A Muslim doctor gets on an airplane...

     The recent events of Tamera Ahmed on a commercial airline and the alleged discrimination and Islamophobia she endured, got me thinking about my own experiences in the air. Fortunately, I have never experienced anything as blatant as the events described by Ms. Ahmed. But as a Muslim-American, I've become too keenly aware of the growing specter of Islamophobia across the world. Whether it's at a TSA security checkpoint, sitting at a terminal or falling asleep inside the plane, I have to admit I sometimes wonder if someone is watching me, thinking I'm capable of committing harm. To those that continue to subscribe to beliefs that all Muslims on an airplane are a potential danger, I offer my own personal experiences that are the opposite.
     I've had the privilege of twice responding to a request for medical assistance on an airplane at over 30,000 feet. The first time, I was a senior resident flying home with my wife from a well deserved vacation. The flight attendant requested anyone with medical training to assist a passenger who had collapsed near the forward bathrooms. Without hesitation, I looked at my wife and headed to the front of the plane in my jeans, t-shirt and baseball cap looking nothing like a physician or a stereotypical dangerous Muslim for that matter. I ended up converging at the front with a nurse and a radiologist on the flight. Without access to a CT scanner on the flight, the nurse and I quickly took charge of the situation :-).  We came to the conclusion the the elderly lady had a vasovagal episode brought on by a lack of sleep, and the effects of alcohol at high altitude on a body altered by gastric bypass surgery. The flight attendants were understandably worried and repeatedly asked me whether the flight needed to be diverted for an emergency landing. I reassured them and gave my blessing to press forward towards our intended destination. After the flight I caught up with the lovely lady outside in the terminal while paramedics assessed her. She was extremely gracious in expressing her gratitude. In addition to her, several random passengers expressed their appreciation. One gentleman was particularly thankful that I didn't divert the plane and take away vacation time with his girlfriend.
     A second and similar episode occurred on another flight a few years later. This time, a passenger that was battling a stomach bug, vomited and subsequently also passed out. I once again marched to the front of the plane to assist the passenger. But this time, as I spoke to the passenger, his sister  next to him started to feel ill and weak. She too almost passed out from a vasovagal episode triggered by watching her brother heave. Fortunately, both passengers were ok as I reassured them and the flight crew that everything would be fine. And once again there was an outpouring of gratitude from a variety of people.
     As physicians, we are reminded early in our training and throughout our careers to treat all patients equally. I certainly did not ask who or what those passengers were on my flight. They were  people in a vulnerable situation who needed some help. Perhaps they even harbored the same biases and fears that plague the bigoted passengers on Ms. Ahmed's flight or the policy makers of the airline she flew. It wouldn't have mattered. What matters is that the vast majority of proud Muslim-Americans like myself continue to advocate unity and peace while in service of everyone in our communities regardless of sexual orientation, race, religion or any other identifier. We are your teachers, lawyers, waiters, engineers, plumbers, mechanics, nurses, doctors and all others. And occasionally we are also your guardians in the sky.
 
 

When the Bells Tolled for Me

     Empathy is a big topic in medical education. How do we teach and nurture it in the next generation of doctors? Personally, I've noticed that students and residents with personal experiences as a patient often "get it."
      I've had a few personal experiences as a patient and I think it's helped me gain perspective. Fortunately none of my experiences were life threatening, but one them did leave a big impression.
     In the fall of 1991,  I woke up on one morning with a strange sensation. I had difficulty speaking and drool was intermittently falling from my mouth. I wasn't in any pain and I remember finding the experience unusual and funny. My father had already left for work and with the situation unclear, my mother sent me to school with an appointment for our family physician later that day. I was happy to go and didn't want to miss school early in the year. I remember later that morning, despite how my mouth felt, I volunteered to read a section of my social studies text book. I always considered myself an adept reader, but that day I sounded incomprehensible. I even remember the quizzical look on my teacher's face after my attempt. I quickly realized I would have to hold back my enthusiasm for education for 1 day until my doctor could fix my ailment.
     My family practice doctor was a nice Indian gentleman with silvery grey hair. I remember vividly that his office was also his only examination room. Right next to his large, expensive wooden desk and leather chair, was an examination table, up against a wall lined by his innumerable degrees. It felt like I was being seeing in his home rather than in the sterile exam rooms I've grown accustomed to. I don't recall the details of the visit, except that he had diagnosed me with Bell's Palsy, given me "steroids," and a consultation with Neurology. As a teenager, I found this amusing but my parents were extremely concerned. They were so concerned that any run of the mill neurologist wouldn't do. We had to find someone affiliated with one of the major teaching institutions in New York City.
     We were lucky to get an appointment the following day. After an hour long subway ride, we were in front of a neurologist who was affable, intelligent but also eccentric with hair that only had chance encounters with a comb.The details from this part of the story are foggy. All I really remember is the concern on my father's face after the doctor advised that we immediately go to the emergency room. For reasons that I don't recall, my neurologist was concerned about meningitis.
       My inpatient story began like many others in the ER. The most vivid memory had to do with lumbar puncture (LP). My father consented for me, as a pleasant male ER resident explained the procedure and how pain would be minimal and to expect some post procedure headaches. I remember laying on my left side facing a wall 6 inches from my face with my arms clutching my knees close to my chest. With my bottom and back exposed, I felt the warm anesthetic burn its way through my back, while the rest of me shivered in the cold room. My father had to wait outside for what seemed like an eternity. The resident was talkative and friendly but I found it hard to focus on anything else besides my fatiguing arms and lower back. I recall several attempts at him guiding the needle to find the sweet spot. It didn't hurt but the repeated pressure and prodding of the apparatus was unnerving. After several minutes, the physician proclaimed success and asked me what color did I think the fluid was. I guessed red. To my surprise it was serenely clear.
      I woke up the next morning with a terrible headache and nausea. This was definitely much worse than the actual lumbar puncture. I couldn't enjoy the view from my window overlooking the East River while the smell of the hospital food made me that much more ill. Despite that, I was happy to see my eccentric neurologist who walked in like the Pied Piper with several medical students in tow. They stood around me, in a semicircle with their shiny white coats, smiles, enthusiasm and words of encouragement. The neurologist demonstrated his cranial nerve exam to the students with my Bell's palsy playing a central role. The student's marveled and I felt really special. I wish I could say this was that sentinel moment in my desire to be a physician and medical educator. But honestly, at age 13 although I fancied being a doctor one day, my real priorities in life were baseball cards and video games.
      The days that followed were less about my Bell's Palsy and more about a nasty pathogen. Although the results of my lumbar puncture were negative, the Varicella Zoster virus (Shingles) reared its ugly DNA. First it was  having a party under the covers of my ear canal which many years later and only in medical school did I learn to call it Ramsay Hunt Syndrome. Soon after, it had found itself on the tip of my tongue in what turned out to be an extremely painful aspect of my illness. I could barely eat for the next several days. To this day, I'm not exactly sure if the steroids that I initially took triggered the Shingles or whether it was the Shingles itself that precipitated the Bells Palsy. Either way, it was a terrible and frustrating combination of events.
     My last distinct memory of this event was the day of my discharge. Like any patient, especially a restless teenager, I couldn't wait to go home. The night prior, the IV line placed in my ante-cubital fossa gave out and a night float intern haphazardly (after several attempts) placed a new line in my wrist. Probably 6 to 8 hours after that, this too infiltrated and started to cause pain. My family and I rang for assistance. As minutes turned to what seemed like an hour, pain became agony as a huge bleb formed at the site, stretching my skin while likely causing pressure on the carpal tunnel underneath. I squeezed my mother's hand as hard as I could and squinted my eyes trying to endure the pain. I'm not sure how long I waited, but I remember the catheter being pulled and the immediate relief that came right after. A large fluid filled blister was left behind on my wrist. I was allowed to go home with instructions not to manipulate the blister. Of course one day it did pop, leaving behind exposed underlying tissue that I took care of myself for several days. Luckily it never got infected, but it did leave behind a scar that I still possess today.
    There are a few other tidbits to the conclusion of this story. I parleyed the illness into a new video game system from my parents. The scar on my wrist gave me a tiny bit of "street cred" with my teenage friends. I quickly lost that  "street cred" when I regained my ability and confidence to read out loud in class (4-6 months later).  I missed over a week of school and when I returned, I got a lot of hugs from girls who would otherwise ignore me. And I remember my class portraits that year. I had an ugly crooked smile to match my ugly multicolored shirt. Most importantly, it was a vivid experience that's given me perspective and a story to share in my life as a physician and medical educator.

“For what are we born if not to aid one another?” 
― Ernest Hemingway, For Whom the Bell Tolls


   

Back to the Future

    Recently, I reconnected with an old friend. We were childhood friends through college and then slowly drifted apart. Around 2001 he got married to his wife while I got engaged to medical school. Several years later, he contacted me and it's been great reminiscing about our past lives. He has a younger brother who's currently in medical school and remarked how he sees the same passion in his brother as he saw in me when we were younger. I chuckled thinking about what a stubborn and immature person I was in my early doctor wannabe years. Despite my ability to memorize textbook facts ( perhaps the most overrated skill for the modern doctor) my friend has a much better memory of those years. He backs his assertion that I've always had passion for my career by recalling a website I built in college.
    I believe I was a junior in college (circa 1998) and my efforts towards medical school were in full effect. MCATs, biochemistry and molecular biology courses, volunteer work, work-study research job and a gradually receding hairline were all happening simultaneously. In between all of this activity I became enamored with the Internet. My free college email address changed my views of human communication and connectivity. Web browsers like Webcrawler, Alta Vista and Netscape opened doors to the entire universe. With WebMD in its infancy, I began exploring health related information on the web. It was scattered and disorganized.  I saw an opportunity to build my own healthcare website that would combine my love for the internet, my desire to serve people while augmenting my medical school credentials.  I wanted a site that would provide quality information on a health topic that also appealed to the young adult crowd. So naturally, I chose sexually transmitted diseases!
   I called it "Scary Things to Discuss." In retrospect,  it sounds cheesy but back then I thought incorporating the letters STD into the title was clever. I gathered information from both old school (library) and new school ways (online) on some common diseases such as HIV, gonorrhea and chlamydia. I also included pictures, which wasn't easy without services like Google Images. I copied some from other websites and scanned some from textbooks to create an easy to follow and colorful page. I wasn't a computer programming major but I did learn some basic HTML code on my own. But thanks to Netscape Navigator, they packaged website building tools in their browser for non-computer folks like me. It was a labor of love that took me several months. Once it launched, it was one of my proudest moments. I continued to swell with pride as the website gradually gained momentum with a steady stream of positive comments from all corners of the globe. I actively maintained the site for about 18 months during which time it had logged over one hundred thousand hits.
     Sadly, the website met a quiet demise. After college and working full-time I didn't have the energy to maintain it. I regret not archiving it for posterity. I don't even remember what company hosted the site but I do remember they went from being a free hosting service to a paid one; a deal breaker for me at that time. The website's success was always a great conversation starter for me personally, but I actually never got to talk about it with the most important people at that time ; US medical schools. I didn't receive any interview offers.
   Since then I still became a physician but the world has changed. I've become a digital health enthusiast and advocate. I see the Web 2.0 (as opposed to 1.0 back in 1998) as a critical component of modern healthcare. And I'm no longer an outlier, shouting random things about syphilis and HIV into the internet void. Rather, I'm proud to be part of an incredible movement that hopes to improve and change medicine by bringing it back to the future.

The Ironic Illness of Izzy

     When I first met Izzy (name changed) he was a portly elderly gentlemen with an effervescent and jolly personality that lit up the clinic every time he visited. His most recognizable feature was his voice. His lifelong hobby was singing opera, as a tenor. The first time I discovered this, he belted out a few lines that echoed through our entire clinic. It was marvelous and since that moment, I always made sure my medical students and residents not just saw him, but heard him as well. He was a spectacular patient and person.
    A few years from our initial encounter, I found myself wandering the halls of the hospital with 2 medical students. They were 2nd year students looking for patients to practice taking histories and doing physical exams. Earlier that day, I received word that Izzy was admitted. Though this was unfortunate for Izzy, it was fortuitous for my fledgling doctors that such a great patient was available to talk to. And not surprisingly, despite feeling unwell, Izzy with his wife by his side, welcomed my students openly.
     I stood off to the side of the room, while my students peppered him with questions for over an hour as they tried to piece together his medical history without much experience and medical expertise to fallback on. They learned about his vocal talents and though he wasn't well enough to sing on that day, Izzy was quick to point out how his voice swept his wife off her feet when they were in college. I thought I knew everything about Izzy from our several appointments together, but these medical students were able to illicit a entirely new story from him that even I was unaware of.
    My intrepid students were taking a travel history when they discovered his wife was originally from  South America. He reminisced about the last time they went to visit her family which was about 4 to 5 years prior. He fondly recalled staying near a seaside town, enjoying the fresh ocean air and wonderful local cuisine. The only thing he didn't enjoy about this trip was going further inland to visit in-laws living in more mountainous areas. He recalled getting sick during that part of the trip, blaming it on some bad food and lack of sleep. His wife reminded him that he almost passed out a few times that week from feeling so unwell.
     After almost 90 minutes of questioning, doing a physical exam and sharing lots of laughs, my students and I left Izzy to go debrief on everything we had talked about. There was just an incredible amount of things to learn from Izzy. We were able to weave together his history, his physical exam, basic pulmonary physiology, and pathology to explain what had happened. I described to the students that Izzy was suffering from pulmonary fibrosis and explained some of general facets of this illness including impaired gas (oxygen) exchange and just the progressive reduction in his lungs' abilities to perform . We reviewed oxygen disassociation curves and the effects of altitude and oxygen saturation. In light of his diagnosis, it became clear why with his reduced lung function and thinner mountain air, Izzy felt so ill on his vacation. This was probably one of the first signs of his illness until later when it became sadly obvious his opera singing days were coming to an end.
     With every patient, there's always something to learn and Izzy's story was no exception. For me, when I look back at his story, I began to appreciate medicine as something more than doctors treating individuals with specific diseases affecting affecting well defined anatomy through different but predictable mechanisms. Medicine, as a science has surprisingly very abstract human qualities. At times, it can be funny, or sad, thrilling, uplifting, unpredictable and often dramatic. When an opera singer that relied on powerful lungs got a relatively uncommon condition affecting those same lungs, medicine got my attention that it also has a knack for irony.


   

OMG, you're alive!

     As a  physician, it's great to revisit the medical miracles you've played a hand in. In the monotony of the common every day events, a visit from that one patient who you brought back from the brink, can really lift the spirit. These moments are rare, especially if they happen while you're a medical student or resident that is destined for a short stay in the community, never to see that one incredible patient again. Even if you stay in one place for a few years, many patients get lost to follow up (for a variety of reasons) and the curiosities for whatever happened to Mr. or Mrs. X  can fade over time.
     As a 3rd year surgical med student, I remember attending trauma clinic and following around a weary 5th year senior resident (Dr. HC) as he lurched from room to room in his scrubs and clogs doing post op checks and removing stitches with little enthusiasm but great urgency. Clinic was a chore, an obstruction from the operating room or his call room bed. One day he picked up a chart of a gentlemen Mr. D (name changed) who presented with stitches that were surfacing from his abdomen from a trauma surgery a few years prior. He knocked on the door while reading the chart, entered the room head down while still reading and introduced himself... while still reading. When he finally looked up, he stopped suddenly, grabbed his mouth and mumbled "Oh my God!"
     3 to 4 years prior, when Dr. HC was a lowly surgical intern on trauma call, he assisted on a lengthy operation on a young Rastafarian gentlemen that suffered multiple knife wounds to his abdomen. I don't recall the details of the surgery but Dr. HC made it clear to me, that he didn't expect this patient to survive once he was patched up and shifted to the intensive care unit. The patient had a lengthy stay in the hospital and despite the visceral experience of doing surgery on him, Dr. HC's gypsy, sleep deprived surgical life turned Mr. D into simply another case to log and a patient unwillingly forgotten.
    After a few more seconds of disbelief, Dr. HC was finally able to drop his hands from his mouth and give Mr. D a  handshake. Mr. D's chief complaint  were put on hold while I was told about the circumstances of how they 1st met. Mr. D actually didn't even know who his doctors were on that terrible day but was pleasantly surprised to hear that this random resident sent to remove some stitches today, helped save his life. But Mr. D's enthusiasm was tempered, probably due to the discomfort he was feeling that day,the difficult post op course, rehabilitation and numerous nutritional issues he'd been battling ever since his abdominal trauma. But nothing could temper Dr. HC's smile as he grinned from ear to ear, repeating several times " Man, I can't believe it's you. "
    Dr. HC was a battle weary 5th year surgical resident, in a bleak inner city hospital. During my 12 weeks as a surgical med student, he was generally pleasant but had always had a morose aura. His chance encounter with Mr. D was the first time, he looked genuinely happy. In one of those very important "teachable moments" that med students crave, Dr. HC emphasized that it's cases like Mr. D that keep you going. It was a valuable lesson and although I didn't become surgeon, I did become a much better doctor that day.

Going back to where it all started

When I look back at my career, there are many different important moments that led me this point. One that really stands out was my decision to attend St. George's University (SGU), in Grenada West Indies.

It was 2001, a time of great personal doubt and uncertainty in my life. Despite that, my dream to become a physician persisted and SGU gave me the opportunity that I knew I deserved. Since then, it's been an incredible fulfilling journey that keeps getting better every day.

I have incredibly fond memories of my time at SGU and despite how busy life can get, I've been meaning to try to give a little back to my alma mata. And with that, I'm really excited to have the opportunity of going back so to speak, to where it all started.

On April 21st, I'll be attending the SGU information session in Fort Worth, Texas. This will be the first SGU event I'll be attending in many years. As an alumni, I'm really looking forward to meeting the next generation of bright minds looking for that same opportunity. I look forward to catching up with SGU people, answering questions and sharing my story with everyone there. 

Hope to see many of you there!

4/21/15 Tuesday

7:00pm-8:30pm

Ft. Worth, TX, USA

Courtyard Ft. Worth Downtown
601 Main St.
Ft. Worth, TX, USA

Learning, food and great memories

I had a few minutes so I thought I'd try and collect some of the many pictures taken at my last job that capture the spirit of learning combined with the fun and joy of eating together like a family.

At least a couple of times a month, we would hold pot lucks at our clinic while we did our Friday afternoon outpatient noon conference. They often a had a theme such as "Pi day"where we all made/bought some form of a pie.

The work we did in that clinic was often quite difficult but small events like these really made the work and learning process so wonderful!

Lot's of great memories and I miss all of you!

The eager Salesman and the stubborn Doctor.

     I really don't enjoy going into a store with a planned purchase only to get hassled and cajoled into purchasing something different. The fact is, with so much information at our fingertips, I decide ahead of time what I want and the price I'm willing to pay.

     Recently, I dropped my smart phone in the toilet bowl.

(Take 1 minute to laugh at me.)

     This event forced me to run to my wireless store and purchase a new smart phone. Despite having done my research, my anticipated 10 minute purchase turned into a 45 minute battle of wills between an eager salesman and my practical sensibilities.

     He couldn't have been a nicer guy. In his mid twenties, he had energy and enthusiasm for his job that likely made him very successful. His great attitude won me over and I let him do his sales pitch despite fully knowing I only came in for 1 specific purpose that I wouldn't veer from. He used numbers, diagrams, compliments, (even mild insults!), jokes, clever colloquial lines all to convince me I was making a huge mistake not heeding his advice. In the end, he relented, went to the back of the store and came back with my phone.

     As he was ringing up my purchase on his tablet,  he made one last ditch effort to win me over. In the process, he asked me what I do for a living. I told him I was a physician and suddenly, the entire tone of our conversation changed.

He paused, gave me a forced smile as I watched the wheels spin in his eyes. For the 1st time I sensed the smallest hesitation in his sales pitch and instead of talking about his product, he came back with this:

"How do you treat vertigo?" 

     I felt bad that I made him expend a lot of energy  knowing he'd fail. I humored him and we switched roles. Standing in a quiet corner of the store, I began asking him all the questions I normally would. After a few minutes of trouble shooting, we changed the symptom description to "disequilibrium" instead of vertigo and I reassured him while encouraging further evaluation with his primary care doctor. He seemed grateful but I couldn't help notice a morose coming over him.

     He explained to me he always worries about something terrible happening to him just like his sister. I delved further to find out several years prior, his 16 year old sister died of a pulmonary embolism. His voice lost clarity as he fumbled around his tablet muttering how all the bad doctors ( pediatricians, ER etc)  missed the diagnosis. He chuckled recalling how an x-ray went missing but was subsequently found and clearly had abnormal findings. Although I didn't ask, I presumed the x-ray was later found as part of some litigation process.

     I couldn't imagine how it must have felt to lose a sister when you are a child yourself. I could understand the frustration and anger under his breath that probably took years to soothe. An unexpected death of a loved one is always a tragedy especially when it seems the answers are so obvious and in the hands of the physicians entrusted to figure it out. I felt terrible for him, as he pulled out his own smart phone to show me an old picture of her,

     As objective physicians we always contemplate alternatives. I didn't know the physicians that treated his sister, but I empathized with them a little bit We are taught very early on in our education that pulmonary embolism is one of the trickiest diagnosis and easy to miss. We are taught about pre-test probabilities and chest pain in a teenager is statistically much less likely to be a life threatening condition. I imagined that could have easily been me, a well meaning physician doing their due diligence and something terrible like this still happening. As a physician, we never get comfortable dealing with the death of a patient. It's even more difficult when there's an unexpected death and you're left wondering what else you could have done. These very personal emotions are occasionally twisted, tossed and turned through malpractice litigation ; a process after which physicians are left confused, numb and questioning their purpose. This is a burden many physicians carry to their own grave, quietly without any expectation of assistance or pity.

     As he finalized my purchase, I completed my thoughts coming to the conclusion that no matter what the circumstances were, he went through a tragic experience and nothing can change that. I was happy to see he survived  and had become a very good salesman with a good attitude and great smile. But on this day he didn't get the sale he wanted. I regained my connection to the digital world with a new smart phone. I'm hoping he regained the tiniest bit of faith that doctors despite being fallible, listen and care.

Health Insurance ; A prerequisite to the American Dream

The American dream is alive and well. We still live in the land opportunity where hard work is the ticket to endless opportunities. On the contrary, bad health poses a major impediment towards fulfilling that dream. Besides the physical toll of an illness, the financial cost of an illness can make the American dream impossible to achieve. Millions of people without health insurance everyday face the spectre of their dream becoming a health care nightmare. Recently I got some great news about a family member who immigrated to the U.S a few years ago. A middle aged man with a wife and 2 kids, he came ready to do whatever it takes to secure a future for his family. An educated man, he struggled to find employment. He latched on to several different jobs that helped continue to build his skills but was given no health care benefits. He didn't qualify for Medicaid and couldn't afford private health insurance. Just like many Americans in this situation, his health took a backseat. But recently, he was finally able to secure a job that offered benefits including health insurance. He now had the security that seemed like a natural prerequisite towards pursuing his own American Dream. He took this opportunity to finally seek out world class healthcare. From a distance, I began to get caught up with what was happening with his health. Fortunately, he didn't have too many medical problems besides benign prostatic hyperplasia (BPH). It was significant enough that he was referred to a urologist. He felt lucky to find a local well renowned urologist with many positive reviews (both online and word of mouth) that also took his excellent new health insurance. After 1 visit, it seemed like he was appropriately placed on some medications to try to alleviate his symptoms. What was surprising is that he was also placed on brand name testosterone replacement. Immediately, skepticism towards testosterone replacement therapy began to engulf my thoughts. I began to wonder if my family member was another victim of the "Low T" marketing campaign. Furthermore, I was shocked to find out that within weeks of seeing this doctor, he was being offered greenlight laser prostatectomy. Granted I am looking at this case as an outsider. But without trying various types of medical therapy at optimal doses and for significant periods of time, the recommendation for surgery seemed very premature. Since then, my family member has been directed to a second opinion.
Health insurance is an extremely high priority issue for most Americans. It is the sensible thing to attain, whether it is to ensure wellness or treat illness that might otherwise derail a lifetime of hard work. But my family member's reward for obtaining health insurance wasn't good health but rather a glut of potentially wasteful and dangerous medical care. As we continue to expand health insurance in an attempt to cover all Americans and provide them access to care, we have to continue efforts towards curtailing health care that is not evidence based, wasteful and only serves to fulfill the American dream of providers and drug companies while taking advantage of hard working naive citizens. 

Don't hate the Anti-Vaxxer

     It's easy and convenient nowadays to take a few minutes to rally against the "Anti-Vaxxer" movement. With the recent measles outbreaks, there's no shortage of articles, memes, jokes and cartoons to share on blogs, Facebook, Twitter etc. But I'm going to throw a very small teeny tiny microscopic bone to the Anti-Vaxxer camp. I will do so with the disclaimer that as a primary care physician I think vaccines are an extremely important part of good health. Anyone that doesn't see their value, is misguided and perhaps misinformed.

    Having said that, there's no denying that the Anti-Vaxxer  movement  is real and unfortunately seems to be growing. They have quietly become a significant part of the general population. The reason for their growth is multifactorial, but the easiest targets are probably defrauded scientists, celebrities and politicians with dubious opinions. But the target that's probably hardest to identify is the one looking right back at us in the mirror.  When a problem afflicts society, the easiest thing to do is blame others. The introspective route asks us to look within to identify causes and offer solutions.

     How did we let this happen? The Anti-vaxxer movement is just another example of the growing mistrust and lack of faith in our doctors and healthcare system. There are many reasons for this. When it comes to vaccines, why aren't we, the trusted physicians able to educate and change their minds? Perhaps we are not living up to the true latin meaning of the word "Doctor" which is "to teach." Perhaps the modern doctor,  gathered and taught in traditional (antiquated?) methods are struggling with modern informed patients who challenge and question rather than accept paternalistic physician decision making. Perhaps we simply just don't have time to have a decent conversation with our patients about the importance of vaccines.

    Whatever the reasons, we need to figure out better ways to connect with this subset of our patients whose beliefs about vaccines post significant individual and community health risks. What we don't need to do is further alienate this population by kicking the proverbial horse while it's down. The amount of  seemingly joyous vitriol pouring from the medical community against anti-vaxxers is disappointing and at times bordering on classless. Social media is teeming with derogatory descriptions of this population.  I think this only furthers many people's views of rampant intellectual elitism in our doctors. The most disappointing stance on this issue is when doctors proclaim they will refuse to see patients who don't believe in vaccines. Hey genius, if you don't see that patient, then they definitely don't stand a chance of getting a vaccine!

   The anti-vaxxer type of population is something that has always existed in most medical practices. They represent a group of people who don't believe in the gospel you are preaching. I have patients who don't believe in cancer screenings, statins and a whole host of other great evidence based ideas. They can be frustrating and time consuming.  But they are still my patients and I will continue to respect them and care for them with the confidence to know I will eventually change some of their minds.

Endings and Beginnings

It's been a while since my last post. I've been busy and life has been changing.

For one, we had our third baby! She's beautiful and certainly takes up a significant amount of our time (disproportionately at night!)

I'm also moving. After a lifetime of calling myself a New Yorker, we're packing up and moving to Dallas, Texas.
I will always be a New Yorker and the emotions regarding this change are far too complex to discuss on this post.

But with this move ends a tremendous chapter of my medical life. Much of my posts on this blog were based on stories and experiences from these past 5 years.

We go into medicine because of the patients. The patients and their stories will always be the crux of my life in medicine. They will always inspire me to write and keep practicing medicine.

But these past 5 years have been about more than patients. I also took care of a different group of people. I got to be a caretaker of some pretty incredible internal medicine and med-peds residents.

They inspired me, taught me, challenged me, tested  me, made me laugh but most importantly made me proud to be a medical educator.

As doctors we love making patients better. As medical educators we love making patients better and making doctors better. It's an incredibly fun and gratifying career path.

So with that, a sincere thank you and good bye to my trainees past and present. I hope your interactions with me were as meaningful to you as it was for me. I can't wait for our paths to cross again as professional colleagues.

To my new patients, I can' t wait to meet you all and take care of you

To my new trainees, I can't wait to meet you all!. Let's get to work to make healthcare better and change medicine!

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.