Co-Residents

Residency provides an interesting dynamic in that you’re placed with a group of other people who want to attain the same goal as you.  I think of it as a team.[1] As with any team, there are those who see being a part of the team as a simple means to an end, and others who truly enjoy being part of a group.  Some residents enter the program with the mindset of simply trying to do the minimum needed to pass.  He or she leaves the program in a whimper.  After this person has graduated, they have not left a mark or made a difference to the program.  On the other end of the spectrum are the residents who do what is asked of them and more.  They attend every function, and perform every task.  I like to think that I fall somewhere in the middle, hopefully more towards the go-getter end.  I do more than what is asked of me; one of the main reasons I wanted to be a chief resident was because I thought that position would allow me to give back to the program.

Sparrow Family Residents
Sparrow Family Resident

——– Bond ——–

No matter what your approach to this team, a strong bond is formed between the residents. This bond exists for a variety of reasons: each person goes through the same struggles, has similar goals[2], and if one is unable to perform his duties, his co-residents are called upon to ‘pick up the slack’[3].  Regardless of where the resident falls on the spectrum of individual to team player, these factors form a bond between residents of the same program, and to a small extent between all residents across all specialties.  I mentioned that I spent almost one year training in the Emergency Medicine program.  One poignant stance that the (then) director said (when asked of all the bad-mouthing that everyone seemed to have to say about the Emergency Department[4]) was that, “Let them say what they want, they don’t understand what we do here.”  I feel that this holds at least partly true for every residency: people in general don’t understand what it means to be a resident—only other residents can have this understanding; for this reason, this bond underlies all relationships between residents.

Me and my wife with our fellow residents at graduation
Me and my wife with our fellow residents at graduation

Even before the surgery, I have always felt incredibly close to all of my co-residents, especially those in my year.  After the surgery, I have become even closer to each and every one of them.  They have all been there for me and my family in one way or another: whether it’s bringing us a dinner, sending me a ‘get well!’ card, or covering a missed shift for either my wife or me, they have all helped in their own way.  These acts of kindness, even though appreciated, were not needed for them to have my love.  Whether it was love my family and me, or just love for the program that motivated them, the bottom line is that love was key in their actions.

When I met with Dr. Janet Osuch[5], she warned me that of everyone, her co-workers distanced themselves the most from her—her rationale was that they feared something like this happening to them, and that a co-worker with this medical condition hit a little too close to home.  But somehow, in a strange twist of fate, this horrible tumor not only hasn’t distanced me from my co-residents but has actually brought me closer to them.

 

[1] I have had much experience in team situations and have often been called a ‘good team player’.

[2] Graduating from residency.

[3] For example, if someone is sick and cannot go to work, another resident (a designated back up resident) is asked to fill his/her place.

[4] I mentioned in an earlier post that the Emergency Department (ED) acts as the whipping boy of the hospital—if something goes wrong, someone has to wait, or a treatment doesn’t work, the blame ultimately and inevitably goes to the ED.

[5] See an earlier post titled, ‘Dr. Janet Osuch’.

Cheris and Val…

Today, I was hoping to post pieces written by two Physical Therapists I have worked with. They provide unique perspectives as my therapists in both the outpatient and inpatient setting.

Cheris Grasse, whom I have mentioned in several previous posts, has been my outpatient Physical Therapist since my discharge in May of 2013. My first impression of Cheris was that she ‘knew her stuff’[1] and that she was tough and had no problem pushing me to my limit (I remember several therapists passing by making the comment after seeing me drenched in sweat, “Oh, you must be working with Cheris.”). I have since become very good friends with her, and now know that in addition to my first impressions being correct, I’ve also realized that she also has an incredibly big heart—I can tell that she truly hopes that I get better and improve. She works with a bevy of patients and is always tough to get an appointment with. I often wonder if they realize or appreciate who they are working with. Many of the effects of my tumor mimic those of Parkinson’s disease (as well as other diseases)—one of these effects is a lack of visible emotion (or ‘flattened affect’ as we call it in the medical field). I look forward to every session I have with Cheris, but I know this eagerness and excitement does not show in my face during our sessions. I hope she knows how happy I am to be there. It makes me shudder to think of where I’d be in my recovery process without her.

I first met Valerie Collins (or ‘Val’ as I call her) while in the Sparrow Rehabilitation Unit in the hospital. Before I even had the opportunity to work with her, many of the other therapists noted that she had much experience in patients with cerebellar damage like me. I could tell immediately she was the type of person who ‘practiced what she preached.’ There are many people who don’t do this- i.e.: a diabetic ice cream vendor, or a physician that smokes.[2] But I could tell from Val’s athletic physique (she was an NCAA swimmer at Michigan State University) that she practiced many of the exercises she imparted to her patients. Besides her extensive experience with cerebellar patients along with her obvious athleticism, I knew nothing of her prior to our sessions. Again, my first impressions were correct—many times, she would do exercises with me. She, like Cheris, would always push me to my limit, then ask for a little more. In a previous post I described my experience in walking again for the first time without assistance; that came during a session with Val. It was obvious that she was one of the best therapists there. I even asked if she would be available in the outpatient setting.   I often trade texts with her with us both wondering how the other one is doing. I hope she knows that not only am I grateful to have had the opportunity to work with her, but I am also thankful to have gained her as a friend.

The courtyard of Sparrow- this picture brings back memories.  Often this is where I would go after therapy sessions.
The courtyard of Sparrow- this picture brings back memories. Often this is where I would go after therapy sessions.

I asked them both to write a little on what it was like to work with me. This is what they wrote:

Cheris Grasse:

I have worked as an outpatient physical therapist with a focus in neurological impairment for the past 14 years.  I met Chris over a year ago when he started Outpatient Physical Therapy at Sparrow.  Neurological injuries (head injury, stroke, brain tumors, and spinal cord injuries) are quite variable in their presentation as are the degrees of recovery that may be achieved.  Knowing this, I try to keep preconceived notions of people likely to achieve a full functional recovery out of my mind. That being said, Chris has been phenomenal to work with. From what I understand about the size and location of his tumor, Chris’ recovery has been astounding.  I have seen far fewer cerebellar injuries versus cerebral in the years that I have been treating patients with neurological involvement.  Cerebellar lesions are hard to treat and usually do not completely resolve. Chris has the “typical” presentation for someone with cerebellar impairment – ataxic gait with a wide base of support and impaired balance and coordination.  Yet, he is both amazing and challenging in the tasks and activities that he can perform.  Everything that I bring for him to do he’s ready and willing, which is so much fun!  It’s been really fun for me to bring in new ideas to “test out” on him, as the vast majority of my neurological patients would never be able to do the things that he does.  I had my husband make us an agility ladder to work on balance and coordination because I was running out of ideas to work on these

Me during a session with Cheris
Me during a session with Cheris

dynamically at such a high level.  While Chris continues to have ataxia, balance and coordination deficits, he also continues to improve.  ‘They’ used to say that what you don’t recover after the first year after a neurological injury you will never get back.  I have seen this disproven time and time again.  I can’t wait to see what Chris is doing one, five, ten years from now.

Valerie Collins:

I had the pleasure of working with Chris as one of his physical therapists while he was a patient on Sparrow’s Inpatient Rehabilitation unit. From the first session, he struck me as a patient that had a tremendous amount of focus and motivation to recover in addition to unwavering family support, both primary features of some of the most successful rehabilitation stories. As a Physical Therapist (PT) my job is to identify and address any mobility limitations a patient has. (How they are able to move, lie down, sit up, stand up, walk, climb stairs. The quality of the mobility must also be established, is it smooth and controlled, even between both sides or reciprocal and at a reasonable speed.)

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Chris presented with a significant level of ataxia (uncoordinated or jerky movements) affecting his core muscles as well as his extremities, one side greater than the other as well as his speech. He was also challenged by visual deficits. Given that ataxia and visual limitations are two of the most difficult physical challenges to maintaining one’s balance, Chris was facing a recovery process that was going to be long and occasionally frustrating. Amazingly Chris always came to therapy ready to work and put forth his best effort with every task presented to him. His level of physical fitness and endurance before his surgery were also a benefit to his current impaired state (often patients in a rehab setting have multiple conditions that need to be accounted for, but often slow the process, Chris luckily did not). Chris was a pleasure to work with as I could challenge him repeatedly with a task and progress him to more difficult tasks within a single session. Gains are more noticeable in this type of progression which helps reduce the frustration and subsequent delayed motor recovery some patients encounter.

I mentioned to Chris recently I consider the our setting the warm up phase of recovery, where we focus primarily on the skills he would need to get back home with his in the quickest manner which is the end goal of patients and practitioners in an inpatient rehabilitation setting. We worked together using several different treatment strategies and techniques such as PNF (proprioceptive neuro facilitation), NDT (neurodevelopmental technique) and FMT (functional manual therapy) to address his ability to move about his environment safely. With his great attitude and hard work ethic, a bit of coaching and cheerleading from me, other therapists and his support network was all Chris needed to get on his way.

 

 

 

[1] Several different inpatient therapists recommended her.

[2] The idea being this ice cream vendor has probably never tried his/her ice cream and is in fact, promoting diabetes with the ice cream. From the first day of medical school the negative effects of smoking (including but not limited to shortened life span, increased risk of cancers and heart disease) are engrained in us.

Therapy Part 2

After being discharged I began therapy as an outpatient.  The prescription called for Speech, Occupational, and Physical Therapy five times per week.  One of the therapists commented that she had never seen it written for so much before.  The only barrier to this came from my insurance company, as there was a set limit to the number of therapy visits I could have covered.  With this cap, I could theoretically only have two months of visits before I would be required to start paying out of pocket.  Thus I had to space out my therapy sessions strategically so I wouldn’t reach that limit too quickly. Unfortunately, I did not plan well and reached my quota on therapy sessions sooner than I anticipated.  I did, however, have the opportunity to experience each of these therapy modalities and have some thoughts on each.

———— Speech Therapy —————-

Outpatient speech therapy begins with the speech therapist conducting a battery of tests in an attempt to decipher first if therapy is needed, and if it were, what exercises would benefit the patient. Each session would begin with an impromptu conversation:  “How was your weekend?” or, “What are your plans for the rest of the day?”  These conversations served as more than just small talk. While I was responding the therapist would be closely listening to my every word.  For example if I said, “my weekenghkthyd was great!  I went to the beach.”  She’d reply by saying, “no, no, say ‘weekend’ again.”

My first experience with outpatient Speech Therapy was with a great speech therapist who was unfortunately retiring.  This was unfortunate for a couple of reasons:  1. Her impending retirement meant that I would no longer be the beneficiary of her expertise, and 2. She knew she was retiring and that any recovery I would have would take place both during as well as after her tenure.  Thus it was only natural that some of the sessions seemed as though she was simply ‘going through the motions’.  At the end of one of our sessions she said to me “Chris, next time you come, I’ll have a student with me. Would that be okay with you?”[1]  Before the tumor was discovered I was known in my residency program for getting good reviews from students—they considered me a good teacher.  I like to think it was my attitude towards having them.  While many of my colleagues see medical students as somewhat of a hindrance, I loved having students for many reasons: 1. Students often bring an eagerness and enthusiasm, which would not otherwise be part of the encounter.  This is an eagerness not only to learn but to help as well.  2. Being with a student breaks up the monotony of the day.  While seeing a patient is a privilege, it can become tedious at times—being with a student can help change this.  3. Lastly, I was in their shoes not too long ago.  Being a medical student is tough in that as a student you’re in ‘no man’s land’.  You cannot make significant decisions without a supervising physician.  Patients often realize this and give you less respect.  Also as a medical student you begin a new rotation every 4-6 weeks.[2]  This means working for a new supervising physician in a new locale every time you begin a new rotation.  Imagine starting a new job every month, having to learn the nuances of the job as well as the quirks of each boss.  It is for these reasons that I always welcome the opportunity to work with students.  This time was no different. When my therapist asked me if it was okay if a student was present at the next sessions, I said “sure” before she could finish the question.  This student was great, she revitalized our sessions with her eagerness to learn.  I often wonder where she ended up landing work.  My stint with Speech Therapy ended due to insurance limitations.  I remember the therapist telling me, immediately after one of my Physical Therapy sessions, “Insurance won’t cover any more sessions. I’m sorry but you’re being discharged.”

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Later the next year, after Sparrow hired a new Speech Therapist to replace the retiring one, I scheduled an appointment to see her.  I had had several sessions with her when I was in the hospital, thus she knew of my deficits.  Regardless of our past work together, an evaluation was still required, as it had been many months since I had been seen in Speech Therapy.  However, because I was reaching my set limit of authorized therapy sessions, my insurance refused to cover any Speech sessions.  I appealed their decision, but was again denied.  This particular therapist was very compassionate, and I think more invested in my case because of her involvement during my hospitalization.  Upon hearing of the denial of my coverage she actually gave me some home exercises to do and told me, “Chris, I had a cancellation in my schedule, after your physical therapy why don’t you stop by my office?”   It turned out her cancellation ended up showing up and she told me that she would call me instead.  About a month later as my wife found an old voice message from this therapist asking me to call her back.  Ever since then I have been meaning to speak to her and thank her, and let her know of the delay in my receiving her message.  It upsets me that she might think I received her message and ignored it, especially when I know she was really going out of her way to help me.

————– Physical Therapy —————

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Video of me in a Physical Therapy session in June of 2013

Prior to being discharged from Sparrow, I inquired about recommended physical therapists in the area.  Multiple therapists recommended the same therapist, a therapist in the Sparrow Health System named Cheris Grasse.  Even before discharge, we promptly scheduled several sessions with her.  From my first session I could tell that she lived up to the hype—she pushed me to my limits while also understanding my condition and the challenges it presented.  She actually had her husband build me an agility ladder to use in our sessions.  She is constantly thinking up new exercises for me to complete, and coming up with innovative ways to retrain my body.  It’s gotten to the point that I refuse to work with other physical therapists.  Nowadays, sessions with her typically begin on the treadmill followed by an exercise that she conjured up the night before.  I have been seeing her since May of 2013, making it almost one year and a half.  We have become close friends, and my only worry is that our friendship might cloud her treatment of me.[3]

My approach to my therapy sessions mirrored my approach to my tennis training[4]: work hard, and work smart.  Sweat is the external manifestation of hard work.  I often leave sessions dripping in sweat and because of this I’ve had many people in therapy tell me that they have noticed my hard work and are impressed by my work ethic.  I am grateful to every person that took time out of their day to tell me such things, but in writing this I realize that my hard work is only half of the battle: Work hard and work smart.  The idea of 10,000 hours as some magic number to attain excellence was popularized by author Malcolm Gladwell: it’s theorized by Gladwell and others, that in order to attain a high, elite level in any endeavor, at least 10,000 hours of practice is needed. He cites examples such as The Beatles, spending well over 10,000 hours together practicing music, Bill Gates spending over 10,000 hours in front of a computer screen in high school, or grand master chess players spending (you guessed it) over 10,000 hours playing chess.  This idea was challenged by Daniel Goleman in his book Focus: The Hidden Driver of Excellence, in which he writes that

The “10,000-hour rule” — that this level of practice holds the secret to great success in any field — has become sacrosanct gospel, echoed on websites and recited as litany in high-performance workshops. The problem: it’s only half-true.

If you are a duffer at golf, say, and make the same mistakes every time you try a certain swing or putt, 10,000 hours of practicing that error will not improve your game. You’ll still be a duffer, albeit an older one.[5]

I estimate that I have spent about 150 hours in physical therapy along with 450 or so hours in the gym working on rehabilitation.  While this equates to a measly 600 hours focused on my physical rehabilitation, it is not the number of hours that worries me.  As Goleman writes, simply reaching the 10,000-hour milestone is not enough; one has to spend the 10,000 hours practicing correctly.  That has led me to wonder: what is the smart way to rehabilitate?  In China, the main mode of recovery following a stroke or traumatic brain injury is acupuncture.[6]  Is acupuncture the answer?  I’ve come to realize that the exercises I am doing are the correct ones, but it is my attitude that needs correcting.  What do I mean by this?  I am not sure if I 100% bought in that all this work, that all these different exercises would make a difference. I used to believe that time was a major player in my recovery.  I realize that this is false thinking.  Now I believe that every Physical Therapy session, every workout at the YMCA, every home session of oral exercises should receive not only 100% effort, but also 100% belief that it is making a difference.

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Video of me in a Physical Therapy session in August of 2014

————– Occupational Therapy ————

I feel bad because I do not feel moved to describe my Occupational Therapy experience.  The saying “No news is good news” holds true here.  My occupational therapy sessions have been uneventful.  I’ve come across many incredible Occupational Therapists during my recovery.  At the moment, because of the aforementioned restrictions on the number of visits, I complete numerous home exercises.  Occupational Therapy is tough to define because technically any activity that entails either tasks of daily living or work skills is considered Occupational Therapy.  In fact, typing this would be considered Occupational therapy.

———- Thoughts on Therapy ———-

There have been times in my recovery that I questioned the difference and impact that therapy could have on my recovery.  I now realize that even though I have completed every task asked of me in the various forms of therapy, this lack of 100% belief has held me back.  I believe that this holds true in any endeavor we choose to undertake—if we hope to achieve our goal, then we must combine both 100% effort with 100% devotion and belief.  Otherwise, we will invariably fall short of our expectations.

I am grateful to every therapist I have had the privilege of working with after my surgery.  In the clinic I would often refer patients to therapy not really knowing what it was—to me it was a button I clicked.  Now it means much more.  Every patient I refer to therapy in the future will bring back a flood of memories and emotions of my recovery process, and will remind me of all the therapists towards whom I will always feel grateful.

 

 

[1] With any medical field, learning makes up a large chunk of the craft.  This takes place through students—people in school in that particular field, who follow and observe more experienced clinicians.  When a clinician has a student it is customary to ask the patient if they are okay with having a student.

[2] The time varies depending on the rotation you’re in. For example, a General Surgery is typically longer than a Psychiatry rotation.

[3] In medical school we are often warned against becoming friends with our patients fearing that friendship could be detrimental to patient care.  My personal belief is that every case is different.  In a diabetic whom you’re trying to improve their diet, yes I agree that friendship in this case may lessen your ability to get your point across.  But in a 31 year old with several cerebellar signs after a brain tumor resection, I see no downside to such a friendship.

[4] I mentioned in an earlier post that I was a serious tennis player growing up, playing in high school, college, and some on the pro circuit.

[5] Goleman, Daniel “Focus: The Hidden Driver of Excellence” 2013, New York, Harper. Page 163

[6] http://www.thecochranelibrary.com/userfiles/ccoch/file/Acupuncture_ancient_traditions/CD004131.pdf

A movie documenting a man's journey through recovery following a stroke
A movie documenting a man’s journey through recovery following a stroke

 

 

Therapy

As I mentioned in an earlier post, my days in the hospital were filled with therapy sessions and revolved around my therapy schedule.  I remember it clearly, every evening a technician would come in to my room and write the next day’s therapy schedule; typically I would have some sort of combination of Occupational, Speech, and Physical therapy, with each session lasting between 45 minutes to 1 hour.  When I was discharged from the hospital, my physicians recommended that I receive these three forms of therapy on an outpatient basis.

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——– Speech Therapy ———–

Every speech therapy session was conducted in a private designated room, and on a one-on-one basis. Every treatment plan is different.  For example, a patient recovering from brain damage that affects speech through damage to the tongue would have a different treatment plan than someone with difficulty speaking due to damage of the vocal chords.  My case provided a unique challenge in that my speech deficit was due to a poorly understood phenomenon called “Cerebellar Speech.”  Different physicians have explained this phenomenon in various ways: one clinician told me that my tumor had detrimental effects to all of my motor skills.  Fine motor skills are typically the last to recover.[1]  Nevertheless, my sessions usually entailed my completing various oral motor exercises, and repeating different phrases.  Writing and logic also fell into the realm of speech therapy. Thus, I would often be asked to perform writing exercises along with logic puzzles.[2]  At every session my mom would ask the speech therapist for exercises that I could practice on my own. My mom would make sure I practice these exercises in my hospital room, so my days were not only filled with official therapy sessions, but also with these in-room training sessions.

Practicing speech therapy in my room
Practicing speech therapy in my room

———- Occupational Therapy ————-

Occupational therapy focused mainly on my ability to complete practical tasks called “activities of daily living” (ADLs).  These tasks, such as showering, shaving, and dressing, are tasks that we normally take for granted, but can become a challenge under certain conditions.[3]  For me, this also included learning to stand from a seated position.  Visual deficits and compensating for them also fell into the scope of an Occupational Therapist’s duties.   Hence I would normally start my days with the Occupational Therapist, who would help me shower, shave, brush my teeth, and tie my shoes.  If we had time we would then work on tasks such as eating and standing up.  Periodically she would check the movement of my eyes to make sure they were improving.  Many times during our sessions I would become frustrated as I had developed a tremor in my right hand that prevented me from completing many of the tasks that she asked of me.  The tremor was sporadic and seemed to be brought on by fatigue.  Dr. Pearson, who saw me almost every day of my hospitalization remarked to me that he believed the tremor to be a positive sign, and that it meant my “nerves are getting better.” The tremor has since gone away.

———- Physical Therapy ———–

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Of all the therapy modalities that I took part in, it was the Physical Therapy that both my mom and I saw as the most important.  Following the surgery, my physical deficits were the most pronounced.  I could not walk and needed a wheelchair to get around.  Before the surgery I was active, playing tennis and going to the gym every day.  I’m not sure if it’s an Asian mentality or a way of thinking engrained in me (or both) but I am of the school of thought that anything can be overcome with hard work—anything can be unlearned and relearned. Since my physical deficits were so pronounced, my thought was that while the tumor stripped me of my ability to walk and my motor abilities, with hard work I could relearn these abilities.  I spent much of my physical therapy sessions either walking (in an attempt to regain my ability to walk) or on a mat (working on my core strength to help stabilize me).  When it came time for discharge I mentioned how the discharging physician only would allow me to leave the hospital under the care of my mom, fearing a fall.  One of my therapists thought that my being discharged was a bad idea and that one more week of therapy would greatly benefit me.  At that point in my recovery I desperately wanted to go home, as I was eager to return to my wife and sons.  When my wife asked me about my thoughts on discharge and the possibility of staying for one more week, my response was, “of course I’d rather be home, but my thinking is that if you ask any specialist what the most important part of one’s health is, the answer will invariably stem from their specialty.  A cardiologist will tell you the heart is the most important part of the human body, a neurologist will say the brain, a gastroenterologist will say the digestive tract, and yes, a physical therapist would say the body.  That’s why I’m a little skeptical when a therapist focused on my physical well-being would recommend an extra week’s stay because of a perceived benefit.”  Thinking back to that time, it’s hard not to think I was a bit biased in my thinking, but I stand by that thought.  Furthermore, I don’t think I’d want to be treated by a physical therapist who didn’t wholeheartedly believe in their craft.  While all the therapists gave their input on each case, ultimately, the physician would make the final decision on whether to discharge me.  As I said in an earlier post, it was decided that I would accompany my mom to Long Beach Island where she could watch over me and help me rehabilitate—the physician thought this to be a fine idea and decided to discharge me.

—— My Thoughts on Inpatient Therapy ———

I am extremely grateful to each and every therapist I had the privilege of working with while in-patient.  I know that even though their job and paycheck came from helping patients, I would not have made half the progress I have without their help and expertise.  I look back on the experience as a step closer to my ultimate goal: a full recovery.

 

 

[1] As an example, fine motor skills would include a physical task like writing, whereas gross motor skills would entail the act of grabbing the pencil or pen.

[2] For example, I would be asked: “if Jane wanted to make a peanut butter and jelly sandwich, how would she do that?”  The correct answer would be something like: “She would first have to get the bread, toast it.  Then she should get both the jelly and the peanut butter from the refrigerator.  She should use a butter knife to spread the jelly on one piece of the bread and peanut butter on the other.  She would then combine the pieces to make a sandwich.”  Luckily for me, the part of my brain that controls logic was not affected, thus these exercises were no problem.  I often tell people who are surprised with my cognitive abilities, such as memory, that “the tumor affected everything else (speaking, walking, vision) just not my mind.”  Unfortunately, there are many people who have impaired cognition affected and what seems like a simple exercise, like explaining how to make a peanut butter and jelly sandwich, becomes complex.

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[3] Michael J. Fox, who has suffered from Parkinson’s disease for over 20 years now, once said when asked whether or not he uses a hand held blade to shave, “I’m not suicidal.”  (http://www.aarp.org/entertainment/style-trends/info-04-2013/michael-j-fox-interview-parkinsons-family-career.html)

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Dependence

Without a doubt my life has changed.  This experience goes deeper than the confused stares I receive when walking into a room.  It also means, as the title implies, that I am now more dependent on others than I ever was in the past.  Initially in the hospital I was dependent on my wife or mom to perform simple tasks such as tying my shoes, or eating.  Now, although I am less dependent on others for these rudimentary tasks, I am not completely physically independent. For example, I still need someone with me to traverse stairs without railings.

———— Social Dependence ————

My dependence on my wife goes beyond the physical aspect; I am also more subtly dependent on her in the social arena.  Because of both the titubation and possibility of a fall, I do not attend large gatherings without my wife.[1]  This also means that she decides where and whom we speak to—I am grateful that she is there for me, but there has been an occasional instance when we are at a gathering and I do not say ‘hello’ to someone because I am following her lead.  I realize that she cannot read my mind and know to whom I want to speak, and it would only take a simple suggestion from me and she would take me there without hesitation.  But as I once described to a friend: “one of the disadvantages to my condition is that, I am often led places.”

This need of others is more obvious when I am not with Fleur.  In January this year, I took a trip to San Diego by myself, which entailed a three-hour flight to the San Diego Airport from Detroit.  My imbalance is usually enhanced after any stint of prolonged sitting.  Needless to say, I was quite wobbly leaving the plane, prompting another passenger to say to me, “Whoa, do you need help?”  I remember my thought at the time was that, I wish my wife were here to help me.

My wife and my younger son
My wife and my younger son

———- Speaking ————-

With my being voice affected, I try to avoid speaking over the telephone when I can—if texts or e-mails are an option I will use it.  At home, this results in more work for my wife.  I try to stay on top of tasks such as paying bills (although I’m not doing a great job with that) and correspondence to friends, but once the situation calls for a telephone call or conversation I immediately defer to my wife.  Even though she understands, I’m sure this is a source of great frustration for her. She has never, however, expressed or even hinted at feeling frustrated.

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I work on my speech every day, completing oral motor exercises on a daily basis.  My hope is that in the future, my speech will not show any trace of impairment and my conversations with others won’t be littered with “what?” or “excuse me?” Most of all, I hope I won’t avoid conversations and will be able to socialize freely.

—– The Lone Ranger —–

I’ve realized through this that no one goes through life or times like this alone. We as a society put Lone Ranger types on a pedestal.   Heroes in movies always seem to do most of their work on their own.[2] When John McCain ran for president, he attempted to revitalize his campaign by calling himself a ‘maverick’, implying that not only did he go against the grain, but that he often acted on his own too. However, at closer look, even the Lone Ranger had Tonto to rely on. The reality is we need other people; nothing is done alone. What separates us as a human race? It is our ability to communicate with each other—this allows us to work together—this is what separates us. Even though in my current condition I perhaps am more dependent on them than I was before, I would be fooling myself if I thought I didn’t depend on them before.

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[1] I’m sure there’s a psychological aspect to it.  If the titubation were to occur then she could explain it to those with me; holding her hand as I walk prevents any falls.

 

[2] There are a countless number of examples here. Characters like Superman, Thomas Crowne, and even James Bond.

Greg and Megha…

For this post I asked two of my close friends and colleagues to write something for the blog. They provide a unique perspective in that they were both the co-chiefs at the time of my diagnosis. To give their writing some context I emailed them and asked them:

What was it like in the program after I was diagnosed? What kind of logistical barriers did my absence present? I knew you both before—what are your thoughts on my return?

 More importantly than chiefs, they are both close friends to Fleur and I. Gregory, or Greg as I call him, now practices Family Medicine in a small neighboring town. He was the one person in the program I would always bombard with questions—no matter what I asked him, he always seemed to know the answer. He is full of confidence, a trait that led him to proclaim on one of his first days in the residency, “Hi my name is Greg. I’m awesome.” It is this belief in himself along with the knowledge to back it up that made me want to practice medicine with him. I would often tell him in passing that once he graduated not to move too far and not to sign a long term contract so we could eventually open up a practice together. Greg has one of my closest friends since moving to Lansing- I regret not spending more time with him since the surgery, as I have not seen too many people since the diagnosis.

Me, Megha, Greg, and his wife
Me, Megha, Greg, and his wife

As an Emergency Medicine intern, the first call I placed was to Megha Tewari. She must have sensed my nerves as she said, “good job” at the end of our conversation.[1] But as time passed and I got to know Megha better, I realized that it was her big heart that allowed her to say those words to me. If I had to describe her to someone else I’d say “Megha doesn’t take any bull$*!% but she has an enormous heart. If she believes your intentions to be solid, then she will be your greatest supporter. If not though, then look out.” She reminds me a bit of my younger sister in that way. When I was in the hospital for a month, Megha would visit me daily, often bringing me great food.

I know they were indispensable to the program and wonderful physician, but more importantly they are both amazing people. This is what they wrote:

Gregory Lawson:

As physicians we are continuously faced with illness. Those we know about or those we would like to know about. Our job is to try to figure out how to help our patients feel better, be it physically or emotionally first by figuring out what is wrong then figuring out how to fix it. We do this day in day out, focused on our patient’s needs but with just enough detachment to remain objective. The question now remains what happens when the patient in question is someone close to you; what happens when the patient is you?

That is one of the many things running through my mind on that day when Chris left the residency continuity clinic at about 1pm saying he had an emergency. This was very uncharacteristic- My first thought was his son Christian. I sent a text soon after he left asking if Christian was the emergency and his response was classic Chris ” Oh God no, Christian is fine, it’s me thankfully” On one hand I was glad Christian was okay on the other hand I was filled with worry about what could possibly be happening to Chris.

My name is Gregory Lawson and one of many people that are blessed to call Chris a friend. At the time when this all started I was in my third year of residency and I was serving as one of the chief residents for the program. I remember getting a call later that evening from Chris telling me he just left the neurologist office and apparently there was a mass in his brain per the MRI. ‘They think it is benign’ and things are already in motion with logistics and processes with everything ending up with a proposed surgical excision soon. He would need to be out for a little bit and we would figure out coverage with regards to his calls and clinic patients. I remember asking him if anyone else knew and how we should handle communicating the information, at the same time keeping in mind that we do not have a complete picture of what was going on. What was interesting was his manner of delivery. Eloquent, concise and complete, I did not detect any fear or worry. In fact, I hung up the phone feeling reassured. That is one of the characteristics that Chris has that few physicians possess. He has a way to make you feel better just by talking to him. The effortless ability to reassure and encourage.

I got home and after a few minutes of going through our conversation in my head I realized that my objectivity in that situation was ‘waining’. The more I thought about a brain mass that was causing symptoms the more I became less comfortable. How does one deal with such information? I would imagine that with my patients I’d probably talk to them and then I’d refer them to a neurosurgeon and for the most part I am done with management until their recovery. How do you treat a friend and colleague?

On some level we all were in the Kluber Ross stage of denial, chatters of ‘we don’t know what it is’ , it might be a cyst’ it could be anything we can’t know much of anything until after a biopsy and therefore after surgery were all around. There was some sense of anxiety in the air even though everything appeared business as usual.

Chris had his surgery at University of Michigan. Through this time we were kept updated by his wife about what was going on at the other side. After a few days he was transferred to Sparrow Hospital. I saw a missed call from Chris on the day he was transferred to Sparrow hospital and he had apparently left a voice message on my phone.

The voicemail went something like “hey Greg, its Chris……some words, some more words…bye” Basically, the only words I could understand were, hey Greg, its Chris and bye and those were slurred. This was the moment that for me it became less abstract and more real. The emotions that coursed through me were fear, helplessness and a sense of anger at why this would happen to someone like Chris. I prayed for the first time in months. We had done some reading about epidermoid cysts after we initially heard about the diagnosis and apparently it’s very rare, therefore there was not a lot of information about it, much less about the outcome of surgery.

With this in mind it was important to figure out the logistics of how to manage Chris’ absence within the residency. How long will he be gone? What will happen to his patients? How will Fleur cope? Will there be family to come help Fleur who was close to term with Cormac? Would we need coverage for Fleur who is also a resident in the Program? What can we do to help? How much privacy can we ensure for them? Should the residents round on him? Won’t that be awkward? How far out do we anticipate we would need coverage?

One thing was clear; the whole program was on board as they are our Family.

Megha (who was the other co-chief resident at that time and one of our closest friends) and I worked on the task of filling in the calls that were assigned to Chris and some assigned to fleur while trying to balance the total amount of calls that each resident had. Most were gracious and we didn’t have to use the “c’mon he has a brain tumor” card. There is a delicate balance being friends with Chris and also having a responsibility to the program. Are we working based on what we hope for as opposed to what is more likely?

This is someone that is loved by everyone in the hospital, always received good evaluations from his rotations, someone that up until a few weeks prior we all went to a coffee shop to study, Megha and I for our certification boards and Chris for his USMLE step 3. Was that why he seemed to miss the stop sign, or why his car seems to not keep a straight line on our way to the coffee shop? Why didn’t he let us know he was having symptoms?

As I mentioned earlier, we don’t have a wealth of information about outcomes of surgery on epidermoid cyst and prognostic data. What we do have is Chris and the effort and strength he has. What we have is an ability to see the great improvements; from being unable to understand his voice message to now talking with him without any apparent deficits in speech. From him being in a wheel chair, to him climbing up and down the stairs. What we see is a continuous improvement and what we hope is for continued strength and perseverance.

I am not in a position to determine when we welcome him back to work but I can’t wait for the day when he comes back to work looking dapper as always, stethoscope on hand going to see his first patient.

Megha Tewari:

Cormac, Fleur, and Megha
Cormac, Fleur, and Megha

Chris asked what it was like in the program after his diagnosis. It seems that the overall sense I got was that everyone of us was affected by his diagnosis and subsequent surgery and recovery process. All of us had our own way of dealing with it. I am going to share the things I noticed at the time of his symptoms. This may be a lot or you may think it is a skewed opinion, but it is how I experienced that month.

“I am going to ask Chris to throw another poker night party”. This was my thought when I wentin for 8 am didactics[2] on Wednesday morning in March 2013 for our residency. I saw Chris come in about 10 minutes into the lecture, and leave within 20 minutes. This was very unusual for him. He is usually the first few residents to walk in to the lecture room, and the last one to leave. I didn’t pay any more attention to this and thought I would just talk to him next day during Thursday afternoon didactics. Being a chief resident along with Gregory Lawson, one of our job descriptions was to keep a tab of all the residents attending didactics every Wednesday and Thursday. I had become quite adept by this time, to notice when and who came in. On Thursday the following day, when I noticed that Chris and Fleur were both absent, I got a bit concerned. This was very atypical for Chris. The Chiou’s apart from being colleagues, are also one of our closest friends. I texted Chris to see if everything was alright. Fleur was in her last trimester of pregnancy at this time, and I was concerned for her health and the health of the baby. If you know Chris, you will know that he always responds to his texts immediately. When I did not get a response from him ‘red flag’ went up. My co-chief Gregory Lawson worked with Chris in the same office and is also a good friend of the Chiou’s, so I asked him if he was aware of anything going on. He implied that something was up, but was not quite sure. That evening Greg and I were studying together when he got a phone call from Chris. He spent about 20-30 minutes telling us what was going on. He talked about his symptoms, his recent onset of double vision- which ultimately made him talk with his PCP and get an MRI of his brain. We talked about the fact that he used to have headaches ever since he started medical school, and even joked about his gait being abnormal. He told us that they were not quite sure what was going on, but they were going to see a local neurologist and go from there. Hearing all this,I was quite taken aback. I had a 6th sense of something being off for that last 2 days, and I was shocked when we got this phone call. I was glad Greg was there. We talked with Chris and tried to be optimistic. Once we got off the phone, we spent about 2-3 hours going over logistical concerns and coming to the realization that if this was something serious, we would need to brainstorm ASAP to help figure out how to cover for both Chris and Fleur during their absence. At first, it was all about- how does this sort of thing happen/how can we help Fleur and Chris etc. Once the shock stabilized, we started shifting gears to practical decisions that needed to be made.

Megha, Greg's wife, Christian, Fleur, Cormac, and me
Megha, Greg’s wife, Christian, Fleur, Cormac, and me

Over the course of next 2-3  we worked on how to keep things smooth with the residency,while making sure Chris and Fleur had all the time and peace of mind they needed to deal with this crisis. When we started out, all we knew was that his MRI was “abnormal”. We talked about many ‘what if’ scenarios. I recall Chris was on an office rotation along with having a few weekend calls scheduled that he had to cover. Fleur, being towards the end of her pregnancy, was scheduled in the office. As chief I made all the call schedules for our inpatient service. I remember that by default I had loaded them with calls towards the end of the residency year. I wanted to make sure they were not worried or concerned about how to juggle residency obligations while going to see neurologists, getting tested etc. Greg and I had long discussions with our Program Director (PD), on how to work around this. It was his first year in our program as PD, and he gave us full reign to brainstorm. I was very appreciative of his thinking and thankful for his confidence in us. During residency things are very fluid and to have an inpatient service fully staffed by residents 24×7 is a challenge as things can change last minute. So not having to go through the process of getting things approved from our PD was a relief.

We started off by talking with residents who were on non-essential rotations like electives or on rotations that could spare a resident for a day or two. We know going in, that these last minute changes to schedules are always received with dissatisfaction and we were apprehensive going in. One of the things we noticed was that few of the third years (senior residents) had a tougher time agreeing to do more shifts on the inpatient service. They challenged our every decision and gave us the impression that they had no faith in our leadership. Usually, the inpatient service is more taxing because of the hours we work. The shifts are usually 12- 14 hours, and may include overnight shifts. So when we asked our seniors to assist and help out, we were met with some resistance. This was a very surprising and shocking thing for us, since these people were our colleagues (and close friends), Greg and I expected them to be the frontrunners in volunteering for coverage. We had known them for the last 3 years and it was disappointing to see that they were the ones who did not support our decisions. We were blamed for overloading them towards the end of residency and not giving them time for their family. On the flip side, the second years, the residents who were in the same year with the Chiou’s went above and beyond our expectations. Some of them, like Shimia Isaac even cancelled their vacation to help cover. I was taken aback at the positive response most residents had. Even the ones who never volunteered for extra work, came forward to do whatever it took to help the Chiou family. It was a humbling and a teaching moment for us to see their love and support for Chris and Fleur.  Another interesting situation that we faced was how to manage keeping our outpatient offices fully staffed while borrowing residents from the office to cover inpatient service. We have anywhere from 2-6 residents in each office every day to see patients in the outpatient clinics/offices. Patients usually can schedule appointments in the office 2 months in advance, and to take a resident out of office, meant delegating these patients to another physician or canceling their appointment.any an attempt, 4-6 hour shifts we managed to cover that entire week successfully. Patients were happy with their care. The week ended with half of our residents being mad at us, and the other half applauding us for being able to juggle things at the last minute.I recall that every time I would see Fleur during this time period, she would apologize for the inconvenience and told us how grateful she was for making sure things remained smooth in the residency. If this was the least I could do to help them, I tried my hardest to make sure they had nothing to worry about regarding their residency obligations.

Personally, I don’t think any of this was hard. Our residency makes us feel like we are a part of a big family. Having something happen to one of our own, we banded together to keep our loved ones/ our friends and seeing kindness and genuine goodness in our Family Medicine group was an emotional time.

 

[1] I mentioned in an earlier post that telephone conversations from the Emergency Department are usually contentious, and typically end with the phrase “you don’t know what you’re doing!” or “you’re an idiot!” I’ve never heard of a conversation ending with “good job”.

[2] During our third year of residency in FM, we have lectures, and workshops 5 hours every week. These are referred to as didactics. One hour on Wednesday morning, and 4 hours on Thursday afternoon. Along with getting some education, we also use this time to socialize with our fellow residents. Even though we are in the same residency, due to different rotations, office locations we usually only get together as a program during didactics.

Residency Part 2…

———– Work vs Learning ————-

During one of my interviews for residency one of my interviewers said something very poignant to me that I always am reminded of when I think of residency.  This was a Program Director of an Emergency Medicine program who said to me, “Chris, residency is a balance between learning and work.  There are some places where the residents are put to too much work, and their learning takes a hit.  There are also some programs, where learning is over-emphasized and they do not get enough work.”  Most residents feel over worked[1] even though most interventions in the past several years has been put in place to protect against this notion of overworking residents.  Hence the job of finding this delicate balance between work and learning becomes the responsibility of the program.

Funny cartoon summarizing residency
Funny cartoon summarizing residency

 

—— The Tumor and the Program ——

image

I remember it vividly, it was a Wednesday morning and I was scheduled for clinic that day. I finally decided to pay a visit to my Family Physician to tell him of my double vision. I remember that I had volunteered to help teach the MSU medical students that afternoon. Upon being told of my MRI and appointment with Dr. Kaufman, I quickly left the clinic, only telling my supervising physician that an emergency had arisen and that I had to leave. I left in such a rush that I left both my hat and gloves on my desk. With questions swirling and rumors flying surrounding my absence, I emailed the program to clear the air. The email was as follows:

Dear Friends,

As some of you may know by now, I am having to take an unexpected leave of absence due to medical reasons. I consider you all my family and would like each of you to know what is going on. The last 3 days have been a bit of a whirlwind between testing and seeing specialists etc that I haven’t had a chance to tell everyone individually. But you are all like family to Fleur and I, so we want to let you know what is going on: Starting this past week I have had disturbing symptoms of progressive double vision. I finally told my PCP (Dr. Pearson) on Wednesday who without hesitation sent me for an emergent neuro consult w/ Dr Kaufman. An MRI of brain/brainstem was done that day which showed a brain mass in the cerebellar region/posterior fossa. Dr Kaufman quickly referred me to Dr. Smith the neurosurgeon. We also saw a neurosurgeon at U of M today who recommended expeditious surgery. Our understanding thus far, is that the lesion is likely benign (epidermoid cyst vs subependymoma), but will have to wait for the pathology to rule out malignancy (ependymoma). I am currently scheduled for a craniotomy w/ resection this coming Thursday. The recovery is expected to be somewhat slow, with initial stay in the ICU, and hopeful discharge within 5 days, however the surgeon indicated it could take 4-6 weeks until I could consider returning to work. I know this is a challenge from a scheduling perspective and greatly appreciate everyone’s understanding for his. Fleur and I are especially grateful to Megha and Greg for dealing with all the last minute schedule changes this has caused and to all those who have offered to do upcoming calls and inpatient coverage for us. Fleur has been incredible throughout this whole ordeal, but my only fear is that this is distressing her more than she is letting on- my only plea to you all is that if you are in contact with her and notice that she is not handling this as well as she lets on to me that you let me know or someone know. The outpouring of support from everyone has been amazing, I have long considered you all my family and going through this experience has only solidified this belief. I will keep you up to date on the latest.

Chris[2]

Everyone in the program emailed me back with their support. Even though part of the reason for the e-mail was to quell any false rumors regarding my absence, I meant every word in that e-mail. I considered everyone in the Sparrow FM residency program to be part of my family—I had grown close to each and everyone in the program and wanted them to know of my situation.

It has now been almost 15 months since that day, and I am still yet to return. I know that while this process has been tough for me and my family, it also has been hard on the program, not only dealing with technical issues such as replacing my calls and covering for my patients but also in having to handle a missing team member.

 

[1] In fact check out this great, brief article on work hours: http://www.npr.org/blogs/health/2012/12/04/166477987/medical-residents-work-long-hours-despite-rules

[2] You’ll notice in the e-mail I predicted a return to work in 4-6 weeks. Did I mention I’m always too optimistic when it comes to my recovery?

Residency part 1…

Today and Friday I plan to devote posts to residency. I have been asked what the reason is for devoting space and taking up your precious time with a post about residency? My thinking is that these posts serve several purposes: next week I intend to release an article with the point of view from different residents in the program—both from the then chiefs and also from the chiefs from my year. More importantly they are all close friends of mine. Their posts will focus on the various logistical hurdles that my absence created. Thus for this reason I thought it necessary to give you a taste of our program. I also wanted to provide a small sample of what our program and residencies are like. In writing this, I realize how unrealistic it is to expect to explain all of residency in one or two posts but my hope is to at least shed a little light on the inner workings of our program. In doing this, I’m hoping some of the groundwork is laid to portray the issues that my absence created.

——– Applying ————

Every year starting in the fall, medical students begin the process of applying to residencies around the country in various medical fields.  Much of the fields these future physicians hope to go into are based upon scores they achieve on the USMLE Step 1 test.[1]  This is a standardized test that all medical students take after their second year of medical school.[2]  The pass rate for this test has been sometimes cited as low as 75%.  This may seem high, but when one considers having ‘invested’ 2 years’ worth of tuition (as much as $60,000) and then having a standardized test halt a quarter of these paths, 75% doesn’t seem so high any more.  If on the day you received your score, you were lucky enough to both pass and obtain a high mark, then you would probably start thinking of the medical specialties that ‘fit’ your score. I was lucky enough to both pass and have my score fit into the range of the specialty I wished to enter: Emergency Medicine.  Then, for most, the next step in the process (after applying) is attending various interviews.  Some applicants decide before the interviews that they wish to stay within a certain radius, thus rejecting any interviews outside of this radius (or not applying there in the first place).  For me, this was a little bit more complicated as my wife was applying to various Family Medicine residencies and we had to go through what is called the Couple’s Match.[3]   It turned out that whenever I really liked a program she hated it, and vice versa—this made deciding on a place difficult.  Luckily, there was a place that we both agreed on and that was in Lansing, Michigan at Sparrow Hospital.  After a program is selected, students then create a ‘rank list’ of places they wish to attend.  Each program also creates their own ‘rank list’—ranking the applicants they desire the most.  A computer program then matches these preferences taking into account the student’s preference first.[4]  Both my wife and I liked the Sparrow programs and thus ranked them #1.  We found out on Match Day[5] that I would be training at the Sparrow Hospital Emergency Medicine program while she would be in the Family Medicine program.

Table showing the average USMLE scores divided by specialty on the Step 1 exam
Table showing the average USMLE scores divided by specialty on the Step 1 exam

In June of 2011 we moved to Lansing to begin our training.  The time of training varies from specialty to specialty.  For example, most surgery residencies require 5 years, while most Obstetrics and Gynecology residencies are 4.  For most Emergency and Family Medicine (FM) programs this number was 3.  However while the number of years to complete a residency varies, the first year of it (known as intern year) was generally the same, filled with the same month to month rotations.[6]  There are a few ‘free’ months during this year, where training typically takes place in the specialty you are in.[7] Towards the end of my intern year, after spending quite a bit of time in the Emergency Department, I made the decision that I no longer wished to practice Emergency Medicine and hoped instead to enter into FM.  After going through an application process I was welcomed in to the FM program and because most of my first year rotations were the same ones completed by the FM residents I began my journey in FM without having to repeat any rotations or years.

——– Sparrow Family Residency ————

residency

Every residency program is unique and so operates in different ways; one of the aspects of the FM residency program at Sparrow that made it unique is the fact that they run their own inpatient service in the hospital—meaning any person that is admitted to Sparrow Hospital that is a patient in any of the FM residency clinics, is managed by the FM inpatient team.[8]  This means that 24 hours every day, someone in the program must be ready to take an admission.  That also means that every day someone must be available to ‘round’ and manage the current patients.[9]  Typically, the FM residency has somewhere between 10-20 patients on their list to round on.  Logistically we have 8 residents per year, and given that the residency is three years makes for 24 available residents.  Of the 12 months in the year 3 months are devoted to our inpatient service, the other 9 months are for other ‘rotations’.[10]  The reason I go into this is to give you a taste of what it means to be a FM resident at Sparrow, and also in an attempt to give you an idea what a logistical headache scheduling can be.  The scheduling and placement of the various residents falls on the shoulders of the chief resident—in our program this is a third year resident who is voted on by both their fellow residents as well as the supervising physicians.[11] I only bring up the topic of chief resident, because in early 2013, prior to my brain tumor diagnosis I was ‘elected’ chief resident.

———- Chief ————-

The reason I put quotes around the word elected is because of the 7 other residents only 1 other person threw their hat in to the ring to be considered for the position.  We typically have two chief residents, thus no actual vote was needed.  I have no problem with this because I believe that had more residents been up for consideration I still would have been elected as one of the chiefs.  I have absolutely nothing against my fellow residents, and strongly believe that each and every one of them would have made great chiefs, but perhaps I have too strong a belief in my ability to do the job.  However, even the decision to put myself up for consideration was a struggle, and entailed many long discussions with the two prior chiefs Megha Tewari and Greg Lawson.  To me the advantages of being a chief were being able to give back to the program.  The only drawback to being chief would be the time it required: every conflict, scheduling or otherwise, would be the chief’s responsibility to ‘solve’.  With a wife and child at home (and one more on the way) I seriously wondered if I had the time to handle and properly devote to it.  But in the end, the opportunity to give back to the program outweighed any possible cons. Thus I chose to submit my name for consideration.

[1] I included a table of the average scores on this test and specialty.  Also, please know that there are exceptions to this- outliers if you will, i.e. there’ll be someone in psychiatry who scored a 250 on their Step 1 and a Plastic Surgeon who scored a 200.

[2]http://en.wikipedia.org/wiki/USMLE_Step_1.

[3] I discussed the Couple’s Match in a previous post.

[4] For example, if Jane Smith out down her top choice as Internal Medicine at UCLA but in turn was only ranked 5th by UCLA (assuming UCLA has more than 5 Internal Medicine spots) then this computer program would place Jane Smith in the UCLA Internal Medicine program.  However, if Jon Doe were to rank UCLA Internal Medicine number 5 while they in turn ranked him number 1—the program would first try to find if Jon’s number 1 ranked program was a possibility.

[5] A day in the end of March where medical students find out if and where they matched.

[6] The thinking is that every physician, regardless of specialty, should have some baseline level of medical training.

[7] For me this meant in the Emergency Department.

[8] This makes Sparrow FM unique because many programs and clinics simply ‘admit’ their patients to other services.  For example, if a patient of Dr. Doe came to the hospital and needed admission to the hospital, but Dr. Doe did not admit patients.  Dr. Doe would have made a (monetary) deal with another group, let’s call them The Doctor’s Group, beforehand that all of Dr. Doe’s patients, if requiring admission to the hospital, would be managed in the hospital by The Doctor’s Group.

[9] ‘Rounding’ is a term that denotes the daily visit and care for your patient.

[10] These other ‘rotations’ are either office months (where you are in the clinic for the month) or various other learning months where  you follow another specialty in hopes of learning from it (for example, a resident might spends a month with an orthopedic surgeon, learning some of the details of orthopedics.

[11] This works differently in other residencies- in some residencies simply reaching the final year of residency makes you a chief, in others the decision of who is the next chief is decided upon by the Program Director—the person who heads the residency program.

Dr. David Kaufman

In medicine a big deal is often made on who made the diagnosis.  I’ve run in to a few physician friends who had no idea about my tumor and their first question is: who made the diagnosis?  As much as I could downplay the discovery of the tumor as a step in this process, I have to say that without the diagnosis I’d probably be dead. Even though the suspicion and quick action by Dr. Pearson connected me with a neurologist, it was Dr. Kaufman who ultimately made the diagnosis.

I did not like Dr. Kaufman before I met him; he heads the neurology department here at Sparrow and has always been known as a tough person to work for. His residents often fear him, the only good words about him prior to our meeting actually came from a colleague of mine, and good friend, Noshir Amaria. He told me that he had known Dr. Kaufman since medical school[1] and that through his tough exterior he is actually a very kind man. Even with this prompting from Noshir, I still was skeptical of Dr. Kaufman. This completely changed when I met him on the day of the diagnosis. Not only has he been incredibly kind during this whole ordeal, constantly offering to help in any way that he can, but I realized that there is a method to his madness: in his eyes training future physicians is not a job that should be taken lightly, if properly training them means that they fear him, then so be it. I realized that he is kind to all his patients, not only me. The ultimate goal in this field is the optimal treatment of patients. By pushing his residents to learn, by being compassionate to his patients, and by being an incredibly hard worker he no doubt accomplishes this goal. He is a tall, imposing figure, but once I became his patient I now liken him to a ‘gentle giant’. I asked him to write a piece about the process of my diagnosis. He did not hesitate and immediately composed this:

Dr. Kaufman
Dr. Kaufman

 

An Atypical Clinic Day:

I just hung up the phone after talking to my good friend Randy Pearson. For the last two years I had spent every Saturday during the fall with Randy along with many Tuesday and Thursday afternoons looking after our university’s student-athletes in football. Randy proved to be one of the best doctors I had ever encountered. He is very well read but surprisingly low key. His style is simplicity in action. His mantra perhaps could be ‘common things occur commonly’. He is never upset, never worried and never in a hurry. Today’s phone call from him was different. He sounded worried, his was   voice ever so slightly upset and above all he made it quite clear he wanted me to see his family practice resident Dr. Chris Chiou right now.

“Dave, Chris is one of the nicest young men you will ever meet. He is one of my Sparrow residents in family medicine. He is in my office right now and he is complaining of a double vision. He says he has been unsteady for maybe a few months but after talking to him it may have been even years,” Randy then added, “I am a little concerned about him after examining him neurologically. I need him to see you today”.

When a man like Randy Pearson is ‘a little concerned’ there was no further need to talk to me about urgency. I asked that we get an MRI with attention to the posterior fossa right now and then send him over to my office as soon as it was done.

Although it has been a year since that conversation, I recall going to review the MRI prior to seeing Dr Chiou. This is something I very rarely do. I almost always examine the patient first, come to a clinical conclusion and then confirm with the imaging. However, not this time. I realized as soon as I saw the plum-sized mass in this young doctor’s posterior fossa his life was about to change. The tumor was putting pressure on his cerebellum and had the most vulnerable part of the central nervous system, the brain stem, in harm’s way.

Even prior to seeing Chris Chiou I realized based on my thirty years of being a neurologist, this was not going to be a picnic. He needed a neurosurgeon to evaluate him within the day and the path for Chris, a man I had never even formally met, would be brutal or if unlucky, much, much worse. Yet, I also realized that something Randy said actually gave me hope. “The symptoms were there for months or maybe years” I recalled Dr. Pearson saying. If that was true, the mass could well be benign and maybe even curable if neurosurgery could be performed in an ultra-delicate but timely way.

I then walked in to meet Chris knowing I would have  to tell him something no man wants to tell another. Yet I had to do it in a way that did not shatter him so he would stop thinking or be unable to act in a timely way. I also needed to let him know there might also be a chance this could be cured. Given the years spent in talking with people about such issues I also knew if I created panic or was unable to establish a bond of trust, all the work Randy had done to move him through the system quickly could be undone, setting back the process inappropriately.

When I opened the exam door to talk with Dr. Chiou, what I saw almost brought me to my knees. I was not at all distracted by his fit and athletic features, good natured personality and smiling face. Nor did the upbeat demeanor of this young primary care resident, who appeared to be in the absolute peak of health, startle me.  It was not Chris’s calm and poised manner. What stopped me cold was the person sitting next to him. It was his petite, very pretty and elegant physician wife Fleur that stunned me.  By all appearances she must have been more than eight months pregnant. I silently thought to myself: ‘all of this and Chris also has a wife about to give birth any second’.  Yet there they were. Husband and wife. He with an ever present smile and she arm in arm with him to provide her support for whatever was ahead.

I took a very deep breath and introduced myself. I pointed out I was David Kaufman, chief of neurology here at MSU and also at Sparrow. I was nice and proper but all the while thinking this is too much for any couple to bear. I said in a fairly formal tone: “Chris you have an issue we need to take care of.”

Dr. Chiou looked up at me with his ever present smile while I talked. When I was done, the smile was just slightly less than when I walked in the room. Then he said, “Dr. Kaufman, I certainly know who you are and your receptionist also let me know I have had an appointment made by you to see one of the neurosurgeons.” Fleur looked at the floor just for a second and then raised her eyes and looked directly at me while hugging Chris’ arm just a little tighter. I then turned to Chris, and noticed the smile returning to his lips. He quietly asked, “what am I dealing with?”

In those ten seconds I realized I had walked into a room filled by two of the most remarkable people a person could ever meet. It also struck me maybe these two would beat this thing, get their baby delivered successfully, adapt, go on with their lives and continue their love for one another.  Only a doctor is allowed the privilege to meet and then help such remarkable people at the moment of their greatest need. The fact this couple happened to be two young physicians at my own hospital, just starting their lives together made it beyond a privilege in my view. It was essentially, spiritual.

I examined Chris and confirmed he had a cerebellar-like syndrome. He had classic rotatory nystagmus with a down beat component. There were subtle signs of dysmetria and a gait that was ever so slightly wide based. I also determined he most assuredly had increased intracranial pressure, but his visual system was fully intact with no loss of peripheral vision from the pressure. Most importantly there was no sign of impending brain herniation that could cause sudden and extreme worsening. That reality gave us the luxury of time. We had an urgent but not emergent situation. This is always a blessing when trying to map out the safest and best therapeutic strategy.

I then turned to Chris paused and then thought for a moment.  I asked him to confirm what Randy had mentioned to me just a few hours before. “Your unsteady feeling, did it just happen or was it going on for months.” Fleur answered, “I think Chris has mentioned this to me for years. Yes I am pretty sure of that.” He nodded yes and for the first time, I found myself smiling right along with Chris, as I realized he now had a chance.

Dr. David Kaufman
Dr. David Kaufman

Epilogue

Chris asked me to write about our first encounter. A year had come and gone. Randy and I spoke about the series of events that happened to Chris only once during that year. I had followed Chris’s situation from afar, seeing him only periodically and then realizing I had little left to offer him.  Then just a few weeks ago he walked into my office. In he came with that smile, his year old baby and physician wife at his side. I told him “I know the biopsy is benign, the follow up MRI was clean and so far so good”. Chris’ gait was a bit unsteady but otherwise was absolutely with the program. I then leaned in and said to him, “what are your plans?” He told me: “I want to go back to work and start helping people”.  I found myself agreeing right along with him as he flashed that impossibly bright smile. I then wondered to myself what other life, except that as a doctor, allows a person to witness such things and meet people like Chris.

 

 

 

 

[1] Dr. Kaufman is a professor at Michigan State University’s medical school.