S2.5 Things I Wish I Knew Before Medical School

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  1. Life keeps going while you are training. Medical training takes a long time; doing a PhD in the middle certainly does not shorten things. Making time for things outside of medicine including family, friends, exercise, and hobbies are critical to success in training, longevity in the medical field, and overall happiness.
  2. Degrees do not define you. There is a reason that you need to get a medical degree from an accredited institution and pass a litany of examinations in order to practice medicine in the United States. You certainly do not want someone with a half baked education and understanding of the human body taking charge of your care. However the degree does not define the person. It does not define their worth or value. It does not tell you whether they can sleep at night. Whether they feel satisfied with their job or whether they truly care for their patients or are just in it for the money. It doesn’t tell you if they are a good person, whether they love their spouse and family, whether they are constantly striving for better. All it tells you is they went to school for a long time and can take standardized tests. Do not be lured into thinking that the degree will be your defining feature. Rather define yourself by what you do, how you treat people, what you strive for, and what you stand for. Allowing your degree to define you settles for too little and sell you far too short.
  3. Your view on faith, religion, or spirituality will significantly change how your patient interactions will affect you.  First note that I did not say that your view on faith, religion, or spirituality will affect your ability to practice good medicine. Rather this view will change how your care of patients will affect you. In medicine you see people endure and sometimes succumb to terrible illnesses. You hear their stories and the circumstances that led up to that place. You often spend weeks or even months sometimes seeing patients year over year. Their family gets to know you and seeing them everyday becomes a ritual. Many people die despite your best efforts. Your beliefs on a soul, an afterlife, a deity, the nature of that deity, and overarching plan for the world will directly affect how these experiences affect and change you. Your beliefs in this area will determine whether you into harden into something unbreakable and unfeeling, crumple under the weight of having to know everything, take every loss personally, or are able to rest in your own mortality, in your own efforts, and in the belief that a greater plan is afoot.
  4. People, not problems are the object of medicine. Going through the first years of medical school it feels like the goal of medicine is to accumulate the most knowledge that you can so that you have the right answer to give the patient to solve their problem. Of course some knowledge is necessary, but the knowledge necessary to become a good physician is less than some might suspect. Frank Abagnale Jr., the inspiration for the movie Catch Me If You Can, once worked in a hospital posing as a physician. He was able to get away with it for some time without any problems simply by managing his junior residents and utilizing his skills as a con man and people person. Being a good physician is about the people. Medical and nursing staff, other support staff, and of course the patients and their families are the focus. The way in which you manage these relationships will be of far greater import than how much you know.
  5. It is worth it. There is always a lot of complaining no matter where you go. The discontented are often the loudest. As the saying goes, the days are long and the years are short, but it is worth it. The failures and successes, the struggles and the achievements are all worth it. Not only because of the end result, but because the process was refining, enlightening, purifying, and clarify. Despite the flaws and failing of the system and the people, there is no better field to be in, no more interesting problems to solve, and no more humbling occupation.

S2.4 Physician… Don’t Kill Thyself

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“Physician heal thyself” has changed to a plea “Physician don’t kill thyself”. Every year it is estimated that 300-400 physicians commit suicide. To put this in perspective, my graduating medical school class is approximately 200. So every year up to twice the number of my classmates who are entering the workforce, exit the workforce in an untimely manner at their own hand. This has been rightfully recognized as a problem; the response? Something called “Wellness initiatives”. 

Wellness is one of the buzzwords that medical schools, residency programs, and academic hospital systems are all touting. Visiting large academic centers around the country “wellness initiative” were defined with some variation of visits from therapy dogs, ice cream, wine and painting, or cookies. Akin to rearranging the deck chairs on the Titanic, these measures are laughable. Just as worrying about what to serve at dinner is a moot point as the ship slips beneath the waters, so junk food and running around with a four legged fur ball is a moot point as the crew drowns in 80 hour work weeks often watching the people they take care of slowly deteriorate and die. 

A small handful of programs are taking meaningful measures including scheduling preventative health appointments and faculty members who could be reached 24/7 to provide support. There are no easy answers to this problem, and no easy solution. Certainly medicine may attract people who are already at increased risk of taking their own life. Or the decade or more of training may play a role. Or the bad outcomes, difficult decisions, and limited time outside of the hospital to attend to ones own affairs may play a role. 

The hours in the hospital are entirely necessary for good training. You must see a lot of cases and work a lot of hours to be a good physician. One of the problems with the hours and the stresses is that you are not given freedom to self regulate. Running long distances you can feel yourself start to overexert, a feeling of panic and uncertainty creep in. At that time you can slow down until you regain control so that you are better off in the long run. In medical training you hop on the treadmill and the system increases the speed. Will Smith is quoted as saying about his work ethic “I’m not afraid to die on a treadmill”. Most physicians would probably agree. Unfortunately on the treadmill of the medical system, many have and many more will. 

80 hour work weeks are fine. Often they are enjoyable because you are doing interesting things with interesting people. However when you are working 80 hours a week, as soon as anything becomes off kilter there is little room to correct before large consequences are realized; the margins are already so thin. Often it is not just the number of hours in a day or week, but the number of weeks and months in a row. One time I accidentally referred to having a weekend completely off as “vacation” because that was how it felt. 

As our current system works, it is a fragile system. The hope is to maintain without any catastrophic mistakes and outcomes. The status quo is intermittently interrupted with major losses, and we return to the status quo waiting for the next catastrophe. Moving toward the antifragile, as Taleb puts it, should be the goal. Where struggles, perturbations, make both the person and the system stronger. Where the goal is an upward trajectory from the difficulties and shattering events instead of simply plodding away where we were before. Wellness initiatives and discussions of physician suicide must be replaced with focusing on strong social connections, honest reflections and the opportunity to rebuild and regroup, and the time to live, sleep, eat, and exercise in a healthy manner. 

The goal is true wellness and longevity for both the patients and the providers. 

S2.3 Relatively Defining

 

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We define ourselves in many ways. People select titles such a “fighter”, “contrarian”, and “creator” and use these terms to define themselves. Dependent identities such as these have the concerning feature of being highly laudable, unspeakably evil, or anywhere in between depending on external factors. In many contexts to be a fighter is a good thing. To fight for other people, to fight for new knowledge, to fight against disease, are all commendable. However to fight for selfish gains, out of spite, or to marginalize a specific people group would be despicable. Using this term to describe oneself is similar to using the term “non-profit” to describe an organization; it provides incredibly little information about the person or organization themself and only provides a passing reference to a relative characteristic. 

Christopher Hitchens, reknown author, speaker, intellectual, and atheist was often well known for his independent thinking and contrarian views prior to his untimely death. He wrote a book titled Letters to a Young Contrarian in which he discusses, as the title would suggest, contrarian thinking, that is holding and articulating positions that go against the prevalent tide of thoughts. The issue with identifying as contrarian is that contrarian is a relative term, it relies upon prevalent thought in order to take a position. To further clarify, it would be better, more descriptive, and more reliable to describe oneself as an independent thinking, that is someone who is willing to put in the difficult work of gathering and analyzing data for oneself and coming to their own conclusion independent of the persuasive powers of the masses. If I am contrarian and you decide that apples are tasty I am obligated to disagree and label them as unpalatable. If I am an independent thinker I am free to try the apple and decide for myself if I believe the apple to be agreeable or disagreeable. In an information and choice rich environment, one of the key underpinnings of societal improvement and uptrending will be a large population of independent thinkers who search out information and do their own analyses. A large population of contrarians will get relatively little done. 

Thinking independently is difficult. Gather information, think critically, and be willing to defend your conclusions. Being either ‘yes’ men (or women) or contrarians both hand all of the power to others as our stance is relative to theirs and not an absolute based on a well reasoned articulation of our analyses. 

One of the key aspects to maturing is defining oneself. This is a good and natural progression. As we are taking on labels and crafting our own definitions of ourselves, we must define ourselves as absolutes, things that are irrespective of the whims of the mob. We must define ourselves by what we are for, what we actually stand for and believe in, not a reactionary definition reliant upon what we are against.

S2.2 Welcoming the Sceptic, Inviting the Questions

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Science is a system, a methodology, that is used to approach empiric truth. It is a construct by which we ask questions, search for answers, and attempt to construct working theories of the world and universe around us. Nothing more, nothing less. Perhaps the most important part of being a scientist is curiosity, having an inquisitive mind that wonders at the world around oneself. Of course there is more to it than just asking questions. Doing science then entails figuring out a way to answer that question, collecting the necessary data, performing the proper analyses, and then drawing the proper conclusion to answer the question that one set forth to answer in the first place. But the question always comes first. 

We should never be afraid to ask scientific questions in good faith. Nothing should be out of bounds as long as curiosity and a search for truth is the driver of the question. As soon as one begins to engage in science, it becomes painfully, and excitingly obvious how little we know about the world around us. Even well founded theories can be questioned and tested. For example at CERN at the beginning of the decade scientists thought particles had exceeded the speed of light, something that challenged the theory of relativity, one of the most foundational physics theories in existence. Although a faulty wire was subsequently found and relativity was upheld as a theory, the fact that something so cherished and foundational could be openly questioned is one of the beautiful aspects of science. In medicine things that we have thought for many years, such as the transfusion goals for blood products, proper ways to prevent infections or do procedures, and even the composition of an “ideal” healthy diet are constantly being challenged and redefined. 

Concerningly there are topics that people are often discouraged from questioning or challenging. When one is unable to challenge or question a particular theory or teaching this is dogma and not science. Three notable examples are evolution by natural selection as the driver of organismal progression to advanced life forms, global warming induced by human actions, and the safety of specific vaccines. First let me clarify that there is great evidence for all three of these points (although for natural selection the specific mechanisms and probability of such a feat occurring is still debated freely and the safety of the common vaccines on the schedule has been well validated although there have definitely been harmful vaccines given in the past). The point is not whether any of these three theories are right. The point is that practitioners of science should ALWAYS be allowed the latitude to question and experiment in order to get closer to the truth. Any time science attempts to limit questions this is simply not science. Skeptics and questions are always welcome to science as long as they want to do science- that is ask questions and address those questions with the proper methods, data, analyses, and conclusions. To limit questions in science is to limit the beauty of the discipline and hamper the search for truth

S2.Intro: Welcome to Season II

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Welcome to Season 2 of the Blog! After the first season we took a break to recalibrate, reimagine, and reorganize. Now we are back and enthusiastic for the start of Season II. Over the next 50 weeks we look forward to exploring medicine, leadership, motivation, and struggle as well as a handful of other topics.

As always the goal is to think on, explore, question, and celebrate the many adventures and challenges of life. We are excited to have you here with us as we start Season II!

S2.1 Pandemic, the new normal

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We have been worried about a global pandemic, something akin to the Spanish flu of 1918, for some time. Whether SARS or Ebola or the new coronavirus, there are always possible pandemics lurking on the horizon. We have dodged the bullet on avian bird flu and swine flu, although that may have had as much to do with luck than with successful intervention from the health system. Is the new coronavirus “the one?” The unfortunate reality is that we live in a time when “the one” is a foregone notion and we will always live with the threat of epidemic or pandemic on the horizon. No innovation currently in the works will completely remove that threat. Here, I outline a few, brief thoughts on what we can be relatively certain about concerning the next pandemic(s): 

  1. There will be other outbreaks of varying severity with a handful reaching pandemic levels after this current outbreak of coronavirus.
  2. Many will originate from Asia. This is due to varying reasons including population density and proximity of animals, including birds and other livestock, to people.
  3. Pandemics will likely be a strain of influenza or a similar virus that is spread through respiratory droplets. Although a bad disease, Ebola was much easier to contain than Tuberculosis or the Coronavirus for which respiratory precautions must be taken and spread is much more difficult to contain. 
  4. Pandemics will likely begin by a known virus mutating to behave in new ways, recombining with another virus to spread or evade the immune system by a different mechanism, or gaining the ability to jump from species to species. In particular the ability to transmit to humans and then transit from human to human will be a likely feature. 
  5. Those with comorbidities will be hit the hardest. Underlying heart disease, lung pathology, cancer, diabetes, and other health problems all make fighting the infection and maintaining homeostasis more difficult. Long comorbidity lists will generally be predictors of lower chances of survival. 
  6. Isolation and low population density will be protective. Especially during the period of an epidemic or pandemic where not targeted treatment exists, preventing human to human transmission is critical. One of the easiest ways to prevent human to human transmission is to be in a community with a low population density and with a low volume of influx from the outside. 
  7. Vaccines or targeted therapies will take many months to affect the population. In the meantime containment measures and supportive care as well as screening similar therapies for efficacy will be critical in mitigating the effects. As always, wash your hands, cover your mouth when you cough or sneeze, and …did we mention wash your hands? 
  8. Hospitals and other healthcare settings will be high risk places where disease is readily spread. This can be limited by the correct preventative measures and precautions, but the simple fact that many of the known cases will come through the hospital means the risk will always be high. Healthcare workers and their families will be at greater than average risk of contracting the disease. 
  9. In advanced stages the flow of goods, including food and water may be affected. Our lives today are enabled by trade from all corners of the world. Our medications, food, clothes, and everything else come from many miles away and require many people to get to us. In the advanced stages of a pandemic, food scarcity, loss of power, water shortages, and medication shortages may all be realized. Having an emergency supply of food, water, and other vital supplies including medications for chronic diseases will be essential. 
  10. Recovery will take years. Similar to recovering from a World War, the loss of human power and faith in economic and political systems will require years, not months to rebuild. 

“God is in control”

 

Copy of 20180705_140525The family of a patient who was unresponsive after a major bleed in the brain posted a card on the clear glass door to her hospital room.

“God is in control”

It struck me how many different ways this could be read.

A question thrown out to the universe, a shout into the void. A query as to whether there was a God and if anyone was in control.

A prayer that in the midst of trials and difficulties there was a compassionate God holding the patient in forefront of his mind. A plea that as their world spun out of control a loving God remained sovereign and sufficient.

A statement of faith proclaiming a truth, a belief that God had not abandoned them, had not grown weary, and remained capable and intimately concerned with the ultimate good of the patient.

Most likely it is all three simultaneously. With each reminder that “God is in control”, a question, a prayer, and a statement of faith are simultaneously made. This was the way of many of the Psalms… a progression from doubtful to prayerful to faithful in one breath.

Regardless of whether today was life-altering or routine may our prayers carry the same pattern. A question as we struggle with the difficulties of reality, a prayer demonstrating our insufficiency and throwing our hopes on another, and a statement of faith confident in the character and nature of God.

A New Straw Man

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In a debate, constructing a straw man argument provides a neat way of constructing a foe from your own imagination who is easily and conveniently destroyed. For better or worse technology has allowed us a neat way of avoiding the trouble of gathering the straw and propping up a straw man ourselves. Instead of carefully creating the shape and character of the hapless scarecrow that we will later destroy, we decided that even this task was too great an effort. Now lounging in bed or draped across a sofa we can, by activating only one thumb, scroll through our feed of news and friends and interests until we find something ridiculous to which we can respond. ‘How dare they’ we cry, forgetting the thousands of reasonable thoughts and suggestions we passed by to get to this atrocious viewpoint. We mutter under our breath and type furiously our response. As we hit “post” we sigh contentedly knowing that we have made the world a safer place, a better place, a smarter place. That was one small post for man, one giant comment for mankind. Settling back into the cushions we begin to scroll, but what is this? Our foe has replied? Surely our wise insight must have brought them to their senses, and they have merely returned to thank us for bearing the lone light of knowledge in a sea of ignorance. But wait, they are doubling down? How could this be? And the ridiculousness has spread to multiple points each of which we must address. Settling in to begin to type, we realize that what began as a quick strike has now become a war of attrition. And thus passes a perfectly serviceable afternoon. But at least we were fighting the good fight against… who again?