Tag: experience

Categories
General Innovation

A Budding Clinician-Scientist

Before I embarked on my second year of medical school, I wanted to try something different — an experience I probably wouldn’t attain during the medical school curriculum.

I have always had an inquisitive mind, hence research held a natural appeal. Research, at least to me, can be broadly categorized into two groups: dry lab and wet lab. I was already involved in the former, but was keen to give the latter a shot. An oncologist took me under his wing, and I was soon introduced to the world of lab-based, experimental research.

Coming from a background with literally no lab experience, it was undoubtedly a steep learning curve at inception. There was an avalanche of lab-based skills I needed to learn and understand. I was tasked to perform lymphoma research, but it wasn’t until a month later that I actually got to perform experimental work on lymphoma cells. The first month was humdrum but necessary. I had to complete multiple safety courses, practice micro-pipetting, and learn about the entire range of complex lab equipment and procedures such as the centrifuge, film development for western blots, and flow cytometry machine.

After one month, I was given my topic and tasked to draft the experimental protocol. In brief, I was investigating complement-mediated cytotoxicity of rituximab (anti CD20 monoclonal antibody) on lymphoma cell lines. Even though I had some prior knowledge about the cytotoxic mechanism, I had to perform an  in-depth literature search to augment my understanding and look for existing experimental protocols that I could potentially adapt.

With a protocol in my armament, I thought I was confident and equipped enough to perform the experiment, until I realized that multiple roadblocks lay ahead of me. An initial protocol with six simple steps turned out to be twice as long after adding several intermediate steps that I had missed. There were other reagents that I had to add. For instance, staining the cells involved identifying the appropriate stain color, optimizing the concentration of the stain solution, incubating it for a period of time; it was not as simple as adding a reagent to a test tube of cells. Hence, it often took longer than expected to complete a single step, which resulted in me being late for the equipment bookings. Time management was the first lesson for me. It was quintessential for me to plan, in detail, the total amount of time I actually needed per step, with some degree of overestimation.

The road ahead was filled with pockets of ups and downs, albeit often the latter. There were many occasions on which experimental results contradicted my hypothesis – cells died when they were not supposed to; cells didn’t die when they were supposed to. When occasions like these arose, I went back to scrutinize every step in the protocol, to make sense of what could have possibly went wrong. But I soon realized that the things that seemed insignificant to me were the sources of the experimental failures. For instance, I had initially assumed that all serum types were similar in composition and purpose. However, the serum I had used was not viable for cell survival. Hence, I switched from commercial serum to human serum in subsequent experiments. The next road block came when my cells became unresponsive to rituximab. It was only much later on that I accidentally happened upon a paper, which stated that the particular cell line in my experiment was intrinsically resistant to the drug. These experimental failures served to teach me one very important lesson — to scrutinize the fine details and consider every possibility that could account for failures.

Lastly, I would like to underscore the significance of perseverance. I consider it to be the cornerstone of being a good scientist and researcher. Amidst the myriad of failures, I would have given up on continuing my experiments if I was devoid of it. Research can be a plodding process with multiple failures; but if you believe in your purpose and persevere, you will eventually reap the fruits of your labor.

I have always had an ardor for research, and I intend to pursue the Clinician-Scientist pathway. I am thankful for this lab experience, for it has opened my eyes to the unappealing — at least to most medical students —world of research. As mundane as it can be, I find both the process and end product meaningful to fellow scientists, doctors, and the society at large. This experience has not stifled my interest and passion for research and science; it has taught me instead the values that are essential for a scientist.

If you’re thinking of doing research or being a clinician-scientist, this is just my two-cents worth of lessons that I’ve personally picked up in my short five month stint thus far in the lab. Be humble. Be hungry to learn. Be careful to look out for details. And, most importantly, persevere despite how monotonous research can be.

Photo Credit: United Soybean Board

Categories
Clinical Lifestyle Patient-Centered Care

Running Low and No Longer Running

I recently completed a rotation in endocrinology, and I learned valuable lessons about diabetes management in both the inpatient and outpatient setting. Today, I wanted to share a clinical pearl generally not discussed in lectures: Diabetic patients often gain weight because of the fear of hypoglycemia.

That’s right. The fear of hypoglycemia drives patients to eat a little more at meals. Let’s backtrack. Patients who have persistently elevated sugars are often started on insulin in addition to oral agents. Depending on their insulin regimen, patients may not eat enough after an insulin dose to prevent a drop in blood sugar. Patients who experience a hypoglycemic event try their best to prevent it from occurring again. This is understandable—fainting is scary and should not be taken lightly (pun intended).

The problem is that patients counteract this fear of hypoglycemia by either eating more after an insulin injection, or by exercising less. This impedes diabetes management. In addition to advising our diabetic patients to monitor their carbohydrate intake, we urge them to start some form of physical activity. Physical activity enhances the body’s insulin sensitivity—it gets to the core of the problem (insulin resistance) and improves overall cardiovascular health as well. But how can we encourage these lifestyle modifications if our patients are getting lightheaded after injections?

The answer: carbohydrate counting and education.

Not the answer: increasing insulin.

My attending explained that “increasing insulin” is actually what happens in some cases. For example, let’s say a patient named Sara comes in for her follow-up appointment and unknown to us, has “fear of hypoglycemia.” Sara brings her glucose meter, and the sugars are poorly controlled. Part of the reason for this poor control is secondary to a) eating more after an injection to prevent fainting and b) decreased physical activity to prevent fainting. Now, if we just treat her numbers, we would increase her insulin.

The lesson here is that one can’t just treat the number in medicine. Talking to the patient, even for a few minutes, will provide the story. Increasing the insulin perpetuates a viscous cycle, and breaking the cycle comes from better regimen management. Validating patient concerns about hypoglycemia and educating them on injecting based on carbohydrate intake is invaluable.

Photo Credit: Melissa Johnson

Categories
Clinical Emotion Public Health

The Day I Took off my White Coat

The man in scrubs stands in the middle of the room. He has a blood-filled syringe in one hand and hand-written lab notes on the back of an envelope in another. He scans the room, looking for someone or something. I follow his gaze. A young man is curled up in a ball on the floor, rocking himself back and forth while groaning in pain (gangrenous wound on leg). A man is throwing all his weight on his wife and yelling in pain (renal colic). A woman is holding a piece of red, soaked gauze tightly on the hand of her screaming 7-year-old son (amputated finger). An older woman in a wheelchair is drooling from one side of her mouth and has a drooping shoulder (stroke). A young man, handcuffed to a police officer, has circular marks around his neck and blood dripping from his mouth (suicide attempt with hanging and ingesting barbed wire). A young woman sits limply in a wheelchair, eyes rolled back, and blood on her clothes between her legs (severe anemia – abortion days prior). In this room no bigger than my mother’s walk-in closet, the suffering is palpable and audible, but the man in scrubs does not find what he is looking for, and begins to walk out. Before he reaches the door, an unconscious man is carried in to the room (antifreeze ingestion). Without missing a step, he reaches over and gives the man a rough sternal rub to wake him up, to no avail. He exits the room.

The man in scrubs is the sole medical resident in charge of the stabilization and triage of incoming patients at this Emergency Department situated in a Low and Middle Income country. As a visiting medical student, I am wearing a white coat, and although I should fit in, my general ignorance about the majority of relevant things makes me feel like an imposter. I shouldn’t be here. I shouldn’t be wearing this white coat.

‘You! You can help me!’ exclaims a woman in a wheelchair as she reaches towards me. Her face is covered, but somehow I know that she is in pain. Reluctantly, and with as much grace as a fish on land, I walk towards her. I walk towards her knowing that the only care I can provide is a hug, a tear, or a smile; the only prescription I can write is a kind word, and the only order I can put in is a prayer to the heavens.

I came to medical school to gain the skills that I need to better care for my neighbors, to share moments of humanity, of suffering and healing with my neighbors, to be meaningfully curious – to ask and answer questions that benefit my neighbors and our community, and to use medicine as a platform to implement meaningful social change. The irony is, I see none of that now; all I can do is stand defeated as I watch my neighbors suffer. I watch because I don’t have the money to cover the 15 pounds admission fee for every patient that is turned away at the door of the ED. I watch because I don’t know whether that comatose child who was just intubated is in trouble because his stomach is inflating instead of his lungs. I watch because I don’t know if that medical student just injured that woman’s radial nerve while trying to get an arterial blood sample.

With tears in my eyes, I fumble out of my white coat and head for the exit. I’m done watching, I tell myself. I’m done watching and I’m ready to learn. I’m ready to learn how to care for the suffering. I’m ready to be a part of the change I want to see in the world. As the door of the ED closed behind me, I managed to catch a final peek of the chaotic scene, as if to tell myself, ‘I will return when I’m ready.’

Looking back, I wish I had kept my white coat on, even if just to care with a tear, heal with a kind word, and pray for the well-being of my neighbors.

Photo Credit: Alex Proimos

Categories
Emotion Empathy General Humanistic Psychology Narrative Public Health

Guter Mann

This city is so peaceful. As the bikes whiz by, I notice the absence of the cacophony and polluting fumes of traffic. I’m walking down the sidewalk in brown leather shoes and a tucked-in dress shirt while eating bougie gelato. I love gelato. I look up and notice the blue sky. It’s a deep blue and the clouds have distinct borders. I’m in Salzburg, Austria for a conference and I’m loving this city. Just as I marvel at the clean streets and begrudge the abundance of luxury vehicles, I turn the corner and see my sister on the floor asking for money. I immediately cross the street and reach in my pocket to hand her the change I received at the gelato stand. My sister is donning the flag of Islam on her head and I greet her with the anthem of Islam, a greeting of peace. She smiles and says, “Allah yijzeek al-khayr” – God reward you with the good. As I walk away, I smile at the beauty and seamlessness of our interaction.

I continue walking back to the conference hall. I review my rehearsed words as I finish my gelato. My presentation is on the data I generated regarding the controversial use of bisphosphonate anti-resorptives in the setting of chronic kidney disease mineral bone disorder. The nephrologists in the crowd won’t be too thrilled. In my head, I am considering all the different questions I could be asked, when I see another of my friends on the corner of an intersection. As I approach him, he brings his hands together and bows his head. When he raises his head again, I smile at him. I don’t have any more change so I reach into my pocket and hand him 5 euros. He has a cup in front of him, but I decide to hand him the money. I think this might make the money more of a gift than a charity. I can see hurt in his eyes as he tries to find a way to thank me. Reaching out I put my hand on his shoulder and squeeze, pointing up with my other hand, trying to tell him that I will pray for him. While my hand is on his shoulder, he turns his neck and kisses my hand. I say, “No, no!” and withdraw my hand. I feel ashamed. I know I should be the one kissing his hand for accepting my miserly gift of 5 euros while knowing full-well that I have another 10 laying comfortably in my pocket. Ten euros that I will, over the next couple hours, undoubtedly spend on a sacherwurfel from the bakery next to my fancy hotel and then on another helping of overpriced gelato.

Lost in my thoughts of embarrassment, I begin to walk away, and as I do, he yells in German, “Guter mann!” – good man. Halfway across the street, I think to myself, I may not be a good man, but I have the opportunity to try, and so I turn back around.

Ten euros was all the money that I had left on me. But 10 euros was all it cost to earn the respect and love of a man I had only met minutes ago. Excitedly, the man begins to talk to me in German. His name is Damien. (We spend a good 5 minutes on my name. I would say, ‘Mo-ham-mad’, and he would then repeat after me, ‘No-han-nam’). Damien is a father of 3 kids. He was doing well for his family until his wife lost her vision. He said, “Now my heart is still good, but children’s stomachs are empty, so my hand is outstretched.”

I notice the tears in my eyes. I had never heard German spoken before, and I shouldn’t know what he’s saying to me, but I understood every word. Home is where the heart is, and this man is my neighbor. As I leave Damien for the second time, I point up again and then turn my palms up to the Heavens in prayer. He says, “Allah.” And I repeat, “Allah.”

On my second day in Salzburg, I take the long way to the conference center, hoping to run into my friend Damien. I turn the corner and there he is, sitting at the end of the block. My stride lengthens and my steps quicken. As I approach him, I see him leaning left and right, squinting his eyes; he’s trying to see if it’s me. He leaves his corner and yells, “Nohannam!!” while jogging towards me and we embrace each other as brothers and lifelong friends. And as my neighbor and friend embraces me, I realize I may not be a good man, but Damien is willing to show me how to become one.

Photo Credit: Sam Rodgers

Categories
General Lifestyle

Goals between 1st and 2nd Year

When we were young, summer days were our most free. Our neighborhoods suddenly became hives of activity; kids playing baseball in the streets, video game sessions lasting all day, trips to the pool, family vacations, and most importantly, no school. Those days of summer seemed too short, and during the long winter months when school seemed to stretch on forever, I often sat and daydreamed of the days when I could wear shorts and a t-shirt. For many, summer vacations can last through college, with time spent abroad or back home enjoying the comforts of their childhood. Medical school, however, changes the game.

For those who come straight to medical school from their undergraduate institutions, the last true summer might be the one between the first and second year of medical school. In fact, most schools give students several weeks off to decompress after the long struggle of first year. Therefore, it’s worth asking: what do we do with this time? With that question in mind, I went out and queried fellow students from all years, as well as several physicians in practice and in academia, in order to collect ideas. Not surprisingly, there were a huge variety of answers, but they divided into two basic camps. About half said to do something, anything, to prepare ourselves for our future careers, and the other half said to enjoy the last vestiges of our youth.

The arguments are valid on both sides of this debate. Amongst those who said to do something “productive,” about 75% said to, more specifically, gather experience in an area of interest. Whether through shadowing or more formal experiences such as research opportunities, the idea is to gain whatever knowledge and experience you can to make choosing a specialty easier. Additionally, these measured voices said, you will gain a little extra something on your CV that might impress residency programs. For instance, a friend who had an interest in mental health and addiction medicine spent the summer doing research in a major university setting. He applied months in advance and said the experience changed his life. On the other hand, the remaining 25% said to spend time studying for the Boards. “They’ll creep up on you quickly, so best to start early,” one professor told me. He suggested creating a plan of action for the summer, including high yield topics to review each week.

The “do nothing” crowd, or those on the other side of the argument, also had their say. Many advocated that this last summer is the perfect chance to do a few things that simply won’t be possible in the years ahead. “For those who enjoy traveling, take the chance to get away,” they repeated again and again.  A student who recently matched into PM&R told me that he went to Europe for 4 weeks, rode the train, met lots of great people, and “stayed as far away from studying as [he] could.” He added that this gave him the chance to recharge his batteries before tackling the challenges of second year and beyond. While traveling Europe might not be possible for all of us, finding ways to decompress should be. A family medicine physician who has spent 20 years in practice told me that he went home, saw family, and spent lots of time fishing.

In the end, there is no clear path. Just like with everything else, how to spend that last summer is a very individual choice. My own experience involved taking time off to rest and reflect, and also spending a month locked in a room with some fellow students crafting a business plan for a student-run free clinic, which, after a lot of work and fundraising, opened the next year. I also completed a 2 week internship in rural medicine. I wouldn’t change anything about the summer; both of those work experiences motivated me in different ways regarding the type of physician I want to become, while taking time to rest rejuvenated me for the trials ahead. No matter what you choose, remember to do what makes the most sense for you. If you need the rest, take the chance to get it. If you want to work on something you feel passionate about, do that. While it may seem like another multiple-choice question, in the end, there is no wrong answer.

Featured image:
travelling by Elvira S. Uzábal – elbeewa

Categories
Innovation Lifestyle

Pathographies

“Illness is the night side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”
– Susan Sontag, Illness as a Metaphor

Words are important. They allow us to meet on a common ground, to share experiences and learn from each other. They can evoke every emotion and open new friendships. They can also be therapeutic, and a way to fill the gap between doctor and patient.

Pathographies, defined by the Oxford Dictionary as ‘the study of the life of an individual or the history of a community with regard to the influence of a particular disease or psychological disorder’, have become more popular over the years (1). Walk into any bookstore and you will eventually come across the healthcare corner: a small stack of books by people who have crossed the abyss into the land of ill health. Such stories speak of hope, love, loss, and despair as patients and their families come to terms with the sudden invasion into their lives. Treading through illness can be an isolating experience, filled with pain and uncertainty.

The Database of Individual Patient Experience is a UK-based charity that runs two websites: healthtalk.org and youthhealthtalk.org. It was created by Dr Ann McPherson, a GP who was diagnosed with breast cancer, but found that she had no one to talk to and share her experiences with. As a result, these websites are filled with patient’s experiences of their illnesses, how they coped, and their family’s reactions. Such websites can open a common ground for those who are suffering, those who are newly diagnosed, and the friends and family who may want to learn about how they can help.

“I am tired of hiding, tired of misspent and knotted energies, tired of the hypocrisy, and tired of acting as though I have something to hide.”
– Kay Redfield Jamison, An Unquiet Mind

How can they help us?

Pathographies are about putting the patient at the heart of healthcare and asking the question: can I truly understand what a person is going through if I have never suffered that ailment myself? By putting experiences into words a bridge is created, allowing those of us who work in healthcare to reach out that bit further. These stories can help us to take a step back from our jargon-filled lives; to not see the routine dialysis, but the precious hours spent with the husband; not the dry numbers of oxygen steadily increasing upon the hospital charts, but the feeling of accomplishment when one is able to take that first breath unaided. Illness is not just a list of problems that need to be crossed off. It is a continuous process filled with dark corners and dead ends.

In an increasingly globalized world, an appreciation of the cultural diversity lying upon our doorsteps is ever more needed. Everyone experiences illness in a different way. The culture we grew up in influences how we look at ailments (3) and the way we handle pain (2). It is through Pathographies that these worlds of illness and health are brought together, creating a narrative that allows us to delve inside the patient’s mind regardless of ethnicity or race. We look beyond the clinical terms, the graphs and the numbers, and not only does this help us to see the patient through a broader lens, it also breaks barriers with the next person we meet. This cultural understanding allows us to look after the ill in the way that they want to be treated – with dignity and compassion. It puts control back in the person’s hands at a time when chaos reigns. Pathographies can help to break the formulaic clinical story. A person is not a machine with a broken part, but an autonomous being with desires and goals, whose need for help cannot always be fit into a category.

All too often we can get caught up in the stereotypes: the smoker with COPD, the teenage overdose, the forty-year-old female with gallstones. We must remember our own biases as we sit in our staffrooms: our own assumptions built from our privileged educations. We no longer live in the world of the authoritative doctor dressed in his white coat. Instead, we let the patient’s words fill the silence.

Instead of opening another lengthy medical textbook, looking up the obscure and the malignant, we can open up a Pathography and step into our patients’ lives. No matter what our role, whether it’s inside healthcare or not, the voice of illness speaks in everyone’s ear and it deserves to be heard.

Further Reading

Illness as a Metaphor, AIDS as a Metaphor by Susan Sontag
An Unquiet Mind by Kay Redfield Jamison
C: Because Cowards Get Cancer by John Diamond
Intoxicated by My Illness by Anatole Broyard

References
1. American Association for Marriage and Family Therapy. 2014. Chronic Illness [Online]. Available at: https://www.aamft.org/iMIS15/AAMFT/Content/consumer_updates/chronic_illness.aspx [Accessed: 28th October 2014]
2. Briggs, E. 2008. Cultural perspectives on pain management. Journal of Perioperative Practice. 18:468-471
3. Wedel, J. 2009. Bridging the Gap between Western and Indigenous Medicine in Eastern Nicaragua. Anthropological Notebooks. 15:49-64

Featured image:
 Speak no evil, hear no evil… by Personal Kaleidoscope