Reflections from a Teacher at Grady: Growing, Growing, Grown. . . .

"Life is Change. Growth is optional. Choose carefully."
-Unknown
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"We think she should stay in house for a cardiac catheterization," said the young, female Cardiology fellow consulting on our patient. "This EKG is concerning. . .definitely a change from her prior."

Okay, so confession: when I first saw that EKG, I wasn't 100% sure if some of the changes were worrisome or simply related to underlying disease. That's why I'd decided to review it with an expert. She held up the shiny piece of paper with its tiny pink gridwork embossed with black ink and squinted her eyes. Such a simple tool, that piece of paper--yet it holds so much information. The electrical activity in the heart, represented by the EKG tracing, can be the difference between life and death, or in this instance, home or the hospital.

"Thanks for your help, as always," I replied with a warm smile. She returned the gesture. I leaned forward on the nurses station with folded elbows and glanced sideways. "So, things are going okay for you?"

"Really good, actually," she answered while placing her pen down. The business part of this discussion was over. "You?"

"Girrrrrllll. . .busy as ever, but you know that's how I like it." I patted my hand on the growing stack of patient cards in front of me.

"That's for sure, Dr. Manning!" she responded. I narrowed my eyes and cocked my head sideways. She tapped her hand on her forehead lightly. "Oh that's right-- Kim! I'm sorry, Kim, I'm still getting used to that!" We both laughed.

I gathered up my billing cards and stuffed them in my pocket. "Thanks again, Tenecia, I appreciate you schooling me!" She gave me a quick hug and scurried off to see the next consult.

As I watched her walk confidently down the hall, I thought about the first time I met her. We sat in a circle of ten chairs in my colleague's office. She was a smart and spunky first year medical student participating in an "End-of-Life" Care learning group several years before. I still recall those earnest and incredibly green questions that she, and all her classmates for that matter, asked of us.

"Can't you just ask the person if they want to be off of life support? Like if you listen carefully are they able to talk?"

Uhhh, no. (How were they to know that no one talks with an endotracheal tube down their voice box--Bless their hearts.) So fast forward to 2009 where now Tenecia and former students just like her are now answering my "special" questions. The teacher has become the pupil. (Bless her heart.)

***

I have decided that one of the very best parts of my job is watching my students and residents blossom into mature clinicians before my very eyes. Their once ginger and nervous gestures have slowly become more deliberate and their statements, formerly with the intonation of a question, are now firmly punctuated with a solid period of authority.

This past month, I worked with Sameera A., a third year resident, on the wards. I've had the pleasure of supervising her before-- we work together in her weekly Internal Medicine continuity clinic. Her work product has always been meticulous and her care of patients thoughtful and complete. However, like many interns I've met over the years, Sameera was still learning to come into her own. Searching carefully for that balance between confidence and humility, firm and inflexible, pleasant and passive. It's such a delicate line. . . . .that generally gets mastered with only time, trial, and experience.

"I think we should keep this patient at least another day," Sameera stated to me on rounds one day with resolve. I had just suggested we discharge this young woman from the hospital with what we suspected to be a community acquired pneumonia. Sameera was concerned that there was more work to do. I decided to challenge her.
"She has no oxygen requirement, and she doesn't have a fever any more. What will you do differently if you keep her here?"
Sameera stood her ground as the entire team quietly watched. "First, I'd like to consult Infectious Disease, or at least discuss her case with them. That x-ray was pretty bad, Dr. Manning. Also, if her HIV antibody is positive, this will change things, and we don't have that information yet." The team looked over at me. Your turn.
"Okay. So even if her HIV antibody is positive. Again, what will you differently? She has clinically improved, and regardless of what Infectious Diseases says, the most important thing is her clinical appearance," I countered eyebrows raised. Eyes back on Sameera. Ooooooohhhhhh.

Sameera continued her seering eye contact and paused for a moment. Her words were always thoughtful. "I will assist her in getting outpatient management for HIV. I will have a social worker and an HIV educator come and talk to her about what it means to have HIV if she indeed has HIV. I will know for sure that she has this information and won't stay awake at night hoping she comes back to the clinic to get an HIV diagnosis." The spectators swung their heads in my direction. Take that, Manning.

I nodded my head slowly, eyes still locked on my resident, and tapped my billing card on the chartbox. I glanced over at the team and shrugged. "The boss has spoken. The patient stays. Let me know what the HIV antibody is and what ID says." I winked at Sameera and watched her stand just a little bit taller as we moved on to the next patient.

I'm pretty sure that Sameera would not have spoken with such conviction during those first clinic encounters of her internship. Even with such exceptional patient care, like most novice physicians, she needed some time to get her chops, spread her wings, and believe that she, too, was everything that we thought she was. That process takes some time. But, if this month hadn't revealed anything else to me, it revealed one thing for sure. This resident had arrived. Somewhere between internship and third year, Sameera had really arrived.

Later on that afternoon, I joked with Sameera and the team that they should be careful not to cross Sameera's alter ego "Samantha."
"Don't let the sweet exterior fool you," I quipped, "Samantha lays down the law, takes no prisoners, and is a hard core patient advocate. . . . she's never mean or unprofessional either--but she will put you in your place. Just when you think you have all the answers, Samantha hits you with some medical literature and says, 'I don't think so, boo!'" We all erupted into laughter. They, too, appreciated Sameera's growth into full on "big girl" status.

For the rest of the month, we made whimsical references to the Sameera/Samantha supergirl combination. It was an affectionate way to say that she had indeed begun to achieve that delicate balance that only Father Time can provide, and that some young doctors, unfortunately, never quite attain.

At the end of the month, I decided to put the jokes aside, and to be specific. "Sameera, it's been awesome seeing you grow up. I know I joked about the Sameera/Samantha thing, but what I was really saying is that you have really matured into a well-rounded physician. You articulate the patients' needs and management so well, you have learned to handle having authority, and also you are an exceptional leader and role model to the interns and students." (I figured 'great job this month' wouldn't be as meaningful.) I went on to describe instances where she excelled as a leader. The day she helped a family navigate the difficult decisions involving care for their dying loved one, the time she offered gentle feedback to a medical student which ultimately brought out the best in him, and the day she carefully pushed consultants to clearly communicate a plan for a complicated patient. I nearly got choked up, because her wide eyes during the discussion were so reminiscent of those from her very first day in the clinic nearly three years ago. . . earnest and green. . . . . but this time, I knew they were knowing and mature. Sigh.

Sameera a.k.a Samantha at work

"Thanks for letting me grow," she replied. Still that unwavering eye contact. Knowing and mature. "It felt good to be trusted to make decisions."

My eyes smiled with admiration. "Sameera, I took off the training wheels and walked behind you, just like someone did for me. It's tempting to hold the back of the bike the whole time, it really is. . .but you never learn to ride that way." I scanned her face to see if she understood my analogy. She did. I went on. "Now it's up to you to do the same thing for your interns and students. I'll be walking behind you, and you'll be walking behind them. You can grab them before they fall, and I can grab you before you fall." She closed her eyes and nodded, taking in the mental image.

I placed my palms down firmly on the table and added with a wide smile,"And you know what's really cool? Don't you know I'm grown, and I still have folks walking behind me?" She softly giggled as I allowed my mind to wander to my mentor, Dr. Winawer, my many colleague-friends, my boss, Dr. Branch, and my former Chair from residency--all of whom I still consult regularly. Still walking behind me. I meant that statement.

That feedback session ended with a hug. It was truly a delight to see her ride without training wheels that month. . . . just as it warmed my heart to have my former first year medical student teach me about the subtleties of reading EKGs. . . .and, in a way, walk behind my bicycle. Full circle.

Growing, growing, grown. . . . .

Right before your very eyes. . . . .if you don't take pause, they'll grow up and you'll miss it. Today, I am taking pause. Appreciating my role in all of this crazy medical upbringing . . . .and taking it very seriously. Perhaps a snotty remark from me to a nurse way back when might have affected Tenecia's ability to be warm and helpful during her Cardiology consults. Maybe if I had humiliated Sameera in clinic, she may have done the same to our students that month. Who knows?

The best part of all of this? I'm growing, too. With every student, every patient, and every resident, I'm slowly but surely mastering that balance just a little bit more each day.

"Life is Change. Growth is optional. Choose carefully."

-Unknown

I choose growth. :)

Me and Tenecia, my first year med student turned Cardiologist and teacher

Zachary finding eggs "all by myself" for the first time last Easter