Fall 2024 Program Director’s Blog
October 15, 2024
Fall is upon us and some notable events should be noted. Matt MacDonald has left the institution after completing his residency, his chief residency and several years as a hospitalist and Associate Program Director. He will be moving to another state. In his place we have appointed two new Associate Program Directors. Andrew Moses, MD completed his medical school at Florida International University Herbert Wertheim College of Medicine and completed his residency right here at Lenox Hill and his fellowship in nephrology at Columbia New York Presbyterian Hospital. He returned to Lenox Hill a few years ago and began teaching bedside ultrasound skills to faculty and residents. He now joins the team of Associate Program Directors for the Internal Medicine training program as Associate Program Director for POCUS training and Specialty Bound Residents. This appointment fills a need we have had for some time for an Associate Program Director with familiarity with the fellowship application and match process. We have also elevated one of our core faculty members to Associate Program Director rank. Dr. Asmaa Bousserhane completed her medical schooling at University Hassan II in Casablanca, Morocco and her residency training at Lincoln Medical Center in the Bronx. She has been a hospitalist and core faculty member for several years and has a particular interest in quality improvement.
In other news, all of our chief residents have once again passed their Board Certification Exams and continue to help us provide the best possible education and training.
OSCE’s have been completed for the PGY 1 and 2 class and a new year of QI projects are being proposed. This year we will be condensing quarters 3 and 4 of the QI curriculum and adding a new section on evidence-based patient safety processes. We are also encouraging more reporting of medical errors to our system wide electronic medical error reporting system.
On a personal note, I am currently appearing in yet another community-based theater project. I am playing one of my heroes; Dr. Abraham Van Helsing in the show “The Passion of Dracula”. Below are some photos of my character interacting with Dr. Seward, Mr. Renfield, and others.
So long until next time.
Welcome to the new year: Academic 2024-2025
As June heated up, so did the Lenox Hill Internal Medicine Residency Training Program. June saw our usual parade of events, the end of year variety show, the final rising PGY 2 and PGY 3 retreats at the Institute for Culinary Education, Resident Grand Rounds of the Year (given so well by Boze Susac on the rationale behind lowering the screening age for colon cancer to 45), Research Day with 8 poster presentations in front of two outside judges (Dr. Larry Wolf, PD of IM residency at South Brooklyn [formerly Coney Island Hospital], and Dr. Gary Stallings (PD of IM residency at Northern Westchester [a Northwell sister program]). Prize winners were:
Third prize was Peanut allergies – Devisha Patel
Second Prize was Cardiogenic shock – Moe Bayat Moktari
First prize was GLP1 inhibitors and colonoscopies – Sam Rubin
All awards to the winners were doubled once again by Dr. Stuart Orsher as they were last year!!
Next was graduation:
The ceremony was hosted by Dr. Ethan Fried and Dr. Dan Dunham and the commencement speaker was Dr. Todd Barton, Professor of Medicine, Infectious Disease attending and Internal Medicine Program Director at the University of Pennsylvania. Dr. Barton gave our graduates wise advice about following their passion and treating every patient as an opportunity to relieve suffering and learn something about the human condition. Dr. Ben Eschenheimer was the class speaker and recalled the events of the last three years and congratulated each of his classmates individually. The event was attended by graduates of the residency, all of the fellowships, the preliminary interns, family members, faculty and even supporting staff of the training program.
Dr. Cyndie Im and graduating senior resident, Dameel Edwards, played a musical interlude on piano and euphonium.
Awards were distributed as well. The past and future Chief Residents congratulated the
Outstanding Preliminary Intern of the Year: Olivia Reyes, MD
Outstanding Categorical Intern of the Year: Rebecca Zeidman, DO
Outstanding Categorical Resident of the Year: Vincent Dong, DO
Outstanding Resident Grand Rounds- Bože Sušac, M.B., B.Ch.
House staff Appreciation Award went to Ms. Samantha Napoleon, our Training Program Administrator
Dr. Dunham congratulated the recipients of the
Patient Advocate Award: Sana Ahmad, MD
Research Resident of the Year: Natasha Vartak, DO
Associate Program Directors, Cyndie Im and Kate Killian congratulated the recipients of the
Fein award for Best Resident – Kolton Smith, DO
The Lawrence Smith MD Award for the Underserved Community Medicine: Simran Parmar, D.O.
Excellent in Ambulatory Care: Nicole Oslance, DO
Alexander Rimar, MD gave out awards for excellence in Palliative Care to
Palliative Medicine Awards (PGY1): Inez Timoney Gomez, MD
Palliative Medicine Awards (PGY2): Alexandra Young, MD
Palliative Medicine Awards (PGY3): Peter Wan, DO
Finally, Dr. Fried awarded the remaining named awards as follows.
Leon Hess Memorial Award: (Best Fellow) Zein Kattih, M.D.
Michael Michelis Award (Research): Nikhil Sharma, M.D.
Dr. Stuart Orsher & Gladys George Professionalism Award: Christian Voto, D.O.
This was the first year for the Orsher/George award.
Lastly Drs Rahul Kurapati and Matt MacDonald read the names of the graduates of the internal medicine program and each fellowship director introduced their fellow graduates. Each graduate received a specially designed cap in the Hofstra University colors of royal blue and gold and then the group turned their caps backward to recite the modern Hippocratic Oath for a Digital Age before turning the cap back around.
Here is where our graduates are headed next:
PGY3 Senior Destinations 2023-2024
Ahmad, Sana: Hospitalist at Locums
Bhandari, Peter: Gastroenterology Fellowship at Morristown Medical Center
Buttar, Irvind: Hospitalist at Huntington Hospital
Chandran, Jenica Gabrielle: Outpatient Primary Care with Northwell Physician Partners
Cimino, Vincenzo: Chief Resident at NYP Brooklyn Methodist
Dong, Vincent: Pulmonary/Critical Care Medicine Fellowship at North Shore LIJ
Edwards, Dameel: Hospitalist at Northwell LIJ
Eschenheimer, Ben: Hospice and Palliative Care Fellowship at Montefiore Medical Center
Floyd, Kayla: Advanced Cardiac Imaging Fellowship with the University of Kentucky
Goldman, Sarah: Cardiology Fellowship at Mount Sinai/Elmhurst.
Kleiman, Jeremy Dorf: Chief Residency, Lenox Hill Hospital
Kossack, Andrew: Chief Resident at Naples Community Hospital, FL
Mccuaig, Elizabeth: Primary care physician at Northwell
Melnick, Jillian: Hospitalist at Huntington Hospital
Shah, Sejal: Hospitalist at NYU Winthrop Hospital
Sharma, Priyanka: Hospitalist in Pennsylvania
Smith, John: Hematology and Oncology Fellowship at Baylor University Medical Center in Dallas Texas
Smoller, Rebecca: Cardiology Fellowship at Lenox Hill Hospital
Syal, Akshay: Primary Care Physician at UCLA
Vartak, Natasha: Preventive Cardiology Fellowship at Lenox Hill
Villarrubia Varela, Lourdes: Chief Resident at Montefiore New Rochelle.
Voto, Christian: Geriatrics Fellowship at North Shore LIJ
Wan, Peter: Hematology/Oncology Fellowship, Lenox Hill Hospital
Wilson, Brandon: Chief Residency, Lenox Hill Hospital
Young, Ta'loria: Chief Residency, Lenox Hill Hospital
Yunus, Shazada: Primary Care Physician at ChenMed Dedicated Senior Medical Center in Jacksonville, FL
In other news I was featured in another stage production. I played “Dan the anthropology professor” in Jerome Bixby’s “Man From Earth” in which a history professor at a small northeastern college admits to his professor friends that he is actually 14,000 years old and that he does not age.
That’s me all the way on the left being “professorly” – not much of a stretch.
Now it’s time for a new crop of first year residents to join us. I wonder how the year will go. Stay tuned and find out.
Winter/Spring 2024 Update
It’s been awhile since I updated my blog. But we have been busy here at Lenox Hill Internal Medicine. Personally, I have taken up a new avocation. For the past several months I have become active in community theater. I recently appeared in a local production of “One Flow Over the Cuckoo’s Nest”, a play by Dale Wasserman adapted from the novel by Ken Kesey. I was honored to play Charley Cheswick and I met a great group of veteran and new actors. It was extremely gratifying.
That’s me, second from the right.
In December we received our American Board of Internal Medicine performance report as well as our match results for the seniors applying for fellowship. Both were somewhat disappointing. Six graduates did not pass the Board examination and six seniors did not match into fellowships. This prompted a hard look at our program and the outcomes of our training.
We developed a new protocol to support seniors preparing for the Board examination.
1) All categorical residents will be required to take the annual American College of Physicians In-Training Examination (ACPITE) at least twice during their three years in the program.
2) Missing the ACPITE exam will only be allowed if residents are assigned to rotations that do not allow them to participate (eg: night float, night medicine). Individual reasons to miss the ACPITE will be determined case-by-case.
3) Residents who miss any ACPITE without authorization will immediately be placed on a remediation plan.
4) Residents deemed at risk for failure in their junior year (defined as having a percentile rank in their year of training of 21% or less) will be required to take the ACPITE in their senior year even if they have already taken the ACPITE twice.
5) An amount of $500 is available to all senior residents to use for Board Preparation materials or review cources.
6) Senior residents will “give back” $150 of the above $500 to help the department offset the cost of a subscription to Uworld ABIM test preparation questions for (6 – 12 months – to be decided).
7) Program leadership will be able to monitor the use of Uworld during this period and be able to remind senior residents that they must both use the question bank and work to answer the questions correctly.
8) Residents who do not use the question bank or who persist to have scores below 50% correct on the question bank will be placed into a remediation plan.
9) Incentives will be used to reward residents who complete Uworld sections and to those who answer questions correctly.
10) A bi-weekly board review group known as “Didactic Club” and consisting of senior residents who score at or below the 21st percentile for PGY 3s. Senior residents assigned to Didactic Club MUST attend 80% of sessions. All senior residents have the option of joining these meetings.
11) Residents assigned to Didactic Group who fail to attend at least 80% of these sessions will be placed into a remediation plan
12) Finally, residents who attend 80%+ of didactic club meetings and who keep up with UWorld use will be greatly subsidized to take an intensive Board Examination Review course like “Awesome Review”, possibly up to the full cost of the course.
Our intent is to provide support to seniors preparing for the Boards. However, we recognize that it is the seniors themselves who must have the discipline to take full advantage of this support.
Next, I need to address the fellowship match:
At this time I want to heartily congratulate the nine seniors who successfully matched into fellowships to begin in July 2024. They matched into Allergy/Immunology, Cardiology, Geriatrics, Heme/Onc, Palliative Care and Pulm/Crit. Two of these matched into fellowship programs at Lenox Hill and an additional three matched into other programs in the Northwell system.
Unfortunately, six seniors did not match. They were hoping for fellowships in Gastroenterology, Cardiology and Rheumatology. These three fellowship matches were extraordinarily competitive this year. In Rheumatology there were only 3 unfilled fellowship positions in the entire country. Gastroenterology and Cardiology also filled more than 95% of their positions through the main match according to a press release from the NRMP. In cardiology, only 40% of applicants successfully matched.
Our training program has looked carefully at current practices and created a new set of maneuvers to support fellow seeking seniors. It begins with a fellowship information session. At the end of March. Like last year, this will consist of fellowship directors from Lenox Hill describing what they are looking for in their applicants. Then graduates who have successfully matched will describe their journey. We will also discuss the construction of CVs, Personal Statements and requesting letters of recommendation. Soon after that we will host a research night which will include brief presentations about research design and statistical analysis followed by opportunities to sign up for projects being done in each division.
Over the past year, our Hematology/Oncology program added two additional fellowship positions and our Gastroenterology program added three. Our Cardiovascular Disease program is in the process of requesting 4 more additional positions. Independent Clinical Fellowships in inflammatory bowel disease, preventive cardiology, and cardiac imaging continue to be offered as alternative fellowships helping prospective applicants to improve their applications and get known by those divisions.
A new set of 21 suggestions to improve the chances of a successful match have been published on cafeloggia.com at https://www.cafeloggia.com/fellowship-2024
We are encouraging the continued activities of specialty interest groups that can meet and discuss clinical and scientific developments, mentorship, and where residents can get to know members of the division.
As the academic year winds to a close we will begin the process of writing letters of recommendation for fellowship bound rising seniors. These are uploaded to ERAS throughout June. Although ERAS officially opens in July we are aware that many fellowship program leaders take vacation in the summer and really do not start seriously going through applications until later in the summer. Nevertheless, we continue to reach out to fellowship program directors to remind them to review carefully our applying senior residents. Around Labor Day is the last big push to generate interview opportunities for our seniors.
As the fall approaches, we again remind our in-house fellowships to pay attention to our internal candidates and we begin to collect the top three to four programs for each applying senior. We cpntact those programs in November before the rank order list deadline.
Every day and in every way we hope to make our training program more effective in producing knowledgeable, confident, and successful internists ready to take on any challenge and have successful careers!
October 6, 2023
quarter two check in:
We completed last year pretty well and Quarter One went about as well as it could have. Another set of Rising PGY 2 and 3 retreats were held at the Institute of Culinary Education (pictured above). We elected to have the retreats very early in the year so as to put all of you in a good mood when the new ACGME resident survey was launched. That may have worked because the survey came out so much better. But I have a different theory. THE PROGRAM GOT BETTER. In our most recent survey, instead of 35 items having a compliance rate below 85% ther were only 20 items below that threshold. One of the things that improved dramatically was the perception that duty hours are not followed in this program. This perception led to a citation from the ACGME that persisted for 4 years. It was embarrasing. I am proud to say that in the most recent survey, compliance with the 80 hour per week rule improved from 77% to 88%.
Here’s how we did that. Firstly, we discovered that Medhub has a subroutine in it that deals with incomplete duty hour logs by taking the existing data and multiplying it by 7. So if you have a 13 hour day and you forget to log the other days of the week, Medhub assumes that you worked 13 x 7 = 9 hours! By going into the actual logs and making assumptions about days off and using more precise averages we concluded that most of the warnings sent out from Medhub are false alarms. Whenever possible, we sent notes to the individuals involved that a better estimate of their hours showed that they were in compliance and that no duty hour violation accured. By the way - the new HOUSE CUP program has dramatically improved our duty hour data collection. So there are fewer incomplete records and fewer false alarms. Secondly, we surveyed residents who had rotated through the rotation where most duty hour violations occured and found out that one or more of the attendings there were strongly urging people to stay beyond their scheduled hours “for educational purposes”. The faculty falsely believed that if people stay “voluntarily” “for educational purposes” then the hours did not count. We re-educated the faculty and the residents about this and the actual violations from that area dropped significantly. Finally, in another part of the hospital we found out about a faculty that was making rounds late in the morning but asking the night team to stick around waiting for them. We re-educated that faculty as well and gave permission to the night team that they could sign out to the day team and go home if rounds were delayed. Our true duty hour violations dropped out of sight there too. I am so proud that we were able to finally dispense with the pesky problem after 4 consequtive years of being cited for it.
Another area of concern that went away on the most recent survey was that teams were under the impression that they were admitting more than the limit of new patients in a 48 hour period. We measured the number of new patients distributed to the teams and found out that we were not out of compliance but it occured to us that people may not be familiar with who counts as a new admission. Let me say first, that an individual PGY 1 resident cannot have ONGOING CARE responsibilities for more than 10 patients. But if an intern is caring for 8 and four go home and 4 come in, they are still at 8 even though they may have interacted with 12 patients that day. The number is based on how many patients they have ONGOING CARE responsibilities. Similarly, a PGY 1 resident cannot have more than 5 new patients for whom they will have ONGOING CARE responsbilities admitted and up to 2 additional transferred patients in a 24 hour period and there must not be more than 8 new admissions for whom they will have ONGOING CARE responsbilities plus 2 transfers over a 48 period. When we studied the distribution lists, we were no where close to those numbers. It is likely, that when answering that question people were counting patients that never came to them for ONGOING CARE. A misunderstanding.
But the news is now all good. A significant number of people were dissatisfied with the quality of teaching by their hospitalist attendings and also dissatisied with the amount and quality of the feedback from that group. Since the survey we have conducted three great faculty development sessions with the faculty and we have begun observing attending rounds and giving feedback to the attendings. We hope to teach them how to establish an environment of inquiry (which is defined as a learning environment in which answerable clinical questions can be asked and answered through library and other work over the course of he day. Clinically answerable questions can take the form of PICO (population, intervention, comparison, and outcome). Check out the signs about PICO posted in your residetn work rooms. As far as feedback we are teaching the faculty to embrace SFED (Subjective, Feedback about observed events, Encouragement about the elements that went right before giving Direction for the future about elements that need to improved). We hope that these sessions will improve their performance of this vital task.
The last important theme in this year’s survey results is the amount of non-physician work that residents feel they are doing. There are four activities to which this commonly refers: transportation, phlebotomy, intravenous lines, and setting up post-hospital follow up appointments. A couple of years ago, residents set up nearly all follow up appointments but with the hiring of Tamone and some other adjustments we hope that most of this went away, especially for the patients for whom dicharge was predicted in a timely way. Transport is not really a problem at Lenox Hill although everyone should realize that accompanying a critically ill patient who is being transported to a test is not the same as doing the transport yourself.
Since COVID, however, phlebotomy services and some IV therapy services have deteriorated. This was due, in part, to many personel in those areas of the hospital leaving us. The program had several meaningful meetings with both phlebotomy and nursing to improve these services. Phlebotomy changed some policies including keeping a record of patients in whom blood was not drawn, allowing addons to be made at the time of drawing even if not ordered the night before, and they have identified a source of workers who can come in when there are excessive abscences. We have also met with nursing about IV setups and agreed that nursing education will be improved about IV setups and even using POCUS by nurses to obtain IV access. We hope that these moves will relieve a significant amount of these ill feelings about the program or the hospital.
In other news, we’ve moved the retreats back to the end of the year where they can have more of an effect on residents transitioning to the secind and thrid year. We’ve moved the Peabody Club debriefings to December and January where they may better inform peoples practice reather than the end of the year when people are disengaged and moving on in their minds. New conferences, new curricula (like POCUS) and new faculty are arriving every day.
All of this is in reponse to YOUR CONCERNS which are communicated to us in a variety of ways. We are not ignoring you. I know that our surveys will continue to improve.
January 19, 2023
Ask not what the program can do for you. ask what you can do for the program
Paraphrased after John F. Kennedy, President of the United States 1960 - 1963
OK, OK, Just this once you can ask what the program is doing for you. We have entered the third quarter of the year and, as such, we have once again entered the dreaded “Winter Doldrums”. This is a time when our anxieties bubble up to the surface and small inconveniences turn into major gripes. It is a time when insecurity is multiplied and burn out becomes acute. The treatment for this time of year is to start looking forward to Spring which brings with it the promise of change, promotion, motivation and a sense of accomplishment. So let me begin with a run down of the projects and changes we have worked on and have implemented on your behalf.
1) First of all, if you haven’t heard, we have chosen our Chief Residents for the 2024-25 academic year. They are Jeremy Klieman, Brandon Wilson and Ta’loria Young. Of course you also know that in a few short months we will thank Megan, Joe and Sam for their service and bring Josef Kushner, Madhari Inderam, and Danielle Sherlock into the Chiefs Office.
2) With the retirement of Dr. Ahmadi being imminent, we are getting ready to overhaul the Program Leadership. I can’t say who will be joining us but there are former Chief Residents involved. More to come as we finalize contracts.
3) A concerted effort is being made to fix areas of the program that are broken. Below are the 35 items from the Annual ACGME Resident survey for which less than 85% of you said we were compliant. Column two is the percentage of you who said we were compliant. Column three is the plan of correction for that item. I hope that you will agree with me that your concerns are taken very seriously by me and the hospital and that we work hard to correct these defects.
May 26, 2022
6 Black Update:
Hi everyone! This will be the inaugural edition of what I hope will be a regular feature of the Chief’s Weekly. There are a few things I want to share with you about myself, the program, and the hospital.
It’s been 206 days since I lost my wonderful wife and as we enter the new academic year, I am starting to see light at the end of the tunnel. For some time, I have been unable to go upstairs and round with you and I have been a bit emotionally unavailable but with the arrival of the new interns in July, I hope to resume a more involved routine. I am very grateful to everyone who supported me during my 2-month illness last year, Joan’s 7-month illness that followed, and the last 7 months since she died. As I have always believed, this is not something one gets over but rather something one must get through. Although this gigantic black hole still swirls around in front of me, I hope to be able to grow around it and be able to get past it without falling in.
Second, I want to thank all of you who sent responses to the “survey about the survey” from the ACGME. We are getting to understand the roots of the problematic areas of the program, and we are working constructively with our new Chair, Dr. Dunham, our new Interim Director of Hospitalist Services, Dr. Ornstein, our new Executive Director, Dr. Baker, our new Medical Director, Dr. Levy (you see, it’s not just hospitalist staff that are moving around) and others to address the issues.
On the subject of “teaching is a skill” we are resuming our faculty development activities. If you attended the rising PGY 2/3 retreats, you are familiar with some of the material we will be sharing with our faculty. Other topics will include the establishment of a good learning climate and moving toward learner control of the teaching session. Furthermore, to promote an “environment of inquiry” we are posting reminders of how to ask clinical questions using PICO (population, intervention, comparison, outcome) to make them answerable using the medical literature in all resident work areas.
Speaking of the retreats, how much fun was that? I will certainly be requesting to repeat the retreats at the Institute for Culinary Education or someplace equally as fun again.
On the subject of ‘non-physician obligations” Dr. Dunham and I are pushing the hospital administration to expand the discharge planning (post hospitalization appointments) program, re-establishing our formerly enviable phlebotomy service, and cooperating fully with the proposed switch to a new and more user-friendly electronic health record which will also include more facilities for completing patient paperwork by clerical personnel.
About the “Environment of Learning”, much has been done and more is to come. The library has doubled the number of workstations and deployed new computers to the carols. There are more new computers being deployed in several departments around the hospital in the coming weeks. New, armless, office chairs have been deployed all over the hospital and there are more ready to be delivered. They are armless because the arms seemed to be the first things to break on our old chairs. In addition, several resident workrooms are being completely renovated including the 7Uris 1 and 4 Uris 1 workrooms. Also, an exterminator has done a major inspection of the hospital and is beginning a rodent mitigation project that includes exterminating the duct system throughout the Loggia line, filling in access points, and eliminating the sources of food which apparently existed somewhere on 6 Loggia.
Once again, I want to thank you all for your patience as we recover from pandemic, financial, racial, and tragic events and reinvigorate our efforts to build the best training program for you and our patients. See you on the floors.
“The world is indeed full of peril,
and in it there are many dark places; but still there is much that is fair, and though in all lands love is now mingled with grief, it grows perhaps the greater.”
― J.R.R. Tolkien, The Fellowship of the Ring
january 26, 2022
It has been almost a year since I added to my blog. That’s because I have had the year from hell. Within a few weeks of my heart operation (see below), my wife was diagnosed with stage IV stomach cancer. Thus began a 7 month ordeal that ultimately led to her death. Even now, almost three months later, it is difficult for me to recall the events without falling into a deep sense of melancholy. Our journey led to so many discouraging walls that, in many ways, I lost much of my motivation to practice medicine. Today, I am rebuilding. Rebuilding my sense that we can relieve suffering, touch patient’s and understand their needs, give hope, apply science and humanity to the healing of patients, snatch victory from the jaws of defeat, and provide a learning environment that allows trainees to gain professional skills and knowledge. I am also rebuilding my own wellness and it is this that I want to share with you in this space.
How can you regather your strength and the balance you need to do your best in this highly stressful and out-of-balance environment? What, specifically, do we even need to gather? Where do you find the time? How can we make this effort when we’re trapped in this spiral of exhaustion?
I have an answer to the last question. You don’t have a choice. Learning and caring and growing are not passive. Standing still is not an option. In fact, the more that you stand still the farther behind you become. Therefore, you must either find a new source of energy or do the work of avoiding exhaustion. Recharging is an activity that pays for itself.
So let me share with you some of my strategies to re-energize.
1) Find something to look forward toward. There’s no time to play? Make time. All of us have vacation coming at some point. Don’t squander it. Make a plan. There’s a pandemic preventing travel? Figure it out. Plan a fascinating “Stay-cation”. Meet someone new and explore the world with them. At some point when I was home wallowing in my loneliness I decided to get on the Long Island Rail Road and go to MOMA (Museum of Modern Art). I spent two hours visiting my inspirations: Picasso, Rothko, Klimt, DeKooning, Warhol, Miro, Hockney, Monet, and on and on. I even bought a book and a poster which I’ll frame and put up to make my space into my own rather than a shrine to my wonderful wife. It’s incredible how this simple action helped to change my perspective.
2) Take care of yourself. Examine the bad habits that are sapping your energy and work to correct them. Your Virgin Pulse app sponsored by Northwell is a great source of guidance to get more sleep, become mindful, exercise, eat right, plan your finances, become more efficient, become more global, and other programs. I use it everyday in concert with Noom which served me well pre-pandemic and is providing me with encouragement and tricks and tips now to loose weight, exercise and generally feel better.
3) Talk it out. Find a friend who you can get personal with. Or, if needed, take advantage of the Lenox Hill Resident Mental Health program. Contact LHHResidentmentalhealth@northwell.edu or call Yanick Joseph in the Office of Academic Affairs for the contact info. The phone number is 212-434-6262. At some point I decided to stop pretending I was “OK” when people asked. I have a whole network now of people I can count on to listen when I’m low.
4) Ask for help. This goes along with #3 above but specifically it is imperative that you not take on more than you can do. You can’t walk it off all the time. Sometimes, you have to say “I can’t handle this” or more correctly, “I can’t handle this well.” Better to get help and ask for more time or more people and get the job done the way it should be done than to tough it out and cut corners to fit it all in to your exhausted ability to work. What you don’t want is to feel even worse when a half-assed job falls apart after you’ve squeezed it in when you weren’t really ready.
5) Reward yourself. When you’ve done the stuff above and you see that the world isn’t quite as black as it looked before, celebrate victories both great and small.
You are special. You are heroic. You are necessary. You are family. You mean something to me and to each other. You can’t be at your best, your smartest, your most empathetic, your most caring and helpful unless you take the time and effort to re-energize. You owe it to your patients, your calleagues, your friends and family and most importantly - to yourselves. I hereby give you permission and the mandate to do it.
March 5, 2021
Might i digress?
Originally I would have posted a fourth quarter message here congratulating you all for surviving and thriving in your training program year. But there have been some developments and I think they are worth sharing.
Over the last several months I had several occasions (giving blood, getting a screening procedure, demonstrating the skill to medical students) in which someone took my blood pressure and found it to be mildly elevated. Finally I went to see an internist. His very thorough exam revealed a holosystolic murmur. After much disbelief I submitted to a workup which confirmed an asymptomatic flail mitral valve. I arranged to have surgery with our own Department of Cardiothoracic Surgery and had valve surgery on February 18. My ordeal was extended by having to return to the OR later that day for a persistent bleed with a 1500 CC blood loss. Four days later I went home but then 3 days after that I went into persistent a-flutter. While trying to manage this new arrhythmia at home with medication I began to pour pleural fluid out of one of the wounds in my chest and six days post op I had to return to the CT Surgical ICU for a new chest tube and bedside cardioversion. I went home again the next day.
I do not tell this story for your pity. I learned some important things that need to share.
it really, really sucks to be a patient
Don’t get me wrong. It was not the people at all. The medical staff from the doctors to the nurses to the PAs to the people that bring the food were all amazingly great. I was even treated by a graduate of our program and I couldn’t have been more proud. But still, the experience is incredibly horrible. As a patient (especially in an ICU environment) you are seemingly tethered from all sides. You have wires running from EKG pads (the glue of which NEVER comes off). You are permanently attached to a blood pressure cuff which automatically inflates and deflates at a minimum of every 30 minutes, even at night. You have whatever drains and appliances are particular to your care. There is a line in one arm or two plus your neck. And there are sequential inflation devices wrapped around each of your legs. You are in a bed with an inflatable mattress against which you cannot generate enough force to move up on your own. And you are trying constantly to perform some simple bodily function from a position that absolutely is impossible to be neat and discrete.
Sleeping in a hospital, for me, is impossible too. Yet sometimes you get in a few drug fueled hours of sleep. Hospital food, no matter how hard they try just can’t be made any more appealing. It’s either overcooked or unidentifiable. Plus most of the meds we give completely obliterate patient’s appetites.
so what’s the point of this blog?
This is not advice. This is not cheering you on. This is not congratulating you or helping you plan for your next stage. This is just to say - when you see your patients each day and you are hoping for them to rally and be cheery about “getting better” consider acknowledging how awful it is to be a patient in a hospital. Empathize (reflect, legitimize, explore) with them and work hard to get them out of the hospital as efficiently as possible so as to spare them even one unnecessary day of the torture of being a patient.
Congratulations on making it to Spring and fourth quarter of your year. As we now finish up the year there will be numerous opportunities to think about and learn new skills that will be useful at your next stage. Pay attention and use them well. I look forward to returning to work soon and seeing you all again.
12/29/2020
The winter doldrums and celestial hope.
As we enter the third quarter we must acknowledge the Winter Doldrums. This is a difficult time of year for residents and residency programs. Made worse by COVID and the oppresive restrictions and crazy work-stress it has brought. But yet - there is light that we can see. By now all of you have been invited to be vaccinated at least once (Actually there is one of you who has not by accident - we are working to correct that). In just a few days the quadrennial overthrow of the government will occur and with it a return to functionality. Each week we are closer to recruiting our next crop of trainees and this quarter is when we will be performing our first rapid cycle tests of change in our QI/Patient Safety projects.
This year, for the holidays I received a gift that I have been wanting for a half of a century - a telescope. I spent last weekend studying the face of the moon (pictured below). It made me think about our Apollo astronauts cavorting around the southwest edge of the Sea of Tranquility and about the fictional monolith found in Tycho Crater near the south pole in “2001: A Space Odyssey”. It filled me with awe and wonder and hope.
Has COVID ruined our social plans? Yes - but think of the party we’ll have once the majority of us are vaccinated.
If this is the halfway point of the year then everything we’ve gone through, don’t we have to go through it again? Yes - but think of how much more satisfying it will be the second time around when we are actually starting to get the hang of our jobs.
Is it cold and miserable out there? Yes - but we’re spending most of our time indoors anyway and there is something nice about winter and holidays, New Years and anticipating the coming of Spring.
Is the next phase (senior residency, fellowship, “attendingship”, etc) looming ever closer? Yes - but that will be our next great adventure.
Since March we have been toiling under clouds. But now as we look into the crisp, cold, cloudless night and watch for the confluence of Jupitor and Saturn or in May when Mars, Jupitor and Saturn will all be visible within a few degrees of each other, we realize the privilege we all have of being a doctor to the patients of Lenox Hill can be our greatest adventure yet. And as we continue to learn about hearts and livers and lungs and thyroids and all of the organs and biologic systems we are also learning empathy and shared decision making and high value and cultural competency and quality and all of the social systems in which we and our patients live.
Where are your high school friends right now? Hunkered down in their homes, trying to work remotely, waiting for relief. Where are you and your heros? On the front lines, identifying with the GIANTS (Fauci, Slaoui, Sanjay Gupta, your attendings and YOU) inching your way to the end of a long dark tunnel with grace and fortitude.
40 years ago the great Carl Sagan said, “We are all made of starstuff.” Today, it is clear you are the stars that light the nighttime sky. Guide us and your junior learners as we navigate this winter squall.
And I’ll see you on the other side.
Quarter two: Enjoy the fall
Well, you’ve completed the first quarter of the academic year. Pretty much all of you have tested yourself and you have been observed in your new role as a first, second or third year resident. So now we’re going to get into the fall. We’re still in masks, of course, and we’re still figuring out how to learn on Zoom. But essentially this is when we are all going to start hitting our stride. For those of you who run this is like that second half mile. Your breathing has adjusted. Your cardiovascular system has shifted into high output mode. You’ve got a ways to go but something feels like you’re going to go the distance.
You’ve completed the ITE. Most of you have completed our first set of Socrative questions. Many of you have received some feedback from your supervisors or at your OSCE about what you do well and what you need to practice more. This coming quarter will be for self improvement.
In addition, I know that you are all anticipating our new QI program and seniors are starting to schedule their fellowship interviews. You will now start working on your future.
The key here is that your future looks bright. Our health system is doing well, recovering from the frenzy of last Spring. Our hospital is doing well. We are returning to pre COVID volume and we have been recognized for the high quality of the care we provide (by US News and World Report which places our hospital in the top tier of New York hospitals and in the top 50 nationally in several areas. Furthermore we are only weeks away from our being named a nursing Magnet hospital which will help our overall CMS star rating as well as our ability to recruit high quality nurses. I have even been told that the building of the new hospital building has been accelerated to meet the needs of the new normal and the expectations of our patients for a modern attractive health care facility.
Speaking of recruiting, I am super excited about our forthcoming “virtual recruitment” season. We have spectacular plans for online hospital tours, a slick video overview of our training program and a high tech video interviewing platform designed by a physician. Many of you will be helping that effort by chatting online with applicants.
So yes - the future looks bright.
Sadly, we are always stalked by the specter of severe, self defeating doubt and desperation. By now you might have heard about the loss to suicide of a medicine resident at Lincoln Hospital. This is a tragedy. But this is not a herald of further tragedy. We are fortunate to work for a health system and hospital that cares deeply about your well being. We have done everything we could to make your work humane and to balance work, learning and your health. We have increased mental health resources by another 50% for a total of 1/3 of a psychiatrist and 1/3 of a psychologist reserved for struggling residents (a model, by the way, being replicated across the health system). I am now recruiting new Mentors for our Lenox Hill Academy for Mentorship in Medicine (LHAMM). We will soon pair protégés who have applied with mentors. This is in addition to our Adviser system to which all of you are assigned. And in a couple of weeks the annual walking challenge “Walk to the Parks” will begin (follow the progress of my team “Heroes on the Hill”).
So you must see that there is no reason for anyone at Lenox Hill to feel desperate. We are here for you. I am here for you. You have but to whisper to anyone that you would like help and help will be given. No one need suffer alone at Lenox Hill.
You get to live the bright future we are viewing from the high ridge of this long cross country run. And I get to see how the exciting story of our program and your career turns out.
COVID, race relations, health inequity, economic stress, a vacuum of leadership in Washington, global climate change? They all fade into the bright sunrise of our future. Ready to put on those Ray-Bans and keep walking? I am.
Ethan D Fried, MD, MACP
Associate Chair for Education
Residency Program Director, Dep’t of Internal Medicine
Associate DIO, Lenox Hill Hospital
VP Academic Affairs for GME Quality and Patient Safety
NorthWell Health System
Professor of Medicine, Zucker School of Medicine at Hofstra/Northwell
O: 212-434-4833, F: 212-434-2246, C: 516-680-7570
Welcome to the team
It’s bigger than you think
It may be natural for you, coming from the generation of which you are part, but it was not long ago that physicians were the first and last word in patient care. Physicians worked in silos and used expressions like “in my experience” instead of “evidence shows that”. Patients knew who their doctor was and had no interest in anyone else’s opinions. There was complete trust in their attending physician. As knowledge increased at exponential rates, as medical care become more specialized, as health care took on more roles in the social constructs of insurers, as length of stay drastically shrunk in favor of post hospital care (home care, sub-acute rehab, long term care) and as we evolved to a more collaborative model teamwork replaced solo practitioners and departmental silos.
You were likely trained in a collaborative environment. You have shared educational tasks with a group of learners solving a problem. You have been part of a multidisciplinary discussion as acting interns. Perhaps you even played a role as an inter-professional care provider (scribe, therapist, EMT, nurse, physician’s assistant, etc). Now as a new member of the Lenox Hill team you are about to up your teamwork game some more.
You are now “Resident Doctors” or so says your badge buddy. That means that you are a member of the inter-professional team responsible for gathering information from or about patients to aid in the delineation of their problems, the formulation of a differential diagnosis and the construction of a diagnostic and therapeutic plan. You will work with others to care for patient’s acute problems, make sure that they have a safe and effective plan of care both in and out of the hospital and coordinate the opinions and needs of patients, families, primary teams, consultants and allied health care providers.
Beyond that you are members of the profession. You have taken an oath to practice scientifically, use humanism, learn continuously, and act ethically both with patients and outside of the patient realm.
Perhaps you have a rudimentary view of medical ethics. Perhaps you already know that these incorporate patient autonomy, beneficence and non-maleficence, justice and accountability into a code of behavior. Whether you understand this or not you need to accept that your ethical duty is to promote equity in health outcomes. You cannot tolerate inequity in relation to health outcomes or social determinants of health. You must keep in mind that even the stress of a worldwide pandemic is not an excuse to allow the poor, the disenfranchised or those in the non-dominant group to be disproportionately effected by disease or the elements that determine the outcome of disease.
So it’s not just the Lenox Hill team or even the Northwell team that you are on. It is the team of health care professionals, New Yorkers, and human beings you have joined. And you can’t let your team mates down. We’re counting on you. Let’s win one for the team.