Time Stamps

• 00:42 Speaking up as a new medical student
• 05:27 Managing expectations as a team leader
• 10:14 Managing expectations with patient care
• 13:25 How to be open to unexpected, and even accidental, feedback?
• 17:35 What happens when you have a wardrobe malfunction on rounds?

Transcript

Dr. Shreya Trivedi: It’s that time of year, everyone…”dun dun dun” JULY! And in honor of all the transitions this month, I went to one of the funniest people I know and asked her if she would be willing to share some of her July stories that humbled her, made her laugh, and everything in between.

Dr. Maria  Rosasco: I’m Maria Rosasco. I’m a hospitalist at Beth Israel, and I primarily work as a nocturnist!

Dr. Shreya Trivedi: Which is such a hard job and you rock it well.

Dr. Maria  Rosasco: Thank you!

Dr. Shreya Trivedi: Maybe there were some stories in the pipeline that prepped you for that.

Dr. Shreya Trivedi: And there certainly was a handful of good stories, five to be exact, that made July extra memorable for Maria. Let’s start with her first July in the hospital.

Dr. Maria  Rosasco: When I was a third year medical student, uh, my first day on a clinical rotation. I was on OB GYN and I was on the GYN onc service and they assigned me one patient to see, and it should have been really straightforward. She was a few days post-op from a major abdominal surgery and I ask her how she’s feeling and she says, you know, I feel okay, but my incision feels a little strange. It feels kind of wet. And so I say, okay, may I take a look and I peel back the blankets covering her abdomen, and I see that her wound has completely dehisced and not only has it dehisced, but I can see wet, glistening organs extruding from the wound. And she says, does it look okay? And I say, um, well, you know, I think, I think there’s something going on with your incision. Let me get someone else. So I press the call button and I say, um, hi, this is Maria. I’m one of the medical students and I think there’s something wrong with this patient’s incision. Could someone come take a look? And you can practically hear the eye roll through the phone.

Dr. Shreya Trivedi: No!

Dr. Maria Rosasco: And they say, yeah, okay. Sure. Um, someone will be in, in a few minutes. And so I excuse myself from the patient to go find my team and I find my intern, and it’s also her first day and her back is to me at the computer and I say, oh, excuse me. So sorry to bother, but I think there’s something wrong with my patient’s incision. And she doesn’t even turn around. She says, okay, well, grab some dressing supplies and we’ll redress it on rounds. And I say, well, um, I’m not really sure what kind of dressing might be appropriate for this situation, and some doubt has started to creep in. You know, the patient seems unfussed, and the nurse seems unfussed, and my team is unbothered. I mean, maybe this is normal, maybe this is expected. I don’t know. And my intern is getting frustrated because her job before rounds is to tabulate by hand all the ins and outs for all the patients. And I have interrupted her math. And finally she turns around and says, what are you trying to say? And with as much confidence as I can muster, I say her insides are on her outside. And she says, well, why didn’t you say something? And of course, calls the attending, they come right to the bedside. The patient gets whisked to the OR and does fine.

Dr. Shreya Trivedi: And that was when she learned how to trust her “gut,” literally. I just loved this story because hopefully this was a reminder to everyone on the team that we all have something to contribute, even a new medical student in July. And most importantly, for everyone listening, I hope this is a reminder to yourself to quiet that a self-doubting part of us that creeps up every now and then. and to trust our intuition.

Dr. Maria Rosasco: When I think about this experience, I think about how self-conscious I was as a medical student to be mis-calibrated, and I don’t know if you felt this way, but I, of course, didn’t want to be under activated about a serious problem. But as a medical student, the thing I really worried about was being over activated about a problem that wasn’t significant. And of course that is what training is for, to gain clinical experience, to become better calibrated. But I think that the value of intuition really never diminishes because even now, you know, sometimes something is wrong with a patient and you can’t quite put your finger on it or maybe you don’t have the medical vocabulary to describe what’s going on, and you have to say something like their insides are on their outside. I think the takeaway for me was that if something doesn’t seem right, it probably isn’t right. And you should ask for help.

Dr. Shreya Trivedi: Exactly and so in July while we are in new roles, some of us are trying to figuring how the right times to speak up or really working on trusting our intuition, while others working on new ways of teaching and how to lead a team. But sometimes this entails kind of falling flat on our face… 

Dr. Maria  Rosasco: When I was a junior resident on wards for the first time, I really wanted to inhabit this new role of team leader and educator. And looking around, it seemed like all of my peers had it worked out. They seemed poised, they seemed like they had all these natural pedagogical skills. And I felt really awkward, and I felt like I hadn’t found my niche. I was interested in art and the humanities, and I really loved to read mystery novels. And so my shtick was that I was telling the team about the art of observation and how the job of the clinician is analogous to that of the detective. And so one day we were caring for this elderly patient with dementia who had come to the hospital as a John Doe, and we didn’t know anything about him. We didn’t know his name or where he had come from or anything about his medical history. And I thought, great, a perfect medical mystery to employ the art of observation. What might we learn about this guy by just observing him and we could see that his fingertips were yellowed. Could he be a smoker? He had hearing aids. Could we trace the serial number? And as I am sort of musing insufferably about Sherlock Holmes at the bedside, my eagle eyed intern spots that he is wearing a bracelet, but it is not a bracelet at all. It’s a locket. And it’s not marked as a medical locket, but we think, oh my gosh, Eureka, we have cracked the case. Inside there’s going to be his name and his address and an emergency contact, and maybe even a list of all of his medications. We have done it. And so with great difficulty, we pry open this locket and this little plume of dust comes out. And inside there is a tiny rolled up piece of paper, and my intern very carefully decants it from the locket and begins to unfurl it like a scroll. And when we finally get it all the way open, we see that it just says two words and it says two stents, that’s it, just two stents. No other information is forthcoming. And we had good laugh about it, and it really punctured my self seriousness about teaching. I feel like for me, the transition from intern year to becoming a resident was the most difficult one. And part of why I think it was hard was that I had sort of this platonic ideal of what a good resident ought to be. And I was so focused on becoming that ideal that I think I lost sight of becoming the best version of myself as a resident. You know, the truth is that I didn’t have to try quite so hard. This was sort of wearing a costume that didn’t fit very well. And in this case, of course, the art of observation did not yield the results that we had hoped for, but I think it helped me see myself better. It helped me observe myself better.

Dr. Shreya Trivedi: Wow, I love that last line. It helped her observe herself. She put so much energy in this teaching exercise to observe this patient, but it didn’t go as planned and unexpectedly it allowed her to put a microscope on herself. 

Dr. Maria  Rosasco: I think I had to think a lot about the things that made me unique or special as a doctor and lean into those. And of course, I wanted to grow as a teacher and as a team leader, but I didn’t have to grow in exactly the same ways that everyone was growing and didn’t need to measure my success in the same way.

Dr. Shreya Trivedi: This makes me think back to the first story where Maria saw that patients’ insides on the outside and she was trying not to be under calibrated and also not too over calibrated. But here we see we have to be cautious not to calibrate so much and become so focused on some ideal expectation of what it means to be a resident or how a teaching session should go. And a similar theme with regard to expectations reared its head in another July experience, but this time with a patient and at a time of life that hit pretty close to home.

Dr. Maria  Rosasco: When I was an intern early in the year, I was rotating on our bone marrow transplant service, and one of the nurses came up to me to let me know that one of our patients who was receiving comfort focus care had died. And she asked me to come pronounce him, but I had never pronounced a patient before and really had no idea how to do this. And I felt a duty to perform this ritual of death well. And my only model for this had been my own father’s death when I was in high school. My father died after a prolonged stay in the ICU, and this cleaved my life into a before and an after. But there was this brief period of time after he died, and I knew that he had died, and when the team pronounced the patient and they told me he had died, that this period felt like it was sort of suspended between these two realities. And so I was thinking about this now, and I knew that I needed to go and perform this ritual so that I could release this family from the before and that they could begin their journey of grief. And so I go into the room and I put my stethoscope on his chest and I’m listening, and I think I hear a heartbeat, and I’m not sure. And so I am listening and listening and listening until finally his wife puts her hand on mine and she says, very kindly, but authoritatively, he’s gone. And I felt so much shame that I had been so incompetent in performing this right, that his wife had had to do it herself. I was supposed to be the one who laid my hand on hers and offered my condolences and made the pronouncement, not the other way around. But she did not need that from me in that moment. And instead she had extended me grace. And I think that when I first became a doctor, I had this expectation about the directionality of healing. But if I could offer one piece of advice for moments of transition, I think it would be to give yourself grace.

Dr. Shreya Trivedi: I was really touched hearing this story, there is just so much to it, but particularly that expectation about the directionality of healing really resonated, and shedding the notion of who may be helping who through a tough situation. Her next July was also an important lesson from a patient, but this time highlights being open to all that you may learn from your patients..sometimes in very unexpected, and even accidental, ways.

Dr. Maria Rosasco: When I was an intern, I cared for a patient who really didn’t like me. She was terse and impatient, and I felt like I was always walking on eggshells, trying not to say the wrong thing to draw her ire. And I had really begun to dread our encounters. And one night she was put on droplet precautions to rule out a respiratory viral illness. And so the next day before I went to see her, I put on a mask and a face shield. And when I went in the room, she did not recognize me. And before I could say anything, she just says, oh my God, thank goodness, a new doctor. That other doctor was terrible. And then she proceeds to enumerate all of my many, many shortcomings. And some of them were unfair, but mostly they were guttingly accurate. And it is a really weird experience to have someone give you this totally unvarnished, unguarded opinion. And I did not have the courage to tell her that other doctor and I were one in the same. So I think I murmured something about, she’ll be back tomorrow. And I just felt totally crushed, but I also felt liberated because I felt like I had this secret weapon now. And I knew the main thing that had been bothering her was that there were a lot of consultants offering their expert advice, but she felt like the communication was not strong and that there wasn’t someone leading the ship. And so the next day I took what she had said, and I asked all of the consultants to come and meet together at the same time in her room and talk about the plan together. And I can’t say that she was exactly pleased, but our relationship really thawed after that.

Dr. Shreya Trivedi: What a gut punch of feedback! Especially when you are an intern and you feel like are supposed to be leading the ship. You are doing your best to do a good job, but then get feedback that you aren’t. And it’s actually really hard feedback to swallow because the system is just not set up as well to lead – so and so team rounding at 5 am, the other consulting team is rounding at 4 pm, someone else is dropping a note at 10 pm and there are so many moving pieces in between. Honestly, I might have gotten angry at this feedback, felt it was unfair and maybe would have gotten defensive, but Maria was able to raise above and focus on what she could at least control, which was getting all the consultants to come at the same time. Which is no easy feat, if you’ve ever tried that.

Dr. Maria Rosasco: I think we all want to have this growth mindset, but sometimes getting critical feedback is just really hard to hear. And I felt like she had held up this mirror and reflected all the doubts that I had about myself. I think even though it was hard, I was grateful that my doppelganger had received this information, but I just wish that my real self had the courage to just ask her what was bothering her and I could have learned information sooner. I think I’ve gotten more comfortable with saying, Hey, could we start again? I think this isn’t going well. Can we try again? 

Dr. Shreya Trivedi: I like that.

Dr. Maria Rosasco: What’s bothering you?

Dr. Shreya Trivedi: I know younger Maria would be so proud that she can just go up to a patient and say “Hey, what’s going on? Can we start over and try again?” I think all these experiences, one by one, as unexpected or tough as they may be at the moment, really do help us become the clinicians we are today. And I think it goes back the idea that our patients are our best teachers, whether it’s they’re giving us feedback, or as in our last July story, sometimes our patients help us question some of our limiting beliefs.

Dr. Maria  Rosasco: I was an intern rotating on medicine awards at the VA. And when I arrived in the morning for sign out, I accidentally dropped my scut sheet on the ground and I bent over to pick it up and there was an audible ripping sound that my colleagues very politely ignored, but I realized that I had torn my pants and it was not a small tear, it was like a catastrophic failure of structural integrity of the seat of my pants. They were just completely off, and, but I had to get to work. And so I threw on my white coat and got to pre-rounding. And at the VA, at the time, they still had a smoke shack. And so if you couldn’t find your patient in their room in the morning, then they were probably outside smoking. And so I went to see one of my patients in the smoke shack, and I am dripping sweat wearing my white coat. And my patient says, doc, you all right? Why don’t you take off your coat? And totally miserably, I tell him, I just can’t, I can’t take off my coat. And takes a long drag on his cigarette. And he looks at me and he says, the uniform isn’t what makes you a soldier. And I realize that he thinks that I cannot take off my coat because then I won’t be a doctor or people won’t recognize me as a doctor. And so I confess to him, I say, it’s not that. I’ve had a wardrobe malfunction. And he just looks at me and he says, so what! Let me tell you that nothing will make you feel more like an imposter when you are on rounds and you can feel like a gentle breeze on your bare buttocks underneath your white coat. I just felt totally incompetent, but exactly, no one noticed. My patient was right. So what? And he was right about something else. He was right that I was wearing it because I needed it to lend me this gravitas that I felt like I hadn’t earned yet. And I also felt like it was an armor against people’s judgments that maybe I looked too young to be a doctor or too female to be a doctor, and I needed to wear my white coat. But as I came into myself as a clinician and got some sturdier pants, I found that I just did not need my uniform as much anymore.

Dr. Shreya Trivedi: I will say that even though I still wear my white coat, I do love the idea of ending with shedding of the white coat. And I think it’s really interesting thinking about how we have this white coat ceremony where we put it on, and then we have all these experiences where we recalibrate, shed some of our expectations as we learned through Maria’s stories, and at some point, in our time, can shed that white coat in our own ceremony…sometimes  in a ceremony that involves a pretty significant wardrobe malfunction. And so after reflecting on her most memorable July stories, I did Maria what advice she had and to share some parting words. 

Dr. Maria  Rosasco: I think I would not have made it through training and becoming an attending without my co-residents and the people that I work with. And I think that sort of leaning into that camaraderie is really important to your wellbeing and survival, and we will all fail and make mistakes. And I think that that is one thing that we should expect. And it’s not a shortcoming to have this happen to you. And I think for me, I felt pretty burnt out during parts of residency. And the thing that really saved me, and the thing that I really kept coming back to was that medicine is really primarily a storytelling endeavor. And we are collecting stories from patients and we are transforming them, and we are retelling them. And so for me, being curious about patients was the key to getting through it all.

Dr. Shreya Trivedi: What a great way to frame medicine as primarily a storytelling endeavor, which is probably why I always read exceptional H and Ps from Maria when I come in in the morning and why she is an exceptional story teller. I hope that hearing these stories will help us all be a little more compassionate. A little bit more understanding to each other as we go through this time of year. And maybe for those that are going through very new transitions, hopefully these stories will help you feel a little less alone in the struggle. And maybe you’ll even be able to laugh at yourself knowing that there was someone else who might’ve also gone through something very similar. 

Dr. Shreya Trivedi: Thank you so much for listening, and thank you to Dr. Maria Rosasco for sharing her stories. If you want to catch the full interview, you can check it out on our new Youtube channel, we’ll link it in the show notes. Thank you also to Marissa LoCastro for helping edit that! And if you have some July stories of your own and you want to come on air, please email us, let us know! And with that, happy July!