The Rambling Resident

I don’t know if that’s an appropriate title or not. Might have to change that.

Just finished reading and presenting a paper during Journal Club that was published in JAMA last week:

Brandt EJ, Chang T, Leung C, Ayanian JZ, Nallamothu BK. Food Insecurity Among Individuals With Cardiovascular Disease and Cardiometabolic Risk Factors Across Race and Ethnicity in 1999-2018. JAMA Cardiol. Published online September 28, 2022. doi:10.1001/jamacardio.2022.3729

It was pretty interesting. They found higher rates of CV risk factors (obesity, diabetes, HTN, and dyslipidemia) and CVD (HF, CAD, Stroke, or any CV disease) in those with food insecurity compared to those who do not across those surveyed in NHANES.

However, these were the most interesting findings:

There was a higher percentage of obesity in those with food insecurity compared to those without (40% vs 32%). Amongst those who reported food insecurity 40% were below poverty line, that means 60% were NOT. Amongst those who did NOT report food insecurity, 11% were below the poverty line. 4.7% of people who did not report food insecurity utilized Supplemental Nutrition Assistance Program (SNAP), so that doesn’t account for everyone below the poverty line as a possible explanation. 40% of people with food insecurity did not participate SNAP. There was a higher percentage of people who participated in SNAP in the group with food insecurity and CVD compared to the group with food insecurity and without CVD. And obviously food insecurity was disproportionately higher across Black and Hispanic people across all disease subtypes. In NHANES, they only had separate categories for people to identify as Hispanic from 2007 onwards and Asian people starting from 2011 onwards. The authors introduced the idea that the relationship between food insecurity and CVD/CV risk is bidirectional.

In terms of reading/writing papers. I learned that adjustment for age is like THE number one thing you should do. Also Table 1 is easy to gloss over but can always tell you more, the more you look at it.

The authors ended with suggesting higher recruitment to SNAP as well as using a 2 Question Food Insecurity screening.

1) “Within the past 12 months we worried whether our food would run out before we got money to buy more”
2) “Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”

MA suggested that there be a third question: Within the past 12 months did you have access to “healthy” foods? This question would attempt to characterize the higher rate of obesity in those with food insecurity.

I think that third question is an excellent point but probably should be asked if the answers to 1 and 2 are “no.” This brought up a number of thoughts/questions in my mind that I think need to be written out.

Access/eating healthy food is hard. Even if you have money. You need time. You need a house to cook the healthy food in because it’s usually homemade and you need a blender (if you’re like me and need to drink spinach). Also if you’re starving are you really going to eat a salad. Lez be real. Also remember that time I passed out cake to homeless people in Baltimore and they complained they had diabetes. Then I tried to pass out apples to homeless people and they complained of not having teeth?! You CAN’T win! But then I look at organizations like GLIDE, they offered decently healthy food in their breakfast tray: eggs, fruit, oatmeal, potatoes, a pastry, water, coffee. BUT what if someone doesn’t LIKE healthy food. Also i have no idea what the served for lunch and dinner….I hope there were greens.

I think this article doesn’t address the grades of food insecurity.

Grade 1, you need calories to live. (this is what i’m telling myself to justify eating the slice of pizza with cheese that looked like plastic the other day, we seriously need to have a food insecurity study in the hospital)
Grade 2, you have access to calories but you need access to healthier calories (that are also fast, cheap, already cooked) because now its not just about maintaining muscle mass.
Grade 3, you need to manage your limited money/time on buying and obtaining your meds and also buying/preparing/eating healthy foods. (I wish that really delicious keto cereal wasn’t so expensive. $15 for a bag that lasts 2 weeks?!?!?!?! That’s even too expensive for me and I love expensive food)

Going back to volunteering at GLIDE, they helped me see that you really can’t help people by telling them what to do. You just have to be present, provide and show them love. Eventually, people see that they are being treated with respect and dignity and they will help themselves…at least that’s what their strategy is. This is the most positive way of achieving success in humanitarian work. Now how do you incentivize providing poor people with healthy food? The paper also mentioned that starting in 2021 SNAP says your $1 is worth $2 when buying something healthy. I guess that’s a start. Is that enough? But it’s true, everyone loves a good deal, whether you have money or not.

Man these are the kinds of thoughts I should think through before presenting the article at journal club.

-is there a silver lining?

Originally posted on April 20, 2020 at https://www.medpagetoday.com/infectiousdisease/covid19/86043

It would be interesting to now write a commentary on this article…over two years later oh how things have changed. (i’ll put it on my to-do list)

—

To say that it is an interesting time in the world right now would be an astonishing
understatement. It’s incredible how COVID-19 started off in one city and within weeks
spread all over the world. If I were to personify COVID-19, I would call it an introvert:
present, but quiet. Reserving its words to speak for when it matters. But when it speaks,
people listen. One, because they didn’t know it could speak and two, because these words are powerful. COVID-19 has had more impact on a global level in modern times maybe since the advent of the household computer — albeit more of a negative impact and in less time. How one invisible piece of genetic material surrounded by a capsid has sparked so much fear, anxiety, and grief, I’m not sure we will ever truly understand. The human race has been terribly burdened in numerous ways: medically, emotionally, economically, technologically, and ethically. But maybe if we really reach, there is some semblance of a silver lining to which we can hold onto. Bear with me while I attempt to come up with some positive streaks of light thus far.

The whole world has united. While there is still potential for the quantity of knowledge and resources we share, it is undeniable we have made significant strides already in the medical community. Physicians in U.S. hospitals are picking up the phone and calling physicians in China for strategies and treatment ideas. Almost any partially formed idea regarding COVID-19 is publishable and freely available. As a community, we are starving for data. We pounce on every new article and every new podcast. Some ideas receive more attention for better or for worse. But still, we are engaging in open discussion and thriving from the exchange of science and theory. The number of resources constantly updating and compiling available information continues to grow. Imagine if we continue to apply this spirit of urgent collaboration in the future, humanity will only reap benefits.

Is it just me or does the sky seem bluer? With fewer cars on the street and fewer planes in the sky, our greenhouse emissions are fewer. Gas prices have dropped to under $1/gallon in some states. Venetians have been seeing clearer water for weeks. Maybe COVID-19 is Mother Earth’s form of revenge for all of the neglect we have shown her, although I hope not. We’ve become creative in designing masks made from home supplies. When posed with a shortage of N95s we are finding ways to disinfect and recycle them. We continue to move forward with a green resilience

Challenging themselves to go beyond their comfort zone, industries outside of medicine are stepping up. Car manufacturers are changing gears to produce ventilators. Restaurants are donating food to hospitals for the workers in need of sustenance. Shoe companies are protecting the feet of healthcare providers for free. Distilleries are making and distributing hand sanitizer. For those of us who have been ignoring our own minds, mental health resources are more widely available on the internet.

Laughter is the best medicine. We can now enjoy the irony in dark coronavirus-related
humor, giggle while watching viral videos of people just being silly, and endlessly smile as we scroll through the explosion of Instagram memes. A golden age for comedy has
transpired.

It is unfortunate that it required a lethal pandemic for this focus on public health, but we
may have finally found a sustainable way to provide a larger bandwidth of care at a lower
cost, via telemedicine. In a matter of weeks, we have implemented telemedicine in clinics
across the country. While nothing can replace the sacred physician-patient relationship derived from in-person office visits over time, I am glad telemedicine is finally here. It is a
work in progress that I am looking forward to incorporating into my future daily practice
long after COVID-19. These phone calls fill that niche of an inquiry requiring more attention than an email but less attention than a costly office visit. We can finally start reaching out to and treating the socioeconomic populations we were not able to reach before, as long as they have access to a telephone.

We may be physically distant from one another, but we are finally talking to one another
again. Whether it’s via Zoom, Skype, WhatsApp, Netflix party, or our actual cell phone we
are no longer making excuses to spend genuine time with one another. We are
communicating. We could have been checking in on one another all along but life, work,
and everything just somehow got in the way.

Because we forcibly strained to block out all of the negativity brought on by COVID-19, we are able to find some of the light. Smaller in magnitude compared to the bad, but good nonetheless. As we continue to battle together, I hope we maintain fullness in our hearts. There are millions of people out there suffering without jobs, keeping their heads high while furloughed, working on the frontlines, fighting to breathe, and facing anxiety in a forest of unknown. One way we can contribute to the greater good even while quarantined at home is to practice the act of kindness to one another and to ourselves.

— Drawing the line between empathy, burnout and productivity

Although I am no longer a resident, I continue to ramble and reflect. I am no longer writing for medpagetoday.com but was taking another look at some of my previous posts. Please click on the link below to read some of the amazing comments that others have written in response to my article. I have found wisdom in these comments and hope you will too.

Originally posted on February 13, 2020 at https://www.medpagetoday.com/opinion/rambling-resident/84850

—

A month into my first year of medical school, I met my first patient as a budding physician, and to this day, this experience remains vivid in my mind. He taught me my first lesson in empathy. That afternoon, we saw a young man in his early 20s who was presenting to the hospital, again, for a flare of hidradenitis suppurativa. Since his diagnosis 10 years ago, he had been hospitalized many times for various infections, and his disease became increasingly progressive. The slightest friction led to incessant skin peeling. Frequent flares and ineffective treatment options crippled him. I thought it was absurd that a skin disorder could lead someone to be bed-bound.

In their youth? That’s when life is supposed to get exciting! Others in their 20s are out there discovering the world, becoming independent beings, learning their way through jobs and relationships.

Yet, there in front of me was this man whose full-time job was to be still enough so that his skin wouldn’t peel. At that point, we were almost the same age, but our lives were so
different. I put myself in his shoes and could not stop thinking about the cruelty of nature. There he lay in bed. He would likely lay there for the rest of his life. All that afternoon and all that night, I would dwell on those thoughts. Not sure if it did me any good, but I did hydrate my eyes.

“Putting yourself in someone else’s shoes.”

That’s what we’re supposed to do as doctors, right? To treat everyone like they’re your
child, sister, mother, grandfather.

Being able to empathize with another human being is supposed to be natural, a sign that
we are all human, but at what point does empathy become a crutch?
That night during my first year of medical school, I was basically paralyzed with fear and
sadness to the point of dysfunction. I only lost one night of studying that night, so I guess it was OK. Over the next few years, I’ve had exponential exposure and increasing
responsibility.

A greater knowledge of medicine seems to bring with it, equally, the feelings of being both empowered and yet powerless. When empowered, I find myself using empathy as a fuel to go above and beyond. When feeling powerless, I feel sad but am no longer overwhelmed with every sad story. I’ve come a long way in terms of controlling my emotions. Yet every time I do cry, it feels inappropriate and debilitating. I feel weak. It feels like a step backward from the strong, steady doctor I’m supposed to be. With each “sad” situation I encounter, I try to find that strength. But what is the difference between being strong and just not feeling in general?

Just like crying too much scares me, the idea of no longer “feeling” scares me too.
Without even trying, and in just a few years, I have made such progress. I’m only at the
beginning of my career. Sick people are now “cool cases,” kind of like how people seem to find entertainment from the TV show “House.” I get excited to see those with rare diseases. It seems dehumanizing, doesn’t it?

What if this trajectory continues? I still look down upon the providers who make
inappropriate jokes and the others who laugh along to fit in. But what if one day, I’m the
one cracking the jokes? I understand the impracticality of disabling emotion in a field
where you have to function at your top game every moment, but at the end of the day we came into this field to treat people, not cases.
We are here to help people get back to their best life. So, where do you draw the line
between feeling and not feeling? Between empathy, burnout, and productivity? How do
you make sure the line stays put and doesn’t keep getting pushed farther and farther away from empathy? How do you protect yourself while simultaneously doing the best for your patients? Unfortunately, there’s no cute algorithm on UpToDate.

Maybe, I just need to try on people’s shoes rather than strap them on and stay in them. But how?

hi everyone, thanks for reading. moving forward my posts will be available at

https://www.medpagetoday.com/blogs/rambling-resident

happy reading.

People will believe what they want to believe.

This is one of the things I’ve learned about people this year.

[[okay, so this is isn’t the funny or happy story I promised, whoops!]]

In the hospital, if a patient even hints at needing that Dilaudid (“you know, that one med that starts with a D”), they’re automatically questioned to having drug seeking behavior. This is a subconscious action that I will admit to being guilty of despite my disdain of such reflexive thinking. Obviously Dilaudid helps the pain, it’s a strong opioid medication. There are not many people who wouldn’t feel relief. But asking for this, doesn’t make everyone a drug seeker.

The reason, I think, for such automatic judgment is two-fold.

1. We’re busy and need algorithmic thinking. It helps streamline, simplify, and organize.
2. We’ve all either been personally taken advantage of by drug-seekers before or heard nasty stories of this happening and would rather not be burned.

Many consequences go along with such labeling. Following providers may become even more judgmental, less attentive and less empathetic. To make matters worse, there’s an ongoing “opioid crisis” which assigns the blame to physicians who prescribe them. In reality, real people have real pain and it’s not always treatable with alternatives. Avoiding opioids like the plague can lead to under-treatment of pain and ultimately result in more harm than good.

Patients with sickle cell disease are a prime example of people who get judged despite having legitimate physiologic reasons for pain. Often times, they have been admitted many times since childhood for “pain crises” and as adults are tolerant to regular doses requiring uncomfortably large doses of opioids. On the other hand, those of us who have worked in poor socioeconomic areas also know that sometimes these patients (or their family members) abuse their access to opioid medications. (Think, The Wire) Clearly, its complicated and not always easy to trust patients to be honest but I still insist that we shouldn’t let a few bad experiences generalize the way we treat everyone who needs pain medication. But we’re busy! We don’t have time to re-evaluate every single person and situation. And this is how generalizations get made and never changed.

This backwards thinking is not only true of how we sometimes judge patients but also how we judge one another.

I think this applies to other fields as well, but residency being my first real work experience, I’ve noticed this now. People seem to hand out and acquire reputations in the work environment rather quickly. One person imposes a reputation unto another and word spreads like wild fire. Now everyone believes a person is a certain way because that’s what they have heard. Is it possible for people to change from the way they were on day #1? Of course it is! And of course they do! Then why does the initial reputation continue to follow people around? Simply because it’s easy. Why not just perpetuate a reputation and find ways to fit each person into an outdated mold? It’s like when I stopped wearing my retainers but still tried to put them on a year later after my teeth moved around. That hurt. People will view one another the way they want to view one another, the way they’ve been told to view one another. But that hurts too if an inappropriately made judgment leads to disrespect and demoralizing criticism! Unfortunately, we don’t have control over how others think. Not unless you’re a real-life mentalist. We just have to work hard and seek validation from within rather than from others’ evaluations. This means we can’t take things personally. Ideally.

We recently had a speaker at Grand Rounds who also touched on the idea that people have unwavering opinions but from the larger perspective of research and scientific discovery. He challenged the importance we place on the “p-value.” Who arbitrarily set the p-value at 5%? And why must we throw away valuable data and information just because the overall result is deemed insignificant if the p-value is greater than 5%? For those of us who have not taken a statistics class in a while, the p-value determines the chance that a result is achieved by luck rather than reality. If a study shows a finding with a p-value greater than 5%, then that is considered to be a very high chance that the results are obtained by pure luck and the results are considered invalid. The whole research study is thrown away including all of the money, effort and potentially valuable information obtained.

Apparently, people will also throw away results with a sufficient p-value if they don’t believe it. For example, this speaker told us about a valid study that demonstrated that certain medicines that bind metal ions may be protective against heart disease. Before this study, these medicines were largely considered to be voo-doo. Now, this study had just validated the voo-doo! The cardiology community was polarized. How in the world could this voo-doo truly be true? The study was well-designed, followed modern day standards and the results had acceptable p-values! Still many cardiologistis chose to reject these specific results mainly because they didn’t want to believe them. Again, there is no p-value that would be good enough for a closed mind. There is no such thing as logic or objective data that can dissuade someone when they want to believe something.

Obviously, it is not possible to re-evaluate every single thing we’re told and to confirm every belief, result or label for ourselves. Sometimes, we just have to trust what people tell us. Whether p-values should or should not continue to determine how we accept results in science is a discussion for another time. For now, my only hope is that we value one another enough to re-assess and re-evaluate a judgment made by someone else or a prior experience. Hopefully, we stop being lazy and approach one another with an open mind to avoid generalizations. These kind of judgments can have harmful and real consequences. If we stick to algorithmic thinking then what differentiates us from a computer? We owe one another more than that.

Let’s continue the series of sad stories from the CICU, shall we?

It was 5 am on Sunday, my second to last day in my CICU rotation. I walked in hoping it would be a calm day because I was going to be the only intern and our patient list was quite large. Obviously, by the laws of nature, this was not going to be the case. The senior resident who was there overnight had bloodshot eyes, she had hardly slept that night because one of the patients had been decompensating for the past few hours. They were at his bedside all night long adding more and more pressors and then increasing the doses of these medications to their max. She quickly tells me about him and goes to lay down for a few minutes.

I immediately start looking through this patient’s chart in the EMR, every intern’s best and only friend. The first thing that pops up is that this patient’s hemoglobin is 5.4 mg/dL with a big, red exclamation point next to it. Looking through his prior lab results, I see that all of his previous hemoglobin levels were around 9.0. I immediately think he must be bleeding so I walk around the unit to find the overnight attending to tell him about this lab result. When I find him, seems like he’s already seen this. He looks just like that big, red exclamation point. The nidus of our patient’s decompensation was starting to present itself. Literally, an internal bleed was the last thing on everyone’s mind. Usually, in the Cardiac ICU it’s easy and generally safe to assume the cause of a decompensation is the thing that brought them to the Cardiac ICU, the heart itself. Not some random bleed.

Over the next few hours that morning, the remainder of the day team, attendings, nurses all arrive and our team is consumed by this patient. We get a CT scan which shows a MASSIVE bleed inside his abdominal cavity. How the heck did this man start bleeding all of a sudden? AND WHY DID WE NOT SEE THIS SOONER? Hindsight is 20/20 or in this case 20/24. Looking back, it seems that this bleed had been going on for a while now but kept oscillating between clotting and bleeding so we couldn’t identify it from his blood pressure or the daily labs. Unknowingly, we had been giving the patient a continuous blood thinner to prevent clot formation (the right thing to do if you are not bleeding inside of your body) and suddenly the bleed opened up again. But because his blood was very thin, this time, the bleeding didn’t stop.
We called upon the vascular surgeons, the cowboys of the hospital, to take our man and fix his bleed in the OR. They came, they looked at him, and then…they declined our patient. His heart was too weak. He was too sick! Too sick for the vascular surgeons?! That’s like saying there’s too much snow on the ground for a snow plow truck.

It seemed like our man was running out of options. But how could this be happening? Usually people as sick as him are too sick for their brains to work properly and are delirious. He had a breathing tube in his mouth
to support his lungs, and while he couldn’t voice his thoughts, he was still able to motion to us and communicate. Everything else that happened today signaled that his time was coming but I hung onto this hope that because his mentation was okay, he would get better.

Whenever we asked him what he wanted or what he thought, he would just motion to us to call his wife. Frustrating, because I had been trying to get in touch with his wife of 60 years all morning long. Apparently they had been undercover CIA agents together in Germany back in the day. As of recent though, our sick patient was her primary care giver. Turns out he was the healthy one in the relationship and she depended on him.

Finally, she arrives. Even if she was that sick, you couldn’t tell. Her back may have started to hunch but her voice and aura emanated strength. You could tell that even if her health was not good, her mind was sharp despite being in her 70s.

Suddenly, his oxygen saturation drops despite being on full lung support with the breathing tube. His wife cries out, “We’ve been together since we were 15 years old! You can’t leave me now!”

He motions to us at this point that he’s done. He wants the breathing tube out. All he wants now is to spend his last moments in peace with his wife.
This is when I realize I have to step away because I cannot keep it together and my tears are flooding out. Their story was so romantic and sad, like a movie. A love story like this can’t be real life. I was not supposed to break down and HE was not supposed to die of a stupid bleed! He came in with a weak heart and we were SO CLOSE to fixing it. The procedure for his heart had been scheduled for the next day!

But it was too late. Many hours later, he passed away in peace with his beloved wife at his bedside.

For my next post I promise I’ll come up with a funny or happy story.