Time to Teach.

I don't want to be a human speed breaker--
some wretched intrusion to your hasty departure
from the hospital

I hate imagining that my bright eyes create too much of a glare for you
or that my bushy tail gets in the way of what you have to do
I don't want to think things like that

but sometimes that's how it feels

It isn't my preference to be scuttled off into dusty corners
pseudo-encouraged to explore answers to sidebar questions
that you may or may not even care about

or at least care to hear about from me

It doesn't elate me to be dismissed with the sun still high in the sky
nudged out of the building
but mostly out of your way while you tend to the things
that I long to learn all about

"I wish there was more time to teach," you told me
because if there were you'd show me all kinds of things
and explain more of the nitty gritty of what you're doing

You would but you can't
because there's too much to do and not enough time

Never enough time
especially to teach me in the ways you want to teach me

And so
I sit in the shadows while you scroll through screens
your industrious gaze mostly indifferent broken occasionally by an obligatory smile
then I walk behind you asking the questions 
the ones that I hope might unlock the door and invite me in
into the reasoning, the bedside discoveries, and the sticky conundrums
into the subtle interactions that can and will shape me into a real doctor

But today, you don't because there just isn't enough time
you blanket me with compliments
before sending me in the opposite direction

away from you
away from them
away from the parts I signed up for and always dream of

And yes
I know you wish there was more time to teach me--
the human speed breaker standing between you and "done for the day"--
and yes, I know that you wish you knew what to do with me

But 

You know what I wish?
I wish you knew the truth

that there's always time to teach
and that you're always teaching me

whether you intend to or not

***
Happy Wednesday.

Oh yeah!

Tonight is our 3rd Annual Fellows Teaching Competition at Emory. The Department of Medicine sponsors this amazing event celebrating our dynamic junior teachers--those in fellowship training. Each has prepared an 8 minute lecture that they'll present to a full house and a panel of esteemed judges. The one with the top score takes home a substantial cash prize. Why? Because we want to put our money where our mouth is when it comes to letting our learners and institution know that we value medical education. Every year this event excites us all and reaffirms what those busy days make us forget--that there's always time to teach.

The order of the speakers tonight was selected by the unbiased and sticky fingers of the seven year-old boy pictured below. Oh, and you can read this post to learn more about the Fellows Teaching Competition.

Had to add this. . . .

When you take the time to teach, learners be like. . . .

Sixteen Questions: The Emotions of Career Decisions in Medicine.

There were these days where I just disappeared into the shadows. I could be there, I could be gone, I could be standing there for the entire time those rounds lasted with my middle finger pointed straight in the direction of the attending or the senior resident and I feel certain -- quite certain -- that no one would have noticed.

Not a one.

"Are you the student joining our team?" my attending asked. His eyes looked nice. Well. As nice as eyes can look when covered with an entanglement of unruly salt and pepper eyebrows. When he said that, they furrowed down first and then raised up. Like two very surprised giant bi-colored caterpillars. Ick.

"Sir?" I answered. That was all I could really say because, actually, that was his second time saying that to me in the two weeks since I'd been there. Complete with eyebrow acrobatics both times.

"Don't worry! I'm one of the nice ones," my attending said to me with a chuckle. "You don't have to worry about me grilling you or anything." And he said that part after shaking my hand and introducing himself to me for the second time in two weeks.

If "grilling me" would mean paying attention to me then I'd take it. I would.

"I think she was here with us last week." This was what the resident said to counter that Groundhog Day-like introduction from my attending. Because, I swear, he said the exact same thing to me the first time. That resident didn't even look in my direction when he said it either. Perhaps he took it as some opportunity to one-up his attending which, I had noticed from my position in the shadows, was something he seemed to relish in doing.

You "think" I was here with you last week? You "think?" Wow.

The interns at this rotation site did sort of talk to me. I'll give them that. The intern on my team was more than happy to send me out on scut-tacular field trips to spin down urine and gram stain slobber. Particularly if said job needed to be done at midnight or later. There was another intern that was very pleasant to us students, but she always seemed so scared that she made me nervous. Then, of course, there were  these other two intern guys who were extremely friendly to my friends and me. Extremely. They taught us things and showed us EKGs and asked us if we wanted to have lunch with them and things like that. And yes, now that I am much older, I recognize that they were being part-medical student centric and part-fresh, and probably even recognized that then, but never really thought much about it. Because at least I wasn't invisible then.

I cannot recall a single teaching point made by that caterpillar-brow attending. I can only remember that he always showed up in a blazer and tie and not a white coat and that he seemed to take great care in picking out his perfectly round, albeit small, afro. Whenever we had attending rounds which, back then before duty hours reform and billing rules changed, was only a few times per week, I would just stand there daydreaming and waiting for it to end.

And that was how it was on my very first rotation as a third year medical student. The good news is that just a couple of weeks later, my next attending seemed far more engaged than that one. And who knows? Maybe the guy had some personal issues going on or was simply burnt out. I don't know. What I do know is that it wasn't one of my more cherished experiences in medical school, that's for sure. (Fortunately, most of my other experiences in medical school were worth cherishing, so note that this is not a dig at my beloved alma mater by any stretch.)

Yeah. I guess it's just so hard to believe that I actually chose to go into the very field connected to such an unpalatable experience. But I did.

Internal Medicine. Imagine that.

Initially, I was pretty certain that I'd go into surgery. In fact, I was rather enamored by transplant surgery and had it set in my head that I would do a general surgery residency followed by a fellowship in transplantation surgery. And then, as I often told people in one altruistic breath, I would get African-Americans to sign up to be organ donors and transplant kidneys into my people.

Yup.

You have to admit that it was a rather noble aspiration. At least I think it was. And honestly, my very next rotation -- surgery -- was the polar opposite of that Medicine rotation. Every attending knew exactly who and where we were as students at all times. They called us by name and had expectations of us. Which, now that I recall my experience on that first month of the Internal Medicine clerkship, I recognize as the problem. No one had any expectations of me. So I rose -- or rather sunk -- to that expectation. Nothing.

It only made sense that my academic advisor was a female surgeon. She was kind and attentive and smart. On most days, I wanted to be her. At least, the professional version of her. And I owe it to her for noticing how much I came alive when caring for our post-operative surgical patients on the wards. She pointed out to me that surgeons get excited by the OR. In fact, they can't live without it.

And that statement led to an epiphany for me. One that made it clear that my future career would not involve twirling into sterile gowns in operating rooms.

I chose a combined residency in Internal Medicine and Pediatrics. And never looked back.

I'm reflecting on this on this early morning because many of our students are choosing specialties right now. They're trying to make sense of all of it and working hard to separate the emotions connected to the specific experiences from the actual field itself. And that's hard.

The emotions I had on my Internal Medicine rotation were mostly negative. Not mattering enough to be remembered stung. And that overpowers nearly all of my memories of that time. So very early on, I was certain that no matter what I did, it wouldn't be that. Pediatrics was a mostly okay experience and my feelings working with the Pediatricians were positive. Still, I didn't necessarily feel my heart leaping at the thought of doing it exclusively for the rest of my life. Of all of those clinical experiences in third year, Surgery was, hands down, the one that I always look back upon with warm nostalgia.

Yep.

See, that's dangerous, too. It's dangerous because it can lead a student down a path that isn't theirs to follow. I know this for sure because now, thanks to that caterpillar-attending-dude, I bend over backwards to make certain that no learner on my team EVER feels ignored. EVER. And I recognize that noticing people makes them feel good and brings out the best in them. Which can lead to very positive emotions.

When I meet with students about their career choices, I tell them, "I want you to choose the field that is best for you. So know that it's okay if you change your mind because I did." And I say that part particularly to the ones who come to me with their sights set on Internal Medicine. Which, yes, is super awesome.

To me.

My rockstar-female-surgeon advisor gave me some good advice that changed the trajectory of my career. And I'm so glad she did. In the spirit of that advice, I have come up with a list of my own that I think could greatly help students who are muddling through the emotions-versus-specialty conundrum with career choices. (Perhaps a lot of this can even be applied to selecting a major in college, although we have several engineers and art history majors in our medical school.)

I bring you:

Dr. Manning's SWEET SIXTEEN questions  

for all medical students to consider 

when choosing (or not choosing) a specialty:

1. How do you feel about communicating with people? Do you enjoy explaining and discussing things? Do you mind challenging interactions? In other words, how do you feel about a career that involves a lot of talking?
2. When you went into the OR as a student, did you finally feel at home? Could you be okay with NOT being in an operating room? Does the thought of NOT being in an operating room make you break out in a cold sweat? Do you feel yourself longing to talk to the patient instead of cauterize their blood vessels? Are you okay with taking care of people who can't talk to you at all?
3. Do you have many, many different interests or a few interests that you spend significant time enjoying? In other words, is it more fun for you to hyperfocus on one area or broadly focus on many?
4. How do you feel about children? Particularly ones that aren't related to you? Do you see them in grocery stores with their parents and want to hold them? Are you the person who asks questions like, "How old is she?" or  "How long has he been walking?" not because they have stepped on your foot in line but because you genuinely want to know? Or do you run the other way and (though you hate to admit it) wish there was a "no kid" rule along with the no smoking rule at certain restaurants?
5. How do you feel about procedures? Do you like them? Does blood freak you out? Can you do with out anything that interrupts the skin's integrity or requires a consent form?
6. Are you willing to be on call? Specifically, would you be against someone calling you on a cell phone or pager in the middle of the night because your expertise is urgently needed?
7. Do you prefer longitudinal relationships with patients or are you okay with short glimpses into the lives of many people? For example, were you constantly wondering what happened to every single person you saw on Emergency Medicine and did you often find yourself reviewing the electronic medical record long after the encounter?
8. Do you like things that get your adrenaline pumping? Does the thought of jumping from a plane or bungee-diving from a bridge make you want to vomit? Or does that make you squeal with glee? Now--translate that to a specialty. How do you feel about high stakes, high paced medical care? Does it excite you or overwhelm you?
9. How confident are you? Some specialties require a lot of it. Just saying.
10. How do you feel about bodily fluids? Not just blood, but all of them? Totally, completely grossed out? Or "meh"? 
11. How do you feel about working with the nether regions? Oh--not clear enough? Does it completely mortify you to examine a tender testicle or to explore an agonizing anus? There is a lot of reward in making people feel better when they have problems below the waist line--but it ain't for everyone.
12. Do you love medicine? Not Internal Medicine, per say, just . . . medicine? Do you feel like it is what you were meant to do? Like, if you won the lottery and you were fully trained, would you go in to see patients the next day? Or would you give the office and hospital the same middle finger that I considered giving the caterpillar-attending way back when?
13. After answering number 12, ask yourself this: How hard are you willing to work? Is it your expectation to be gone every single day by 2PM? Are you (though you hate to admit it) kind of lazy? Or is your mantra "go hard or go home?" 
14. Are you okay with fields that involve high incidences of death? Are you okay with managing problems for which there is no known cure to date? 
15. How do you feel about research? How do you feel about teaching? For each of those things on a scale of one to ten for "OMG-yes-I-love-it"-ness, what would you give them?Also, how do you feel about practicing in rural or international settings? Apply that scale to that as well for both of those settings.
16. How do you feel about taking care of poor people? How do you feel about taking care of rich people? How do feel about taking care of very, very poor people? How do you feel about taking care of very, very rich people? (These are things you ask yourself and answer to yourself only.)

Oh, and you probably noticed the absence of the money-slash-earning potential questions on this list. My feeling is that, in general, all physicians make "good money." Now. How you define "good money" is personal. It's up to you to decide whether or not that will be factored into what you do. It wasn't a consideration for me, but I acknowledge that that's just me. I don't judge anyone who feels differently because at the end of the day, all anyone can be is happy.

Ya dig?

Now. After exploring these sixteen questions (which YES, I KNOW were far more than sixteen)-- you will find that voila! Some work environments and specialties will be narrowed down, nixed or frontrunners for you as a result. Next, schedule a meeting with a trusted advisor to help you explore this some more. The key is to tease the emotion away from the "real" parts. And yes, the emotions could be because of things on that list of questions, but you just want to be sure that -- good, bad or indifferent -- it isn't because of. . . . . well. . . people or a person. Especially the "indifferent" part. Does that make sense? I hope so.


Hmmmm.

You know what? I just realized something. That caterpillar-eyebrow attending did teach me something. He taught me what not to do with medical students. And now that I think of it, he changed the trajectory of my career, too.

That's all I've got this morning. Pass this on to a medical student. 'Cause you know I love the kids.

***
Happy Sunday.

Now playing on my mental iPod. . . ."Emotions" by Mariah Carey. And yeah, she was speaking of a different kind of emotion, but you get the picture.

The Mind of the Med Student: Might as well jump.

"I ain't the worst that you seen

Can't you see what I mean?"

~ Van Halen

Heart pumping. Hard. I bet you they can hear it. Do I look nervous? Don't look nervous. Relax. This is not that big of a deal. Just open your mouth and talk. Simple.

"You ready to present your patient?"

"I think so."

Shoot. I should have said something more definitive like, Absolutely! Shoulders back. Head up. Look confident. Even if you don't feel confident. You can do this. You totally can.

"Excuse me--sorry to interrupt your rounds--but is Mr. Albertson your team's patient?"

My senior speaks up first. "Yes, Ms. Johnson. Is everything alright?"

Dang. How does she know every name of every nurse? I think I will try to learn their names, too. Johnson. Johnson. Johnson. Got it. I think.

"He's a bit agitated. I haven't had him in a couple of days and hadn't seen him this way."

"Hmm. Let's go and check it out. Thanks, Ms. Johnson."

Johnson. Johnson. Johnson.

"Hey--push pause on that presentation for just two seconds, okay? Let's go see what's up with Mr. Albertson."

"Sure. I mean, absolutely."  Hope that didn't sound as dumb as it felt like it sounded.

In we walk. A whole big team of white coats and industrious expressions. The long coats with the surest footing. Me, I try to keep up. Mimic it all in my short coat.

"Hey there, Mr. Albertson! What's going on?"

Wow. My senior resident is awesome. So confident. I want to be more confident. Shoulders back. Head up. Like her. Yeah, like her.

"Nothing is up! I just need to go water my lawn!"

Lawn? Rut roh. Mr. Albertson is more than just agitated. He's confused. Or as my senior and everyone around here says, "altered." Short for "altered mental status."

My senior looks over his medications and through the electronic chart. The intern begins to ask him more questions and they examine him. I watch from the foot of the bed as Mr. Albertson writhes about with wrist restraints on and also against the ones on his ankles.

"My lawn! It's gon' dry out!"

"Where are you sir? Do you know where you are?"

"What? I'm at my house! 2733 Hopkins Place Decatur, Georgia."

Now I may be new but I know that this isn't his house. I stayed quiet as my senior and intern continued to discuss his mentation.

"I think he could be sundowning. He is eighty-four you know. No fevers or anything." Sundowning. Of course. The intern said this with that confidence that I wish I had so bad.

"That's possible. But that should be a diagnosis of exclusion." My resident scrolled through the medications on the screen as Ms. Johnson came back into the room to flush is IV. "Hmm. What about this Ambien? This could be the problem."

"He hasn't been getting that," Ms. Johnson replied nonchalantly.

So much for that. I stood there feeling. . .I don't know what I was feeling. Unhelpful? Nervous about still having to present my patient? Something. I felt something. I decided to keep quiet. Look interested and engaged. That wasn't hard to do since I think I actually am feeling both of those things.

The room is quiet. People are moving and checking and scrolling and doing. Me, I'm just standing there. Zoning a little bit but not really. I look at Mr. Albertson and feel bad about his lawn. I wish we were at his house, actually. So that everyone would stop calling him "altered."

I look at his arms and feel bad about those restraints, too.  My brow furrows every time he beats his wrists against those soft cuffs and this time, that nurse saw me.

"He yanked his Foley catheter clear out on Sunday. Balloon inflated and all." She said. I guess she needed to explain to me why we had him tied down. I had already assumed it was for his safety, but appreciated the fact that she actually spoke directly to me.

I jumped at the opportunity and asked her a question. "Ms. Johnson?" Johnson. Johnson. Johnson. "What was his temperature?"

She looked down at the sheet in her hand. "Excuse me, baby? Oh, it was. . .let's see. . . .35.4. That's celsius."

I love how everyone stops to interpret things for the new med student. I nodded and felt something happening. There were mechanical sounds in my head and I think that--just maybe--it was the sound of my wheels turning. Say something? Jump in with my thoughts?

"Could. . . " I thought about taking it back right after spoke. Everyone swung their heads in my direction. Alright. Now they're looking at me. Might as well jump.  "Could. . .um. . .like. . .maybe he could have like a urinary tract infection. . from, I mean, because he . . . well, he has a Foley catheter. So maybe a UTI? Or like, urosepsis since his temperature is low?"

There. I said it. Could be a dumb thing to say but it was at least a thought. And honestly? This was my first unscripted thought or statement so far. Deep breath. Shoulders back. Try to look confident.

"That's a really good thought." I looked at my resident and waited for the obligatory "but." It never came.

"The restraints could also be making things a little worse?"  That's what my fellow student said. And I remembered someone telling us that, actually.  I smiled at him and felt proud of us. Wheels turning and everything.

"You know what? You all have great points!" the intern exclaimed. "Our students are awesome."

That part sounded kind of patronizing but hell, I'll take any compliment I can get. Our resident was still focused on Mr. Albertson and his labs and his perturbations in mentation.

"Gram negative rods. Wow."  She opened up a screen on the computer that had just reported a new value from a blood culture. "Urosepsis. You're right. He's infected."

I could feel my heart pounding. Harder and louder than it had before. Guitars playing like crazy in my head. Want to drop to my knees like Eddie Van Halen.

"Let's get him some Ceftriaxone right away. I'm entering the order now, Ms. Johnson."

"Okay, baby."

The only sound was that of my resident typing that order into the electronic record. That and my heart pounding.

"Let's get him out of bed and into a chair, too. We can take off the hand and foot restraints and just use a soft Posey vest to keep him safe. And a one to one sitter."

"You got it," Ms. Johnson responded to my resident once again.

Wow. This is what it feels like to contribute. To help.

"Orders in, Ms. J. Let us know if you need anything else or just page us with any changes."

"Thanks."

"Thank you for letting us know, Ms. Johnson. Alright guys. Let's get back to hearing about this next patient." My resident waved her arm and we followed her sure footing once again.

For whatever reason, I was the last duckling to file out of the room. Johnson. Johnson. Johnson. "Um, thank you for your help with him, Ms. Johnson."

She smiled at me wide and genuine. "Thank YOU for yours."

My heart. Now? It might explode. My feet are lifted like a gust of air has been pushed under them. Team waiting for me in a semicircle. Looking. Watching. Waiting. For me.

I step into the group and my resident is standing directly across from me. Without saying a word she holds up her fist directly aiming it at me. She nods slowly and smiles in approval. All eyes on me. Me. Heart about to leap from my chest. Guitars wailing, howling, squealing at such a high pitch that I'm afraid a window will shatter. This was my celebratory fist bump.

*Bump*

"Hypothermia can be a sign of sepsis. Particularly in the elderly." My senior said this and then added in a few more teaching points that all hinged upon my wheels that had turned right there in that room. I listened and learned and heard things that I didn't know before. Feeling myself learning. Yes. Yes!

"Alright. You ready to present your patient now?"

All eyes on me. Shoulders back. Head up. Heart still pounding. Come on. You can do this. Don't be nervous. Go ahead. Jump.

"Ready? Absolutely."

***

Happy Wednesday. Go ahead--jump!

Now playing on my mental iPod. . . . .