sure many of you read the story of the African American female doctor who wasn’t allowed to help during a medical emergency on a flight because no one believed she was a doctor.) When you do studies and ask people to look at a male figure, and you tell them that they are demanding, have temper tantrums, you easily get on their bad side, but they get good results – people will say they are “good leaders”, “strong” “forthright”, “have convictions”, but when you show a picture of a woman and give them the same traits, they are “moody”, “(the b word)”, “whiny” “aggressive”. Why is that? When an African American patient starts asking you lots of medical questions, do you roll your eyes and feel that they are coming from a place of cultural “misinformation”? And what about a Caucasian patient? Do you roll your eyes and assume they have been on the internet too much? Why not vice-versa?
So now it is back to being about us and our residency. Dr. Yedavalli and I often tease each other about our cultural backgrounds, and we admit to certain biases we have about what we think of our own cultures, and perhaps even some of our prejudices about them. We also comment (more often than we will admit) on the current generation of learners, and I wonder sometimes if we have biases there. So before writing this I took the Harvard IAT tests that I thought would be relevant to who I am and what I do. Drum roll please….at least according to the tests, I have no preconceived biases on age, race, and skin color, nor do I have a bias for women having a career in the sciences. I do, though have a slight bias in considering women more nurturing and family oriented, so less likely to be career-oriented and leaders. Now because I have to be careful, and work with such a diverse population of residents and patients, was I careful in how I took the test? Who knows, but being forewarned, and being aware of your own bias will help you overcome it – and studies show just being aware of your own implicit bias helps improve your ability to avoid it. I would like to think the results of my tests show that I try to look at each of you as individuals, without a preconceived notion based on your gender, your age, or your race. So it is your actions that tell me the most about who you are and what you can be. Or, because I can’t be around to observe all that you do, are other’s biases unduly influencing my perceptions of who you are? Food for thought.
Do you feel you have no strong preconceived notions? I encourage you all to google “Harvard IAT” and take some of the tests. They are very interesting, and you may or may not believe your results, but there has been validation as to the relative accuracy of the tests. Even if you don’t have time, this newsletter is meant to get you thinking.
ANILA LUMANI IS BACK! Come on downstairs and say HI! She is happy to be back at her old desk. She is a little surprised about everything that has happened since she left, so I squarely blamed her for it…just kidding. I am extremely pleased to see her back, and to have someone else help with all the administrative duties. Thanks so much to Sandra Gallego for covering for this period of time, she was a tremendous asset while Anila was gone.
INTERNAL MEDICINE RETREAT –We had a great time, though many of us came home with more than a few bruises from paintball. Hopefully some of you learned a little bit about team play. As those of you who have ever read the Calvin and Hobbes cartoons, maybe you thought this was all about having fun (going to a casino, playing Escape room games, paintball, talking about social media), but it was not….”Nothing spoils fun like finding out it builds character.”
GRADUATION CEREMONY – Saturday JUNE 1 – Please RSVP as soon as you know if you are coming. If you have not received an invitation, please let Sandra know ASAP. All residents and faculty have been invited.
FOCUSED BOARD INTERVENTION (FBI) and MKSAP 18 – Ongoing. I have worked with some of you, and will be working with more of you soon to see how you are faring. As well, I continue to encourage all of you with MKSAP 18 to join the MKSAP webinar on Tuesday nights…
Take care everybody…
“If caring for people is the journey, then courage needs to be our banner and path. It’s time to be courageous. We need to train our residents to have courage as well.” Dr. Vivek Murthy
“Courage is an essential ingredient for society to thrive but courage is not always convenient. It’s not easy to look upon ourselves and see where we are falling short…The real challenge is how to stand up when you are at risk.” Dr. Vivek Murthy
“What we all need is to love, to be loved, to know we belong, and to know there will be people to comfort us when we need it.” Dr. Vivek Murthy
“The joy you get from patients is important but we also need the joy we get from colleagues who see us for who we are. The care of patients and caring for each other need to be equal priorities.” Dr. Vivek Murthy
“As individuals we also need to think about our connection with ourselves…What that means is that you know that you matter.” Dr. Vivek Murthy
“Medicine is about more than making diagnoses…it is about the interactions and the relationship that can be cultivated between the physician& the patient that can make a difference in healing.” Dr. Vivek Murthy
“Be responsive, forward facing, outcomes oriented, promote inter professional team-based care and most importantly, be true to our values. Medicine cannot survive as a profession in the absence of a strong and enduring commitment to Professionalism.” Dr. Tom Nasca
As I sit, alone (my wife is visiting family in NJ), in my house and work on this newsletter, and look at the blank page, I am less than inspired. In fact, I just filled out the Maslach Burnout Inventory test, and I am ranking higher on Emotional Exhaustion than I have had in awhile. Now some of it is the fact that I have been dealing with a bad cold for about 3 weeks, and, frankly, I am SICK of being sick. Never can do as much or feel you have accomplished all you want to do when feeling ill. Realizing that I can’t will myself to do more work, reflection and meditation (as well as watching some good NCAA basketball) is helping, at least for the moment.
I will get over it – I always seem to. In fact, just before I got sick, I was in Orlando at the ACGME national meetings and had the opportunity to listen to a fireside chat (the Keynote address) between Dr. Thomas Nasca, the ACGME CEO, and Dr. Vivek Murthy, the 19th Surgeon General of the United States (2014 – 2017) (picture above). It was an absolutely stunning conversation which ran a large gamut; of deep loneliness both on a personal level and about health consequences at the population level, to courage, and how courage is hard when we stand alone, to gratefulness, for the opportunities that he has been given. He was emotional, he was in tears at times, he was funny, he was inspirational. I know I won’t do the talk justice, but I want to relay some of the messages (most of the quotes above come from the talk) that came from the keynote chat.
The first story Dr. Murthy told was of growing up in Miami and how his mother, who is a physician, would care for the underserved. One story in particular stuck with him, as he told of how a patient’s mother (also her patient) had died, and his mother knew that the patient was currently alone. So his mom took him and they drove out to the trailer park where the patient lived, and the two of them sat with the patient that evening for several hours. His mom noted that people are people, and “no one should have to mourn alone.”
I don’t know if it was this experience, or his own personal story of feeling lonely (as a shy kid growing up) that has inspired him to research loneliness. Bold of someone to be so openly vulnerable to tell stories about his own bouts with loneliness. His research has led him to find that chronic loneliness is similar to a chronic stress state, which has the same negative impact on people’s health and decreases life span as much as smoking cigarettes. Loneliness leads to a pervasive harsh inward self-evaluation, emotional pain, shame, and isolation from others. Behind addiction, mental disorder, violence, chronic diseases like obesity, he found commonality in the human experience of loneliness. And maybe that is the key to social connectedness across all racial and socioeconomic strata. Being a painfully shy Chinese kid in Alabama, and then California, I wonder what would have happened to me if, in second grade, Eric Chappell, still my friend, had decided to not introduce himself to me and let me hang out with him. Dr. Murthy offered another “solution” to create connections, especially at the work place, which I will relate at the end, and I want to try this in our residency a bit (and yes, as much as he goes to the “put down the smart phone” solution, this one is different).
Secondly, Dr. Murthy related the story of his nomination and fight to secure the position of US Surgeon General. The best story was how, when he got the initial call from the White House, he was picking up his dry cleaning, and ignored the call. Then, when he did end up talking to them, he told his wife “You won’t believe who just called?! And she said “it was the White House asking you to come discuss becoming the next US Surgeon General?!” (Similar conversations like that have happened with me with my wife…) But what he really wanted to talk about was the fact that he put his nomination in jeopardy, when, just as he was announced as the nominee, the Sandy Hook public shootings occurred, and he publicly stated that “gun violence is a public health issue.” He knew this would potentially destroy his nomination, even though being the US Surgeon General would be an incredible honor, but he was compelled to stick to his beliefs. Courage – how we can nurture it, grow it, and develop it is a story for another day, and was unfortunately not discussed.
Finally, Dr. Murthy talked about being grateful. First he talked about the difficult 13 month battle it took to get the position as US Surgeon General as the NRA considered Dr. Murthy a serious danger to their cause and lobbied (read threatened) hard for Congressmen to not vote for him. As history shows us, he was sworn in as the 19th US Surgeon General with his family around him. He told of how, during the reception, then VP Joe Biden went to his grandmother, got on his knees, and told her “thank you for choosing us, for choosing America.” Dr. Murthy stated “For the grandson of a poor farmer from India to be asked by the President of the United States to look out for the health of a nation, that spoke to the power of America.” He expressed enormous gratitude for the opportunities he has been given, and asked us to also appreciate our impactful place in people’s lives.
As mentioned, Dr. Murthy talked about battling loneliness in the workplace. He told us about what he does at his work, and it is something I want to try. To better connect with his workmates, he asked that one person, at their weekly/monthly/quarterly meeting(s), bring personal pictures, and the stories, that are important to that individual, and talk for the first 5 minutes of each meeting. Worth a try to help create real connections in the workplace.
As for “training residents to have courage”, that is a whole different ballgame. Let’s have a fireside chat ourselves someday. Courage to every individual is different, but my definition would include doing what is right, or good, for you or for society, even though it makes you uncomfortable, or takes you out of your comfort zone. For me, writing this musing every month is hard, and uncomfortable, but from this I feel everyone has a better sense of who I am and where I come from, and it can only help build on this program. For my son, with his anxiety, it is facing the day, everyday, going to work in a restaurant and dealing with various personalities. He might just well be the most courageous person I know. So let’s talk…
INTERNAL MEDICINE RETREAT APRIL 20th PAINTBALL EXPLOSION (in East Dundee). I will be sending a separate email soon on all the details. I know many of you will be gone on vacation, but please come if you are in town. We will need to make reservations, so we will need a head count soon. It will be fun! I can’t wait – seriously, shooting paintballs at residents – what is not to like?
IMS CHANGES – I am NOT going to write a long email on this one – already did. I will try to be available as much as possible to answer any questions this month and into the next few months.
ACGME FACULTY AND RESIDENT SURVEY – Please take some time to complete the survey – we need 80% to complete the survey to be compliant. I sent a separate email about how important this is, and ask again that you think through your whole experience before answering. Thank you.
PHARMACEUTICAL FAIR – May 7 or June…. During one of our academic half-days. This is an opportunity to raise money for the IM residency through a non-profit. I have established a non- profit – WSIMEA (West Suburban Internal Medicine Education Association), where we will use these funds to further education and wellness in the IM residency program. It is a charitable organization – we will raise money by asking pharmaceutical companies to come and display their products 2- 4 times a year, and donate money to this fund. We have other potential resources that can donate as well. If we are successful, we can look at more wellness activities, have possibly even an overnight retreat like Family Medicine Residency, host community dinners at service foundations in Oak Park like Hephzibah and Sarah’s Inn, host a free clinic, etc. So giving back, and promoting wellness. Let’s hope this is successful.
SIGN UP FOR YOUR BOARD EXAMINATION. THIRD YEARS – Please make sure you have signed up to sit for the IM Board examination. Early registration ends on April 15th. I continue to encourage all of you to sign up for the MKSAP Webinar on Tuesday nights if you have MKSAP 18. I know many of you have signed up, and I hope to see you on there. I am on, usually behind the scenes, almost every Tuesday night. As mentioned before, I will soon (I keep saying that don’t i?) be grabbing some of the third years to review some test taking skills.
ICU ROTATION NEXT YEAR. I know some of you have expressed a desire to go back to the 3/3/3/3 rotation in the ICU, and I think that is preferable as well. Unfortunately, FM has already made scheduling commitments so we need to stick with the current schedule for now. Last year’s 5-month layoff from the ICU was not good for us, but now we won’t be away from the ICU longer than 3 months as before. With the Cerner transition in March 2020 I am hoping transitions will be smoother as well.
KUDOS to Ayham Alagha, for doing a community speaking engagement in Rooms ABCD on colon cancer screening. See picture below.
KUDOS also to last month’s ICU team, who was lauded for a job well done. Keep up the good work!
Take care everybody,
“Your words matter. Your actions matter. We look to each other for inspiration…so being a role model isn’t optional. Live well.” Rolsey
“It is not only for what we do that we are held responsible, but also for what we do not do.” Moliere
“You express the truth of your character, your dedication to your goals, and your commitment to your relationships with the choice of your actions.” Dr. Steve Maraboli
“There is something to learn from every patient encounter. Whether it is the medical condition, or their social situation, every patient has a story from which we can learn.” paraphrased from Andrea Blitzer, former preliminary resident at WSMC current ophthalmology resident at University of Chicago.
“Responsibility equal accountability equals ownership. And a sense of ownership is the most powerful weapon a team or organization can have.” Pat Summitt
“It turns out no one wakes up in the morning and jumps out of bed because they can’t wait to get to work today to look ignorant, incompetent, intrusive, or negative.” Amy Edmundson
“This is a story about four people named Everybody, Somebody, Anybody and Nobody. There was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry about that, because it was Everybody’s job. Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn’t do it. It ended up that Everybody blamed Somebody when Nobody did what Anybody could have.” Anonymous (?)
When I write my monthly newsletter, I sometimes feel like I seem tone deaf to what is going on in our residency program at the time that I send this out. So much happens in a month, whether it is outside the residency, or within the hospital, and many different incidents occur that are ripe for a possible post/musing. If I had the ability and skill to write more often, I would want to do it, but unfortunately these “simple” newsletters take me a day or so to write. This month, I feel there is an overarching issue going on, and that there is at this moment an underlying current of discontent. I know that a lot of it has to do with this never-ending winter. I for one can’t wait to be off to Orlando this coming week. Of course as you all are probably guessing, I am not going on vacation but I am going to the national ACGME meeting to learn more about education and how to run a residency program (do as I say, not as I do – gotta work on this balance thing….) Mostly I can’t wait to leave because it will be sunny and WARM, and a change of pace from the day to day. Still, warm weather and the end of the year can’t come soon enough for some of you, and I want to address what we may be able to do together to get through the rest of the year amicably until then.
Unbelievably, (I swear this is a total coincidence) a series of three articles in the New England Journal of Medicine just came out addressing JUST THIS PROBLEM -about the work culture and environment in hospitals. The articles are in the section “Medicine and Society”, all written by Lisa Rosenbaum MD, and ran weekly from 2/14/19 through 2/28/19. The first article is titled “Divided We Fall” (NEJM: 380: 684-688), the second is “Cursed by Knowledge – Building a Culture of Psychological Safety” (NEJM: 380: 786-790) and the last is “The Not My Problem Problem” (NEJM: 380: 881-885) They are a fascinating read (yes I am a total medicine geek sorry) and I encourage all of you to read the articles. I will try to sum up as best I can the lessons learned and how to build a better work culture, which we can certainly apply here at WSMC. Would love a dialogue if you disagree (or agree). This is going to be a long musing…
The first article comments on the inherent difficulty of caring for a complex patient when so many things go on at the same time, with a division of labor often including the medical student, the intern, the resident, the social worker, the RN, the case manager, the attending physician, the different consultants. NO ONE, with the exception of the resident team, has seen the patient at the same time, so each subset of management people may/will have a different sense of how the patient is actually doing, will have a different set of data at any given time, and will have different interpretations on work priorities. Of note, who ultimately feels responsible and will put the burden/onus of care of the patient on their shoulders?
The other salient comment in this article is that medicine has a HUGE challenge – we are trying to achieve great care within a structure so focused on personal achievement. We unfortunately support that – we idolize and choose as role models those physicians who are smart, and always seem to know the right thing to do. BUT, conflict arises when that doctor has an ego that prevents them from collaborating, or makes a mistake and refuses to admit error, or denigrates and belittles those who have a different opinion. The best industry at promoting safety in the work place, the airline industry, has learned that good teamwork works better than the hierarchical structure in creating an environment of safety. They have been front and center in facilitating great teamwork, realizing that more data, and constant and frequent communication can reduce error (or even find more mistakes early but at a correctable point). As well, they have worked to create a team culture where everyone shares in the responsibility for the outcome. The better teams have a shared sense of purpose, with no barriers of judgement when one person, or maybe no one, knows the answer, or everyone realizes that important additional information needs to be obtained to create a better outcome.
The second article confronts the issue of antagonism among and between physicians, and how that significantly harms the culture of safety such that individuals become afraid to speak up. The article talks about a seminal study in the United Kingdom that assessed “rude, dismissive, and aggressive” (RDA) communication between doctors and found that nearly one third of physicians experienced such communication multiple times weekly, with more-junior physicians encountering it about twice as often as their seniors. Being subject to that ridicule deeply effects how we work, and some early studies suggest that also leads to error. Some of the barriers to preventing adversarial relationships are eroding – the physician lounge where everyone gets a chance to know one another, and the EHR where we are in our computer silos rather than talking face to face.
There are additional issues regarding the physician as worker. First, we have a need to, out of necessity, create our own language as medicine has become so sub-specialized, yet we forget that those without that subspecialty training can’t know it all or possibly understand our language (the “curse of knowledge”). Second, we have a deep need for impression management (that we always look confident and all-knowing, omniscient even).
Finally the article talks about what makes a good team dynamic. This is where individuals show willingness to take interpersonal risks at work, whether to admit error, ask a question, seek help, or simply say “I don’t know.” This is what organizational psychologists refer to as “psychological safety.” Amy Edmondson, a Harvard professor, has spent two decades elucidating why psychological safety is critical to effective collaboration in environments involving dynamic teams, high stakes, and significant interdependence — environments, that is, like the hospital. Now, how do we as physicians, maligned in this article as rude and self-centered, create psychological safety in a hospital? We have a guide here as to what works, but how to get there is not entirely clear. Everything here kind of hits close to home, doesn’t it?
The last article, by its title, seems self-explanatory. The opening story is medically related, and discusses how a patient in the hospital was admitted to cardiology but was having a GI issue – but they turfed the problem to IR to put in a drain, and IR says the primary team needs to deal with the pain– so sound familiar?). This story, plus a bystander effect story (true story of everyone ignoring pleas for help from someone who had been attacked, and that person eventually died), and other stories, highlights how, from the outside looking in, it appears that we look lazy, passive, callous and uninterested. But the author highlights that in general, we systematically underestimate the ways in which social contexts can shape our behavior. So if you are the individual in that situation at that time, there is a context that likely resulted in your inaction at that time, though it doesn’t necessarily JUSTIFY it. In studying most of these situations, the overriding issue resulting in inaction is…TIME. A different patient needs your time. In a resident case, duty (work) hours limits your time. A family situation needs your time.
The hero in the first story, a GI doc, decided to take ownership of the situation, and spent an inordinate amount of time waiting to talk to the IR doc, and talk to the family, to review old records, etc. to get the patient help because at the end, she just said “it was the right thing to do.” But the author found that just using that mantra didn’t help her get any better at collaborating with others, or prevent her from getting stuck in the same “not my problem problem”. So what is the solution? Again, no clear answer, but the author asks us to appreciate the ordinary as extraordinary. So the physician who waits for an hour to talk to their colleague to start a conversation that leads to a good patient outcome should be lauded just as much as the resident that clamped their hand around an arterial bleed and held it until the patient could get to the OR (true story of a former resident here) and survive.
I won’t go into the specific details of some of the tense issues that are going on among us in the hospital, because this is not the forum to give a specific answer. But I am more than willing to take the time to help come up with a “solution” to each of the different issues. For me, the two big take home lessons are to work together to create an environment of psychological safety, so everyone can collaborate, and establish a sense of responsibility for everything you do – your teaching, your care of the patient, and even the well-being of yourself.
I am also encouraged (or is it discouraged!) by the fact that we are not alone in struggling with the incredibly difficult job of having a nurturing environment for us to learn but also to work together for the betterment of our sick patients. West Suburban Medical Center, just like every other place, has its unique and quirky traits. We need to think carefully, and work together, to rid ourselves of the traits that are selfish, and that slow down progress, and embrace those that can improve care for all. That includes a shared ownership on the responsibility and care of our patients, and a willingness to listen to one another in a nonjudgmental way, as we each have something to contribute. We are a COmmunity hospital. As you work and walk and think within the halls, think about the CO in the word Community. Let’s COoperate, COordinate, COllaborate, and COmmunicate. Cheesy I know, but I want to believe we can do it.
HOSPITAL OWNERSHIP TRANSITION – Dramatic change has already occurred, specifically the Westlake Hospital closing. So are you a glass half empty or a glass half full person? You all know me by now – as much as I feel bad about the employees, and the loss of services for the Melrose Park citizens, I look forward to the potential opportunities that will be coming our way, including community service, and expansion of services. Just an FYI for those who have not heard, in March 2020, the inpatient floors will go to a fully integrated EHR – Cerner. The outpatient EHR will remain Athena at this time, and the expectation is that the two systems will fully communicate.
MATCH DAY IS MARCH 15th. Come downstairs to L700 after 12noon we will have our match list out. We are going for some drinks early after work – anyone care to join us?
INTERNAL MEDICINE RETREAT APRIL 20th time TBD. By popular demand, we will, cost permitting, be playing some paint ball! I anticipate we will first try to find a space that we will spend the morning doing fun educational activities. Whether it is near the paint ball place, or at the paint ball place is TBD. Then we will cater a lunch, then go out and have some fun. Hopefully some attendings will be able to come out after lunch to participate. Then I am thinking of a whole group educational activity afterwards, and we can find another place for happy hour afterwards, or just some snacks and call it a day. I anticipate we will close service starting early – possibly no NF on 4/19, and all day 4/20. This year, again cost permitting, we will have a family practice resident cover during the day of 4/20. Service starts again 4/20 NF.
FOCUSED BOARD INTERVENTION (FBI) and MKSAP 18 – Ongoing. I will be grabbing some of you soon to see how you are faring. As well, I continue to encourage all of you with MKSAP 18 to join the MKSAP webinar on Tuesday nights…
Take care everybody…
“Laugh as much as possible, always laugh. It’s the sweetest thing one can do for oneself & one’s fellow human beings.” – Maya Angelou
“It is a curious fact that people are never so trivial as when they take themselves seriously.” – Oscar Wilde
“A sense of humor is part of the art of leadership, of getting along with people, of getting things done” – Dwight D. Eisenhower
“Humor is the affectionate communication of insight.” – Leo Rosten
“I’m struck by how laughter connects you with people. It’s almost impossible to maintain any kind of distance or any sense of social hierarchy when you’re just howling with laughter. Laughter is a force for democracy”. – John Cleese
“A positive attitude may not solve all your problems, but it will annoy enough people to make it worth the effort.” Herm Albright
“Life is too short to be serious all the time. So, if you can’t laugh at yourself call me….I’ll laugh at you.” Anonymous
According to research (okay probably marketing campaigns rather than true research), the most depressing day of the year in the Northern hemisphere is the third Monday in January. The holidays are over, in the US MLK day was the previous week, and now comes the realization that long stretches of work without a break are coming along for a LONG time. Then locally, add to the fact that the flu is again here in full force, the hospital is busy, our emotions are frayed, outside is FREEZING, and oh yeah, we were recently purchased and are now undergoing some major transitions. It is enough to make you want to scream….
Last year at this time, I made humor the topic of my monthly musing, and I thought it would be meaningful and appropriate to do so again. Part of the reason of course is it is much easier to do this than to write a difficult musing on implicit bias, or conflict resolution, or social media, or transparency, or education etc. etc. – all fascinating topics (well at least to me…) in which I will ruminate on another time. But another reason is that even I, the eternal optimist (as I stand in front of a mirror in my superhero pose), get tired and down, and get filled with self-doubt and worry. And so I find myself going online looking to read about physician wellness, and instead find myself distracted looking at cute puppies and silly pictures. Humor helps me deal with conflict, bring some joy into the air, and at the very least “hold off my fear of the unanswerable and the unacceptable.” (from Al Gini, a local author).
So, once again, for your enjoyment – really bad jokes, humor, and bad pictures (at the end). And again, as weird as this sounds, don’t take any of the jokes seriously, they are not in any way meant to offend – just meant to have a little laugh at ourselves and our profession…
Actual writings from hospital charts…
1. Patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
2. Many years ago the patient had frostbite of the right shoe.
3. After quitting cigarette smoking, the patient started smelling again.
4. The patient gets hives from contrasts, strawberries and shrimps and also two of her children.
5. Patient had no past history of suicides.
6. Patient experience sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.
7. The patient was in his usual state of good health until his airplane ran out of gas and crashed.
8. The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.
9. Pt. experiences frequent nausea and vomiting, and should therefore be wearing a small diaper at night.
10. Patient refused an autopsy.
11. Discharge status: Alive but without permission.
12. Pt. is mildly agitated, but good in bed.
13. Patient told me she lost her heart the last time she was admitted.
14. She slipped on the ice and apparently her legs went in separate direction in early December.
15. Patient eats death threats for breakfast.
16. The patient has done well without oxygen for the past year.
17. Enteral tube feeding should be administered at 160 km per hour.
18. Regarding to the patient’s impotence, we will continue his medication and let his wife see to the treatment.
19. All visible brain tissue had been removed. The patient has no neurological complaints after surgery.
20. Pt. is increasingly aggressive, but can be put down with a cup of coffee.
21. The lab test indicated abnormal lover function.
22. A midsystolic ejaculation murmur heard over the mitral area.
23. Exam of genitalia was completely negative except for the right foot.
24. When she fainted, her eyes rolled around the room.
25. I will be happy to go into her GI system, she seems ready and anxious.
26. Patient was released to outpatient department without dressing.
27. I have suggested that he loosen his pants before standing, and then, when he stands with the help of his wife, they should fall to the floor.
28. The patient will need disposition, and therefore we will get Dr. Blank to dispose of him.
29. He had a left-toe amputation one month ago. He also had a left-knee amputation last year.
30. The patient is a 79-year-old widow who no longer lives with her husband.
31. The bugs that grew out of her urine were cultured in the Casualty and are not available. I WILL FIND THEM!!!
32. The patient left the hospital feeling much better except for her original complaints.
HOSPITAL OWNERSHIP TRANSITION – Yes indeed it happened! Woohoo! You all know me by now – I am the person who embraces change, and l look forward to working with the new administration to make our residency program a more vibrant community residency program.
RECRUITMENT IS DONE! Thank you so much for highlighting the strengths of our program, and helping us make the interview day enjoyable for all of them. We received GLOWING notes from many of the applicants thanking the residents for an enjoyable time. Also thank you for the feedback as we reviewed the applicants one final time with all of you. Many of you mentioned it wouldn’t be a bad idea to review the applicants intermittently during the interview season. Good idea. We will do that next year.
ICU ROTATION – The pulmonologist/critical care issue has been resolved, and there will now be continuity in the ICU. Just an FYI, we are an ACP elite status program and have some extra educational resources, including videos of common ICU scenarios that can be helpful. Let me know if you are interested I will try to figure out how to get to them. Should be pretty straightforward. GOOD LUCK next two months!
FUTURE INTERNAL MEDICINE RETREATS – Thank you all for your input during the buzz session. We will send out a doodle poll soon on the preferred date – 4/20 or 4/27. We will also poll on what you would all most like to do on that day. For those of you not at the recent buzz session, I announced that I have created a non-profit in which I am looking to get donations (from pharmaceuticals mostly) to help provide more and varied educational opportunities, and, specifically, wellness activities.
FOCUSED BOARD INTERVENTION (FBI) and MKSAP 18 – This has started. Look for notices on when there will be Board review in the hospital – we are looking to transition it to academic half day, so that for the first hour those required to go, and those interested, can go, and the rest of the Academic half-day teachings will come after that. Thanks very much to Dr. Mel Speisman for heading this program. I will be pulling some of you aside to assess your test taking skills on an individual basis. It is something I learned at an academic conference and can help discern where an individual’s weaknesses are in terms of test taking ability. Reminder also that there is also the MKSAP 18 Webinar on Tuesday nights at 8pm from the cozy confines of your own home. You must have MKSAP 18 – let me know if you are interested.
TEA TIME(S) WITH LEADERSHIP – We are going to start it up this month – we will invite a small group of residents (and I would say a small group of faculty at times as well) (separately!) to meet with us somewhere on Tuesday afternoon (4 – 6pm?) outside of the hospital, and review teaching and residency, and continue to work on innovative ideas for your education.
Take care everybody….
“Feeling gratitude and not expressing it is like wrapping a present and not giving it.” ~William Arthur Ward
“Gratitude is the ability to experience life as a gift. It liberates us from the prison of self-preoccupation.” ~John Ortberg
“Gratitude unlocks the fullness of life. It turns what we have into enough, and more. It turns denial into acceptance, chaos to order, confusion to clarity. It can turn a meal into a feast, a house into a home, a stranger into a friend.” Melody Beattie
“Enjoy the little things in life, for one day you may look back and realize they were the big things.” Author Unknown
“Gratitude bestows reverence, allowing us to encounter everyday epiphanies, those transcendent moments of awe that change forever how we experience life and the world.” John Milton
Welcome to 2019!
This is usually a time when we each put together our list of New Year’s resolutions, and I am sure many of you would like to give me a few resolutions as well. Okay, kidding (maybe not), but instead, for me, I would like to spend this time reflecting on the gifts (literally but mostly figuratively) I have been given over the years, and give thanks for the blessings in my life. I hesitate a bit to give such a public thanks, as I am going to not mention some people who may feel slighted by not being mentioned, and at the same time some may be surprised. My thanks here are also meant to give you all some insight into who I am as a person, and maybe a little bit of the “why” when I act or do something a certain way.
As I give my thanks, this can be your opportunity as well to reflect and think through the influences that have shaped your life. As all of you can probably attest, not all influences have been positive, and this is not the time to talk about those (we can talk about resiliency another time). There are definitely influences in my life that have been harsh and difficult, and have taught me how NOT to do certain things. Instead, these are brief expressions of gratitude that reflect positivity and hope. I am grateful for where I am, and the fact I am still living and breathing on this earth, and I have many people to thank for that. So starting from childhood and moving forward, here are some of my top reasons to be thankful…
Thanks mom, for instilling in me the importance of family, not just immediate members but everyone we touch. Also, thanks for making me take typing lessons in high school – comes in handy with EHR…
Thanks dad, for always being a wonderful teacher. You have instilled in your children and grandchildren the love of education. You passed too young in 2003, but if you were around you would be so proud of your grandkids now.
Thank you to Roger Halstead – my high school world government teacher. Mr. Halstead was the first teacher to illuminate that education isn’t about rote memorization. First day of class, he had us sit down in seats, then just walked around the room and waited until there was silence (didn’t even take roll). He then asked us a question: “if I were to tell you that I know the exact date that you are going to die, would you want to know?” Was the first time EVER that I spoke up in class without being called upon to speak. He was the first person to challenge and question my beliefs. I learned about critical thinking. I learned that by becoming uncomfortable and learning to challenge and question yourself constantly, you develop a stronger foundation.
Thanks (this is probably more of an apology) to all my sophomore year college roommates for putting up with me during a confusing time in my life, when I was a total jerk, trying to reconcile my desire to be a “cool jock” (playing rugby, going out partying), with figuring out how to be a student, and dealing with the insecurities of finding so many people brighter than me. Those ex-roommates are now prominent physicians, writers, and historians. I still chastise myself sometimes for how thoughtless I was, and still think about the mistakes I made then. Though I have reconciled with some, I thank them all for being patient, and letting me figure it out eventually. I would hope I have learned to be more forgiving with these experiences.
Thanks to the University of Chicago plastic surgery team in October 1990. For many of you who don’t know this I was in a freak chemical accident in a lab when nitric acid exploded on me (for those who have seen my arm scars this is why). My thanks isn’t for their surgical repair (I wouldn’t let them do what they really wanted to do – I am okay with scars…) – it is a thanks for listening to me – for giving me hope that I wouldn’t go into ARDS for inhaling the acid, for listening to me when I didn’t want my blood drawn everyday, for treating me with respect and letting me cover the non-damaged parts of my body while reviewing the burns in early morning rounds, and treating me like a human. Not that I wish this on anyone, but being a very sick patient on the other side of the stethoscope is a powerful lens in which to view medicine.
Thanks to Mike Powell, an OPRF high school wrestling coach, who embodies the principles of caring for everyone you have influence over like family. Mike was featured in a Sports Illustrated article because he is a championship caliber coach while dealing with a horrific muscle wasting disease – polymyositis. He is so authentic, caring so deeply about every individual under his care. He was the first person we called when our son entered a dark place his sophomore year (again with the second year….) of high school, and was a bulldog to be sure our son was okay. If I could make a difference in the life of one person like he has done for so many…
Thanks to Dr. Karen Weinstein – the previous Associate Program Director at WSMC, who, by circumstance and her network, created the opportunity for me to be where I am now, but also allowed me to meet and work now with some of the influential leaders in medicine in Chicago. Thanks Karen for recognizing that I had the potential to be more, to drag me to do Improv (stepping out of that comfort zone…), and re-discovering my love for the field of medicine, albeit in a different way.
Thanks to the WSMC residents and faculty and leadership team, who I think are getting a sense of my vision for this program. I want all the residents to have a transformative education, but you are all well aware that we have a long way to go. In the interim, I appreciate that you understand the hard work, the accountability, the communication and the transparency of effort that I want from all of you.
Finally, a heartfelt thanks to my wife, Cathy, who I have known since my sophomore year in college, an angel who appeared across the quad one relatively warm winter evening, and who enjoyed my company that day, and hopefully still enjoys my company 33 years later. She is my best friend, and someone I can bounce ideas off of, who always has an outside the box approach, and thinks from all angles. Best problem solver I know. She is by far the most empathetic person I know as well, always thinking of everyone else before herself, and able to read a room unfailingly. She is my role model, and we help each other out as life partners as we navigate how to best make a difference in this world.
HOSPITAL OWNERSHIP TRANSITION – How long do you think I will have to leave this announcement on here? I have been given reassurances that this is indeed going to happen in January. What does this mean for our future? Optimism! I think with new leadership we really have an opportunity to make impactful differences in our residency program. But, we wait for now….
PULMONARY TRANSITION – This is a difficult subject, and you have seen numerous emails about this. Come to me if you want to discuss issues you are having. We are working to have you still have a meaningful pulmonary rotation, and we will resolve to have the ICU situation solved by the time we are back in the ICU. DO NOT GET CAUGHT IN THE MIDDLE! Defer any issues/conversations that put you in the middle to leadership.
RECRUITMENT IS ONGOING –Eleven days DONE – THREE to go… Thank you so much – we have found some excellent candidates, and, with your help, have identified those who may not be as good a fit here in our culture. We will have a “ranking” meeting date soon for all residents who have any final thoughts on the candidates that came through. We are struggling with getting the simulation lab at Loyola on January 29th Tuesday, so it might be we will do it on Tuesday afternoon with lunch. For faculty, the “ranking” meeting will either be January 18th or January 25th – Friday at noon in the Board room. More to come.
FUTURE INTERNAL MEDICINE RETREATS – We usually like to do this in the spring, and we are in the ICU in March and May, so it should be in April. However, many of you are on vacation the first week, the ACP national meeting is the second week, Easter is the third weekend, and I have an event the 4th weekend evening. We can make it an all day event (paint ball anyone?) instead of running into the evening possibly on the 4th weekend? So tentatively reserve 4/27. More details to follow and let us know if you have other good ideas!
FOCUSED BOARD INTERVENTION (FBI) and MKSAP 18 – I already sent out an email to second and third years, but am giving you all a head’s up that we will start to really focus on the boards, especially the third years. We will have a more intense weekly Board Review, mandatory for those who have not done well on their ITE, and all third years. We also have MKSAP 18 Webinar on Tuesday nights at 8pm from the cozy confines of your own home. For this, you must have MKSAP 18. I can help you get it set up.
TEA TIME(S) WITH LEADERSHIP – I am totally making up this name – but at the Brooklyn Boulder’s outing this past fall Dr. Yedavalli and I had an opportunity to spend some time with a small group of residents, and really got a better feel for how your education is going at WSMC. We have started instituting some changes from that meeting, and hope to do more of these informal get-togethers to continue to make innovations. More to come, but I expect we will invite a small group of residents (and I would say a small group of faculty at times as well) to meet with us somewhere on Tuesday afternoon (4 – 6pm?) outside of the hospital, and review teaching and residency. We will do this towards the end of every month.
DEEP WINTER – The holidays are over, and now comes the drudgery of winter and no holidays, and long hours of darkness, and the flu. Remember why you decided to go into this, and, though each day will not be a joy, know that you make a difference every day to those who really need it.
Take care everybody….
SSY (just a picture of my “kids” being silly in Belize – (March 2018))
“The complicated, ambiguous milieu of human contact is being replaced with simple, scalable equations. We maintain thousands more friends than any human being in history, but at the cost of complexity and depth. Every minute spent online is a minute of face-to-face time lost.” Daniel H. Wilson
“Nothing replaces being in the same room, face-to-face, breathing the same air and reading and feeling each other’s micro-expressions.” Peter Guber
“The difference between face-to-face conversation and any other medium of communication is simple: No distractions are permitted.” Alexandra Petri
“Digital communication is completely different from in-person, face-to-face conversations. One will give you surface insights, and the other really gives you depth.” Joe Gebbia
“Social media websites are no longer performing an envisaged function of creating a positive communication link among friends, family and professionals. It is a veritable battleground, where insults fly from the human quiver, damaging lives, destroying self-esteem and a person’s sense of self-worth.” Anthony Carmona
My kids are adults now and, mostly, out of the house now. So we are trying to reclaim some space and get rid of junk that they have collected over the last 21 years. We are a reading family, and have collected an extensive library of PAPER books (not Kindle!), including books I would be embarrassed to say I read once. Anyways, enough about me – I ran across my son’s college freshman required reading introductory book and found it to be a very interesting and appropro read. The book’s title is “Reclaiming Conversation” by Sherry Turkle. As you may suspect, it is a commentary on the changes of how we communicate in this era of social media and the digital platform. I haven’t completed it yet – (I stopped when I reached the chapter on romance), but there are several observations noted by the author that I found illuminating. I am going to reflect on the lessons I learned from the book through my own lens– from my experiences working as a Program Director, and my experiences in practicing medicine.
The opening chapter grabs you fairly quickly – educators are noting now that middle school kids, don’t make eye contact, and they don’t respond to body language, mostly because they are looking at their phones. Even in the playground, teachers have noted kids don’t seem interested in each other. In one instance, one child excluded only ONE classmate out of 25 from a celebration, and had NO concept of the hurt and potential damage that they caused. There is a sense from educators that kids are losing their sense of empathy, and have a lot of trouble reading emotions in their peers. In another part of the book a study showed a 40% decline in empathy among college students (don’t ask me the scale or how they defined it…).
The second set of notable stories that the book talked about pertains to education, and how we may or may not absorb information in a way that is retained. How many of you are “google-jockeys”? In the middle of someone lecturing or doing a talk you hear something and either disagree with it or want clarification so get on your smart phone and start looking it up? According to one college student the author interviewed, conversation died in 2009, but so did boredom. If you aren’t particularly compelled by what is happening at that moment, you have the WORLD, or your friends (I will get to “friends” in a moment), at your disposal to explore right on your phone. Even in a small meeting where there are only 3 to 4 people, how many of you have your phone out ON THE TABLE (evidence shows face up or face down doesn’t matter), announcing, or hoping, that there might be someone more important than those in the room that needs to talk to you (or more, you wish would interrupt the meeting so you can leave)?!
So back to the first part. The loss of empathy is concerning, especially as some of these “kids” are going to grow up to be doctors. More and more we live in a world of acquaintances rather than deep friendship. To truly know someone takes hard work, difficult and long (dare I say “boring”?) face-to-face conversations. Human relationships are rich, messy and demanding. The book gives one example of a person who tried to console their friend, in person, who had recently been fired. The friend instead spent time on the phone checking out how many “likes” she got on her social post about her firing, and the pithy statements that her 200 “friends” sent her. How many of you wish you could just tell someone they had cancer, then walk away and let them post it so they could “chat” with their “friends” over it. By how I phrased that you all certainly realize how deeply disconcerting and WRONG that is. Sherry Turkle notes that a physician and author, Abraham Verghese, has written about how medicine has moved away from treating the patient to treating the “iPatient” – the sum of the data we have collected about a person, rather than talking to the patient. Mr. Verghese argues that when we lose the empathic connection with the human being in their care, we lose the ability to cure. One last story, this one recently from NEJM 360. One resident noted that the most significant thing they learned from their attending one day during rounds was, after the resident presented a patient who came in with chest pain while walking their dog, the attending asked, “What was the name of the dog?”
Now for the second part. As a profession, we are probably the most dopamine addicted people in the world. We feel the need to multi-task, and don’t (or do we argue “can’t”?) live a life with boring parts. We have our pagers, and our cell phones out, because we TRULY believe that there is someone more important out there than the person in front of you right now. In many ways we are right – there are code 54’s, code blues, and rapid responses that need our immediate attention. But there is a certain arrogance to that, and we can then carry through that logic to then assume that the dopamine surge from Dr. A is more important than Dr. B, who is more important than Dr. Consultant, who is more important than nurse D, who is definitely more important than academic half day (which has many “boring parts” after all), and, in the end, is still more important than patient Z, who wants someone to talk to them just asking for some clarity on their care….
Life will have boring bits – in work, love, and friendship, but what might be boring to you is of interest to someone else. So what is my ask? I am going to ask that we all work through the boring parts together. I am as guilty as the majority – I try to multi-task and do one thing while trying to listen to you present a case and look at my phone. (Let’s be honest, that dopamine surge is hard to resist…) Let’s develop our emotional intelligence, put down the phone for a bit, look, and listen to each other, and our patients, as we tell our stories. It takes real intentionality. When I converse “correctly”, I often actually say to myself, just before the conversation starts, “Stop doing what you are doing, look at the person and pay attention!” What can we get out of doing this? Well, first and foremost, the lack of focused attention now is so pervasive that we ALL forget that, at the end of the day, not paying attention to someone talking to you is JUST PLAIN RUDE (and I am as guilty as everyone else..). On the positive side, the experience of boredom is directly linked to creativity and innovation. If we remain curious about our boredom, we can use it as a moment to step back and make a new and real connection. And, when I have focused attention, some of my best ideas come from really listening in at a long meeting.
There is some irony in the fact that I am sending this musing about the loss of conversation via an EMAIL. This musing has been deeply edited and reviewed multiple times by me to ensure that there is no overly inflammatory commentary. Yes, face-to-face talk is difficult and messy as I noted, so the edited self seems so much better. The way social media presents a “perfect” version of yourself, one that you yourself edited, and one that is impossible to live up to, is a discussion for another day.
I don’t want to digress too far from medical education and our own experiences, but one last comment. The anonymity of social media has so divided this country with people, especially politically, on opposite sides who will only listen to the blurbs that come out from their side. Too often, neither side will enter into the deep conversation and conciliation that is needed to heal this country. Because to do so takes HARD WORK. There will be boring parts, and there will be the smart phone with the next blurb, and the next ”like” out there, and so we start the work, then get distracted… But I have hope that we as physicians will be successful in reconnecting. Residency by its very nature is made up of physicians who work exceptionally hard – I mean, whoever heard of a business that says it is OKAY to work EIGHTY HOURS/week? ‘Nuff said….
KUDOS – Just want to give a quick congratulations to Ricky, who got third place for his research poster, and Chari, who received 2nd place for her QI poster, at the recent ACP RESIDENT AND STUDENT’S DAY on October 10th. I also want to congratulate everyone again who had posters there as well as Babak for his oral vignette. I mirror Ayham’s thanks to all of you who volunteered at the meeting. It was wonderful to see such great participation. And I want to thank Ayham for all his hard work that day! Interesting end to the Doctor’s Dilemma – Ayham and I can tell you the story if interested…
TUESDAY NOVEMBER 6th – WELLNESS OUTING. VOTE!!! Brooklyn Builders outing. 100 S Morgan St. in Chicago. All residents on elective need to be there no later than 2pm. Admin will be there by 1:30 at the latest to set up and arrange things. All IMS regular teams should be done and be there close to 2pm. I will advise the attendings to assist you and get you out and to take calls and do orders and the work after 12noon. ICU members who can get out would be great. I don’t expect NF there unless you want. We are still trying to find a happy hour place – around 4pm. Might just make it Lou Malnati’s again, like last year. SO’s invited to all parts of the afternoon. NO need to pay for now.
HOSPITAL OWNERSHIP TRANSITION – Switch in ownership has been delayed – it is still going through but getting 3 hospitals exchanged is hard. In the meantime, as soon as we know, we will let you know about signing up for benefits (trust me – I need insurance for my whole family – I will let you know AS SOON AS I KNOW). Also, I will send a separate email about our outpatient EMR, but Athena is also going to transition, and it will be messy. We are going to lose our platform, and it will be “read only”. More to come, and we will work through it.
RESEARCH PROJECTS – RESEARCH DAY TUESDAY NOVEMBER 27TH. This is only ONE MONTH AWAY. Second years, I have not signed ANY forms to get IRB approval for your projects. Please contact your research advisor, or to Ayham, for help. We will discuss the consequences if this is NOT complete.
RECRUITMENT IS ONGOING – We have already had two recruitment days – THANK YOU! Please do your best at being good hosts – introduce yourselves to the applicants, sit among them and talk with them, and continue to actively participate in Medical Chopped. Make sure you have all checked when it is your turn to sit with them in the morning and take applicants on tours. If you are free at that time also come by and talk to the applicants. Remember, applicants eat first. We will get more food – but last recruitment day we ordered for FORTY people, and we ran out…Be mindful of waste please.
COMMUNITY OUTREACH – If I have time, I will try to find ways to promote some outreach projects as winter approaches…
Enjoy the pictures from ACP Resident’s day
Take care everybody….
Scott S Yen MD FACP
Internal Medicine Residency Program
West Suburban Medical Center
(O) 708 763 2256
“Quality is not an act, it is a habit.” Aristotle
“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” Steve Jobs
“Quality is never an accident. It is always the result of intelligent effort.” John Ruskin
“Quality means doing it right when no one is looking.” Henry Ford
“Error is pervasive. The unexpected is pervasive…What is not pervasive are well-developed skills to detect and contain these errors at their early stages.” Karl E Weick
“An incident is just the tip of the iceberg, a sign of a much larger problem below the surface.” Don Brown
I know this newsletter is pretty late, but this is a difficult (read “uncomfortable”) subject to write (talk) about…and it deserves a measured strong voice….
In July 2017, the ACGME (the governing body of residency programs) required that ALL residency programs begin complying with Common Program Requirement VI, which is a descriptor of what the ACGME expects us to have in a residency program’s “Learning and Working Environment”. It’s thrilling reading, let me tell you (19 pages of single space type…). Anyways, there are FIVE parts to it – the latter FOUR parts (B-F) has received the most publicity and has been praised in the media and from all medical societies – that the ACGME has mandated that residency programs promote wellness, provide a professional collegial environment (i.e. don’t “dump” on the residents), provide fatigue mitigation, promote resiliency and prevent burnout in residents (this section also describes in detail supervision and duty hours). Definitely important. NO question about it. Medicine and residency is HARD. It is relentless and time consuming and scary at times. It is our responsibility (this is the all-encompassing “we” – so includes the hospital, leadership, faculty, AND residents) to work together to find ways to take safe, quality care of our patients, learn medicine to become an excellent physician, be professional, and learn to balance this all without burning out and losing our love of this profession.
What I think we have lost sight of a little bit is the FIRST part of this requirement (Part A – which suggests that this is the “more” important component). Part VI A’s TITLE is “Patient Safety, Quality Improvement, Supervision and Accountability.”
Here is the opening summary statement of this section:
“All physicians share responsibility for promoting patient safety and enhancing quality of patient care. Graduate medical education must prepare residents to provide the highest level of clinical care with continuous focus on the safety, individual needs, and humanity of their patients. It is the right of each patient to be cared for by residents who are appropriately supervised; possess the requisite knowledge, skills, and abilities; understand the limits of their knowledge and experience; and seek assistance as required to provide optimal patient care.
Residents must demonstrate the ability to analyze the care they provide, understand their roles within health care teams, and play an active role in system improvement processes. Graduating residents will apply these skills to critique their future unsupervised practice and effect quality improvement measures.
It is necessary for residents and faculty members to consistently work in a well-coordinated manner with other health care professionals to achieve organizational patient safety goals.”
The section goes on to explain CORE requirements that our program and residents must do, within this context. These include participating in QI projects, including QI within your own panel of patients, promoting a culture of safety, activating error systems, doing root cause analyses.
So why am I talking about this component of your medical education? I think most of you are worried (groaning?)/thinking that I am now going to get on your cases about; procrastinating on your QI projects, or not showing up to hospital committee meetings, or not putting reports in the Midas system, or not contributing at our biweekly M and M. NOPE! (okay maybe a little…) I am here to APOLOGIZE on behalf of leadership – we have probably not been able to provide the oversight nor the metrics to “properly” educate you on this topic. We haven’t provided you with the details on how you practice medicine so that you can make changes to your panel of patients (inpatient and outpatient). I ask myself if all of us have been promoting a real strong culture of safety and quality (with the exception of Dr. Marinelli who is truly our performance distinction champion). For us, and for you, this is probably THE single most difficult component of your residency education. This section is a new component of medical education, and you have probably not been adequately exposed to this in medical school. You have probably not been taught in medical school how to promote safety, other than on an individual basis (ie. working to be safe one patient at a time), nor learned how to do a QI project. These things are out of your comfort zone, and also a bit out of our comfort zone.
What’s the “best” way to solve this conundrum and “gap” in your education? How do we all become better at this part of your education? I think the absolute EASIEST AND HARDEST way to solve this is to END the culture of silence. (Though I promise – we will do more than just this – we will find our quality and safety champions.)
In medicine, more than almost any other profession, we have a culture of silence. We have all grown up with this idea that “OMERTA” is cool. In medicine, this comes at a very high cost – for patients – medical errors, morbidity and mortality. For doctors – the cost is suicide, depression, burnout. We need to do better. And I get it – it is VERY uncomfortable. We don’t want to speak in front of a panel of people explaining yourself and your actions, so we also hope to protect our fellow doctor, or nurse from having to do the same, and don’t say anything. We are human – we make mistakes. Systems are not infallible, they are made by humans, mistakes can occur. We LEARN from mistakes so we don’t do it again. We fix systems, so that error doesn’t happen again. We ALL have to be better, and that absolutely includes me. At the most recent buzz session, I want to give a quick thanks to those who spoke up about a potential ED throughput problem, and not getting calls about patients for several hours. But get us the MRN’s. JUST this Wednesday morning, at the Medical Executive Committee meeting, ATTENDINGS BROUGHT UP THE SAME PROBLEM. Same issue – no one wrote down MRN’s, no one spoke up at the time of delay. When we collect the data, Dr. Anthony will look, and help figure it out – is it a system issue? Is it a case by case basis? Is it one attending in the ED that is an issue? Changes can only occur IF WE SPEAK UP and write it down. (FYI – and yes, you spoke up – so once all of you have worked on a template for the progress note that will satisfy faculty and your fellow residents, we can go back to typed progress notes.)
Here is an example of a problem that the residents brought up first, and now there is going to be a change. We switched to a new tele-psychiatry company last winter. After the first month, some residents came to me to discuss problems with the system and how it works, which I brought up to administration. Later, there was some improvement. Then, in the spring, there were more complaints from residents, about the setup, and lack of timely follow through. This too was brought to administration. This year, more complaints, some from residents, which again administration was made aware of. We have all had enough. We are changing tele-psychiatry companies. Of course, it took time, but change happened. Thanks to you.
The ACGME are made up of smart people, and they are often prescient about the future of medicine. I think there is another reason that they have made quality and safety a program requirement. We are at a critical juncture in medicine. With a huge physician shortage, more and more physician assistants and APN’s are given the responsibility to care for patients. Minute clinics manned by APN’s, hospitalist APN’s, APN anesthesiologists, PA’s in physician offices now often do the work of taking care of patients, and they don’t cost insurers or patients as much money. Anyone with some medical education can follow a protocol – “chest pain protocol, ACS protocol, pneumonia protocol, sepsis protocol. But the ability to notice the variations, to find the flaws in the protocols, recognizing the patterns when problems occur – THAT is what makes the difference between a doctor and an allied health professional. This is what patients want to see their doctors do. That is what makes doctors leaders in patient care. My wife likes to say – do you want to be a line cook, or do you want to be chef? Something to contemplate…
KUDOS – Just want to give a quick congratulations to the IM residents and the ICU team for completing the first month in our ICU. Lots of busy days, interspersed with some lighter days, but always full attention.
Wednesday October 10th. Coming next week! Congratulations again to all who had their posters/e-posters/oral vignette accepted to compete for prizes and potentially a trip to the national ACP meeting in Philadelphia in Spring 2019. Make sure you have put an attending’s name on the poster. Make sure you have the template for the poster format. Remember that you will need to have your poster on a hard board. This year to save money the ACP has purchased easels (trust me it seems “cheap” but the old way costs $3000/year for one hour of work). There will be hard boards available for purchase there for those looking to travel by public transportation or who feel strongly they will win and go on to the national meeting…
As well, we are one of the hosts of the event this year. That means we will be running the Doctor’s Dilemma competition – so we will be there all day. ALL HANDS ON DECK!. We need everyone who is free to come help out. There are all sorts of ways to help out – see Ayham for details.
We have a research forum end of November! That is only TWO MONTHS AWAY. Second years, I have not signed any forms to get IRB approval for your projects. Please contact your research advisor, or to Ayham, for help. See above to understand how important I feel this is for you to get done.
Hard to believe that we are starting interview season again. Didn’t this most recent class of hard working interns just start? I can’t even begin to explain the large role that all of you play in bringing in the next class of residents. Ayham has already sent a memo to some of you who have been assigned to participate in the first set of interviews at the end of this month. We will give a mini-orientation at one of the academic half-days this month to describe everyone’s role during interview day, even if you have not been specifically assigned to participate.
I have enclosed a few pictures of community fundraisers that my wife and I have attended in recent weeks. My wife and I did the Heart walk on September 22, in Oak Brook. You may have seen many of the bake sales and other fundraising efforts in the lobby for many weeks. West Suburban did a great job raising funds for the American Heart Association. The other picture is of a roast of my son’s old wrestling coach, raising money for Beat the Streets Chicago. Many of you know that my wife was the Executive Director for the Oak Park River Forest Chamber of Commerce, supporting small businesses. Well, she is moving on, and will now be the Executive Director for Beat the Streets Chicago, which is looking to help inner city youth get off the streets and into a safe environment – for wrestling, for tutoring, for learning. I know that the Housestaff has a committee looking at doing more community outreach. It is getting colder, I am hoping we can start hearing about some projects to help those in need.
Take care everybody….
Scott S Yen MD FACP
Internal Medicine Residency Program
West Suburban Medical Center
(O) 708 763 2256
“It is easy to make stuff up – and easy to dig up information and repeat it or report it to others. But to find a real life story with real people in real life situations is quite difficult and time-consuming. Yet, the rewards are worth the effort.” Lee Gutkind
“I like to listen. I have learned a great deal from listening carefully. Most people never listen.” Ernest Hemingway
“Listen to your patient, he is telling you the diagnosis.” Sir William Osler
“Tell me the facts and I’ll learn. Tell me the truth and I’ll believe. But tell me a story and it will live in the heart forever.” – Native American Proverb
“Stories are memory aids, instruction manuals and moral compasses.” – Aleks Krotoski, The Guardian
“You have to understand that the shortest distance between a human being and truth is a story.” – Anthony de Mello
I think I saved my friend’s life this past weekend…
I will get to safety and quality in medicine another day – life sometimes brings a different reflection…
My wife and son and two of our best friends, a married couple, were at a restaurant enjoying a wonderful meal last Friday when my friend left for the bathroom. He was in there an unexpectedly long time, and when he came back he leaned heavily on our dining table, and said in a raspy whisper “I don’t feel well we need to go.” He was blue in the lips, pale and plethoric. I yelled out to him to ask what was the matter, but he didn’t respond and stumbled, spilling the wine on the table and knocking some chairs over. I grabbed him and looked up to my wife, who took the words right out of my mouth and said “I am calling 911.” Another restaurant patron assisted me in getting my friend to a chair, but he remained staring into space, unresponsive. I couldn’t get a pulse, so we got him to the floor. He started gurgling, and making grunting noises, and continued to stare, it seemed in abject terror, up and to the left. He wasn’t breathing otherwise, and I still couldn’t get a pulse, nor could the Good Samaritan next to me. Those of you who have been first responders, especially out in the community, will understand the dawning realization I had that told me “oh, f…., I need to do something NOW.” So, I said a small prayer, and started CPR. I heard some cracking of cartilage, which I took as a good sign that I was getting proper compressions (thanks Tony and see picture below), did a set of 30, and then stepped back…and by fortune, he was breathing. His pulse was also strong now and in the 70’s. There was a tense several minutes as he started blinking and looking around, then coughing and gagging a little, while EMS had yet to arrive. A side, now funny, note. As I was over him monitoring him, a guy dressed in a coat and tie who had come from a rehearsal dinner party in the room next to the main dining floor, barges in – actually pushes me aside, looks at me balefully, doesn’t identify himself, and immediately feels for a pulse on my friend’s neck. At that point EMS arrived and took over, and I was able to tell EMS the story above. (We figure the guy was probably a surgeon…)
We went to the nearest emergency room (not here FYI) where we waited to hear news about my friend. We were eventually allowed to go into the room to visit him. His color was back, and he was better but weak. He was nauseated and dizzy, and still a little dazed, so he and his wife told me to sit tight as they had told the ED doc that they weren’t sure what happened and they should probably talk to me. We waited, then a CXR and a chest CT was done, and then we waited some more. Then the ED doc came back. The doctor was nice, they stated that the CXR and CT chest angiogram was okay, they weren’t sure what happened, he didn’t have a heart attack, that all his labs were normal except his potassium was 2.8 and they were going to replete it, they weren’t sure why his potassium was so low, but that might have set off an arrhythmia, but he may have also had a vasovagal response, or this was all just severe dizziness so we gave you some meclizine. They also, appropriately wanted to keep him overnight. Then the doctor LEFT. My friends had me nearby, and as soon as the ED doc was gone they turned to me and asked – “so in laymen’s terms, what did the doc just say?” So another hour passes and my friend gets to the floor and the nurse settles him in. She asks what medicines he is on – he mentions he is on losartan HCTZ. After the nurse left, I decided to ask my friend what he did that day – he had mowed the lawn, walked the dogs, and worked in the yard a lot of the day. Did he drink much water? In retrospect about 2 glasses, but not much else, and also hadn’t eaten much all day. Was this the first time anyone asked you about this? YES. Did anyone ask you about your meds? NO.
My friend is fine – he is home and resting, though they had the extra trauma of having to put their dog of 17 years down this weekend as well. We are still not entirely sure what happened, though based on my story I think we can all guess at what likely happened. He will go for further testing soon and maybe I can report what was found. At the end of the day he received EXCELLENT care, and I am thankful to EMS, the hospital and the very friendly staff that did everything that needed to be done to be sure he was okay and safe. (Okay I have to give one comment from my administrative hat – they kept him an extra day unnecessarily because no one read the tests done on Saturday morning, no hospitalist pushed to get results back or came back on Saturday afternoon to talk to him or his wife, so he sat until Sunday.) Even his ribs aren’t that sore, so maybe I didn’t press hard enough…
At the end of the day I tell you the story of the scary event to draw you in, but I think it is obvious, from the above quotes, and from what I wrote, of the lesson, or reflection, that I want you to think about this month. Every patient has a story that is just WAITING to be heard, that can help clarify and give answers to the differential diagnosis that goes on in our heads as we review the patient data. Sometimes, (though I admit it would be rare indeed) a knowledgeable physician who happened to be on the scene could help provide some of that story – they just need to be asked. AND, most of you know this, IT TAKES WORK AND TIME to get the story. I know, it is sometimes just a lot easier to just get all the data, depend on the ER history, and figure it out from there. But sometimes the story is the memorable part, and helps us remember better the individual, the person that we took care of, and not the numbers, or the disease process. Do you better remember the “78 year old NH patient with dementia and ulcers coming in with AMS and with an overbearing family…” or the “78 y/o AAF who was the first female Illinois Supreme Court justice who unfortunately has dementia and ulcers coming in for AMS. Family is worried and is struggling with the balance of being aggressive to know what is going on vs. comfort care…” Which is more memorable? Which presentation is more positive? Which story probably took longer to get?
This was a reminder to me this past weekend that for all we push to learn about data, about numbers, about throughput and discharges, about processes, etc. that there is a human being with a story, and they can inform us about the life they live, and the choices they have made that have led them to become, for likely a brief time, a part of yours or our life experience.
KUDOS – Can I just say WOW! We had TWELVE abstracts accepted for ACP Resident’s day! Once we have compiled the whole list of winners we will send it out. This is probably a record number accepted from our residency – strikingly impressive! Along with Babak’s oral presentation, we will have prominent representation at this event this year, taking place Wednesday, October 10th. Because we will be in the ICU, I cannot close services for this event this year, but everyone who is competing in the live poster competition (we have students AND residents competing in both research and clinical vignette categories) will be able to go. Ayham will have quite a challenge for scheduling, but we will figure it out. CONGRATULATIONS! Great Job!
CONGRATULATIONS! To Eric Chung, who is getting married next week. Studies show a happier and longer life when married…so cheers!
ICU – HERE WE COME! We got a little bit of a break this year and have not been in the ICU for the last 5 months. I am hoping that was a nice break for all of you, but now we will be back taking care of the critically ill. I hope that our participation in the Simulation lab that we just had will be helpful to prep you for some procedures as well as code protocols. Ayham sent you some videos on ICU care, and we had a nice presentation by some seniors at the last Academic half-day on working in the ICU. Best of luck to all of you.
RECRUITMENT IS COMING! We start reviewing applications on September 15th, and interviews will start end of October. If any of you know students who might be interested in coming to West Sub for either a preliminary or categorical position next year let me know, I will take a look at their application. We have a change this year in that we will be busy in the ICU during much of interview season, so we will be moving more interview dates into December and January, when we are out of the ICU. We will send out the interview dates next month. Thank you to all who have helped bring in this excellent class that we have this year! We will have a brief talk on resident responsibilities and how to present our program during recruitment season at one of the Academic half-days prior to interviews starting (Ayham I promise the talk will be brief)!). Be ready again for Medical Chopped!
CONCORDIA UNIVERSITY STUDENT CLINIC RESUMING THIS MONTH. For those of you new to our residency, we oversee the walk-in student clinic at Concordia University in River Forest, Illinois, which is the city just west of Oak Park. This is an opportunity to care for a different population of patients than we see in our AIM continuity clinic. We are there every Monday, Wednesday and Thursday afternoon from 1 – 4:30pm (or 1:30 – 5 – TBD) while school is in session. It is always interesting to note how little school there really is, especially once you start really working…. Be prepared to give allergy shots, do PPD testing, and deal with acute illnesses, and musculoskeletal complaints in a younger generally healthy population. Last year, we dealt with some unique diseases, including acute Lyme disease, and Marfan’s. I will send more information to those specifically going regarding parking, location, etc. Good luck!
ROSS STUDENT EXPERIENCE ENDS. Thanks to all faculty and residents who have helped educate the Ross University medical students all these years. We have matched with some wonderful residents who did their track here. We will continue to have Loyola students come for a third year experience in IM, so continue to put on your professor hats and give your time to them. With the administration’s permission, we are seeking a relationship with another medical school (currently talking with three schools), but that won’t happen for a bit.
EVALUATIONS – Help improve our residency program, be honest in your opinions, give some written feedback, or come to Ayham, Dr. Yedavalli or I to discuss issues. We can’t make changes without real feedback. Just as a start, from honest feedback, we are looking to create more structure in teaching rounds. More to come…
For those of you who have the weekend off – enjoy. Best of luck to those starting a new service tomorrow, esp. the ICU. Take care everybody….
Scott S Yen MD, FACP
Internal Medicine Residency Program
West Suburban Medical Center
(O) 708 763 2256
Our doubts are traitors, and make us lose the good we oft might win, by fearing to attempt.” – Measure for Measure, Shakespeare
“I alone cannot change the world, but I can cast a stone across the waters to create many ripples.” – Mother Teresa
“We must become bigger than we have been: more courageous, greater in spirit, larger in outlook. We must become members of a new race, overcoming petty prejudice, owing our ultimate allegiance not to nations but to our fellow men within the human community.”- Haile Selassie
“If by a “Liberal” they mean someone who looks ahead and not behind, someone who welcomes new ideas without rigid reactions, someone who cares about the welfare of the people-their health, their housing, their schools, their jobs, their civil rights and their civil liberties-someone who believes we can break through the stalemate and suspicions that grip us in our policies abroad, if that is what they mean by a “Liberal”, then I’m proud to say I’m a “Liberal.” – John F. Kennedy
“Oak Park is crazy – it’s like a social experiment”
“Instead of being six feet deep that boy is six feet tall with the will to be a Harvard graduate color accurate black panther doctor of neuroscience innovator
They know we are not thugs or high school dropout or target practice
We are monarch majesties pyramid building slave plantation-taking, Million man marching Rulers of the Country.” A spoken word rap from a student in “America to Me” a documentary on Oak Park River Forest High School coming to Starz starting August 26, 2018.
A whole lot of everything has happened in the very first month of this academic calendar year (well, our hospital was sold to a new owner, for one…), and I have numerous times thought about changing my topic this month. Also hence the lateness. I have decided to stick to what I wanted to talk about originally, so here goes….
When I was 3 ½ months old, my father moved our family to Huntsville, Alabama, to work as an aeronautical engineer for NASA for the Apollo projects. It was an amazing and, as it turns out, a historic opportunity as my father helped put men on the moon. As you are probably deducing, yes, we were one of very few Asian families deep in the South in the 1960’s-70’s, so few, in fact, that I don’t remember a single child my age that was like me. Additionally, I was a sickly kid, suffering from allergies, and often sick. In school gym, I vividly remember being made to swim along the side wall, as I was the only one who couldn’t make it across the pool without having to stop and rest. I was also painfully shy, especially with girls, so that, if a girl even looked at me, I would start to blush, and sometimes even ran away. Yet I NEVER experienced any prejudices or bullying while I was there, as far as I recall (in retrospect, I had a friend and, probably, a protector – a boy named Andrew who was two grades above me, who probably made sure that nothing happened to me). Huntsville, despite its deep South roots, was a progressive community that seemed to understand that the economics of the town depended on engineers of all shapes and colors and sizes to work in the town together to win the space race against, at that time, the Soviet Union. Progressive to the point that, when the Apollo projects ended, and we moved back to California, that a small contingent of Asian families stayed to raise their kids in Huntsville, Alabama.
Which, of course, brings me to the communities of Oak Park and Chicago-Austin. I think one should always learn a little bit about the communities you work and/or live in to understand and get a flavor of the type of people you will be working with, and caring for, and taking care of, and learning from, and doing outreach for. There are entire books out there (including a book cover picture I have included at the bottom of this musing) that talk about Oak Park and the surrounding neighborhoods, particularly the Austin community, but I want to limit (okay not really but I figure I have 10 minutes of your time….) this musing to a few paragraphs. So I want to bring you my perspective having lived here for 24 years.
Oak Park, like Huntsville, is a progressive town. Perhaps the desire to preserve its own roots, yet, with its location right across the street from urban sprawl, necessitated that the denizens of Oak Park have this liberal attitude. (I should probably read a book on Oak Park…) Hence Oak Park is a mix of dichotomies, or mixed messages. Oak Park is a phenomenally wealthy town – home of Frank Lloyd Wright multi-million dollar homes, but highly desirous to help with fair housing…as long as that fair housing is not in their neighborhood which lowers their property value. We love the independent business and their green nature, but they need to have convenient parking and have prices equal to the big box stores. Oak Park desperately wants to help the Austin neighborhood become better, but is rightly concerned with crime, and sets up barriers along Austin. Oak Park – a little hypocritical at times, but enthusiastic to help and do good, sometimes misguided in direction, but always earnest and heartfelt.
My wife Cathy probably said it best in her TedX talk a year ago about the Oak Park bubble (I have alluded to this talk in the past). If interested have a listen.
Austin community, where 60% (70%?) of our patients at WSMC come from, is, to put it mildly, a community in need. Rotary International, a philanthropic club that I talked about last newsletter, yearly looks around the WORLD for communities in dire need of funds, scholarship, infrastructure, etc. This past year, because they have been so successful in helping around the world, including being so close to its goal of ending polio, they have looked in the US for communities in need. Austin community is one of those communities considered in high need. Yet still there are pockets in Austin with nice houses, friendly neighbors, and wonderful people. My daughter, growing up, had a great friend that lived in the Austin community (knew her through dancing at the Chicago Multicultural Dance Center). I was always afraid for my wife and daughter as she was driven to birthday parties, etc. in the Austin community, but felt safe once they arrived.
So here you sit, at West Suburban Medical Center, here in wealthy, liberal Oak Park, but running alongside a community that is considered one of the neediest IN THE WORLD. How does one understand this dichotomy? Here is my plug to encourage all of you to watch “America to Me” coming to Starz, a documentary about our local high school (filmed by Steven James, who also made the critically acclaimed documentary “Hoop Dreams”). The film crew spent an academic year following 12 Oak Park River Forest high school students, predominantly African-American students, as they navigated life in a racially integrated wealthy suburb, and how they survived, failed, or thrived in this community. Our family was very close to two of the featured kids (both wrestlers) so, on a personal level, I am excited to see if my son (filmed during his senior year) and my wife will get some air time. But why I encourage you all to watch it is this – much of the documentary talks about closing the achievement gap – so you will get a chance to see Oak Park adults being earnest, heartfelt, liberal, maybe misguided, in trying to help the African American student – perhaps a reflection of trying to help the Austin Community. And you will see the African American perspective, who objectively needs help but maybe doesn’t always want help. (The documentary has not aired yet and I am not privy to the final cut, but I think it will be compelling theater).
Lastly, I want to comment a little bit about the sale of our hospital. I want to laud our current administration, particularly Joe Ottolino, and BJ Krech, and Stasia Thompson, and Marta Alvarado, with working with Tenet Healthcare and pushing to become a bigger part of the Oak Park community. They have become sponsors in many philanthropic endeavors. Now, the new investors from TWG group, have Chicago ties, and public health ties. I have already reached out to Eric Whitaker (he was my medical school classmate and has been integrally involved in public health and community service for many years), and talked to him about our community minded hospital and my desire to want to talk about making more inroads in helping the Austin community. Just taking care of our patients in the hospital and sending them back into the same environment that they came from doesn’t lead to long term success and change in the community. I am looking forward to the relationship with our new owners.
CONGRATULATIONS! First, I want to mirror Ayham’s recent acclamation in his Chief’s update, and congratulate our first-year residents on getting through the first month, hopefully still excited to learn – from faculty, from each other, and, foremost, from our patients…
LOYOLA UNIVERSITY SIMULATION LAB –1pm – 5pm Friday August 17th, followed by HAPPY HOUR 5:30-7:30pm at Trattoria 225. Be ready! We will close all services all afternoon so everyone can attend. For the Thursday night Night Float team, you will be excused around midnight. For Friday night, the NF team will be expected to start around 8pm. For the IMS teams, you will finish up your work and be excused after 12noon. The on-call team should probably pick up the last admission of the day at around 10am to give you time to finish to get to Loyola University. The Simulation lab is at the Loyola medical campus in Maywood – about a 20-minute drive from the hospital. We start at 1pm sharp, so get there early if you can. This is an opportunity to practice procedures, do some ACLS and Rapid Response simulations, and overall start feeling more comfortable with this part of your training.
AFTER the simulation lab, we will have happy hour at Trattoria 225 on 225 Harrison Street in Oak Park Illinois. We will have plenty of food for all of you. ALL FACULTY ARE INVITED AS WELL.
ACP ITE – Just another heads up. Friday August 24th and Friday August 31st. This is for categorical residents only. This is much like a Board’s practice exam. I would hope that third years take this test seriously (not necessarily to study for it, but to concentrate as if it was the actual Boards), as it is your opportunity to practice taking a day-long test. We will close AIM clinic on August 31 so that group will take the test on that day. The rest we will try to limit interference as much as possible with work and schedule accordingly.
GOOD LUCK TO ALL THE SENIOR RESIDENTS TAKING THE IM BOARDS THIS AUGUST. Wish them a hearty good luck!
We will be heading into the ICU next month. Ayham will be sending out a link to videos, some from the ACP as a privilege with being an elite status program., on ICU topics to help you prepare.
Next month, I am going to focus on Common Program Requirement VI…sounds stultifyingly boring – but stay tuned…
Take care everybody….SSY
Scott S Yen MD FACP
Internal Medicine Residency Program
West Suburban Medical Center
(O) 708 763 2256
“The need for connection and community is primal, as fundamental as the need for air, water and food.” Dean Ornish
“Everyone desires relationships and community. Most people want to belong to a cohesive, like-minded group. It staves off loneliness. It promotes identity. These are natural and very human instincts.” Joshua Ferris
I want to give a hearty welcome to the new internal medicine (and FM too) residents to West Suburban Medical Center! To those new to my musings, this newsletter is my chance to reflect on this whole “educating the next generation of internists” thing. I find this experience immeasurably fascinating, frustrating, fun, and fulfilling (any other “f”s you can think of?), and this format gives me the chance to reflect on this through the written word. This newsletter is meant to be informational, inspirational, thoughtful, helpful, or, a complete waste of time…
As I mentioned at the White Coat ceremony (and thank you again to Dr. Scott Levin and the FM program for going first while I raced back from the airport), I was just in Toronto accompanying my wife as she attended the Rotary International conference. I was utterly impressed with the easy diversity and unassuming ease at which the eclectic population of Toronto intermingled and existed together. Two examples. We were eating at a nice restaurant, where our extra attentive waiter felt compelled and comfortable inviting us to the Gay Pride parade the next day. Another day, we ate at an old Italian restaurant, with communal tables, where young and old, Bohemian and Preppy, and every race sat together and enjoyed the fantastic food.
But as eclectic as the city of Toronto is, I was also struck by how groups still want to have an identity tag, to say that they belong, or are a part of, another, more close knit family. One family was Rotary. I think when many of you think of Rotary, you think of rich older suburbanites (I certainly did once). Instead, I have found that Rotary is a world-wide organization, with members coming from every part of the world, dedicated to ending poverty, and disease (the organization’s biggest goal is almost complete – ending polio) by being innovative and creative and putting in the hard work. You would be amazed at how proudly they wear their Rotary bling! They love wearing their light blue and yellow shirts, scarves, vests, hats, etc., and fill their lapels with pins with the Rotary logo.
The other very large family was the LGBTQIA+ family. The largest Pride parade in North America was filled with the colors of the rainbow. No matter the color of your skin (and there was lots of that showing too), or your gender (or neutral), all the colors sparkled during the parade. A completely different group than the one I was with at the Convention center, but the same sense of belonging occurred with wearing the colors of the rainbow.
So where am I going with this? We are an eclectic group of doctors coming from all over the country and from different parts of the world. We are each our own individual person who will bring a unique brand of you to this institution. But we all also share a mutual interest which I hope brings you all closer, and makes you feel comfortable becoming part of the West Suburban family. I want each of you to feel like you belong here, however temporarily. We too have our “bling” (we plan to order your fleece soon – sounds distasteful in this current hot weather but is plenty nice in the fall/winter). We share a common goal – taking care of the patients in our community as best we can. You have already seen this family come together just this Friday, when a fire broke out in the North hospital floors, requiring evacuation of patients from the area. I know some of you were among those who aided in the evacuation, as I had just left the floors (holed up in the basement with the door closed after the Code Red I didn’t hear the ongoing announcements), and I am proud of the fact that you all stepped up to help.
Over the years I have been bemused, “thought it was cheesy”, (and probably more than that) by the “rah rah” that occurs over sports teams, over schools, etc. As an introvert, I felt like I was above that. But I have come to realize that part of being human is wanting to be part of a tribe, and I am very proud to say WSMC is my tribe. I am hoping that, even after you graduate, we will make this place feel like a place you can belong, and that you will always be welcome here. As we go through this next academic year’s journey together, let me know how I can make you feel like part of the family.
ACADEMIC HALF DAY. Starting this Tuesday, July 3, and every Tuesday hereafter, we will work hard to bring you an academic curriculum that will be fun, interactive, and educational. Be participatory in this endeavor, and as time goes on, bring us your ideas and we will work to incorporate them into the half day (my idea – monthly radiology rounds?). Of note, any month that there are FIVE Tuesdays, the fifth Tuesday will be a “mini-retreat”. Okay, no escape rooms, but happy hour, bowling (again?), scavenger hunt, architecture tour, rock climbing?. Anyone?
ACP RESIDENT’S DAY and oral vignette/poster submissions. Please work hard on getting poster submission to ACP Resident’s day by July 11, 2018. For those who don’t know, West Suburban’s IM residency program will be one of three hospitals hosting the event this year, which will be on Wednesday, October 10, 2018. So let’s represent! As IM will be in the ICU in October, I will be unable to close the IM services fully this year for everyone to attend, but will do my best to get most of us there. Of course, if you are chosen to do the oral vignette, or get your poster chosen to present, you will get to go (hint hint).
LOYOLA SIMULATION LAB – Friday August 17th. We will close service so everyone can attend. This is an opportunity to practice procedures, do some ACLS and Rapid Response simulations, and overall start feeling more comfortable with this part of your training.
ACP ITE – Friday August 24th and Friday August 31st. This is for categorical residents only. This is much like a Board’s practice exam. I would hope that third years take this test seriously (not necessarily to study for it, but to concentrate as if it was the actual Boards), as it is your opportunity to practice taking a day-long test. We will close AIM clinic on one of the Fridays so that group will take the test on that day. The rest we will try to limit interference as much as possible with work and schedule accordingly.
Take care everybody… SSY
Internal Medicine Residency Program
West Suburban Medical Center
(O) 708 763 2256