An End, a Beginning, and Some Thanks

My last post. I wish I had something sage to say, but I don't. It's amazing to me that it was only five years ago that this all began. As I say every year, I still remember exactly where I was when I got the news. I was so happy, taller even. A dream realized, and now, I'm only months away from the actual diploma. It has gone by so fast (though some parts faster than others).

So this is the end. In truth, it is also a beginning. This blog was the start of something special for me personally. Perhaps 95% of what I wrote here was garbage, but I think there was something good in the other 5%. Some posts were the skeletons for eventual journal publications, two were the outlines for research projects that I currently coordinate, and many were important for my own self-development. It is also the impetus for my next writing project, Resident Murmurs, which will give my writing new meaning in the medical community.

Numerous people have asked me if I was ever worried I would publish something wrong or naive, something that would hurt my career. As I look back on past posts, there was a ton of stuff that was wrong, and a lot of posts that were naive. But that's growing up. That's why I write -- to look back and do better, teach better, and learn better for next time. I have no regrets; it has been a wonderful process.

There are a few people I should thank. Above all, my mother, Kathy Swendiman, who is a saint. She read and revised every single post (all 235!) that I wrote. Every misspelling, every made up word (of which there were many, she likes to remind me). This blog would not exist without her. I used to joke that writing was a way of keeping my parents "posted" as I went through medical school, ensuring that they wouldn't call so much. Truth is, I called them anyway, and they put up with my inane drivel for five (going on 28) years.

This blog was actually inspired by my sister, Shelley. While she was in Ukraine for two years plus, she wrote regularly in her Peace Corps service blog. For better or for worse, thank you Shelley for reminding me the power of story-telling and reflection. You ignited the fire, i.e. this is your fault, per usual.

Finally, thank you to anyone who actually read this crap. I just hope you got something out of it -- insight into the musings of an aspiring doctor, an occasional giggle, or thinking differently about something, I just hope it was worth it. Thank you.

And with that, I retire from the Blogosphere. Starting March 21st I move on, writing with some of my colleagues at Resident Murmurs (www.residentmurmurs.org). I hope you continue to follow us on our journey through medical training. See you never.


Writing is a form of therapy; sometimes I wonder how all those who do not write, compose, or paint can manage to escape the madness, melancholia, the panic, and fear which is inherent in a human situation. - Graham Greene

See You In Court

Kathy Swendiman is a legislative attorney at the Congressional Research Service of the Library of Congress. The views expressed herein are those of the author and are not presented as those of the Congressional Research Service or the Library of Congress. Kathy is also my Mom, and has edited this blog for the past five years. She is wonderful :).

The Affordable Care Act, also known as "ACA" or "Obamacare," is so divisive it recently provoked a federal government shutdown. It is also the subject of over 100 lawsuits. I will leave the policy debates to my son and his wonky friends, but it might be useful to look at why this statute, in particular, is the subject of so much litigation.

While the Supreme Court’s 2012 decision in NFIB v. Sebelius upheld most of ACA, closing the 30 or so cases that had been filed up to that point, there are now more than 70 ongoing legal challenges involving that statute.

Why so much litigation? To quote a famous poet, let me count the ways...

First of all, health care represents one-sixth of the domestic economy. Reform efforts in this sector are going to create winners and losers. Affected groups will naturally seek to protect their gains and reduce losses, often through litigation.

Health care reform necessarily implicates issues of ethical, moral or religious concern for many persons. Should there be a right to health care? If so, how much? And who will pay for it? Is it ethical for the government to pay for medical care for some, but not all? Who decides? Indeed, forty years after Roe v. Wade, our country still remains deeply divided on the issue of abortion; many have moral concerns about the appropriateness of modern reproductive health technologies.

To the extent the provisions of ACA allow federal agencies to decide what medical care can or must be covered by insurance plans, significant conflict will ensue. How much money is involved may be less important than the government's role in making controversial health care decisions. Such has certainly been the case for the Administration’s decision to require contraception coverage in most health insurance plans.

The law continues to be unpopular with a significant portion of the public, and ideological objections and congressional repeal efforts continue unabated.

The Affordable Care Act is also vulnerable to legal challenges due to the complex, unusual circumstances surrounding its passage, which precluded last-minute efforts to amend the unwieldy bill. Every major statute, including Social Security and Medicare, was amended after initial passage, often including both significant structural changes and routine "technical amendments." However, opposing political party majorities in the House and Senate, and the lack of bipartisan support for the original bill have contributed to a conspicuous absence of post-enactment legislative fixes.

It has fallen to the Obama administration to make numerous tweaks and adjustments as it has implemented ACA. Many agency regulations, and some unusually broad exercises of executive discretion -- such as the President’s most recent declaration that insurance companies can allow customers to keep their insurance plans even if they do not meet the law’s requirements -- have ended up in court.

Do I think there will be another High Court showdown for this statute? Possibly. The Affordable Care Act may have survived a first strike, but NFIB v. Sebelius hardly ended the contentious debate over the statute. Some argue that the Supreme Court’s ruling was only the end of the beginning.

So far, this seems to be the case.

Forward

There is something different about a dead body. I usually relish the opportunity to cut -- as a budding surgeon, it is often a chance to cure, to heal, to save. Disturbing a lifeless body, though, even in the name of Science, evokes an uneasiness, a violation of the human form. I feel comfortable operating on the living; the dead is Someone else's realm.

This "violation" is not wrong, though I do wonder if it is right. Just as the hopeless coding patient enters a gray-zone -- not dead, but not quite alive either -- just as the medical team shocks, compresses, and forces air into her lungs, I wonder if we as clinicians too often cross this line. We push past the cancer and the fatigued heart, denying humanity's limits without pause or reflection. We push past the wishes of the patient and their family. For Science and Medicine, we move in one direction: forward.

In an autopsy, we disregard death entirely. Laying in front of me now was (is?) a person. Over the next hour or so, she will become unrecognizable, literal pieces of her former self. Her heart, brain, gut, lungs will all be weighed, measured, sliced, and cut into pieces to be examined grossly and under the microscope. The skin over her face will be peeled back; only her legs and arms will be left intact. A human being in jars of formaldehyde. What is left is splayed on a cold, metallic table. The soul already gone.

She happens to be a 280 lbs., 31-year-old female, approximately 5'6'' with no external deformities or obvious causes of death. Without pause, the cutting begins. There is no moment to consider her as who she is and was, nor a "timeout" as typical in the operating room. Unlike in surgery, there is room for error. She is already dead. We waltz across the line... forward.

I flash back to my first clinical experience with death. A woman similar to the lady in front of me, found on the floor of her bedroom by her 10-year-old son. The firefighters had already begun CPR when the paramedics and I arrived. Though I was a new EMT, I knew she was gone. We tried to sustain her life all the way to the trauma bay at the local hospital, to no avail. I watched quietly as the attending physician directed each of the residents to practice intubating her. When they were through with her, she was pronounced dead.

The woman in front of me overdosed on pain-killers, fully depressing her respiratory drive to the point of asphyxiation. Apparently this is a relatively common cause of death in the medical examiner (ME) domain. I watched. In less than an hour, the ME and nurses fully dissected the body. A kitchen knife was used to cut a "Y" shaped incision across her chest. The heart, lungs, and gut were removed, washed, examined, weighed, cut, palpated, placed in formaldehyde, and sent off to the pathology lab. The liver was chopped like a piece of meat. The heart was excised in sections to evaluate the patency of coronary and major vessels. Even the tongue and oral cavity were removed to look for obvious signs of choking and bruising.

In a typical medical case, one pauses to listen to the patient's story -- their history. The vast majority of diagnoses can be made from the history alone. I wonder what she would have told me. Was she depressed or angry? Who had hurt her? Was this her first and only attempt? Had no one heard her call for help? Did she have children? A partner? Who found her? I hope it was not a child.

This autopsy, however, is not a typical medical case. We investigate without the opportunity to ask questions. Forward. The ME splays open a dead body to discover the cause of death. In some cases, the diagnosis is simple and straightforward. In others, there is no answer. Either way, Science dissects the human form until it is unrecognizable, pronouncing final judgment -- Medicine's final word.

But this is training. No pause, no time for reflection. Patients await, and I must keep pace.

"Talk To Me"

(this is a piece that I've submitted for publication; I will post a link here if it is published, or the full version if it is declined)

Interviews Schedule

The headache is (almost) gone, likely because my interviews are (almost) completely set. The uncertainty was the most not-fun part. You submit all your information into many different parts of a single website, and you just hope that it all comes together correctly. You hope that the administrative team at your medical school uploaded your picture without drawing a mustache on your face (can't blame them if they did), and you hope that your letter-writers didn't discuss the time you called them "ma'am" instead of "sir" (repeatedly). If the interviews start rolling in, then at least one of these things didn't happen. Then, you are baked til golden.

The interviews are the fun part. Most interviews consist of an evening gathering the night before with the residents, followed by a full day of interviews starting the next morning. Based on most of the schedules, it looks like there is usually a Grand Rounds, a tour, some presentations, and some interviews. Though some places have a reputation for being intense (asking medical/ethical questions until you are thoroughly embarrassed by your lack of knowledge), most of my friends have had relatively chill interviews. Just people trying to get to know other people. The interview goes both ways too -- you are trying to show your stuff, but at the same time, they are trying to sell you on their program. Both parties are looking for the right fit.

While I am still waiting on a couple more to roll in, my interview schedule is fairly set. Organizing my flights and planning when and where I must be was more harrowing than I thought. Some places that I would have loved to interview just wouldn't fit in my schedule. I would've had to cancel two (or sometimes three) of my other interviews just to get there. Geographically, I applied all over the map, so logistics were a little bit of a bear. But anywho, this is likely the final line-up, listed in chronological order. My first stop will be Atlanta in mid-November, ending up in Philadelphia in mid-January! Ten interviews over two months. I am excited for all of them.

• Emory University (Atlanta, Georgia)
• Oregon Health & Science University (Portland, Oregon)
• University of California - San Francisco (San Francisco, California)
• Stanford University (Palo Alto, California)
• Washington University - St. Louis (St. Louis, Missouri)
• Northwestern University (Chicago, Illinois)
• University of Chicago (Chicago, Illinois)
• Vanderbilt University (Nasheville, Tennessee)
• University of California - Los Angeles (Los Angeles, California)
• University of Pennsylvania (Philadelphia, Pennsylvania)

Next comes the interview prep. Gotta be ready for the standard questions (Why surgery? Why here? What's that in your teeth?), and you have to have questions ready of your own. Each program has a website full of information about their clinical experience, research, and philosophy, and some have mailed/emailed additional information to peruse. Lots of prep, lots of prep.

But this is indeed the fun part. After January 18th, it's two months of the not-fun part again...

The Waiting.

Announcing @ResidentMurmurs!

For the three people (and my Mom) who actually read these posts, I want to go ahead and announce that I will be officially retiring The Language of Medicine after its five year anniversary at the end of December. Five years is a nice round number, and it is time to move on to bigger and better things.

Instead, I will begin contributing to Resident Murmurs (www.residentmurmurs.org), an online forum that is halfway between personal blog and academic journal. This is a joint venture comprised of three of my closest friends and me, all of us soon-to-be physicians. As we write in our mission statement, "We are four physicians committed to the core principles of integrity, compassion, empathy, humility, respect, and delivery of holistic care. Resident Murmurs is a forum in which we explore and promote humanism in medicine through thoughtful reflection, based on patient and provider experiences with health, illness, life, and death." Through narrative, we seek to acknowledge and advance the powerful role of human experience in healing.

You can sign up for our mailing list on our website, and don't forget to follow us on Twitter (@ResidentMurmurs). The full site will launch in mid-February, with content beginning on March 21, 2014 (aka "Match Day").

Seed money was provided by the Center for Public Leadership (CPL) at the Harvard Kennedy School. You can find our first press release here on their website.

My peeps... I met Sophia McKinley and Eric Seymour last year, as they were both Zuckerman Fellows at CPL. Dinushika Mohottige you actually already know (she is one of my closest friends and I profiled her here on this blog years ago!). Sophia, Eric, and I are all applying now to residency, while Dinushika is an Internal Medicine intern at Duke. Future Dr. McKinley and I are applying in General Surgery; Eric will be a Pediatrician. The four of us have very different backgrounds and writing styles, which will make the next few years the absolute funnest.

The four of us will initially start with weekly content, slowly building our web and social media presence. We eventually hope to partner with other organizations and institutions as we move #humanisminmedicine forward. To help do this, we will start accepting submissions from patients and providers alike within the first year. We hope to hear from all of you! More on that to come.

On that note, "we invite you to join us in building this special space where medicine, writing, and humanism can intertwine to provide reflective pause, combat the corroding effects of training, and promote more caring in medicine."

www.residentmurmurs.org

The Headache Relieved

So I told you that I've had a headache. It's from the stress. On days that I'm busy, the headache goes away. But most days I'm on my computer... for hours and hours and hours. In class. Doing research. Always on the computer. I watch that little Gmail tab, waiting... And waiting. And waiting.

Yesterday, though, my headache was relieved. For good. In the same way that I felt about three inches taller when I got my first acceptance to medical school, everything was right with the world. I got one of the "big ones." Not necessarily my number one (because there really isn't a "#1" until you've interviewed at all the schools ), but it could be. I received an invitation to interview at a program that makes me feel like everything is going to be okay. One these programs where I say, "Hey, if they'll interview me, anyone will." So now my headache is gone. And then a few more rolled in. They have generally been trickling in at about a rate of one every other day.

Usually, the more I stare at my computer, the less likely one of these "noreply" emails is likely to show up. But right in the middle of my Writing class, I clicked on the "Inbox (1) - rswendim..." tab in Google Chrome, and there she was. Beautiful. Wondrous. Headache-relieving. In my head I did a little dance (a solid C-walk, or the "Not My Baby" dance), and I may or may not have swore out loud (though not loud enough for the professor to hear, fortunately). I worded the acceptance email so so so carefully, making sure the spelling was just perfect.

I have to be care, because in my excitement, I've already make a couple mistakes on the salutations. As embarrassing as it is to say, I've incorrectly addressed one program coordinator as "Mr." instead of "Ms.", and for an invite I received recently, I put "Dr." because I could not figure out who I was replying to (it was at night, I only had my cheap Windows phone, and the Google search function was being ornery). No bueno.

As you can see, I'm barely keeping it together. Each day is an emotional roller coaster.

Over the next few weeks I will finalize my list. Each specialty has the golden match statistics - ideal number of programs to apply to and interview with to match (on average - obviously it is different per person). For General Surgery, the target number is somewhere around 22 programs and 11 interviews. I applied to 26 residencies, and I think I want to interview at about 10 places total. My programs are very spread out across the country, so there will be a lot of flying. Ten's a good number; I like ten. I like ten. And I've started repeating things (repeating things).

Okay, no more stress posts. Next stop, the interview trail!

The Headache Builds

Being in back in class this semester is both a blessing and a curse. My classes are wonderful. I am taking one called Public Narrative: Story of Self, Us, and Now which teaches a leadership framework for drawing others to a cause. It's basically a class on how to tell a good story. The second is a writing course, where I am (re)learning the basics of writing, revising, and editing. In addition, I have the chance to pursue my own freelance writing, and start finishing up some research projects early (though the chance that these will finish before the spring is slim to none).

The downside is that I am on my computer 24/7.

I first started getting headaches only towards at the end of the day. Originally I thought it was due to staring at a large white screen for so much of the day. But the dull pain has started earlier and earlier. Today I realized that it is more likely due to the stress of interviews, i.e. the stress of not getting more interviews, though I'm sure being on the computer for eight hours a day only compounds the problem.

I figured that after October 1st, I would start hearing from program after program, either with invitations or rejections. However, all I hear from my inbox is crickets these days. Those first few invites have ruined me. Such a tease. Being in class and on my computer all day, the minutes now tick by so slowly. Each time I see a new email come to my inbox, the tab says...

"Inbox (1) - rswendiman@gma..."

I immediately rush to check to see if it's from a residency program, but it never is. It's just another Priceline.com email again. I get about 100 emails a day at this point, and each of them is a huge letdown.

One of my classmates told me that some interviews won't go out until beginning of November. I think my head is going to explode.

SO WHAT IF I'M CRAZY!?!? SO ARE YOU!

I'm also leaving my phone on at night so I wake up to new emails. Generally, I'm so tired by the end of the day that I wouldn't pop up to a fire alarm, but some nights I do wake up to that damn ding-a-ling sound. Lately, I've been waking up at 2:33am. That's when the Kennedy School sends out their daily announcement email for the day. Thanks, HKS.

The weird thing is, I won't be like this for the actual interviews. I enjoy them. It's the part that I can't control that I hate.

This will all be better in a month.

Or maybe not.

AHHHHH!!

Clicking "Submit"

So it's actually been two weeks since I first clicked "submit" on my ERAS application, and it is such a wonderful feeling. Fortunately, the initial application process wasn't too harrowing. I finished my personal statement early, had no trouble getting all four letters of recommendation in on-time (corralling attendings can be like herding cats), and applied to 26 programs without breaking the bank. It was actually cheaper than applying to medical school. So overall the application process has not been too stressful.

Yet.

In these first two weeks, I have heard back from five General Surgery programs (halfway to my golden number of 10 interviews!). I am told that most programs wait until after the Dean's Letter is sent out on October 1st before making any decisions. So starting next week, I will be on my computer constantly. I have heard horror stories of classmates who were away from their phones/computers for just a couple of hours, and they 1) didn't get the interview day they wanted, or 2) didn't get an interview scheduled at all. Some programs apparently send out more invitations than they actually have spots, and if you snooze, you lose. One internal medicine program sent out invites at three in the morning. When my friend woke up at 7am, she was too late.

I can feel the headache building.

Being ready to reply to these "invitations" is a process in itself. Per suggestions from former applicants, I have multiple copies of "acceptance" emails in my Gmail Drafts box. When an invite comes in, I copy and paste in the following:

____________, 

Thank you very much for the invitation. I was hoping to interview on ____________ if that date is still available. If not, my second choice would be ____________. My specific areas of interest are Pediatric, General, and Rural Surgery. Please let me know if you need any further information from me. 

Thank you again for the invitation, and I very much look forward to interviewing at ____________! 

Best,
Robert Swendiman

I insert the name of the residency coordinator, first and second choices for dates, and school name. Goal time from invitation to acceptance? Five minutes. And this is only half of the craziness.

The other half comes from the MASTER LIST. This is a list of the 26 programs I've applied to, complete with their prospective interview dates. Most schools have posted these online, so I have created an ideal, virtual schedule that would allow me to visit all of my top choices. But there are some mystery programs, and for them I just have to bite my nails. (By the way, I am not the only one who is the this nuts; this is fairly par for the course among the people I know). So if an invitation comes in, I must consult the MASTER LIST first, and then try to get my number one choice of dates. So far I'm 5/5, though one program didn't give me any choices...

What a mess. October 1 is next week and I'm already a nervous wreck. Let the craziness continue...

My Favorite Story

I have one story from my clinical years that I have yet to tell. I must keep some of the details a bit vague (you will see why), but I don't think that takes away from the (ummmmm, explicit?) content.

The tale goes like this...

Once upon a time, I was seeing a seven-year-old boy (we'll call him "Patrick") in one of the specialty pediatrics clinics. He was adorable. Like any normal boy of this age, Patrick was already bouncing off the walls when I walked in the exam room. I let him wear himself out while I sat and took a history from Mom. Patrick had been complaining of headaches, though he certainly was feeling well at the moment. After finishing up some standard questions regarding his birth and past medical history, Patrick finally decided to insert himself into the conversation.

Mommy, can I play on your phone?

Ahh, times have changed. Kids are now born iPad-in-hand. I am unsure how I was able to entertain myself as a kid.

Mom let Patrick play on her phone while I resumed my questioning. Patrick was successfully entertained for perhaps only a half a minute before returning to the adults. He held the "toy" in his outstretched arm, holding the large smartphone screen just a few inches from my face.

Hey! This is a picture of my Dad's car!

It was indeed. Pops apparently was something of a car connoisseur, and though I didn't recognize the make and model, it looked like a restored antique. I smiled at Patrick and affirmed his statement that it was his Dad's car (such a smart kid!). Patrick looked back at the phone and swiped the screen to the right.

This is my Dad's other car!

Again, a true statement. I smiled and told him that it was a very cool looking car. Before I could return my attention to Mom, Patrick again swiped the screen to the right, paused, and a very confused look spread across his face.

I don't know what this is...

Patrick pushed the phone six inches in front of my eyeballs. I wish I could have been a fly on the wall, watching my own reaction. There are few times in my life when I've been left truly speechless, and this was one of them. I felt my face flush.

I was staring at a picture of (someone who I could only assume was) his mother, waist down, naked, and spread eagle on a couch.

A moment of shock and panic. I do remember taking the phone away from Patrick, clicking the "Home" button, and handing the phone back to Mom. Why don't we let your mother hold onto this for now? That didn't last long. He grabbed it out of his mother's hands, sat down on the floor, and went back to perusing photos.

Right on cue, Dad walked into the exam room.

Also right on cue, Patrick showed me another picture that he wasn't quite sure about...

This time I grabbed the phone (again, quickly pressing the home key), and handed it back to Mom. You should really hold on to this. I made the statement as emphatically as I could. I skipped the rest of my questions and went right in for the physical exam. Anything to keep the little guy occupied.

It was a cursory exam.

After I was done, I went straight to my attending's office to discuss what had gone down (a little advice at this point would be nice). I explained the entire situation, but s/he didn't seem to be too concerned. I was told not to worry about it, and we completed the encounter like nothing happened.

Is this a frequent occurrence or something? Ah, another naked parent. Don't worry about it, Robert. It happens all the time.

Fortunately, in my (very short) career as a budding clinician, this is the only time I have been exposed to nude photos of relatives of my patients, and I hope it is my last. This story should illustrate two important points:

       1) Don't take naked pictures of yourself unless you want other people to see them.

       2) Parents, password protect your damn phones!!

Thank goodness Patrick wasn't a wee bit older... now only one of us is scarred for life.

Why Harvard's Not Exactly My Thing

The first -- and last -- patient I told that I was going to Harvard was a man with an abscess on his left buttock. At the time, I was a fourth year medical student, working in a general surgery clinic in Linville (pronounced "Lin-vole"), North Carolina.

Dr. Tate was teaching me how to perform an incision and drainage, a routine office procedure. After we finished, the patient asked me what type of medicine I wanted to practice. I told him, "I'm going to be a general surgeon like Dr. Tate, but I'm taking a year off first."

"Oh yeah? What are you going to do?" he inquired.

"I'm going to study public policy at Harvard," I replied, perhaps a little too eagerly.

The man lay quietly on the exam table while I applied his gauze dressing. After Dr. Tate left the room to write a prescription for antibiotics, he stood up and offered a prescription of his own.

"Son, do you know what you get when you take a son-of-a-bitch and you educate him?"

"No, sir," I replied.

He smiled, "You get an educated son-of-a-bitch." He shook my hand, and limped out of the exam room.

As I begin interviewing for residency programs, I know the Harvard name often opens doors. However, I cannot forget that it also does not carry the same weight in all circles.

There is a "We-Know-Best" philosophy that is often perceived to come with the Ivy League pedigree. Doctors are especially prone to this kind of paternalism. Of course we know better, with our years of schooling and postgraduate training. Just do as I say and don't ask questions! It is an attitude that is often counterproductive to patient care and never human-centered.

Though I try to be mindful, even as a medical student, I am certainly guilty myself. I must always be conscious of the language I use in and out of the clinic.

Unfortunately, this elitist attitude permeates our classroom language here at Harvard.

After returning from a summer working in several rural clinics in North Carolina, it has been particularly noticeable. The tone of some off-hand comments demonstrated the stark contrast between working in a family medicine practice in Mars Hill, NC and here. In my first full day back at the Kennedy School, it was mentioned that the individuals who get made fools of on The Daily Show and Colbert Report interviews must be from "some podunk town."

Clearly, the urban and educated would never fall for such silly traps.

Later, after reading an op-ed discussing the erosion of American culture, just two weeks after Miley "twerked" it all over the VMAs, a classmate questioned the timeliness of the piece: "Certainly any reasonable person has already forgotten about this by now."

Well, we know best.

Perhaps I am "podunk" and "unreasonable," but I would not last a minute under the Stephen Colbert spotlight, and I am sorry, but I still find the Miley-saga entertaining.

A world-renowned professor in leadership at the Kennedy School tells the following story. There was a small African village where the women had to walk a great distance every morning to get water for their families. Seeing this time-consuming endeavor as an impediment to social and economic progress, an NGO decided to help the women by building a well immediately outside the village. Later, officials from the NGO returned to the village to witness how they had improved the women's lives. To their surprise, they watched the women walk right past the well, traversing the same great distance as before.

The women did not want a well. Their morning pilgrimage was an important part of their social life and culture. No one had actually asked them what they wanted. The volunteers just assumed they knew what was best for them.

So as we start a new school year, let us remember that we do not necessarily know best. We do not know best because we live in the Ivy Tower. We do not know best because we think Miley is old news. We will not know what is best unless we ask.

Let our language reflect our humility. And if we don't, then each of us is just an educated son-of-a-bitch.

Theory of Change

Doctors are taught a biomedical perspective on how to treat human disease. With the right medicines or cutting-edge procedures, physicians may alleviate a patient’s physical suffering. But this physiologically based view which is emphasized during the four years of medical school is incomplete. Medicine is much more complex. Every day it collides with politics and conflicts with our faith. It challenges us. It fails us. While treatments are often necessary, sometimes a touch or a few words are equally important.

Physicians are taught to cure, but as humans, they must also care.

Unfortunately, the mental, physical, and emotional rigor of medical training often deteriorates a medical student’s or resident physician’s compassion and desire to serve. Ethical erosion, burn-out, and loss of patient-centeredness are epidemic among medical trainees.

The four of us -- all physicians in training -- reject the inevitability of this loss of caring. Thus we have dedicated ourselves to fighting the erosion of core values through humanism inspired writing. Humanism in medicine “describes relationships between physicians and their patients that are respectful and compassionate. It is reflected in attitudes and behaviors that are sensitive to the values, autonomy, cultural and ethnic backgrounds of others.” Humanism is integrity, compassion, and empathy in every encounter, all of which align with the values and atmosphere that we aspire toward.

We write to witness, reflect and record the journey of becoming practicing physicians and to name and consequently accept or reject the cultural waters in which we swim. By intentionally exploring our own development through writing, we each hope to guard against the erosion of humanistic values that so commonly affects resident physicians. We want to invite and inspire others to share in this journey.

So with support from the Harvard Kennedy School’s Center for Public Leadership, we have created Resident Murmurs, where providers, students, and patients alike can reflect and share their stories with one another as a means to combat the loss of humanism in medicine both by identifying when it is lost and celebrating when it prevails. This online forum will lie at the intersection of academic journal and personal blog. Beginning with a weekly column in the first year, we aim to grow to accept submissions on a range of interdisciplinary topics such as individual patient care, the education of new physicians, health policy, and population health.

We invite you to join us in building this special space where medicine, writing, and humanism can intertwine to provide reflective pause, combat the corroding effects of training, and promote more caring in medicine.

A White Male of the Worst Kind

“So, why are you doing this?”

It’s the usual question, combined with a skeptical look. I’m researching perceived barriers to career advancement for female academic surgeons. I’m curious, I tell them. And why shouldn’t I be? I’m going to be an academic surgeon myself. Shouldn’t I better understand the system of which I’m a part?

The problem is I’m a white man – a white man of the worse kind: educated and privileged. I’m the establishment, the status quo.

We dominate academic surgery. Surgical leadership is depressingly homogeneous. One thing I’ve learned from my time at the Kennedy School is leveraging diversity is crucial to innovation and progress in business and public policy. So in what ways am I, a white, male surgeon, going to hold surgery back? It's cause for introspection, and a question I hope to answer.

If we are going to improve the system, we must understand it first. This starts with becoming aware of the dynamics within our systems. Ask yourself, "What does my own profession look like?" There is difference everywhere. But do we see it?

Jennifer Boylan examines this beautifully in her recent New York Times piece, One Classroom, Two Genders. Boylan has the unique experience of being a college professor as both a man and a woman. For the first 12 years of her career, she was a man; for the past 13 years, she has taught as a transgender woman. She notes how her students now perceive and interact with her differently. They ascribe traditional gender traits to her; she is “safe,” inviting, and able to share feelings.

Boylan begins her piece by discussing her favorite teacher in high school, an experience we all share. She wonders if her relationship with him might have been changed in a different gender dynamic. She comes to no conclusions, but asks us to think more critically about who we are in a system. She asks us to “see” difference.

So why do I do this? I just want to be more aware. Being curious is my small way of moving surgery forward.

Mission Statement

We are four physicians committed to the core principles of integrity, compassion, empathy, humility, respect, and the delivery of holistic care. ______ is a forum in which we hope to explore and promote humanism in medicine through thoughtful written reflections, based on patient and provider experiences with health, illness, life, and death. Medicine is complex and touches all of our lives, at one point or another. It challenges us. It cures us. It fails us. Yet through careful listening, self-reflection, and narrative, we strive to acknowledge and advance the powerful role of human experience in healing.

Deep Listening

(this was a piece that I wrote that was accepted to Academic Medicine; I will post a link here when it is published)

Madison County, NC

I literally could not understand the first patient I saw in clinic. His accent was so thick I had to use every ounce of active listening power to comprehend his statements and questions. At one point, I just laughed and nodded because he did. I have been hanging out in the city way too long. A year in Boston will do that to you. Even Chapel Hill (pretty close to the dead center of the map, pictured above) is too far away.

I began my final rotation in primary care last week. After this month, I will spend four months in class and on the interview trail, then finish my MD with four straight rotations: Radiology, Nephrology, Palliative Care, and Neuro Trauma ICU. It's a busy last few months of fourth year, but the goal is to not be an idiot when I start as an intern. This month, though, I want to firm up some of my primary care skills, taking care of patients with the usual array of chronic medical problems: high blood pressure, diabetes, congestive heart failure, depression, anxiety, etc.

While I have done some chronic disease management, I have actually spent most of my time as an urgent care / emergency medicine medical student. Many of my preceptor's patients use his clinic much like I would use urgent cares and EDs. On the average day, one or two patients will roll in with a deep laceration to the leg, hand, or face, and we will just sew them up right in the office. In fact, I've done more sewing in my first two weeks here in Mars Hill than I did during my entire Pediatric Surgery clerkship. I am also sharing time with a third year Family Medicine resident, so we will sew and do procedures while our preceptor works up patients. It's a good gig and super efficient.

Originally, I thought that doing two rural rotations as part of the Asheville Longitudinal Curriculum might be a burden. But these clerkships are turning out to be some of the best hands-on experience I'm getting as a medical student. I spent my first surgical acting internship in Linville, NC, where I truly felt like an intern. I had all the responsibilities that the interns at UNC had on Pediatric Surgery (except for the fact that I could not sign my own orders, which was probably a good thing). And here in Madison County, I'm in a similar boat. See one, do one, teach one.

After finishing up clinic on Wednesday, I flew to New York City for the weekend. My friends were appalled with my "southern accent." Apparently after two weeks here (and another two months in North Carolina), I was speaking reeeeeeaaal slooooow. And yes, I say "y'all" - something I promised my sister I would never do after she came back from Furman University in South Carolina saying it. In New York City, I'm just a country boy.

Funny. Because all my friends at Carolina call me a Yankee.

#whatshouldwecallfourthyear

HOW I FEEL AFTER FINISHING MY FOURTH YEAR SUB-INTERNSHIPS...

Roadhouse.

Drowning

(this was a piece that I wrote that was accepted to JAMA Pediatrics; I will post a link here when it is published)

Welcome to ERAS

So if you can't read the fine print here to the left, you should at least be able to appreciate that applying to residency programs is a little bit of a hot mess. The "match" itself is completely unnerving. Over the next few months I will apply to dozens of programs, hope to interview at about 10 to 12, and then "rank" these programs in order of my preference. Students all across the country will do the same, and then on March 21st, a computer will spit out where each of us will end up. I could match at my number one choice, my fifth, my last, or not at all.

Cray, right?

Alright, so here's how it all breaks down. The application itself is all through a single website (thank goodness), affectionately known as "ERAS." This is where you upload your CV, personal statement, and letters of recommendation. In addition, the medical schools will submit transcripts and their "Dean's Letter," which summarizes your schooling and explains the grading system. It also recommends the student as "outstanding," "excellent," "very good," "good," or some other modifier (there is no "bad" med student; that would hurt our feelings too much). Students are supposed to have everything ready by September 15th, and on that morning, we can click (and pay lots of money for) all the programs to which we want to apply. Residency programs can then begin downloading applications and sending out interviews.

On October 1st, our Dean's Letter is released to the schools. Apparently (and I'm not sure if I'm right about this), a lot of programs wait until October to send out invitations, once they've skimmed the Dean's Letter. Invitations go out, and students schedule interviews as fast as possible. This can be a bit of a cluster, because sometimes programs offer more invitations than actual spots (one of my close friends last year got an email from a program at 3am; she responded at 7am when she woke up, and all the spots were filled...). November, December, and January will be a great opportunity to accrue Delta SkyMiles.

Interviews are scheduled, and then we hit the "trail." Quickly, we start seeing a lot of familiar faces, as the same people keep popping up at all the same interviews. Other recruits are a great source of information, and many students bond on the trail (some even find true love, I hear, which is a little scary). After the trail, programs will have a "second-look" day for students who are interested. Before we know it, it's mid-February, and it's time to rank programs.

Skip to the Monday before the match. All applicants get an email letting them know if they have matched or not. If they've matched, it does not tell them where. This allows students who haven't matched to "scramble" into programs with empty spots. I don't know how this works, and I pray I don't have to find out. So that is all I will say about that.

On March 21st, we find out where we'll learn to become a real doctor. And it could be anywhere.

Everyone who's been through the process says, "Have fun! Enjoy it! It's just as much about you interviewing them as them interviewing you." Fiddlesticks. Actually, the interviewing could be fun; it's the scheduling that will drive me nuts. I don't want to be up at 3am every day to make sure I don't miss an opportunity at one of my top choices. And I don't want to spend all the money I'm going to have to spend. I just keep telling myself it will all be worth it...

I will update y'all on the process as it moves forward!

Surgery vs. Swimming

There is a flag in the surgical intern call-room, pictured left. This sentiment is oddly reminiscent of my swimming days (in fact, I think this is a direct quote from a number of my previous coaches...). Maybe this is why I am drawn to surgery; the similarities are abundant. Either that, or I am just a glutton for punishment. It's never made sense: I love to sleep 10 hours a night and I'm kinda lazy. Nevertheless, I keep choosing activities with horrible hours.

It has been a while since I've posted any countdowns or lists, so I bring to you the 7 reasons surgery and swimming are exactly the same. I encourage you to add to this list...

1. Four in the morning is considered an acceptable time to begin the day. Four is early, five is normal, and six is sleeping in. Three I just refuse to do. When I was in high school, I remember having to wake up at 4:11am to get to the pool exactly on time. Not a minute too early. I've never understood why we have to wake up so freaking early to get stuff done. In Surgery, it's because you have to start operating by 7:30 or 8am. Well, when I'm an attending, we'll start at ten! But getting home at midnight is as equally depressing as the pre-dawn wake-up.

2. Everyone falls asleep during class. If you're going to wake up at 4am or earlier, you aren't getting much sleep. One thing I like about surgery is it's go-go-go. Always moving, always working. But lectures and tutorials are sandwiched in between. The moment I sit down, my eyes start to droop. And I'm not the only one. Five minutes into a presentation, the interns' heads start to bob. The residents are pretty crafty though. In a big lecture hall, it can look like you are reading, but if you listen closely, you can hear a faint snore. The only difference between surgical lectures and college classes is I could straight up just skip the latter.

3. BEEEEEP, BEEEEEEP, BEEEEP!! Pagers beep, swimming clocks beep. They are both loud and annoying.

4. Everyone around you is just as crazy as you are. Swimmers are their own breed. I could walk onto any college campus right now and pick out who the swimmers are walking to class. Athletic gear, slightly slower pace, broad shoulders. The women have damp hair; the men have just bleached disgustingness going on. Med students are their own breed too, but surgeons are a cult. I shouldn't say too much, but spend enough time in the hospital and you'll know exactly what I mean.

5. You are always doing something incorrectly. I once talked to a sports psychologist who told me I was the quintessential trained rat in a maze. If you put a piece of cheese in the middle, I would run around the maze until I found it. Once I found the cheese, I would go back to that spot every time I was put in the maze. Even if there was no cheese, I would keep running to that spot, over and over again. So long as a piece of cheese was put in there once in a blue moon, I would keep running. She told me this is how I am with positive feedback and praise. I'll keep working for it. I'll bitch and moan when I don't have it, but I want that one piece of cheese, and I'll keep working for it, even if it's only thrown out every once in a while. This is the best way to get me to perform. All my best swim coaches understood this. This mentality is perfect for surgery. Most of the time you are meant to feel barely adequate, but every once in a while...

6. Everything is a competition. Whether its knot-tying or taco bell burritos, you want to be number one. Either the best surgeon, the fastest swimmer, or the burrito eating champion. And it's not just in the OR or the pool. Our annual swim team beer pong tournament at UNC was just as fierce as ACC Championships.

7. Nothing is more rewarding, but the grass is always greener on the other side. "I should've played tennis." I used to say that constantly (in fact, I still do). Swimming is like the worst sport ever. The hours are terrible, there's no career in it, chicks don't really dig it, and you completely lose out on a college experience.  But at its best, there's nothing better. Beating UVA is still one of the greatest experiences of my life. A number of surgeons have told me that if they could go back and do it all over again, they'd be radiologists or dermatologists. But then you see them when a life is on the line, and they love it. They love the rush. They would quit if they could, but they can't. Addiction.

To the Big House!

Rebekah likes to tell the story of our first day on Obstetrics and Gynecology (OB/GYN) as third year med students. There were three of us traveling up the elevator at Mission Hospitals: Rebekah, Blake Pemberton, and me. The ride up four flights from the parking garage was pin-drop silent. It was the first time she'd seen me with my mouth shut. She also says that I looked a new shade of pale, but I think that was just the lighting.

Truth be told, I was overly apprehensive. OB/GYN was the one rotation I was not looking forward to. It was my second clerkship, and though I was definitely nervous for Surgery six weeks prior, it was a different type of nervous. Everyone is nervy when they start third year. The comfort of the classroom is gone. Patients bite. Doctors bite. Nurses bite. Snakes bite. You realize you know nothing. For OB/GYN it was different. It was the kind of nervous I hope most 20-something males have when they realize that for the next six weeks they are going to be completely surrounded by female parts (in a clinical way). Lots of female parts, and they don't really know how they work...

Ma'am, I understand you are going through a lot of pain right now.
YOU DO NOT UNDERSTAND MY PAIN. YOU WILL NEVER HAVE A BABY AND YOU WILL NEVER MENSTRUATE!!!

This is how I imagined most conversations would go. Also I would have to not smile when people would say the words "penis" and "vagina" (I made it the entire six weeks without giggling by the way - Mom, I'm so grown up!).

Anywho, I tell you that story to help you understand how nervous I was for this Monday (and by "you" I mean future Robby who will change the story in his mind about how cool, calm, and collected I really was). Here, as a fourth year, I was starting perhaps my most important rotation in medical school, and I had never even been to UNC Hospitals, my home institution. I didn't know where anything was, didn't know if my badge would work, didn't know if I would be able to eat (i.e. where would I steal food from?!), etc. Pediatric Surgery will be my only UNC rotation on my transcript, and I also need to garner a letter of recommendation (LOR) from a surgical faculty member. The pressure was on.

So we met at 6am in the PICU on Monday, and my resident tells me to go print off a "list" (list of all the patients that are on our service). Zero clue how to do this. When I sit down at the computer, I realize I don't even know how to log-on to a generic UNC computer. I ask the nurse. Ohhhhh, so you are like "new-new." Here ya go, honey.

I am not a "honey." I'm just new-new.

The administrative mayhem this week went from bad to worse. Absolutely nothing worked. My badge didn't open any doors until I got a new OneCard, and spent 20 minutes on the phone with the hospital IT people. My parking badge was an epic fail, and I accumulated two parking tickets along the path to fixing that disaster. I couldn't view radiology images, and I couldn't find my way to the operating rooms. Oh, and there are two third year med students with me that know a heck of a lot more about the UNC computer system than I do. #FourthYearFailure

But the OR is the OR, no matter where you go. Clean, sterile, precise. The rules are the same everywhere. So, for the first case I scrubbed in on with the attending and chief resident, I was ready. It was a laparoscopic case, so I was able to operate the camera. I did not induce motion sickness in anyone. I held the trocars in place when they were inserting instruments. I knew when to turn the lights away. I knew how to scrub. And when the attending asked, I told him I was a fourth year going into General Surgery. He replied, "Oh, that makes sense. I thought you knew what you were doing in here..."

FOR THE WIN!!!

Unfortunately, I think that was my only victory of the week. There is a steep learning curve that I have to climb on this rotation, and as my resident says, "Our goal in Surgery is to make sure you always feel barely adequate." Excellent.

Migas!

Alright, so I wanted to keep the cooking posts down to a minimum, especially now that I'm back in medicine... but this recipe was too good to be true. It is fast, hot, and delicious. 20 minutes start to finish. From now on I promise to only post recipes that qualify as the-best-I've-ever-made. This recipe qualifies, and it certainly rivals the shrimp pad thai that this book (The Best 30-Minute Recipe) has to offer. Okay, now the dish: Migas is a combination of crushed tortillas, eggs, onions, garlic, and chiles. I think this is the Tex-Mex version (my masterpiece, pictured here). You will need:

• 8-10 large eggs
• Baked tortilla chips, broken into 1/2 inch pieces, about 1 cup
• 2 tablespoons unsalted butter
• 1 small red onion, minced
• 1 red bell pepper, cored and chopped fine
• 4 garlic cloves, minced
• 1 jalapeno chile, minced (I like to keep the seeds in there)
• 1 cup shredded pepper jack cheese
• Fresh cilantro, minced for garnish
• Hot sauce
• Salsa

Mix the eggs, chips, and 1/4 teaspoon salt with a pinch of black pepper in a bowl. Add a touch of hot sauce for an extra kick. Set aside. Melt butter in large skillet over medium-high heat, and add onion and bell pepper until softened (~3 minutes). Stir in garlic and jalapeno and cook until fragrant, about 30 seconds. Reduce heat to medium. Add egg mixture, and stir and fold eggs for 3 minutes. Off heat, gently fold in cheese. Season with salt and pepper; garnish with fresh cilantro. Serve with salsa and extra chips. Eat hot.

Easy squeezy. Try it and let me know what you think! Good for breakfast, brunch, or dinner.

The (New) Language of Medicine

Doctors are taught how to cure disease. With the right medicines or cutting-edge procedures, we can alleviate a patient’s suffering. But after four years of medical school, this view is obviously incomplete. Medicine is far too complex. Every day it collides with politics; it conflicts with our faith; it challenges us; it fails us. While treatments are often necessary, sometimes a touch, a hand, or a few words are equally important.

We are taught to cure, but as humans, we must also care.

As Fellows at Center for Public Leadership (CPL), Sophia McKinley, Eric Seymour, and I have been inspired to drive social change in medicine. As doctors-in-training who recently pursued Master's Degrees at Harvard University, we each sought to better understand how our social environment affects the practice of medicine -- how to better "care." Through study, practice, and leadership development as Zuckerman and Dubin Fellows, we nurtured our passion for improving medicine at intersection of education, community health, politics, and business.

Medical training is rigorous and mentally, physically, and emotionally demanding. Though initially drawn to this field out of compassion and desire to serve, many medical students and resident physicians suffer from ethical erosion, burn-out, and loss of patient-centeredness. Thus, next spring we will launch an online platform dedicated to fighting this erosion of core values through "humanism."

Humanism in medicine is by no means a new concept. It “describes relationships between physicians and their patients that are respectful and compassionate. It is reflected in attitudes and behaviors that are sensitive to the values, autonomy, cultural and ethnic backgrounds of others.” Humanism is integrity, compassion, and empathy in every encounter, all of which align with the values and atmosphere we cultivated together at CPL.

With support from CPL, we are creating online space where providers, students, and patients alike can reflect and share their stories with one another. This online forum will lie at the intersection of academic journal and personal blog, beginning with a weekly column, and growing to accept submissions from physicians, residents, students, other providers, and patients.

We write to witness, reflect, record, and share this journey. We write as a way to name and consequently accept or reject the cultural waters in which we swim. We write to reveal the hidden curriculum, good or bad, of our training. Along the way, we aim to provide multiple viewpoints in a respectful yet rigorous discussion on a range of interdisciplinary topics such as individual patient care, the education of new physicians, health policy, and population health.

Each of us has met other providers and patients who also see writing and humanism as a means of alleviating suffering. This space will bring all these individuals together in one place. It is our hope that this endeavor will become a special place for medicine, writing, and humanism to intertwine.

Please join us in this movement.

Sincerely,
Robert A. Swendiman
University of North Carolina School of Medicine | Class of 2014
Harvard Kennedy School of Government | Class of 2014
Dubin Fellow for Emerging Leaders


References

• The Arnold P. Gold Foundation: What is Humanism in Medicine? Accessible at: http://www.humanism-in-medicine.org/index.php/aboutus/what_is_humanism_in_medicine

"I Have Arrived"

"We believe that happiness is possible only in the future. That is why the practice "I have arrived" is very important. The realization that we have already arrived, that we don't have to travel any further, that we are already here, can give us peace and joy. The conditions for our happiness are already sufficient. We only need to allow ourselves to be in the present moment, and we will be able to touch them." - Ticht Nhat Hahn.

For the past two weeks, I have begun each morning with a meditation. There has been a significant bump in my quality of life. After waking up and getting ready, I sit on my bed and take a couple deep breaths. Then I read a short passage in Ticht Nhat Hahn's "Your True Home" (thank you, Scott Hugo!). The book has 365 meditations, one for each day of the year. I try to read each word intentionally, sometimes going through the paragraph a few times. Then I dedicate my day to that meditation. Right before bed, I read it one more time, reflecting on how well I was able to incorporate the teaching into my life.

It takes maybe five minutes a day?

Since getting back to Asheville, I have tried to live every day in the present (something I didn't do well in Boston at all). I attempt to take each day as a gift. This specific meditation above really resonated with me; it was one of my early ones, and I actually spent two days on it. The thought that "happiness is possible only in the future" is something that is very prevalent in physician-training. It starts early. I will be happy once I get into the right college, into the right medical school, into the right residency, once I get OUT of residency, once I'm an attending, once I get this or that position. It is difficult to break the cycle. I have to give a conscious effort each day to just live in the here-and-now. It is amazing that amount of crap that we are willing to put up with to be happy (later). And the cycle continues.

In the here-and-now, every patient is a gift. Every person I have the opportunity to see I need to completely immerse myself in their life. For some, this has meant just being a good listener. I recently had a patient who was admitted for chronic pain control. She has many other medical issues, but just sitting there for 30 minutes and listening was the best care that I could give. In a year, I may be able to offer more. But patients don't come to the hospital because it's fun. Everyone is in need, and it is a privilege to figure out exactly what that need is.

I'm feeling very Zen today. It's a good, calming feeling - to know that we have already arrived.

Family Medicine - Acting Internship

Yes, Meredith, but it is good to be happy every once in a while. And today was a very good day for happiness. Today I had a case where everything went right (although it helped that it was a bread 'n butter General Surgery case!). I had plenty of time to read about the condition before I saw him, I was able to do a leisurely admit, the resident and attending physicians told me I had a "great" presentation and plan, and then the patient himself told my superiors that I was going to be a great doctor. It doesn't get much better than that. I told my patient that I would slip him a check for saying nice things about me...

There's nothing more satisfying than when an entire encounter goes well. Obviously, this is not the norm, but it is wonderful when everything clicks.

So, this month I am in "Block 0." It is a four week rotation before the beginning of the medical calendar year. Everything starts on July 1 in medicine. The new interns arrive at the hospital, the residents become a year older, and the chiefs graduate and become fellows/attending physicians. Third year med students hit the wards, eager and scared shitless (I certainly was - "Today I was called doctor and that was scary..."). After a year off, I really wanted to do a Block 0 clerkship before starting on a surgical service at UNC. Family Medicine in Asheville was a perfect choice. I could re-train in internal medicine, pediatrics, OB/GYN, and admit surgical cases. Family Medicine is the specialty with the broadest spectrum (which in my mind, makes it the most difficult to practice well), and I certainly still need a lot of work relearning the knowledge that I've lost. There are quite a few axons that need to be rewired.

The schedule isn't too bad. Each morning we meet on the 7th floor to check out with the night float resident. We hear about any complaints or calls that the resident had to field the night before, and any new admissions. Typically, our service runs about 10-15 patients, although today we had six. Last Friday we had 25. After sign out, we divvy up who to see, and then we round on all our "peeps." Depending on the census, I see between two and five patients. I get a history of the nights events, perform a focused physical, then write up the encounter with an assessment and plan. Then it's off to rounds, where we discuss each patient individually as a team. I present my patients, but a resident and attending have generally already seen them as well. Finally, I spend the rest of the day helping to manage the issues on the floor and admitting new patients to the service.

Then I'm off in time for dinner. Rinse and repeat.

That is my schedule during the week. On the weekends, I just have two nights of call during the month. This is when I'm at the hospital with the night float resident. Sometimes the call schedule will be every third or fourth night ("Q3" or "Q4"), so having a Q14 call schedule here is not bad at all! I expect to take call Q3 on Peds Surgery next month, and some preceptors have even suggested I try to take Q2 call so I can impress my attendings.

Being back in Asheville is also wonderful. I have already been to White Duck Taco twice, and the Bywater once for a (very brief) happy hour. Rebekah and I have a dinner scheduled for Sunday night at the Admiral, thanks to Mom and Dad. At Christmas, they realized how much I missed NC and I received a lovely gift basket of Carolina stuffings, gift certs included. So we will cash-in this weekend with some beef tartare.

It's going to be an intense month. I am also trying to spend some time in the OR to get comfortable again, and I will have to re-learn how to tie knots. But it is indeed exciting (I don't know if you could tell).

Back to Medicine!

I literally felt taller the day I got back to North Carolina. It was like a weight was off my shoulders. All year I have been talking about getting back into medicine, and this week I was finally home. Finally home. My Family Medicine "Acting Internship" (AI) began on Tuesday, and it felt so good to be back in the hospital. I was finally back doing what I love (have I used the word "finally" enough?!). I left Boston with mixed emotions. It was difficult to leave, and the week prior to Day #1 was a tough transition, for personal reasons. But when I showed up for 7am rounds with the team, I was so ready to be back.

So ready, but not so ready. Have you ever heard the expression, "If you don't use it, you lose it...?" Well, I lost it. Badly.

I could've used a few less white russians in Cambridge.

The week actually started off well; however, my presentations were horrible. It was like I was relearning how to talk to a physician about a patient. I was dropping all the wrong words, repeating phrases, going through the work-up in the wrong order. It literally took me until today before I really felt I could give a solid presentation. Today I had my 3 minute, 1 minute, and 30 second verbal notes ready. I finally nailed the first sentence, was coherent, and could put together a decent plan together for my people. So it does come back fairly quickly (please everyone, stop tell me it will come back quickly!), but it took me four days to relearn what I had honed in one year of training. And the battles continue...

On Wednesday, I admitted (or "attempted to admit") to the hospital a child with an asthma exacerbation. I ran down my history and tried to ask all the right questions. What medications do you take? Has this ever happened before? How many times have you been to the hospital for your asthma in the past year? Ever? I performed my physical exam, chatted with the family, and then left the room to discuss the patient with my resident. I recounted the tale briefly, and then he asked me what I wanted to do for management. With confidence, I told him I would do this-this-and-this, and absolutely, by no means, under no circumstances, would we start steroids in this patient (because there was no evidence to suggest that steroids work for an acute exacerbation, I stated emphatically!).

My resident stared at me blankly. Then he said, "We will absolutely be starting her on PO steroids. That's what you do for an asthma exacerbation in the inpatient setting." Then he looked at me funny.

It took me a couple hours to realize that I had confused an acute asthma attack with a bout of pediatric RSV. So I went off to Starbucks to do some more reading on the topic.

There seems to be a lot of that going on. Once I see something - a diagnosis, lab value, or physical exam finding - I remember it again. Then it sticks (hopefully). And off and on I will remember the random things, such as the mechanism behind right upper quadrant pain in a patient with transaminitis or what Kerr's sign is. But then when someone says that a patient had "HCC," I draw a blank. I have to look up a lot of stuff up that I already knew (HCC stands for "hepatocellular carcinoma" by the way). It's coming back, slowly but surely. I just wish it would come back faster.

The days fly by in the hospital. We begin at 7am, and when I look at the clock again it's noon. It feels like only minutes later we are signing out to the night float resident. It is amazing how fast this week has gone. Ten or eleven hours in the hospital, then eat, workout, study for an hour, catch-up on emails and finish lingering work, read, and repeat. It's nonstop and I love it. Screw work/life balance! Who needs it?!?

I'm sure that philosophy won't last.

Personal Statement Draft #2

Earlier this year, I was told that I would be “irrelevant.” The physician who spoke those words cited numerous studies, stating, “Health care only contributes 10-15% to health outcomes and life span.” The remaining 85% stems from life circumstances that are out of a doctor’s control. In short, he wanted me to understand that “doctoring” is only part of the story.

While some would find this news disheartening, I see it as a challenge. Providing high quality care will require me to be both an excellent clinician and a physician-leader. I see no better vocation to meet this challenge than as an academic surgeon.

As an M3, I was enjoyed the intense connections my attending surgeons had with their patients. I eagerly sought to develop Dr. Johnson’s sincere compassion with his breast cancer patients, and Dr. Bradshaw’s knowledge base and technical competence in the operating room. Throughout the year, their mix of experience, procedural expertise, and kindness was unparalleled, leading me to consider the choice of surgery more seriously.

I elected to spend my sub-internship in rural General Surgery in Linville, NC. There, I met an elderly woman, Rose, who presented with stage IIA melanoma. She had been a patient at the Tate Clinic for 77 years. Her relationship with my preceptor, Dr. Tate, was special. His grandfather birthed her, his father removed her gallbladder, and now Dr. Tate would treat Rose’s cancer. Again I was inspired by the deep, meaningful relationships that surgeons developed with their patients, who were often objected to scary and terminal diagnoses. By the end of this rotation, I knew I wanted to pursue a career in surgery.

Dr. Tate and my other surgical preceptors were both role models and leaders. Through careful observation of their work, I have seen the value of leadership in the operating room and the clinic. Leadership as a core principal of success, and I have experienced its value as a student, a researcher, an EMT, and as captain of the UNC Men’s Swimming and Diving Team. During these last few years, I have begun to better understand the need for leadership in health care and policy.

Even with Medicare, Rose struggled to gain access to consistent primary care. Linville is in Avery County, which has one of the highest ratios of patients to PCPs, and ranks worst for clinical care in all of North Carolina. This is why I chose to pursue a Master of Public Policy, as a fellow at Harvard’s Center for Public Leadership. There, I have studied leadership in the classroom and the lab, and am currently finishing my Master’s thesis, which analyzes the role of reimbursement in hospital quality for the largest rural health system in North Carolina. During residency, I hope to continue these research interests in nontechnical skills and health policy.

My primary focus, however, is to become an excellent clinician, as all my role models are expert surgeons. I believe that academic surgery provides the best opportunity meet this goal, as well as the challenge I was presented earlier this year. “Eighty-five percent” is a daunting figure, but through practice, leadership, and good policy, surgeons can make an even greater impact on patients’ lives than they do today. I look forward to meeting this challenge every day as a surgical resident.

Between a Rock and a Hard Place

Here is the link to a collaboration piece with Dr. Latessa called, "Between a Rock and a Hard Place." I can't seem to get access to my own poem for some reason. So I've attached the poem below, and then read the commentary. It is super cool to see myself as a first author on PubMed! Yup, go ahead. Search for "Swendiman," and I now can take credit for all FOUR publications (even the one from 1950 by a Mr. GA Swendiman). Headache case report? That must have been me too...


Between a Rock and a Hard Place
by Robert Swendiman

Operating Suite #9. We waited in silence for the pathologist to call.
A 15-month-old boy lay before us. Flaccid, sterile, powerless.
There were only two possibilities, given the X-ray and MRI.
We prayed it wasn't cancer.
"I only see blood, no abnormal cells. No cancer."
Sigh of relief. The diagnosis was child abuse.


Swendiman RA, Latessa RA. Medicine and the arts. Between a rock and a hard place: [excerpt] by Robert A. Swendiman. Commentary. Acad Med. 2013;88(6):778-9.

The Dubin Retreat

Look at these people just working so hard. What a classic photo. Pictured left are some of my favorite people (Sushma, Alvin, Dan, Katherine, Tommy - left to right). I had the opportunity to spend the weekend with all the Dubin Fellows, past and present, at Glenn Dubin's house in the New York countryside. This was our first ever "Dubin Retreat." We have three classes now (the D1s, D2s, and D3s), with former fellows in Boston, DC, New York, Columbia, Australia, and more. People flew in from all over the world to meet, greet, reunion-ize, and develop our alumni network. And we got to spend some quality time with Glenn himself.

Just talking to Glenn, you wouldn't know he's a billionaire. Once everyone had gotten to the ranch, we sat outside for introductions, as our class had not met many of the D1 and D2s. Just chilling in the middle was our benefactor - flannel shirt, khaki pants frayed and torn at the cuffs, old sneakers. Hands on his head, leaning back. Not how I picture billionaires (I don't know how I actually picture billionaires). He's quiet, humble, a family man, and is totally involved in our fellowship, which is not the case for many of these scholarships. He has also made "The Giving Pledge," which is a campaign started by Bill Gates and Warren Buffet to recruit the richest people in the world to give away most of their wealth to philanthropic causes. The commitment is to give at least 50% of total wealth to charity, before or at the time of death. According to Wikipedia, 113 billionaires have made the pledge. Peeps include Ted Turner, Mark Zuckerberg, and George Lucas, among others.

That's pretty cool.

If you do get a chance, check some of these people out. I really need to start profiling some of them on this blog in the fall.

What was so awesome about the retreat was the amount of energy in the room. Everyone goes nonstop. My usual inertia was gone (by the end of the weekend I was on a "subcommittee" - SAY WHAT?!). I have been co-conspiring to build this blog into a real journalistic/opinion platform (more on that coming) with a couple of my friends, and each fellow was a valuable resource for expertise. They've started their own organizations, recruited funding, written theories of change... all working towards social progress. By the end of the third day, I was exhausted (and full of ideas). I went around promising discounted medical care as a return on their investment.

I like to poke fun at Harvard a lot, but there are some really good people around. More to come on some of these ideas later.