Oh no, I said too much.

"Every whisper. . .
Of every waking hour I'm
Choosing my confessions
Trying to keep an eye on you
Like a hurt lost and blinded fool, fool

Oh no, I've said too much. . ."

~ from R.E.M. "Losing My Religion"

_______________________________________________________

Sometimes patients ask you things that catch you off guard. Things like, "Hey, what race are you?" or even funny ones like, "When's the baby comin'?" when you aren't even pregnant. And sure. Those questions can be both perplexing and amusing at times -- which reminds me-- why is it that only black folks ask (black) me "what are you?" or even why is it that the very day you feel your most sleek and trim post-pregnancy just happens to be the day that some patient winks at you in the elevator and says, "Is it a boy?"

Um, yeah.

But those questions? Those questions are easy. Here's a question that can be a hard one:

"Do you believe in God?"

Or more specifically if you work at a place like Grady Hospital:

"Do you believe in Jesus?"
Now here's the thing: even for folks that have a very clear answer in their head to that question, it isn't necessarily an easy one. It steps into a fuzzy place that sometimes doctors get squirmy in with their patients. That personal space place. That inner thoughts and feelings place. And for some, that flat out none-of-your-business place.

Hmmm.

Today I'm reflecting on this because yesterday I was leading a session with my second year small group students and the topic was "Spirituality and Medicine." Our discussion started off simple enough and then evolved to this one where we got into a very interesting dialogue about how one responds to patients asking questions about your religious beliefs (or lack thereof.)

The students had some interesting perspectives. They represent many different beliefs on a myriad of intensities, so I was keen on hearing their thoughts. One person asked if the best thing to do was to "just tell the person what they want to hear." Another was firmly against that. Some offered thoughtful examples of how they could navigate respecting where the patient was and protecting their own privacy. A few weren't sure what they'd do. And eventually, they asked me what I thought.

members of "Small Group Beta"

Okay. So, I think I am fairly transparent on this blog, or at least I try to be. Most have probably gathered that I am of Christian faith and wouldn't be surprised when I describe myself as observant. Nope, I'm not fire and brimstone. Nope, I don't have flaming stones to sling from my purse or hateful, disgusted stares for boys who hold hands with boys. Nope. I generally stay in my lane when it comes to judging since the whole judging thing is not my lane. I tend to focus more on that whole "love everybody" thing that Jesus was so into.

Anyways.

I don't pretend to be anyone other than who I just described and have what I like to refer to as a "personal relationship" with God. I pray regularly. Some days more than others. And fortunately, since my relationship with God is personal and we know each other so well, my guess is that He's cool with that. Some people fall into this "personal relationship" category, too, but their relationship with a higher power is so personal that chatting them up about it is like asking them about their weight. A major no no.

Though that isn't usually where I am, I do sometimes wince a teeny bit when the topic comes up. Sometimes it's because I am accompanied by someone else. Other times it's because I fear it will take me somewhere I am not sure I want to go with a patient. So, to answer their question, I tell them something that I heard a resident once say on rounds when asked those very questions:

"May I ask a question of you? Can you tell me why it is that you'd be interested in knowing that about me?"

It was one of the most kind replies to such a question that I'd ever heard. This came out of the mouth of a second year resident, too. He softened his eyes and his voice and respectfully countered with this beautiful response. And I meant to say "beautiful" because it was just that.

This resident happened to not be of Christian faith at all. But the answer the patient gave was so endearing. She simply said, "I want to know because I really like you. I want to know that your soul is saved, so that I can be praying for you if it's not."

And he replied, "I always appreciate prayers."

And she simply smiled back and nodded.
I have used a version of this ever since. One patient answered me by saying, "I want to make sure that the doctors caring for me are believers and that they don't think they God!"

I was with my entire ward team that day, and through this insight was able to answer accordingly.

"Ma'am, to be honest, I am of Christian faith. But more important, I certainly do not think that I am God. I also work with a number of wonderful doctors and students--some of whom are of Christian faith and some of whom are not--and I feel sure that they don't think of themselves as God or all powerful either. We just try our best to do right by you and give you our very best effort. That's something you should want all of your doctors to have in common."

And that answer feels good to me because it doesn't exclude or disrespect the scores of colleagues I have that have different beliefs than my own. Particularly when they are present when I'm asked.
Now. I'd be dishonest if I told you that there hadn't been many a time that I'd joined a patient in prayer or agreed to pray for them. In fact, I've closed my eyes and prayed for a patient right then and there at their bedside before. This has depended upon a lot of factors. The relationship I had with the patient, the urgency of the situation, and of course, the wishes of the patient. Other times, those prayers have been uttered quietly at chart boxes or in stairwells. . . oft times the nearest place I can privately reach to interlace my own beliefs with what I can do medically.

I am not sure these answers are the right answers. In fact, somebody reading this is probably saying that they aren't even close to the right answers. I don't know. But here's what I do know: Medicine is about a whole lot more than medicine. And regardless of what you believe or don't believe. . .it involves having some faith. Sometimes in you. Sometimes in your doctors. And sometimes, if that's your thing, in something altogether different.
***
Anyways. That's all I've got today. Happy Wednesday.

Now playing on my mental iPod. . . . .



Losing my religion by REM

Food for thought: Hard times?

image credit

Today I'm reflecting on just a few of the things I heard from patients in just a single half-day at Grady Hospital . . . . .

• Hurt in an accident so now have chronic back and neck pain due to a disk injury. Due to poor performance on a job that involves manual labor, was "let go."  Tried to get a few other jobs but never went beyond middle school and "not too good with secretary stuff that involve reading." This month got an eviction notice. Will likely have to move into a shelter.  
• Off drugs and alcohol for almost fifteen years.  Lost job. Has three adult kids--one with a family living in a one bedroom and another with unstable housing due to mental illness. Other child just got married and patient "don't want to be a burden on nobody." Could move back with "old man" but not her first choice since "he still use and still drank" and "he one of them 'mad drunks' that like to hit on you when he get to drankin' too much." Probably will live in her car until gets another job. Drank an entire six pack of malt liquor last night due to "nerves bein' bad."
• Overweight but affected by an illness that required high doses of steroids. Gained more weight due to steroids. Due to being overweight has terrible arthritis. Needs to exercise but finds it hard due to weight and pain. Needs to lose weight but on fixed income and relies upon "meals on wheels" for food which is not low fat at all. Can barely walk due to pain and probably needs knee and/or hip replacement. Can't get replacements due to weight. Needs to lose weight before replacements will be done, at least seventy five pounds. Can't exercise or change diet because. . . . .
• Terrible toothache and mouth full of decayed teeth. Thought this appointment was with a dentist. Gets referred to dentist to get tooth extraction but will need at least the minimum co-pay. Doesn't have a single penny. Literally.  Received some pain medicine and antibiotics. Found a place that will give the antibiotic for free but for pain medication has to pay. Really needs the pain medicine. On way to see dentist who decides on no pay treatment on a case by case basis. If isn't deemed a suitable "no pay" patient, will either have to find the money or just deal with it.
• Makes exactly three dollars too much to qualify for medicaid and exactly sixteen dollars too much to qualify for food stamps. Pays for medications out of pocket. All ten of them.
• Previously homeless, likely due to mental illness. Came to Grady, and finally got a diagnosis. Has never been gainfully employed due to uncontrolled mental illness and incarceration. Receives disability due to mental illness, just enough to pay for apartment and live in government housing.  Two months ago, check cut in half due to child support judgment. Getting evicted in a week. Can't go to family because estranged due to mental illness. . . .

Wait. . . . .what did I have to complain about again? Oh, yeah. . .that would be a whole bunch of nothing.

***
Happy Tuesday.

The (wo)man in the mirror.

*names, details changed to protect anonymity. . . yeah, yeah. . .you know the deal.

Today we celebrated the end of the spring soccer season in the park with Isaiah and Zachary's team. The Cheetahs had just finished their last game and, despite the fact that we totally weren't supposed to be keeping score or even being remotely competitive, we creamed the other team. Instead of the lovey-dovey-kumbaya-everybody-gets-a-turn-to-make-a-goal soccer that we were expected to be playing, the Cheetahs rolled differently all season long. Abbas, Harry and the rest of the coaches had the kids learning all about defense, blocking goals, and passing. And let me tell you, man. Those kids were walls, do you hear me? Walls. Oh yeah, and to be only four and five years old? They were totally bending it like Beckham, for real.

Therefore. . . we had a lot of butt-kickings to celebrate.

Wait--is it bad that I said that about a four and five year old team? If so, forgive me, alright?

Anyways. So there we were after our game having a lovely fellowship in the park with pizza and cupcakes. They kids ate a bit, received their trophies, licked icing off of cupcakes and disappeared into the giant contraption recently built in this newly renovated park. Even though we didn't bring any grown up drinks, us parents had a great time chilling under the gazebo.

That's when I felt the first rumbly in my tumbly. I knew that my quasi-breakfast and diet Coke would not hold me past one p.m., and seeing as it was now past three, it was official. I was hungry.

The problem is . . . all there was to eat was pizza and cupcakes. If you are, like, in kindergarten or pre-k, then that menu is fine. But if you are, like, over forty and, like, trying to make sure you keep the same wardrobe, then that's a problem. Well, not a major problem. It's just a problem if you ate a big juicy hamburger on Friday and cookies on Saturday. It's also a problem if you broke up with bread last spring.

Anyways. I felt my tumbly go rumbly again, and said, Bump it. I'm eating me some of this here Papa Johns. Which I did. Two greasy slices with a pepperoncini on the side. I followed it up with a cupcake since it was homemade and--I'm just sayin'--I didn't want to be rude. Washed it down with a juice box. Yeah, man. It was quite the meal.

I watched Harry from the corner of my eye as I scarfed all this mess down, especially since I am normally the one giving him the hairy eyeball for eating "kid food that you know is not even worth the calories or fat." God forbid he turn around and see me for the hypocrite that I am.

And speaking of being a hypocrite. . . . this reminds me of this one time at the Gradys. . . .

I was rounding in the hospital one day and came to see a patient with severe high blood pressure and heart failure. Before I even got inside of his room, I could smell the aroma of McDonald's french fries wafting out into the hall. I narrowed my eyes and folded my arms as I followed the floating potatoe-y smell to its source--my patient's bedside.

"Mr. Porter! I just know you aren't eating some McDonald's!" I scolded him with my hands on both of my hips. "McDonald's? In the hospital, Mr. Porter? Come on! You have to know how salty that is!"

But Mr. Porter just looked up at me and raised his eyebrows. Folding back the wrapper of his Quarter-pounder, he sunk his browning teeth into the sesame seed specked bun and chewed without apology.

"Mr. Porter!" I repeated with an incredulous laugh. "McDonald's?"

He dug into the french fries and then plunged the straw to his oversized drink into his mouth. His cheeks sunk in as he took a long, hard slurp of his refreshment. He was totally blowing me off.

"Mr. Porter, sir. . . you know, we're trying to work on your blood pressure and your weak heart, you know? Cutting back the salt is a real important part of everything we need to do. The McDonald's is so, so salty and--"

"I don't eat McDonald's every day. Just today." He said it dryly while making searing eye contact. I could tell that I was kind of annoying him, but not enough for him to really care. The indifference made me a little uncomfortable.

"But you shouldn't have McDonald's no day, Mr. P. Especially while you are in the hospital."

"Y'all didn't bring my tray this morning since I was off the floor and I was hongry. I got me some Mickey Dees, I sure did."

Did I mention that there is a twenty-four hour McDonald's right next door to Grady Hospital? Oh and allegedly it is the busiest, most money making McDonald's in the country. Um, yeah. But that's a whole 'nother post for a whole 'nother time.

"But Mr. Porter, sir. For you, even a little bit of Mc--"

"What YOU eat last night, doctor? What YOU eat for dinner last night? A salad? Some steamed broccolis and boiled chicken?" He snorted, a sarcastic snort. Yikes.

He caught me off guard with that. "Excuse me?" I queried.

"I said, 'What YOU eat for dinner last night?' You heard me."

And so I stood there nervously shifting side to side in silence, trying to recall what I had eaten the night before. It was then that I remembered that we'd gone out to La Fonda Latina and I'd eaten some flash-fried fish tacos and a whole, whole bunch of tortilla chips with salsa. I'd eaten part of Zachary's dessert and had even enjoyed a Mexican beer con limon.

Wow. I was no angel, that's for sure. For some reason, I told him the truth about my meal, down to the "con limon."

"Is that salty?" he asked. "Fish tacos and chips and salsa? That sound real, real salty."

It sounded real, real salty because it was hella-salty. I nodded and gave him that. I thought about saying, "But I don't have severely uncontrolled hypertension, so there." But I didn't. Instead I just kept standing there looking at him without answering.

"Don't you ever just do something bad sometimes? Eat something fatty and salty just to enjoy your food? Sometimes I just wont me a Quarter Pounder and some fries. And today, since my tray was late, tha's what I got."

I studied the white paper bag that he'd ripped straight down the middle. The fries were as aromatic as they were when I'd first entered. I tried to think of something to say, but came up with nothing. Suddenly, I felt relieved that there weren't any residents or medical students there to witness me getting called out like this.

"Doc? Let me ask you something. . ."

Lawd. Here we go.

He didn't bother to get my permission before launching into his "something."

"When was yo' last check up? Like. . .do you always do all that you s'posed to be doin' or do you cheat sometimes? Well, we already know that answer since you's eatin' chips and all. See, I bet even you done some thangs that would make yo' doctor a little disappointed in you, too."

All I could do was smile. I'd just run into my primary care doctor at a meeting a few days before and had avoided contact with her for that very reason. I was already overdue for my annual appointment, and knew that if he weren't my patient and instead was, say, one of the women I see in the hair salon, that I would have been on my third handful of McDonald's fries by now.

And so. . . .all I could do is just nod slowly and keep smiling. Because he was right. He was really, really right.

"Look here, doc. Jest be careful about sounding all like you preaching to folks, you know? I'm a grown man and I'm a lot older than you so jest be careful. It's like the bible say: don't be busy pointin' specks out in folks eyes when you got a plank up in yours."

Damn. I love the Grady elders.

"I hear you, Mr. Porter. That's real talk, for real. You got me." We both chuckled. "Okay, but seriously? I'm trying to get you out of the hospital. So if you are eating a lot of salt and drinking a jumbo sweet tea, you might be setting us back some, that's all I'm saying."

"Okay. Then jest say that then. The way you came in here at first, you sound like a hypocrite. Like yo' shit don't stank. And I been living long enough to know that everybody stuff stank. Everybody's."

Whew. Real talk, man.

"I'm sorry, Mr. Porter. I guess I overstepped my boundaries that time."

"Naw. Jest remember all the stuff you do that ain't perfect, you know? Even when folks got they weight under control, they still got they vices. You probably wish I'd give you some a these fries!" He threw his head back and laughed hard. He pushed the bag toward me. "You know you wont some. Come on, Dr. Mannings, you know you do." He was cracking himself up.

I just looked at him smiling and shaking my head. "I appreciate that honesty, Mr. Porter. I really do."

"That's jest me. I always calls it like I sees it."

"Okay, Mr. Porter. Can we back off on the salt so we can get the fluid off of you? What do you say?"

"I say, 'Okay.'" And with that, he balled up the fries and half-eaten Quarter-Pounder in the bag and tossed it like a basketball toward the trashcan near the door. It bricked off of the edge and hit the floor and as I reached down to grab it, he added, "Now don't go busting that paper open and eatin' my fries, doc." We both laughed that time.

Today I'm reflecting on how hypocritical I've been at times as a physician. Telling folks to exercise during the times that I'm not. Instructing folks to eat a low salt diet when I eat processed foods like crazy. I guess Mr. Porter reminded me to infuse that into my voice and body language when wagging my fingers at others. Maybe acknowledging how hard a low salt diet can be might be the first step in getting a patient to adhere to one.

image credit

"Why do you look at the speck of sawdust in your brother's eye

and pay no attention to the plank in your own eye?"

~ Matthew 7:3

Whelp. Guess he told me.

***
Happy Monday.

Standards of "I don't care."

2011 graduates Zwade M. and Andrew B., after matching at Harvard programs.

Zwade M. and Andrew B. are two of the most professional, respectful and altruistic young doctors I have ever met. Seriously. I met Andrew B. on his first day of medical school back in 2007, and I met Zwade M. very early in his second year of school.  I can tell you that from the moment I met both of them, they were ultra-gentlemenly, exquisitely thoughtful and unbelievably careful in every single one of their professional interactions.  Although several of us Grady doctors were involved in both of their medical educations, I am pretty sure that we can't take any credit for their excellent behaviors.

Check it. Unlike these two dudes, every now and then you encounter a learner in the hospital that makes you scratch your head and say, "Huh?"  Or better yet, makes you want to say, "You do realize I can hear you and see you, don't you?"

One of my friends and fellow Grady doctors was working with an intern recently who, for all intents and purposes, simply didn't give a damn. I mean a damn.  Now let me clarify:  This wasn't a situation where he was poking patients in the eyes or sedating folks so he could sleep. He was doing his work, and wasn't an assassin but. . . .as far as his interactions with my colleague, his supervising physician?  This dude might has well have given her the finger.

The guy showed up every day dressed like a slouch, and was totally unapologetic about it.  He walked off of her rounds, texted on his cell while she was talking, announced repeatedly that "he was just trying to get through the month," and even took the liberty to alert my friend repeatedly of the fact that he was going to be leaving at some oddly unappointed-by-her time.  It was crazy.  This was a whole new standard of "I don't care."

So this particular person was just rotating on Internal Medicine for the month, and had made it abundantly clear that doing so was a nasty little lump that he was being forced to take.  My colleague, who could quite possibly be one of the most caring, kind, empathic, thoughtful, humanistic, professional physicians I know, was really bothered by this. More than bothered. It hurt her feelings.

I'd like to think that I wouldn't have put up with this kind of behavior. I'd like to think that the reason that I haven't really been in a situation is an attestation of the handle I have on my teams. Ha. I'd like to think that. Instead, I've probably just been lucky.  

Another one of my fellow Grady doctors was dealing with a similar situation with a medical student--you know, that same perplexing don't-give-a-eff behavior that is so puzzling to the faculty member that they wonder if they've somehow become invisible.  This particular attending knew this learner well, and Lord knows had fought the good fight in trying to get the student on the straight and narrow. More than the first person, this person was also bothered. And maybe even a little bit hurt, too.

So what does all that mean?  Like, what does it mean when a learner simply tells a faculty member to "stick it" in no uncertain terms?  Does it mean that we have fallen short?  Does it mean that the person simply has no "home-training?" (As the Grady elders call it.) Is it just a sign of the times, where these young whippersnappers have just become more entitled?

Beyond Zwade M. and Andrew B., I know plenty of students and residents that are beyond professional. Jackie G., Alanna S., Francois R., Roger A., Roy A.. . . .the list goes on and on. Now that I think of it, there is this one second year student that I know quite well who is, in particular, professionalism personified.  She is an eager learner. She values medical education so much that the excitement oozes from every part of her being.  Her coat couldn't be whiter. Her posture couldn't be straighter. And as far as being bright-eyed and bushy-tailed? Fuggeddaboudit. This student has taken that to a whole 'nother level--and not in that brown nosey way, either. And you know what? This student was like that from the start.

That leaves me with the point of this random rambling:

Can we teach professionalism?

Here's the deal--as medical educators we are expected to help guide our learners toward professional behaviors. Yeah, yeah. . . .we serve as role models and such, but seriously, we are actually mandated to teach and evaluate the students and residents on their professionalism. They are supposed to be competent in the area of "professionalism" before they graduate, which gets hard, especially when they aren't, well, professional.

The Zwades and the Andrews of the world are easy. They show up in their white coats with their deferential behaviors, their pleases and their thank you's. They take notes while you teach and listen intently during rounds. They show up on time and pitch in to help others.  And with the flick of your wrist, you sing their professional praises on evaluations, feeling like you somehow can take a little credit for it knowing deep down that most of that has to do with what the Grady elders call "mama 'nem."

So what's a medical educator to do?  What do you do when someone just doesn't give a damn?

I am really asking because I am interested in your thoughts. I really want to know how folks suggest we go about doing this. Not just doctors, either. But people's mamas and you non-medical folk.  See, because you guys are the ones that will be lying in hospital beds when folks like that middle-finger-giving young doctor strolls in to write life saving orders in your chart.

Do we put them in time out?  Do we shrug it off and suggest that some are lost causes?  Do we pounce on top of them with a knee in their chest and a nasty snarl saying, "Don't make me put my foot in you. . ." Uhhhh, you get what I'm saying.  Like. . . I don't know. I really don't know.

Oh yeah, and I acknowledge that we could be the problem, too. Are we not firm enough? Are we sending the wrong message to the learners through our behaviors or is it that weak leadership manifests as the egregiously unprofessional behavior in those don't-give-a-damners? Is it a respect thing? Is it a . . .gulp. . . woman thing?  Like, would these same learners tell a man to stick it?  I hate to even go there, but neither of the aforementioned faculty were male.

Sigh.

So that's what's on my mind this morning. What y'all got to say about all this?

A day late and a dollar short.

Trying to measure up.

"Here comes the sun
Here comes the sun
And I say. . . 
It's alright."


~ George Harrison of The Beatles
_____________________________________________

 
On December 2, 2008, The Institute of Medicine released their greatly anticipated report on “Resident Duty Hours.” Like many academic physicians, I sat in front of my computer listening to the live webcast, trying to make sense of their recommendations for more sleep and less continuous duty hours for resident physicians. I perused the New York Times article that followed, but it wasn’t until I read the subsequent barrage of online commentary that it really set in.  Let me tell you--folks were not happy.

“We are officially in the ‘No Accountability Era,’” one physician wrote. “Our patients will be the ones who suffer from the ‘clock in-clock out’ monsters that we are creating.” I read on, serving as my own amen choir with exaggerated head nods. Another passionately added, “Our residents are becoming more interested in getting out of the hospital than getting to know their patients.  No one seems to care anymore. This will only make it worse.” 

Ouch.

Next came recommendations from the Accreditation Council for Graduate Medical Education (ACGME.)  These recommendations first came as ones that weren’t etched in stone. They said, “Okay, interns—meaning first year resident physicians—need to get up out of the hospital after sixteen consecutive hours of work. Oh, and you faculty? Y’all need to do a little, no a lot, more supervising. For real.”   Okay, maybe this isn’t exactly how they said it, but that was my take on it.

After that, the ACGME solicited input from a bunch of academic institutions and professional societies.  We had a slew of institutional meetings at Emory to discuss our suggestions and with the help of leaders in our Graduate Medical Education Committee, sent them off. Organizations like the American College of Surgeons sent theirs in, too, and man. . .  they didn’t sugar coat things. Like I said. . .folks were concerned. No, more than concerned. Folks were worried. And folks meant us.

The thing is this: If an intern can’t work beyond sixteen hours straight, it means that they can’t work overnight. A lot of folks will tell you that their biggest learning during training went down in the middle of the night.  I wish I could say that I didn’t agree with that. But for me, it’s true.

Well, turns out that the ACGME came back with the official recommendations after getting all of that feedback, which essentially was:

“Okay, interns—meaning first year resident physicians—need to get up out of the hospital after sixteen consecutive hours of work. Oh, and you faculty? Y’all need to do a little, no a lot, more supervising. For real.”  

Um yeah.

Faculty weren’t so giddy about this. In fact, the “new duty hours situation” was smattered throughout our conversations in the resident continuity clinic that day. Between patients we pondered what these changes would mean to us as faculty. We worried about two years from now when more inexperienced second year residents were being expected to teach one when they hadn’t yet seen one or done one. What would that mean to us?

When the residents were out of the room, the discussion got pretty unfiltered—everyone was sharing their unsolicited stories of residency in the “real” trenches, and collectively tsk-tsk-tsking this mandate that would further pull house staff away from the hospital. Next thing we knew, the conversations kept going even with house staff around. Before we knew it, we had all exploded into a fraternity of “old school” doctors unabashedly hazing our young learners by insulting their potentially soon-to-be inferior training experience.

The irony is that there’s really nothing new under the sun. No matter when a person starts their training, there is bound to be some omission in the “new way” that appalls the village elders. We’ve all been there and felt the sting of criticism for things out of our control.  The “new way” always seems to lack the pieces necessary to build intestinal fortitude and sear the heart with nostalgia.  And it has been this way for years. The freshman experience never ceases to be a day late and a dollar short.

I can still recall this snapshot from my own internship in 1996—amid the late lunchtime crowd, I wolfed down a sandwich in the cafeteria with my senior resident following my first night on call. I couldn’t tell if the nausea that churned in my gut was a factor of the inexplicable exhaustion I felt or the pre-packaged hoagie that my two-dollar meal ticket afforded me. My upper level resident described our evening as “not so bad” when a classmate asked in passing. Not so bad? I silently protested. She must have read my mind. She turned toward me, rolled her eyes and trivialized the mere nine patients I had just admitted with the dreaded “when I was an intern” preamble.  (Major emphasis on ‘I’.)

Her, perhaps tall, tales of working up eighteen patients alone with virtually no supervision or chance of sleep in sight were further encouraged by my incredulous gasps. How could I possibly become as fearless, decisive, and knowledgeable as she with a measly one night in four call schedule and someone enforcing a patient cap? I can still feel the way my shoulders slumped down that day; ashamed for believing that it was impossible to do more than I had just done the evening before.

I grew up, and despite the patient cap and less frequent call schedule, I turned out all right. My medical knowledge increased, I accrued my own arsenal of lessons, and eventually became a clinician-educator. Time marched on, and at some point, I forgot those hunched intern shoulders. More rules came along, and eventually, I found myself duly initiated into the “old school” fraternity of those who “really” trained.

 In my ten years of teaching residents and medical students, I have certainly had moments of disappointment with their work products. But honestly, I have had far more hopeful moments about the physicians we are helping to mold. The more I reflect on the myriad of driven, selfless, and responsible residents I’ve worked with over the years, the more conflicted I feel about labeling them all products of the “No Accountability Era.” 

Our attitudes suggest that they don’t stand a chance, when the truth is that, more than likely, they really, really do. The rules were out of my control in the mid-1990’s, and today’s learners have little to no say about the current mandates. In fact, when researchers asked them what they thought about it, in a paper published last year in the New England Journal of Medicine, they made it real clear that they, too, took issue with all of these changes. Interesting situation, ain't it? 

Anyways. . . . just as we can recall the incredibly empathic and the egregiously irresponsible during our own residencies, the same exist today. Just because you work less than twenty-four hours doesn't mean you are automatically shady. Oh, and the converse absolutely applies, too--and to that I can personally attest.  Alas, there's really nothing new under the sun.

Let's be real. I can’t say that I am thrilled about the idea of trying to figure out how to do the same amount of patient service with less manpower. I also would be lying if I said I wasn’t extremely worried at times for specialties like general surgery and obstetrics and gynecology whose unpredictable schedules make the continuity of working a full twenty-four hours critical to learning the ropes. 

But still . . . I am inspired by so many of the learners I know. Many, if not most, do feel accountable for their patients. They do shed tears for their patients in a locked bathroom on the wards, and just like we did, and they are still plagued with the need to read all about their patients’ conditions.

So I guess what I’m saying is. . . .contrary to what the message boards (and sometimes we) are saying,  I can say firsthand that there are legions of caring, earnest, and accountable young physicians waiting in the wings. On July 1, these recent medical school graduates will come rushing on our hospital lawns looking for their chance to be initiated.  Now I guess it’s just up to us to find creative ways to welcome them into the fraternity.

*** 
Here comes the sun, man.  With nothing new under it. And I say? It's alright. It has to be.  
Now playing on my mental iPod (Geo. Harrison with a super-gnarly line up behind him!):

Top Ten: One awesome week.

This week was a good week. In fact. . . it was great week. Here are the top ten moments from it. Enjoy!


#10 -- Snoopy came home. Well, actually, Puppy did.

We found Puppy. (I won't go into all the detail again since that was Wednesday's post.) But isn't this a funny text from my mother? I love how texty my parents are!




Yes. My mother wrote "LMAO" and profusely uses emoticons. You gotta problem with that?

#9 -- You are not alone.

Small Group advisor and former Grady doctor Nat F. watching his small group enter commencement.

On Monday, our senior medical students all graduated. By now, you all know how special the medical students are to me, so I won't go into that again. Instead, what I am reflecting on right now is how I am not alone in those feelings. At commencement, that was ever apparent. For every drop of pride that I had swelling up in me for all of these special students whose lives I'd had the honor to enter, there were at least five other faculty members who felt the same way.

Small Group Advisor and Grady doctor Lisa B. congratulates her advisee. (Dean Eley hugs another behind her.)

What a beautiful thing it was to see that all of these special feelings weren't just my own! One of my colleagues who I'd describe as rather stoic cried while hooding his small group students. Wow. I can speak for all of us when I say this-- our hearts were all up in their education. And now, they are all up in our hearts.

#8 -- Extraordinary Grady.

I was covering my friend and fellow Grady doctor Neil W.'s team for the day. The team was post-overnight call and I was rounding with them on the new admissions and also the pre-existing census of patients. We went to see one patient being treated for something truly life-threatening whose family members were at the bedside. That's when this happened:

Me: "So, essentially, that's our plan for today. It looks like you are really tolerating the treatments well, and your labs and physical examination look fantastic. Dr. Winawer will be back here to see you tomorrow along with the team, okay?"

Patient: "That sounds great."

Me (to patient and her family): "What questions do you all have for our team this morning?"

Patient: "Honestly? None. I have not questions. You all have been wonderful. From the moment I came in with this scary, scary illness to right at this very second. Every question has been answered and I am at peace."

Me: "At peace? Wow. What a high compliment to the team."

I looked over my shoulder at the interns.

Patient: "Yes. Everyone has been . . . .wonderful."

Patient's daughter: "You know what, Dr. Manning?"

Me: "Yes, ma'am?"

Patient's daughter: "I thought Grady was just a place you go if you're poor or if you get shot. Never in a million years would I have wanted my loved one to be here. But y'all have shown me how wrong I was. I mean it."

Me: "Wow."

Patient's daughter: "I know for sure that my Mom could not receive better care anywhere else. Maybe more bells and whistles, but care? I mean real, true care? This has been unbelievable. Grady gets a bad rap."

Me: (smiling) "I'm so happy you feel that way." Because I agreed with her. And I was happy she felt that way. I looked back at the patient who was smiling, too.

Patient: "You know. . . .It feel good to trust the people caring for you." 

She put emphasis on "good" like she meant it. Daughter nodded in agreement.

Me: "And it feels even better to be the ones you are trusting with your care."

I'm so happy I covered Neil's team that day and even happier that I got to meet them.

#7 --- Girlfriends first.

Yolanda's 40th birthday

On Thursday I went over to the Morehouse School of Medicine to give a lecture for their institutional resident orientation. My medical school classmate and good friend, Yolanda W., is the head of Graduate Medical Education at Morehouse and invited me to give the talk.

As she introduced me, I looked at the faces of the residents and then at her. Suddenly her mouth seemed to be moving in slow motion as I suddenly imagined us studying together almost twenty years ago, giggling and head-scratching over concepts that are as every day as riding a bike now. I remembered us on match day, fingers crossed and nervous, at our celebratory post-match trip, and even later when she drove all the way from her residency program in Chicago to watch me receive an award in Cleveland.

Graduation week, senior year of medical school 1996

Here we now were, full on grown up medical school faculty members slash residency program directors slash medical school leaders slash wives slash mommies. After reflecting on our many years of friendship in those moments, I felt a mini wave of emotion come over me. Instead of simply thanking Yolanda or shaking her hand after the introduction, I gave her tight shoulder squeeze to let her and all of those residents know that although she is my colleague and med school classmate, she is my girlfriend first. And honestly? That's why I was there.

Oh and Yolanda? She's kind of a big deal. Trust me on that.

#6 -- Promotion emotion!

My friend and fellow Grady doctor, David M., was promoted to Associate Professor this week! For those who don't know how the ranking works in academic medicine and universities, it goes like this:

Senior Associate: Woo hoo! You aren't an assassin! You have a job!

Instructor: Not only are you not an assassin, you can actually teach people a thing or two!

Assistant Professor: Hey! We kind of like the way you teach, man! Now, build yourself a national reputation for it and get some publications and we can talk!

Associate Professor: You are officially kind of a big deal. And officially at a senior rank which means that people should recognize you as a big deal everywhere you go.

Professor: Such a big deal that you have license to ill. And sometimes even chill. But mostly to scare the crap out of people when you ask really hard questions.

Endowed Professor: You are such a big deal that you get two names. Not just "Joe Schmoe, Professor of Medicine" but "Joe Schmoe, Pee-Wee Herman Professor of Medicine."

Go David!

#5 -- I, too, sing America.

This speaks for itself. You tell me what's better than the Preamble at the crack of dawn?

#4 -- Yet I do marvel.

Say it ain't so!

The graduating medical students at Emory give this really rad award at the end of their four years called "The Golden Stethoscope Award." Word on the street is that they all take a vote and decide on one attending physician or faculty member in the school of medicine that they single out as the most . . .uhh. . .things like. . . . inspiring, a good teacher, a halfway decent role model and such.

Turns out that this year they thought that person was me.

Wow.

'Preciate that. For real.

#3 -- Reading my Nook.

Even though I own and LOVE my iPad, I haven't been able to fully get into it as an e-reader. I recently received a "Nook" e-reader from The B.H.E. that I am so very in love with. I'm currently reading "The Help" which I'm thoroughly enjoying (although my Mom gives that book the hairy eyeball.) The point is, it feels like a book in my hand which I am digging.

#2 -- Dinner with my besties.

Lisa D. and Tracey L. are two of my med school classmates, but more important, are two of my very best friends in the world. Last night we had dinner together and yucked it up over wine, soft shell crabs, and juicy burgers. We laughed out loud and just enjoyed each other.

Of course, we ooh-ed and aahh-ed over Lisa's 4 month old sugar plum of a baby boy. We also decided that it is slightly eerie how much he favors Isaiah at that age. Maybe it's because Tracey delivered them both? Hmmm.

After the obligatory kid talk, we switched subjects to all things grown up. It was a lovely evening, I tell you. There's nothing like having good friends. Nothing, man.

#1 -- Speechless.

A lot of folks who teach get the chance to receive an award here or there for their efforts. Of course, being human and all, it always feels good to be recognized and appreciated. But every now and then, somebody does something that takes it to a whole 'nother level.

Adam C. is one of my advisees that graduated last week. In addition to being one of my absolute favorite people of all time, he is often thoughtful yet stingy with outwardly showing extremes of emotion. In fact, our going joke was always that in four years, Adam is the only member of our entire small group that I never once saw cry. The good news is that he has never been appalled by my touchy-feeliness so it's always worked fine.

Adam was at the speech I gave a few weeks ago to a group of high school students, and as I mentioned before, the topic was "mentoring." He was one of the volunteer mentors to the high schoolers as a part of something called the Emory Pipeline Program. The main theme of my presentation was about how we mentor people whether we realize it or not, and that our lives can serve as mentors. In other words, just the fact that you have done something or achieved something or said something can give someone else the audacity to believe that they can, too. Even if you've never met face to face.

Me and Sparky aka Dr. Carlisle.

After commencement, Adam gave me a brown paper bag and asked me to open it at home. When I reached my house later that afternoon, I opened it up and inside was this:

Yes. It is a service award with his name on it that he received for mentoring others. And yes, he gave it to me.

On the back of it were these words that Adam had added:

"Your life should be a mentor. You never know who's watching."

~ Dr. Kimberly D. Manning

I cried. Thanks for everything.

Love, Adam.

::insert tears here::

Yeah. That was on a whole 'nother level.

***

I hope your week was great, too.

For the record. . . .

. . . .the blogger.com site was down from Wednesday through Friday which explains why I did not have a Thursday top ten this week.  It also caused some wonky things to go down with my posts and the comments--okay, well not just me, but everyone who uses blogger.com. 

Anywho.  Good stuff is a-comin'. 

Trust me.

****
Happy Friday

My so-called life outside of Grady: Never say never.

(*warning:  100% nonmedically related or relevant post ahead.  Patient care only types, return in two days for more enriching material. You were warned.)

Zachary on a bouncy-Tigger day

 "I will never say never. . . ."

~ Justin Bieber (a.k.a. Justin Beaver)

__________________________________________________________

Today was a pretty decent day. I got a lot of residency-related work done that needed doing, had a couple of productive meetings, and even managed to sneak by the eyebrow place to get my unruly brows threaded. Since I was making good time, I took my time driving toward after school care to get Isaiah. I listened to NPR and took a scenic route. No cell phone chats, just me, my open sunroof, and Kai Ryssdal. Stolen moments like these are wonderful, even when they're brief. But whenever I do get these little quiet windows, I do take a few seconds to savor the fact that they are finite and that I do have my screaming kids waiting for me. Live long enough and you'll meet some people who remind you of how quickly life can change in the twinkling of an eye. Especially when it comes to your children.

Anyways.

This isn't a heavy post, so let me move to where I was initially going with all of this (which is really no where important.) So, like I was saying, I had my little me-moment and then eased on over to get Isaiah first. He was in a part chipper/part whiny mood which I decided was better than all whiny. He threw a paper airplane five extra times before getting into the car, and finally buckled himself in after I told him that I'd be really unhappy if I have to pay the late fee at Zachary's school. Fortunately, Isaiah doesn't like the thought of me being unhappy, so off we went.

I listen to tales of monkey bars, super heroes and pretend battles between several kindergarten boys turned imaginary komodo dragons. I hear of who got a time out, who had to have a silent lunch, and exactly which person would like to marry whom. I am asked if there will be homework and get a high-pitched whine when I answer in the affirmative. It then falls silent as Isaiah decides to pick up a pad of paper and draw pictures from his booster seat.

We get to Zachy in time, and he is in a bouncy-Tigger mood which makes me smile but can sometimes make getting him into his booster seat a challenge. He bounces and he sings and he bounces and he sings all the way out of school and into our commute. There is obligatory arguing over "Zachary disturbing my art-creating time" which is countered with even louder, bouncier singing. Today, a repetitive loop of 16 dreadful bars of Justin Bieber's "Never Say Never."

So finally we make it home where I promptly park in the garage and shut it behind me to keep the bouncy-Tigger-boy from bouncing out the door. It's a homework night for both kids, so I am all business. "Get inside, get your hands washed, get your backpacks and come to the kitchen table." Easier said than done, but eventually said and done.

Isaiah is writing about what he plans to do this summer. Zachary is tracing numbers. I am preparing a dinner that fortunately is only for the kids since Harry has a meeting. This means no consideration for an adult palate or a grown man appetite. Yay.

Then there is quiet. Isaiah independently working. Zachary not bouncing and actually doing the same. Milk is poured, food is on plates and I decide to pick up a few things strewn about the house with my twenty-seven extra seconds of time. I try to sing something, anything out loud to get the bouncy-Tigger version of the "Justin Beaver" song out of my head. All I can hear though is this, like a broken record:

"I will NEVAH say NEVAAAAHHHHH! I will bite you for-EVAAAAAAAHHHH!"(repeat)

It's like a horrible reciprocating engine looping around and around in my head. I give in and start humming it. Then I start singing it. "I will never say neverrrrrr. . . " Bleccchh.


That's when I heard the doorbell ring. Hmmm. We weren't expecting anyone. I look through the peephole and. . . . . .

Awww, hell naw!!

No. It must be a mirage. It can't be. Is it?

I fling open the door, just to be sure!







Is it really. . . . gasp. .. .the Dogfather of the Puppy Mafia? Has our prodigal pup returned home? Yes! He did!!! And on such a mundane day, he did!

I yell for Isaiah. Yes, the boy is knee deep into some hard core sentence composition and sight word recognition, but this is an emergency, people!

"Isaiah! Isaiah!"

The boy can't believe it. No, I take that back. He can believe it. He said, "I knew he would be found! I knew he would not be lost forever!" Then he looked at me and said, "See, Mom! I told you he was already brave!"

And then he commences to hold a full on conversation with Puppy saying things like, "What were you doing? How was your adventure? Are you hungry? Were you on top of Mommy's car?"

But the Boss was tight-lipped, I tell you. A vault, man. His disappearance deemed officially classified information. Only to be discussed with other Puppy Mafia bosses, which we do not happen to be.

And so. A day that seemed totally ordinary turned out to be extraordinary. Because the Puppy Mafia is again complete.

The saga of Puppy the sometimes wayward don of the Puppy Mafia continues.

He's baaaaaack.

Oh, and to all of the naysayers that believed that Puppy aka the Dogfather was lost forEVER and who didn't believe me when I said he got lost for a year in my grandmother's house and found again and therefore could never be lost for good, AND who just can't seem to understand the concept of being "already brave" no matter how many times it is explained to them. . . .I say to you:

"I will NEVAH say NEVAAAAHHHHH!"

::Sigh::

Welcome to yet another part of my so-called life outside of Grady. New readers to this blog? Read about the Puppy Mafia when you are totally bored and have absolutely nothing to do or at least ten things to do that you'd really love to procrastinate on. Old readers and new readers, I promise something patient care related real, real soon.

And Mom? Yes. I used tons and tons of literary license on this story. . .well, mostly from the doorbell ring on. So if you must have a more concrete version of what really went down, Harry couldn't find his iPod Touch and took his search to the maximum levels possible. Unbeknownst to me, while digging deep into the bowels of the living room couch, he found Puppy! Deep, deep, deep down in the deepest, darkest parts of that couch. Satisfied?

 ::shrug::

That might be the real version, but I personally prefer the first version a lot better. . . . . .

***

Happy Wednesday.

Random Rant: P.D.A.

Okay. So at this very moment, I am sitting in this (crowded) restaurant in the Emory village doing a bit of work. Why am I working here? Eh. Don't worry about that. Anyways. . . .

Check it--how about just now, the door opened and these five male physicians walked in wearing their lab coats and scrubs. I am assuming they are physicians, although not one of them has a stethoscope. But either way the question is: What is up with the lab coats and feeling the need to bring them and yes, continue wearing them on a five zillion degree day in this restaurant??

For real, y'all. It is seriously one hundred trillion degrees here today. I take that back. It is one hundred kazillion degrees AND it's a freakin' "ozone-alert day." (So the "I was cold" consideration for wearing their coats was out the window.)

This brings me to what I have chosen, at this moment, to vent about:

PDA (public doctor attire.)

Dude. Can I please just. . . ugggh! There is not a lamer thing than random public doctor attire. It is the lamest. No, even lamer than that. It's the lame-ultimate.

When my first group of students reached their hospital rotations, I threatened them with bodily harm if I ever caught them strolling through Target in scrubs. Or worse, in a bar or restaurant. Not that I have ever been to a bar since joining the faculty--ah hem--but you get my point.

Which reminds me: Students that I advise and know currently--you had better not let me hear about you being a PDA-er. Same for you recent graduates. Not that it's terribly unprofessional. More just because it's really, really, really lame. Lame like that guy on Scrubs who had the "DOC" tattoo. Lame like this hat I had as an undergrad that said "M.D 2B." Blecchh.

o_0

Oh shoot. I think they saw me giving them the hairy eyeball. Now one of them looks paranoid that I might be writing about them. Which really wouldn't be paranoia because I am writing about them.

Hmmm.

I was just thinking: This could be just my own personal pet peeve and not an issue at all.

Naaaah.

Gasp! One is wearing the surgical hat. You know. The one that ties in the back? Lawd.

0_0

Am thinking of passing a note on my way out that says,

"Excuse me. Are you doctors? Or do you just play them on TV?" or better yet,

"WHY THE HELL Y'ALL GOT ON THEM HOT A-- LAB COATS AND THOSE NASTY-BLOOD-AND-GERM-INFESTED SCRUBS IN THIS RESTAURANT?!?"

(Because that's what I would really be thinking.)

Eeew. One has the chest hair explosion thing going on from his scrub top. I cannot. Take it. Sorry. Just threw up in my mouth a little bit.

Hmmm. Maybe there is a good explanation for this. Maybe they are all surgeons who JUST got out of a seventy-five hour surgery only to emerge so hypoglycemic that they have temperature instability and cloudy mentation. Hmmm. I'd welcome your suggestions.

Anyways. That's all I got right now. Guess I'll pack up my laptop and go before I say or do something blogworthy. Okay, bye.

***
Happy Tuesday.

Pomp and circumstance.

My small group graduated today. All but one (who is pursuing a dual degree) walked across the stage where I joined the Dean in hooding them as medical doctors. Them. They graduated.

Yes, definitely.

I've had the fortune of growing close to and being touched by many students in this class, not just my advisees. But the thing is . . . . with my small group . . . . .meeting with them just sort of got hardwired into my life over these past four years in that way that picking your kids up from school or brushing your teeth does. Important, yes. . . .yet so every day that it seems like it will always be that way.

Somebody said this: "The days are long but the years are short."

Ain't that the truth.

Yeah, man. I'm still looking for the words that I want to say about this day. Right now, they are in big cartoon-looking clouds over my head, but not yet in paragraphs. Those clouds include words like "proud" and "moving" and "honored." Then I get choked up and stop there. Because seeing them graduate was a lot. It was a whole lot.

I am happiest because they did it. I am saddest because I will miss seeing them. I am proudest because I was there. And not just there. I was really there.

Okay. Whew.

I'm going to stop here. Will write more when I get the words together. Maybe. For now, I hope pictures are okay.

More people who were there who know how I feel.

Me? I was there. Oh, and if this medical school seems awesome?
That's because it is.

Small Group Alpha - EUSOM Class of 2011 from Kimberly Manning on Vimeo.

***
Congratulations, doctors. And welcome. We've been waiting for you.