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.