doc w/ pen

a journalist becomes a doctor before your eyes

Month: April, 2018

Home-grown exotics

A few days before leaving for rural Uganda, I had an exotic adventure right in my own backyard. I trekked out to the Bronx to visit the New York Botanical Garden, one of my favorite places in the city. It’s always a fun trip, and I walked through some of my favorite haunts, like the ornamental conifer garden. But I made this particular visit to see the annual orchid show, which would conclude while I was out of the country. This week was my last chance.

The show didn’t disappoint. I ooooohed and aaaaahed as I made my way through the greenhouse, stunned by the magnificent and many colors, shapes, and sizes. Some blooms hung in clusters from trees; some strutted in giant pots on the ground; others wound their way like strands of delicate glass beads around a gigantic frame of green bamboo-like rods, a structure which reached up for the ceiling, and for the sun.

My photos don’t do these beautiful blooms justice. But they give you a glimpse at what the show was like:

Outside, the Japanese apricot trees (below) were blooming, as were the azaleas. It was early April, too early for many of the spring bulbs, but some precocious daffodils (also below) and even a few tulips had popped up to say their spring “hello.”

All this green (and pink, orange, yellow, purple, and so on …) was so refreshing to see. It was a pleasant respite from all the concrete and steel that surrounds me on a daily basis. It was also a lovely reminder that someday, I want to have a house again, with a backyard, and my own garden.

japanese apricots

daffodils

 

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The white coat

Me in my white coat: a piece of clothing that started as a costume, but over time has become a uniform — just like we were told it would at our white coat ceremony almost three years ago.

At my white coat ceremony almost three years ago, a physician gave a brief speech about this new attire we were about to don. I don’t remember his name, but I do remember, with stunning clarity, his simple premise:

When you start medical school and put on your white coat, he told us, it will seem like a costume. But eventually, as you embrace your new profession, you will come to see it as a uniform.

I’ve thought about this concept throughout medical school, tested its truth as year 1 became year 2, and then year 3. As I approach the start of year 4, I conclude the speaker was right. The first time I put on my white coat, it felt completely foreign. The first time I wore it in the hospital, to spend an afternoon observing in the burn unit, I was shocked at how my white coat and hospital ID acted as an all-access pass. With them, no one questioned my presence, even in “restricted” areas. No one, that is, except for me.

I don’t recall the precise turning point when the white coat finally felt comfortable. What I do recall is that at the start of my psychiatry clerkship, a rotation in which you don’t generally wear your white coat, I initially felt confused, almost naked, as I went about my medical student duties in the hospital. Then I knew with certainty that I had accepted the white coat as a uniform, and not a costume. It had become a part of my identity.

It was with all this in mind that I selected a date for my Step 2 Clinical Skills (CS) board exam recently.

I took my first board exam, Step 1, the February of my second year of medical school. We have to take two more board exams during our fourth year, prior to graduating. Step 2 Clinical Knowledge (CK) is a daylong multiple-choice test. Step 2 CS is a daylong series of 12 encounters with standardized patients (actors). Each encounter lasts 25 minutes. You have 15 minutes to conduct a focused history and physical exam based on the patient’s chief complaint (known as the presenting problem). You then have 10 minutes to write up your findings, top potential diagnoses, and the diagnostic tests you would order next. You are graded on a number of things, including your interviewing skills, physical exam skills, and diagnostic reasoning. The exam is pass-fail. I have to pass to get into residency — but no pressure, right?

Step 2 CS is only offered at a handful of sites throughout the country, the closest to New York City, where I live, being in Philadelphia. So it’s a bit of an ordeal. You have to take the train or bus the night before and stay in a hotel. And you need to plan for a week or two of studying first — this is not a test to go into blind or unprepared. It’s an expensive ordeal, too — $1,285 to be precise. Aside from the terrible effects a “fail” would have on your residency application, you don’t want to shell out that application fee a second time. So, you choose your date carefully.

Based on my fourth-year schedule, I had planned to take the exam in late October or early November. Sitting at my laptop, looking at the dates available, I had to make a choice. But how do you decide between a day earlier and a day later? Was there a strategy to this? There must be. I groaned (audibly, I imagine), with the weight of this decision, and the frustration of indecision.

I looked at the available dates again, more closely this time. As I did so, that speech from my white coat ceremony came back to me.

Halloween.

It was perfect. Poetic.

I would slip into my white coat to take Step 2 CS, an exam that heralds a further transition from costume to uniform, the transition from medical school to medical residency, and from medical student to medical doctor, on the holiday when millions of other people wear costumes too.

I smiled as I clicked on “October 31” as the date to take my exam, and completed my registration. I had no doubt that this was the right day. Suddenly, I had transformed a day that had so far filled me with dread into one filled with meaning.

Changing my attitude in this way won’t erase the anxiety surrounding this exam. But it will ease that anxiety. And I believe approaching the exam with this positive perspective will lift not only my spirits, but my confidence too, because what started as a costume has in fact become a uniform. And I have both been given the privilege, and earned the right, to wear it.

 

Note: This essay was first published in the online magazine The American. You can read the original version here.

28 hours later

 

IMG_3980

Some 28 hours after I left my Manhattan apartment, I arrived at the Naggalama Hospital guesthouse in rural Uganda. Having just spent some 17 hours speeding through the sky in two different airplanes, and then 3 hours loping along in a pick-up truck, and having just forced my circadian rhythm ahead by 7 hours, I felt a bit … disoriented. To say the least.

At the same time, I’d felt a rush of familiarity when our Emirates flight touched down in Entebbe, Uganda and I caught a glimpse of the brick-red Ugandan soil zooming by. And my heart immediately warmed when I saw the “Welcome to Entebbe International Airport” sign.

“It was a grueling trip to get here,” I thought to myself. “But I’m so glad to be back.”

 

“You are welcome.” (above)
This was a phrase I learned to love my first time visiting here, two years ago. I felt the same sense of welcome as I peered through my rain-splattered airplane window and saw this sign when we landed yesterday at Entebbe. I felt similarly when I caught sight of the brick-red soil you find everywhere here, also seen through my airplane window.

 

Before and after. (above)
Selfies from my cab ride to JFK airport in New York City, and more than 20 hours later on my flight from Dubai to Entebbe. Notice that initially, I’m wearing makeup. My hair is in lovely, tight ringlets. I’m wearing contact lenses. In the second photo, we’re about an hour away from touching down in Entebbe. And here, I’m wearing glasses. The makeup is long gone, and my hair quite ruffled by my attempts to sleep (every single one of them foiled). I am, however, still smiling in this second picture — mostly because even though I feel uncharacteristically exhausted and unkempt, I have in my hand a cup of fresh, French press coffee. I learned on my first trip here that I could survive without my morning coffee ritual, but that I’d be much happier with it. So I brought with me a travel French press and my own coarse-ground coffee. Highly recommended for fellow coffee connoisseurs who travel internationally.

The city speaks, if you listen

Stopping to snap a photo while heading down a busy NYC sidewalk is a very touristy thing to do. I live here, but I do it too, when what I’ve seen seems important to capture, as this window decal did. Its message — to commit; to eschew indecision — is a good reminder.

Tourists in New York City are pretty obvious. One way they often stand out is that they stop in the middle of the sidewalk (blocking the rush of pedestrian traffic) to take pictures of things that those of us who live in New York City find commonplace.

I live here. I’m no tourist. But I still find myself frequently staring in wonder as I make my way through the city. And I, too, want to record those moments of wonder. What sets me aside from so many tourists is that I do my best to step out of the pedestrian traffic, making my photo-op as unobtrusive as possible.

I probably still look like a tourist. And I’m ok with that. The moment I stop approaching my surroundings with awe, and a desire to share that awe, is the moment that I’ve lost the childhood curiosity that I both nurtured and sharpened as a journalist. The same curiosity that prompts me to ask a patient careful questions to probe her story and uncover the root of her malady.

In this post I’ve included several city photos I took recently, several signs whose messages spoke to me. Whose messages I thought might speak to some of you, too.

The photo at the top right of this blog post is from a high-rise building I passed; I don’t remember quite where. The photos below were taken on different occasions in front of Pure Barre, a fitness studio on 2nd Avenue that I pass frequently (and whose signs I’ve written about before).

Boxes, boxes, everywhere

My pile of “savory” snacks to bring to Uganda.

In a peaceful coup, Uganda has assumed control of my tiny, 1-bedroom apartment.

There are boxes everywhere

A box of food. LOTS of food. I don’t consider myself a picky eater. But on my first trip to Uganda, which lasted 3 weeks (this one is a month), I discovered quickly that I wasn’t getting as much protein as I was used to. We had fruit, wonderful fresh fruit, but almost no vegetables — we can’t eat them unless they’ve been peeled because we can’t drink the water. In general, the diet there is very starch-heavy, which is not what I eat at home. As a result, I was also just eating less than usual. I’ve tried to remedy all that with an assortment of goodies that I’ve pictured here, separated out into “sweet” and “savory” piles on my kitchen table so you can see the variety. Some things are from Trader Joe’s, some from Amazon Pantry, some from my grocery delivery service. When I put everything into those piles, and realized how much I’d bought, I thought I’d gone overboard. I said as much to my research mentor, Dr. Randi Diamond. She didn’t think so. “Bring as much of it as you can,” she told me earlier this week. Luggage weight permitting, I will.

My pile of “sweet” snacks to bring to Uganda.

Not pictured here is the mound of coffee I’ll bring. I survived on tea last time, but it wasn’t pretty. I’m not in any way religious, except perhaps about my morning routine: coarse ground, brewed in a French press for precisely 5 minutes while my ceramic mug heats up too, filled with extra boiling water from my electric kettle. I add a little sugar and half-and-half, take a sip, and then, finally, can really take on the day. After some searching on Amazon, I found a travel French press that I’ve tested and found to pass muster. I’ll have sugar there, but no cream; refrigeration is iffy due to frequent power outages. It may be rough, but I’ll survive.

Boxes of our teaching guides. Twenty-five each of red, black, and blue plastic folders, the kind with metal prongs. One of my trip-preparation tasks has been to put the correct number of sheet protectors into the folders for each of our three modules (11, 10, and 9 sheet protectors, respectively), and then shimmy each printed page into each sheet protector.

One of the 72 little notebooks we’re bringing with us to Uganda, to encourage reflective writing.

A box of notebooks. I mentioned in my last post that in our teaching guides, we include reflection questions to try to get people thinking about how these lessons apply to their own lives and practice. We’re going to encourage discussion of their thoughts, as well as journal writing. So we’re bringing along 72 little notebooks, each with a sticker I’ve designed and stuck on identifying it as part of our program.

A box of surveys. This box holds a 4-inch-high stack of stapled packets, color coded in green and yellow printer paper so we know what’s what.

A box of office supplies. There’s no Amazon Prime in rural Uganda, no Office Depot, no Staples. So we’re bringing along our own stapler, scissors, paper clips, binder clips, pens, tape, a Sharpie, Post-it notes. Some of the items, we know we’ll need. Others we’re not sure of. But we might need them, and there’s no good way to get them in rural Uganda. So into the suitcase they go.

In addition to the boxes, I’ve also got some stacks going, and some piles.

There’s a stack of paperbacks I’m bringing with me, for my downtime. Due to limited suitcase space (and weight), I’m also downloading a bunch of audiobooks onto my phone.

Then there’s the pile of clothes and toiletries that I’ve set out to pack. Bringing everything you need for a month — but not so much that your suitcase goes over the 51-pound weight limit — requires some serious thought. Especially when you need to dress for multiple occasions. I’ll be wearing “professional” clothes (nice pants, a blouse, dress shoes) for the days when we’re out doing our research sessions at the various rural hospitals. I hope to head out with the Palliative Care Outreach Team too, during some of my downtime. On those days, I’ll wear casual clothes and tennis shoes.

I’m constantly stepping over these boxes, stacks, and piles; shifting them from kitchen table to desk to floor and back depending on what I’m doing and where I need space. But it’s a welcome merry-go-round, a constant reminder that exactly five days from the moment I’m typing these words, I’ll be at JFK airport, waiting to board my flight.

I can’t wait.

Celebrate!

Every day, it gets a little more real. The fact that in just over a year, I’ll be a doctor.

Some moments, that timeline feels more concrete than others. Like today, when I logged in for the first time to my new best friend ERAS, the Electronic Residency Application Service.

I’m sure I will grow to loathe the purple, orange, and green color scheme of my ERAS dashboard, given how much time I will spend on this website. (And really? Purple, orange, and green? That’s a little much, isn’t it?)

But today, the colors seemed festive and celebratory. And so I am celebrating.

That’s right, I’m applying to RESIDENCY. Wow …

 

Back to Uganda …

In less than 2 weeks, I’m headed back to Uganda for another palliative care research project. This picture was taken during my first trip there in July of 2016.

I’ve mentioned in several recent posts that I’m on a four-month research rotation. Then I realized that I haven’t said anything about what I’m actually doing. It’s time to change that.

Before I delve into the details of the project itself, though, I need to provide some background and context so that the project itself makes sense.

Those of you who have been following along for a while may remember that I went to rural Uganda in July of 2016, the summer after my first year in medical school. I went with a palliative care physician from Cornell, Dr. Randi Diamond, to do both clinical and research work, looking (in part) at the understanding palliative care patients there have of their illnesses, and why people present at such late stages of illness to the medical system.

One thing palliative care patients told us during that trip was that they perceived their health care workers to have poor communication skills. And as a result, the patients were distrustful of medical workers, and the health care system as a whole.

In rural Uganda, it’s also important to know that medical workers have limited access to continuing medical education (“CME”). Much of the palliative care CME (and CME in general, for that matter) is Internet-based. As I learned during my first trip there, even in places that have the equipment for Internet, it’s completely unreliable. Not only that, but medical education materials are mostly developed for a Western audience like ours — one with incredible resources. What’s discussed and taught isn’t always relevant to medical workers in rural Africa, who work in a very different environment, as you can see from pictures I’ve included below, taken during my first trip there. (If you want to read in more detail about the hospital environment in Uganda, here is a post I wrote about it in 2016.)

All of this got Dr. Diamond and me thinking about whether we could do something to help improve communication skills among health care workers in rural Uganda.

As did some things we learned from an organization we’ve now partnered with on this new project, the African Palliative Care Organization (APCA). APCA has developed its own palliative care curriculum for use in Africa, and one of the key competencies is communication. In developing this curriculum, they did a needs assessment, and found “communication” to be one of the gaps in both skills and knowledge in health care workers there. They also found a shortage of culturally appropriate materials for teaching palliative care.

Putting all this together, there is a clear need for culturally appropriate continuing education directed at communication skills.

Both Dr. Diamond and I found ourselves in a unique place to help fill that need. During Dr. Diamond’s last two summer trips to rural Uganda (2016 and 2017), a documentary film crew accompanied her and the local Ugandan palliative care outreach team on home visits to palliative care patients. So she has footage of palliative care taking place in rural Uganda, with local medical workers, that could be used to illustrate best practices.

As part of Cornell’s curriculum, I have 6 months to do full-time research, 4 months now and 2 months at the beginning of 2019. After my first trip to Uganda in 2016, I knew I wanted to work with Dr. Diamond again, and go back to Uganda. From my past life as a textbook editor and freelance writer, I also have experience in developing educational materials.

It was a perfect match.

In less than 2 weeks, we leave for Uganda to pilot test the multimedia educational modules we have developed. There are 3 different modules:

  • Basic Communication Skills in Palliative Care
  • Delivering Bad News
  • Pain Assessment (with a focus on the communication aspect of assessing pain)

Each module includes the video clips I mentioned, and a teaching guide that Dr. Diamond and I wrote. The teaching guides have educational content as well as reflection questions to get people thinking about how what they’re learning applies to their own lives, and their own patients. This kind of “reflective practice” is so important in palliative care (and all of medicine, really). It’s not done much in Uganda, but it’s something that APCA has identified as a goal for integration into medical education there.

To give you an idea of what we’ve created, here is a page from the “Basic Communication Skills in Palliative Care” module:

Here are the basics of our research design:

Hypothesis: Communication training with culturally appropriate modules will enhance health worker confidence in, and knowledge base about, communicating with PC patients.

Methods:

  • Pilot test the modules at 6 different rural sites in Uganda, identified by APCA
    • Hoping for 6-12 participants per site (targeting medical workers such as physicians, nurses, and nurse assistants who interact with palliative care patients)
    • Planning to test 2 of our modules at each site
  • Conduct pre- and post-intervention surveys to assess the effectiveness of the modules
    • Surveys will assess both knowledge base about, and confidence in, palliative care topics and skills
    • Future data analysis will measure whether there is a change in knowledge and/or confidence after the participants complete the module

This project is not just about research, though. It’s also about leaving something behind that people can actually use. At the conclusion of each pilot testing session, we will leave printed copies of our teaching guides, as well as flash drives with the video clips and the teaching guides in PDF form. Hopefully, this strategy resolves the access issue; while Internet is spotty, these rural sites do have computers.

I’m in full trip-prep mode right now: assembling the printed guides, survey packets, mosquito repellent, and lots of protein to take with me for the month I’ll be there (the Ugandan diet is mostly starch based).

I’ll be based at the same place where I stayed during my last trip, St. Francis Naggalama Hospital, working with the wonderful Naggalama Hospital Palliative Care Outreach Team. I will sometimes have Internet access there (hopefully, more often than not). As I do, I will try to post updates on my trip.