Disha M. Patel

As a medical student during a global pandemic, it has been an immense honor, but also a heavy burden, to shoulder the responsibilities of a healthcare professional. From battling vaccine misinformation to managing chronically ill patients via telemedicine, I have been able to have these first-hand experiences owing to the longitudinal chronic care curriculum offered at my school. The longitudinal chronic care curriculum at the Medical College of Georgia provides the opportunity to work with a real patient to gain knowledge and confidence, and to experience patient care ownership, in preparation for our entry-level encounters in the hospital setting. This curriculum allowed my student partner and me to follow an assigned patient monthly through our telemedicine chronic care clinic during our first year. During our last scheduled visit, we learned that our unvaccinated patient had unfortunately passed away following a long stay in the hospital due to COVID-19 complications. The experience has left me with lessons learned and unanswered questions that will shape me as a person and a future physician.

The first time we met RP, it was a telemedicine visit in January 2021. RP had an extensive medical history including a previous stroke, heart bypass surgery, hypertension, congestive heart failure, chronic ulcers on his legs due to poor blood flow, and nerve damage in his feet as a result of his type 2 diabetes. However, during this first visit, his biggest concern was his non-healing open ulcers on his legs that had made moving around very difficult. We talked about his pain management and wound care and discussed exercises to help with the blood flow to his legs. At the end of the visit, RP disclosed that he had experienced some right-sided weakness that resulted in a fall around Christmas. This took me by surprise because this was my first visit with a real patient and, from what was being described, it seemed like the patient may have had a stroke. I felt that the weakness and fall should have been the first things he told us about during our visit, though afterwards I realized that he may have not understood the importance of that information. We contacted patient care coordination to get him an appointment to see his primary care physician as soon as possible and get him scheduled for an MRI.

During our second visit, we learned that RP never went to get his MRI due to his claustrophobia. We tried to comfort and counsel him on the importance of getting the MRI, but he never overcame his fear. I realized that sometimes, no matter how hard you try, patients may not do what you want them to, even if it is in their best interests. But I was frustrated, because I wanted to do right by my patient and to help him get better. Our subsequent telehealth appointments with RP mostly focused on wound care, physical therapy, and whether he had experienced any more stroke-like symptoms.

The last time we talked to RP he was in the hospital, though we didn’t suspect that it would be the last time. He had been in the hospital with COVID pneumonia for over two weeks. He had gotten somewhat better, but he still had not fully recovered because of his other chronic issues. He was discharged two days after our conversation but returned a day later due to respiratory failure and shock that led to his passing. I did not learn of his death until it was time for our regular telehealth visit the following month; when I checked the chart before his visit it stated that RP was deceased. This caught me off guard and I did not know how to feel. The longitudinal curriculum had allowed me to get to know this patient and to follow him over the past year, but now he was just gone. He had died only two days after we last saw him. I felt lucky that after all our video calls I had the privilege to see him in person that last time and to meet the man behind the screen because of a missed telehealth visit.

I’m sharing my experience with RP because I need people to see and acknowledge that the medical education I have received during the pandemic is not the same medical education that others before me received. Not only did I have to learn how to navigate the pressures and difficulties of medical school, but I had to deal with unanticipated major life changes brought on by the stresses of the pandemic that were taking a heavy emotional and mental toll on the global population. Starting medical school during the peak of COVID, I was overwhelmed with the frustrations of virtual lectures, the inability to shadow/volunteer in-person, and restricted social interactions. But the pandemic not only affected the structure of the classroom; it made my first patient into my first patient death.

Because of COVID, the many high risk and immunocompromised patients we saw in the chronic care clinic were now predisposed to an additional risk that increased their rates of morbidity and mortality. Many students might not encounter their first patient death until they are well into their clerkship rotations or even into residency. Yet I had to learn how to navigate the emotions of a patient death as a second-year medical student with my first patient. When I first learned that my patient had died, I was not equipped to process my emotions. I could not fully comprehend that the patient to whom I thought I was about to speak had passed away almost three weeks ago without me even knowing.

I had spent the past nine months talking to RP every month, getting to know his health struggles and the challenges in his life. And now he was gone, and those conversations were over. Even though I knew he had many chronic problems, I never really thought about the fact that he could die while he was in my care. I thought he would be there for our remaining visits.

After wrapping my head around the fact that my first patient had died, I began to question myself: Could I have done something different to have changed his outcome? Could I have convinced him to get the COVID vaccine if I had pushed a little harder? And if so, would he still be alive today? I had a responsibility to take care of the well-being of this patient and I felt like I failed him. This is a tremendous burden to carry. Even though I know RP had other physicians taking care of him, I can’t help but wonder if just maybe, if I had said something different or done something different, that he would have gotten vaccinated and could still be alive today. No one can truly prepare you to deal with your first patient death. But entering medical school, I never thought that I would be experiencing a patient death so soon and so remotely.

By Brooke Schwartz

I feel off this morning. My head feels heavy, and my throat is sore. I roll out of bed and reach for one of the at home COVID-19 tests stacked in my bathroom. I discard the instructions, as I have them memorized by now, and wait a few minutes. It’s negative. I put on my scrubs, grab my new monofilament, and head to the free clinic where I am currently rotating as a third-year medical student. 

It’s time to see my first patient of the day. I am excited because he is an elderly man, Mr. E, whom I have seen before. He is a 78-year-old struggling with homelessness, depression, hypertension, peripheral claudication, wet macular degeneration, and sensorineural hearing loss. His gratefulness to our clinic and his warm personality are endearing. I can hear Mr. E in the waiting room asking the volunteer for help filling out his paperwork because he can’t see the small print. The reems of paperwork at a free clinic can be daunting. I listen more closely as the volunteer carefully goes through each question with Mr. E. He speaks with her in Spanish and his voice is deep and strong.

Eventually, the door leading from the waiting room to the central hallway of the clinic swings open, and I see Mr. E dressed in his usual green cardigan and button-down plaid shirt. He waddles into the exam room floating his cane above the ground. “Why does he refuse to use his cane the proper way?”

He reminds me of my grandma who recently passed. She, too, was a strong-minded spirit stuck in a weak, withering frame. She, too, clung desperately onto her independence to the detriment to her overall health. Their refusal to accept their frailty evokes a strong desire within me to protect them.

From what I remember about our last visit, I know Mr. E. does not view his health as a concern, but his lack of employment is at the very top of his priority list. He sees himself as a failure of man, relying on his eldest daughter to house him, which she does—begrudgingly. On the other hand, my priority was keeping him from having a heart attack and ending up unconscious on the side of the street. We will discuss both issues again this visit.

I knock on room number two along with my in-person translator and find my dear patient behind it. We exchange smiles and a handshake. The translator and I have both seen Mr. E four times now, and we are well adjusted to effectively communicating with each other. We know to speak in short sentences and to allow ample time for the patient to express all his concerns before responding.

“Hello again, I am so glad you came back for your follow-up. How have the at home blood pressure readings been?” As the translator begins, I cough. Immediately, I feel guilty. Is my throat still hurting? Did I take the COVID test too early? Do I have a fever? Suddenly, I picture my vulnerable patient hospitalized, intubated, and falling ill to COVID-19 because of me. I quickly pull myself back into the conversation; over the course of my medical school, COVID-19 has forced me to become comfortable with this nagging anxiety of infection and transmission.

Mr. E. responds, “My pressure has been a bit better, but I couldn’t pick up the medication you prescribed at the last visit because it is $18 at Publix, which is just too much right now.” I zone back in as the ever-present difficulty of treating uninsured patients rears its ugly head.

“Did you use the GoodRx coupon we showed you last visit?” He looks confused. “No, I forgot what that is.” I pull out my phone and open the application. “I found it for $6 at your local Winn-Dixie for a 90-day supply.” He reaches up and taps my phone screen to zoom in as I make a mental note to print out the coupon for him this time. There is a look of relief in his eyes, and he says, “That is much more affordable. I promise to pick it up after I leave today.”

We finish the visit and I exit the room to present the patient to my attending. She is concerned he does not remember much of what we talked about at the last visit and suggests we perform a mini-mental state examination. He scores phenomenally, and we are relieved. We send him off with the prescription, GoodRx coupon, and plans for another visit in a few weeks.

My attending sees the despair in my face as I wave goodbye to Mr. E. She allows me a moment to reflect. Elderly patients have always been a difficult population for me to see due to their vulnerability. I feel a sudden urge to walk them to their car, drive them to the pharmacy, and, overall, deliver care I would not consider for others. Unlike most other patients, I saw Mr. E. weekly for a month and spent time in between other patients calling MEDICAID representatives to help with his case.

I must let go of my emotional attachment to Mr. E as the waiting room fills up, but I know it is this compassion that will help to make me a good doctor. I plan to practice in a way my emotions can aid in patient care, and I refuse to allow the hardships of medicine to hinder raw human-human interactions. I will allow myself to feel the emotions of my patients, while also providing them a strong backbone to lean on.

Time for the next patient.

The day progresses and I begin to feel more ill. I excuse myself from clinic and head home. Another COVID test is pulled from the stack and once again, it’s negative. As I fall asleep, I’m worried the test tomorrow might not be. “I can’t believe I shook Mr. E’s hand. I can’t believe I let him touch my contaminated phone! Am I a horrible provider?” The guilt consumes me as I wonder if I have put the very patient I want to protect the most at risk of acquiring the frightful illness of COVID-19.

Brooke Schwartz is a third-year medical student at the Florida International University Herbert Wertheim College of Medicine. She is interested in pursuing Pediatrics.

Bearing Witness:  Storytelling by Healthcare Professionals and Learners During Times of Uncertainty

Lisa Howley, PhD¹; Virginia Bush¹; Elizabeth Gaufberg, MD, MPH^1,2

1. Association of American Medical Colleges
2. Harvard Medical School

Corresponding Author: Elizabeth Gaufberg, Elizabeth_gaufberg@hms.harvard.edu

When the coronavirus pandemic hit North America in March of 2020 the medical profession was plunged into a crisis more devastating than any it had faced in the previous century. Trainees and physicians were called to the frontlines to care for extremely ill patients for long hours in the context of inadequate knowledge, skills, and equipment; patients were dying without loved ones to hold their hands and ease their passage. Ethical dilemmas around distribution of limited resources permeated each medical decision and led to moral injury for providers who could not deliver the quality of care that was standard just weeks prior. Healthcare professional burnout and suicide increased from the already significant pre-pandemic rates^.1 Many medical schools limited students to virtual learning to protect them from exposure to the virus; yet a byproduct of this prudent decision was that many students found themselves isolated from peers and teachers, and in living situations suboptimal for class attendance and studying. Some questioned whether they were getting an education that would allow them to become good doctors.

Amid the first surge, following mounting protests over policing practices in communities of color, the murder of George Floyd on May 25, 2020, ignited a period of civil unrest with urgent calls for structural change within policing and other societal institutions. Racial disparities in Covid-related hospitalizations and deaths drew attention to inequities in health and healthcare. Academic medicine embarked on a period of self-examination around issues of race, resulting in efforts to address racism in medical schools and health systems. Ideological divides within our profession and nation were intensified at a time when uniting around a common purpose was never more critical. And yet for many, an enhanced sense of meaning and rededication to one’s calling permeated the chaos; among them were medical students who assumed the mantle of advocate, discovering avenues for self-expression and collective action.  In a time of devastating illness, social upheaval, and economic ruin, we invited the academic medicine community to tell their stories.

AAMC FRAHME AND CREATIVE EXPRESSIONS DURING TIMES OF UNCERTAINTY

In 2017, the Association of American Medical Colleges launched a new initiative called FRAHME (the Fundamental Role of the Arts and Humanities in Medical Education). This initiative advances the powerful and transformative role of the arts and humanities in achieving core 21^st century outcomes for medical learners. FRAHME has produced a robust and diverse portfolio of programs and resources.² Well-designed and integrated arts and humanities educational experiences can foster many core skills of doctoring, including close observation and interpretation, reflection and metacognitive awareness, empathy, teamwork, well-being practices, and the ability to engage respectfully in difficult conversations. Some of the desired outcomes of arts and humanities integration have come to the fore during the pandemic. Those include improving the capacity of health professionals to be adaptive, resilient, lifelong learners who appreciate the impact of social factors on health and illness and can respond effectively to complex challenges.

In the Spring of 2020, with the support of the National Endowment for the Arts, FRAHME established a creative forum for healthcare professionals and trainees to bear witness to these unimagined and rapidly unfolding challenges. Making stories, narrative, or poetic, spoken or written, or performed as music or movement, is an essential part of being human.  Storytelling allows us to give form to complex or ambiguous experiences; we may then metaphorically walk around that form, stand back or come closer, examine curves and imperfections and possibilities.  Engaging both the head and the heart, stories allow us to share our personally unique vantage points as well as our shared humanity with one another. Listening to stories within a community enables us to identify common values and goals, and to bridge ideological divides. Perhaps most important in these times of adversity, story sharing reminds us that we are not alone in our suffering.

Creative Works

Three distinct opportunities to share —55-word stories and poems, The Good Listening Project collaborative poems and StoryCorps recordings — have resulted in a repository of oral and written creations, providing opportunities for current reflection and an historical imprint of these uniquely challenging times. This repository can be found at https://frahme-aamc.org/.³

• 1. 55-word stories and poems: The 55-word story or poem activity has been used in many U.S. medical schools to encourage reflection and meaning-making in support of professional identity formation.⁴ The exact word count specification invites attention to language choice as well as the creation of a narrative arc that may not emerge from a more open-ended format. In June 2020, we launched a broad call for 55-word submissions and original poetry and collected over 300 submissions over the course of one year.

• 2. Listening Poet Sessions with the Good Listening Project:  In partnership with The Good Listening Project, FRAHME provided a creative opportunity for members of the academic medicine community to take part in a private conversation with a trained Listener Poet.⁵ Listener Poets engaged in brief virtual sessions with hundreds of volunteers who each shared their unique experiences during this period of upheaval and suffering.  The poet then produced a custom poem based on the conversation, which was emailed to the recipient within 24 hours. In the words of one recipient “When I received the poem the next day, it brought me to tears. It put everything into words that I was feeling; it was very healing for me.”

Figure 3

One Listener Poet shares the following example which emerged from a conversation with a faculty member who had been a Professor of Integrative Physiology for almost four decades. The Professor brought the tools of mindfulness and self-care to medical students, many of whom had been studying long hours, day after day, in isolation for the past year.  

Caregiver, Care for Yourself

You have come here to help others

and yet it has been a year of

unrelenting work

isolation

stress.

Your chest tight, tired, heart hungry for touch.

We were born to engage

but can you embrace

and be held through a screen?

Here, here are the tools:

ancient and intimate as a whisper

known in every mindful moment.

Rise, take your precious body

and walk,

run,

race back to yourself.

Rise, taste hope in another’s eyes.

Here is the first patient.

Caregiver, care for yourself.

Listen, you are here, you are held in hope,

made whole in a moment of awareness and connection.

You asked to serve, to heal others,

but you were swallowed by a pandemic

and in the fearful dark

you leaned to breathe, to wait,

to trust, and believe.

Caregiver, care for yourself.

Anonymous, Professor

Through our partnership, we conducted 254 listening poet sessions and a curated collection of the poetry is available online and in a TGLP published hardback set of books. In the 15-series The Good Listening Podcast, a Listener Poet brings three poems along with the stories shared in the conversations that inspired each work.⁶

• 3. Oral History Project with StoryCorps: The AAMC also established a partnership with StoryCorps, one of the largest digital collections of human voices, featuring conversations recorded across the United States and around the world.⁷ Healthcare trainees and professionals were audio-recorded telling their own stories or engaging in meaningful dialogue with one another.  These stories are now preserved in a special AAMC collection within the StoryCorps Archive, which is housed in the American Folklife Center at the Library of Congress. As of the time of this essay, a total of 13 recordings are included in this collection.⁸ In addition, several longer clips were edited into a set of 4-minute offerings which may be shared in educational settings and on social media.⁹

Closing Reflections

The AAMC FRAHME story collection has opened a window into the emotions and lived experiences of our pandemic storytellers. One story at a time, we have learned something about grief and loss, guilt and shame, racism and poverty, and the enormous power of loving relationships, spirituality, gratitude, and resilience.  The intensity of the pandemic continues to wax and wane to this day, and we have intermittently returned to somewhat more normal educational, professional and life circumstances. Yet burnout and post-traumatic symptoms are likely to plague our healthcare learners and workforce for a long time to come. Story-sharing may allow us to greet each other in places of honesty and hope, and to begin to heal.

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Funding: The authors received financial support from the National Endowment for the Arts (NEA) for work described in this article.

Acknowledgement: The authors extend their gratitude to the following individuals and organizations for their efforts to make this story sharing initiative a reality: StoryCorps; The Good Listening Project; Alison Whelan, MD; John Nash; Brandy King and Adrien Barrios.

References:

1. Linzer M, Stillman, M, Brown, R, et al. American Medical Association – Hennepin Healthcare System Coping with COVID Investigators. Preliminary report: US physician stress during the early days of the COVID-19 pandemic. Mayo Clinic Proc Innov Qual Outcomes. 2021;5)1):127-136. https://doi.org/10.1016/j.mayocpiqo.2021.01.005

2. The fundamental role of arts and humanities in medical education. AAMC. June 30, 2020. Accessed April 12, 2022. https://www.aamc.org/what-we-do/mission-areas/medical-education/frahme

3. Creative expressions during times of uncertainty. AAMC. October 15, 2020. Accessed April 12, 2022. https://frahme-aamc.org

4. Scheetz A, Fry ME. The stories. JAMA 2000;283(15):1934. https://doi.org/10.1001/jama.283.15.1934

5. The Good Listening Project. Accessed April 12, 2022. https://www.goodlistening.org

6. The Good Listening Podcast. The Good Listening Project. Accessed April 12, 2022. https://www.goodlistening.org/podcast

7. StoryCorps. Accessed April 12, 2022. https://www.storycorps.org

8. AAMC. StoryCorps Archive. May 2020. Accessed April 12, 2022. https://archive.storycorps.org/communities/aamc

9. AAMC. On the front lines: stories recorded with the Association of American Medical Colleges. StoryCorps. July 13, 2021. Accessed April 12, 2022. https://storycorps.org/on-the-front-lines-stories-recorded-with-the-association-of-american-medical-colleges

By Sunny Nakae

This piece is dedicated to all the phenomenal Black women in my life (you know who you are!) who teach, inspire, challenge, advocate, and slay on the daily.  I am not speaking FOR Black women here, I am speaking TO white women.

I grew up as part of many worlds: white, Japanese, religious, secular, sporty, musical, school, and manual labor – to name a few.  As an adult I view places and spaces from a lens of different perspectives of the identities and experiences I carry.  This essay is born of many conversations, witnessings, observations, personal missteps, and triumphs of the experiences of women of color in professional spaces. While I share many intersections as someone who identifies as a woman of color, I recognize that there are aspects of Black identity that I only proximally understand.  My identities give me safety to speak to white women, with whom I share experiential bandwidth.  I write this in hopes of building more bridges of trust and solidarity for all who identify as women. By centering Black women, I shift the burden onto white women to know better and do better. 

Why Black women don’t trust you:

1. You say too much.  Black women are always paying attention.  Always.  They do not have the luxury of ‘running their mouths’ to anyone but their most trusted circles.  If you’re a colleague and wondering if you’re part of that trust circle, the answer is likely no.  Black women are accustomed to small things devolving into blowback, and therefore they are careful about what they share and with whom.  If you seem like you are always talking about people’s business, you’re inherently unsafe. 
2. You criticize people of color publicly.  There is a deep and abiding solidarity that Black women have for the cause of justice.  They are keenly aware of the collective whole and therefore almost never criticize people of color in professional spaces, even when they agree behind closed doors.  I have observed that in professional spaces Black women often say more with their silence.  Black women know that racism spreads uncontrollably and any endorsement of small criticisms by people of color become wholesale indictments of competence for all people of color. 
3. You are too familiar, too fast.  Black women do not have the luxury of being goofy or overly familiar at work.  They may not be able to dress or speak casually without coming under criticism or having their authority undermined.  When you are the first to drop casual language or tone, indicating familiarity, you signal that you don’t understand how code switching impacts Black women. Do not use “sis” or “sister” or nicknames or vernacular that are culturally gratuitous or disingenuous to your usual communication.  It comes across as taking for granted that trust must be built. Assuming familiarity can feel a lot like assuming superiority.
4. You don’t name whiteness.  If you want Black women to trust you, regularly own your whiteness, and your white womanness.  Stop using whiteness as default without naming it.  Stop using women’s issues to masquerade racism.  Black women got the right to vote in 1965. White women were enfranchised in 1919, which is labeled by historians in a very exclusionary way as “women’s suffrage” while leaving out women of color.  If you benefit from whiteness, own this history of exclusion by naming whiteness without centering it.  Never use sexism to excuse racism because Black women deal with both on the daily.
5. You don’t name racism.  When acts of bias, discrimination, and mistreatment occur white women often rationalize away the racism in these acts.  Even if it’s the same person doing the harm, it does not have an equal impact because racism structurally and interpersonally mediates the realities of women of color.  If you want to build trust, work through your discomfort and label racism when it occurs, including your own.  Don’t try to reframe, genderize, or whitewash harm.  Listen and abide in the muck of non-closure. Your ability to be uncomfortable will allow you to be more proximal to Black women.
6. You perform happiness too much.  Don’t misunderstand this.  Black women aren’t distrustful of genuine joy.  But when women in professional spaces conform to smiling a lot and performing happiness to appease the white patriarchy, it makes things even more unsafe for Black women.  Black women are subject to tone policing and stereotypes around being angry or unhappy.  Your withholding of genuine emotions for the sake of peace depletes the emotional oxygen out of the room and leaves even less space for Black women.
7. You correct your subordinates but not your superiors.  This signals being invested in caste and hierarchy systems at work.  If you never speak truth to power, you tacitly endorse the status quo of misogynoir that Black women face daily.  If you’re unforgiving to those who report to you, while making excuses for those above you, you’re part of the problem.  The hierarchy does not protect Black women, so being invested in it creates mistrust.
8. You do not disrupt, you only notice or apologize after.  I heard a Black woman CEO state it best, “If one more white person comes into my office gobsmacked at how their white colleagues are treating me, I’m going to scream.  I think ‘Why didn’t you speak up in the meeting when it was happening?  What are YOU doing to disrupt the racism?’  No, I don’t want to hear you apologize for your white colleagues. I want to see you confront them.”  If you are not willing to battle white supremacism, it should be obvious why you’re not trusted. Black women don’t need your sympathy.  They need your solidarity. Intervene without needing a pat on the back.
9. You ask about or comment on hair, skin, or clothing uninvited, non-reciprocally, and/or with a patronizing admiration or dehumanizing curiosity.  Before you comment on a Black woman’s appearance, reflect on whether you are coming from a place of objectification or curiosity, or whether you have a relationship that would make it relevant that you like their hair/clothes/skin.  (Hint: Black women do not care what you think of their braids or skin, like ever.)  Black women’s appearances are often policed and judged to a far greater extent than white women. A well-meaning compliment can feel like a microaggression of being othered or objectified. 
10. You demonstrate unyielding and bottomless solidarity for white people while simultaneously applying “prove it bias” or “exception to the rule” logic for people of color.  In other words, your world revolves around confirming whiteness and the power centricity it yields.  If white people “just didn’t know any better” but people of color “should have known better” you’re not going to build trust with Black women. 

The Thin Book of Trust by Charles Feltman defines trust as, “Choosing to risk making something you value vulnerable to another person’s actions.” For Black women there is often no choice.  Because of structural and interpersonal racism, Black women often must navigate places, spaces, and dynamics where power is unequal and a great deal of their personal and financial wellbeing is at stake.  Trust without choice is risk.  Being subjected to unwanted risk depletes safety and can cause trauma.

White women, if you have not thought much about trust, I ask you to rumble with that.  Do you take trust and comfort for granted?  Do you expect trust from hierarchy, affinity, or position?  Get curious instead of defensive.  Interrogate your perspective and your privilege. If you blame Black women for not trusting you, you are contributing to the dynamic that makes life harder for Black women.  I ask you to consider what it would look like for you to take responsibility for building trust.  Honor confidentiality.  Respect boundaries.  Name whiteness, white womanness, white supremacism, and racism.  Speak truth to power.  Spend some social capital on increasing safety and inclusion at work.

How skeptical should we be of our patients?

By Juan C. Alvarez Jr.

Aesop was a Greek slave and storyteller from the 600s BCE who is accredited with the authorship of many common stories and folklore. One of his most well-known stories is of a Shepherd boy who was well-known throughout his village as a “prankster”. His most well-known prank was to call the entire village to his aid in fighting off a wolf from attacking the town’s flock of sheep. Time and time again the town would gather their weapons and run to the pasture just to find a young boy laughing as he was able to make a fool of the entire town. After continued false alarms, the town eventually caught on to the boy’s foolishness and decided to no longer entertain the “prankster” by rushing to his cry for help. At first, the boy did not give this much thought as he assumed the joke was just overused. Nevertheless, he, unfortunately, learned his lesson at the cost of his life when the town did not rush to his cry for help in the presence of a real wolf. The lesson to be learned from this story is that once someone is marked as a liar, no one would believe them, even if they are telling the truth.

 While this is a great life lesson on how to portray yourself to others, I believe the story should have a different meaning for physicians with their patients in the medical field. If just one person, even though the boy was an established liar, had rushed to the boy’s aid, he may have survived his encounter with the Wolf. This is immediately what I began to think of during my emergency medicine rotation when I witness how a bias towards a patient could have potentially come at the cost of their life.

“Frank” was a homeless person suffering from addiction to heroin and opioids who was considered a “frequent flyer” within this particular emergency room. He was well known among the staff as he had visited the emergency room upwards of 50 times in the last year in attempts of obtaining pain medication for a false illness. The patient had “cried wolf” for everything from broken bones to a heart attack to abdominal pain: he apparently had even hit himself and claimed he was attacked. After a while, the medical team started to entertain his complaints less and less as each visit always ended up in a negative work up and the patient would leave when he realized he wasn’t going to “score” some free drugs. This continued until one day Frank came in with severe abdominal pain. My attending physician, knowing Frank was a “frequent flyer” for drugs, thought it would be a great learning experience for me as a 3rd-year medical student to conduct a history and physical. So he asked his colleague who oversaw Frank’s care that day if I may evaluate the patient.

Not yet knowing any information about Frank or his extensive history of drug-seeking behavior, I began to take a full history and perform a physical exam just as I would any patient. As the encounter progressed, I began to rule up and down my differential diagnosis until I believed his presentation was consistent with a bowel obstruction. Feeling confident with my history & physical, I finished up with Frank and return to the doctors to present my findings. Throughout my presentation, based on the look on their faces, I started to realize they knew something I didn’t. Once I finished, they both laughed and said that I had been fooled by a great actor. Still lost I asked for clarification which is when they explained Frank’s history as a frequent flyer with drug-seeking behavior. I followed with questions along the lines of “How do you know he’s faking it?” The colleague replied, “I’ll show you” and had me follow him towards Frank.

During this second encounter, the colleague mostly spoke over, brushed off much of the complaint, and accused Frank of making up his symptoms. It was even stated that he was taking resources away from patients that “actually” need them. We then walked out of the room without conducting another physical exam and I was told “You see, that’s how you can tell they are drug-seeking.” I was then sent back to my attending who asked me about the experience and wanted my honest opinion on the situation. With the freedom to speak my mind, I told him regardless of the patient’s history of drug-seeking behavior, I didn’t think the patient needed to be treated like a dog by the other physician who put little effort into questioning Frank. How could we be sure if he was acting or not, especially since there was no physical exam conducted by the doctor? After some back and forth with my attending,  he decided that it was a good idea for us to evaluate “Frank” one more time, this time conducting a physical exam.

In the room for a third time with Frank, his story was consistent again. As my attending performed a physical examination, I could see he was becoming more convinced this may not be another episode of drug-seeking behavior. We then walked out and advised the colleague to order a CT scan which he was reluctant to do until my attending told him “If he isn’t faking it and you refuse to evaluate him, he could die or live and sue you.” To which he replied, “Fine but it’s a waste of our resources plus a drug addict can’t afford a lawyer”. Less than 2 hours later, the surgical team came down and took Frank to immediate surgery for a large bowel obstruction which is a medical emergency.

Reflecting on this situation I realized that as physicians our profession comes down to simply being there for each patient and treating them with dignity and respect regardless of their past. As my attending put it, “Drug addicts get sick too, and there’s no reason why their life and health matter any less than someone else’s”. By being allowed the privilege to practice within an art focused on the healing of others, we carry the responsibility to treat everyone as equals. This means doing everything within our ability to help them improve from their current state as all life is precious, regardless of any label society places upon certain people. As physicians, we need to be prepared to take on the wolf regardless of all the false cries in the past.

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.

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.

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.

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.