Kudos to Inna!

A huge shoutout to Inna Blyakhman, one of our incoming interns, who was featured in a recent TIME article sharing the stories of medical trainees personally affected by the COVID-19 pandemic. In her segment, Inna detailed her parents’ battles with COVID-19. She eloquently described her perspectives and lessons she learned from the experience.

We are truly lucky to have her onboard. Welcome to the UCSD Internal Medicine family, Inna!

2019-2020 Six Word Stories

During the 2019-2020 academic year, our family of residents responded to three 6-word story prompts.

My pandemic silver lining is…

  • Zooming with friends, zoomies with doggies
  • gratitude for snail mail and amazonprime
  • Residents who inspire me every day!
  • A crisis without precedent or president
  • my dog loves me even more
  • relearning how to read leisure books.
  • wearing jammies and blankies to work.
  • online church any day, any time.
  • memes, online dance workouts, virtual concerts.
  • Innovative collaborative scientific medical staff worldwide
  • less plans, free time, slow down
  • Time to reconnect with support system
  • more snuggles with the best pup
  • Almost a PGY2; no more prerounding
  • no cars no traffic smooth drive
  • parents finally learned how to facetime 
  • the tiger king is outrageous and addicting

New Year, New Me- This year I am looking forward to…

  • finally getting around to PDSAs…maybe
  • Making new memories with old friends 
  • counting to six without making any errors
  • First job, long vacation, celebrating friends!
  • Finally achieving better work life fit
  • Vegas bod inspired by Jon Chung.
  • Being done with intern year yay
  • Starting fellowship, new city, mksap first!
  • Super seniors finally graduating from residency
  • The birth of my first baby!
  • Trying a new taco every month
  • Publishing my first author research paper!
  • Becoming an ultrasound guru, like Gary
  • Finally mastering the art of mealprep
  • Watching my baby learn to walk

Today I am grateful for….

  • Light rain, comfy sweaters, Jassal hugs.
  • The chance to serve through medicine.
  • My Family, My Patients, My Residents.
  • The last parking spot in Gilman
  • warm drinks, lights, things merry/bright
  • Not being a patient in hospital
  • F Words: Family, Friends, Food, Festivities
  • Compassionate co-workers who keep me sane.
  • EDIS is all green. I sleep
  • Rain in the desert, no fires
  • My amazing va interns and attending
  • No wards, no call, no problem 
  • A good night’s sleep without interruption
  • Happy hour after Friday School, yeah!
  • Turkey Turkey Gobble Gobble Yummy Tummy

COVID Perspective Piece in NEJM

I read this piece in this week’s NEJM and found it to be very thoughtful. I hope you do too.

n engl j med 382;19 nejm.org May 7, 2020

Fear and the Front Line

Susan L. Murray, M.B., B.A.O.

I have been thinking a lot about fear lately, and how much it behaves like a virus. How it can spread insidiously, person to person, or airborne, through new media and old, faster than we can contain it. How it induces so many of the same symptoms as a virus does: sweating, palpitation, nausea, shivering, and sometimes an almost overwhelming desire to curl up under a blanket in a dark room and stay there. How once fear has infected you, it is hard to get rid of, but extremely easy to pass on to others.

It is 2014, a different virus is splashed across the front pages, but the same sort of unease is in the air. I am a newly minted fellow at a small-town hospital, a long, long way from the epicenter of infection or anywhere that a genuine case of Ebola virus has been confirmed. On the street and on the wards, people are anxious. Having the wrong color skin is enough to earn you the side-eye from your fellow passengers on the bus or train. Cough once, and you will find them shuffling away from you.

The hospital is caught up in uncertain paroxysms of preparation for an epidemic that it hopes will never come. There are meetings and then more meetings. We are taught how to do the personal protective equipment hokey-pokey of gowning and degowning. There is ongoing debate as to whether we have the right gear. A sign appears on the entrance to the pneumatic tube leading from the emergency department to the laboratories: “If patient has Ebola, please do not put blood in chute.” Everyone seems uncertain.

“What will you do if we get a case?” my resident asks me, after yet another querulous staff meeting.

I eyeball the rows of gleaming new anti-Ebola Wellington boots lining the back wall of the ward. “Maybe I’ll just call in sick that day,” I sigh.

And then, one otherwise ordinary day, a young man arrives in the emergency department. He is in pain and shaking, far from home and struggling to overcome a language barrier. His cancer, when I assess him, is one of the most advanced cases I have ever seen. The edge of his liver is craggy with cancerous deposits. His bones are pockmarked with metastases. His skull is swollen with disease and pushing into the substance of his brain. He squirms in pain in the bed. We do what we can for him, but he is almost too sick for treatment. All we can do is try our best to make him comfortable.

Just before midnight on the second day of his hospitalization, he spikes a fever.

The possibility that he is infected with Ebola is remote, hypothetical. The embers of the epidemic in his home country are guttering. In 3 days’ time, the World Health Organization will declare it officially extinguished. But the guidelines for quarantine are clear. I discuss it with my attending, and she agrees that we need to take every precaution.

And just like that, the atmosphere starts to change.

The rumor spreads like ripples from a stone dropped in a still pond. I watch faces turn gray and eyes turn glassy as I try to explain that our suspicions are low, but yes, we are taking every sensible precaution. Work on the ward slows to a crawl. We do not have enough protective gear stocked, and other departments are suddenly guarding theirs jealously. I am told by a senior doctor that he and his entire department are unavailable to consult on the patient until further notice, since their safety cannot be guaranteed.

I am lucky, or maybe I’m just reckless, but the knowledge of the remoteness of the risk, and of the shiny, red patch of phlebitis on the man’s left arm that is almost certainly the source of his fever, inoculates me a little against the fear. In fact, I am almost certain that Ebola virus did not lay quiescent for a month and then travel 600 miles across the country to infect this man before he got on a plane to come here. I am prepared to bet my life, but not to ask others to do the same.

Still, at 5 a.m., wrapped up in a protective gown, trying and failing to get an IV access into his thrombosed vein because no one else will enter the room, I want to scream my frustration. The patient is only semiconscious now. He moans in pain as he sleeps.

At 8 a.m., when the day shift arrives, things only get worse. There are nurses hiding in the ward storeroom and doctors threatening to turn around and go home. The head of nursing arrives to demand that one of the nurses take responsibility for caring for the dying man. Eventually, she takes off her suit jacket, gowns up, and cares for him herself.

Most health care workers I know are brave people who perform demanding jobs in difficult circumstances. But one of the terrifying things about an outbreak of transmissible disease is that it’s not just our own life and health that we are being asked to put at risk in caring for patients. We risk being the vector that brings the illness home to the people we love — to our children and partners and parents — and that can be truly terrifying. It is easier to risk our own safety than to threaten the people we care about. Without support, without proper education, training, and contingency plans in place to help protect health care workers and their families, fear can run riot through a hospital or through a community. If we are not prepared to fight fear and ignorance as actively and as thoughtfully as we fight any other virus, it is possible that fear can do terrible harm to vulnerable people, even in places that never see a single case of infection during an outbreak. And a fear epidemic can have far worse consequences when complicated by issues of race, privilege, and language.

At 5 p.m. that evening, the man’s tests return, giving him the all clear. Around the ward, life begins to relax, heart rates slow, people smile again, the whole thing begins to seem a little like a bad joke, as the effects of the fear virus ebb.

The patient dies at 6 p.m.

What Will We Remember?

A quiet street, a closed building, an empty parking lot, a sad voice, a missed connection.  Pride, anger, fear, compassion, remorse.
What will we remember from this time? How can we use language to understand this experience?
Let’s try to capture a moment together to do some directed narrative writing.  Like a photograph, a short narrative tells a story in a moment’s time but leaves a lasting impression.  We can’t un-see, and we can’t un-read.  Let’s make something that lasts.
We’ll do a couple short writing exercises and share them with each other.
-Dena Rifkin, MD

Dr. Rifkin, our awesome nephrology attending and medical humanities expert has kindly agreed to lead us through this exercise!

Please fill out this survey so that we may figure out the best time for a Zoom event for those interested! Narrative Medicine

Perspective Piece in the NEJM

Dear UCSD IM Family,

I read this piece in NEJM and found it to be a powerful reminder of the difficult lives so many of our patients face.  This year, as part of our Health Equity Advocacy and Diversity (HEAD) initiative, we will be discussing many important aspects of social determinants of health, how they impact our patients and our responsibility as physician. Stay tuned for more opportunities.

August 15, 2019
N Engl J Med 2019; 381:600-601
DOI: 10.1056/NEJMp1903828

Mike’s Labels

Otis Warren, M.D.

Mike is a homeless chronic alcoholic. I know this because I wrote his label right here on his medical record. The first sentence, variations of which appear hundreds of times in his file, reads, “53-year-old homeless male, chronic alcoholic, presenting here via ambulance after being picked up behind a McDonald’s.” The EMS crew seemed ambivalent when they brought Mike in; they, too, knew his label. The nurses, recognizing Mike, started the “alcoholic protocol orders” long before I saw him: breathalyze, search belongings, transfer to the intoxication holding unit. In fact, all of us in Mike’s world know him by his labels — markers that help us recognize him and place him firmly in the role in which we’ve cast him. They identify his medicosocial conditions so we don’t have to go looking for new evidence of the root of his problems. We layer these labels and others on top of each other so that finding Mike the person becomes difficult, if not impossible.

Mike wears three layers of pants. The outer one, a pair of jeans, once blue but now asphalt-gray, is strung around his waist with a woman’s belt. In its left front pocket, there’s a congealed mass of papers, wet from the recent rain. I peel them apart and find old discharge instructions advising him to cut down on drinking, with phone numbers for local Alcoholics Anonymous (AA) chapters. A few pills (phenytoin, possibly) and $1.57 fall out of his pocket with the papers. In his otherwise empty right front pocket sits something green and soft — a jalapeno pepper. A Guatemalan man he shelters with gave it to him a week ago, “for seizures.”

Years ago, Mike would have been called a “Skid Rower” — a label that harkens back to the days of the logging industry in the Pacific Northwest, when logs were skidded down city streets, attracting men who drank and slept on the curbs. Policy and research from the 1950s and 1960s used “Skid Rower” as the accepted term for people like Mike. Cities around the country eventually carved out Skid Rows, not because they were logging towns, but because of Mike’s predecessors — the Amerigo Vespuccis of the inner city, whose occupied territory was named after them. Though it’s pejorative and not “politically correct” (PC), “Skid Rower” accomplished something that “homeless chronic alcoholic” can’t: it painted people like Mike into their community, describing not only what they were but also where they stayed and where they came from.

Beneath the baggy outer layer of jeans hides a pair of sweatpants, equally well aged. They are warm and moist. In these pockets, Mike keeps a half-smoked cigarette and a plastic bottle of vodka that’s one swallow away from empty. We set it aside, intending to return it later. Mike came to us last night singing loudly to the triage nurses, who were expecting him, “Honey, I’m home!” As I pull down his sweatpants, I ask Mike if he’s homeless. He looks at me cockeyed and asks, “You mean, where do I stay? I stay behind the McDonald’s on Prince Arthur Street.”

“And if it’s cold?” I ask.

“Then I stay here, with you.”

So Mike “stays” places. “Homeless” is our word for his situation, our label for who he is. But outside the hospital, Mike stays in a world populated by housing advocates and social workers. When I talk with them about Mike, they refer to him as a “person who experiences homelessness.” This “person-first” labeling liberates Mike, and homeless becomes something he experiences, not who he is. But it’s also clunky and far too PC. I am nauseated when I say it (I do not “experience nausea”). Ironically, most pushback against this terminology has come from the people to whom it’s applied.1 In AA meetings around the country, people are not standing up in church basements, proclaiming, “My name is Mike, and I experience alcoholism!”

Beneath Mike’s sweatpants is a pair of long underwear. They are utilitarian and worn, like a craftsman’s tool. They have a patina conferred by Mike’s survival on the street — and by urine. We remove them, turning them inside out as we drag them over his feet. He’s in a clean hospital gown now, his legs exposed; his transformation into a patient is complete. Mike’s layers gave him the appearance of perseverance, if not strength. Now that he’s nearly naked, we notice that his face is weathered and swollen and his legs are frail and withered.

Besides the emergency department and the alley behind McDonald’s, Mike and others like him are frequently found in Table 1 of scientific research articles. There, they are labeled “homeless, male, non-Hispanic white” and are compared with people bearing other labels. Before studying people, scientists must label them. In the hospital, too, our labels communicate patterns so we can place Mike into categories of people we have treated before. When I hear that Mike is a “COPDer,” I know his beard will be yellowed and smell of cigarettes. To an older generation of physicians, he would be a “pink puffer,” thin and ruddy. When he spent 2 months in the intensive care unit last year, he was an “ICU player” — intubated and edematous with a Foley bag hanging at his bedside.

Mike’s socks are last to be removed. They are the familiar, hospital-issue, grippy kind, dirty and infiltrated with dried skin. We pull them off, turn our heads, and hold our breath, anticipating the “skin blizzard” as his feet become aerosolized. I turn to his bothersome knee and notice that it’s cool, with bony protuberances that aren’t covered in anatomy class. As I palpate, I feel a popping as his patella courses over his tibia. “You hear that?” he yells. “It’s bone on bone. They won’t operate on me because I drink and stay on the street.” He knows I won’t be fixing his knee today but asks politely, “Could you wrap it with an Ace bandage?” I oblige. Wrapping his knee, I imagine the person who will discover the bandage perhaps a week or two from today. Like Mike’s labels, it will be another layer adhered to him.

The next morning, Mike steps out, now sober and blinking, into the sun. He is wearing a fresh pair of pants from our donation closet and a new pair of grippy socks. His Ace bandage is bound tight. Somewhere underneath is Mike, but finding him is impossible. He has grown into the labels we have bestowed on him. Mike is a homeless chronic alcoholic. Mike is a COPDer. Mike experiences homelessness. Mike is a Skid Rower. Mike stays behind McDonald’s and drinks. Mike has become his labels, and his labels have become him. Our emotional desire is to liberate Mike from these labels and to see who he is without them. But when we strip them off to find the “real” Mike, we lose a part of him in the process. Mike’s labels have allowed us to care for him, to research him, and to search for the housing he doesn’t have. We cling to them as much as they cling to him.

A Timely Reminder

Hello UCSD IM family!

I just read this perspective piece in this week’s NEJM.

As you set out to care for patients, a thought provoking reminder of how important it is for each of us to listen to our patients!


Taking Note

Raphael Rush, M.D.

July 4, 2019
N Engl J Med 2019; 381:9-11
DOI: 10.1056/NEJMp1816537

“Not so hard!” howled the man with abdominal pain, his body tense against his stretcher.

His skin looked sallow under the fluorescents illuminating the crowded emergency department (ED) hallway. My fingers had barely brushed his belly.

Although we’d just met, his records told a familiar story of months shuttling between EDs with various pains, no cause ever found. Old prescriptions in his chart had raised my suspicions. The normal preliminary ultrasound report seemed to confirm them. Still, I resigned myself to referring him to the surgeon on call. I wrote my note carefully, thinking about what to say.

Writing a history is as much a process of editing as composition. It takes a long time to learn what matters. As my training progressed, each note formed a rough draft for the next, another chance to focus on the bare facts of each case. My presentations became shorter, as online templates and the glazed eyes of senior residents taught me which questions to ask and which to ignore. Others’ notes identified the relevant diagnoses and framed my perspective on each patient. Just as patients all changed into the same blue gowns, we fit everyone’s life into the small set of stories we prewrote in our minds.

Brevity wasn’t the only reason details were cut. One attending physician with the frown of a grammar teacher marked residents’ notes in red pencil. One she returned to me bore a bold circle around a woman’s social history.

“Take out her marijuana usage,” she told me, as we sat side by side in her cramped examination room, reviewing my notes. “It’s not relevant, and I don’t want that staying in her chart.”

The patient’s marijuana use seemed unimportant to me, but I understood what concerned my attending. The words in a chart stay there forever, passed on to everyone a patient meets. If I wasn’t careful, all kinds of conclusions might be drawn from my notes. Even then, during fellowship, I still wasn’t sure what went into the record and what stayed out.

The details that are recorded can significantly affect how a story is perceived. Susan Sontag, writing about the stories conveyed by war photography, questioned the belief that photographs are meant “not to evoke but to show” — to state facts rather than imply conclusions. Sontag pointed out that whether intentionally or not, photographers choose which details to show. Viewers, removed from the context in which pictures were taken, use those details to impose the biases of their experiences in developing their own interpretations of the underlying story.

All I really knew about the patient with abdominal pain was what he’d told me and the results of my exam. But my perceptions were colored by his old notes and by my experiences with other patients. As I wrote my note, I remembered what he claimed about his alcohol and smoking history; I thought about the tension in his abdomen and his red-rimmed eyes.

Then I recalled the list of narcotic prescriptions on his chart. Other, more experienced doctors had seen him before. None of them had found anything wrong.

I was used to making quick decisions in the ED using all the information I had available and felt certain about my initial conclusion. But as I came to the end of my note, something made me hesitate.

The psychologists Daniel Kahneman and Amos Tversky named the tendency to lend excessive weight to a compelling story the “representativeness heuristic.”2 It’s a heuristic that physicians often apply. A group of researchers presented family physicians with the case of a 43-year-old woman with a sudden-onset headache and stiff neck, classic signs of meningitis. Physicians were 14% less likely to order further investigations if they were also told that the woman had a recent history of stress.

In the end, I didn’t record my patient’s apparent lack of reaction when he seemed unaware that I was feeling his abdomen. Nor did I indicate my own conclusion as to why he was there: that his abdominal pain was a ruse to obtain narcotics. Slipping his chart almost stealthily into its cubbyhole, I consulted general surgery and called in the next patient from the packed waiting area.

I find it a constant struggle to determine which details matter most. The challenge is partly prospective, when I’m writing notes that others will read. It’s tempting to say that the solution is to write even less in a chart, avoiding any detail that might bias a reader.

Certainly some things are not worth recording. When I returned to the hospital for another shift, I opened the chart of the man with abdominal pain. The surgeon who saw him had rethought the case. Unconvinced by the ultrasound, she ordered a repeat study, which showed cholecystitis. His pain resolved once his gallbladder came out. I tightened my lips, ashamed. I was relieved only that I had left my suspicions out of my note: my omission meant that another physician could assess him with an unjaundiced eye.

But details that are irrelevant at one point may prove crucial at another time. In another context, the patient’s old medication list could have saved his life. And it is often impossible to predict how a note will later be read. Sontag suggested that any detail can reinforce existing biases or introduce new ones. From the moment they see a photograph, viewers start reinterpreting its story to fit what they think they already know.

So our larger problem is retrospective: how to interpret what is already written about the patients we see. The surgeon who cared for my patient saw the same chart I had seen. But she was willing to assess him without preconceptions. She didn’t interpret his symptoms in light of his chart — she recast the old notes in light of the patient in front of her.

My past mistakes live on within me. I thought of that patient recently, when a woman came to my clinic with pain “NYD” — not yet diagnosed. It wasn’t for lack of trying: several other physicians had seen her already.

Sometimes I’m frustrated by requests for second opinions. The woman’s general practitioner had sent me the assessments of the other specialists she’d seen. It seemed unlikely that I would be the one who diagnosed her problem. For a moment, I was tempted to spend the appointment reading her chart, copying and pasting and inserting my own brief additions while she spoke. She seemed to sense this inclination, sitting down without removing her coat, as though she didn’t expect to stay long.

Shutting the door behind her, I noticed that my small waiting room was empty. From the window behind us came the gray light of late afternoon. In the corner of my screen, I had an eye on my schedule. Clinics always seem to run late. But after her name on my calendar came a large block of unscheduled time. There would be nobody else for a while. My time was my own, to use as I chose.

I turned my chair away from the computer and angled toward her. My stethoscope weighed on my neck and I removed it, along with my smudged glasses, which forced me to lean in. I picked up a pen and some paper, ready to transcribe whatever she said.

After a moment, she took off her jacket and settled into her chair, resting her coffee cup down on my desk. She seemed to relax. I confirmed her name and date of birth, and then we began.

“I have a lot of records from your other doctors,” I said. “We’ll review those together in a bit. But I want to hear your story again, in your own words, if that’s OK. From the beginning.”

A Thoughtful Narrative from Annals of Internal Medicine “On Being a Doctor” Series

ON BEING A DOCTOR |20 NOVEMBER 2018 The Privilege of Grief Michelle M. Kittleson, MD, PhD   As a cardiologist specializing in advanced heart failure and transplantation, I have saved lives and witnessed plenty of tragedy. The faces of the patients I have lost stay with me far longer than those of the patients I have saved. For years I lay awake at night grieving the losses, but this grief has nowhere to go. Loved ones may move through Elisabeth Kübler-Ross’ stages of grief—from denial to anger to bargaining to sadness and, finally, to acceptance—but what is the trajectory of a doctor’s grief? Through bitter experience and self-preservation, I have fashioned stages: Separate fault from fluke, distinguish the unforeseen from the expected, and accept that control is an illusion. The first step: “Was it my fault?” As a cardiology fellow, I cared for a patient with mechanical aortic and mitral valves who underwent pacemaker placement. The next morning, she was bradycardic

read more A Thoughtful Narrative from Annals of Internal Medicine “On Being a Doctor” Series

Curiosity and What Equality Really Means

June is here, which means we will soon bid farewell to our graduating residents!  I found this recent piece by Atul Gawande in the The New Yorker really inspirational, and I hope  you do too as you take the next step in your careers. “Graduates, wherever you go from here, and whatever you do, you will be tested. And the test will be about your ability to hold onto your principles. The foundational principle of medicine, going back centuries, is that all lives are of equal worth.” Congratulations class of 2018!! https://www.newyorker.com/news/news-desk/curiosity-and-the-prisoner  

Book Club: Dr. James Forrester

Last week, many of our internal medicine housestaff, cardiology fellows, and faculty enjoyed an amazing book club with Dr. James Forrester hosted by Dr. Tony Demaria and his wife Mrs. Demaria at their home!  We discussed Dr. Forrester’s excellent book The Heart Healers: The Misfits, Mavericks and Rebels Who Created the Greatest Medical Breakthrough of Our Lives.  We appreciate Dr. Demaria’s hospitality and Dr. Forrester’s attendance at this wonderful event!