By Scott Haig, MD

My favorite inanimate thing — and I have owned many things — was an old wooden boat.

Sixteen feet long and too heavy to lift, I could just barely drag her over a sandbar to the water. She had been, long before, a lifeboat on a ship. They made her lapstraked and beautiful back then, and strong. But they did make her heavy; it took three strokes just to get her moving. Get her going though and boy she went — she rowed out straight as a city street, through waves and wind with a wonderful, easy motion.

As a young teenager, I would take little kids, dogs, even old aunts on hours-long rows in that boat, way offshore with neither sail nor engine, just a box of cookies and some cushions and they were as happy as I was. I sanded and painted and caulked and coated that boat, I even injected her softening timbers with chemicals to stop it. But nothing beats the rot. A morning in August I couldn’t drag her anymore. She buried herself right there on the beach. Broke up under her own weight. The sand really did close up over her. I found the mound it made years later and dug. You could still smell the wet wood in the discolored sand underneath. But there was no boat there anymore. A man-made thing, so perfect, but so gone. Reduced to tiny particles. It’s what happens to the things we make, around salty water.

Our bodies are just the opposite. They love salty water — can’t get by without it. By weight we’re mostly made of it. We get formed in a sack of it. We get sick (quite often) just from the lack of it. This is one of the first things you really learn as a surgical resident: a patient who isn’t doing well probably needs fluids. After antibiotics, the greatest advances in patient-care during our fathers’ generation were in this area. Unsung, unglamorous, and inexpensive, the understanding of fluid and electrolyte balance — basically knowing how much salt and water to give people when they’re sick — has probably saved as many lives as our wonder drugs have.

I do a lot of shoulder arthroscopy now. We give quarts and quarts of salty water during this type of surgery. It accumulates under the skin. (The salty water is what lets it be “minimally invasive” — its transparency lets us see what we’re doing.) I was worried sick when I started this: they were so swollen. Could they take all that fluid? Many thousands of cases later the answer is clearly yes — no problem. By the next day, it’s always gone. It’s just salty water.

So here is a simple test to tell if a thing is alive. Put it in salty water. Some things, like babies and crayfish, will do well. They get bigger, stronger and more organized. Others, even “smart” things like iPods and cell phones, laptops, cars and TVs, stop working immediately. Then they rust and decompose. ( I know this, I’ve dropped most of them in). Inanimate things, including, alas, my boats, naturally fall apart. They are obeying a law of nature. The salty water just makes them do it faster. They might be made of chrome and plastic but they are, curiously, “natural” — obeying a principle that’s been observed countless times. The principle, or law, says “things become less well organized over time.” But the salty-water-loving things — the living things — do something distinctly unnatural. They get bigger and better organized. Think about it. The little kids who sat in my rowboat are all big and smart now. It might only be for a short time and in a certain place but all life violates the law which says “Things fall apart.” It does it at every level; from algae organizing pond gunk into good-looking little green cells, to you yourself, who having read this far now have a brain which is a little bit more organized than it was at the top of the first paragraph. Minds and brains are perhaps the least natural things of all.

But it’s so striking at the mechanical level — especially to us concrete, surgical types. I had to operate on the knee of a 99-year-old man a few years ago. He was in good shape but had been hit by a car. The cartilaginous articular surfaces of his knee — what rubs together when the knee bends — were amazing. They were pristine. They were as smooth and white and glistening as those of a teenager. Now we generally expect a normal knee to wear out because it bends, with full body weight on it, two to three million times a year. Here was a surface that had rubbed against another surface with 150 pounds of force pressing them together, at least two hundred million times. And it was still perfect — there was absolutely no arthritis. How could this be? Only by virtue of being alive. The living joint has all sorts of intricate self-repair machinery, machinery that works to undo damage — right down to the molecular level. And frankly, it doesn’t usually work as well as it did in that man. But it’s there in all living things — an automatic machinery that works against the laws of nature. We can call it hypercomplexity, or fearful and wondrous manufacture but no one who works closely with it can still call it “natural.”

Scott Haig has been an Assistant Professor of Orthopedic Surgery at Columbia University for over 20 years. He has written extensively for Time magazine, published two professional books and has taught classes in Old and New Testament Studies since 1994. He remains in full-time private practice. He is a 2018–2019 Doximity Author.

How Saline Makes Bodies Act Against Nature was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

By Lauren Klingman

“Ok, sweetie, you’re going to feel a little bit of pressure.” In retrospect, I found this statement to be laughably under-representative of what was about to happen to the woman lying on the operating table in front of me with a sea of blue drapes encircling the object of our interest: her stomach.

I was standing, legs shoulder-width apart, hands buried up to my knuckles in this woman’s suprapubic incision, grasping at the slippery fat along her abdominal wall, her blood coating my gloves. On the word “pressure” it was my cue to pull, to sink my weight into the floor and use all of my strength to tear this woman’s abdomen apart.

It ripped. A quote from MacBeth describing a cesarean section immediately entered my head: was from his mother’s womb untimely ripped. I shuddered at Shakespeare’s acuity, though the flesh and blood in front of me were the reason I had left a career in theatre for medicine. I had craved real people over characters, wanted to witness real human experiences, trade in words for action, and assist the human experience in a tangible way. But this particular view lent a whole new definition to Operating Theatre.

This was my first day of my first clinical rotation. It was the evening of July 4th and within 5 minutes of arriving at the OB ward I was delivering a placenta as fireworks blasted outside. Now it was 2 in the morning and I was entering my first C-section.

This particular case was upsetting to me. I had triaged this patient. She was friendly and funny and made me laugh. When asked who would be with her in the C-section she had stated the child’s father, adding darkly, “or he better be. I will kill him if he doesn’t show up.” And she had waited, patiently, for him to come. And he had not. And breathing heavily, begging the OB team for a few more minutes to stall, we wheeled her back to the OR unable to wait any longer. Her baby was breach and had proceeded to decelerations on the monitor. And he still hadn’t come. And she was alone in this struggle with no one to hold her hand or comfort her besides us.

The anesthesia team administered the potion which placed her into a semi-daze. With the first cut of the knife she winced, saying she could feel it. I felt dizzy. More drugs flowed through her IV. The scalpel sliced skin, fat, fascia, and mucosa horizontally above her pubic bone. It exposed the rectus abdominus muscle. Then my hands were on the side of 5-inch incision and she was being called “sweetie” and I was being told to pull with all of my strength. She moaned loudly. I gritted my teeth because I hated that she could feel anything and hated more that she had no idea how little she felt compared to what it looked like.

I yanked apart her body, sacred in its ability to serve as life force for herself and this unborn being, butchering it like an empty carcass now discarded to expose the uterine sac underneath.

I thought about how unfair the female experience is. Biologically we, as half of the species, were disadvantaged from the beginning of time, sacrificing our bodies to gift human life to this planet, dying to preserve our species. Men would subsequently treat women inferiorly for millennium, often citing the female body’s miracle-making capabilities as an excuse for why. But looking at this woman splayed in front of me, it was clearer than ever that they missed something key: the power within a woman, her strength, power, and resilience.

The patient had sunk to a primal place within her moans as her body performed the miraculous. In the center, like a sacrificial act to humankind, we circled her, all women, physicians, nurses, techs, completing the sterile séance blending medicine with nature. Like the end of a dance, she opened like a chasm, her innards exposed and glistening in front of us.

I slipped aside. The resident sliced across the uterus, and the amniotic sac erupted splashing up like a fountain. The resident’s hands were inside grasping onto the slippery form, and pulling it out from its depths onto the mother’s stomach. Suctioning the nose and mouth elicited a cry.

“Is he crying?” the mother asked groggily. “I can’t hear him, is he alright?” We assured her he was robust, and from behind that blue curtain I heard the anesthesiologist comforting her as best she could through the barrier of a surgical mask, promising she would get to see him soon.

The mother was sewn back together, piece by piece and was handed her final part, the child. She gazed at him with an immediate bond so intense I couldn’t stop looking. It was a display of pure emotion. It was a look which completed an intricate and complicated puzzle of pain, love, and hope. It was a look which a thousand actors I know would do anything to be able to achieve on stage. But this was life, not the mimicry of it.

Thinking back on my first clinical night, it would stand like a Fellini film in my head with whirling colors and the musical lilt of labored screams, the characters all basted in fluid spilling from every orifice, mingling sweat, secretions, saliva, and tears. But this woman would stand out. She would insist upon a place in my memories like the heroes of plays and books I looked to in an effort to explain the intricacies of humanity. She would imprint on me her emotional complexity and physical capability and force me to appreciate the human spirit in a new way.

Lauren is a 4th year medical student at Georgetown University, SOM. She had a career in theatre before switching to medicine, and still enjoys writing, acting. and all things art in her spare time.

Butchering the Female Form Taught Me Humanity was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

By Samad Khan, MD

Fear, anger, sadness, joy, disgust, surprise, trust, anticipation; Plutchick. Love, envy, indignation, pity, benevolence, shame, courage, friendship; Aristotle. All instinctive and intuitive sentiments as distinguished from reasoning or knowledge, which makes us fragile human beings.

Experience youth, undergo a transformation, adapt to diversity, persevere education, culture innovation, achieve success, contribute to society. Welcome adversity, overcome failure, strive for excellence, practice mindfulness, celebrate an accomplishment, embrace humility, demand beneficence. Love openly, forgive easily, find balance. Survive life, inspire peace, feel content, recognize satisfaction.

Of the 12 stages described by Dr. Thomas Armstrong, the above describes my synopsis of 4 basic metaphysical chapters of a physician’s life. I love clinical medicine. It’s the ego of everyone involved (patients, nursing, doctors, administrators) that gets in the way of being able to deliver impartial care.

No one is impervious to their own emotions. If you have not had the misfortune and privilege of being on the other side of that hospital bed next to which you stand, you may find it difficult to understand your patients’ frustration. Many call it the soft side of medicine, others call it bedside manner. That’s not the only emotions which are difficult to overcome; it is our own and that of our colleagues. If you cannot endure momentary verbal inadequacies from a patient at a time of weakness, if you cannot empathize with the harsh tone from a grieving family member, you may not be in the correct profession. If you cannot forgive the seldom emotional outburst of a fellow professional, it may be time to redefine collegiality.

If only Zeno of Citium could teach us Stoicism in medical school! Let’s face it, we’re trained in the hard sciences but most of us only implement the soft sciences after trial by fire. If this was not experienced during training, expect to feel the vast array of sentiments within the first 3 months of being an attending. At times you will feel as if your psyche is trying to stay afloat in this deep ocean we now call healthcare.

Sympathy and empathy are the backbone of Stoicism. Imagine having no insight into a colleagues’ personal issues, whose animus was heightened by a difficult caseload, which ultimately resulted in a snide comment towards you/another colleague. One could pursue a quarrel, which would most likely lead to unnecessary consequences. Or one could simply accept that it was a misdirected, subconscious response in the setting of hardship caused by the same burdens we all endure. And continue to endure.

Unfortunately, this is a common scenario. Unfortunately, it occurs repeatedly in the professional setting. Emotional intelligence may possibly be the only measure of adulthood. Harboring negative emotions will only lead to further animosity. That snarky colleague probably doesn’t even realize how they spoke to you, let alone that you are upset and feel emotional about it. Overcoming ego and mastering tolerance are the essentials in the third stage of a physician’s lifecycle. Only after we triumph through this can we enjoy the final stage.

Any of my veteran colleagues will attest, essentially the only way to maneuver graciously through medicine, especially in this day and age, is to deliver humanism first and practice medicine second. This was a hard pill for me to swallow. This was not what I was taught during the first stage of my medical lifecycle.

The most influential to my early formidable years as an attending were the embedded instrumentalist theories of Kenneth A. Richman. Ethical dilemma and medical metaphysics will always be an important arena for the future of healthcare. I feel communication and respect for autonomy are the most distinguishing factors of an astute clinician. The precept of primum non nocere is most valuable to my moral compass. I truly believe every practicing professional upholds their oath. Removing our ego and delivering unbiased evidence-based health care should be our goal. Patience, to allow the ill and their families time to experience emotion and acceptance; courtesy and appreciation for the aloof overworked colleague, are the approaches necessary for succeeding in this everchanging battlefield.

Medicine is easy, humanity is the real challenge was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

By Asha Devereaux, MD, MPH

At the recent American College of Chest Physicians CHEST conference in Austin, Texas, I gave a talk on Disaster Preparedness for Oxygen-dependent patients and Out-patient physicians on behalf of its Disaster and Global Health Network. This is an important subject and I wanted to share a few take-away points for anyone who wasn’t able to attend the session on October 7, 2018.

As we in healthcare watch disasters unfold, we are saddened by loss and suffering. There have been tremendous strides in preparedness and coordination at hospital, local, state, and national levels; however, every year, disasters are increasing in frequency and devastation. Lack of power, communication, and transportation are common in the aftermath of any disaster, whether hurricanes, fires, or floods. As our population ages, the number of people using durable medical equipment (DME) is rising.[1] According to Medicare, over 1.4 million adults were receiving supplemental oxygen in 2008.[2] Many more adults are using CPAP daily. During and following a disaster, these individuals are particularly vulnerable.[3]

Unfortunately, disaster resources and preparedness is insufficient in targeting the number of people using life-sustaining DME equipment and these individuals are often left to fend for themselves or appear at hospitals to find a source of power for their equipment. This issue is ubiquitous with every disaster and receives very little planning by office-based providers and patients. DME providers may be impacted by the disaster and unable to deliver oxygen to their patients as occurred following Hurricane Maria.[4] It would be beneficial to pre-identify these individuals, educate them and their families regarding evacuation, and be able to support them before, during, and after a disaster event. Unfortunately, current electronic medical record (EMR) systems do not integrate with DME companies and it is impossible for hospitals or practices to identify patients within their system using oxygen support equipment.

I believe this is a missed opportunity of EMR systems. The Kidney Emergency Response Community (KCER) has been effective in the identification of their patients and maintains a registry which is incorporated within the US and International disaster response systems.[5] Until systems are in place to support these individuals, it is paramount for physicians and providers to help their vulnerable patients anticipate their medical needs at minimum, in the event of a power failure. Here is a list of recommendations which I provide to my patients. There are some other valuable guides developed by the Department of Health Services-ASPR, the COPD Foundation and the American Thoracic Society referenced below. [6,7, 8]

1. Know your DME provider: Document the # and POC (point of contact) in your phone, wallet, and carry-case at all times. They will be your source for O2 replacement and will be quite busy during a disaster, but often will send out extra-tanks when possible. Ask your DME provider for a portable tank of oxygen prior to a disaster.
2. Inform your electric company of your need for DME equipment: in many areas, regional power outages can be limited to avoid your section. Discounts may be available.
3. Maintain a mini go-bag at all times with a small supply of your meds, nebs, cannulas, and inhalers.
4. EVACUATE early: most disasters result in some aspect of power limitation, poor air quality, and disruption of supply chains. Shelters, hotels, family members will have people and backup power to assist you.
5. Batteries: make sure you have charged batteries for any portable device. Keep a flashlight handy by your bed.

It is also important for physician offices to maintain preparedness and have a plan to function following a disaster event. In 2016, CMS mandated preparedness for out-patient rehabilitation facilities, DME providers, surgical centers, and various other institutions contracted with Medicare and Medicaid.[9] Private office practices do not fall within this mandate; however, physician offices have been impacted by disasters and may need temporary relocation due to damaged structures and equipment.

Significant declines in revenue and ability to meet expenditures can result in physicians abandoning a region where their services will be sorely needed. According to The Doctor’s Company[9], a physician insurance provider, it is recommended offices should have an all-hazards plan to include methods to: communicate with their staff, establish a telephone triage system, consider plans for medical records salvage or documentation, check their insurance coverage, have a plan for replacement of drugs/equipment/inventory, and establish a method for informing patients of any new office contact information. By initiating preparedness conversations amongst ourselves and our patients, we can help mitigate the impact of disasters on individuals and the community we serve.

Dr. Asha Devereaux is a Past-chair of the ACCP Disaster Response Network and Task Force for Mass Critical Care. She has responded to disasters since 2003.

References

1. Bernstein AB, Hing E, Moss AJ, Allen KF, Siller AB, Tiggle RB. Health care in America: Trends in utilization. Hyattsville, Maryland: National Center for Health Statistics. 2003
2. Nishi SPE, Zhang W, Kuo Y-F, Sharma G. Oxygen Therapy Use in Older Adults with Chronic Obstructive Pulmonary Disease. Chalmers JD, ed. PLoS ONE. 2015;10(3):e0120684.
3. After Hurricane Maria, Physicians Team Up to Provide Care, Ricki Lewis, PhD October 06, 2017, Medscape.com
4. Keeping Facilities Open: Stabilizing and Restoring Puerto Rico’s Health Sector Following the Island’s Worst Hurricane Season Ever ASPR Blog by mary.radebach@hhs.gov on 12/14/2017
5. Kidney Community Emergency Response https://www.kcercoalition.com
6. ASPR TRACIE: https://files.asprtracie.hhs.gov/documents/aspr-tracie-ta-oxygen-therapy.pdf
7. Developing a Disaster Preparedness Plan, COPDFoundation.org
8. Adapted from ATS Pt Education Series- How to Prepare for an Emergency or Disaster When You Have Lung Disease or a Sleep Disorder, Permut, Satti, Sockrider, Am J Respir Crit Care Med Vol. 194, P13-P14, 2016
9. Federal Register. Publication Date: 09/16/2016 (/documents/2016/09/16) Agencies: Centers for Medicare & Medicaid Services (https://www.federalregister.gov/agencies/centers-for-medicare-medicaid- services) Effective Date:11/15/2016Document Type: Rule Document Citation:81 Pages :63859–64044
10. Brightwell, J. Disaster Preparedness for Your Medical Practice. Department of Patient Safety and Risk Management-The Doctors Company

Preparing Your Patients Who Use Oxygen or CPAP For Natural Disasters was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

The medical resident has seen the new Infectious Diseases consultation and she is presenting the patient in a matter of fact manner: “40-year-old male with a history of diabetes type 2, hypertension, homelessness, chronic right leg wound which has been draining purulent discharge for the past two weeks with increasing pain and swelling in the leg. He does not get regular medical care. Exam shows a disheveled man with poor personal hygiene. The leg wound has a very foul odor. It is hard to say whether the odor comes from the patient or the wound itself…” The resident’s subconscious aversion is easily readable on her face and her presentation makes me chuckle. I start to reminisce…

Many years ago as a young, enthusiastic medical student, I went to a rural town hospital in Spain as an exchange summer student. I was warmly welcomed and was allowed to watch an open cholecystectomy case in the OR. I was thrilled to be there. As the surgery slowly progressed, the surgeons carefully used the electrocautery device to control the bleeding as they opened the abdominal cavity. The smell of the burning flesh hit my nose like a ton of bricks. I had never smelled anything like that, and I was caught completely off guard. While the odor filled my nostrils and seemingly engulfed my head entirely, I slowly started feeling numb in my extremities along with the dizziness and nausea. Even in my inexperienced medical student mind, I knew these were signs of vasovagal response. Shortly after that, I passed out.

I don’t know how much time passed, but when I opened my eyes I was laying flat on my back on the floor. There were faces looking down at me wearing blue masks and caps speaking a foreign language. It took me a few moments to realize I was neither dead nor dreaming. The staff picked me up and got me out of the OR. During lunchtime in the cafeteria, I felt many eyes looking at me and there were a lot of smiles and jokes. I could hear ‘Ella se desmayo’, Spanish for ‘She passed out’ in almost every conversation and that became one of the first phrases I learned in Spanish.

Surely I was embarrassed but it was far more than that; I was devastated. I knew that if I were to become a physician, I would have to be able to tolerate bad smells as part of my job. I thought about choosing a field where I would not be exposed to much of that, such as radiology. But still, the idea of a doctor who could not stand the bad odors just did not sit right with me. I remembered a classmate who, earlier in medical school, felt that medicine was just not for her after attending anatomy lessons. I remembered her ashen face after seeing a cadaver for the first time. After the second anatomy class, she decided that she did not want to be a doctor anymore and she quit. Eventually, she became a successful industrial engineer. Medicine was a lifelong dream for me, a true calling, and images of myself doing anything but medicine were just painful.

The Eureka moment came shortly when I got sick with a sinus infection. My nose was so stuffed and I was so congested, my head feeling like an aquarium, I was unable to breathe through my nose at all. I had completely lost my sense of smell. ‘Of course!’ I thought, ‘If you don’t breath through your nose, you can’t smell the odor!’. It was so simple. Ordinarily, the brain has the breathing function on automatic pilot, we don’t even think about it. But we CAN consciously control our breathing. After I recovered from the sinus infection, it took only little practice… I could breathe entirely from my mouth and avoid nose breathing for brief periods of time when exposed to bad odors.

Decades later, as an infectious diseases specialist today, I see many infections associated with peculiar, unpleasant odors. “Don’t you get grossed out?,” I get asked often… “No, not at all!” I answer with a smile followed by an explanation of my trick to block the bad odors. A trick that may have saved my career in medicine.

Gul Madison, M.D. is an infectious disease specialist practicing in Philadelphia.

A Survival Guide for Bad Odors in Medicine was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

By Andrew Nimmich, MD

You’re getting so close to graduating from medical school and moving on to your first job as an M.D. Congratulations. You are probably filled with optimism as you prepare for “The Match” and the days of travel and interviews ahead of you. Prepare to be available for residency interview invitations. Turn on your push notifications for your emails.

You might need to book travel ASAP to a different state. You have so much travel ahead of you. Planes, trains, and automobiles. The financial burden of this travel can be quite significant. As a medical student who is probably in debt, you cannot ignore the expense of traveling to residency interviews. Below are some tips to help optimize this time in your career:

Set a budget and stick to it.

As I’m sure you’re aware, you haven’t started earning yet. In order to make it to every interview, you need to keep the expenses on an all-time minimum. Making plans without a budget comes with the risk of overspending and misappropriating funds. Set a reasonable budget that is enough to cover all expenses during your travels.

Travel and eat economically.

To minimize travel expenses, drive to your interview instead of purchasing a flight/train ticket, when the interview is within driving distance. Find the best travel rates! I use Google Flights for flights, since it compares all rates available. Pack a lunchbox or cooler with food for the interview. Eating every meal at a restaurant is a sure way to lose a lot of money.

Dress well on a budget.

You don’t have to wear an expensive suit to the interview, you just have to be neat and professionally presentable. Don’t break the bank on your interview attire. There are so many bargains where you can find fashionable professional wear without dropping hundreds on name brands.

Plan your interview suitcase.

Be prepared. Don’t be ashamed to write down a list of everything you will need in your interview suitcase. Review this list every time you are preparing to leave for an interview, ticking off each item once it is safely packed in your bag. What documents will your interviewers ask you to present? What suit will you wear to the interview? Do you need to bring an iron? How about a stain stick in case of emergency? How many days will you be staying? Make sure you have everything, and enough of everything. You don’t want to panic the night before the interview when you realize you forgot to pack toothpaste. Most hotels don’t even offer free toothpaste anymore, so this means you would have to make an extra trip to go find toothpaste. Ensure everything you need is well packed, including any travel or educational documents.

Lodge lightly.

Weigh your accommodation options. Accommodations can be expensive, but a comfortable place to sleep is a crucial component during your interview travels. While sleeping at the airport might be cheapest option, it’s not be the best option, as it may end up reflecting on interview day. Hotels, on the other hand, are expensive– so what do you do? Good news is that most programs provide the option of staying with a resident. I would encourage you to take advantage of this option, as you will not only be saving on accommodations, but you will have the opportunity to interact with the residents and learn more about the program. If you have friends and relatives that can host you in that city, you should consider that option.

Remember time differences.

One thing to keep in mind while traveling is the different time zones. This travel is going to take a toll on you. While booking flights, be aware of the different time zones and make your plans in accordance with the interview time and location. You must allow yourself enough time to travel to/from the airport, to/from the hotel to the hospital, etc. Once you arrive, make sure your phone reflects the appropriate time zone. Most smartphones do this automatically, but it never hurts to double check. You want to make sure you arrive at the airport at the right time so you won’t miss a flight.

Sleep well.

It’s very difficult to sleep soundly the night before an interview. Do all you can to ensure you will be able to sleep. Bring exercise clothes and hit the gym the night before. Take a long walk to get to know the area. Do whatever you can to make sure your body and mind are ready to rest! Traveling is exhausting on its own and chances are, you are a nervous wreck already in anticipation of the interview. Adequate sleep will enable you to show up at the interview well relaxed and composed, and avoid being edgy. Showing up at the interview with eye bags and an exhausted look may not reflect well.

Get to know the other interviewees.

Interact with the other interviewees. They’re also nervous. See if they already interviewed at a place where you have an upcoming interview. You can learn a lot from one another. You can also split Uber rides. Furthermore, they could be your future co-workers!

Bring a book or headphones.

Carry a book along to keep you relaxed. Bring your headphones so you can listen to your favorite music. Do whatever you can to get yourself in the right mindset for performing well during your interview.

Half the success of an interview is being well prepared and confident, and the other half is how you carry yourself during the interview. Traveling for these interviews is tiring and expensive so you need to make it count. Do all you can to put yourself in the best position to represent yourself well. Try to avoid going into debt with the traveling expenses. Save in advance! Look into travel credit cards. You could end up getting a free flight or two.

Good luck in your interviews!

Dr. Andrew Nimmich is a PGY-1 in Integrated Vascular Surgery. He’s also a Co-Founder of Tutor the People, an online and in-person service that provides one-on-one MCAT test prep, as well as all other graduate entrance exams.

Words of Advice for Your Residency Interview Travels was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

A recent op-ed piece in the New England Journal of Medicine, written by a fourth-year medical student, Mr. Leo Eisenstein, suggests that physicians should organize to fight burnout. The student reminds us that burnout was described by Dr. Herbert Frudenberger in 1974. Dr. Frudenberger opined that the root of professional exhaustion was the result of monotony and also caring for patients whose illness results from the consequences of socioeconomic disadvantage and marginalization.

Mr. Eisenstein believes the crux of burnout is individual powerlessness to assist the disadvantaged.

Maybe.

But I suspect the root cause of physician burnout today, is much different than that of 1974.

When I was a fourth-year medical student, burnout was the furthest thing from my mind. I was excited and nervous over the prospect of taking care of patients and being responsible for their lives. I saw myself as the physician hero that Mr. Eisenstein believes is extinct.

I refuse to accept this.

To me being a hero, or really a consummate patient advocate is my way of preventing burnout and definitely monotony. It has worked for forty years.

A case comes to mind (patient’s identity obscured):

I attended a young African-American woman who developed a severe illness, survived, and was restored to health. However, she developed a complication of the treatment and suffered facial deformities.

She told me that when she left her apartment, she wore a surgical mask. When she spoke of her facial scarring, tears flowed from her eyes to be pathetically absorbed by the mask.

“Can’t you help me?” she asked.

“I’ve called your HMO,” I said. “They said your policy doesn’t cover cosmetic surgery.”

“This isn’t a nose job I’m asking for. I want my life back. If it wasn’t for my daughters, I’d have ended all this.”

“Are you suicidal?”

“Yes, but don’t give me Zoloft, don’t give me Prozac, get my face fixed. I won’t go through this much longer. I’m barely hanging on.”

“Please, don’t do anything. I’ll think of something. If only I could get the HMO doctors to see the problem.”

“Why won’t they examine me?”

“It’s easier to say ‘no’ over the phone.”

She left the office, she neglected to put on her surgical mask, people in the waiting room stared.

My wife works in the office, she took me aside, squeezed my arm firmly and said, “Do something, whatever it takes, do something.”

“Her HMO won’t pay for cosmetic surgery.”

“This isn’t right.”

“I have a stack of denials for the past year, and she is suicidal and would have done something if it wasn’t for her two little girls.”

“This is no longer cosmetic.”

“It is on paper,” I said.

She wept.

* * *

My wife was relentless in getting the woman help. She was not used to dealing with prior authorizations, out of network issues, doesn’t meet admission requirements, not approving ordered tests, financial accreditation of physicians, DRGs, peer to peer reviews but the other “peer” didn’t see the patient-just the EMR, the forced labor of EMR and its specious “meaningful use” qualifier.

She is a lay person who believes patients should get the care the doctor prescribes.

“You are naïve,” I said.

She was silent then said, “Call the NAACP.”

“What?”

“You heard me.”

She was resolute.

“If you don’t call, I will.”

I knew she would.

I got the phone number of the HMO patient helpline. I dialed and got a recorder. I waited for the “your call is important to us, please leave a message after the tone…”

“This is Dr. Kroneman, my patient needs help. I have been trying to get her cosmetic surgery for over a year. This African-American woman needs surgery and you have denied her. You have two hours to call me back, or I will call the NAACP and see if they can help.”

Within minutes the phone rang.

“Hello,” I said.

“Who am I speaking with?” the voice on the other end said.

“To whom am I speaking?” I asked.

“This is the medical director of the HMO.”

“I’m Dr. Kroneman.”

“Did you just call threatening to involve the NAACP?”

“That’s me.”

“I don’t like to be threatened.”

“It’s not a threat. It’s a courtesy call.”

“You’re angry.”

“Damn right I’m angry. I don’t like you jacking my patient around.”

“What do you mean, jacking the patient around?”

“It’s an expression for making her fill out forms and making me write letters knowing all along you won’t approve her surgery. I’ve been trying for a year. She is horribly disfigured.”

“I have reviewed her policy. She is not covered for cosmetic procedures.”

“If you saw her. If you knew her before — if you had a heart, you would have approved this a year ago.”

“I have a heart.”

“If so, would you examine her?”

“I have reviewed her case. She is not covered.”

“Listen,” I said. “My friend is a plastic surgeon. He goes all over the world, fixing children with cleft palates in third world countries. He said he would do her surgery for free.”

“No,” he said.

“I’m going to drop the dime on you.”

“What do you mean, ‘drop the dime’?”

“It’s an expression for calling the NAACP.”

“Look, I’m a brown man, and I know prejudice.”

“I’m a Danish white guy, but I can’t determine if you’re prejudiced or not because you denied the patient care without seeing her. You had no idea she was black until I informed you of my intent to call the NAACP. I’ll give you a pass on prejudice.”

“You’re playing the race card.”

“Your words, not mine.”

“Will they listen to you?”

“Are you willing to take that chance?”

“Okay,” he said. “I’ll approve this.”

“Don’t you want to see her? Get a good look at her face?”

“No.”

“I want a date and time and approval number.”

“I can’t give you the date.”

“I’m a reasonable man. Just give me the approval number.”

“Okay.”

He gave me the number.

“Dr. Kroneman, I just want to say you are a difficult man, with no tact, and no bedside manner.”

I didn’t know that bedside manner was relative to this conversation but let it go.

“When my bedside manner gets really bad, I’ll become a director of an HMO, just like you.”

He hung up.

I got my approval number and she got her surgery and her face back.

All is well.

The medical bureaucracy can be cruel and impersonal. But it is well funded and organized as evidenced by the tragedy of doctors employed to work for corporations that sabotage the efforts of other doctors who actually examine and care for patients. This is an indictment of our profession’s willingness to accept the violation of previously sacrosanct medical tradition.

I am not proud of the conversation. I don’t like confrontation. I definitely would have called the NAACP. It is a shame.

David Bowie sang it, “We can be heroes.”

In today’s healthcare environment, we must be heroes.

Olaf Kroneman, MD, is a nephrologist at The Southeast Michigan Kidney Center. He graduated from the Michigan State University College of Human Medicine, interned at the Mayo Clinic in Rochester, Minnesota, then attended the University of Virginia to complete a residency in internal medicine. He completed a fellowship in nephrology at Massachusetts General Hospital and Harvard Medical School. His work has appeared in literary magazines. He is also a 2018–2019 Doximity Author.

We Must Be Heroes was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

By Christopher Storey, MD and Connor McGuigan

The education of physicians in the United States is in revolution. New York University is offering full scholarships to its medical students. There are calls to disrupt the eight-year college-medical school admissions pathways. However, we have become so caught up in devising ways of how we educate physicians that we have neglected an issue that is quite possibly even more pressing — Are we realistically preparing physicians for a dynamic healthcare milieu?

Over the past 100 years we have witnessed the informational revolution that has resulted in an explosion in medical discoveries and have thus extensively broadened the required knowledge base for mastery in medical training. The shift from a medical education focused on the ethos of physicians to the rigorous, science-based curriculum of today may be the very fault that is creating our current dilemma. Given this, it has become increasingly difficult for medical students to learn the breadth of knowledge that is expected of them in the short 4 years of medical school. And in actuality, the clinical knowledge component is shrunken into two years.

Outside of the mass of knowledge required, medical students, if they want to match in competitive specialties, have to contribute a substantial portion of their time in medical school to conducting research and publishing papers. The integration of basic sciences and translational research is vitally important. However, the reality is that the majority of young or old physicians will not practice in the marketplace of the ivory tower. They will practice in a world of insurance pre-approval, Medicaid funding crisis, accounts receivable, billings, and collections.

Can we say, in good faith, we have prepared physicians for this world[MRP1] ? A study conducted by Roberts et al at the University of Massachusetts showed that newly practicing physicians felt that they were not well prepared to handle aspects of the job such as patient scheduling, and did not possess the ability to participate in management decisions regarding cost-effective medical practice. This only compounded by the financial burden that NYU has chosen to alleviate, but also drives physicians into the arms of hospitals waiting to employ them. Once upon a time becoming a physician meant being your own boss, but we are afraid those days are numbered. We have seen a measurable increase in the percentage of employed physicians compared to the number of physicians who run independent practices. In 2007, over 60% of physicians were independent which has declined drastically to only 35% in 2015 according to surveys run by the AMA and The Physicians Foundation (American Academy of Family Physicians).

This mismatch between training and the real-world has become even more accentuated as our society as a whole has been expecting more from their healthcare providers. It has become obvious that the “simple” diagnosis to treatment methodology that has defined the medical field for the majority of its existence has become difficult to balance with the need to treat the patient in line with socioeconomic concerns. The physician is no longer the subject-matter expert. They are the leader of a complex healthcare team in a complex healthcare world.

Is that a sustainable educational model?

Organized medicine has different political action committees and organized governing bodies that seek to impact the socio-economic sphere (Council of State Neurosurgical Societies). But how are we going to educate our young physicians to be active and responsible participants in this process?

We need physicians who are able to understand the current social climate in a way that allows them to care for patients in an efficient and cost-effective manner. We need an education system that teaches future physicians to understand the societal and economic issues outside of the clinic so that they can spend less time clicking boxes and more time understanding their patients and how to lead in their local healthcare environments. Long gone are the days when physicians could run a successful practice using only the tools and skills they learned in their medical training. We need to embrace this truth and educate our future physicians about the realities of running a medical practice.

Christopher Storey MD, PhD is a neurosurgeon and a lead editor of The Business, Policy, and Economics of Neurosurgery.

Connor McGuigan is an undergraduate student at Cornell University and the socioeconomic research fellow with the Neurosurgical Advancement Foundation.

Are Our New Physicians Ready to Practice? was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

By Margaret A. Pisani, M.D., M.P.H.

I recently attended the American College of Chest Physicians conference in San Antonia where I was part of a panel of speakers titled “Challenges for Women in Medicine.” This session addressed three areas, imposter syndrome, breaking the glass ceiling and mentorship which was my piece. With all the recent discussion regarding women in medicine and gender parity, this session was particularly timely.

For there to be gender parity in medicine several areas must be addressed: salary parity, mentorship and sponsorship, equity in research funding, support of universal access to family and medical leave policies, leadership development programs, implicit-bias training and concerted efforts to recruit and retain women physicians. While all of these areas are important for women to achieve parity with men in medicine, my task at the Chest meeting was to address mentorship.

A recent medical blog survey demonstrated that 42% of respondents did not know the difference between mentorship and sponsorship. The term Mentor has it origins with The Odyssey by Homer. Odysseus, the king of Ithaca, goes to fight in the Trojan War and leaves the care of his household to Mentor, who serves as a teacher and overseer of Odysseus’s son Telemachus. In the story, Athena, who is the goddess of wisdom, courage and inspiration, takes the form of Mentor and advises Telemachus. Hence the term mentor arose and is now synonymous with someone who imparts wisdom and knowledge.

On the other hand, sponsorship is the public support by a powerful, influential person for the advancement and promotion of an individual within whom they see untapped or underappreciated leadership potential.

There are differences between the roles of mentors and sponsors. Mentors can be at any level in the organization and one does not need to be in a position of power to mentor. Mentors are selected for their content expertise and often work behind the scenes to support their mentees. Sponsors, on the other hand, are highly placed with the organization and have an influence on decisions regarding appointments to committees, promotions, and awards. Sponsors act as advocates for individuals.

Why do mentoring and sponsorship matter for women in medicine? When examining the data insufficient mentoring is cited as one of a myriad of reasons for the underrepresentation of women in leadership positions in medicine. But, mentoring alone isn’t sufficient, women also need sponsors to aid with promoting them to higher positions such as chairs, Deans, or CEOs.

Studies on the outcomes of mentoring in women are often based on self-reported, subjective measures and focus on short-term outcomes. But they do demonstrate increased retention rates and more success in promotion and obtaining research grants for those who have mentors. In addition, mentoring has been shown to help avoid feelings of isolation and contributes to increased self-confidence and work engagement. These are positive aspects of mentoring for women, but a study from 2016 demonstrated that 13% of academic women faculty have never had a mentor and 34% had prior mentors but none currently. Early career women are more likely to have mentors, but mid-career women need mentors and sponsors to attain leadership positions.

Despite the fact that there are 50% of women graduating medical school, the numbers of women in leadership positions are far less with only 16% of Deans being women. With the majority of current leaders in medicine being men we need them to be strong advocates for women. I am fortunate to have had a strong female mentor and male sponsors in my career and to work in a division that is comprised of 50% women. This is a rarity in the pulmonary and critical care world. I hope the tide is turning on a national level as we recognize the importance of diversity; not just of gender, but of race, ethnicity and sexual orientation.

One concerning aspect when addressing mentorship for women is the potential impact the #MeToo movement will have on men’s willingness to mentor and sponsor women. Recent articles in both JAMA and the NEJM have raised this question. Denying women access to mentorship and sponsorship will perpetuate the gender gap which needs to be closed. There is concern that being afraid to mentor women is not only about fearing false accusations of sexual misconduct, but about discrediting women who speak out against harassment.

“What one word best describes what you are looking for in a mentor?” A recent medical blog survey where the majority of participants were between the ages of 18–35 years asked this question. Patience was the most frequent response, followed by honesty. Mentees are looking for mentors who don’t assume that something is understood or obvious. Mentors who remember what it is like to be new, afraid and ambitious. Mentors who recognize that what the mentee needs is outside the scope of what they can offer, acknowledges this and refers them to the appropriate people. Mentees seek mentors who work towards the mentees best interests and support them in reaching their goals.

Being a mentor is a way to give back and to help the next generation succeed, but it is a two-way street and I have learned as much, if not more, from my mentees as they have learned from me. Asked my rules for my mentees I would say it is to come prepared to meetings and be the driving force behind your career.

Finally, institutions need to recognize the important role that mentors and sponsors play in the lifeline of the organization and in the future medicine in general. The women and men that we mentor and sponsor today become our leaders of tomorrow and will carry us forward. Academic credit should be given and acknowledged for successful mentors as we recognize their roles in the future of medicine.

Margaret A. Pisani, M.D., M.P.H. is an associate professor at Yale School of Medicine in the division of pulmonary, critical care and sleep medicine. I perform research on delirium, sleep and outcomes in ICU patients with a focus on older ICU patients.

Women In Medicine Struggle With Mentorship and Sponsorship was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.

By James Henderson, MD

Months ago I decided that this was great, CHEST was coming to my hometown. San Antonio is a great tourist city composed of a combination of many little cities all united by hospitality, community, and highways. Obviously, everyone knows the city for the Alamo, the RiverWalk, the great TexMex food, and the Spurs. Sometimes it’s hard to believe it’s the seventh largest city (24th largest metro area) in the country because that’s not what it feels like if you live here. I’ve always loved the small town feel mixed with enough big city amenities and cultural diversity that would allow anyone to feel at home. The food available is an eclectic mix of Americana and Texan with enough European, and Asian variety available (if you know where to go) to please anyone. Everyone coming would be able to enjoy whatever free time they had.

I’d be able to sleep in my own bed, save a little money, and still have a great experience. I started the conference early enough, 7 am, but as usual, there were other braver, hardier souls who managed to drag themselves out of bed to attend the 5:45 am breakfast meetings. They always have great topics in those early sessions, but driving the 30–40 minutes in for those meetings would afford me little rest. For many years I was convinced that was the way to get my money’s worth; carefully crafting a plan to hop from session to session throughout each day. In doing so, I certainly was able to feel like I’d adequately sampled the educational opportunity provided. After all, these conferences are always frustrating because there are always 3 or 4 sessions you want to see at almost every time period. But a few years ago I realized that I often left these conferences more fatigued than when I arrived by blowing and going 14–15 hours a day, going to breakfast, lunch, and dinner sessions. I also realized that I tended to go to symposia that catered to my favored topics and would sometimes find that I’d hear repetitive lessons and concepts. It was time to get smarter and more discerning. It was also important to find sessions that added to the armamentarium I bought to the patients I care for now and not get stuck solely in academic interests.

And there was plenty for that. The word for this meeting was Phenotype. It was code for stepping back and reverting to old school medicine seen through new technological eyes. Every patient is an individual and as we proceed further into an era of personalized medicine, we first have to recognize both similarities and differences. Research trials have to be seen through the eyes of the patients we treat and their characteristics, not just the diseases that attack them. Understanding the metabolic, physiologic, environmental similarities as well as barriers to care between patient groups will better inform our treatment recommendations to our patients. This thought permeated presentations on the wide variety of pulmonary, critical care, and sleep patients studied. For example, I attended many discussions around ARDS filled with interesting discussions that highlighted the heterogeneity of ARDS patients. They noted the wide variation in illness timeline and outcomes present in our large studies. More, there was increasing recognition, 20 years after landmark articles on lung protective strategies and the dangers caused by our therapies, the continuing persistence of failing to utilize lung protective strategies early in disease course. Also noted was our use of newer technologies such as ECMO in patients who might have benefited from other, less costly therapies such as prone positioning. In other words, we were continually encouraged to open our minds to each patient to match both proven and promising therapies to the patient before us, and not be trapped into “one size fits all” mentality.

Still, this conference for me was more one of recognizing transitions. I recognized this meeting as one over the years where great experiences once cherished and loved, were now fading into the cobwebs of my memory. I found myself remembering friends lost to follow up and friends lost to eternity.

I had the opportunity to spend a few minutes with an outstanding physician who is now succeeding to a position I once held for many years almost a decade ago. I was smiling to myself, thinking of words my mentors had one spoken to me and now hearing those words coming out of my mouth to this eager, talented, intelligent physician. What would my mentors be thinking? Here was this young one, always looking and listening with respect, fully seeming to soak up everything I said like a sponge; but making intelligent responses, parrying thrusts in rapid succession, delving into possibilities and eventualities.

I found myself remembering the past times and fading memories of being in the same position. These kids with faces so young, so fresh, so excited. Their smiles illuminated by this opportunity to speak of things that were their future, research they loved, patients they had cared for. It brought back so many memories when I must have looked the same. I can’t remember having that much excitement, but I know it was there and I now know what I must’ve looked like to those more experienced and wise. So, in the end, I found myself smiling; knowing that it had been a good week and those more energetic than I were now in charge. And that was a good thing.

James “Chris” Henderson II, MD is a retired Air Force Pulmonary/Critical Care/Sleep physician now embedded as Critical Care faculty in the Santa Rosa Family Medicine Residency Program in San Antonio, TX and is an avid Science Fiction and C.S. Lewis fan.

How I Finally Got Smart About Attending A Medical Conference was originally published in Op-Med on Medium, where people are continuing the conversation by highlighting and responding to this story.