The Power of Holding Someone’s Hand

By Samantha Gogola

It’s pitch black outside and my alarm is blaring. Rubbing the crust from my eyes, I remember that it really is 4:00 AM right now, and it really is my first day of surgical breast oncology.

After gathering my compression socks, high-arch shoe inserts, fanny pack, and protein shake, I am finally ready to leave the house. I try listening to Online Med Ed in the car but it’s hard to pay attention when I’m simultaneously trying to think of the questions I might get asked today. I park, chug my protein shake, and head inside.

 “Here you go,” the nurse says as she plops the heaviest patient chart in my arms. Suddenly I am glad that I was still an hour early. The words “ductal carcinoma in situ,”  “BI-RADS 4,” and “sentinel lymph node biopsy,” flash before my eyes.

“I’ll go bring the patient in,” the nurse says. And then I see her. I can’t believe how young she is. Going back to her chart and quickly flipping through the pages and pages of pathology reports, lab results, imaging, and histories I find it. My eyes go wide as I look back at her – 20 years old.

I continue listening as the nurse fills out the final consent forms with the patient and notice how, even though the nurse is speaking to her in English, she will only respond in Spanish. When I speak, she doesn’t even look in my direction or acknowledge my existence.

She disappears behind the curtain to change into her gown. The next time I see her, she is surrounded by so many people that there isn’t a spot for me next to her bed. As I am standing in the corner on my tip toes and craning my neck in a thousand directions, and through all of the coordinated hands and wires swaying above her like a symphony, I finally catch a glimpse. “Wait… is she crying?”

Someone leaves her side and I make my move to be beside her. I instinctually grab her hand and am surprised that she immediately squeezes it. Her breath is shaking as she tries breathing deeply. I am looking at her trying to come up with the right words to say, everyone else notices what I see.

“Sorry that we had to stick you twice for the IV, but you can relax now,” says the anesthesiologist with a smile before he walks away. “It’s okay, this is a very simple procedure. You have nothing to worry about,” says the nurse as she pats her shoulder before following him out. “We caught this early, you’re going to be okay,” says the doctor as he shuts the curtain, leaving me and the patient alone. “How are you feeling right now?” I say, surprising myself in finding the words without thinking.

She grips my hand harder and looks up at me for the first time. “I’m just really worried about the anesthesia. I don’t like the idea of being asleep and not having control over my body.” As we talk, I can see her heart rate decreasing on the monitor. 102, 99, 96. The anesthesia team comes back and I continue to hold her as she is rolled to the OR. The symphony of hands and wires plays again as she is hooked back up to the monitors. 85, 81, 78. “Thank you, I really appreciated that,” she says as an oxygen mask is stretched over her face.

As I walk away to scrub in, I am amazed at the power of holding someone’s hand.

We have been told time and time again throughout our medical training that touch can soothe our patients, but I had no idea the magnitude of its power until this moment. This patient would not have felt comfortable with me or relayed her true fears to me otherwise.  I do not know why this patient initially did not want me there to participate in her care, and my thoughts early on were centered on trying to figure out why this was. Was it because we were close to the same age? Was it because I do not speak Spanish? In the end it did not matter the reason. Although I may have felt hurt at the start of the encounter, I made sure to remind myself of why I was there in the first place and to continue offering the best patient care and support that I could. This wound up making all the difference.

Samantha Gogola is a third-year medical
student at the Herbert Wertheim
College of Medicine. She is interested in pursuing
family medicine with a focus on women’s health

The New Normal: Practicing Medicine Quasi-Masked and Semi-Remote

by Melissa C. Janse

It’s 7:30 am. My husband glances over at me and queries, “Are you seriously in a med school faculty meeting right now?” I look down at my striped pajamas and pull the comforter further over my shoulders with as much dignity as I can muster and without toppling my laptop, which is open to a virtual meeting. I am propped up in bed with two pillows, sipping a ceramic mug of coffee with a picture of our 3 boys glazed on it, and petting my dog’s head, which is deeply snuggled into the crook of my leg.

“It’s not like the camera’s on,” I reply defensively. “Or the microphone. I’m paying attention. It’s…well, it’s how we do things now.” My husband glances over skeptically, finishes knotting his tie, and grabs his cell phone.

“Well, I’m heading to work. To actually see people. In person. Enjoy your meeting.”

Several hours later, prepping for my Emergency Department shift, I put on hospital monogrammed scrubs, tug up my pink striped compression socks (it’s going to be a busy one), hurriedly twist my hair in a facsimile of a bun, and take a quick minute for some minimal makeup.  I skip the lip color, as the lower part of my face will be hidden behind a mask anyway.  I also leave in my nose stud; no one’s going to see it. This mask is the final part of my uniform, which I passive aggressively delay until just before walking through the doors of the Emergency Department. With a practiced hand, I guide the elastic loops around my sore ears and pinch the light blue covering over my mouth and nose, which immediately fogs up my glasses. I emit an audible sigh which only worsens the fogging. Every. Time.

My first patient is a bright-eyed, pleasant octogenarian with dementia who was sent by her nursing home for some changes in baseline behavior. I introduce myself. She has absolutely no idea where she is or why she is here. She furrows her brow at me when I approach her stretcher. “I can’t see your face.”

“Pardon?”

“I can’t see your face,” she staunchly re-announces.

“Oh.” Sheepishly, I pull the mask down and give her my best winning smile. “We have to wear these now. Because of Covid.” She looks unconvinced. I see a flaccid, unused mask in her lap and opt not to tell her that patients are supposed to wear them, too. Later, I pull my mask down again to review her EKG, as my glasses are still intermittently fogging and instead of improving my vision, they are obscuring it. 

When I call the hospitalist to admit the patient, he initially asks me to repeat several sentences as my voice is muffled.  In frustration, I jerk the mask off so that my words can connect to him clearly, without barrier. I leave it off another few minutes to gulp down a quick cup of tepid coffee as the waiting room census mounts. 

Mid-shift, a fourth-year medical student passes through the ED and sweetly takes the time to enthusiastically greet me. I taught her during her first year of medical school. I enthusiastically greet her back although I must surreptitiously read her name badge to figure out who she is since it has been a while, and the mask is hiding the lower half of her face. I am having a hard time recognizing her without all the puzzle pieces to put together- it’s harder with just eyes and hair. I want the nose and mouth, too.

It has been over two years since the onset of the Covid pandemic. We keep waiting for things to get back to normal. But they’re not going to, are they? Ever positive, we call it the “new normal.” There have been incremental shifts in the way that we practice and teach medicine, and some of those changes seem that they are here to stay. 

One of the positive effects is the convenience of virtual meetings. I don’t have to shower, dress professionally, fix my hair or put on makeup, or even leave the comfort of my own home. I can effectively conduct business in sweatpants, sitting on my sofa, with my dog contentedly sighing in my lap. Or even while I’m on vacation in a different state. Thankfully, I’m an introvert. I’ve been preparing for this scenario my whole life. 

But these scenarios admittedly blur the lines between home and work life. Instead of being a calming respite from work, your home inexorably slides into an extension of work. Yet we know that in any healthy relationship, there need to be boundaries; we need a differentiation of self. Our getaway vacation is no longer a retreat for wellness if we spend every morning virtually dealing with work and work stressors, meeting via screen with students or giving lectures. We no longer have the uninterrupted, dedicated time to ourselves and loved ones to restore our spirit and replenish our physical and emotional needs if we are always reachable, always accessible, even if we aren’t physically in the hospital or our office…or the state. It’s on us to create healthy, personal boundaries and keep our job from becoming that needy, jealous partner who consumes all.

And there’s something else missing, too. I think it’s that human-to-human connection and communication. Even if we are seeing a patient or colleague, resident, or student, in person and not through a screen, the physical barrier of the mask on our face is inhibiting. You miss subtle facial expressions and non-verbal messages playing around the nose and mouth:  irritable nasal flaring; a corner of a lip raised in irony or sardonic amusement; the mouth twisted in contemplation; a broad, unguarded smile of joy; or pinched lips of pain and distress.

The post-pandemic changes, with their requisite benefits and detriments, are continuing to evolve, and we are continuing to adapt. But in the interim, patient care must come first (always) and continue. So, I keep working my shifts. But now when I go into patients’ rooms to introduce myself, I quickly lift my mask to give them a glimpse of my face in its entirety as well as a warm smile of greeting before pinching it back onto my nose. And fogging up my glasses. Again.

Melissa C. Janse, MD is an Emergency Medicine physician at Prisma Health-Upstate. She is also a clinical associate professor who teaches first-year medical students and serves as a career counselor at the University of South Carolina School of Medicine Greenville.

Bias in the Clinical Setting

By Alyssa Cartwright

The pre-operative suite felt abnormally chilly that Tuesday morning. Or perhaps it was  the lack of hot coffee coursing through my body since I woke up too late to stop for my daily  Starbucks latte before arriving to my Anesthesiology rotation at 6am. Either way, I had to power  through because the team had a full day of surgeries ahead of us for which we needed to prepare. 

I began my pre-rounds like any other morning, popping in and out of various pre- operative bays to introduce myself to patients, chat with them for a bit, and grab them anything  they might need (warm blankets were a hot commodity that morning!) I was finally hitting my  stride when I stopped by Bay 19. I quickly scanned the chart and saw that the patient inside was  documented as a 46-year-old male presenting for hernia repair. As I entered the bay, I stood in  front of the bed as the elderly nurse continued talking with the patient and their visitor about how  the flow of the day will work, what to expect after the procedure, etcetera. 

As I listened to this conversation, I observed the body language of both the patient and  their visitor – they both seemed uncomfortable, beyond that expected of a person about to  undergo surgery. I quietly continued to listen to the interaction and quickly realized the reason  for their joint discomfort: the patient was a transgender woman and was being continually  misgendered by the nurse. While of course this is an uncomfortable situation to begin with,  matters were made worse when the nurse made the statement “okay gentlemen, and I use that  term very loosely, let’s get ready to go” with a tone of disdain in her voice. 

The patient and her partner visibly cringed at this comment and there was a tangible  sense of awkwardness in the air as the nurse left the bay. I took this opportunity to introduce  myself and sit down by the patient’s bed so we could chat. During my introduction, I ensured to  state my personal pronouns in hopes that the patient would feel comfortable enough sharing  theirs. This tactic seemed to work, as the patient sighed a breath of relief and introduced herself  along with her pronouns as well. I immediately apologized for any discomfort she or her partner  might have felt from the interaction with the nurse, and the patient quickly dismissed it, saying  she was “used to it”. 

I reflected on this encounter for a long time, growing more and more angry and deeply  saddened the more I thought about it. While it is important to take generational differences into  account, healthcare workers are tasked with the responsibility of prioritizing patient comfort and  safety above all else. While the patient’s pronouns were not documented in the chart (which is  an entire issue in and of itself), if this nurse had been paying closer attention to the tone of the  room, she would have realized that the patient was extremely uncomfortable during the  interaction and could have addressed it in the moment, thus likely rectifying any issue before it  escalated.

The patient feeling uncomfortable and likely unwelcome given the snarky comment made  by the nurse is entirely unacceptable, but what also concerned me deeply about this situation  was the possibility that patient safety could have been compromised. If a patient does not feel  that they can trust their healthcare team (whether it be for reasons of prejudice, bias, or anything  else), there is a substantial chance that they will not be forthcoming with information needed for  proper health management, which can in turn lead to a plethora of safety issues.

Although this encounter occurred several months ago, I find myself reflecting on it  almost daily in my clinical rotations. While thinking back on this experience recently, I asked  myself, “what interactions have I had with patients who made me uncomfortable?” I began to  think of patients I had seen in the hospital who were imprisoned for dangerous crimes and even  those who had extremist or aggressive political views. Then, a realization suddenly dawned on  me: not only is it imperative to address our judgments and biases against patients in terms of  their gender, sexual orientation, home life, or health history, but also regarding things patients  have done that we do not necessarily agree with morally, such as the aforementioned political  extremists or those with a criminal history. Now, before knocking on the door to see a new  patient, I have been actively reminding myself to mind my biases and do my absolute best to stay  open-minded and non-judgmental during the encounter no matter what, as that is our duty as  healthcare workers — to respect the humanity of each and every patient we see. Maintaining this  attitude and utilizing open and honest communication with our patients are some of the most  useful tools we have as healthcare workers to nurture trusting relationships and ensure that  patient comfort and safety are always being upheld.

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Alyssa Cartwright is a third-year medical student at FIU Herbert Wertheim College of Medicine in Miami, FL. She is currently pursuing her decade-long dream of becoming an Emergency Physician to serve her local community in their most difficult times.

Do You Know The Maharaja? The Art of Listening

By Brian Gross

I walk into the common room of the facility to find a man sitting in a chair hunched over a table. His face was covered by long strands of tangled white hair. He was intently scribbling notes into a book. I glimpsed at the notes to see wildly drawn symbols and disjointed sentences. His eyes were fixated on the writings. I tapped him on the shoulder, and he looked up and smiled. “Good morning”, he said. “Do you know who the maharaja is?” I stood there puzzled and told him I was not sure who that was. He then began to tell me about “his master, the maharaja” and all the teachings of peace and tranquility he instilled in himself. I listened intently, wondering the significance of this conversation. What did he want me to get out of this? Why is he talking about this person? The conversation continued until the point was exhausted, and yet he continued to state the same points repeatedly. It became clear that this “master” was an important figure in this person’s life. A point was reached when I could steer the conversation away from this topic. I thanked him for sharing about himself and introducing me to such an important person in his life. I then continued with the rest of the mental status exam.

When speaking with him he seemed calm and collected. His words came rapidly as he switched from one topic to the next, but he seemed level-headed. I then asked if I could read his notes. He agreed and handed me a pile of papers, strewn about in different directions. Swirling circles of green and red were superimposed on a backdrop of red numbers. Statements were scribbled in the margins reading “the green ball sits on the silver court”, “the children are being euthanized”, and a plethora of random legal statutes. It was clear that he was in the midst of psychosis. I finished my exam and told him I would see him again tomorrow. He thanked me for my time, and for listening and we went our separate ways. Me, back to the comfort of my apartment, and him back to his small one-window room.

When I got home, I thought about how a man who seemed manic yet collected, could internally be experiencing a psychotic break. How did he keep his internal thoughts from spilling out into his speech? I never would have guessed he was psychotic unless I asked to read his writings. How could I better understand his experience? With his psychosis, how could I build enough trust with this patient?

                                                            “The Maharaja”

I began to read up on the maharaja, his teachings, and practices. I learned more about meditation and yoga, and the peaceful tenants of the maharaja. The next day I arrived at the facility to once again find my patient hunched over his notebook, legal papers strewn about the table. I greet him and tell him I looked up his master. He smiled and began to talk about how much his teachings mean to him, how these tenants of peace and tranquility allow him to survive his “imprisonment”. We spent a little while talking about the teachings of the maharaja and the importance of meditation and yoga in the patient’s day to day life. I listened and learned. I discovered the needs of my patient, his interests, and his desires. This interaction with my patient seemed to change our relationship. I was no longer a student prodding and poking at him so that I could learn. We developed a partnership, one in which we began to understand each other and with this understanding, he began to trust me.

This partnership culminated on the last day in clinic. When I first met the patient, he was unmedicated and uninterested in treatment. While he was cooperative, he had little interest in following our recommendations. Begrudgingly, he began treatment in response to a court order, but we knew that he would require further pharmacological intervention for which he would have to provide informed consent. Instead of purely focusing on convincing him to start medication by discussing his symptoms and labs, I learned who he was as a person.

As we discussed further treatment options, I was shocked to hear the words uttered: “whatever you think is best for me”.  He explained that his acceptance was due to our connection, and I was honored to be given his trust. This experience will always serve as a reminder to learn about who my patients are as a whole. It reinforces the importance of learning about their lives, their passions, what made them the person they are today, and the person they hope to become. Despite the many pressures that the day-to-day work of medicine will bring, I hope I continue to remember the importance of listening to our patients, learning about them, and striving to build a strong therapeutic alliance built on partnership and trust.

Brian Gross is a fourth-year medical student at Florida International University (FIU). He is an aspiring psychiatrist, home-brewer, vinyl collector, and cinephile.

An Unmatched Graduate’s Query: How faith and peer mentoring provided answers.

By Emmy Abraham

Since graduating from a Caribbean medical school in 2015, the wait for residency entrance has been a lesson in enduring perseverance interspersed with rewarding, unique experiences. It has been an eye-opening path with many unyielding doors that would have been difficult to open had it not been for my strong support systems such as my mentor group and my faith.  

I vividly recall multiple attempts to enhance my clinical or research experience including looking for medical internship opportunities locally and, as last resort, in the Middle Eastern countries. Oh, how devastated I was to realize it was a dead-end trying for an internship as a non-resident of the Middle East.  

Even searching for clinical research opportunities was cumbersome. Vigilantly going through various career sites and expectantly applying – only to then wait and receive no response or to be told I am over qualified. I was even told I am disqualified simply because I am awaiting residency entrance. To add another dimension, my full-time income had to manage my family expenses while I actively pursued these clinical enhancement opportunities, dealt with the medical school debt agency, arranged student loan payments, and single-handedly mothered my two young boys. Amidst these regularities, one must never forget the yearly mental work-out regarding ways to attain the best letters of recommendation. At the same time, the yet unknown Match outcome was a focus of deep analysis daily and a difficult mental process given there were no naturally known solutions at the end.  

Year after year, the Match Day has been a teary and a heart-breaking day for myself and my family, a family who has been a strong foundational pillar. All brimming up to the throat with battling, questioning thoughts asking, “What is the reason it did not work out this time?” “What different course of actions could I have taken?” and “How long is this going to take?”. After all, all that is needed is a single Match to a single program! Often, I sat thinking, “Why, oh why, why no Match this year?” 

Though I eventually would surface out of the despair, the terrorizing grip of the feelings of helplessness was traumatizing and a vicious circle; potentially much like the stories of the three unmatched medical graduates who ended in suicide due to being unmatched. However, my faith, centered on a relationship with the Almighty God, brought me up out of pits of despair. I know my God can change impossible situations. So, my helplessness did not progress into a mental health crisis. My faith gave me the privilege of de-stressing through worship music that uplifts the soul much like an eagle soaring high in the sky

Creating worship lyrics and tuning the words was a fond hobby of mine. During one moment of deep anguish about the Match, I wrote a particular, divinely-inspired song. Singing and meditating on the words of that song has repeatedly bolstered resilience, enabled re-orienting of focus, and set me up to progress into a better version of myself. I fondly recall, singing it daily before going to bed at night. Sometimes, I even made my kids sing it with me before their bedtime. My faith got energized when I repeatedly heard those meaningful words. These words fanned my hope and propelled me through the next day of seeking new opportunities. It cleared my mind of the negativity and enabled a flow of creativity as I tried to answer the flood of questions – What can I further do to enhance my credentials to stand out among the applicants? Are there available academic mentors that may assist during the process? Is there a support system that I could lean back on?  

Reflecting back, I would have stayed drowned in the surrounding negativity of the situation had it not been for my faith in God and the resultant coping through the use of worship music. Even now, despite the years of waiting, I live with the strong hope that surely an end to this is very near. Furthermore, while recalling the suicide news previously mentioned, a God-inspired deep concern resonated for others traveling on the same road as me. I realized that a journey together would be much safer and rewarding. A search commenced, with which I ended up among a well-knit peer group under the direction of a faculty mentor who opened opportunities for research, manuscript writing and review of scholarly abstracts.  

I am utterly indebted to our peer group for advancing awareness of available residency resources through our research collaboration. Empowered by the unseen intellectual support from these researched sources and the knowing that you are not alone in this journey have tremendously strengthened my resolve. It created a safe space to bounce ideas, seek answers without criticism, and educate self through scientific activities. It provided a basis to foster mentoring, be it guidance regarding United States Medical Licensing Examination Step 3 resources or sharing past research experiences. The developed camaraderie surely will remain for a lifetime since the strongest bonds are formed during the direst of moments. Surely the need for connections is vital. When we take the focus off of ourselves and deviate to help others, something happens to our mind and body to enable positive wiring, diffuse self-negativity, and uncage ourselves to utilize the full potential in ourselves.  

Truly, faith and peer support has added to my overall well-being during this journey. Therefore, I would recommend to all fellow residency re-applicants out there to please know there are accessible support systems available within your reach to de-stressing before a crisis arises. It is never too late to seek out a faculty mentor and a strong peer (virtual) support group with whom you can grow and succeed.  

Emmy Abraham, MD, is a medical graduate of International American University – College of Medicine and eagerly looking forward to the 2022 Residency Match outcome. She is passionate about serving under-served communities and has a strong interest in clinical & medical education research. She also enjoys time with her family, listening to contemporary music, learning piano and gardening. 

Acknowledgements:  

I am sincerely thankful to Dr. Juan Narvaez, Dr. Jessica Obi and my mentor Dr. Monica Van de Ridder for reviewing prior versions of this reflective writing. 

Unmatched, now what? The Hazy Path of the Qualified Medical Residency Candidate 

by Jessica Obi, MD

On March 15, 2021, I found out I didn’t match. Needless to say, I felt alone, disappointed, and uncertain of my next step(s). “Dr. Obi!” is what family and friends would call me. The next question I would hear and would still feel uncomfortable answering was, “Which hospital do you work in?” or “What residency program did you match to?” My reply would always leave them asking, “It’s not automatic to match into a program?” followed by “I thought there weren’t enough physicians?” Then my favorite question, “So what are you to do now?” Although these questions are asked from a sincere place and valid, I could not, and still sometimes can’t help but question my worth, intelligence or if I made the right decision to pursue a medical degree. I feel the medical educational system is broken in that it lacks support for candidates like myself – support that includes mentors for such situations and jobs that would allow our degrees to still be useful. Instead, unmatched candidates are left to scramble for positions and other areas of work to repay student loans. The worst part of not matching is not having a sure direction to follow that would guarantee matching during the Supplemental Offer and Acceptance Program (SOAP) or the next  cycle. 

As any unmatched candidate would do, I began searching for mentorship and guidance. I happened to join Twitter to network and follow physicians, and by chance stumbled upon a few accounts dedicated to helping the unmatched. I was able to learn of zoom webinars dedicated to guiding unmatched applicants down this tricky road in terms of personal statements, letters of recommendation, curriculum vitae, and networking.1-2 Of  course, my family, friends, and medical school have been supportive; however, to my utmost surprise, social media, particularly Twitter’s @Inside_TheMatch and @unlikelymds, has provided the most useful support. I have met and networked with awesome physicians and mentors via social media, and I have also found a peer support group  with the same goal of matching. This has undoubtedly powered my strength to persevere. 

The recent match cycle left many unmatched with unanswered questions. There were 42,508 active applicants and roughly 6,254 candidates that went unmatched. Yet, we are forced to forge a unique path to residency. As I reflect on this, I find myself finally at peace to have had this experience. I can use my struggle to gain empathy and experience that will help my patients navigate their struggles e.g., decreasing blood sugar or losing weight. My struggle to achieve residency is analogous to a patient’s struggle to achieve healthy outcomes, and in both cases, it is crucial to have proper guidance and strategy. My attributes of resilience and perseverance developed over this period, will fuel my passion and strength. 

I believe every path, albeit hazy, is unique to the individual whether one is a patient, student, resident, or a physician. Some practices I’ve adopted to cope include remembering my why and my faith, mentorship, networking with other qualified candidates, and following the stories of others   who have previously tread this path and are now residents. Currently, I’m also working on a few  projects that I’m hopeful will be ready for the next match cycle. 

Creating a path to reach this goal is not easy. I find on this journey that I’m developing resilience, endurance and relationships. I’m essentially creating a story, my story, that just may provide enough hope for that competent unmatched candidate – who may be on the verge of quitting – to not give up. 

To all the qualified unmatched reapplicants, you’re not alone. There is a virtual community of faculty, residents, physicians, your peers, that are supportive and are willing to aid as you carve your unique path to matching. 

There is hope. Keep going. 

Dr. Jessica Obi is a 2020 medical graduate of Ross University School of Medicine, from Los Angeles California, and learned in 2022 that she matched in Internal Medicine. She is passionate about health equity and medical education, and outside of Medicine, Dr. Obi enjoys spending time with her family, traveling and fashion and hopes to positively impact the medical field. 

References
1. van de Ridder, J.M.M. [@MvdRidder]. (2021, April 28). INVITATION Zoom network meeting for UNMATCHED STUDENTS, organized by UNMATCHED students. Please register in advance. Please RT.[Tweet]. Twitter. 
 
 2. Stulak, J. [@JohnStulakMD]. (2021, April 19). As promised, for those who went unmatched in #MatchDay2021, feel free to sign up for an informal webinar in which we give our insights and your answer questions No matter who or where you are, we are happy to help and be a resource [Image attached]. [Tweet]. Twitter. 

Acknowledgements 
I would like to thank Kyle Swearingen, MD, Emmy Abraham, MD, and Monica van de Ridder, PhD for their support and feedback on the earlier drafts of my reflection. 
 

Just a kid.

by Samantha Rodriguez

19, Baker acted –
heart sinks

no reason, really.
eyes inquire

I dropped out of school –
frustration overwhelms

fresh out of jail, now for trespassing.
thoughts race

I smoke meth, crack and weed since 16,
heart aches

no one ever really asked why.

I still take care of my son –
shock ensues

I just go into another room.
maternal instincts take over

It’s fine though; I control it with my mind.
confusion arises

But I can’t see him anymore.
provider lens resumes

No one asked why.
emotions run high

My dad knows everything;
stomach churns

he’s never tried to stop me.
heart breaks

She’s just a kid,
but no one asked why

Samantha Rodriguez is a fourth year medical student at Florida International University Herbert Wertheim College of Medicine. She is applying for residency in Pediatrics and enjoys yoga and gardening in her spare time. 

The Dahlia & The Mantis: Awakening to the Healing Beauty of Nature

by Mary P. Guerrera

With more time to putter in the yard during the days of the pandemic, I am discovering new ways to work with my hands (and feet) to care for the small grassy grounds surrounding our family cottage.

Using a good old-fashion reel mower, I walk at an easy pace while hand-pushing the rotating blades to their rhythmic swishing.  I am alert to other living beings along the way, and stop instantly if any are noted in my path. 

I’m surprised when a tiny frog jumps onto my toe.  I watch a bunny nibbling a leaf.  I see and hear the springy grasshoppers and winged song birds.  On quite days, the sound of the surf as the tide rolls in seems like the sea is breathing.

With my enhanced attention, I notice mole tunnels and vole trails.  And of course, the wild flowers, shrubs and trees, all with their unique micro-habitats. 

If a neighbor happens by, we chat as I rest.  Now in my second summer of planting dahlias, we share our anticipation of blooms and bouquets.  Taking a simple, root-like tuber and planting it into the dark earth is a process that engenders patience – tending to the area and waiting as months pass, until a green sprout finally emerges.  Even having studied the sciences, I am amazed at how a stunning flower emerges from such a seemingly mysterious process. And now we come to my first dahlia bloom of the season – a beautiful, intricately circular patterning of soft orangey glow.  As I stand near admiring the blossom, I notice another being’s presence too.  A large praying mantis is perched just above, seeming to honor its beauty — what an awe-inspiring pair!

The photo is of my actual dahlia bloom and the visiting praying mantis.  The photo was taken by my neighbor, Maggie Rose Regan

The mantis, a master of the art of being motionless, teaches us the value of stillness – and the attention and closer observation skills such a practice brings.  Indeed, my slowing down and ability to bring more mindfulness into my day-to-day activities has awakened so much more beauty and awe in my life, and reminds me of my interdependent relationship with Nature.

And connecting with our natural, or “other-than-human” world is showing to be beneficial to our health and well-being in many wild and wonderful ways.1,2,3,4.  So inviting a bit more stillness, or ‘human-beingness’ rather than ‘human-doingness’ into our lives, will likely open our senses to the beauty and awe around us, and perhaps cultivate more joy and gratitude along the way – as it has for me.

These experiences inspired me to create a new elective for our first- and second-year UConn medical and dental students during the fall of 2020:  Nature as Medicine.  For our pandemic weary and virtually exhausted students, I thought a shift in environment would be refreshing.  The course was thus designed with the following student learning objectives:

  • Directly experience & learn practices for Rewilding, esp. Forest Bathing;
  • Understand the physical & mental benefits that connecting with Nature has on human health & healing;
  • Enhance observational skills, which are fundamental to the practice of medicine & dentistry;
  • Learn mindful movement practices known to decrease stress/burnout, e.g. Qi Gong, mindful walking/Labyrinth;
  • Deepen their appreciation of the natural world;
  • Share their class experiences with course participants.

Offered as a daily, two-hour class, each gathering was held out doors during our schools’ one-week elective time frame.   Sessions included experiential activities such as mindful walking, sensory awareness, and gentle movement as we explored the trails of local woodlands and green spaces, masked and physically distanced.  We also practiced quite observation by finding a ‘sit spot’ for sitting in stillness for 15-20 minutes.  Opening one’s senses, noticing any movement, and nonjudgmentally bringing attention back to the present were key parts of this practice.  Our small group of twelve students were invited to share their experiences and reflections during each class via an opening ‘check-in’ and at the close of each session.  In addition, some brief readings and web-based resources were offered to stimulate further curiosity and provide evidence for Nature’s benefits, e.g., the scent/exposure to pine terpenes enhances immune system function in humans.3

The results and general feedback were remarkable, with overall enhanced well-being, improved sleep, and less anxiety reported by most all students.  The students also experienced first-hand the health benefits and value of human access to safe, green spaces – an important lesson as future advocates for their patients and communities.  As such, I am planning to offer the elective again this spring, and look forward to continuing to evolve a Nature-based curriculum.  As health professionals and educators seeking innovative ways of bridging both virtual and in-person learning opportunities, I recommend giving the nature-based learning ecosystem a try! 

Mary P. Guerrera, M.D. is Professor Emeritus of Family Medicine at the University of Connecticut School of Medicine, Farmington, CT where she enjoys teaching medical students and residents.

Residency Training in the COVID-19 Pandemic: Adaptation, Exhaustion, Opportunity

By Ecler Jaqua

As the COVID-19 pandemic advanced, many rapid changes had to be made in medical education. Residency programs had to be adaptive and creative to deal with the ever-changing CDC landscape protocols to educate residents in a restrictive in-person environment.

In a matter of days, our family medicine residency clinic had to change all the in-person visits to telehealth. Video visits were something that was being tested and executed in the faculty clinic, but nothing similar was done on the residency side. At first, it was very challenging to our residents, but especially to our patients who had no idea how to use the app for the video visits. Many appointments had to be changed to telephone visits instead due to technical issues and poor literacy. However, as time went by, most of the residents, faculty and some patients started to get more familiar with the current system. Telehealth is here to stay, and I don’t think it will ever leave us. On the positive side, telehealth has now opened up opportunities for patients who previously were unable to attend their doctor’s visit.

Unfortunately, the pandemic just not affected the way we take care of patients but also negatively affected the training of residents. It led to many modifications for safety reasons within the clinics and hospitals that resulted in decreased volume of procedures, simulation laboratories, face-to-face teaching, hands-on training, and skill-based teaching activities. Elective rotations had to be canceled, reducing interpersonal connections in favor of social distancing and home isolation. The residents’ clinical skills competence in doing a physical exam weakened as they no longer have access to patients under supervision. The conventional bedside teaching where residents and faculty can ask patient questions in real-time and have essential discussions as a team had to be discontinued. Numerous residents were unable to attend conferences, complete research projects, or participate in extra-curricular activities that could help them get a competitive fellowship or their dream job.

Several residency programs at my institution had to restructure their residency training and redeploy many residents to services in need. Due to these rapid changes, the hospital shifts were at times very exhausting for the residents – not only because of the long hours and multiple days working in a row but also the constant fear of spreading the virus to a loved one. On top of all these changes having to wear personal protective equipment (PPE) all the time can be very uncomfortable. Residents many times felt a mix of anxiety, fear, emotional and physical exhaustion during these extraordinary times.

The weekly didactic teaching sessions, a crucial component of residency training, changed radically with the pandemic. All the in-person lectures moved online through platforms such as Zoom. The advantage of having the didactic session online was the ability to have everyone attend from any location and being able to invite speakers from different institutions. Virtual rounding was also implemented in countless residency programs to keep the whole medical team safe. The virtual rounds involve a pre-round done by the residents and medical students, and the attending physician would join remotely to discuss the cases with the whole team. During this time, it is an excellent opportunity for the attending physician to teach, showing research papers and PowerPoint slides about the cases that are being presented. As soon as the virtual round is ended, the attending physician would see the patients by him- or herself and resume the virtual round in the afternoon to discuss their physical exam findings and any other pertinent information from the patients or medical staff. Although there is no replacement for the face-to-face bedside teaching and observation of the resident or medical student performing the physical exam, this model is efficient, delivers substantial educational value, maximizes patient care time, and provides a safe environment to both trainees and patients.

Residency programs across the nation adopted video interviews for virtual residency recruitment. One of the advantages of virtual recruitment is the amount of money and time saved during the interview season. Not having these expenses can be a relief to the medical students and the residency program, especially as the financial crisis precipitated by the pandemic led to budget cuts for recruitment in many programs. Virtual recruitment also allows the residency program to interview more applicants as more interviewers may be available. The downside of virtual recruitment is the limited opportunities to socialize with current residents and faculty. It may also cause video fatigue if an applicant doesn’t take a break or stays uninterrupted for more than two hours in an interview.

Although these are challenging times, we were able to reconsider our current resident education and welcome ground-breaking methods while providing a high quality of care. Even though the pandemic affected residency education, several research studies show that the level of knowledge and clinical practices with virtual learning was acceptable. I believe we gained an understanding of how to integrate technology with the current teaching modality without compromising patient care. We also learned how to improve health care systems and redesign curriculums to ensure appropriate training.  

In the near future, as the pandemic subsides, we will see a hybrid of these models. Learning telehealth skills along with classroom and bedside teaching, the flexibility to have lectures in person and virtual so that everyone can attend, and virtual interviews with an option for an in-person interview and visit the residency program site. These adaptations are still a work in progress, but I am hopeful that all the changes and discoveries we had this past year will positively impact medical education.

Ecler Jaqua, MD, DipABLM, DipABOM, FAAFP is a geriatrician and assistant professor of family medicine at Loma Linda University Health. She is the California Academy of Family Physicians Riverside-San Bernardino Chapter president-elect.

I Have Hope – Reflections on Medical Education from the First Wave of the Pandemic

By Suzanne Minor, MD, FAAP

Every month I receive the evaluation comments written by fourth year students about their rotations, sites, and preceptors.  I read through these looking for possible concerns around faculty development and resident development especially with regards to teaching our students.  I want to make sure that if there are any trends, I am on top of them; if there any opportunities, I can quickly work to support faculty as needed.  

This past Fall, I read our first evaluations since our students started back after the pandemic.  I did not know what to expect.  Actually, I expected negative comments to jump out at me.  In the months since our faculty had last worked with students, the coronavirus pandemic had ravaged  South Florida.  Our affiliate hospitals were overwhelmed with COVID-19 admissions and our already busy faculty had born the burden of caring for sick patients with limited PPE. They had to attend to patient families through virtual means, and do so while working long hours. They often had to isolate from loved ones to protect them from possible illness.  And there was not reprieve in site.  One of our affiliates had asked community physicians to do hospital shifts to spell over-worked hospitalists.  I didn’t know what students would experience as they returned to the clinical setting. 

As I read, I noticed I had been holding my breath and my shoulders were tight with tension. But I didn’t need to be worried, after all.  I felt my throat catch and a surge of sad happiness, probably a release of pent up emotions related to this crazy pandemic.  The comments by students were amazingly positive.  Over and over students spoke about the excellent, high-quality teaching provided.  Students on hybrid rotations commented about the incredible learning experiences they received through virtual rounding and cases plus in-person scrubbing for surgeries. Particular patient care experiences were sometimes cited.  I know those hybrid rotations were crafted quickly and with great effort in order to provide optimal learning experiences despite the pandemic.  Some faculty took more students than usual yet still provided outstanding teaching and supervision.  They were taking on added duties even in this situation and I imagined that they would probably write quite a few letters of recommendation in the coming months, adding further to their time demands. 

There are just a few comments about faculty performance being negatively impacted by COVID-19.  Still, those comments are rare.  Our dean of clinical education took great care in working with sites to ensure that students would not work with patients suspected of having or diagnosed with COVID-19 and to ensure the safety of patients, students, staff, and faculty.  The COVID-19 admissions slowly declined; students are only able to be in the clinical setting because the numbers were coming down. Yet, in spite of this pandemic, our faculty is giving their all to students and patients.  Not only are faculty teaching during a pandemic, they are teaching well even in this different environment, providing meaningful experiences to learners while also accounting for safety. 

As I continue to review the report, I am aware of the halo/horn effect and wonder if students were so grateful to be back in the clinical setting that they are providing more positive comments about faculty that they might have  had there not been a pandemic-mandated pause in their clinical training.  I also wonder if faculty were just so grateful to have students back that they were nostalgically reminded of the joys and wonders of teaching and passing on our wisdom and passion for patient care to those coming after us – those who will probably be our doctors one day.  Whatever the reason, joyous teaching interactions leapt from the report with jubilant aplomb. 

The end of the report contains students comment about the teaching they received from residents.  The comments about resident teaching were just as positive and strong.  I admit that I shed a few tears when I read comments about our former graduates who are now residents in multiple clinical programs and sites teaching our students in such a challenging situation.

These comments weren’t just positive.  They detailed specific high-quality teaching moments.  I’m so grateful to bear witness to the interpersonal connections at play with each other: patients, students, staff, residents, faculty.  

These observations carried through to the personal statements of our fourth-year students applying to residency.  So many students were inspired by the physicians that cared for them or their loved ones in their formative years.  We are all interconnected.  It may sound very “airy fairy” or New Age, but I notice this connection again and again: physicians inspiring patients to become physicians-in-training, physicians and residents teaching students who will one day become physician educators themselves, patients receiving care but actually who are educators.  We are all connected and in this report I see this so clearly.

I’ve been thinking a lot lately about the interconnectivity of each person within society and on this planet.  It is so clear to me during this pandemic that we as a people are only as strong as the weakest link.  If just a few people are not wearing masks or are gathering together, the novel coronavirus will continue to spread.  But if we follow basic guidelines, we are strong together and our unity-in-action speaks to our interconnectedness.

Medical education and patient care are intricately woven together like a tapestry with every thread contributing its own texture and color to the pattern and strength to the structure. I am so honored and grateful to witness and be a part of the beauty on the report before me, because I know that the words written are just a glimpse of the overall experience students had at their sites with their preceptors, residents, and patients. 

Suzanne Minor, MD, FAAP, is the Assistant Dean for Faculty Development and an Associate Professor at the Florida International University Herbert Wertheim College of Medicine She is a member of the Editorial Board of Reflective MedEd. Follow her on Twitter @minor_se