Thursday, February 27, 2014

A Wasteful Week

     I'm a bit of a backseat driver these days. As a result of the economy and the number of people who have lost insurance (and gained Medicaid) we're seeing a lot of new patients who previously had commercial insurance plans and were being seen by community providers that do not accept Medicaid. Some of them reluctantly come to our resident clinic, but the majority are very grateful for the opportunity to receive excellent comprehensive care from our well intentioned trainees during a difficult transition in their lives.
I've never really worked as a private practitioner in the community, but this influx of patients switching to our clinic has given me some (albeit very limited) perspective on the care they receive in the community with commercial insurances. For the most part, everyone receives excellent care and they often express disappointment that they have to leave their long standing doctor. But on several instances, when we investigate their past medical histories, we've been seeing several instances of what appears to be wasteful unnecessary care.

In 1 week, here is a sampling of a few of these cases.

1: Middle aged gentlemen in good health, well controlled high blood pressure and some family history of heart disease was getting yearly stress tests because " My doctor  was thorough and wanted to be sure."

2: Gentleman who got his first colonoscopy at age 47 because according to his wife "We had really good insurance."
3: Twenty something  year old female, with mild occasional anxiety was getting yearly EKG's as part of her "Annual Exam."
I know I'm looking at these cases as a backseat driver. Perhaps I was getting an incomplete history and there were good reasons why these tests were ordered. But my instincts, medical knowledge and perspective on our current healthcare system suggests it falls under the category of wasteful care.
Reuter's Report on Healthcare system waste 2009

We are all guilty of practicing wasteful care and it's a multi-factorial problem. It start's by changing our mindset towards healthcare by looking at things in terms of value. We also need to make a concerted effort towards following the evidence, and when the evidence is overwhelming, use validated clinical decision support tools.

Case 1: See number 2. Choosing Wisely (American College of Cardiology)
Case 2: USPTF Colon Cancer screening guidelines
Case 3: Rethinking the value of the annual exam

We also have to hold each other accountable for these problems, and sometimes that means being an annoying backseat driver with a computer and a blog :-)

Monday, February 17, 2014

Wegener's and Wikipedia on a cold winter morning, 2008

     The year was 2008 and I had a real swagger about me. After another long Philadelphia winter, the calendar was about to flip to March and spring. More importantly, the end of my internal medicine residency was within reach. It seemed like every day, I was doing something else for the last time. My last admitting shift, my last ICU rotation, my last 30 hour call. These were the many little aspects of a grueling residency that seemed so terrible at the time, but today is a memory I'm proud of.
     I carried that same swagger into my last morning report presentation. A miraculous catch by David Tyree and a Super Bowl victory by my New York Giants gave me the confidence to present my case with ease despite an audience full of Philadelphia Eagles fans. I presented a case about a gentleman that I had admitted for acute renal failure from Wegener's Granulamatosis. It was a great case that generated a lot discussion between students, residents and faculty. I concluded my presentation like others by reviewing some of the evidence and literature for its treatment. With my last PowerPoint slide, I paid homage to my interests in medical history by revealing the onerous story behind the gentleman for whom Wegner's was named. German pathologist Friedrich Wegener apparently had ties to the Nazi regime.
     My digression into medical history was well appreciated. It was a welcome break from discussing antibodies, drugs and the pure science of my case. I looked across my audience and started to notice eyes perk up as the decibel level in the room slowly increased while my presentation neared its end. I concluded my digression about the infamous Dr. Wegener by displaying my reference. It wasn't a journal or a textbook. It was "Wikipedia, The Free Encyclopedia that anyone can edit."
     My reference was met with a variety of reactions. There were those who looked confused and probably had never heard of Wikipedia. But there were those who laughed and found the reference humorous or perhaps comical. I wasn't surprised by the laughter or snickers. My residency and its faculty prided themselves in the strong academic traditions of evidence based medicine. Some residents even hesitated to cite established resources like The Washington Manual or Up To Date because it wasn't JAMA, or NEJM or Annals. I suspect back in 2008, a reference to a quirky online fad where any Joe or Jane could pose as an "expert" had little or no place in the halls of medicine academia. But as far as I could tell, the world was changing.
    Wikipedia is obviously not a fad. It is rapidly becoming the go to reference for everyone. Since 2008, the number of articles on it has doubled to 32 million, 4.5 million in English. Back in the day, I had a 25+ volume edition of the encyclopedia Britannica. I used it for all my school projects and I never questioned its authenticity. I never checked up on its references. I accepted it as truth and it got me through my academic life until Wikipedia. Modern education systems are and should rely on Wikipedia as a vital information resource just as I did with Britannica. In my opinion, Wikipedia is a monumental leap forward in civilization since it has democratized knowledge by taking the price tag off of it and allowing every citizen to contribute. One could even argue, it is everyone's civic duty to contribute to Wikipedia, just as we expect everyone to pay taxes or perform jury duty.
   In medicine we love our traditions and the knowledge that we guard is sacred. We also have a very high standard for the quality of that knowledge. It's part of the reason why we will probably be the last to accept Wikipedia as a legitimate source of information. But it's already happening whether we like it or not. In my own social media study at my institution, nearly all the students who responded are using Wikipedia for both personal and professional reasons.

Social Media in Medical education student survey, Blog Post

In my day to day work with residents and students, Wikipedia is a fast, quick reliable source of pulling up a variety of types of information. I find it especially useful pulling up basic sciences information (anatomy, biochemistry, physiology etc) which is often forgotten in the fast paced clinical real world.

I think medical academia is finally understanding that we cannot hide from the digital world and that we should understand it, participate in it and help shape its future. The University of California in San Francisco medical school is embracing this.

UCSF First US Medical School to offer credit for Wikipedia articles.

The Cochrane collaboration will also be partnering with Wikiproject  Medicine to help advance this movement.
Cochrane + Wikimedicine

These are just a few examples of how medicine is embracing something like Wikipedia and the body of literature supporting it is rapidly growing. It is part of the ongoing evolution of medicine as it looks to reshape its concept of knowledge and in the process better meet the educational needs of the next generation of physicians.

Thursday, January 2, 2014

Our healthcare and "The Wire"

A few months ago, I finally started watching "The Wire.” For anyone unfamiliar with it, “The Wire” is a police drama on HBO that takes place in Baltimore, Maryland. It takes a hard look at inner city drugs and violence from the multiple points of view of an incredible tapestry of characters. It's a wonderfully gripping show and I give kudos to the creator David Simon for painting this haunting and tragic picture of modern urban Americana.
I don't watch a lot of TV, but right now I can’t stop thinking about this show. The show has a lot of social commentary and I’m finding its messages everywhere around me. No, I don't work in the inner city, though I'm somewhat familiar with it. I grew up in a humble New York City neighborhood that over the years started to struggle with drugs and violence. I did my residency training in downtown Philadelphia, and as a young doctor saw many facets of inner city life from a medical perspective. Although I don't currently work or live in the harsh inner city streets, I do exist in a place that is failing its citizens just like "The Wire." Our healthcare system sometimes seems just as tough, destitute and hopeless as the streets of Baltimore as depicted on the show. 
Instead of street drugs, we have diseases in healthcare. But the story of "The Wire" isn't about the drugs itself, but rather how its omnipresence shapes the lives of the entire ecosystem. The same can be said for diseases in healthcare. Diseases are the constant in healthcare and how all the players deal with its presence is diverse and fascinating. But drugs in the show and diseases in healthcare are not the antagonists in these stories. The TV show makes this painfully clear. Any attempt to physically remove drugs from the streets by arresting the end users is an exercise in futility. In medicine simply fixing one artery, treating one infection, doing one CT scan or taking a pill, solves a problem temporarily for the end user  (the patient) but does little to answer the bigger question of why someone struggles to overcome a chronic illness or in the case of "The Wire" why citizens struggle to climb the social ladder out of the ghetto. 
The show also has an incredible cast of characters. Most of them have positive attributes and an innocence that is constantly challenged by drugs and violence. I feel for  these characters. As I watch them, I cross my fingers and hope they find a way out before the "the game" catches up with them. As a primary care physician, I peer into the lives of my patients just like the characters in the TV show. I get to know them, their hopes, dreams, and their intentions while they face difficult odds against conditions like morbid obesity, diabetes, psychiatric illnesses, HIV and heart disease. I cheer for my patients while hoping that my interventions will avert some catastrophic event in their life. In "The Wire" a teenagers’ dream to become something in this world may get derailed by a random act of violence that inevitably pulls them into a life of drugs. In my world, a heart attack, stroke or any other random medical malevolence sets of a chain reaction that often makes it very difficult to meaningfully recover from.
The show also shows the perspective of the police department, the good guys. I like to think I'm one of the good guys. Instead of the guardians of the law, I view myself as a guardian of health.  In the show, the police department is depicted as a bureaucratic mess with leaders pushing misaligned incentives and convincing the hard working street cops they are doing the right thing. Street level arrests (aka "rip and runs") of low level drug users and dealers are depicted as ineffective to curtailing drug violence and therefore a complete waste of resources. Nevertheless, arrests fill up stat sheets for the police department and numerically give the false impression that good is being done. As a primary care physician, I feel like the street cops, at the front lines of healthcare. Instead of arrests, I'm trying desperately trying to achieve numerical benchmarks which some might think are good indicators of excellent medical care. Although these numbers look good on paper, I question how effective they are in the grand scheme of changing healthcare outcomes and improving lives. True investigative work that looks deeply into patients’ lives to solve and treat root cause is not rewarded in our healthcare system nor are the investigators appreciated who take this approach in the show.
Finally, I've read that the creator of the "The Wire" views his show as a modern day Greek tragedy. Greek tragedies often describe a doomed people who exist at the mercy of angry, greedy, vain and selfish Olympus gods who hurl lightning bolts, pestilence and misery at their subjects. In “The Wire,” the modern gods come in many forms. Politicians, police commissioners, corporations, drug kingpins all have a responsibility to protect and help their followers, yet inevitably fail them time and time again to their own benefit. In my world, the gods are politicians, insurance companies, drug companies and perhaps the physicians themselves. In their efforts to serve, politicians fight over policy decisions while people remain without insurance. Insurance and drug companies continue to profit despite questionable business practices that often hurt average citizens. Too many physicians, despite their best intentions, mired in debt and bureaucracy blindly plunge ahead doing more and more in a fee for service world without ever stopping to see if we're not only helping but also hurting our patients.
Occasionally I get asked about the myriad of healthcare related TV shows and which one is the most realistic. The easy thing is to point to any show that has doctors in it, be it a comedy, drama or reality show. Though “The Wire” isn’t about healthcare, its themes are very relevant to what I see every day as a primary care physician. With one more season left to watch, I’ve unfortunately come to expect a tragic hopeless ending. With several seasons left of my own story in primary care I expect many tragic story lines. But in this case, hopelessness will never be in the script.

Thursday, December 5, 2013

Top 10 reasons I use Twitter in Healthcare

This post also appears on the Stony Brook Internal Medicine unofficial Blog
Stony Brook Internal Medicine Blog

I’ve been on Twitter for almost a couple of years now and when I talk to people about it, I still get a healthy dose of skepticism.
So I've put together a top ten list of why as a physician and medical educator, I use Twitter.
10: Connecting with Leaders
To be lead, you must know what your leaders are thinking. Twitter has made leaders accessible. Now, instead of spending time looking for their opinions or hoping to catch a handshake or meeting at a conference, they send their thoughts directly to me, in small increments of 140 characters, everyday!
9: Connecting with Followers
As physicians, you are a leader. Whether it ‘s in your office, your patient panel, your learners, your colleagues, your academic society, you have the opportunity (and responsibility? ) to lead and lead effectively. Twitter allows you to share your thoughts in small increments, reach a vast audience with minimal effort. Quoting #10, “To be lead, you must know what your leaders are thinking.”
8: Networking
The importance of professional networking cannot be understated. Twitter easily connects people with similar interests. In less than 2 years, I have been able to access a vast network of people interested in things that are important to me such as Primary Care, Medical Education, Social Media, Evidence Based Medicine and Healthcare Technology. In the past, networking for me occurred in spurts, at pre-determined locations over a finite period of time. With Twitter, networking happens 24/7, with little effort no matter where you are (and in your pajamas, while watching tv!).
7: It makes me an active learner.
All through my education I took notes. Writing things down helped solidify that piece of knowledge. A notebook was also useful for exams, reviewing and reinforcing information. Now instead of a notebook, I have a tablet and instead of a piece of paper, I use twitter. The 140 character limitations forces me to be succinct which makes my virtual notebook very easy to review.
6: I can educate the world
This is a grandiose statement, but Twitter makes it real. As a Medical Educator, I take pride in being able to influence the learners in my immediate proximity. With Twitter I can take all those notes  (See reason #7) and broadcast it to learners in other cities, states, countries and continents! Currently I’m using the the hashtag #sbmgr to broadcast what we’re learning in our Internal Medicine Grand Rounds every Wednesday 8:30 to 9:30 AM.
5: I can attend multiple conferences simultaneously, year round.
Until human cloning technology advances, Twitter is the best way to be at multiple places at once.  I wish I could attend every medical conference out there. But thanks to people who prescribe to reason #7, I can virtually attend other conferences through my smart phone, all throughout the year. There are thousands of people out there like myself, live tweeting from conferences. This year, I personally attended ACP and APDIM live tweeting from both. But in addition, while being back home, I followed the tweets from Kidney Week and Chest in the past couple of months.
4: It’s a forum for debate
Healthy debate is part of our lives as physicians. New guidelines and treatments are always coming up, and Twitter I get immediate access to viewpoints from a wide variety of people. I often get immediate feedback on my own opinions.
3: My mom taught me to share
We are all online, all the time. As a physician, I’m always finding a great journal article, an interesting blog,  or an important news article. Before twitter, I had no mechanism to share that, besides e-mailing to a small set of people or writing it down somewhere and hope that I have an opportunity to suggest it to people. Now, every website has a Twitter link. You see something cool, you can share it with a large audience with just a few clicks.
2: The world at any given moment
Whenever I have a free moment, Twitter  is my go to activity. In 2 minutes, I can scroll through a myriad of messages and get a burst of information from a network of my choosing.  So it’s whether pumping gas, waiting for an elevator, a 15 minute lunch, a commercial break during the football game, Twitter helps me use these small snippets of time, constructively.
1: It broadens my mind
In patient care we are emphasizing a team-based approach that values the roles of every individual in a healthcare team. The same can be said for my continuing medical education. I think I have something to learn, from everyone. As a result I follow folks in Internal Medicine, sub-specialties, family medicine, psychiatry, surgery and so on. I follow nurses, physical therapists, social workers and patient advocates. I follow patients (not my own) sharing the story of their medical conditions. I am learning something from everyone from the palm of my hand.
If this doesn’t get you interested in Twitter, here’s a a blog post from someone who’s listed 140 Health Care uses for Twitter
In addition, here’s another post to help you make the leap.
This is written by Dr. Vineet Arora who is Director of GME Clinical Learning Environment Innovation and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago.

Monday, November 18, 2013

Medical Education (MEDED) App Reviews

The convergence of medicine and technology is a major topic of discussion in healthcare. The role technology plays in how we practice medicine continues to expand every day in innumerable ways. Besides the actual “practice” of medicine, technology is playing a vital role in how we educate our future doctors. As a technology enthusiast and an internist involved in resident and student education, I see tremendous opportunity to improve the medical education (MEDED) experience utilizing technology. Specifically, mobile applications or “APPS” have a great potential to deliver point of care education in a convenient, efficient and fun way.

                Currently, there are thousands apps out there that can be utilized in MEDED. I’d like to begin a new series of blog posts that reviews some of the apps I'm using. Hopefully other medical educators out there looking for apps will find this information helpful. 

Each month Ill review an app by breaking it down into the following categories.

1: Appearance
                An app has to look nice, clean and professional to have maximum impact. 
                Max Score 10. Weight 1.0
2: Ease of Use
                An app for a busy physician and or trainee needs to be easy to use without a steep learning curve,
               Max Score 10 Weight 2.0
3:  Educational Depth
                The depth and quality of information can vary greatly between apps. Since these apps are geared towards medical education, this category is weighted more.  
                Max Score 10 Weight 3.0
4: Clinical Impact
                This category reflects the app’s ability to translate into effective and meaning clinical decisions. 
                Max Score 10 Weight 3.0
5:  Fun Factor
                An app that is fun to use always gets my attention and has staying power.
                Max Score 10 Weight 1.0
6: X-Factor
                 If there's anything about the APP that can't be fit in the above categories, that deserves mentioning.

The maximum score an app can get is 100.

If anyone has suggestions on other categories or things I should consider, please let me know! Feedback is always appreciated!

If there are apps you'd like me to review, I'd be happy to take a look.
Currently I'm working on writing up my first review.

Tuesday, October 29, 2013

Peer Mentoring Program at Stony Brook Internal Medicine

I posted this at our internal medicine blog site last week.
Thought I would share it here as well :-)

Stony Brook Internal Medicine Residency Blog

Stony Brook Internal Medicine Peer Mentoring Program

So this afternoon, I get the distinct pleasure of being part of a new project here at Stony Brook Internal Medicine.
Under the direction of our wonderful associate Program director Dr. Rachel Wong, we have started a peer mentoring program in our residency program. Along with one of our chief resident’s Dr. Ali Sheikh, this afternoon we will continue this very cool project.
Mentoring is a broad concept, and everyone has different ideas about it. Today’s workshop will go into some very specific elements of mentoring such as “Mission Statements”, “Personal Networking Maps” ” Peer Check-ins, ” and more.
As a physician and especially as a young trainee, I may walk into this asking, what is this really about? Is this useful? It’s not about diseases, it’s not about evidence based medicines, it’s not about diagnostic tests or the latest drug developments, it’s not about patient care.  So what’s the point of committing 3 hours of potentially valuable resident time to such a project?
Well, when I take a step back and look at this, the program to me is about 1 thing.

It’s about going from Good to Great.

I have 100% confidence that everyone in our residency programs are and will continue to be very good physicians. Years of commitment to studying, testing, practicing, committing to long hours in residency have established this baseline of being “Good.”
But how do you get to Great? There really isn’t a defined road map for this. Taking the next step towards a bigger goal, requires guidance and tools that we’re rarely taught in medical school and residency. Mentoring, and more specifically Peer mentoring, can be one of those tools that helps all of us take that next step towards greatness.
In this era where our healthcare system and the world at large is struggling on many fronts, it’s simply not enough to be good. Good maintains the status quo. Great makes a difference.
I challenge everyone reading this and everyone in our residency program to utilize whatever tools you have at your arsenal (including this mentoring program) to make a commitment to exceed your own expectations  and set forth on a journey to achieve great things in your professional and personal lives.
“As human beings, our greatness lies not so much in being able to remake the world – that is the myth of the atomic age – as in being able to remake ourselves.”
-Mahatma Gandhi

Wednesday, October 16, 2013

The Fall AAIM 2013 Experience

I've a had a couple of weeks to digest my first experience at AAIM/APDIM , in New Orleans.
Here's just a few thoughts.

First of all, I feel really fortunate to have had the opportunity to go. One of the best things about working in academia is the variety of things you get to participate in. Patient Care and Medical Education are at the heart of what I do. Attending conferences is a terrific bonus!

A quick note on New Orleans. This was my first time there. New Orleans is a wonderful city, steeped in history and culture. It has it's own vibe, it's own aroma, it's own ambiance, different from most other cities. I was physically in the USA, but it felt like I was somewhere wonderfully different. And then you juxtapose present day New Orleans to everything related to Hurricane Katrina. You can't help but marvel at the resilience of the people who call Louisiana home. Granted, I didn't have time to step into the more rural regions that are probably still suffering from the after effects. But it's safe to say,  New Orleans is back.

Some global thoughts on the AAIM (Alliance Academic Internal Medicine) conference itself.
You always go to conferences knowing you're in a room full of people interested in the same things. It's a great feeling. When I went to ACP in San Francisco, I knew everyone cared about Internal Medicine. I'm sure at sub-specialty conferences, people really care about their specific diseases or systems.
What's unique about AAIM is that you're in a place with hundreds of people who not only care about Internal Medicine, but they care about making people within Internal Medicine, better. It's about educators who are making sacrifices for a lifelong commitment towards making better doctors. It's not about the newest treatment modalities, it's not about the newest diagnostic tests, it's not about emerging diseases, it's not about healthcare policy. It's about educators who take on the daunting task of making the people around them reach their maximum potential. I think this gives the conference a very unique flavor.

I also had the pleasure of attending AAIM 2013 with several key educators from Stony Brook Internal Medicine. What a great group of people! They are just as much fun outside of work, as they are during business hours :-)

I attended several talks and workshops throughout the few days.
Some of the themes I came away with are as follows:

1: Leadership skills are critical for personal career advancement and making positives things happen at your institution. I had an opportunity to sit down 1 to 1 with a Dean of a medical school and pick their brain. How cool is that?
2: There's tons of research going on, looking at novel approaches on how to maximize the education of our medical students and residents in Internal Medicine
3: There are some spectacular physicians out there receiving lifetime achievement recognitions for helping people those with the greatest need
4: Milestones are a challenging concept which we need to embrace to ensure future generators of doctors achieve proper benchmarks for successful clinical practice.
5: Lot's of interesting remediation, and coaching options out there for program directors to help their trainees reach their potentials
6: The psychology of learning is critical for educators to appreciate, understand and actively apply in their programs
7: Adaptability is a critical trait for program directors to ensure their program continues to thrive
8:  There are many novel approaches to improving medical education utilizing technology (my favorite part of the conference)

Finally, There was the networking. I met many educators with similar interests.The atmosphere is very collaborative and I can't to work with some of my new friends in academia.

A quick shout out the @AAIMonline social media participants. Twitter was a huge part of the conference for me personally. I really enjoyed tweeting and reading other people's tweets about the event. The official hash-tag was #aimw13. Social media made this an even more fun and interactive experience.

Next stop Nashville TN for the Spring Meeting!

Tuesday, August 6, 2013

Alex Rodriguez MD

The recent suspension of Alex Rodriguez (famous baseball star, accused of using performance enhancing drugs) has me thinking. The debate about performance enhancing drugs (PED) is an interesting one. On the one hand, the sanctity of baseball and doing things the right way, makes me think "PED" use is wrong. On the other hand, they are entertainers, and if they want to damage their own body, so be it. They're not hurting anyone. Would I do it, if I was a professional athlete and millions of dollars were at stake? I can't say for sure honestly.

Some say "Every man has his price."
You don' have to be an athlete. In all walks of life, there are temptations to stretch your morality for personal gain. Medicine, like anything else in life, is no exception to this.
And just like professional athletes, there are significant dollar figures at stake.
Recent studies have indicated the significant differences in life time earnings between various specialties.
The numerical value is in the millions. Here's a link to one of these studies

Lifetime Earnings for Physicians Across Specialties

When millions are at stake, are our future doctors facing the same dilemma as professional athletes?
If so, what is the "PED" of choice?
If I had to guess, it would be stimulants. This might be one of those dirty secrets of medical school.
Listening to medical students and residents, the question isn't whether students are doing it, it's how many?
And there's also some literature to suggest its a problem.

Prevalence of stimulant use in a sample of US medical students

Here's a blog post, based on the same article

Stimulant Use Exceptionally High Among Medical Students

And so, those same questions of money, morality, right and wrong that has me  interested in the Alex Rodriguez story, has me thinking about our medical students. Athletes are entertainers that hurt only themselves and the integrity of the game.

Medical students that excel because of stimulant use in theory are helping people and excelling at a noble cause.
There are some potential long term harmful individual effects of stimulant use, but are they hurting the integrity of our noble profession? This is a question we need to start asking ourselves.

Baseball, has been dancing around the issue of performance enhancing drugs for over 30 years, and now after years of struggling, we have a watershed moment to help the game move forward.

I suspect PED use in medicine (especially medical school) is a growing problem. It's important we bring this issue out into the open with more research, more root cause analysis and delve further into the medical ethics of this issue.

When patient care is involved and the question of right or wrong is debatable, it cannot be a dirty little secret no one wants to broach.

"Every man has his price." This is not true. But for every man there exists a bait which he cannot resist swallowing. To win over certain people to something, it is only necessary to give it a gloss of love of humanity, nobility, gentleness, self-sacrifice - and there is nothing you cannot get them to swallow. To their souls, these are the icing, the tidbit; other kinds of souls have others.

Friedrich Nietzsche
German philosopher (1844 - 1900)  

Sunday, August 4, 2013

An Intern again

I am an intern again. Not literally.

I still remember some of the raw emotions from my first few weeks of internship at Hahnemann Hospital at Drexel in Philadelphia. July 2005.

I was afraid.
I was afraid of actually being responsible for things, and making a mistake.

I felt clueless.
I felt clueless, because I was in a new place, unfamiliar with all the rules and regulations. I didn't know anyone. I didn't who or where to call for help.

I felt pressure.
I felt pressure to impress. I knew a lot was riding on my performance and I wanted to impress my senior residents, faculty and program directors.

I feared the fire.
I feared being the only physician around when a patient was crashing, with the task of putting out the proverbial fires.

"Where's my senior?"
I constantly needed my senior resident to guide and educate me.

But above any negativity, I was excited.
I was excited because despite the fear, pressure and lack of knowledge, I was given a rare opportunity to make a difference. Despite having worked hard for this opportunity, I still felt lucky to be given the chance to be a physician.

Almost ten years later, I feel like an intern again.

Recently, I was given the incredible opportunity to be Co-Program director of our Med-Pedes combined residency program here at Stony Brook. I couldn't be happier, despite experiencing some of these same intern emotions.

I am afraid once again of making mistakes. You never want to mess up with other peoples' careers in your hands.

I feel clueless once again, dealing with all sorts of new regulations, accreditation bodies and numerous new administrative responsibilities.

I feel pressure once again, to make the program even more successful than it already is. As always, there are people above watching. You want them to know they made the right choice.

There are still fires to put out, but different.

I still need a "senior resident." My more experienced Co-PD and other faculty mentors have been incredibly supportive and helpful with my transition to this position. Not a day goes by that I don't have questions.

But most importantly I am excited, yet again. Despite a recurrence of some challenging emotions, they are overridden with an immense sense of pride and excitement to be given the opportunity to serve an absolutely wonderful cast of residents.

The years have changed, but the message hasn't. You have to keep pushing yourself to the next internship. You have to keep putting yourself in positions that are not in your comfort zone. Only through this process, can you grow as a person and eventually be given opportunities to make an impact.

Friday, July 12, 2013

Guest Blog Post: Tips for new Interns

It's always exciting when our residents delve into the blogo-sphere sharing their terrific insights.

Dr. Christine Garcia is one of our terrific 2nd year Internal Medicine residents. She's been blogging at Medscape.

It's July and we've got a great pack of new interns.
She wrote a terrific post titled.

"The 'July Effect': Tips for New Interns"

Check it out!