Wisdom comes from a multitude of teachers, and not always from expected sources

Looking back at the people who taught me throughout residency, a multitude of nurses, residents, faculty, ward clerks, and various techs all taught valuable lessons. I’m not forgetting how integral patients were to my education, but I’ll save them for a future blog.

My very first code was as the medicine intern on night call. When the code pager went off, I ran a short distance to the MICU and entered a room as the only physician.  The nurses looked at me and gave me a quick rundown—a 65-year-old septic patient, now unconscious with unmeasurable blood pressure. Adrenaline flooded my brain; a myriad of code medications and doses swirled in my head; and, instead of fight or flight, I was about to freeze.  I locked eyes with an experienced ICU nurse who said, “Doctor, what can you do quickly to help the blood pressure,” as she then looked down to the pedal on the bed and back at me.  I said, “Trendelenburg?” as she was already changing the position. “Yes. Good. What else?” as she pulled the IV pole over. “Give a bolus of normal saline.” It was just enough to calm my nerves and help me think logically, and I was able to start down the memorized ACLS algorithms. It seemed like an hour but was likely closer to 3 minutes before my medicine senior and the senior resident covering the ER arrived. The patient lived. That nurse would have done all the right things had I been delayed in arriving. She didn’t have to walk me through step by step patiently, but I’m so grateful she did. Those first steps became natural after that. (PS The other big lesson here – respect the nursing team.)

I had a fabulous senior medicine resident.  We were getting slammed one call night and admitted a very sick patient with hypercalcemia.  Rather than just take charge or expect me to figure it out on my own, he sat down with his Washington Manual and put it in front of us.  He calmly turned to the section on hypercalcemia. We made sure we had ordered all the necessary tests, reviewed what had been done in the ER, and compared it to how we would move forward treating our patient who had multiple issues.  We reviewed each diagnostic section, and it all came together. I then had a framework for working up and treating hypercalcemia and the process of treating new diagnoses.  Sit calmly, read meticulously and compare it to the case in front of you, unless it's dire enough to call for immediate help. That lesson stuck.

My introduction to Pharm D’s came from a brilliant woman with great clinical insight.  She modeled during rounds reviewing the MAR in detail, especially when a patient had an unexpected new symptom or finding. She taught us about practical important things such as liquid Dilantin needed to be shaken prior to nursing drawing up the dose. We loved that she taught us in real-time to listen critically to pharmaceutical reps and to view their graphs with full understanding. She was kind to them but often pointed out how their graph or statement was misleading. In fact, she made us sign a document when we graduated to 1. Never rely on a drug rep to learn about a new medication, and 2. wait at least a year after a new med is released before prescribing it. (Most meds that have to be removed from the market due to adverse consequences are identified in the first year). That advice has served me very well. 

Our core family medicine attendings were pretty amazing as well.  Some excelled in teaching behavioral health, others in gynecology and obstetrics, some in procedures, others in sports medicine, some in pediatrics, and others in internal medicine.  However, all were generalists that knew how to be comfortable with anything that came in and knew how to treat, find best treatment options, or who to refer to and how fast. They also understood the importance of continuity, the relationships with the patients, advocacy, and care coordination – the things they modeled every day. This reinforced that I had chosen the right specialty.

There was one attending that we loved to chat with when we had time, but we really dreaded the days he was the preceptor in clinic.  He slowed us down. His messages seemed random and painful to the hurried learner. His approach contrasted what I desired from preceptors in clinic-- fast pearls of clinical medicine or sometimes just their signature. What I now know is clinical pearls change as medicine evolves; they aren’t lasting.  

I was most resistant to the enduring lessons – the ones taught by Dr. Henry “Moon” Mullins.  “Dr. Mullins,” I recall saying one time as he was precepting, “She’s here for recurrent sinus pressure, and I’m going to give her a refill on her Entex LA.” Most other attendings would have noticed I wasn’t sitting down and was in a hurry and let me move on. But not Moon. He wanted me to tell him everything I knew about the medication. “It’s a decongestant,” I said. He responded, “Well, how long does it last? Does it have anything else in it?” I answered by mustering up patience and giving my quick full defense, “It’s what she’s used for years, she can’t breathe without it, and no, she doesn’t have heart problems or high blood pressure.”  He said, “Well, let’s just look,” as he reached for the gigantic PDR. I’m fairly sure I sighed out loud.  My window for catching up in clinic on this easy patient was closing. “Hmmm, this is interesting,” he mused. “It has phenylephrine and guaifenesin. Also, it says phenylephrine may lead to tachyphylaxis and rebound congestion.” After listening to him rattle off some other important things I didn’t know, I got his point. I needed to know more about any medication I prescribed, even a chronic medication familiar to the patient. 

The most painful precepting moment is still very vivid in my memory. It involved a younger woman with benign chest pain. He said, “Why is she here?” I had just told him of the chest pain. I wondered - did he not hear me? I mean, he was a bit older.  So, I repeated a bit louder, “I said she’s here for chest pain.”  He replied, “Yes, but why? Why now? What’s she worried about?” I impatiently retorted, “She’s worried about having chest pain!”  He said, “Tell you what, go ask her why she came in and why now?” So, I reluctantly did. It turned out that her uncle had just traumatically died in front of her the week before with a massive heart attack. Dr. Mullins’ point, again, well taken. This uncomplicated ‘easy’ chest pain symptom was a tad bit more complicated than I realized. It involved emotional trauma, anxiety, and bereavement, the need for reassurance and possible counseling, education on cardiac symptoms, and how to maximize her health for the long-term. If we don’t get to the root of why the patient has come in, it doesn’t matter how good a job we think we’ve done. Thanks, Moon!

So, I guess I would summarize in this way.  Be curious and open to being taught by all the healthcare team. Some of the most important lessons come when you take the time to slow down. Also, intangible lessons often stand the test of time.

Have a joy-filled day!   Tonya

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