Stethoscope Journal

President’s

Message: Robert Feezor, MD

Vascular Surgeon

UF Health-Halifax Health

The old adage of “physician, heal thyself” seems run-down and played-out. But at the risk of losing readers in the second sentence, I think it remains relevant if not more so now. My intense research (i.e., Google search on my phone) and the fact that my amazing mother is a Methodist preacher has confirmed that the origin of the phrase is the physician and Disciple Luke. No matter one’s spiritual inclinations, I think the phrase merits re-inspection and even resurgence now.

I recently was challenged to give a lecture on leadership to an amazing group of students at Bethune Cookman. (“Shout out” to Megan Johnson, the president of the Daytona Beach Gator Club). As I stressed over what to say that would be entertaining, informative, and maybe even helpful, I had an epiphany: give the advice of ….. Rest.

In my passion of UNC basketball, many of life lessons can be gleaned from Dean Smith. One of my favorites is the “rest sign”. If a player is tired, raising a fist to the bench signifies that he wants to be taken out of the game. My extrapolation to personal leadership pearls is that as a clinician, it is not only appropriate but also necessary to know when you are tired. And when you are, know how to rest and let the other clinical leaders around you drive for a while.

As physicians, we are super-human, never fatigue, and are capable of complex vascular surgical procedures after staying awake for over 40 hours straight. We don’t feel or suffer the same lack of coordination and judgment as non-clinicians. In fact, operating and taking care of patients when you are fatigued is a badge of honor. ….. or not. Clearly this is an outright lie and a dangerous fallacy. As a surgeon who did residency during the era prior to the term “duty hours” I can tell you that there is NO benefit to propagation of such malarkey.

I have the amazing advantage of wonderful vascular surgical partners and a great community of support, starting at home and continuing at work. I feel blessed to know that when I am in fact tired, I can step back, rest, and recharge. I have even gone so far as to tell my patients that I am taking vacation, almost without guilt. But I am working on that.

I would encourage all who are reading this to find his/her “zen”. Whether that is a walk on the beach, playing with a dog, reading a book, travelling, or going to dinner. There are two parts: 1. Find out how you recharge, and #2. Raise your fist and take yourself out of the game for a few minutes. Start this week and make it a tangible goal. Your patients, your family, and your self will thank you. It is not a sign of weakness, but strength. - RJF

ReconstructingLives:ThePsychologicalImpactofPlasticSurgery

Ariana

Genovese, BS and Ashley Lentz, MD

Itiswellknownthatplasticsurgery,whileasurgicalspecialty,resultsinprofound psychologicalimplications.However,theliteratureoftengravitatestowardsconcernslike bodydysmorphiaorborderline,narcissistic,orhistrionicpersonalitydisorders.These labels,whilevalidforasubsetofindividuals,haveinadvertentlycreatedastigmathat paintsthefieldofaestheticplasticsurgerywithanegativebrush.Thislimitedperspective failstoacknowledgethetypicalpatientwhoseeksplasticsurgerynotoutofobsession,but asameansofreclaimingtheirlifeandboostingtheirself-esteem.

Contrarytopopularbelief,thetypicalaestheticpatientisanindividualwhohasfacedsignificantlifechallengesandwishestoembrace theirphysicalappearanceaspartofalargerjourneytowardsinternalpeaceandhappiness.Forexample, considerthewomanwhohas battledobesityformostofherlife.Aftergatheringthedeterminationtoloseoverahundredpound,sheisleftwithexcessskinthatserves as aconstantreminderofherformerself.Everytimeshelooksinthemirror,thephysicalevidenceofherpasthindersherabilitytofully embracehernewlife.Forher,plasticsurgeryisnotaboutvanity,butaboutclosingapainfulchapterandmovingforwardwithconfidence. Similarly,takethecaseofamotherwiththreechildren.Pregnancyandchildbirth,whilebeautiful,cantakeasignificanttollonawoman’s body,leavingawomanstrugglingwithabodythatnolongerfeelslikeherown.Shelongstofeelcomfortableinherskinagain,tobeable toenjoyadayatthebeachwithherchildrenwithoutfeelingself-conscious.Plasticsurgeryoffershertheopportunitytorestorenotjusther physicalappearance,butalsohersenseofself.

Thenthere'stheyounggirlwithdisproportionatelylargebreaststhatcauseherbothphysicalpainandunwantedattention.Hergoalis nottoconformtosomesocietalidealofbeauty,buttolivealifefreefromthephysicaldiscomfortandsocialstigmathatherbodyhas broughtuponher.Forher,abreastreductionisameansoftakingcontrolofherlife,allowinghertofocusonhereducationandpersonal growthwithouttheburdenofconstantpainandobjectification.

Theseexamplesillustrateanoften-overlookedtruth:plasticsurgerycanprofoundlyimpactaperson’sself-esteemandoverallqualityof life.Thesocialjudgmentspeoplefacebasedontheirphysicalappearanceareharshandunforgiving,butevenmoredevastatingarethe internaljudgmentstheypassonthemselves.Thenegativerhetoricthatplaysonaloopintheirmindscanbeincrediblydishearteningandis oftenfarmoredebilitatingthananyexternalcriticism.

Imaginethedifferenceitwouldmakeinsomeone’slifeifthisnegativementaldialoguecouldbesilenced.Theimpactontheirdaily experience,joy,andconfidencewouldbeimmeasurable.Thementalstaticthatoncecloudedtheirthoughtsanddrainedtheirjoywouldbe lifted,allowingthemtolivemorefreely.InthewordsofDr.AshleyLentz,aboard-certifiedplasticsurgeon,“Yousavedmylife,”isa phraseshehasheardcountlesstimesfromherpatients.However,sheistrulysavingtheirminds.Whileshemaynothaveperformed life-savingcardiovascularsurgery,shehasremovedafigurative“cancer”-theconstantnegativethoughtloopthathasbeenerodingtheirjoy foryears.

Somemayarguethatifaperson'sunhappinessstemsfromtheirthoughts,therapyshouldbethesolutionratherthansurgery.While therapycanbeincrediblybeneficialandisoftennecessary,itisnotaone-size-fits-allanswer.Weliveinasocietythathasingrained specific standardsofbeautyandnormalcyintoourcollectiveconsciousness.Fromayoungage,peoplearebombardedwithimagesandmessages thatdictatewhatitmeanstobeattractive,successful,andaccepted.Thesesocietalnormsaresodeeplyembeddedinourmindsthatthey shapeourperceptionsofourselvesandothers,ofteninwayswearenotevenfullyawareof.

Formanyindividuals,yearsoftherapymayhelpthemcopewiththeirinsecurities,butitmaynevercompletelysilencetheirnegative internaldialogue.Thisdialogue,bornfromsocietalexpectationsandpersonalexperiences,continuetopesterthem,makingtheirday-to-day experiencemorechallengingthanitneedstobe.Insuchcases,plasticsurgerycanprovideasolutionthattherapyalonecannot-atangible changethatalignstheiroutwardsappearancewiththeirinnerself,bringingthemasenseofpeacethathadpreviouslybeenoutofreach.

However,itisessentialtoacknowledgethatnotallplasticsurgerypatientsaregoodcandidatesforsurgery.Thosewithpsychological conditionslikebodydysmorphiamayfindthatsurgerydoesnotalleviatetheirdistress,astheirfocussimplyshiftstoanotherperceived flaw.Thisiswhyscreeningpatientsforpsychologicalreadinessiscrucial.Dr.Lentz,emphasizedtheimportanceofthisinherpractice, offeringtipsforothersurgeonstoconsider.Sheadvisestalkingtostaff,aspatientsmaybehavedifferentlywhenthesurgeonispresent,and trustingone’sintuitionwhentheoverallatmosphereoftheroomfeelsoff.

Screeningforabuseisanothercriticalaspectofpatientevaluation.Itisvitaltodeterminewhetherthepatientgenuinelywantsthe procedureoriftheyarebeingcoercedbysomeoneelse.Dr.Lentzrecommendspayingcloseattentiontooverlyinvolvedcompanionsand

ensuringthepatientcanspeakprivatelywiththesurgeon.Thishelpstoensurethatthedecisiontoundergosurgeryistrulythatofthepatient. Inconclusion,thetypicalplasticsurgerypatientisnotanarcissistorsomeonewithapersonalitydisorder,butanordinarypersonseeking toimprovetheirqualityoflife.Whetherit’sawomanreclaimingherbodyafterweightloss,amotherrediscoveringherpre-pregnancyself, orayounggirlseekingrelieffromphysicalpain,plasticsurgerycanbeatoolforenhancingself-esteemand well-being.Byaddressingboththepsychologicalandphysicalaspectsofpatientcare,plasticsurgeonscanprofoundlyimpacttheirpatients, helpingthemnotonlyreconstructtheirappearance,buttheirlifeexperienceaswell.

BalancingArtificialIntelligenceandHumanTouchinModernMedicine

Pavlo Kravchuk, Madeleine Keenan, Lauren Frankle

Therapidadvancementoftechnologywithinthehealthcaresector,particularlytheproliferationofalgorithmsandAI,hasbrought significanttransformation.Frompredictiveanalyticsandpersonalizedtreatmentplanstoenhanceddiagnosticcapabilities,thepotential benefitsarevast.Yet,theseinnovationsalsoposeafundamentalchallenge:howdoweintegratethesetoolswithoutdiminishingthehuman aspectsofmedicinethathavebeenthecornerstoneofpatientcare?

TheRiseofAlgorithmsandAIinMedicine

Healthcarehasalwaysbeendatadriven.Theadventofelectronichealthrecords(EHRs),coupledwiththeincreasingavailabilityoflarge datasets,haspavedthewayforAIandpredictivealgorithmstotakeamorecentralrole.Thesetoolsofferthepromiseofenhancing diagnosticaccuracy,predictingpatientoutcomes,andoptimizationoftreatmentplans.Machinelearningalgorithmshavedemonstrated excellenceatinterpretingradiologicalimages,oftensurpassinghumanperformanceinspecifictasks.Predictivemodelsarebeingusedto gaugetheriskofdiseaseprogression,hospitalreadmission,andevenpatientdeteriorationinreal-time.Thesetechnologiesarenotmerely adjunctstohumandecision-making;theyarereshapinghowcareisdelivered.

Despitetheseadvancements,thereisagrowingconcernthattheincreasingrelianceonAIcouldleadtotheerosionofcriticalthinking skillsamongproviders.Medicineisnotjustascience;itisalsoanartthatrequiresintuition,empathy,andtheabilitytonavigatethe nuancesofpatientcare.Over-relianceonalgorithmsriskscliniciansbecomingdisengagedfromthedecision-makingprocess,trustingthe outputsofAItoolswithoutfullyunderstandingorquestioningtheunderlyinglogic,ultimatelycompromisingpatientcare.

TheRiskofOverrelianceonTechnology

Theshifttowardstechnology-drivencarecomeswithrisks.Oneoftheprimaryconcernsisthepotentialforoverrelianceonalgorithms, whichcouldinadvertentlystifleclinicaljudgmentandcriticalthinking.Physicians,whilesophisticatedintheirunderstandingofmedicine, maybecomeoverlydependentonAIoutputs,riskingascenariowherethe“artofmedicine”—thenuancesofpatientcare,theintegrationof complexhumanfactors,andthesubtletiesofclinicalexperience—becomesovershadowedbyablack-boxapproachtodecision-making.

Moreover,algorithms,whilepowerful,arenotinfallible.Theyaresubjecttobiasesbasedonthedatatheyaretrainedon,andtheymay notalwaysaccountfortheuniqueindividualitiesofpatients.Amodelthatperformswellinabroadpopulationmightnotbeaseffectiveina specificsubset,leadingtopotentialmisdiagnosesorinappropriatetreatmentplansifnotcarefullyvalidatedandcontextualizedbythe clinician.

PreservingtheHumanElementinMedicine

Thephysician-patientrelationshipisattheheartofmedicine.Empathy,communication,andtrust,whichformthefoundationofthis

relationship,cannotbereplicatedbytechnology.AsAIbecomesmoreintegratedintoclinicalpractice,itiscrucialtoensurethatthese humanisticqualitiesarenotlost.Physiciansmustremaintheinterpretersofdata,placingalgorithmicinsightswithinthebroadercontextof thepatient'slife,preferences,andvalues.

Todothiseffectively,physiciansmustretaintheirroleascriticalthinkers.ThisinvolvesquestioningtheoutputsofAI,understanding the underlyingdataandassumptionsthatdrivethesetools,andbeingvigilantaboutthelimitationsoftechnology.Importantly,thisinvolves knowingyourpatientandmeetingthemasanotherhumanbeing.Forthepatientwithaterminaldiseasethateveryalgorithmadvises hospice,yettheystillwanttopursueaggressive,evenexperimentaltreatment,thatconnectionwiththeirphysicianwillbecriticalin developingacareplan.Thispatientwillrelyontheirphysiciantohearthemasaperson,notadatapoint.Medicaleducationandtraining mustevolvetoemphasizenotjustthetechnicalskillsnecessarytousethesetoolsbutalsotheinterpretativeandjudgmentskillsrequiredto contextualizethemandkeepthehumanisminmedicine

StrategiesforIntegratingAIWhileMaintainingClinicalAutonomy

Topreservethehumanaspectofmedicine,healthcareprofessionalsmuststrivetomaintainadelicatebalancebetweentheutilizationof advancedtechnologiesandthecultivationofmeaningfulrelationshipswiththeirpatients.Thiscanbeachievedthroughamultifaceted approach:

EnhancedTraininginAIandDataLiteracy:AsAIbecomesmoreubiquitousinmedicine,thereisaneedforenhancedtraininginAIand dataliteracy.PhysiciansshouldbeequippedtounderstandhowthesealgorithmsworkandbeabletocriticallyappraiseAI-driven recommendations,understandingboththeirstrengthsandlimitations.

Fosteringempathyandemotionalintelligence:Whilealgorithmscanassistinidentifyingpatternsandmakingdata-driven recommendations,thetrueartofmedicineliesintheabilitytounderstandandrespondtotheuniqueemotionalandpsychologicalneedsof eachpatient.Cliniciansmustprioritizethedevelopmentofempathy,activelistening,andeffectivecommunicationskillstomaintainthe humanconnection.

Patient-CenteredAI:AItoolsshouldbedesignedwithapatient-centeredapproach,wherethetechnologysupportspersonalizedcare ratherthanimposingaone-size-fits-allsolution.ThisinvolvescreatingAIsystemsthatareflexibleandadaptabletothenuancesof individualpatientcases.

EthicalOversightandGovernance:TheexpandinguseofAIinmedicinerequiresrobustethicalframeworksandregulatoryguidelinesto ensureresponsibleandtransparentdeployment.PatientsmustbeinformedaboutAI’sroleintheircareandhavetheopportunitytoprovide informedconsent.ThisincludesensuringtransparencyinAIdecision-makingandcliniciandiscretionwhereAIrecommendationsmay conflictwithclinicaljudgment.Collaborationbetweenclinicians,datascientists,andethicistsisessentialtoensurethatAIenhances,rather thandiminishes,theclinician'srole.

ByembracingabalancedapproachthatleveragesthepowerofalgorithmsandAIwhileprioritizingthehumanaspectsofhealthcare, physicianscanplayapivotalroleinshapingthefutureofmedicine.WeshouldstrivetouseAIasanotherhealthcareteammember providingstatisticalexpertisetobolsterthephysician-patientdecisionmakingprocess,nottheendallbeallforpatientcaredecisions.This delicatebalancewillbecrucialinupholdingthecorevaluesofthemedicalprofession,ensuringthatpatientsreceivethecompassionate, personalizedcaretheydeserve,andthattheartofpracticingpatientcenteredcareiskeptattheforefrontinmedicine.

AHero

Sophie Gorelov

Shewas26yearsold,justafewmonthsolderthanIam.WalkingintotheroomtomeetKjustafewhoursbefore shemetherson,Ijoinedagroupofsupportivefamily,alleagertobeapartofthisbignight.Afterthenurse examinedheragainandsaidKwasreadytostartpushing,IwatchedasK’smom,sister,niece,andnephewall huggedheronemoretimebeforeexitingthedeliveryroom.A,K’ssignificantother,remainedbehindtosupport. Ajokedwithus,“Ihopethebabyarrivesat10:29pm.”WhenIaskedwhy,hesaid,“Iwasbornat11:29pmona Wednesday.”Glancingupattheclock,Isaidwithasmile,“Wellmaybehewillbebornat11:29pmthis Wednesday.”WehelpedKeaseintopositionasshepreparedtopushforthefirsttimeduringhernext contraction. Thenursecalmlyexplainedhowtobreatheandpushduringthecontractions.Thecontractionswerestillmore widelyspacedout,andKwouldrelyonthenurse’sinstruction–“Takeabreathin,nowbreatheout.Takeanother breathin,nowbreatheout.Nowtakeanotherbreathinandpush…1,2,3,4,5,6,7,8,9,10,andbreatheout…”

Placingmyfingersinthebirthcanal,Icouldfeeltheoutlineoftheheadasbabyventuredfurtherout.AsK progressedthroughlabor,shebecamemoreandmoreconfidentindeterminingthesensationofthecontractions, pushingwithstrength,spurredbythedesiretomeethernewbaby.Oncethebaby’sheadwasmorevisible,I removedmyglovestocallinthedoctortoleadthewaytothefinishlineindeliveringthisnewlife.OnceDr. Carbienerarrivedtothescene,wegownedandpositioned,readytocatchthebabyasDr.CarbienerguidedK throughcontinuedpushing.Inthefinalmoments,Dr.Carbienerguidedmyhandstohelpdrawthebabyfullyout ofthebirthcanal.AsIthinkbacktothismoment,Iamfilledwithwonder–ithappenedsofast,andyetIam unmistakenatthebeautiful,miraculousmysteryoflifeIbeheld.Inmyownhands,Iheldanewlifeandwitnessed asheletouthisfirstcry,whileoxygenatedbloodflowedthroughhisveins,transforminghisbluehuetoa healthfulpinktinge.Hisfirstbreathandfirstcrywerewhatweallwaitedforwithbatedbreath.Itwas11:29pm onaWednesday.

WatchingK,Ibeheldsomeonewhowithgraceandstrengthdidwhatherbodywasdesignedtodo:bearachild. Thatnight,shejoinedthegenerationsofwomenwhohavebeentheconduitsofnewlifeintothisworld.She becamethelinkinanewgeneration.Risingtorespondtodifferentcrises,withdifferentsolutions,MotherTeresa, whobroughtcomfortwithcompassionatehands,MartinLutherKingJr,whobroughtinspirationandhopewith hisvoice,andCorrieTenBoom,whopreservedlifewithherheartofcourageandconviction--allshared somethingincommon.Theseworldchangerseachhadamother.

AsIthinkabouttheroleofamother,Ithinkaboutmyownmom,whobore5childrenandraisedusasa stay-at-homemother.Inowthinkalsoaboutmymother-in-law,whoboreandraised9children,includingmy husband,David.Ourmoms,bothimmigrantsfromEurope,gaveeverypartofthemselves–includingtheirbodies –forus.

Welcominganewbabyintotheworldthatnight,Icouldnotyetseethefutureherohemayonedaybecome,butI alreadyknewwithcertaintyImetahero:hismother.

TelemedicineandItsImpactonAccesstoPrimaryCareforMentalHealth

Kevin Salimi and Pavlo Kravchuk

Mentalhealthdisordersareamongtheleadingcausesofdisabilityworldwide,yetaccesstomentalhealthservicesremainsasignificant challenge.Factorssuchasstigma,geographicbarriers,andashortageofmentalhealthprofessionalshavehistoricallylimitedpatients’ability toreceivetimelyandappropriatecare.Telemedicine,byenablingremoteconsultationsandtherapysessions,hasthepotentialtoovercome manyofthesebarriers,makingmentalhealthservicesmoreaccessibletoabroaderpopulation.

Theflexibilityofferedbytelemedicineallowspatientstoengagewiththeirprimarycareprovidersandmentalhealthspecialistsfromthe comfortoftheirhomes,reducingtheneedfortime-consumingandcostlytravel.Thisisparticularlybeneficialforindividualslivinginrural orunderservedareas,wherementalhealthresourcesareoftenscarce.Moreover,telemedicinecanfacilitatemorefrequentcheck-insand follow-upappointments,improvingcontinuityofcareandenablingearlierinterventionforemerginghealthissues.

BreakingDownBarriers

Mentalhealthdisordersarenotjuststatistics;theyaresilentbattlesfoughtdailybyourfriends,family,andneighbors.Theseinvisible strugglescontributetoaglobalburdenofdisability,affectingcountlessliveseachyear.Fortoomany,accesstotimelyandeffectivemental healthcareremainsfrustratinglyoutofreach.Ruralcommunities,low-resourcesettings,andunderservedpopulationsoftenfindthemselves in‘caredeserts,’wherehelpseemsadistantmirage.Entertelemedicine:arevolutionaryapproachthat’srewritingtherulesofmentalhealth caredelivery.

Telemedicinebreaksdowntraditionalbarrierstomentalhealthcarebyaddressing:

1. Geographiclimitations:Eliminatinglongdrivesandprovidingaccessinremoteareas.

2. Timeconstraints:Offeringappointmentsthatfitintobusyschedules.

3. Continuityofcare:Allowingpatientstomaintainrelationshipswithtrustedproviders,evenafterrelocating.

4. Reducedstigma:Enablingpatientstoseekhelpfromtheprivacyoftheirownhomes.

Considerthefollowingscenarios:

● Imagineasinglemotherinaruraltownmilesawayfromthenearestpsychiatrist,jugglingwork,childcare,andherownmental health.Takingadayofftodrivehourstotheclosestclinicisoftennotanoption.Forher,andmaylikeher,telemedicineismore thanaconvenience-it’salifeline.

● Ayoungprofessionallivingwithanxietyfacesasimilarchallenge.Theirjobleaveslittleroomforself-care,andtakinghalf

● adayoffforanin-personvisitmightmeanlostwagesanduncomfortableconversationswiththeiremployer.Withtelehealth,they candiscreetlyconsulttheirtherapistusingtheirphoneduringabreakorbetweenmeetings,maintainingboththeirincomeand privacy.

● AconstructionworkerbattlingPTSDpreviouslyhadtolosewagesandendurelongcommutesfortherapy.Now,hecanconnectwith histherapistduringhislunchbreak,usinghisphonefromtheprivacyofhistruck.Thisflexibilitynotonlysavestimeandmoneybut alsoreducesthestigmaoftenassociatedwithseekingmentalhealthcare.

● Acollegestudentwhorecentlymovedacrossthestate,cancontinuehersessionswiththepsychiatristshe’sbuiltarapportwithover years.Thiscontinuityofcareisinvaluableinmentalhealthtreatment,wheretrustandunderstandingplaypivotalroles.

ChallengesandLimitations

However,telemedicineformentalhealthcareisnotwithoutitshurdles.Areliableinternetconnectionisoftenaluxuryinruralorlow-income areas,makingvirtualcareinaccessibleforsome.Forexample,anelderlypatientinasmalltownwithspottybroadbandmightfindtheir telehealthsessioninterruptedbypoorconnectivity,turningapotentiallytherapeuticexperienceintoasourceoffrustration.Thedigitaldivide isalsoasocio-economicone;thosewithoutsmartphonesorcomputersareoftenexcludedfromthetelemedicinerevolution, creatinganewkindofinequalityinaccesstocare.

Privacyanddatasecurityconcernsarealsosignificant.Ateenagerinaconservativehouseholdmightfearthattheirtelehealthsessions couldbeoverheard,orthattheirrecordsmightbeaccessedbysomeonetheyknow.Thisfearcanleadtohesitanceinseekingvirtualcare, particularlyforsensitiveissueslikesexualhealthortrauma.Ensuringrobustsecurityandconfidentialitymeasuresiscriticaltofostering trustandwideningtheappealoftelemedicine.

Theregulatorylandscapefortelemedicineremindatangledwebofstateandnationallaws,reimbursementpolicies,andlicensure requirements.Theseinconsistenciescancomplicatethecontinuityofcare,especiallyforpatientswhomovebetweenstatesorwhoare seekingcross-stateexpertise.Atherapistlicensedinonestatemightnotbeabletocontinueseeingalong-termpatientwhomovesjusta fewmilesacrossaborder-afrustratingbarrierforbothpatientandprovider.

TheRoleofAIandFutureDirections

Lookingahead,artificialintelligence(AI) offersexcitingpossibilitiesforfurtherenhancingtelemedicineservices.AIcouldassistin triagingpatients,personalizingtreatmentplans,andevenpredictingmentalhealthcrisesbeforetheyoccur.Forinstance,AIalgorithms couldanalyzespeechpatternsoffacialexpressionsduringavideoconsultationtoprovidetheclinicianwithreal-timeinsights,allowing formorenuancedcare.

However,aswithanyemergingtechnology,theintroductionofAImustbeapproachedcautiously,ensuringthatethicalconsiderations, privacy,andequityareattheforefront.TheintegrationofAIintelehealthcouldredefinementalhealthcare,butitmustbedonewitha commitmenttoreducing,notexacerbating,existingdisparities.

Conclusion

Telemedicinehasalreadytransformedmentalhealthcarebyincreasingaccess,convenience,andcontinuityformanypatientswhowould otherwisebeleftwithoutoptions.Yet,aswecontinuetointegratetechnologyintomentalhealthservices,wemustbemindfulofthenew barriersthatariseandremaincommittedtoovercomingthem.Withthoughtfulimplementation,continuedresearch,andafocusonequity, telemedicineandAIholdthepromiseofafuturewherementalhealthcareisnotonlymoreaccessiblebutmorepersonalizedandeffective thaneverbefore.

TheFutureofPersonalizedPreventiveMedicine:EnhancingScreeninginPrimaryCare

Pavlo Kravchuk and Daniella Devaney

Preventivemedicinehaslongbeenafundamentalpillarofprimarycare,aimingtoidentifyandmitigatehealthrisksbeforetheyprogress intoseriousandsometimesfatalconditions.Traditionalapproachestopreventivecare,suchasstandardizedscreeningprotocolsbasedon age,sex,andfamilyhistory,havesavedcountlesslives.However,thesescreeningtoolsarereliantona“onesizefitsall”methodthatmay notbeadvantageousforallpatientdemographics.Withcertaincancermortalityrateshigherinoneracecomparedtoothers,andspecific infectiousdiseasesaffectingcertainsocioeconomicgroups,itraisesthequestionofwhetherequalityinscreeningtoolstranslatesto equitableandidealpatientcare.

TheCDCstrivestocreateguidelinesthathelpscreenpatientsatappropriatetimesusinggeneralizabledata. However,inaneraof medicinewhereknowndisparitiesbetweengroupsarestatisticallyproven,isitstilladvantageoustoscreeneverypatientthesameway? Thisisespeciallypertinentconsideringthateverypatientpresentswithauniquesetoffamilyhistory,racialbackground,andsocialreality thatcouldaffecttheirhealth?

Advancesingenomics,dataanalytics,andartificialintelligencearedrivingtheevolutionofpersonalizedmedicine,arevolutionary approachthattailorspreventivecaretotheuniquegenetic,environmental,andlifestylefactorsofeachindividual. Bymovingbeyondthe generalizedscreeningmeasures,personalizedpreventivemedicinepromisesmorepreciseriskassessments,earlierdiseasedetection,and moreeffectiveinterventions.

Oneofthemostpromisingaspectsofpersonalizedpreventivemedicineisitspotentialtoenhancescreeningprotocols. Traditional screeningmethodshavelimitations,includingfalsepositives,falsenegatives,andtheoverdiagnosisofconditionsthatmayneverhave impactedthepatient’shealth. Personalizedapproacheshavethepotentialtoreducetheselimitationsbyfocusingscreeningeffortson thosemostlikelytobenefit.

Considerprostatecancerscreeningasanexample.Foryears,theguidelinesforPSAscreeninghavebeenvagueandreliedonshared decision-makingbetweenthepatientandtheprovider.ThetraditionalapproachinvolvesPSAtestingstartingatage50(orearlierfor high-riskgroups).Thisscreeningguideline,relyingontheprincipleofautonomy,soundsgoodintheory,especiallybecauseanincreasein PSAismostcommonlydetectedbutnotlikelytocauseanyharm.

Thatisthecaseformostmen,butmostcertainlynotforBlackmen.Blackmenfacetwicethemortalityrateanda60%higherincidence thanWhitemenregardingprostatecancer.Yetthescreeningguidelinesforallmen,regardlessofrace,arethesame.Weproposea personalizedapproach,whichconsidersgeneticriskfactors(e.g.,BRCA1/2mutations,whichalsoincreaseprostatecancerrisk),race(as AfricanAmericanmenareathigherrisk),detailedfamilyhistory,andpotentiallyincorporatesnewbiomarkersorimagingtechniques. Thiscouldhelpreduceunnecessarybiopsiesinlow-riskmenwhileensuringhigh-riskindividualsreceiveappropriatescreening.

Otherareaswherepersonalizedpreventativemedicinecouldenhancescreeninginclude:

1. CardiovascularDiseaseScreening:Traditionalapproach:Basedprimarilyonage,bloodpressure,andcholesterollevels. Personalizedapproach:Incorporatesgeneticmarkers(e.g.,apolipoproteinEgenotype),advancedlipidtesting(particlesizeand number),inflammatorymarkers(e.g.,high-sensitivityC-reactiveprotein),anddatafromwearabledevicestrackingphysical activityandheartratevariability.Thiscomprehensiveassessmentcouldidentifyindividualsathighriskforcardiovascularevents whomightbenefitfromearlierormoreaggressiveinterventions.

2. Type2DiabetesScreening:Traditionalapproach:Typicallystartsatage45orearlierforoverweightindividuals.Personalized approach:Considersgeneticriskfactors(e.g.,TCF7L2genevariants),ethnicity,bodycomposition(beyondjustBMI),dietary patterns,andcontinuousglucosemonitoringdata.Thiscouldhelpidentifypre-diabeticindividualsearlierandallowfortargeted lifestyleinterventionsormedicationtopreventprogressiontofull-blowndiabetes.

3. LungCancerScreening:Traditionalapproach:Recommendedforadultsaged50-80withasignificantsmokinghistory. Personalizedapproach:Incorporatesgeneticmarkersassociatedwithlungcancerrisk,exposuretoenvironmentalpollutants, occupation,andmoredetailedsmokinghistory(includingsecondhandsmokeexposure).Thiscouldhelpidentifyhigh-risk non-smokerswhomightbenefitfromscreeningandallowformorepreciseriskstratificationamongsmokers.

4. OsteoporosisScreening:Traditionalapproach:Bonedensityscanstypicallystartatage65forwomen,laterformen. Personalizedapproach:Incorporatesgeneticfactorsaffectingbonemetabolism,detaileddietaryandexercisehistory,hormone levels,andpotentiallydatafromwearabledevicestrackingimpactactivities.Thiscouldidentifyyoungerindividualsathighrisk whomightbenefitfromearlierintervention,aswellasolderadultswhomightsafelydelayscreeningduetoprotectivefactors.

Theseexamplesdemonstratehowpersonalizedpreventivemedicinecanrefineandenhancetraditionalscreeningapproachesacrossa rangeofcommonhealthconditions.Byconsideringawiderarrayofindividualfactors,includinggenetics,environment,lifestyle,and real-timehealthdata,personalizedscreeninghasthepotentialtoimproveearlydetectionrates,reduceunnecessarytesting,andultimately leadtobetterhealthoutcomes.

Inamedicalerarevolutionizedwithnewstatisticallyprovendata,itistimetostartimplementingthesefindingstoclinicalpractice.Of coursetheguidelinesshouldprovidestrongguidancetotheprovider’sdecisionforscreening.Ultimately,itshouldbeuptotheproviders’ knowledgeofthepatientinfrontofthemtomakeuptodatedecisionsonwhichscreeningtoolswouldbemostadvantageoustotheir health.

Aspersonalizedpreventivemedicinecontinuestoevolve,itsintegrationintoprimarycarewilllikelyexpand.Thedevelopmentofmore sophisticatedAItoolsandtheincreasingaccessibilityofgenetictestingwillmakeiteasierforclinicianstotailorpreventivecareto

individualpatients.Moreover,ongoingresearchintothegeneticandenvironmentalfactorsthatcontributetodiseaseriskwillcontinueto refineandimprovescreeningprotocols.

However,thefuturesuccessofpersonalizedpreventivemedicinewilldependonacarefulbalancebetweentechnologicalinnovationand thepreservationofhumanisticcare.Cliniciansmustremainvigilantinensuringthattheseadvancesareusedtoenhance,ratherthan replace,thecriticalthinking,empathy,andpatient-centeredapproach.

MultidisciplinaryApproachestoReducingMortalityinPatientsSustainingHipFractures

Cameron Gerhold BS, Todd McCall MD, Lindsay Lucas MD

Oneofthemostconcerningorthopedicinjuriesarehipfractures,whichoccurinmorethan300,000individualseachyearintheUnited States.1Patientpopulationsatriskofthisdebilitatinginjuryincludethosewithasedentarylifestyle,patientswhotakemedicationsthat decreasebloodpressureorcausedrowsiness,thosewithosteoporosisorarepostmenopausal,smokers,andindividualsover65.1,2 AccordingtoFlorida’sDepartmentofElderAffairs,Floridaranksfirstinthenationforthehavingthehighestpercentofresidentsover theageof65.3Therefore,physiciansacrossthestateneededucationonhipfracturestobestprotectourvulnerablegeriatricpopulation.

Predictors of mortality in hip fracture patients

Perhapsoneofthemostimportantriskfactorsassociatedwithmortalityamongthosesustainingahipfractureisanincreasedage.4,5 Currentdatasuggestssubstantialfunctionaldeclineistobeexpectedforgeriatricpatientswithinthefirstyearfollowinghospital discharge,alongwithahighrateofmortality.5Therearetwomainapproachesindecreasingtherateofdisabilityandmorality:proactive andreactive.ProactiveapproachestopreventhipfracturesincludesupplementationwithcalciumandvitaminD,medicationsfor treatmentofosteoporosis,limitationofsmokingandalcoholintake,moderateexercise(whichcanslowboneloss,maintainmuscle strength,andimprovebalance),andensuringhomesafety.2

Homesafetyisespeciallyimportantforcaregiverstoaidelderlypatientinimplementing.Thisprocessmayincludeaddinghandrailsto staircases,installinggrabbarsinbathroomsandotherareasofapatient’shome,ensuringadequatelightingtopreventfalls,organizingor removingclutterinthehome,andremovingdecorativecarpetsthatmayactasatriphazardforolder,lesscoordinatedpatients. Ifthepatientisadmittedtoahealthcaresetting,suchasanursinghomeorhospital,bedalarmsandhourlyroundingaretwoproven techniquestokeeppatientssafefromharm.Reactiveapproachestopreventingmortalityassociatedwithgeriatrichipfractureswillbe discussedbelow.

The impact of surgical timing on mortality following hip fractures

Akeyfactorinthereactiveapproachtodecreasingmortalityamonghipfracturepatientswaselucidatedinarecentlypublished JAMA study:theroleofsurgicaltiming.6Themaintakeawaymessagefromresearcherswasthatindividualswhounderwentoperativerepairof theirfractureafterawaittimeof24hours(sincearrivingatthehospital)essentiallypassedathresholdthatplacedthematmuchhigher riskofdeathwithin30daysfollowingtheirinjury.6Therefore,apossiblesolutionwouldbefororthopedicsurgeonsandemergency personneltocollaborateanddevelopanalgorithmthatdetermineswhichpatientsareinneedofexpeditedorthopediccare.Onewayto shortentimetosurgeryisforemergencyphysicianstoconsulttheorthopedicsurgeonearlytodiscusstheplanofcareforthepatient. Then,thesurgeonshouldengageanesthesiologytoexpeditecardiacclearancegiventheorthopedicinjuryisthepredominantissue.This willallowforearlieradjustmentanypreoperativeandintraoperativemedicationsthatwillbeadministeredtothepatient.Thisproposal willalsoallowcircumventionofthecurrentprocesswhereintheemergencyphysicianconsultscardiologyfirst,slowingtimetooperative repair.

Thesehigh-riskpatientsshouldundergoextensivemonitoringwithintheirfirstmonthpost-operatively.Themostimportant,andmost common,deadlymedicalcomplicationsnotedwithinthesefirst30dayswerevenousthromboembolism(VTE),pneumonia,myocardial infarction,hipdislocation,andproblemswithsurgicalhardware.6Whilethelattertwocomplicationswerepresumedtobeunrelatedto waittimes,theyarenonethelessimportantcomplicationsthatmustbemonitored.

Healthcare collaboration

Allprecedingdataleavesuswithasinglequestion:Howcanwecreatea“dreamteam”tooptimizesurgicaloutcomesforourpatients? Whilethisisnoeasyproblemtofix,andthusthereisnoeasysolution,thereareseveralstepswecantake.

Firstly,achievingdesiredresultsinorthopedicsurgeryinvolvesmorethanindividualexpertise;itrequiresacoordinated, multi-disciplinaryapproachtobestaddressthecomplexneedsofeachpatient.Theroleoforthopedicsurgeonsistoprovidecustom, precisecareforeachpatientwithanimmediategoalofachievingmedicalstabilityandanendgoalofattainingmobility.Surgeonsmust decidetheoptimalsurgicaltechniqueforrepair:whetherinternalfixation,hemiarthroplasty,oratotalhipreplacementisbestfortheir patient.Additionally,implementationofevidence-basedprotocolsforanticoagulationtherapy,plansforinfectionprevention,andplans forearlymobilizationarealsocritical.

Whiletheorthopedicsurgeonsensurevigilantpostoperativecare,physicaltherapistsarecrucialinbringingthesepatientstofully recoverythroughtargetedrehabilitationprograms.Thesepatientsshouldnotonlybecoachedthroughtheirhipfracture,buttheymustbe educatedwithtoolstostrengthentheirmusclesandimprovebalance.Ultimately,thiswillhelppatientsregainsomeindependencewhile hopefullydecreasingtheirriskoffuturefalls.Additionally,anexemplarygeriatricianisanimportantmemberofthemulti-disciplinary careteamforpostoperativehipfracturepatients.Thesephysiciansarethemostqualifiedtounderstandthecomplexmedicalneedsof olderadultsandcanusuallyprovidetheirpatientswiththebestsolutionstoadjustingtolifefollowingthismajorinjury.Thesedoctors areequippedtoaddressissuessuchascognitivedecline,delirium,chronichealthconditions,andotherthingsthatmayimpederecovery orattainmentofoptimalpostoperativeoutcomes.Geriatriciansmayalsoelecttoconnecttheirpatientswithdieticianswhocanprovide nutritionalsupportandcounselingtosupportimmunefunction,promotewoundhealing,maintainmusclemass,andensureadequate intakeofkeyvitaminsandminerals(suchascalciumandvitaminD).Dieticiansmayalsoaddressanyunderlyingnutritionaldeficiencies whichincreaseapatient’sriskofsustainingfuturefractures.

Future directions

Whilecontinuingeducationisapracticeallphysiciansandhealthcareprofessionalsarefamiliarwith,stayingontopofthelatest developmentsintechnologyandresearchiscrucialformaintainingthehigheststandardofcare.Byunderstandingthenewest technologiesandtechniques,orthopedicsurgeonsarebestequippedtoservetheircommunity.Additionally,anyopportunitiesfor membersofthesurgicaloremergencyteamstolearnabouteachother’srolesandpotentialchallengesfacedcanincreaseawarenessand understandingofsetbacksincaregoals.Developingtheseopportunitiestoenhanceunderstandingamonghealthcareteamsmayleadto morestreamlinedcollaborationinfutureemergencysituations.Additionally,werecommendthatmaterialsregardinghipfracturesbe disseminatedthroughoutcommunitiesviaprimarycarephysiciansandgeriatricianstoensurepatientsandtheircaregiversarealertedto theseriousnessofthisinjury.

References:

1.HipFracture&BrokenHip.ClevelandClinic.RevisedJanuary21,2021. https://my.clevelandclinic.org/health/diseases/17101-hip-fracture

2.HipFracturePrevention.OrthoInfo.https://orthoinfo.aaos.org/en/staying-healthy/hip-fracture-prevention/

3.FloridaStatePlanonAging2022-2025.StateofFloridaDepartmentofElderAffairs.PublishedAugust5,2024. https://elderaffairs.org/wp-content/uploads/FINAL-Florida-State-Plan-on-Aging-2022-2025-10182021.pdf

4.LeBlancES,HillierTA,PedulaKL,etal.Hipfractureandincreasedshort-termbutnotlong-termmortalityinhealthyolderwomen. Arch Intern Med.2011;171(20):1831-1837.doi:10.1001/archinternmed.2011.447

5.AardenJJ,vanderEschM,EngelbertRHH,vanderSchaafM,deRooijSE,BuurmanBM.HipFracturesinOlderPatients: TrajectoriesofDisabilityafterSurgery. J Nutr Health Aging.2017;21(7):837-842.doi:10.1007/s12603-016-0830-y

6.PincusD,RaviB,WassersteinD,etal.AssociationBetweenWaitTimeand30-DayMortalityinAdultsUndergoingHipFracture Surgery. JAMA.2017;318(20):1994-2003.doi:10.1001/jama.2017.17606

Florida State University College of Medicine

Pathographies

Essays by medical students on patients encountered during their third-year rotations and all patient names are fictional.

Mortality in Medicine

by Jessica Browder

Onemorningonmyinternalmedicine rotation,Ilookedoutthe12thfloor windowattheverytopofthehospitaland wasshockedtoseeanenormousvulture staringbackatme.Iamnotusuallya superstitiousperson,butthisdidn’tstrike measagoodomenasIhadbeenbattling withtheconceptofdeathallweek.My patientlistincludedacachectic 90-year-oldwomanwithalungmasswho yelledatallofthestaffandrefusedtoeat, a71-year-oldwomanwithmetastatic pancreaticcancerwhosefamilykicked palliativecareoutoftheroom,andan 86-year-oldmanwithpneumoniaanda pneumothoraxwhoseconditionwas rapidlyworsening.Thelastcasehitme particularlyhard,asIhadgrownquite fondoftheelderlygentleman.Every morningwhenIwouldpre-round,he wouldgreetmewithasmileandofferme someofhisbreakfast.WhenIobviously politelydeclined,hewouldlaughand insistthathissurplusbesharedwithhis nurseinstead.Hehadoriginallycometo thehospitalduetoafewepisodesof hemoptysis,andthework-uprevealedthe pneumoniaandpneumothorax.WhenI firstmethim,healreadyhadchesttubes inplaceaswellasanasalcannula.His onlycomplaintatthattimewassomemild shoulderpain,whichwasquicklyand laughablyresolvedwhenitwas discoveredthathewasactuallyjust accidentallylayingontheremote.Atmy secondencounterwithhim,Igathered informationonhowhewasdoingafter exchangingourusualpleasantries.He statedthathewasdoingwell,butI noticedaspotofbrightredbloodonthe frontofhishospitalgown.Imadesureto

updatemypreceptor,andwedecidedto monitorhimclosely.ThenextdaywhenI camein,Ipracticallyskippedtohisroom inanticipationofanotherpleasant conversationwiththesweetolder gentleman.Tomysurprise,Ialmostdidn’t recognizehimwhenIenteredandbriefly wonderedwhetherIhadmixedupthe roomnumber.Uponseeingmehebegan immediatelymoaningthathehada terriblenightandcouldnotsleepatall sincehewasgaspingforeachbreath.He wasclearlydecompensating,andnothing Isaidcouldsoothehim.Whenmy preceptorcametocheckonhimshortly after,hestartedbeggingforahospice consultandaDNR.Icouldn’tbelievethat thesamemanwhowashappilyjoking aroundwithme24hourspriorcouldnow beinsuchdistressthatherefusedany medicalintervention.AsIwatchedin shock,mypreceptorpulledoutaDNR formandgentlyandpatientlywent througheachlinetomakesurehe understoodandwasmakinganinformed decision.Hevehementlyagreedandhis healthcareproxywasalsonotified.After weconsultedhospiceuponhisrequest,I feltdefeatedasIbelievedtherewasmuch morewecouldhavedoneforhim. Fortunately,mypreceptorwisely remindedmethatwewerenotpersonally experiencingwhathewasgoingthrough, andourjobincludesrespectinghis autonomyasapatienttomakethat decision.Shejokinglycomparedour professiontothatofaserver,offering medicationsandinterventionsonaplatter withthepatientchoosingwhattheywould liketoorder.EventhoughIagreedwith thiscodeofethics,Istillcouldnotgetthis patientoutofmyhead.Afterafewdays ofintrospectionandcontemplation,I realizedthatIwaslettingmyowndesires andegogetinthewayoftreatingmy patientaccordingtohiswishes.Itake prideinmyabilitytobeagoodlistener andcaredeeplyformypatients,butI neededtoletgoinorderto

trulytreathimwell.AfterthisepiphanyI begantoseehoweachpatienthandledthe processofdyingdifferently,whetherthey reactedwithanger,denial,oracceptance. Uponcloserinspection,thereseemedto beacommonthreadoffearunderlying thesecomplexemotions,eveninmy patientswhowerenotcriticallyill.AsI comfortedanelderlypatientwith dementia,IimaginedthatIwouldalso havefelttrappedintheunfamiliar environment.Whenanotherpatientwho struggledwithhomelessnesstearfullytold meshewouldloseherbelovedcattothe shelterifshehadtostayonemoreday,I feltthepainthatsuchanunfairlosswould bring.Theseencountersstirredupamix ofemotionsinmetooandleftalasting impact.Inthemidstofthedailyhustle andbustleofthehospital,Ifeltasenseof humblegratitudethatIwasableto connecttootherhumansatsomeofthe mostvulnerablepointsoftheirlives.In myfuturecareerasaphysician,Ihopeto boldlykeepmyselfgroundedin compassionwhilestayingtruetomy ethicalprinciplesinthefaceoftragedy, death,oryes,evenvultures.

I Will Never Forget

by Renish Contractor

Obstetricsandgynecologywasmyfirst rotationasathird-yearmedicalstudent.I rememberthedeerintheheadlightslookI hadasInotonlyembarkedonmyfirst rotationbutalsoexperiencingamotherin activelabor.ThiswasarotationIfelt underpreparedforbothclinicallyand emotionally.Thisfearledtomehavethe preconceivedbeliefthatIwouldhave littleintereston

thisrotationcomparedtotheonesthat wouldcomelaterintheyear.Atthetime, littledidIknowhowwrongthat judgementwouldendupbeing.

Duringthisrotation,onepatientlefta profoundimpactonmeandmyjourneyto becomingaphysician.Samwasa 26-year-oldG2P1at25weekswho experiencedsecondtrimestervaginal bleedingathomeinthemiddleofthe night.ShewasbroughtintotheEDand admittedtotheobstetricswardfor observation.Duringroundsthefollowing morning,Samexplainedtomypreceptor andmethatshewokeupinthemiddleof thenighttoherbedcoveredinbloodand thefearofbleedingoutandlosingher baby.Thepatientmentionedthather previouspregnancywasfurther complicatedbypostpartumhemorrhage.I couldsensethefearoftheunknowninthe roomasthiswasadelicateandrare situation.Overthenextfewdaysfurther work-uprevealedplacentaprevia superimposedwithvasaprevia.The physicianexplainedtoSamthatshe wouldbegoodhandsbutunfortunately, shewouldhavetostayinthehospital untilherdeliveryorriskdemiseofher fetusandmassivebleedingforherself. Samexpressedthatalthoughlivinginthe hospitaloverthenextfewmonthswould bedifficult,butshewantedtodo whateverittooktoensureherbabygirl wouldbedeliveredaliveandhealthy.

Overthecourseofthenextfewdays,I followedSamonroundsdailyand watchedasherfearandanxietycameand wentinwaves.Thisiswhenithitmethat thiswastherealdeal,Iwasnolongera youngchildsittinginmyplayroom playingdoctor.EverythingIhadbeen lookingforwardtomywholelifewas trulyhappeningandIwasalmostabit nervousunderstandingthatIhadnoreal lifeormedicalexperiencetobeguiding thisyoungwomanthroughsuchacritical periodinherlife.Igrewtolearnthatshe wasnotjustapatientwitharare diagnosis.

AsIinteractedwithSamoverthese followingweeks,IlearnedthatSam,her

husband,andIhadmanythingsin common.Despitebeingindifferentstages inlife,wewerethesameage.Samwas marriedwithan11-month-oldathome andwellintohercareerbuthada youthfulcheerfulnesstoher.Ilearnedthat wesharedinterestsinthesameTVshows andloveforsports.HerhusbandandI bondedoverthefactthatbothofushad mustaches.Wequicklybondedandseeing Saminhercornerhospitalroomwould oftenbethehighlightofmyday.

Overthecourseofthenextfew months,despitenotbeingonSam’s service,Iwouldoftengovisitherinher hospitalroom.Weplayedboardgames andlearnedabouteachother’slivesand experiences.Samwouldquicklygrow boredofwatchingTVinthehospital roomandspenttimereadinguponher condition.Whenvisitinghershewould teachmeaboutplacentaandvasaprevia.I cametolearnagreatdealaboutthese conditions,moresothanIcouldthrough AnkiorUWorld.FromSam’shusbandI learnedaboutthedaytodayofbeingan EMTandsomeoftheheroicbutscary situationshehadbeenapartof.

Duringthesevisits,Icametorealize justhowmuchIcouldlearnfrommy patients.IcametolearnaboutSam’s experiencesinthehospital,heremotions, hercomfort,andherwell-being.Sam expressedfeartohope,lonelinessto attachment,andunfamiliarityto familiarity.Herthoughtsracedfrom optimismtoconcernsoffearofwhatlay ahead.Samnotedalossofcontrol–of hersenseofself,ofherautonomy,andof comfort.Eachlookdownatherhospital gownremindedherofhervulnerable state.

Physicalandemotionalcomfort becomesanafterthoughtinthehospital setting.Asapatientyoulongforthe comfortofyourownbed,asmall commoditytakenforgrantedindailylife. Thesmellsofyourfavoritecandles becomereplacedbythenauseatingscent ofantisepticwipes.Thecomfortfoods youprepareathomebecomereplacedby standardizedhospitalmeals.Theconstant

flowofhealthcareprofessionalsfeels comfortingyetisolating,takenawayfrom thecommunityandfamiliarfacesyou normallysee.Throughtheseexperiences, IbecamemoreawareofSamexperiences ofbeinginthehospital,beyondthe medicaldiagnosisgiventoher.

BythetimeSamwasableto safetydeliverherbabygirl,Ihadmoved ontoadifferentrotation,butshe expressedthatshewouldlikemetobe presentforherdeliveryafterthe numeroushourswehadspenttogetherin hercornerhospitalroom.At4AMone morningSamwasreadytodeliver,andI wokeupfromacallfromherdoctorand rushedtothehospitalwhilescarfing downonaproteinbaronmydriveover. Afterdeliveringapremature,yethealthy babygirlIsawthejoyandreliefonSam andherhusband’sfaceafteralengthyand difficultpregnancy.

AlthoughIwaslearningsomuch fromamedicalstandpoint,Irealizedin themomenthowmuchjoymyselfandthe restofthe teamwereabletobringto thisfamilyandhowonedayItoowanted thisformyself–tohaveafamilyand bringnewlifeintotheworld.Irealized duringthistimewhatlifereallymeant andhowmuchjoyaphysiciancould providetoapatientandtheirlovedones duringsuchanintimateprocess.Icameto appreciateSam’srangeofemotionsand herresilience

overthemonthsshelaidinthathospital bed.Iamgratefultobeabletoexperience thiswithSamandisanexperienceIwill neverforget.

More Than a Diagnosis

by Brady Culpepper

Iwasextremelyexcitedtobeginmy familymedicinerotationduringtheFall ofmythirdyear.Notonlyinthisthe

specialtyIwillbeapplyingto,butI genuinelylovethedepthof communicationandinterpersonal understandingthatisthebackboneofthis profession.Thereisnobetterwaytotruly knoweachpatientasapersonthanthis continuityofcareseeninprimarycare. Thelargescopeofindividualsand clinicalscenariosallowsonetobe exposedtoamyriadofpersonalities, cultures,socioeconomicbackgrounds, andthecomorbiditiesthataccompany suchpersonal,social,andfamilial histories.

Asamedicalstudent,Iliketothinkof theseaseye-openinglessonsthatbroaden myownexperienceandexpandsmy perspective.Thelargestoftheseoccurred duringthisfamilymedicinerotation,as mypreceptorspenttwodaysaweek managingsubstanceusedisordersthrough addictionmedicine.Upuntilthispoint, mytraininghadnotinvolvedthisspecific community,withsuchspecificdifficulties anddiseases.Addictionoftenelicitsmany falseorunconsciousbiases,andIwasnot immunetosuch,enteringthisfieldina verynaïveway.

Itcanbesoeasytopassjudgements andassumesimplereasonsforcomplex obstacles,butIwasquicklyhumbledon myfirstdayofaddictionmedicineasI wastransportedintoawayofpractice thatrequiredimmenseamountsof empathy,understanding,andaboveall, listening,thelikesofwhichIhadyetto see.Iwasluckytoenoughtofollowthe samepatientsforall6weeks,forming strongconnectionswiththeseindividuals andhavingtheprivilegetoheartheir storiesandlifeexperiences.Throughout thispaperIwillsharepiecesofone individual’sstories,whatleadhertoseek addictionmedicinecare,andhowshe changedmeandhelpedshapehowIwill onedaypracticemedicine.

Anenormousmisconceptionweas societyliketosayisthat“addictsarejust addicts,”thatlazinessandboredomalone spurtheonsetofaddictionwithdrugand alcoholuse.Inmyexperiencethiscould notbefurtherfromthetruth.Thefirst

notbefurtherfromthetruth.Thefirst patientIhadtheprivilegetoseewasa womanwhohadsufferedfromopioiduse disorderfor20years.Onthesurfacethis canappearstraightforward,butIhave learnedthatstraightforwardisrarelythe case;Onlythroughtakingtimeto communicatecanonelearnthe underlyingtruthsthatmustbeaddressed ifoneistotreatthewholehumanrather thansimplypatchingthemostovert problem.SittingdownwithherIlearned thatshegrewupsurroundedbytrauma, startingwithherfatherabusingher mother,whichlaterturnedintohim abusingher.Toescapethisterrible circumstance,shemovedoutatanearly age,workinganyjobsshecouldtofind herselfastableenvironmentandhome. Butinoursociety,education,money,and success,canbeacripplinguphillbattleif notbornintosuchstabilitywithample support.Thisyoungwomanfindsherself livingwithaboyfriendtosavemoneyfor herself,however,thisexposeshertoa communityofindividualsthatareusing opioids,whichbecomesherintroduction tosuchsubstances.

Thewomanthatsatbeforemehad thenenduredyearsofaddictionwith transientperiodsofsobrietytoraiseher threechildren,andremittingaddiction.A womanwhohadnofamilialsupportatan incrediblyyoungage,ahistoryof profoundtrauma,whohadbeenturned awaybyothermedicalprofessionalsdue toverybiasesImentionedearlier,who wantssobadlyabetterlifeforherself. Addictionisfickle.Yes,itisadisease. Andlikeanychronicdiseasethereisno easyfix.Itrequiresregimens,medical andphysical,itrequireseffortfromboth providerandpatient,anditrequires patienceandaboveall,acaringspirit.

Adiabeticpatientcomestotheclinic afterChristmas,theyhaveaspikeinA1c because“Iwentalittlecrazyoverthe holidays,there’sjustsomuchgood food!”Thedoctormaylaughin understandingbecausethatissomething mosthumanscanrelateto,lettingour humannesscatchuptouseveryoncein-a-while.Butwhyisthesamepatience

notbestowedtothosesufferingfrom substanceusedisorder?Arelapseisnot metwiththatsamerelatablechortle, ratheritismetwithfiercejudgmentin manysettings.Whileitisimpossibleto fullyunderstandasituationthatonehas notencountered,itisthejobofadoctor toempathizewithandtreatequallyall individualsthatseekcare.Noonehuman deservesmorequalitycarethananother, nomatterthepathology.Anypotential biasformedhasnobusinessinamedical setting.

Throughoutmytimewiththispatient, Ilearnedincreasinglyaboutherlife.How shehadsoughtouttherapyasayoung adultbutcouldnotafforditandwasnot givenanyresourcestoaccommodateher. Ilearnedthatsignificantanxietyand depressionstillfollowherandisa tremendoustriggerforhersubstanceuse. Ilearnedthatherlastproviderhadtreated heranxietywithbenzodiazepines, ignoringherrequeststoreceiveformal therapeuticcare.Ilearnedthather relationshipwithherchildrenhasbeen horriblytainted,andthatrepairingthose relationshipsisanenormouspushforher tokeeptrying,everyday,toachieve sobriety.

Mostofall,Ilearnedthatthis informationiscrucialinhelpingthis patient,crucialinfullyunderstandingher andmeetingherwheresheis.Inever wouldhaveknowntherealreasonsthat leadhertothispositionifIdidnotask. Thisexperienceillustratedtomethegreat importanceofdoingallyoucanasa providertoknowyourpatients,asthisis trulytheonlywayyoucantreatthem withthehighestofqualityandfairness. Nomatterthereason,nomatterthe patient,eachindividualdeservesthe utmostrespectandeffort.Iwillaimtosee thesepatientsforthetotaloftheir experience,findingwaystousetheirpast andpresenttoguidetreatmentplansand leadthemwithpatienceandempathy, neverlettingjudgmenteffacethe wonderfulpeoplethatentertheoffice, askingforhelp.

Giving It All We Have

by Luke Farmer

SaraisayoungwomanIhadthe pleasureofmeetingonmyobstetricsand gynecologyrotation.FromherchartIwas abletoseethatshehashadoneother pregnancyinthepast,atermcesarean sectionforfetalintoleranceoflabortwo yearsago.Iwasalsoabletoseethatshe wasuptodateonallofherrecommended screenings,vaccinations,andhadan otherwiseuncomplicatedmedicalhistory. At26weeksofpregnancywithnoacute complaintsIwassurethiswouldbea relativelysimplevisit.

Ienteredtheroomandcaughtsightof ayoungwomanwithfairskin,brightred hair,andadimlookonherface.“Hi,my nameisLukeandIamathirdyear medicalstudent”Iexplainedwithmy usualintroduction.“HelloLuke”,she repliedinaquietvoice,lookingoverat mefromtheexamtablewithsunken, exhaustedeyes.Iexpectedthatapregnant womanwouldbeverytiredfromthe manychangesherbodyisgoingthrough, butSaraseemedexceptionallyfatigued. “Iseethatyoupassedyoursugartest sinceyourlastvisit,howhaveyoubeen feelinglately?”Iasked.Sherepliedwith asighthateverythingisfine,shefeelsher babymove,andshehasnobleeding,asif rehearsedlikealine.Wesatinsilencefor afewmoments,asIlookedoverata patientwholookedmoreconcerningthan sheseemedtodescribe.“Iamgladtohear that,howelsehavethingsbeenforyou sinceyourlastvisit?”Iasked.She seemedtorollthequestionaroundfora moment,andwhenshewasconvincedI genuinelywantedtohearaboutherlife beyondthechartandreviewofsymptoms shebegananswering.“Well,Iamjustso tired.Mydaughteristwoandhasdaycare 3times

perweek.Iworkatthegasstationbyour housefortwelvehourshifts,andbythe endofitmyfeetaresoswollenIcan barelystandit.Iwanttoworklessbutwe needthemoneysobadrightnowsoIcan getmycarfixed.It’soldandneedsnew everythingitseems.Iamjustlooking forwardtodeliveringmybabyandbeing donewithallofthis!”shepouredoutto me.

Ifeltbothhonoredthatshewould sharesomuchofherlifewithme,but alsosohelpless.Wehaddoneeverything medicallytohelpensureherpregnancyis safe,yetshewasstillindistress.Iknew thatnomatterwhatIpresentedtomy preceptor,therewasnothingwecoulddo tofixhercar,pickherdaughterupfrom schoolormakehershiftsatworkshorter. AllIcouldmutterupinresponsewas,“I amsorrytohearyouaregoingthroughso much,youmustcarealotaboutyour children.”Aslightsmileappearedacross thesideofherface,“yesactually,sheisa prettycoolkid”.

Severalweekslater,whileonthelabor anddeliveryfloor,Isawhernamecome uponthelistofpatients.Ireviewedher chartasIwasscheduledtoscrubinfor herscheduledC-section.Searching throughherchart,myheartskippedabeat asIreadthewords“recentmotorvehicle accident”.Iwasterrifiedforher,and quicklyreadthroughheremergencyroom visit4daysbefore.Shewasarestrained driver,andhadbeenrearendedby anothervehicle.Shehadnovisible injuries,andwasclearedmedically,but wasclearlyshakenbytheexperience whenIvisitedherintheroom.“I’mokay, itjustscaredmealot.

I’mjusthappymybabyisokay”she repliedwhenIaskedherhowshewas feeling.Iwashappytoseeherandher babywerewell,butIcouldnotshakea guiltyfeeling.IfonlyIhadwarnedher morestronglywhenshedescribedhercar notworkingwell.Ifonlyshedidnothave toworksohard.IfonlyIcouldhavedone more.Theonethingthatgavemesolace waswhenshesaid“Thankyouforasking, it’sgoodtoseeyouagain,the

doctortoldmeIgettohavemybaby today.”

Iassistedintheprocedurelaterthat afternoon,andwiththepatient’scomfort musicoftheBeatlesplayinginthe background,sawahealthybabygirl placedonSaratofinallymeet.Ichecked onherandhernewdaughterthe followingdaysonrounds,ensuringthat thesurgicalsitewashealingwell,and alsocheckingonhermentalhealthby seeinghowshehasbeenfeeling.She madeajoketomethathermotherwho waspickingherandthechildupfromthe hospitalwillcertainlynotbetakingthe carfromtheaccident.Herhumorboth shockedandencouragedme.

Ourfinalinteractionhappenedather4 weekpostpartumvisit.Itwasincredible supportingapatientthroughseveral stagesofherpregnancy,andbeingableto seethefinalresultofamom,andtwo healthychildrenafterallofherhard work.Beforeleavingherappointment, shetoldmeandthedoctor“thankyoufor beingthereforme.”

Sarataughtmethatdespitethemany thingsweasahealthcareteamare responsiblefor,themostsignificantthing wecandoislistento,andsupportour patients.Gettingtoknowaboutherlife andsituationhelpedusestablishtrust,and whileIcouldnotchangeeverythingin herlife,theactofunderstandingand listeningtoherstruggleswastherapeutic. Ibelieveitisauniversalstrugglefor providerstoalwayswanttodomorefor ourpatients.Insomecaseswemaybe abletomakesuggestionsorconnectthem withresources.Inothers,wemustaccept andbecontentwithwhatwecan contribute:ourmedicalguidance,and humanconnection.Walkingsidebyside withpatientsthroughtheirdifficult momentsinlifemotivatesmetowork hardtoprovidethemwithcompassionate, andexcellentcare.

Life Through Their Lens

by Michael Filoramo

Duringmythirdyearofmedical school,Ihadtheopportunitytocomplete afour-weekrotationinmychosenclinical field.Havingpreviouslyworkedasa technicianforanophthalmologistduring mygapyear,Ihopedarotationinthis fieldwouldrekindlemypassionforit. Undertheguidanceofalocal ophthalmologist,mymixedemotions soongavewaytofamiliarityand enthusiasmasIswiftlyrecalledthe intricaciesofconductingeye examinationsandusingtheslitlampas wesawpatients.

Oneparticularencounterleftan indeliblemarkonmeduringthisrotation –myinteractionwithMrs.Smith. Initially,sheappearednonchalantabout hervision,attributingminordifficultiesto agingandhertrustyglasses.However,a routineexaminationunveiledastark reality–Mrs.Smith'svisualacuitywas severelycompromised.Uponfurther questioning,wefoundthatitwas impairingherdailyactivitiesand diminishingherjoy,notablyaffectingher abilitytowatchhergrandson'ssoccer games.AsIcheckedhervision,Iwas shockedthatherbestcorrectedVAwas OD20/70andOS20/100.Aswewrapped upourexam,IledMrs.Smithtothe examroom,whereshewasnexttoseeher doctor.

IpresentedMrs.Smithtomypreceptor, andtogether,webegantoperformour physicalexamwiththeslitlamptogather moreinformationtoseewhyMrs. Smith’svisionwassolimited.Upon examininghereyes,itwasclearthatMrs. Smithhadsignificantcataracts. Fortunately,thiswastheonlything impairinghervision,andtherestofthe eyesappearedhealthy.Afterthedoctor

explainedtoMrs.Smiththatshehas significantcataractsthatarelikelythe culprittoherlowvision,Mrs.Smith appearedshockedandconfused,asthis wasallnewtoher.Iexplainedthat cataractsare“liketheheadlightsonyour car,whenthecarisnewtheheadlightsare clearandweareabletoseethroughthem withoutissue,howeveraswegetolder, theytendtofogandgetyellow,muchlike theheadlightsonyourcar.”Afterhearing thisandexplainingfurtherusingamodel, onecouldsenseMrs.Smith’sunease begantounwind,andsheseemedopento theideaofundergoingcataractsurgery. Shetoldusthatshehadneverhadsurgery beforeandwasalittlenervoustohaveit forthefirsttimeattheageof69!We explainedthatwhileallsurgerieshave risks,cataractsurgeryisverysafe,with oneofthehighestsuccessratesacrossall operativeprocedures,andtypicallyonly takes10-15minutes.Wedecidedtowork onthelefteyefirst,asthateyehasthe worstvision,andcorrecttherighteyea fewweekslater.WeexplainedtoMrs. Smiththatthereisafollow-upvisitfor measurementsinafewdays,andthenin 2weeks,shewillhavethefirsteye completed!Aswewerewrappingupour visitwithMrs.Smith,shesaidshewas “excitedwiththeideaofgettingher visionbackandhopefullybeingableto seehergrandsonplayonthesoccer field!”

ThenexttimeImetwithMrs.Smith,she wasinpre-opholding.Iwashappytosee thatherhusbandwasatherside,andshe saidthatshewas“readytogo”whenI askedherhowshewasfeelingaboutthe procedure.Ishookbothherandher husband’shandsandwishedthemboth luckwiththeprocedure,asthenexttimeI sawMrs.Smith,shewouldbeunder anesthesiaforthesurgery.

Thankfully,thesurgerywentasplanned, andMrs.Smithhadnocomplications! WemetwithMr.Smith,andhewas relievedtohearthatallwentwellandthat shewouldbeoutandreadytogohome shortly.Afterreviewingtheinstructions forrecoveryoverthenextfewdays,we

saidourgoodbyesuntilthefollow-up appointmentscheduledfortomorrow morning.

Thefollowingday,Mr.andMrs.Smith arrived,andIwaselatedtoseethatMrs. Smithwassmilingear-to-ear!Iaskedher howhernightwentandhowshefeltthis morning,andshesaid,“Ican’tbelievethe differencealready!”Shewasdelighted that“onthewayoverIwasabletomake outtheleavesonthetrees,andIcan’t rememberthelasttimeIcoulddothat.”I wasthrilledtohearthatthingsweregoing sowellforMrs.Smith,andwewentback totheexamroomstomeasurehervision andlookatthehealingeye.Wewereall astoundedtoseethatthevisioninherleft eyewasmeasuringat20/25lessthan24 hoursaftersurgery!Thiswashuge comparedtothe20/100shewasseeing previously.

Atthispoint,Iwasstruckbythe profoundbeautyofmedicineandthe impacthealthcareproviderscanhaveon thelivestheyserve.Notonlydidthis interactionreaffirmmyloveformedicine, butitalsoguidedmeinthedecisionto trainasanophthalmologistmyself!I knewthatIwantedtocontinuetohave interactionsliketheoneIhadwithMrs. Smith,anditservesasareminderofthe privilegeandresponsibilityinherentin thepracticeofmedicineaswehavethe powertomakeaworldofdifferencefor thepatientsweserve.

Listening Beyond Language: the Need for Integration of Cultural Values in Healthcare

by Ariana Genovese

I’mfromItaly,yousee.Ibelieveitis importanttoliveinthepresentmoment, tosoakupeverydropoflifeandnot stressaboutthethingsthataren’tworth stressingabout.Loveyourfamily,love yourneighbor,feelthesunonyourface, drinksomenicewine,eatsomething

yummy.ThisisthewayIwasraised,and thiswayoflifegivesmepeace. WhenIenterthesesterile,white rooms,thesepeopleintheirsterilewhite coatstellmethatthewayIlive,thewayI wasraised,myculture,iswrong.I disagree.

Nonetheless,Ishowuptomakemy wifehappy.Shewantsmetobearoundto livea“long,healthylife”withher. Wouldn’titbebettertolivea“shorter, happierlife?”

Anway,thenursecomesinandstarts pokingatme.Iunderstandmostofwhat sheissaying,butthereisabitofa languagebarrier.ShehasamaskonsoI can’tevenseehersmile.Isshesmiling? Hereyesare,butmaybesheisjustbeing politebecauseI’mnotfromhere.Where isthehumanconnectioninthat?

SheaskedifIbroughtalogofmy bloodpressuresandsugars.I’ma 63-year-oldman,Ishouldn’thavetodo homework.Whydoesitmatterifmy bloodsugarishigh?Well,mywifehas beencheckingthese“numbers,”soIhand inmyhomeworkandsitbackandwaitfor theappointmenttobeover.

Next,thisyoungwomanwalksin.I haveseenherbefore,she’sthestudent doctor.Imakeconversationwithher becauseIdon’treallycareaboutthis medicinestuff.Itellheraboutmy country.Itellheraboutmyconstruction businessandhowitallowedmetotravel theworld.Toseethings,tosmellthings, totastethings.Tolive.Thatthereisso muchmoretolifethantheconfinesof thiswhite,sterileboxofaroom.

Sheseemsgenuinelyinterested,butI canalsoseethathereyesglancedown towardsthebottomofherlaptopscreen andthatsheprobablyneedstogetonto herrealjobsoon.Iletheraskmethe annoyingquestions.“Yes,I’vebeen eatingwell.”No,Ihaven’t.“Yes,I’ve beenexercising.”Ifsittingonatractoris exercising,Iguessso.“Yes,Ihavebeen takingmymedicine.”Whenmywife

shovesthemdownmythroat,Ido.What evenarethosecolorfulpills,anyway?

SheasksifIwanttogetinjectedwith someweirdvaccines,soIdon’tgetsick. Aren’tIalreadysick,sotheysay?So,it wouldn’treallypreventmefrombeing sick.Itwon’tcuremydiabetes.Idon’t reallybelieveinthose.Itellherno.

Iletherlistentomychest,lookinmy ears,squeezemyankles.Whyisshe squeezingmyankles?Shesaidmylegs arealittleswollen.IthinkI’mjustalittle overweight.

ShetalkstomesomemoreandsaysI shouldtrytomakesome“lifestyle changes.”Whilesheisgentleaboutit,I lovemylifestyle.MylifestyleisItalian, it’smyculture.ItellherifIdie tomorrow,Idon’tcare.Iwilldiehappy andhavinglivedfully.

Icanseethatthereisadisconnect.We bothwantsodesperatelyfortheother persontounderstand.Butnotjustto understand,tosee.Totrulyhearwhatthe otherpersonissaying.WhileEnglishis notmyfirstlanguage,theissuehereisnot thatIspeakItalian.Theissueisthatour prioritiesinlifearedifferent.Iknowthat thesepeopleinthesesterilewhiteboxes wantthebestforme.Dotheyknowwhat istrulybest,though?IthinkIshouldbe abletomakethatdecision.

Finally,shecomesbackwithamanin alongerwhitecoat.Sosterile.Theyare bothkind,andtalkaboutgettingmeon the“righttrack.”Iquitelikethetrackthat Iamon.Icanseegenuineconcerninhis eyes.Hecaresaboutme.Icanseeit.He asksmeifwecanaddinsulinintomy routine.Anotheroneofthosestupid, colorfulpills,Iassume.Wait,thisone isn’tevenapill,itneedstobeinjected! Nope,nothankyou.HesaysthatIwill needtomakesomechangesifIdon’t wantinsulin.WhatisanA1canyway?I nodpolitelywhiletheyaskmetomake changes.TochangethewayIhavebeen livingsinceIwasalittleboy.Theydon’t understand,andIdon’tthinktheyever

Itellthemthatthepeopleinmy country,mypeople,wedon’tliveaslong. However,wediericher.Notcoveredin money,notsurroundedbythings.Inmy country,wediewithafullheart,full belly,andsurroundedbythepeoplewe love.WhywouldIgivethatuptolivea fewmoresterileyears?

Fractured Hip, Healed Heart

by Cameron Gerhold

Completingearlymorningemergency departmentroundswasalwaysrefreshing. Arrivingtothehospitalbeforethesun wasup,meetingwiththeteam,and headingtothefirstfloortoseewhich patientsneededorthopedicsurgerythat daywasaspecialopportunitytolearn medicineinafast-pacedenvironment.It wastheperfectwaytohittheground runningeachday,workinghardtohelp thosewhoaredesperateformedical interventionandseekingtheprofessional expertiseofourorthopedictraumateam. Wesaweverything:victimsofmotor vehicleaccidents,individualswhowere pushedoffbuildings,sportsaccidents, andeverythinginbetween.Thisparticular morningwasslowerthanusual.Wehad twopatientstoseeintheemergency departmentbeforewestartedoursurgical casesfortheday.Thefirstpatient sufferedasevereworkplaceaccident.A concretesawshatteredintohundredsof pieces,sendingfragmentsoftheblade intovariouspartsofhisbody.Alarge piecewentthroughhisquadriceps,a problemourteamfixedlaterthatdayin theoperatingroom.Thesecondpatient wasanolderwomaninherlate80s.She wasjoinedbyherson,whodoubledas herprimarycaregiver.Whentheattending andIwalkedintotheroom,Icouldsense shewasbothrelievedwewerethereto helpher,butscaredwiththe

newsthephysicianmightdeliver.She brokeherhipandsurgerywasabsolutely necessaryifsheeverwantedtowalk comfortablyagain.

Whileitisnotanuncommon phenomenonforelderlypatientstofall andsufferseriousinjury,suchas fracturingahip,asaresult,Ifelt compelledtolearnmoreaboutherstory. Itwassimple.Lastnightwhileherson wasasleep,shebegantocravecookies thatherneighborhaddroppedoff.These wereplacedonthecounterinherkitchen andatthattimeshewasseatednottoofar awayinthelivingroom.Shemadeher wayovertothekitchen,andgrabbedone cookieasalate-nighttreat.Soonafter,it slippedoutofherhandandbouncedoff thecounterandontothefloor.Insteadof wakinguphersonforassistancepicking upthesnack,shewantedtodothis herself.However,shewasnotrewarded withthechocolatechipcookie,but insteadfelttheextremepainofherleft hipfracturingwhenshefeltontoher kitchentileflooring.“It’snotfungetting old,youcanneverdothethingsyouused tobeableto”,shetoldme.

Ihadadéjàvumoment.Thisstory soundedalltoofamiliar.Amemory buriedinthebackofmymindwas broughttotheforefront,leavingtearsin myeyes.DuringcollegeItookaroadtrip tosouthernLouisianaafterfinalsweek withmydad,hopingtospendtimewith mygrandparentsbeforethechaosof jugglingschool,work,and extracurricularsresumedthatJanuary. Uponarrivingatmygrandparents’home, Isoonfoundmygrandmothersleepingin herroom.However,mygrandpawas nowheretobefound.MydadandI lookedineachroomuntilIhadtheidea tocheckthegarage,mygrandpa’s sanctuary.“Pa?Areyouinhere?”,I stated.SuddenlyIsawsomethingmovein myperiphery.Ilookeddowntomyleftto findmygrandpaontheconcretefloorof hisgarage,unabletogetbackup.“Get yourdad”,hesaid.Weneverspokeabout thisincidentagain.

Perhapsthisiswhytheelderlywoman Imetwhilerotatingwiththeorthopedic traumateamaffectedmesodeeply:Isaw mygrandfatherinher.Bothindividuals recognizingtheirage,health,andphysical statuswereholdingthembackfromfull independenceandsweetfreedom.Both hadstrongpersonalitiesandtookpridein caringforthemselvesandprovidingfor others,twotraitsthatageandlimited mobilityhadgreatlyaffected.Meeting thiskindwomanwillforeverbea cherishedexperience.Itactedasa reminderthatlifeisfragile.Wemust protectourseniorpopulationwhile providingthemwithasmuch independenceastheydesire.Most importantly,itwasareminderthatwe careforourpatientsasiftheyareour family.Ourjobistostandbytheminthe darkestmomentsandontheirworstdays, assistingthemontheirjourneytorecover.

DoctorinTraining: CaringforaPatient withChronicIllnesses by Phasin Gonzalez

Livingwithchronicillnessesisabig challengeformanypeople.Forsome,it meansareductioninlifeexpectancy.For others,itmeansareductioninqualityof life.Theseissuesoftenstemfromvarious complicationsofchronicillnessessuchas lossofmotorskills,decliningmemory, musclewasting,respiratorydisorders,and harmtodifferentorgansandtissues. Duringmylongitudinalrotation,Ihave encounteredvariouspatientslivingwith chronicillnesses.Iamoftenamazedby theconcernsandquestionsthatthe patientshaveabouttheirmedical conditionsduringtheirvisitinthe doctor’soffice.

Irememberonepatient,inparticular,a 68-year-oldfemale,whopresentedtothe clinicforherhealthmaintenance evaluation.Duringthatvisit,shehadan extensivelistofmedicalproblems.She hadachronicbackpainformorethana

decade.Shehadanasthmasinceshewas ateenager.Shewasaformersmokerwith a30-pack-yearhistoryandaCOPD.She hadanatherosclerosisoftheaortaanda hypertensionthatrequiredseveral antihypertensivemedicationstokeepher bloodpressureundercontrol.Shewas obeseandhadtype2diabeteswith associatedneuropathicpain.Shehadan osteopenia,anosteoarthritis,andasleep apnea.Totopitalloff,shehadastroke lastyear.WhenIfinishedreadingthrough herlengthylistofdiagnosesinherchart,I knewIcameacrossaveryfunand challengingpatienttoday.

WhenIenteredtheexaminationroom andaskedherhowshewasfeeling,she stated,“Iamdoinggood.”Then,she added,“I’mjustalittletiredtodaylike usual.”“MaybeI’mjustgettingold,”she laughed.

Aswedivedintoherconcernsin today’svisit,shereportedanachypainon theleftsideofherbodythatstartedabout ayearago.Shereportedassociatedmild weaknessontheleftsideofthebodyand mildtremorinherlefthand.Sheshared withmeastoryofwhenshesuddenlyhad astrokelastyearasshewasgettingoutof bed,causinglefthemiparesis.Shestated thatshecouldnotmoveherleftarmand wasunabletowalkorclimbstairs initially.Shehadtoundergoastroke rehabilitationfor6months,andshemeta reallygoodphysiotherapist.Withsheer determinationtogetbetter,thepatienthas nowbeengoingtothegymand exercisingregularlytoimproveher musclestrengthandmotorfunctioning. Althoughshestillhassomemildtremor andweaknessinleftsideofherbody,the patienthadmadeasignificant improvementinherrecovery.Ireassured mypatientthatstrokecantakesometime torecover,andthataslonghersymptoms continuetoimprove,andshecontinuesto exerciseandregularlytakeherprescribed medications,wewouldcloselymonitor hersymptomsandorderadditionaltestsif newsymptomsarise.

Patientalsoreported,“mylegis

gettingugly.”Shehadpersistentswelling ontheleftlowerextremitythatstarted aboutthesametimethatshehadastroke oneyearago.Shereportedassociated mildtinglingandnumbnessbutdenied anyfeverorchills.Shereportedthatshe didsomeresearch,andshewasworried thatherantihypertensivemedication, amlodipine,wascausingtheswelling. WhenIconductphysicalexamand examinedherlegs,Inoticedshehadsome swellingfromherleftankleuptoher kneewithassociatedflakyskinand purplishdiscoloration.Iinformedherthat theswellingwasunlikelytobecausedby amlodipinesincewewouldexpectboth legstobeaffected.Instead,shelikelyhad achronicstasisdermatitissecondaryto chronicvenousinsufficiency.Iadvised thepatienttowearcompressivestockings toreduceswellingwhilesupportingvein valvestoimprovebloodflow. OnceIfinishedaddressingherchief concernsoftoday’svisit,Iproceededto discussherlabresultstogetherwithher. Allherlabresultswereexcellent.She wastoleratinghermedicationswelland deniedanysignificantadverseeffects. Hermostrecentcolonoscopyand mammogramresultswereallnegative. Shewasuptodatewithhervaccinations. Weexhaustedouragenda,andthenmy attendinggavehisfinalclosingthoughts. Ourvisitwasnowover,andshewaslater dischargedhome.

Theencounterwaslong,andtheroom hadseemedsosmallgivenallmedical conditionsandconcernsthatthepatient hadbroughtwithherduringthatvisit.But thecoreofwhatIdoafuturedoctoristo identifyandaddressalltheconcernsthat mypatientsbring.Toidentifyandaddress alltheseconcerns,Imusttakeonmany roles.Theseincludeanadvocate,aguide, aninterpreter,adiagnostician,anda healer.Asanadvocate,Ilistentoallof mypatients’stories.Asaguide,Itryto investigateandunderstandtheirconcerns andhowtheyperceivedtheirproblems. Asaninterpreter,Iperformaphysical examinationtogatheralltheobjective dataaswellasreviewandinterpretallthe labs,procedures,andimagingresults.As

adiagnostician,Ireassembleandcombine alltheinformationthatIhavegatheredto comeupwithadifferentialdiagnosis, focusingontheuniqueneedsofmy patient.Asahealer,Icomeupwithplan toaddressmypatient’sneedsand concerns.Inplayingtheseroles,I diagnose,andItreat.Althoughmy medicaltrainingisstillongoing,Ido whatmyfutureselfwoulddoasa physician—Itakecareofmypatient’s needsasbestasIcan.

Swallowing, Smiling, and Speaking is a Gift

by David Gorelov

infection,andshehadaneyepatchover herrighteye.Iintroducedmyselftoher, makingsureItalkedloudenoughforher tohearme.Shewasafriendlyladythat wassufferingterribly.Avirusthatshe previouslyhadwhichlaiddormantfor manyyearsreactivatedasshinglesinher facialnerveandparalyzedherfacial musclesonherrightside.Shecouldnot smilewhenIaskedhertoasItestedher facialmuscles.Shecouldnotfullyclose herrighteyeandwaswearingtheeye patchtoprotecthereyefromdryingout andlosinghervision.Thevirusalso affectedherswallowingandspeech.This terribleconditionwasnamedRamsay HuntSyndrome.

OneofthefirstpatientsIevergotto takecareofinthehospitalsettingwas Ms.M.Itwasduringmyinternal medicinerotation,thefirstclinical rotationofmythirdyear,thatIhadthe privilegeofmeetingandtakingcareof Ms.M.Justlikeanyhospital,itwasa mazetofindaroomasweroundedon multiplefloors.Thatfirstweek,the attendingtoldmetopre-roundonMs.M. AsIwasgettingmybearingsandfiguring outthefloorplansystem,Istumbledupon Ms.M’sroom.Ididnotknowwhatlay aheadbeforeme,tookadeepbreath,and walkedinconfidentlyjustlikedI practicedmanytimesbeforeduringmy firsttwoyearsofmedicalschoolwith standardizedpatients.Butthesewerereal patients,withrealdiseases,andreal problemsthatIwasdealingwith.No patientwasstandardized.Everyonewas differentintheirownspecialway. Everyonecarriedstories.

Ms.Mwaslayingonherbedwitha trayofuntouchedbreakfastinfrontof her.Shewasapleasant88-year-old femalepatient.Halfofherrightsideof herfacewasdroopingdown,herright externalearwasscarredwithscabsand lookedlikeitwasrecoveringfroman

IdidnotrecalllearningaboutRamsay HuntSyndromespecificallybut rememberedthatcertainvirusescould causeBellpalsiesandthatshinglescould reactivateinnerves.Atfirst,Ithought thatmaybeshewassufferingfroma stroke,butfurtherworkuprevealed RamsayHuntSyndromeastheculprit.It madesensetomewhyherbreakfastwas untouchedandgrowingcold,sinceshe couldnotswallow.Itbrokemyheart seeingasweetoldladythatwasthesame ageasmygrandmothersufferinglikethis. Iaskedherhowshefelt,andshetoldme whateveryoneknew,shefeltterrible.She toldmethatshesleptwellbutdidnot knowwhatwasgoingonwithher.Isat downnexttoherbedandputmyhandon topofhersandslowlybutloudlyenough forhertohear,explainedthe pathophysiologyofRamsayHunt Syndrome.Shethankedmeforhelping herunderstand,butinthatmoment,itdid notreallymatterhowthisdiseaseworked. Whatmatteredwashowshewasfeeling andwhythiswashappeningtoher.There Ilearnedthatpatientsjustwanttofeel betterandgraspforanyhopepossiblefor recoveryandlifebacktohowtheyknow it.Wehumansareinterestingpeopleand donotalwaysappreciatethesimple beautiesoflifelikebreathing,talking,or swallowingfood.Andusually,we rememberandbecomegratefulforthose simplethingswhenthatgiftistakenaway fromus,albeitevenfor

ashorttime.Wemissthefeelingof swallowingwithoutithurtingwhenwe haveasorethroat.Wemissthefeelingof breathingnormallywhenournosesare stuffy,andourlungsarefilledwith phlegm.Whatthatvirusdidtothatsweet ladywastakehergiftofswallowing,the giftoftalkingnormally,thegiftofclosing hereyesfullyshut,thegiftofsmiling completely,andthegiftofhearing properly.

Ms.Mdidnotdeservethesegiftstobe takenaway.ItoldherIdidnotknowwhy thisspecificallyhappenedtoher.Icould notanswerthatquestion,nordoIthink anyoneelsecould.Itriedtocomforther bytellingherthatwe(themedicalcare team)woulddoourbesttogetherfeeling ascloseasbacktonormal.Iaskedherif therewasanythingIcoulddoforher,and sheaskedforicechipssincehermouth wasdryandwantedassistanceforeating. Iaskedthenursestohelpandlearnedthat Ihadtheuniqueopportunitytoadvocate forthepatientevenifitwasassimpleas quenchingherthirst.Mydesiretomakea differenceintrulycaringforthispatient spurredmysearchforatreatmentthat wouldhelpher.ThroughresearchI learnedthatacyclovirandprednisone couldimprovehersymptomsandIwas hopefulforabreakthroughwhenthe medicalteaminitiatedthistreatment.I learnedthatoneofthebestwaystocare forpatientsistreatingthemasifthey wereyourfamily.

IhadtheprivilegeofroundingonMs. Mforoveraweekandsawherslowlyget bettertothepointthatshewasableto startswallowing.Iwantedtoknowmore aboutherstory,butbecauseshehad troublewithspeech,Isparedhertheextra talking.Iwonderedwhereherfamilywas, whatlifeshehadbeforethisdiseaseled hertothehospital,andifshehadany grandchildren.ButevenifIcouldnotget herstory,IknewIcouldhelpherfeel betterandadvocateforherneedsand

comfort.Thedoctorswereplanningtoget heragastrostomytube(g-tube)andI knewthatshedidnotwantthat.So,I askedmyattendingtogiveheratleast oneortwomoredaystoseeifher swallowingwouldimprove.Ms.Mwasin myprayers,andIwasrootingforher. EverymorningIwouldpre-roundonher withhopethatshewouldbealittlebetter thanbefore.Thedaycamewhenshe passedherswallowingtest!Iwasso happyforher.Shewasabletostarton pureedfoodsandeatslowlyandIfeltlike wehadateamvictory.Shegotbetterand wasdischargedtoaskillednursing facilityandthenreturnedhomeamonth latertolivewithhersisteranddaughter.I wasgladtoseetherecoveryofoneofmy firstpatientsandfeltgratefultobeapart ofhercare.

Afewmonthslater,whenIwasinmy electiverotation,theattendingtextedme tellingmethatMs.Mwasback,andthe newswasnotgood.Rightaftermyshift ended,Idrovetotheotherhospitalwhere Ms.Mwastoseehowshewasdoing. Unfortunately,shewasintubatedinthe ICUduetorespiratoryfailure,leftonce againunabletospeak,smile,and swallow.Herfamilydecidedthatthey wantedtotransitiontocomfortoriented goalsofcareandsoMs.Mwas transitionedtohospicecare.Ms.Mfelt likeagrandmothertome,anditsaddened metoseeherinthisstate.Shewasonce someonewhoneverhadtothinkabout swallowing,speaking,orsmilingandnow thatgiftwastakenfromhertwice.May wealwaysrememberthesesimplegiftsin lifethatcanimpactourpatientsgreatly whentakenaway.

Cheer On

by Matthew Harris

“Whichofthefollowingisthenext beststepinthemanagementofthis patient”.ItisafamiliarquestionpromptI thatIpersonallydeemedparticularly frustrating,notleastofwhichbecause medicaltestwritersnevermissan opportunitytoincludeacaveatortwo intoaclinicalvignettethatalterswhat shouldbeaprettystraightforwardanswer intosomethingmuchfurtherdownthe diagnosticalgorithm.Forme,thesetypes ofquestionsbrilliantlyillustratethedual realityofthe“medicineonpaper”aspect ofmedicaleducation(whichincludesall thevariousrequiredstandardizedexams) fromthe“thisisarealpersonwiththeir ownuniquestories,idiosyncrasies, symptoms,clinicalpresentation,etc.that maynotfitintoaneatclinicalpearl” aspect.

OrderinganMRIofthebrainseems simpleenoughasananswertoanexam question.Forthe“real”patienthowever, itentailshavingacageplacedovertheir headtoimmobilizeitwhilebeingslowly easedbackinsidetheconfinedspaceofa magneticdoughnutholefora30-minute sessionofloudbanging,alarms,and roboticswooshingsounds.Thatlumbar punctureyoujustorderedforyourpatient whomyoususpectmeningitiscondemns themtohavingaliteralneedlestuckinto theirspine.Whatseemsamundaneand casualansweronaclinicalexam manifestsintorealordealsand tribulationsourpatientsexperience.

IfMr.Gilligan,apatientImetwhile onahematologyoncologyelective rotation,hadhisexperienceformulated intoanexamquestion,ittoowouldhave astraightforwardanswer.Atage62,he

begantoexperienceincreasingdifficulty swallowing,aconsistentmildsorethroat, andchangestohisvoicethathehad attributedtoexcessiveyellingoverpower equipmentattheconstructionsitehe managed.Eventually,hecametobe diagnosedwithoropharyngealcarcinoma. Oncemypreceptorhadovercomethe hurdleofexplainingtoMr.Gilliganthis cancerwasmostlikelythecauseofan HPVinfectioninthebackofhisthroat,he wasstartedonacombinationofradiation therapyandachemotherapyregimen.

Asimpleanswertohisquestion,select andmoveon.ForMr.Gilligan,reality wasnotassimple.Mypreceptor highlightedhowheadstrongand committedtoattackinghiscancer diagnosisaggressivelyMr.Gilliganhad been.Hehadeveryreasontobe.Given theuniquecharacteristicsofhiscancer, prognosiswasincrediblyfavorable.Ina matterofdays,he’dscheduledan appointmentwitharadiationoncologist andhischemotherapyagentswe'reon theirwaytotheinfusioncentertobe administeredtohim.

Treatmentstartedoffwell.Hemade histhriceweeklychemotherapyinfusions andhisweeklyradiationsessions.Hedid hisbesttomaintainasmuchnormalcyin hisworkandpersonallifehereasonably could.Thingschangedafterthefifthor sixthweek.Mr.Gilliganbegantomisshis regularoncologyandradiation appointments,aswellfailedtoshowupto theinfusioncenter.Eventuallyhisdoctor feltcompelledtoreachoutandinvited Mr.Gilliganforanappointmentto discussanydifficultieshemaybe experiencing,reevaluatehistreatment goals,andgethimbackonhisregimenif hesodesired.ItwasmadeclearthatMr. Gilliganwasnotinanytroublefor missinghisappointmentsandtreatment, butthathissuddenabsencewas concerning.

ThisappointmentwaswhenIfirstmet Mr.Gilliganandhiswife.Ican'tspeakto howheappearedpriortohisdiagnosis,

butsuperficiallymyfirstimpressionwas hislookswerenotthatofa“thriving” person.Hiswifeexplainedhehadlost25 poundsinonlysixweeksoftreatment. Thechemotherapyregimenwastoxic enoughtohisbody,buttheradiationwas provingtobethemainsourceofhis misery.Itwasdoingitsjob,blastingaway therapidlyreproducingcancercellsinhis throat.Itwasalsodestroyingthenormal mucosallininginthesamearea.In layman'sterms,hehadadevastatingly painfulsorethroat.Ithoughtbacktoall theterriblesorethroatsI'dexperienced throughoutmylife.Thiswaslikelytwice asbadasanyofthem,andwhileIcould alwaystrustthattheywouldimproveover afewdaysasIrecoveredfromwhatever illnesshadinitiatedthismostunpleasant symptom,Mr.Gilligandidnothavethat luxury.Hisweeklyradiationtreatments ensuredthatjustashisthroatwas beginningtomenditself,thenextblastof radioactiveparticlewasincomingtostart thewholeprocessoveragain.Drinking andeatingforhimwasakinto swallowingrazorblades.He'dbeen chronicallydehydratedforthelastseveral weeksandhisweighthaddropped precipitously.Hewasn'tabletoworkand hadtroublesleepingdespitethe chemotherapiessappingawaymostofhis strength.

AtsomepointMr.Gilligancouldno longerendureandsimplystopped showingforhisappointments.Hewas steadfastthathehadnot“givenup”the fight,buthefelthisqualityoflifehadso diminishedthathestruggledtobring himselfinfortreatment.Partofme harboredthisnotionof“comeonman, I'msureit'sunpleasantbutyourcanceris potentiallycurableandyou'realready halfwaythroughtreatment!Suckitupand getbackonboard.”Theotherpartcould completelysympathizewithhisplight. Nohonestpersoncouldblamehimforhis recentabsences.

Mypreceptoravoidedanycriticismof Mr.Gilligan’sdecisiontopassuptherapy, andinsteadacknowledgedthesacrifices he’dmadeandresilience

shownalreadythroughallthetreatment hebeensubjectedto.Whileencouraging himtostaythecourse,hecompromised andofferedanalternativeregimenwith lowerdosesofchemotherapyand radiationsessionsthatwerespreadmore widelyapart.Itwasn'tidealofcourse,it didintheorylowerhisoddsoffull remissionandlong-termsurvival.Butit wasanarrangementthatthepatientwas abletopersonallyacceptonhisown,with alittleextraencouragementfromhis oncologist.Theproposalwasacceptedby all,andMr.Gilliganwaspromptly escortedtotheinfusionroom,withplans tore-establishwithhisradiation oncologist.

Speakingwiththeoncologist afterwards,heemphasizedthatoftentimes hisroleasaphysiciansismoreakinto thatofa“cheerleader”,encouraging patientstoendure,tostepbackinthering forthenextround.Someillnessesand indeedtreatmentscanbejustplain devastating.Thereisnogettingaroundit andlittlerecourseexiststoalleviateit. Therefore,honestywithpatients, acknowledgementofboththeirsuffering andtheirprogress,andsomeextra encouragement,whenindicated,goesa longway.Medicalstudentsandan increasingnumberofphysicians recognizethatweliveinanerawhere doctorsdonotdictatetopatientswhat theywillorwon’tdomedically.Wedon't simplycheckaboxandmoveon,asthe examquestionssymbolicallyseemto wanttosuggest.Acceptingwhatisoutof ourcontrol,attimesallwedoischeerour patientstopushforwardontheirown accord.

Unpacking Bias: A Personal Lesson from Substance Use and Recovery

by William Hixson

Asapersoningeneral,Ihavehada general,negativeassociationwiththeuse ofbenzodiazepinesandopiates.Ihave

associatedtheminmyheadwiththeir highlyabusivenatureandthatpeopleare purelyaddictedtoamedicationthatmay ormaynotbenecessary.These associationscouldbeduetocomingupin aconservativeenvironment,thenatureof anti-drugusecampaignsemployedin school,orseeingtheirabuseinthose closetome.Tiedtothatwasanegative connotationwithhealthcareproviders whoreadilyprovidedthesemedications tomanyoftheirpatients.However,the inflexiblenatureofmyincorrectthought processwasnarrow-mindedandrequired change.

ThroughmyOBGYNrotation,my preceptorheavilydealtwiththetreatment ofthosewhosufferfromsubstanceuse. Sheseespatientsonaneardailybasis undergoingabstinencebasedor medication-assistedrecoveryfrom differentsubstances.Wemetthese womenwheretheywereatintheir recoveryprocessandassistedtheminany waywecould.Mypatientwasseenhere inthiscontextandthelessonslearned fromtheextensivetimeIspentwithher arewhyIhavechosenthistopic.

MissJDisa29-year-oldfemaleG3P3. Shepresentedtotheclinicafterrelapsing onopiateswhileprescribedsuboxoneand alprazolam.Shelivesinatrailerwithher threechildrenandhassincekickedher boyfriendoutofthehome.Priorto relapse,herboyfriendphysicallyabused hertothepointwhereshewas hospitalizedwithseverefaciallacerations andafracturedjaw.Sheisinthemiddle ofthatcourtcase,andheiscurrentlyin jailforhiscrimes.Shehasherthree childrenathomethathermother sometimescanbabysitwhileshegoesto workasa“dancer.”Inthepast,ifher motherisunablethenshewouldbringher childrenwithhertothestripclubwhile theysleepinthecar.Shestateshowever thatshehasnotdonethisinalongtime. Herworkhereiswhatsheattributesto causingtherelapseasshehatesdancing. Shestatesthatshehasrecentlybeen takingupto180mgofoxycodoneduring hershifts.Sheis

visiblyupsetwithherselfandstatesthat shefeelshopelessbecauseofher disappointmentinrelapseandcurrentjob. Sheisseekingouthelpforthisand desirestobeabettermothertoher childrenandgetadifferentjob.

AsIlistenedtoMissJD,theonly thingonmymindwastotrytostaycalm andtobethereforherhowevershe neededmeinthatmoment.Shehasgone throughsomuchandtocomeinseeking helpshowssomuchaboutherstrength. Mypriorinformationdescribingthe eventswastheprofessionalversionofher story.Intruth,thiswasapersonfacing insurmountablestressandhardship.She washavingtobalancefinancialinstability whileloathinghermoststableformof income.Shewasterrifyinglybeatenby thefatherofherchildrenintoa life-threateningstate.Shewasstruggling withrelapse.Shewashavingtobalance allofthiswhilestilltryingtobeabetter mothertoherchildren.WhatcouldIdoor saytohelpher?HowcouldIeverknow howhardlifehasbeenforher?So,Ijust listened.

Indiscussion,asateam,withher physicianandJD,wecontinuedher alprazolamandstartedadecreasingtaper ofoxycodonewithincreasingtaperof suboxone.Afterourvisitwithher,we discussedthedecisionsmadeforthe treatmentplan.Anastutepointmadeby herphysician,“Wehaveawomanwhois dealingwithsubstanceuseandhas previouslygottendrugsoffthestreet.If givingherbenzodiazepinestocontrolher stresspreventstheuseofstreetdrugsis thatnotthesafestthingforherinthis acutetime?”Ihadneverhearditputthis wayandneverbroughtthatoutlookinto consideration.Iwenthomethatdayand reflectedonthis.Myentrenchedopinion ofthesedrugshadbeenallwrong.Like everymedication,thereisausecase.For JD,thesemedicationsmaybetheonly thingkeepingherfrombuyingdrugs containingpotentiallyharmfulsubstances.

Iunderstandthatthisisaveryspecific

use-casescenario,butitwastheroot causeofapersonalchangethatwas necessarytobemade.Asaproviderinthe future,Imustalwayskeepanopenmind. Medicinehashadthehumblingtendency tocausemetoalwaysquestionifmy beliefsaregoodinnature.Theonlything tobedoneaboutthisistocontinually questionyourbeliefsandevaluateifthey servethegreatergoodofpatients.Inmy life,Ihopetobeanopen-minded,kind, andreliablepersontothosearoundme.

Breaking the Stereotype

by Catherine Maige

ItwasatypicalMondayafternoonon mygeneralsurgeryrotation.The emergencydepartmentcalledmy preceptorabouta48-year-oldfemalewith analarminglylargebreastmass.Scans revealedalargetumorinherrightbreast withmultiplemetastasestoherspineand sternum.Mypreceptorwasextremely busyseeingpatientsintheoffice,sohe askedmetogatherhermedicalhistory andperformaphysicalexam.

WhenIarrivedintheemergency department,theattendingphysician primedmeonthepatient’shistoryand raisedconcernsregardingherdruguse.I didn’tknowwhattoexpectuponmeeting her.IknockedonthedoorofRoom28 andwaswelcomedbyaquiet,“Comein.” Thesmallroomwasdarkandfrigid. Layinginbed,wasanill-appearing femalenamedK.T.Istartedoffour conversationwithasimple“Howareyou feeling?”whichledtoastreamoftears. K.T.said,“Icalledtheambulance becauseIaminsomuchpainandIcan’t breathewell.”Thensheliftedherbed sheetsandgownandsaid“Ican’tbreathe aswellbecauseofthis.”The“this”she referredtowasherrightbreastwhich

lookedasifalargegrapefruitwas embeddedwithinherbreast.Herskinwas inflamedandabrightruby-redcolor. WhenIaskedherhowlongthemasshad beenthereshesaid,“Inoticeditasa ‘pimple’twoyearsagoandit’sbeen growingquicklyeversince.”

Icontinuedalongwithaskingher healthhistoryquestionswhichledto questionsaboutsubstanceuse.K.T. sighedandsaid,“Iusemeth.Istarted usingitafewyearsagoaftermyhusband died.”Sheexplainedthatsheandher threeolderchildrenmovedfromNew JerseytoasmalltownoutsideofDaytona tobeclosertohermother.Shesaidthey couldn’taffordahouse,soshefounda trailer. K.T.explainedthattheirtrailer hadnorunningwaterandnoelectricity. Wheneversheneedstochargeherphone, shehastogositinsidetheDollar General.Shealsodidnotownacarand thereisnopublictransportationinher town.WhenIaskedherifshecouldget aholdofherfamilysheexclaimed,“Ileft myphoneathomeandmydaughter probablyalreadysoldmyphonefordrug money.”Shewasvisiblyupsetandshe hadnoonetheretosupporther. Myheart wasbreakingforK.T.Icouldtellshewas tryingtoholdittogetheremotionally.

ThefollowingdayK.T.became establishedwithanoncologynurse navigatorandplansweredraftedforher treatment.K.T.’stumorwasdeemed inoperableanditwasdecidedthat chemotherapywastheonlyfeasible option.TheoncologistassignedtoK.T.’s case,however,refusedtotreatherwith chemotherapyduetoherhistoryofIV druguse.Thisledtoaseriesof discussionswithmypreceptorabout ethicalclinicaldecision-making.Isit ethicaltowithholdlife-saving chemotherapytreatmentsintheeventofa patientabusingIVaccess?Orisitworth theriskwiththechanceofsavingthe patient’slife?

Itwasdecidedtochangetheoncology teamtoonethatwaswillingtotreather withchemotherapy.Igreatlyadmiredthe

careteam’sdecisiontochangethe oncologyteamassignmentonhercase. TheyvaluedK.T.’sintentiontocomply withtreatmentandreceivehelpforher addiction.Theylookedbeyondthe preconceivednotionsthatsomanyofus have,includingme.

OnthethirddayofK.T.’s hospitalization,Iwenttoseeherbefore ourscheduledcorebiopsylaterthat morning.Shewasoverwhelmedbythe amountofpeopletraversingherroomand wasexhausted.K.T.wasterrifiedofthe biopsy,buttoldme,“I’lldoanythingthat willhelpfigureoutwhatisgoingonwith mybreast.”MypreceptorandI completedthecorebiopsyrightasK.T.’s motherandcousinwalkedintotheroom. Theairimmediatelyfelttense.

K.T.’smotherstartedfiringoff questionsather.Thensheraisedhervoice andsaid,“Thiscouldhaveallbeen avoidedifyoustoppedwiththemeth!” K.T.tearfullyreplied,“Yes,Iknow,but thatisnotalltrue.Grandmahadbreast cancerandtheysaidthisislikely genetic.”MypreceptorandIexitedthe roomasthetensioncontinuedtobuild.

IreturnedtothehospitalonMonday andK.T.hadbeendischargedoverthe weekend.Thatwholeweekthenurse navigatorcalledK.T.dailywithno answer.WeweresureK.T.wouldbelost tofollow-up.

Thenoneweeklater,K.T.cametoher follow-upappointment.Everyonewas shocked!Noonecouldevengetaholdof herforremindercalls.K.T.wantedto knowherbiopsyresults. Wereviewedthe pathologyresultswithherandtoldher thatshehadcancer.Wethenexplained thathertypeofcanceriscalledinvasive ductalcarcinoma.Shewantedtoknow, “Whatisaductinthebreast?”whichled ustodiscussionsontheanatomyofthe breastaswellashowchemotherapy works.Withoutourhelp,K.T.wouldhave likelylivedashortlifewithout chemotherapy. Allittookwasbelieving inherandsettingasideour

judgments.OneofthemainthingsI gleanedfrommytimewithK.T.isthat theGoldenRuleof,“Treatothersasyou wouldwanttobetreated”alwaysapplies.

Listen

by Jackson May

Ijumpedoutofbedasmyalarm screamedatme.Ihadtogettothe hospitaltoroundformyOBGYN rotation.AsIspeddownthehighwayI receivedatext,“Don’tseethepatient withfetaldemise”.Fetaldemise,those wordslingeredonmymind.Ihadnot seenthishappentoamother.Ihadnot seenanypatientsdieinmymedical career.WouldIabletohandleasituation ofthisgravity?

Iwenttothenursingstationandasked whichroomnottogoin.Theypointed downthehallandtoldmeitwasayoung woman,herfirstpregnancy,andnoheart tonescouldbefoundwhenthepatient cameinlastnight.Iroundedonthe expectantmothersandexhausted postpartummotherswiththeirbabies.I lovedaskinghowtheirbabiesweredoing. Everymotherwouldsmileandbragon theirbabies.Itseemednomatterwhathad happenedduringpregnancyanddelivery, theyweregratefulforahealthybaby.

Myattendingarrivedonthefloor.I briefedhimonthepatientsIroundedon. HesaiditwastimetoseethepatientI wasinstructednottosee.Wewalkedinto aquietroom.Thepatientcurledintoa ballonherbed.Thewould-be grandmotherleaningoverher.The husbandholdingherhand.Shesaidshe hadnotfeltthebabymovesince yesterday.Thiswasgoingtobeherfirst child.Yesterdayshewasahealthysoonto bemotherwithaneagerfatherbyher

side.Todayshewassuffering,wondering whatshecouldhavedonedifferently.My attendingexplaineditwasnotherfault. Hedidhisbesttoputheratease. However,heexplainedshehadtobirth thebabysoontoprotecther.Hereyes welledup,andshereluctantlyagreed.

Wewentbackfordeliveryattheend oftheday.Shewasexperiencingmore frequentcontractionsandreadytobirth thefetus.Tearsstreameddownherface fortheentireordeal.Thepatientstated shedidnotwanttodothis.Shedidnot wanttoseethebaby.Thewould-be grandmotherandfatherheldupacurtain duringthebirth,soshedidnothaveto see.Shebirthedthefetus,theplacenta, andmyattendinghadtorepaira first-degreelaceration.AllIcouldthink was,shestillhadtosufferevenafterthe ordealoflosingherchild.Aftercarryinga babyfortwenty-fiveweeks,nomother predictsitwillendlikethis.

Myattendingaskediftheywantedto seethebabyanddeterminethecause.The fatheragreedandsaidhewantedtosee hisson.Wetookthebabytotheback room.Myattendingandthenurses removedthesactofindaseemingly healthyboy.“Nuchalcordtimestwo…” hesaid.Thewordshungintheair.My attendingshookhisheadbackandforth. Helookedatmeandsaid,“thisisso muchharderwhenyouhaveababyat home.”Hewasthinkingofhisbabyboy thatwasonlyafewmonthsold.Thisjust aseasilycouldhavebeenhischild.

Wewentouttothehalltofindthe husbandseated,headinhishands.My attendingbroughthiminandexplained thesituation.Thebabywasabeautiful boybutpassedawayduetotheumbilical cordwrappedaroundhisneck.Hewas holdingbacktears,tryingtocometo termswiththesituation.Howdoesa parentcometoacceptsuchadevastating fate?Howcantheymoveon?Thefather

lookedroughlythesameageasme.I triedtoputmyselfinhisshoesfora moment.MywifeandIhadbeen discussingwhenwewouldstartour family.Thisscenariocouldeasilyhappen tomywifewithnopreventablereason. HowwouldIreactifthishappenedtous? WhatwouldIsaytomywifetoeaseher suffering?WouldIbehelpless?

OneofthemostdifficultlessonsI havelearnedinmedicineissometimesno treatmentcanbegiven.Nobreakthrough insciencewillbeavailabletosavethe day.Duetonofaultofthepatientor physician,youcannotprovidethecare theyneed.ButIhavelearnedtoprovide comforttomypatientsthroughlistening. Multipletimesinmycareer,whenfaced withapatientwhohasaterminalillness ordevastatingnews,Ihavefoundthey simplywanttobeheard.Iaskthemtotell meabouttheirdiagnosis,andIwaitfor themtofinishtellingalltheywishto share.Asamedicalstudent,Icannotbe theirphysician,butIcangivethemmy timeandattention.Often,patientssimply wanttobereassuredthatsomeonecares forthem.Tocareforapatientdoesnot meansimplytoprovidetreatment.Sitting withthem,listening,givingatissue,or holdingahandmakesallthedifferenceso theydonotfeelalone.

It’s the Little Things

by Liam McLoughlin

patientswouldbe,andwhethertheir storieswouldhaveahappyending.

Ihadtakenaconsiderablelikingtothe fieldafterspendingaweekwitha gyn-oncologistduringmyOB/GYN rotation.Iwasimpressedbythe complexityofthesurgeriesandthesheer technicalskillandgritrequiredto performthem.Ikeptthinkingbacktothe enormous30centimeterovarian cystadenomamypreceptorandIremoved fromapatient.Hisarmsdisappearedinto theabdomenashefeltaroundthe posteriorpartofthemasstoorient himselfwiththedistortedanatomy.Iwas inaweofhowheseparatedsuchagrowth fromthesurroundingorgansand retroperitoneumwithoutdamaging anything.Thetearsofreliefourpatient criedwhenwerevealedhermasswas benignissomethingIcouldneverforget. Thereissomethingspecialaboutwalking alongsideawomanduringhermost challengingofcircumstances,andI lookedforwardtotheprivilegeofdoing soonceagain.

Iremembergoingonalongrunthe daybeforethestartofmythirdyear gyn-oncologyelective.Filledwith nervousexcitementaboutthefourweeks tocome,Iwonderedwhatkindsof surgerieswewouldbedoing,whoour

Duringthefirstweek,Ihadthe pleasureofmeetingoneofthemost memorablepatientsofmymedicalschool career.Mrs.Ppresentedwithalarge cancerofthevulva.Ithadbeenbothering herforsometime,butasisoftenthecase foravarietyofsocialandpsychological reasons,shehadputoffseekinghelp.By thattime,shewasintoomuchpaintosit comfortably.Shewasdeliberatewith everystepshetook,andgoingtothe bathroomhadbecomeanordeal.Tothink shehadbeenwillingtoenduresuchpain formonthstoavoidthediscomfortor potentialhumiliationofgoingtothe doctor;Iwasproudofherformakingitto theclinicthatday.

Irememberhowscaredandvulnerable Mrs.Pandherhusbandappearedasmy preceptorexplainedherconditionand prognosis.Hedeliveredtheinformation withempathy,usingsimplelanguageand

pausingregularlytoleteverything register.Theymaynothavebeenfamiliar withmostofthemedicalterminology,but thatdidn’tmatter.Bygivingherhishand tohelpherupfromtheexaminationtable andbringingheratissuewhenshebegan tocry,hehadearnedherultimatetrust.

Mrs.P’ssurgeryinvolvedaresection ofthemaintumoralongwiththe identificationandremovalofpotentially cancerouslymphnodes.Aradioactive isotopewastobeinjectedaroundthesite ofthetumor.Itwouldthentraveltothe nearestnodes,therebyidentifyingthem forremoval.Unfortunately,theisotope tooktimetoreachthenodes,andhadto beinjectedhourspriortosurgerywithout generalanesthesia.Asmypreceptor preparedtheneedleandsyringe,hetried hisbesttocomfortMrs.P,remindingher theinjectionswouldbeoverquickly. Almostautomatically,Iheldherhand.I didn’tknowwhatelsetodo.

Nothingcouldhavepreparedmefor whatunfolded.IwatchedasMrs.P receivedeightinjectionsaroundthe peripheryofthetumor.Thelidocainedid littletoanesthetizesuchapainfullesion insuchasensitiveplace.Witheach injection,Ifeltthesqueezeofherhand. Herfacecontorted,tryingwitheverything shehadtoremainquiet.Inthatmoment,I thinkweallfeltsomewhathelpless.As thefinalshotwasdelivered,atear trickleddownherface.Everyoneletouta sighofrelief.Theworstwasover.

Thesurgerywentseamlessly.After resectingtheprimarytumor,several inguinalnodeswereimmediately identifiedandremoved.Thatday, everythingthathappenedintheOR seemedtomeanmore.Iwatchedmy preceptorashecarefullypositionedthe patientforsurgery,repeatedlyadjusting thetableandstirruppadstoensurethere werenopressurepoints.Intypical fashion,hehelpedtheORtechnicianstie theirgownsbeforescrubbinginhimself, somethingIhadalwaysadmiredabout him.AsIhelpedsuctionandretract,Ifelt

incrediblygratefultobeinvolvedinMrs. P’scareandtobelearningfroma physicianwhohadsuchanoverwhelming giftofmodesty.Mypreceptorhandedme theneedledriverandhelpedcutmy suturesasIclosedthefinaldefect.While Ithrewthefinalknots,IprayedMrs.P wouldsoonexperiencethereliefsheso deserved.

WhenIroundedonMrs.Pthenext morning,shewasfrowningatthe herhowmuchIadmiredherforher strengthandcourage.Lookingback,I willbeforevergratefultoherfor remindingmeofwhyIchosetogointo medicineandtomypreceptorfor showingmethekindofphysicianIhope tobe.

“Sorrow hath changed its note: such is his will”

by Jacob Myhre

Mypatientexperiencecentersaround asingleexchangebetweenmyselfanda patient.Ithinkitismostfullyunderstood inreferencetoapieceofart.

HalfwayalongBromptonRoadin London’sKensingtonboroughstandsthe LondonOratory.Itsgreat19th-century stoneedificeloomsoverthecivilityofthe streetunderneath.Attheendoftheday, itsshadowscreepwidelyoverthe surroundingstructures,trees,benches, people.OneparticularobjectisCharlie Mackesy’sinterpretationof“TheReturn oftheProdigalSon”.Constructedof bronzein2005,thestatuedepictsthe NewTestamentlessonwithrenewed interestandparticularattentiontothe physicallovethefathershowedwhen embracinghisprodigalsonwithout reserve.Thearmsappeartobemelting intooneanother,theirgarmentsvirtually inseparable.Whilemuchaboutthework isparticularlymoving,thefather’sarms thrustintotheson’sperson,thegrasp,the

touch,theinvolutionofoneintotheother withoutwordconveystheselflesslove thesonreceives,andthefathergives. Unlikeourframesthatgrowwearyand needsleep,ourmusclesthatacheand needrest,thebronzefatherandson remainunweariedbygravitational damnations.Theywordlesslyremain embracedastheyhavefortwentyyears anddemonstratethesimple,beautiful, andprofoundwordsofTraceyEmin, knownforherneonsculptures,who writesoverthegreatwestdoorsof LiverpoolCathedral,“IfeltyouandI knewyoulovedme”.

FarawayfromLondon,thestatue,the greatwestdoorsistheFranceTowerat HalifaxHealth.Ononeparticularfloor, ononeparticularservice,wasa sixty-eight-year-oldwomanwhowill remainunnamed;Isawhereveryday duringmyinternalmedicinerotation.

Shehadbeenadmittedtothefloor someweekspriorfollowingatherapeutic hemispherectomyforawidelymetastatic StageIVGlioblastomacausing obstructivehydrocephalusandfocal neurologicaldeficits.Adramatic diagnosis.Aterminaldiagnosis.A“my lifechangedfourmonthsagowhenthey foundthisonimaging”diagnosis. Mypatienthadlosttheabilitytospeak. Shehadalsolosttheabilitytorisefrom bed.Shespentherdaysinthecompanyof herfaithfulsonanddaughterwhokept watchatherside.Whilewithoutvoice andmuchmovement,mypatientwasable tolookmeintheeyesandsqueezewith herrighthand.Consideringwhatshemay havebeencapableofjustoneyearprior, theontologicalstatisticsseemed incrediblycruel.

Asinstructedbymyattending,Iwould interviewthepatient’schildrendaily, inquiringaboutanychangesthatmay haveoccurredovernight.Iwouldinquire aboutappetite,foodconsumption, physicaltherapy,etc.Withabitof personaldiscomfort,Iwouldconducta briefneurologicexamtoassessforany changesinfunctionorstatus.Inmy

arroganceandignorancethattwo-decades oflifeoftenmercilesslyaffords,Ifeltthe teststobefutile,butconductedthem nonetheless.Afterseveraldaysoftesting, inquiringandrounding,Iconcludedmy examandreachedforherhandtolether knowthatIwouldseeherthefollowing Monday.Inamoment,shesqueezedmy handandlookedwithallIcanassume wasgreatintentioninhereyes.There weretearswellingupandevennowI cannotfullyexplainthemessagesthat musthavebeenconveyedinherlook.The exchangewaswordless,whichwasby productofthesituation,butalsoperfectly appropriate.Thesituationdemandedno words.Thefirmgrasp,thewarmth,the tactilecommunicationbetweenhandsand eyesbroughtmetoBromptonRoadand thestatue.Thestatuewasnowmore three-dimensionalthaneverbefore.The intentionofthehumangrasp,thegrace andmercyaffordedinphysicaltouch,the fathergraspingthesonandthebond visiblyseenalldemandedmyfull attention.Itdemanded,firstlyasahuman, thatIunderstandthepowerofahand grasped,andthevulnerabilityofhand extendedforassurance.Orforsuccor.Or forunderstanding.Orforwarmth.Orfor allthesethings.ItdemandedthatItakeit. NotthatIfaultlesslyprovidesuccor, understanding,andwarmtheachtimethat Itakeit,butthatItakeitknowingthe greatresponsibilitythatliestherein.

Asaresultofherdisease,mypatient diedinFebruary.Ididnotlearnmuch aboutherlifebutforthefewpleasantries Iexchangedwithhersonanddaughter.I donotknowwhatkindofmothershewas orwhatkindofspouseshewas.Shelived herlifewithmanyothersandinreference tomanyothersforalongtimebeforeI mether.

Isaythisforimportantreason:toquell anynotionthatherdebilitatingandtragic conditionaffordedmea“lessonlearned”. Whatasordidanddisgustingthought.I cansayhowever,withoutreserve,thatin ourshorttimetogetherandimpactful exchangelastingbutafewseconds,I

becamemorehuman,asdidshe. Inmyfuturecareerinmedicine,Iwillnot forgethername,norhergrasp,norher look.

My First Goodbye by

Lauren Rafanan

Itwasmyfirstweekofinpatient internalmedicine,wherewewouldround ondozensofpatientsforhours.Ienjoyed talkingtopatientsanddiscussingtheir conditionswithmyattendingbut sometimesthepatientsbegantoblur together.Itwas“231hasaheartfailure exacerbation,giveLasixandcheckonher tomorrow”oritwasaCOPD exacerbationorliverfailureorkidney failure.Itwashardformetokeeptrackof everypatient’sstoryandbackground. Thereisonepatientthatstandsouttome whenIthinkofdemonstratingempathy andhowitaffectsmyfutureasa clinician.PatientMisa47-year-old femaleseenintheintensivecareunit. Itwasnearingtheendofa12-hourshift whenImetpatientM.Mwasbeing coveredbytheintensivistbuthadbeen treatedbeforebymyattending.The intensivistaskedmyattendingtospeakto heraboutend-of-lifecare,thinkingmy attendingwouldbebetterequippedto havetheconversation.

IwastoldthatMhadstage4ovarian cancerandithadspreadtomostofher body.Iwalkedintotheroomwiththe doctorandsawapatientbreathingheavily onoxygen.MyattendingsaidhelloandI introducedmyselftothepatient.Icannot rememberexactlyhowthefollowing conversationwent;ithasblurredinto moreofageneralfeelingforme,butIdo remembersomespecificthingsthatwere explained.

IlistenedtomyattendingtalktoM aboutchangingthecodestatusto

do-not-resuscitate.Heexplainedthat sinceMwasalreadyhavingsomuch troublebreathingitwaspossibleshe wouldgetworseandneedtobeintubated. Heexplainedthatbeingintubatedcould meannotbeingabletobreathewithoutit. Heexplainedthatifherheartstopped“a bunchof20-somethingswouldpoundon yourchestandbreakyourribsinan attempttosaveyourlife”.Hegently explainedhowhospicewasanoptionand thateverythingwouldbedonetomake hercomfortable,butthatultimatelythere wasnothingwecoulddotocureher becausethecancerwassowidespread.

Mdidnotwanttochangethecode status.Shetoldusshewas“strongand wantedtofightthisthing,”shesaidshe didnotwanttoleaveherdaughters,and howshewas“notreadytodie”.My attendingempathizedwithherbut emphasizedthatshewasnotgoingtoget better.Hesaidthatifshehadtobe intubateditwouldbeoneofherdaughters whowouldbeforcedtomakethe decisiontoendcareifMdidnotmake herwishesknown.Thisreminderseemed tobeenoughforMandshechangedthe codestatustodo-not-resuscitate.

Wesaidgoodbyefortheeveningand walkedoutoftheroom.Afterweclosed thedoor,Iletoutasharpexhale.Ididnot realizethatIhadbeenholdingmybreath. IdidnotrealizethatIhadbeensochoked upthatitwouldbehardformetospeak tomyattending.Ithankedmyattending forshowingmeanexampleofa compassionatewaytotalktoapatient.

Thenextmorning,Mhadchangedher mindaboutthecodestatusandthatshe didnotwanttogotohospicecare.She saidanotherdoctorhadseenherandsaid therewasapossibilityofextendingher lifewithacertainchemotherapy.M’s eldestdaughtercalledmyattendingand saidthatshewouldliketohavea conversationwithhiminvolvinghertwo sisters,heraunt(whowasanurse)to discussplansforcare.Myattending

agreedtomeetwiththeminthe afternoon.

WesawMandherfamilyafter rounding.WhenIsawherfamily,Iwas shockedbyhowyoungheryoungest daughterappeared.Themiddledaughter remarkedhowtheyoungestwasfinally oldenoughtodriveherselftoM’s appointments.Weagainhadthe conversationabouttheoutlookofher condition,hospice,andchangingthecode status.Herdaughtersdidnotwantherto endupintubated,theydidnotwanttheir mothertosufferthetraumaofCPR,and theydidnotwanttobetheoneswho decidedtoremovecare.Aftertearful discussionwithherdaughtersandsister, Mmadethedecisiontogotohospice.

Afewdayslater,myattendingtoldme thatMhaddied.Iimmediatelyfeltapain inmythroatasItriednottocry,afterall, thereweremanypatientsthatneededto beseenandcaredforthatday.Ipushed downmyfeelingsandsawtheother patients,tryingsohardnottoletthenews gettome.WhenIgothomefromthe hospitalIsatdownonthecouchand, withinafewminutes,thetearswere flowing.Isobbedforthispatientandher family.Mwas5yearsyoungerthanmy mom.Icouldnotimaginelosingmymom atthispointinmylifeandwasthinking ofhowdevastatedIwouldbeifIlosther. IpicturedM’s16-year-olddaughter makingittoanagewhereshewould realizethatshehadlivedlongeronthis earthwithouthermotherthanshedid withher.Icriedthinkingitwasunfair.I criedthinkingIwasnotsureifIcould handlebeinginthisfield.

Inmedicine,weareexposedtodeath anddyingpeoplemoreoftenthanthe averageperson.Weseepainandlossso oftenthatsometimesitlosesitsimpacton us.AsIcontinuethroughmycareer,Iwill getbetteratseeingpatientsand devastatedfamiliesandnotbeing emotionallycompromisedforanother patient.Sometimesit’s“231hasaheart failureexacerbation”andsometimeswe loseourconnectiontothepatients.Iwill

remindmyselfthatitisnecessaryto connectwithourpatients,evenwhen thereisnothingwecandotohelpthem.It isanhonorandaprivilegetobewith peopleintheirworstandmostvulnerable moments.IamgratefultopatientM,a 47-year-oldfemaleseenintheICU,who allowedme(astranger)toprovide comforttoherandherfamilyasshewas nearingtheendofherlife.

I Hope We Meet Again

by McKenzie Seitz

Unfortunately,todayIhavethe gruesomejobofdiscussingtherecent PETscanandbrainMRIwithMargand herdaughter.Beforewegetintothegory pathology,however,IaskMarghowshe’s beensincethelasttimeIsawher. Who are you living with nowadays? Are you still eating and drinking enough? How are you spending your time? Margstayed silentandofferedmethatsamesoftsmile. Irepeatedmyself,louderthistimeand shenoddedbeforeresponding.“Oh,I’m doingjustfine,sweetie.Mydaughteris takinggoodcareofme.”Iremainedsilent forafewsecondshopingtoinviteherto keeptalkingandsheshruggedher shouldersbeforesaying,“ButI’mreally missingJim.”

Margisan86-year-oldmother, grandmother,andwidowwithtanskin andlightblueeyes.Sheisfrailand slightlyhardofhearing.WhenI’mtalking toher,shesmilessoftlywithhereyesand hermouthturnedupeversoslightly.This meansshecan’thearme,butshe’stoo embarrassedtoaskmetoraisemyvoice. Sheisfrailandseatedinawheelchair withextracushionforherbuttocksand sheisalwaysdressedasifitis20degrees coolerthanitreallyis.Sheweighs94 pounds,andherclotheshangfromher shouldersasiftheyarestillonthe clotheslines,butshetakescaretopickout heroutfiteverytimesheleavesthehouse.

Todaysheisaccompaniedbyher daughterwholoveshermotherdearlyand hasclearlyalreadyreckonedwiththe changesthatoldagehascastuponher mom.Margstruggleswithnormal pressurehydrocephalusthatshehas chosennottotreat,makingher incontinentandsometimesalittle confused.Overthepastcoupleyears,she hashadseveralTIAsthathavelefther memoryslightlydiminished.Today, however,Margisheretodiscussarecent biopsyprovenmelanomathatresideson herforeheadandhasmetastasizedtoher brain.

JimandMargweremarriedfor62 yearsbeforehepassedawayfromlung cancertwoyearsago.Theywere companionsineverysenseoftheword andlivedsomuchlifetogether.They wereoriginallyfromSanibelIslandwhere theyfirstmetasclassmatesinhigh school.Theydidn’tbecomeacoupleuntil aftercollegeandtheymoveddownto Daytonatwodecadesagebeforethey retiredonthebeach.

Marglitupwhenshewastalking abouthim.Hermemorywasperfectly intact,andsheremainedsmilingand bright-eyed,asItriedmybesttoremain stoicandpreventthetearspoolinginmy eyesfromrunningdownmycheeks. Margwaswearingacrossnecklace,and shegrippedthenecklacetightinherhand assheassuredmeherbeliefthatshe wouldonedayberuinedwithhersweet Jim.IaffirmedherthatIheldthesame belief.“God’snotdonewithmejustyet,” sherespondedshakingherfist.Her daughteratthebedsidesmiledandsaid, “that’srightmom!”beforedirectingthe conversationbackatmeandaskingifwe coulddiscusstheresultsofherimaging studies.

Marg,however,didnotwanttoknow theresults.Shewasreluctanttohaving anyimagingdoneinthefirstplace becauseshedidnotwishtotreather

cancerafterseeingthepainandsuffering thatJimwentthrough.Herdaughter, however,hadinsistedthatshewanteda diagnosissothatshecouldpreparethe properresourcestohavehospiceorhome healthcoveredifitgottothatpoint.Marg instructedmetotellherdaughterthe resultsasthemedicalassistanthelped wheelheroutsideoftheroom.

“It’sinthebrain,isn’tit?”her daughterasked.Inoddedsomberlyand readhertheradiologyreportand answeredherfollow-upquestionsthatI feltwereappropriateformetoanswer.I assuredherthattheattendingphysician couldanswermoreofherquestions,but shedidn’tseemtohaveany.Shewasat peaceknowingthatregardlessofwhatthe reportsaid,hermomwashavingither way.

Margcamebackinafewminuteslater stillcheeryandmadeajokeaboutthe girlstalkingbehindherback.“Itfeelslike I’mbackinmiddleschool!Bedonewith italready.I’mreadytogohome.”When theattendingcamein,Margaskedifshe couldbedonewithdoctorsalltogether. Notinarudewayordismissiveway,but shewastired.Gettingoutofthehouse wasabigeventandshewantedtolivein “ignorantbliss,”asshecalledit.

Marghadalreadystoppedtakingall hermedicationsyearsagowhenJimdied, andshewascontentlivingouttherestof herlifewithoutpillsorproceduresor morelabdraws.“MyGodwillcallme homewhenhe’sready.”Iturnedtolook atMarg’sdaughterasshespokethese words.Shewasn’tsadorangryather motherfor,whatsomepeoplemightcall givingup.Shewasnotemotionalor regretfulorembarrassed.Shewasso proud.Proudofhermomforspeaking confidentlyaboutwhatshedesired.They werethepictureofcontentment.

Inmedicine,weareconstantlytrying topreventdeath.Welivealongsidea currencyofantibioticsandchemotherapy, surgeryandrehabilitation.Reflectingon myvisitswithMarg,itwasrefreshingto

gettoknowsomeoneunafraidofdeath, clungtoherfaiththatherlifewasin someoneelse’shandswhomshetrusted wholeheartedlyandeternally.Asa medicalstudentandphysicianintraining, it’snicetofeelneeded.ButwhatI discoveredthroughMargwasthebeauty ofnotbeingneededatall.Suchbeauty thereisinawomanwhoknowsherdays arenumberedbutliveseverydayjustthe same.

Howoftendoweaskpatientswhat they really wantandnotsecretlywishthat theirplanisthesameasours?Howoften doweplaceorpatients’desirestruly beforeourown?Howoftendowefeel peacewhenourpatientsarereadytodie? Iwouldargue,notoftenenough.Itwasan honorandaprivilegetogettoknowMarg andhearherstories.Shewilllikelynever knowhowmuchshetaughtme,butI hopethatonedaywemightmeetagain.

A Losing Battle

by Shwetha Shetty

Doesheknowthecanceriswinning?

Thispatientwasan83-year-old, CaucasianmaleawaitingaGI consultationintheemergencyroom.Asa third-yearmedicalstudentwithtwo weeksofexperienceontheGIservice,it didn’tsurprisemewhenIsaw“possible GIbleed”listedasthereasonforconsult. Ihadreadhischartbeforeenteringthe room,tryingtogatherasmuch informationaspossibletoknowwhatto expect.IthoughtIcouldhandlethisone. Helivedinanindependentlivingfacility. Hehadrecentlybeendiagnosedwith advancedesophagealcancerandwas evaluatinghisoptions.MayoClinic deemedhiscancerinoperable.Noteven radiationtherapywouldreversethe damageofthecancergrowinginsideof

him. Apparently, his medical oncologist had discussed palliative therapy, and this was the path he had chosen. Was he left with no option but to choose comfort care?

Amidsttherealityofbeingdiagnosed withthisuntreatablecancer,thetumor wasn’tdonetroublinghim.Hechecked himselfintototheERwithconcernsofa GIbleed.Hismedicaloncologisthadtold himthathishemoglobinwasdangerously low.Singledigits.BythetimeIsawhim intheearlymorning,hehadalready receivedthreetransfusionsandwaslying inahospitalbedwiththelightsturned off.Hishemoglobinlevelsweremuch improvedaccordingtothelabstakenat anungodlyhour.Stillsingledigits though,butbetter.

Hisfeettouchedthefootofthebed. Hiseyeswereclosed.Hewaswearinga gown,buthewascoveredsnugunder severalblankets.Hewasaround6’5or 6’6.Hewasleanandappearedyounger thanhisstatedage.Igreetedhim, introducedmyself,apologizedforwaking himup,andwaitedforhisresponse.“Can youturnthelightson?I’vebeenwaiting foryouguys.”Heknewthatitwasthe tumordisruptinghismorning.Heknew heneededanendoscopybeforeIhad completedmyfullevaluation.Iaskedif thishadhappenedbeforeandhe responded,“that’showIfoundoutthe firsttime.”Hisnonchalancecaughtmeby surprise.Iconfirmedwhatthe hospitalist’snotereadearlierthis morning,“nofamilybypatient’s bedside.”Hiswifehadpassedawaylast year,andhecamealone.Hisdaughter wasonherway.Thephysicalexamwas unremarkable,butthedigitalrectalexam waspositiveforblood.Itonlyconfirmed whatweallknew.“I’mreadytogetthis overwithbecauseIhaven’teatensince lastnight.” DespiteknowingtheGI schedulewaspacked,Iknewhewouldbe squeezedin.Icouldn’tmakepromises, butItoldhimIwouldchampionhiscase. Ididn’tknowwhohewasoutsideofthis hospital,butinsidethishospital,hewasa lonesoldier.Ibecamehisally.

Ipresentedhiscasetomyattending, whorespondedwithaknowinglook.A lookthattoldmeheknewwhattoexpect duringtheprocedure.However,wewould stillperformthescopetoascertainthe extentofthedamage.Intheprocedure room,mypatientwaswheeledin,andhe recognizedmeonceIgreetedhiminmy mask,gown,andcap.Iwasafamiliar voiceinthedimmedprocedureroom.His feetnearlytouchedtheendofthe operatingtable.Iaskedifhisdaughter hadarrivedintimetoseehim.“No,butI amsureshe’llbeherebythetimewe’re done.”Helookedalittleworriedforthe firsttimesincethemorning.Helooked likeamanwhowasn’tcomfortablewith losingcontrol,andonthisoperatingtable, hewasleftinthedarkinmorewaysthan one.

Westartedtheprocedureaswewould anyotherendoscopy.Withinthefirstfew secondsofdescentintotheesophagus,we encounteredagrowththatdisfiguredthe normalanatomy.Myattendingguidedthe scopewithagentlehandaswe approachedthebleedingmass–afraidit wouldupsettheangrytumor.We achievedhemostasisbutthiswasa temporaryfixtoalosingbattle.Noone saiditoutloud,butoursilenceechoedthe prognosisofthisoozingtumorinhis esophagus.

Ihadafeelinghewouldbebackand returnasmanytimesasneededwhenhis hemoglobinhitsingledigitsagain.This wouldbecomehisnewnorm.Ididn’t needtoknowwhatkepthimgoingor why.Whetheritwasthispatientorthe manyIwillencountermovingforward, eachwithstoriesunbeknownsttome–I willcareforthemduringabriefperiodof theirliveswithoutknowingtheirpastor future.I’mstartingtorealizethatIdon’t needtoknowtheirwhytogivethemmy best.Icouldseehisspirit,andhisspirit wantedtofight.Ifhehadthewillandwe hadtheresources,thenbyallmeans–we weregoingtofightthisfight.Wewerehis soldiers,andhewasour commander-in-chief.Weanticipatedthe inevitable,withnohopeforvictory.

So,Iaskedmyself,doesheknowthe canceriswinning?

Yes,heknows,buthewon’tgiveup.

Master Chef by Sally Stauder

knewtheywouldpayoffwhenhebecame amasterchefwithhisownrestaurant. Thiswashisdream.Hispassion.Thefirst thinghethoughtaboutwhenhefirstlay asleepatnightoraroseinthemorning. Thiswashiscalling.

Duringmythirdyearofmedical school,Ihadtheopportunitytomeeta widevarietyofpatientsdiagnosedwitha myriadofdiseasepathologiesand prognoses.Thereisonepatientwhose storystandsouttomeasoneofthemost meaningful—JohnSmith.

JohnSmithisa26-year-oldmalewho firstpresentedtotheEmergency Departmentwithaweeklonghistoryof retractablevomiting,diarrhea,and abdominalpain.Hesaysthatthispain "cameoutofnowhere,andhehasnever experiencedanythinglikethis!". He hadn'teatenanythingoutoftheordinary, traveledabroadrecently,orbeenaround anyoneelsewiththesesimilarsymptoms. Hewasa"normalguylivinganormal life."Herecentlygotengagedandhad beensavingupforafuturewedding.He graduatedfromculinaryschoolafew yearsagoandworksasasouschef. ThroughmytimewithJohnSmith,Ihad theopportunitytolearnalotaboutthe fieldofculinaryart.Idiscoveredthe rigoroustrainingandlonghoursofhard workrequiredtoworkuptheladderof rankandgainrecognitionasagourmet chef.Hedetailedhisownjourneyfrom graduatingculinaryschool,becomingan apprenticechef,andultimatelybecoming asouschef.Ilearnedofhisdaysworking withlittletonopayasabusboyand difficulthoursthatrequiredphysicaland mentalstress.Ilearnedofthestrainthis putonhisrelationshipsandhistemptation tousesubstancesasastressreliefafter workingweekendnightshifts.Hespoke ofthedrivetoendurethesehardshipsof lowpayandlonghoursashe

Icouldn'thelpbutseeparallelsinthis patient'slifetomyown—he,too,had beenworkingthroughthe time-consumingandrigorousprocessof attaininghisdreamprofession.Hehad steadilyandpatientlypreservedthrough thestepsrequiredtobecomeamasterof hisfield,justasIhavetobecomea physician.Fromhighschooltomynow thirdyearofmedicalschool,Ithoughtof myownjourneytothisgoalofbecoming aprofessionalofthemedicalfield.

Iworkedwiththispatienteveryday forfourweeksintheinpatienthospital wards.Iwatchedhimundergoamyriad oftestsandprocedurestodeterminethe etiologyofhiscondition.Isawhowhis waterdiarrheaturnedintorelentless bloodydiarrheaeverytimeheatesolid food.Iwatchedhisabdominalpain transformfromadullachetodiffuse abdominalpainwithguarding.

Iwastherewithhimwhenwe discussedourfindingsthathiscultures andantigentestswerenegativeforsigns ofaninfectiousetiology.Isawhowhis good,spiritedattitudechangedtofearand anxietywhenwereceivedtheresultsofa colonoscopyindicatingdiffuseulcerative colitisspanningfromtherectumtothe cecum.Iwitnessedhisunderstandingof receivingaterminaldiagnosisandhisfear ofhislifeneverbecomingthesame.He spoketomeabouthisworryabout missingwork,fearsoflivingalifefullof physicalpain,anddistressabouthowhe wouldmanagethisnewlifeinstorefor him.Hespokeoffinancialstrain;hehad missednearlytwoweeksofworkandhad alreadytakenafinancialhitfromthe medicalbillsduetohislackofhealthcare insurancegrantedinhisfield.He wonderedifhewouldeverbeableto recoverfromacareerstandpointfromthis hiccup.Washestillnextinlinetoreceive apromotiontomasterchef?

Asthedayswentonandfirst-line treatmentsbegantofail,hebecamemore emotionallylabile."Nothingisworking!I amonlygettingworse",heexclaimedto meonemorningafterhehadfailedto receivereliefwithbothsystemic corticosteroidsandbiologictherapywith TNFinhibitors.

Myheartbrokeforthispatient.This patientwasjustlikeme.Hewasmyage, sharedalifegoalsimilartomine,andwas intheprocessofalmostmakingittothe finishlineofachievinghislifelonggoal ofbeingamasterofhischosenfield.The differencebetweenthispatientandmyself isthatIdonothaveahealthobstacle obstructingmyjourneytowardsuccess.I amfortunateenoughtobehealthy, pain-free,andwithoutachronicillness thatisimpedingmygoalofbecominga physician.

Atthebeginningofhisfourthweekin thehospital,wediscussedanelective totalcolectomyinhopesitwouldcontrol hispain.Johnwasdevastated.Afew weeksago,hewasahealthy26-year-old withnopastmedicalhistory.Hecouldnot andwouldnotlivetherestofhislifewith abagcontainingfecalmatterinit.He worriedhowthiswouldaffecthis relationshipwithhisfiancé.Thispast monthhadalreadybroughtstressinto theirrelationship,andhefearedthatthis woulddeterthemfurtherawayfromeach otherthantheyalreadyhavebeen.

Overfourweekswiththispatient,I wasneverabletoseehimpain-free.I finishedmyclerkshipininternalmedicine andbegananewoneinpsychiatry.Ina way,IfeltlikeIwasdesertinghim.Iwas ontothenextexcitingjourneyofmedical schoolandbecomingonestepcloserto mydreamwhilehewasstuckina hospitalbed,forcedtoputhislifeonhold bydebilitatingpain.Iwonderedifroles werereversed,howwouldIfeelaboutthe situation?WouldIbeenviousofthis medicalstudentforbeingpain-free? WouldIbeangryfortheirabrupt disappearance?Wouldthisdisappearance makemefeellikeIwasjustanother

difficultpatientcasethatwaspassedonto someotherdoctor?Thesethoughts disturbedme,asthestatusofJohn's healthhadinfiltratedmymindeachday sinceIlefthisservice.

Idecidedtofollowupwithmyinternal medicinepreceptortogetanupdateon John'scondition.Mypreceptorinformed methatduringhisfifthweekofstay, John'spainbegantoincrease dramatically.AnX-raywasordered, revealingsignsofatoxicmegacolon.He wasinformedofhisconditionand reluctantlyagreedtoemergencysurgery. Hereceivedatotalcolectomywithan ileostomyplacement.

Thispatientservesasaremindertome ofthedelicateroleofthephysicianin treatingpatientswithchronicdiseasesor illnesses.John'slifehadchangedforever inthecourseofafewweeks.Hehadgone tothehospitalforwhathebelievedwasa badviralbugandleftwithoutamajor organandatubetodrainhisfecalmatter.  Hewouldlivehislifewithseveralnew physical,emotional,andsocial challenges.Thispatienthelpedme understandtheprivilegeofbecominga provider.Wearegiventhechallengingyet humblingtaskoftreatingpatientsintheir mostvulnerablestates.Ourpurposeisto provideguidanceandsolaceduringsome ofthemosttransformativemomentsin theirlives.Wearetheretosupportthem bothphysicallyandmentallythrough theirdifficultjourneyahead.This experiencehasstrengthenedmy aspirationtobecomeaphysicianwho caresforpatientswithunwavering respect,empathy,andcompassionwhile theyareenduringthechallengingbattle fortheirhealth.

Learning From Regret

by Vivian Tanios

Doyourememberwhatlifewaslike asaone-year-old?I’msureyoudon’t haveconcretememoriesfromthistime, butyouknowenoughtorecallthatyou neededhelpwitheverything.Yourparents helpedfeedyou,giveyoushowers,and changeyourdiapers.Thereweremany momentsofcryingbutalsolaughter. Now,imagineyouarestillinneedofhelp withallthosethings,butyouareinthe bodyofa40-year-old.Youliveyourlife beingcaredforbyyourparentswhothen passaway.Yourbrothergetscustodyand thenpassesawayfromcovidandnow, yoursister-in-lawisyourlegalguardian andtheonecaringforyou.

Thiswasthecaseformy40-year-old patientintheintensivecareunit(ICU) whowasbornwithcerebralpalsy.He cameintothehospitalwithaspiration pneumonia,wasintubated,andputunder anesthesiaformostofhishospitalstay. Duringthistime,hewasgivenfluids, antibiotics,andnutritionthroughIV’sand tubes.Canyouimaginehowscaredyou wouldbeinhisposition?Ican’timagine beingsoaloneandunawareofwhatis happeningtome.ThefearIwouldhave experiencedbeingsurroundedbypeopleI don’tknow.Strangerstouchingme withoutasking,placingcatheters,sticking mewithneedlesanddoctorswalkingin andnotevenintroducingthemselves.

Myattendingexplainedthepatient casetomebeforewewalkedintothe patientroom,andthenheimmediately hadmefeelthepatient’sfirm,distended abdomen.Hehadmelookatthe ventilatorsettingsandwhatmedications weregoingthroughhisIV.Iwishwe wouldhavejusttakenthetimetosayhito thepatientandintroduceourselvesevenif heisunconscious.Ourbodiescanstillbe soawareofwhatishappening.

Ihaveaheavyweightonmyheartfornot speakingtothepatientduringthistime.In themoment,Iwassoscaredtobetheodd oneoutbyintroducingmyselftothe patientandexplainingwhatIwasdoing orcheckingforduringthephysicalexam. Iknownowthatitisokaytobetheodd oneoutifitmeansIamhumanizingthese patientsandnotbecomingarobot.Iwant tomakesuremypatientsarealwaysat easenomatterthesituation.

Ibelievetheonlycomfortthispatient hadwashavingsuchalovingfamilyand supportsystemaroundhiminsucha foreignplace.Hissister-in-lawwould alwayscomeinafterworktocheckupon him.Thenursesfromthefacilityhewas transportedfromwouldalsovisithimand makesurehewastreatedwiththebest carepossible.Thoseinteractionswerethe onlythingsthatgavemecomfortwithall thatthispatienthadbeenthroughinthe ICU.BeingintheICUevenasamedical studentgavemeanxietyandthefeeling likesomethingwrongcouldhappenin anysecond.Icannotimaginebeinga patientthere,allaloneboundwithinfour wallsandachoirofbeepingmachines singingatallhoursofthedayandnight.

Thepatient’ssister-in-laweventually madethetoughdecisiontotakehimoff ventilatorsupportandallowhimtopass awaypeacefullyandwithdignity.During thistime,hewassurroundedbyfamily comfortinghimandultimatelyeachother. Hislifeendedbeingsurroundedby peoplethatlovehimandnowhecanjoin hisparentsandbrotherinHeaven.

IwishIcouldhavetoldhimhow muchofanimpacthehadonmeduring thisrotationandthatIwasthankfulto witnessunwaveringloveandsupport fromthosewhocherishedhim.WhileI cannotchangethepast,Iwilltake everythingIlearnedandfeltfromthis situationintoeverypatientroomIenter.

The Volusia Volunteers In Medicine (VVIM), a 501(C)(3) organization, provides free primary healthcare to low-income, uninsured residents between the ages of 18-64. We are a 100% volunteer driven organization that benefits Volusia by providing a healthier workforce, reducing non-paying hospital and emergency room visits and building a strong sense of community.

In 2023, VVIM partnered with the Department of Health to open a satellite office in the New Smyrna Beach area. Our office manager schedules patients by appointment only at both locations. For more than nine years, VVIM has provided FREE medical care through private donations, small fundraisers, and grants since 2015. Laboratory tests, X-rays, even MRIs and CT scans are provided for free or with discounted rates. These services can be very expensive under normal circumstances and especially expensive if no insurance is available.

We are looking for volunteer doctors and nurses who would like to serve their community. Retired or semi-retired medical professionals are the backbone of our organization. We are specifically in need of a cardiologist and primary care physicians who can volunteer time at our clinic or who will see our patients in their office. Any physician who provides their services free of charge, whether at our clinic or at their own private office, is covered under the State of Florida sovereign immunity law.

Anyone who is interested in joining our team or finding out more information, please contact our office at 386-316-2771 or email at vvimmanager@gmail.com.

Chronic Shoulder Pain: Why does my shoulder always hurt and what can my primary care provider do/order to help? Connor Hermida, Halifax Health FMRP

Chronic shoulder pain is a common issue in primary care that significantly impacts patients' quality of life. It can arise from various causes and understanding these can help guide effective treatment.This article explores common causes of chronic shoulder pain and what your primary care provider may offer for management.

Rotator Cuff Pathology

The rotator cuff, comprised of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis), is a frequent source of shoulder pain. Common problems include rotator cuff tears and tendinitis.Tears, particularly partial ones, often occur with age or repetitive overhead activities, such as those performed in tennis or baseball. Small tears are usually managed with activity modification, physical therapy, and NSAIDs (like ibuprofen). Larger tears might require surgery, but initial treatment often involves conservative measures.Your primary care provider (PCP) will likely perform a physical exam to assess your rotator cuff.They will also likely order a X-ray to evaluate the bones of your shoulder or MRI to evaluate the muscles of the rotator cuff.After diagnosis, your PCP will likely refer you to physical therapy, discuss activity modification, and dependent on their training may offer corticosteroid injections to help with pain.

Osteoarthritis

Osteoarthritis (OA) involves the degeneration of cartilage and bone in joints, commonly affecting the acromioclavicular and glenohumeral joints of the shoulder. OAtypically presents with pain and reduced range of motion.Your PCPwill assess your shoulder through a physical exam and X-rays to confirm the diagnosis of arthritis.Treatment usually includes activity modification, physical therapy, and pain medications such as acetaminophen (Tylenol) or NSAIDs (Ibuprofen/Motrin). Corticosteroid injections may be used for acute pain relief if the provider is trained to administer them.

Adhesive Capsulitis (Frozen Shoulder)

Adhesive capsulitis, or "frozen shoulder," is characterized by pain and stiffness due to inflammation and thickening of the shoulder capsule, leading to reduced motion. It is often seen in patients who have diabetes or thyroid disorders.Although the condition can resolve over one to two years without treatment, treatment aims to shorten symptoms duration.Treatment includes activity modification, anti-inflammatory medications, physical therapy, and possibly intra-articular steroid injections.Your PCPmay refer you to a specialist for intra-articular injections or surgery, rarely surgery is needed.

Summary

Chronic shoulder pain can stem from various causes, including rotator cuff issues, osteoarthritis, adhesive capsulitis, and much more not covered above. Effective management involves a combination of physical therapy, activity modification, medications, and sometimes injections.Athorough evaluation by your PCPis essential for accurate diagnosis and personalized treatment. If you’re experiencing persistent shoulder pain, consult your primary care provider to develop an appropriate treatment plan.

New Member Highlights

Dr. Brent Fulton was raised in the Daytona Beach area. He was the 1991 Father Lopez Catholic High School Valedictorian. He earned an appointment to the United States Naval Academy, graduating with Merit in 1995. He was commissioned a Special Operations Officer and spent five years on active duty before attending Bowman Gray School of Medicine at Wake Forest University. Dr. Fulton completed his residency and fellowship at the Mayo Clinic in Jacksonville, Florida.

Dr. Fulton is Board Certified in Family Practice and Sports Medicine. He treats spine, head, shoulder, elbow, wrist, hand, knee, ankle, and foot injuries. Dr. Fulton also assists patients in controlling their hypertension, obesity, hyperlipidemia, diabetes, fibromyalgia, and other chronic diseases through specialized diet and exercise programs. He has been in practice in the area for 15 years and recently opened a solo practice, Trident Sports Medicine and Rehabilitation. He is also the volunteer team physician at his alma mater, Father Lopez Catholic High School. He works as an attending with the Family Medicine residency and Sports Medicine fellowship at Halifax Health.

New Member Highlights

Charles Dunn, MD completed a pediatric residency at the Naval Medical Center Portsmouth, and served in the U.S. Air Force Medical Corps as a pediatrician and pediatric hospitalist. He served as medical director for the Department of Pediatrics at the 673rd Medical Group Joint Base Elmendorf-Richardson in Alaska and was recognized as a Top 10 Primary Care Provider and "Pediatrician of the Year" in 2021 by the Uniformed Services and American Academy of Pediatrics. After leaving the service, Dr. Dunn pursued a dermatology residency at KCU/ADCS Orlando where he served as Chief Resident. Since then, he has received numerous awards from the American Academy of Dermatology, Florida Academy of Dermatology, and Florida Society for Dermatologic Surgeons for his work in artificial intelligence, public health, camp medicine for kids with medical needs, medical dermatology, surgical dermatology, and Mohs micrographic surgery.

Charles Ross, M.D. is a Board-certified Family Medicine who is also Board-certified in Lifestyle Medicine and plans to be Board-certified in Obesity Medicine by November. Since 2006, he has practiced as a full-time physician in Primary Care, Urgent Care, Sports Medicine, Pain Medicine, and now Lifestyle Medicine. During this time, he has also served as a Clinical Assistant Professor for the University of South Florida, Nova Southeastern University, and Barry University in Miami, clinically training Medical Residents in Family Medicine and Internal Medicine, Medical students, Nurse Practitioners, and Physician Assistants. As a sub-investigator, Dr. Ross is primarily interested in research involving lifestyle-based therapies and evolving pharmacologic options for treating weight-related health problems, other metabolic and endocrine disorders, neurodegenerative and psychiatric disorders, and sleep disorders.

Food forThought Goes West

I have done many articles on restaurants in Volusia County.All of these articles have been restaurants between the East Coast and DeLand as well as one in De Leon Springs. Recently I discovered a fantastic Italian restaurant in the town of DeBary. Aldo Yos Cucina Italiana. Entering the parking lot of this fine establishment, One comes across a small stand alone building with its name across the top. Nothing fancy from the outside but upon entering the restaurant the transformation begins. Just as in seen in the movie the Wizard of Oz, black and white is now transformed into color and fine dining is set upon us. Linen covered tables with fine silverware are seen.The tantalizing scent of fresh hot bread in the oven met us as we were led to our table. Bella and Lexi were our Hostess and servers for the evening.

As soon as we were seated and started perusing the menu the delicious hot bread was presented to our table with fine olive oil laden with spices just waiting to be soaked up by the bread.The appetizer we selected was Gamberi E Calamai con Olive E Pomodorini Picante which in English was a combination of sauteed shrimp and calamari in a fresh spicy kalamata cherry tomato sauce.To go along with this delectable appetizer I chose their house Chianti Classico which paired perfectly.

Next came the Secondi Piatti (second course).All of these were served with choice of spaghetti or vegetable of the day.All of their pasta is homemade.Thus I chose spaghetti with their homemade marinara. For my main course I chose vealAllah parmigiana.The veal was extraordinarily soft and could be cut with a fork.The marinara sauce that came with it along with the melted cheese on top was phenomenal, just writing about it makes my mouth water. Lisa chose the fish of the day (trout) encrusted in almond with a berre blanc sauce that was superbly succulent.

We were too full by this time to even think about dessert. Bella and Lexi told us that they do have a phenomenal tiramisu and homemade cannolis.They also have gelati.At this point in time chefAldo introduced himself at our table and proceeded to tell us the tale of how he started preparing meals when he was seven years old.This led him to become a chef in Naples, Italy and eventually led him to emigrating to Florida where he opened his restaurant. He has done a phenomenal job and Lisa and I know we will become frequent customers of his in the future.Aldo yos is located at 94 S Charles Richard Beall Blvd. in DeBary FL.They are openTuesday through Sunday and closed on Monday.They have a nice extensive wine list. Reservations are accepted at (386) 742-7379.They also serve lunch and have homemade pizzas during the week as well as tapas. Some examples of the tapas they serve are shrimp in garlic with white wine sauce, SpanishTripe Stew with chickpeas and chorizo, stuted red bell Peppers with goat cheese, and smoked prosciutto with parmesan cheese. Prices are very reasonable My veal parmesan cost $11.48 and Lisa’s extraordinary fish was $15.42. My glass of wine was $5.83.

I rate this restaurant the following:

Quality of food: 5 stethoscopes

Ambiance: 4 stethoscopes

Value: 5 stethoscopes

Service: 5 stethoscopes

PO Box 9595

Daytona Beach, FL 32120

Are you a physician in Volusia County seeking to explore the benefits of joining a medical society?

Membership Benefits:

● Physician referral service

● Online directory

● Legislative updates and voice

● 24/7 access to an on-call healthcare attorney

● Exclusive webinars and CME courses

● Access to free confidential mental health sessions

● Annual Daytona State College scholarship partnership

● The Stethoscope Journal, a member driven magazine with member articles

● Access to community banking, investing and insurance companies

● A monthly digital newsletter posting current articles, legislative news, and VCMS events

● Job postings and referral services

● Social networking events, outings and more

VCMS memberships are also available to medical students and residents seeking to become involved! New or Returning Members – talk, type, or text for a membership application or visit us online www.vcms.org / vcmedsociety@gmail.com / (386) 255-3321