Tim Porea, MD, MPH
Clinical Director, Cancer and Hematology Centers at Texas Children's Hospital
He served in the Navy for 22 years...
"The buzz phrase you'll often hear when we're teaching in Navy pediatrics is, 'When you're on your island...' The question they want you to answer is: how are you going to manage that unforeseen problem when, you know, you're the only doctor?
When I was in Okinawa, there were no pediatric subspecialists. There were four Navy pediatricians and that was it. If a child came in with an emergent issue, we had to do what we could to stabilize them. If they needed a higher level of care, the closest place we could go to was Hawaii, which was a 10-12 hour flight. So we would have to keep this child alive in an adult ICU until a plane could be spared, then one of us would fly with them and make sure the kid made it through alright. Then of course, there's only three pediatricians left on the island. Any military physician has to be ready and able to do something like that when they're called upon."
...And he's been a camp counselor for pediatric cancer patients for 24:
"Camp Periwinkle is a week-long overnight camp in the Texas countryside for kids undergoing cancer treatment. I've been a counselor there for 24 years. I never go as a doctor--I much prefer being a counselor there taking care of a bunch of kids in a cabin. I started my first year of medical school, and I've missed four years between then and now. I couldn't make it during my two years in Japan, and you just can't get away during your intern years…
…The hook, I think, for all of us that serve there, is just seeing how resilient these kids are, and how they deal with all the curveballs that have been thrown at them. And they get this one week to just separate from being reminded that they have cancer. No one is staring at the scars or the bald head because everyone's in a similar boat. They don't have to explain themselves to anybody. The facility, Camp for All, goes to extraordinary lengths to make sure any one can do anything out there. If you want to slide down the zipline and you're paralyzed, they will figure out how to get you to the top of the tower so you can do it safely. It's an amazing, perfect week."
Niraj Mehta, MD
Associate Professor at the Baylor College of Medicine, Department of Internal Medicine
Why he always kept an eye on the patient's birthday:
"I trained in the early 90s, at a County Hospital--LBJ, here in Houston. We were taught by our upper level residents that the most important thing on the chart was the stamp stating the patient's date of birth. When we were interns, this was emphasized over and over again. When we would ask why, upper levels would say, 'This is a county hospital. Volume is high. We don't have a problem diagnosing things but you have to realize that, therapeutically, we're very limited.' That birthday stamp was crucial because if a patient was 65 or older, they would qualify for Medicare. If that was the case, we could get the patient to one of the best medical centers in the world, just 10 miles away, and get them much better care-- transplant, dialysis, etc.
When those birthdays started to take on a different meaning:
"When I was a third year resident, in 1996, I was looking at the stamp one day and I happened to notice that it was my patient's birthday. And, just on a whim, I went down to the cafeteria and got him a cupcake and went to his room. This Is the county hospital, so there's like three other patients in the room separated by curtains. And at his bedside I just said, 'Hey John'-- we'll call him John--'Happy birthday.'
He looked at me and smiled, and he said, 'Well aren't you gonna sing me happy birthday?' And maybe it was because I was tired, overworked, or something, but I started crying. Like, twin waterfalls on my face crying. A couple nurses were tending to other patients in the room. I called them over, and then we sang. And it was just this very impromptu, unexpected, sacred thing.
A few years later, I was an attending physician at the same hospital. Things were busier than ever. And now I was the person telling my residents that the most important thing to look for on a chart was the birthday, that if they were 65 they could get better care, the same thing I was being told when I was training. We were at a patient's bedside and I asked them the question I'd asked and answered so many times before, and one resident chimed in that it was this patient's birthday. And, of course, as fate would have it, I looked at the patient and realized it was John. Birthday John. And he told me he was ready for me to sing.
That was sort of my eureka moment, where I said, 'Gosh, I had totally lost track of this guy, hadn't seen him for years, much less spoken to him. But here he was, and he remembered that little birthday ceremony from a few years back.'"
How he brought birthdays to the bedside:
"After seeing John again, I started to wonder, well, geez, why don't we celebrate more birthdays? I got in touch with the food prep staff, and they were on board. It was like $2 for a cupcake. Since we were a smaller hospital, there were only a couple birthdays a month. So it didn't cost much, and it meant a lot to everyone--the patient, the nurses, the staff.
I moved to Ben Taub in 2010, which is a much bigger hospital. And I felt that the birthday celebrations shouldn't be confined to just the medicine service. I submitted a formal proposal to Harris Health, which went through, and we haven't looked back. I get an email every afternoon about birthdays happening the next day, and make sure the cafeteria knows about it. The following morning, a small team gets the cupcakes, prepares the cards and balloons, and we do the celebrations around the hospital."
Drs. Pat And Susanne McLaughlin
Dr. Patrick McLaughlin is a current fellow in Pediatric Emergency Medicine at the Baylor College of Medicine.
Dr. Susanne McLaughlin is a current fellow in Nephrology at the Baylor College of Medicine.
Where they met, where they went, and why they did it:
Pat: "Susanne and I met in residency, in the Navy, and got married right at the end of residency. That was in Virginia. Both of our ultimate career goals were to specialize, to pursue fellowships. Susanne always wanted to be a nephrologist, I always wanted to do pediatric emergency medicine. But we had been out of the game for a couple years! We had been attending physicians for two or three years. Most people go straight from residency into fellowship. Our daughter was less than a year old. At the time that we were applying, we had no idea what the interest would be in our candidacy.
So we cast a huge net. East coast, up and down, and about as far west as Texas. The first couple of weeks, the interview requests came fast and furious. Maybe Susanne would hear from one program, so that day I would email the program director, 'Have you reviewed my application, could we schedule an interview at the same time, or maybe even on a different day so we can fly our daughter with us?'
Our daughter went on 6 interviews with us. Sometimes we would fly to one city, drop her off with family that we had that could take care of her, and keep flying to another city to interview."
Susanne: "It was particularly hard because there was a pediatric specialty match and there was an adult specialty match, and they don't coincide at all. We had to plan our applications, our acceptance of interviews, and our ultimate trips based on places we felt we could get in, places we thought had the best opportunities for the both of us."
Their unorthodox path gave them fresh perspective...
Susanne: "Having four years of experience practicing on your own, gaining confidence and wisdom, gives us a different perspective than people who enter directly into fellowship following residency. I'm very comfortable with general internal medicine and Pat is very comfortable with general pediatrics, and there's not much that walks through the door that we feel like we couldn't handle if they fall within those respective fields.
...And brought them plenty of challenges:
Pat: "The academic requirements of fellowship are more challenging with a family. You want to spend your free time with your wife or your daughter doing something, have a tea party with them and just hang out. I want to do that. But oftentimes I can't because I have to complete a presentation or work on research on my own free time, which is already slim."
Susanne: "The hardest part for me has to be the schedules. The way the ER works, Pat will have a week where he works night shifts, then the next week it'll be day shifts. If I happen to be on call, and he's on a night shift, we have to have the nanny come and spend the night. There are stretches of time where we don't see each other for days. We can be like ships passing in the night."
What it's like raising a kid on top of it all:
P: "It's a daily adventure. I have so much respect for single parents who work and never have the option of leaning on the other parent. I can't wait until Susanne gets home. If I'm home all day with our daughter, it's always a blast, but after 7 hours straight of taking care of the tiny things I feel like, it's incredible to have Susanne come home and take over so I have a bit of time to breathe.
When I was chief resident, a lot of your job is coordinating a very intricate schedule. You have to cover all the residents, fill every service, make sure that the attendings have what they need for their service, etc. Our family right now is like doing a chief resident's schedule every month. Every month, I sit down in a room with a computer and put our family's schedule together for hours. I would say, 'Honey, I need your schedule,' then shut the door and say, 'No one is allowed in here.' It's not just for us--it's got our nanny's schedule there too. Like, she's working two overnights on a weekend this month."
S: "I struggled a lot this year as a mother with a busy work schedule, feeling guilty not spending as much time with her. The work hours, when we were attendings, were much better. I was there in the mornings to wake her up, so I was the first face she saw every day, and I was always there to put her to bed. This year, it's been hard not seeing her every morning. I leave for work before she wakes up. I've only been to her preschool three times this year because time is so tight. It's made me feel guilty, it's made me feel sad this year. But then I think about our family, and I think about what we're doing as ultimately for her benefit. I think that later in her life, our daughter will be able to look back at this time and appreciate that her mother had a strong work ethic and wanted to achieve her career goals."
Diane Treadwell-Deering, MD
Co-chief - Fragile X Clinic, The Autism Center at Texas Children's Hospital, Associate Professor at the Baylor College of Medicine, Department of Psychiatry
On training when females lacked representation in medicine, how quickly things have changed, and how they need to keep changing:
"I grew up in a time when women were just starting to enter occupations traditionally held by males. Before that point, if women were not going to be homemakers, they were going to be teachers or nurses. For me, pursuing medicine was really exciting because most people in my family hadn't had the chance to pursue higher education. My mom did go to college when I went into first grade, and she did become a teacher, and she was a very serious student. I didn't have any brothers. My mom went to college, and my dad didn't, so there wasn't this notion that men get educated and women don't. So I think a lot of those things combined in a peculiar way. If I had a brother, maybe he would be expected to be the doctor and I would have been expected to be the nurse, but that pressure wasn't there. So I kind of grew up in a unique household in that regard.
When I applied to medical school and started interviews, I have to say that schools I interviewed at in the South did respond to me differently than schools in the North. The southern schools were the only schools that would ask me things like, 'How to do you foresee combining this career with marriage? Are you expecting to have children?' And part of me was thinking, 'Are you asking men these questions?' But obviously I didn't say it out loud because I wanted to do everything I could to get into medical school...I had to play the game. So I would smile and just say something.
One time I got asked, 'How do you think you're going to compete with Southern belles?' And I didn't know what that was. Like it didn't click when I heard the question. I was thinking, you know, ding-dong bells. And a second later I realized, 'Oh yeah, he means those ladies that can curtsy and wear big dresses…' I don't even remember how I responded. Isn't it kind of great that, in the course of one generation, questions like that have disappeared? As in, it's illegal to ask that question. It's crucial that that has changed.
When I was a medical student on surgery rotation, the resident was showing me some stitches, and all of a sudden I said, 'Oh I know how to do that, that's a French knot.' He showed me another one and I say, "Yeah, that's a running mattress stitch." So a lot of these sutures are also embroidery stitches, and yes, I knew how to embroider because I grew up as a female in a certain era. And he was kind of annoyed because he couldn't really lord this knowledge over me. It felt pretty nice, but I don't think it was particularly wise of me to say that to this guy and kind of reinforce some latent sexism. I was definitely an outlier, and I definitely took myself a little too seriously. But I think that might have been necessary for the times. You had to be strong-willed because people were telling women, 'Well, don’t you want to be a nurse?' and if you didn't fight it, you might respond, 'I mean, I guess…' If you were going to be the person who broke the mold, you had to be a little bit tougher.
Having kids during residency was not easy. People weren't thinking about maternity leave for residents because, you know, they were all men. I, along with many other women, had to make choices about specialties partially considering their flexibility in regards to starting a family. That is certainly still the case, but its slowly changing. There aren't a ton of women surgeons. There aren't a ton of women who are heads of departments. But it is happening, and it needs to keep happening."
On choosing psychiatry, then specializing in developmental disorders:
"During my mom's struggle with multiple sclerosis, before she lost the ability to speak, she would often describe how people can accommodate their legs not working, or their arms not working, but how incredibly difficult it is to accommodate losing your own mind. So when she started to have an increasing number of cognitive issues, that left a strong impression on me.
I started treating kids with autism because there was a push during my training to develop a multidisciplinary team that focused on treating the disorder, and I felt that it was important that psychiatry was represented on that team. So serendipity took the lead on that one--specializing in developmental disorders wasn't on my radar. And it ended up being this incredible match."
On the most difficult, most rewarding things about her job:
"When you bring clarity, even if its not the news people necessarily want, it helps people understand their child. That's always a great thing. It's rewarding to me to have helped the family clarify what was once unclear.
Sometimes, it's simply the fact that you have gone down a path together with a patient and their family. It's often a difficult path. It can be uncomfortable, even sort of dangerous sometimes. One day, one of my patients had a violent outburst outside of the clinic. The patient managed to pin down his father. The nurses managed to pull him off of his dad, and they brought him over to a play area near the office, and someone came to get me. I got some folding chairs and some water. We sort of just sat down and talked and he calmed down. I don't really have a medicine that makes episodes like that go away, but I can talk to him. Oftentimes, just being there can be the most important thing to families. Sometimes its the only thing you can do.
And these families are unbelievably amazing. They abide by their children, they stay loving, and patient, and warm. They're strong. They keep going even when they're really discouraged. It happens across the board--it doesn't matter if the family has a ton of money or not much at all, educated or not--they take incredible care of their kids. They do the best they can, and its absolutely incredible."
On living with multiple sclerosis:
"My mom was ill before I was born, but she was diagnosed with MS relatively late in her life. It can be a hard thing to diagnose, and some people just thought she might be a hypochondriac. But she had some really rough episodes during my childhood, and they are still very vivid in my mind.
I remember my daughter asking me if I had multiple sclerosis. I think I was 45. MS typically manifests early on, so I told her, 'No, I'm too old for that.' And soon after that conversation, I got optic neuritis, which is the classic early sign of MS. So I got the full work up--a couple MRIs, a week of IV steroids, etc. I went to a specialist on MS and he told me that, had it been MS, they would have expected my MRI to change after the steroid treatment--it didn't--and that the lesions didn't look like MS either. So he told me, despite the family history and the symptoms, they didn't think I had MS.
Eight years later, I'm riding my bike because I'm training for the MS 150, because, you know, my mom had MS! And I get this weird patch of numbness on the bottom of my foot. In a week, that numbness had spread to the entire half of my body. Also, my previous MRIs had been destroyed in a flood in the meantime because the hospital kept MRIs in the basement. I got another workup, and, yes, I had MS.
I was so scared. I am still scared to death for my daughters. It was the worst news in the world. But its been 10 and a half years, and I have had a very light burden of disease. I'm extremely lucky. I used to have to take this intramuscular injection every week that made me feel like I had the flu, but it was only 1 day a week…yeah it sucks, but its not like full blown MS. Now I'm only on an oral medication. And I'm scared it will get worse, but right now I am lucky. I take my medicine, I exercise, I take vitamin D, I go to the doctor sometimes…but by in large, it doesn't rule me. I let my doctor be my doctor, and I don't try to learn every little thing about my disease. There are a lot of people with MS that know a lot more about the disease than I do. That’s what works for me."
Precious Uwaezuoke, NP
Nurse Practitioner, Department of Hematology and Oncology at Texas Children's Hospital
She grew up in the hospital where she now works...
I am a nurse practitioner at Texas Children's Hospital. I work primarily in the hematology/oncology unit. I focus specifically on managing, treating, and providing supportive care for patients with sickle cell disease and its variants.
I actually grew up here. As in, I grew up in this hospital. I was born with sickle cell disease, specifically with hemoglobin SS, which is considered the more severe form of sickle cell. So as a child I was under the care of Dr. Mahoney and Ms. Ross here, and now they're my co-workers. I remember growing up and them asking me what I want to do, and I would reply, "I want to be just like you!"
...And she also has three other siblings with sickle cell.
I have 4 other siblings, three brothers and one sister. Out of the 5 of us, 4 had the SS variant of sickle cell. I was the oldest of the 5. It wouldn’t be uncommon for me to be in the hospital while a couple of my siblings were there, too. It was hard because my parents would come to the hospital and have to look after us, and often had to take care of the younger ones. It's hard on you as a kid because you're often alone, you're not feeling well, and you want attention.
It's the place where she met the nurse that changed everything...
Our interaction was fairly brief because it was during one of my hospitalizations, but she managed my care for three of the six days I was in the hospital. I was 10 or 11, in that kind of awkward stage where all I wanted to do was sleep, eat, not talk to anybody.
Nursing is a hard job, it asks a lot of you, you give and give and people often don't realize how taxing that is. Working in hematology/oncology can be particularly difficult because you're seeing kids with a lot of chronic disease, which is emotionally wrenching. Some of the nurses that took care of me were clearly at that point where it was a lot of, 'hi, hello, how are you, etc.' but they weren't clearly engaged. And it was because they had hit that point, they were just protecting themselves emotionally and mentally.
This one nurse, however, was persistent. I wouldn't say much, like one or two words, but she would just keep on trying to make me laugh and talk. We had a conversation where I told her I grew up loving Winnie the Pooh, and the last day that she was working that week, she came and surprised me with this stuffed Pooh bear and a book because she knew I loved reading too. And it was unbelievable, I was floored. You're ten and you just want to do what everyone else can do, you want your mom and dad, but you're alone, but here was this person who wouldn't give up, who stayed. Like, she didn't have to do any of that, but she did. And it made all the difference.
That day she said things like, 'You have so much potential, you're so strong,' and that has served as inspiration to me to this day. Before she left, she said, 'You have to promise me that you won't let this break you.' And I told myself, 'I want to be her, for people like me.' She's the reason I went into nursing. She saw a little girl that was scared, and she tried her best, and that changed my life.
...And it's where she does the same for her patients:
One time I had a patient, a little girl, who wouldn't speak to anybody. She wouldn't interact with people and made her mom do the talking. I went in to see her, and she was super quiet, but I kept pushing because I remember there was a time when I was in the hospital and didn't want to talk to anyone. And I kept trying to talk to her, and over the course of a couple days, she really opened up. She would light up when someone would walk into the room, and she became very talkative.
All it really took was figuring out that she was frustrated. At one point, she just said she had all this pain and didn't know what to do about it. And she made some sly comment, the classic, 'You don't understand' kind of thing. And so I got to tell her that I actually have exactly what she has. And she said, 'Sickle cell?'
And I made it clear I had been in her shoes, frustrated, in the hospital, in pain. I have had that, I have experienced that, I've been angry. Even more importantly, I had to tell her that I made it through. A lot of these kids don't want to keep fighting it, they're tired of it, and they don't know when it might end. At that point, I say, 'You can, you will. If I can, you can.' I told her that she couldn't be angry at the world because of the disease, that people here wanted to help make her feel better. It changed her demeanor completely.
When I meet kids like that, I can truly feel that this is my purpose. I was given this battle, this fight for that very reason. Again, there are incredible providers of care here. But a few patients simply need to see someone who has done it, so they can make it.
Jennifer Blumenthal-Barby, PhD
Cullen Associate Director of Medical Ethics, Center for Medical Ethics and Health Policy at the Baylor College of Medicine
On the experiences that nurtured her passion for medical ethics:
I first got interested in medical ethics in college. I was a health science major, and I ended up having required courses like the philosophy of medical ethics and the philosophy of death and dying. And I went into those classes thinking that they were burdens right? A lot of pre-health majors get frustrated when something seems to take them way from their core science requirements, unfortunately. But I just fell in love with those classes. They were asking deep, interesting questions about personal identity, the nature of death, why humans think they're special, etc. I was having to wrestle with concepts like physician-assisted suicide vs. prolonged life support, questions about medical practices that most people take for granted.
I remember sitting in the science library studying for a final and finding a copy of Leo Tolstoy's The Death of Ivan Ilyich. It's this amazing piece of literature describing a man's dying process. I ate it up. And I started noticing this tension between the things that I was required to do for my major and things that I was intellectually passionate about.
When I graduated, I said, 'I'm going to get a masters in philosophy. It doesn't necessarily have to lead to anything, but I know I want to have a couple of years to explore these ideas.'
So I went to Bowling Green, where they had a program with an emphasis in applied ethics (i.e. medical ethics). They had a relationship with the Cleveland Clinic, about two and a half hours away. Each year, one person could go and spend a semester at the Clinic to work with their clinical bioethicist. You'd round with that person, work cases with them, and scout out the ethical issues arising on various services. So in my last year of my masters, I spent a semester in Cleveland. That really solidified my desire to go into medical ethics. I not only got to learn the theory, but I also got to see it in action with real doctors, nurses, and committees that were struggling with these issues, and I saw that the ethicists were playing a huge role in helping them resolve the issues.
Embracing the field of "nudge" ethics and decision making:
I got my PhD at Michigan State. I knew that I wanted to write my dissertation on a case that I had seen during my semester at the Cleveland Clinic. It involved a man in his early 70s, originally in very good health. He was later involved in a head-on motor vehicle accident. He was paralyzed from the neck down and placed on a ventilator. He was also in a coma. The doctor asked his wife and two adult sons about what they felt the man would want, and they replied, 'He was always clear with us that he would never want to live in a state like this.' He even had an advanced directive that confirmed what they said.
So the team prepared to withdraw him from life support. Right before they were about to withdraw, he completely regained consciousness. The team stopped to see if he would regain capacity to make decisions about his care. And he did. He was intubated, but he could nod and shake his head to communicate, he could write. To the surprise of everyone, he said he wanted to stay on the ventilator and live. It was this complete reversal of what he had said to his family for much of his life and what he put down on paper. So what was challenging about that is, when you learn about autonomy, you think about listening to the patient's wishes. But in this case, it wasn't so clear. He used to want this, now he wants that. And the patient continued to vacillate between these two desires for two months. They would go in and talk to him, and some days he would say, 'Just take me off of the ventilator,' and other days he would say, 'I want to live.'
For me, the case raised the issue of how we think about what's going on with this man. One way to think about it is to say that he is weak-willed, that he's in an understandably scared and fragile state and thus can't carry out the belief that he's held for so long. Or maybe he truly changes his mind very frequently on what he wants. Or perhaps he is seriously ambivalent--he truly does not want one thing or the other.
Then you have to ask, how do you ethically respond to each of these possible scenarios? Do you try to push him in one direction or the other? Do you wait it out and let him struggle with this decision, hoping that he'll figure it out? If you push him in some direction, are you infringing on his autonomy, or are you actually helping it? Which direction do you nudge him in, and why?
So I ended up writing my dissertation on the topic of ambivalence and indecisiveness. And thus the field of decision making and autonomy became the focus of my work. You have to combine the realistic side of decision making, the in-the-moment psychology of it, with the more idealistic model of decision making that involves encountering information, processing it according to your beliefs, and making a choice. I'm fascinated by that balance.
On how she helps protect the doctor-patient relationship:
In most situations, it's very difficult to say, 'This is always okay, and this is always wrong.' So much depends on the context. But my work attempts to build a framework that lets doctors reason and decide whether advice is appropriate or not. The biggest thing is always patient autonomy and figuring out if you have crossed the line. As a physician, you have to ask, 'Have I taken a choice off of the table, or is it still possible for the patient to make a different choice? How hard is it for them to make that other choice?' It ought to be reasonable and possible for the patient to do things in either direction. And you must ask 'How does this affect my relationship with the patient?' The therapeutic alliance is a sacred privilege, and you do not want to disrupt it.
It gets even more complicated because doctors also have obligations towards beneficence, to help their patients make the decisions that are best for them based on what their values are. If a patient says they want to stop smoking, the doctor probably shouldn't just say, 'Well here are the pros and cons of smoking.' They should take a stronger stance. The job of a physician is not necessarily to be as neutral as possible; instead, it can involve a lot of beneficial persuasion.
Alexie Cintron, MD, MPH
Associate Professor at the Baylor College of Medicine, Department of Internal Medicine - Geriatrics
He got into medicine because he witnessed what great care could be...
I'm originally from Puerto Rico. My family came to the states when I was 11. My family moved here because my younger sister had cerebral palsy. She was severely neurologically disabled--she didn't develop cognitively beyond the capacities of a six-month old. Puerto Rico didn't have the resources to take care of her. My dad was lucky because my dad had a job that allowed him to transfer here to Houston.
My junior year of college, my sister died. In her early teens, she started to develop more complications associated with being bed bound--she never had pressure ulcers, but aspiration was a big problem. She was always in and out of the hospital, and because of these frequent visits, my mom decided she wanted to draw the line at tracheostomy. In her belief, it was too much technology, it would be miserable for my sister. When my sister turned 16, she had a serious case of pneumonia, which turned into empyema. That meant chest tubes, intubation, etc. She was in the ICU for four weeks. It became clear that she was not going to be extubated, and soon after we decided to withdraw life-sustaining treatment for her.
The experience we had with the team, it's hard to put in words. I was impressed by how many different conversations were had with the healthcare team. They gave my parents the time they needed to make a decision. My parents were well counseled. Those talks convinced me to pursue medicine.
...and ended up becoming a leader in improving end-of-life care:
I was increasingly frustrated with having these do-not-resuscitate conversations during emergent situations, and I started thinking of ways to help doctors have conversations with patients about advanced care planning before things became emergencies. So I started doing research on developing tools to do that, which lead to a fellowship in health services and outcomes research at Harvard. I got my masters of public health at that time, too. I started looking at the various ways we could increase access to those advanced care planning and end-of-life care conversations.
In my own internal medicine practice, however, I was finding that the need for those conversations was not as high. I wasn't getting to practice what I was researching. At the same time, the palliative care movement had really taken off, and there was a fellowship in palliative care across the street at Dana-Farber [Cancer Institute]. I was lucky enough to get a spot, and I've been doing palliative care ever since.
So I ended up coming full circle, practicing the kind of medicine that had originally convinced me to pursue medicine in the first place.
As you might expect, there are lots of difficult conversations:
The main thing that we do in palliative care involves taking care of patients with advanced illnesses. We manage their symptoms to improve their quality of life, during the time they might be pursuing potentially curative treatment. We help them through the decision making process, especially when it gets tougher with life-and-death decisions and limiting life-sustaining treatments. When things are getting closer to death, we help alleviate their suffering.
It takes a lot of practice. It takes making mistakes. Some conversations have to go poorly, so that you can understand the nuances that surround these topics. It isn't black and white, there is a ton of gray, and it makes these conversations very difficult. You have to know that you're not going to convey everything you want to in one conversation, that it will take multiple conversations at different times to allow families to absorb the information. Then they can see for themselves how the patient's condition is evolving, what the outcome is likely to be. Then they can start to answer for themselves, 'Is this the right thing to do? Is this the right way to go? Is this what the patient would want?'
Often, people have a fear of leaving people behind. I try to help them figure out how they can reach out to those people and make the impact they want to make, leave the legacy they want to leave behind. A lot of times, it's people writing letters for their children or grandchildren to be opened on certain birthdays. Or maybe make a photo album, a video.
...but there are many joys to uncover, too:
When patients tell me, 'No one has ever put what's happening into words, and I feel like I understand this now,' feeling that I helped them find that clarity is very fulfilling.
Also, when people tell you that you have prescribed a medication or regimen that finally allowed them to sleep, or allowed them to be with their grandkids, or just to do something they love. I had a patient with metastatic breast cancer. She had significant hip pain from this metastatic disease. The one thing she kept saying over and over again was, 'I just want to get my swing back on.' She just wanted to dance again! After one or two visits, she was happy to tell me she could dance, just for a couple minutes. That's the best.
Toi Blakley Harris, M.D.
Associate Provost of Institutional Diversity & Inclusion and Student Services, Baylor College of Medicine. Professor, Menninger Department of Psychiatry and Behavioral Sciences.
During medical school, she saw the importance in understanding one's background...
"Something that drew me to psychiatry was seeing how the different aspects of someone's life come together. Resilience in the face of adversity and growth after trauma is possible. . As a medical student, regardless of what rotation I was on, I would often ask, 'Why is this person’s level of disease tolerated better in comparison to another?' Oftentimes, it was clear that it had to do with the person's background, resources, as well as their mindset. Their socioeconomic status and their family situation at home played a large role in their healthcare experience, along with their temperament and ability to cope. Understanding and working with the social determinants of health was very interesting to me, so psychiatry was a great fit."
...And practicing rural medicine continued to show her the power of cultural awareness:
When I finished my fellowship in child and adolescent psychiatry, I moved to the West Coast and practiced rural psychiatry. I had the privilege of working with migrant families in Santa Barbara County. I encountered the challenges of working with a diverse patient population with mental health stigma in an under-resourced mental health system. One of my first clinical encounters was with a young girl from the Hmong community who was struggling with Tourette's syndrome. In order for our team to address her symptoms effectively, we provided care in her home with the support of her family and other elders. According to her family’s cultural values and beliefs, it was necessary to engage cultural brokers in her community as a part of the treatment process. If a doctor wasn't willing to go to those lengths, she would not have received the kind of care she needed and deserved.
Today, I am honored to work with a dedicated team in a pediatric medical home clinic within the Harris Health System. I continue to partner with community and faith-based leaders to reduce mental health stigma in underserved communities. Our church, the Missouri City Baptist Church, received a grant from the Hogg Foundation for Mental Health to increase mental health awareness in African American churches and collaboration between mental health providers and clergy.
When you're training in psychiatry, you receive training about the bio-psycho-socio-cultural factors that influence health and mental health. However, demonstrating cultural humility and sensitivity in practice in order to provide excellent care to someone from a background that is unfamiliar to you is a different matter entirely. It can certainly be challenging, but it is also an incredible opportunity.
Now, she's working to expand cultural awareness and diversity at the Baylor College of Medicine:
BCM has a long-standing commitment to increasing workforce diversity and community engagement. Our office was established to leverage existing expertise, resources, and to expand diversity and inclusion efforts across the College. My current position has only existed for a little over a year, but we've already started several initiatives with leaders from across BCM! Dr. Klotman recently formed BCM’s Inclusion and Excellence Council, which I will chair. This group will bring together students, trainees, staff, and faculty from all four schools to work on improving workforce diversity, health equity, inclusion and cultural competency and awareness. I've been working with departmental and school leaders, as well as various student organizations such as the Association for Graduate Student Diversity, the Latino Medical Student Association, the Student National Medical Association, and BCM Pride on multicultural events and inclusion activities.
It's amazing to see what happens when people with different perspectives, backgrounds, and experiences come together for a common purpose. Our potential to ‘do good’ is that much greater when we collaborate.
Stephanie Gordy, MD.
Assistant Professor of Surgery, Division of General Surgery at Baylor College of Medicine
From a young age, Dr. Gordy had a fascination with the inner workings of the human body:
"I grew up in a small town in Georgia. Of course, as a child I didn't know what it meant to be a surgeon, but I was fascinated with anatomy from a young age. My parents didn't let us have TV because they thought that we would just watch TV all the time, so I read a lot. One of my earliest memories involves our subscription to National Geographic for kids, and I was always enthralled by the 'Bodies' editions."
She also knew she had a desire to serve the underserved. As she explored the field of medicine, she found that trauma care provided the perfect avenue for her to merge her interests:
"While I was an undergrad, I considered a bunch of different career options--psychology, teaching, even missionary work. The one thing that united those interests was a desire to help underserved populations. However, after getting to work in a hospital on a year off, I really felt a strong calling to pursue medicine.
In particular, surgery really incorporated a lot of different desires of mine. I knew I wanted to help sick people get better. Not only that, but I knew that I wanted to do something more immediate, something where I could quickly see results. For a while, I considered gynecology oncology, which also involves big, complex operations. But I had the opportunity to rotate in Savannah, which had a Level 1 Trauma center. That meant exposure to a lot of very serious, difficult cases. Oftentimes the patient came from a disadvantaged background. After seeing the opportunity to provide that kind of care, I was sold on trauma surgery."
Now, she's working at one of the busiest Level 1 Trauma centers in the nation--Ben Taub Hospital:
"Here at Ben Taub, we are a very high volume Level 1 trauma center. On any given day, it can be completely quiet or totally nuts. Last week on a Monday morning at 11:30 AM, I had a patient with a gunshot wound that hit just about everything in their chest. Then that Friday, at 9:00 AM, I had another similar case. Most people probably think that these kinds of situations happen at night, on weekends--in reality, it can happen anytime, when you least expect it.
That's something that I love about my job. I show up, and I have no idea what my day is going to look like. Then, what brings me joy is feeling that I really make a difference. I see people in a very terrible state, then most of the time, hopefully, we get to fix what is wrong, then we get to see them get better. It's a very immediate satisfaction. And of course, if we're being honest, there's a bit of an adrenaline kick that I get out of it. It's thrilling. It's the perfect package. There's not another job that I can think of that I would want to do more."
It gets busy, and it can be very tiring:
"When I take call on weekend nights, I like to order food for the residents. Last week, I ordered tacos at 6 PM. But, as things go, we got absolutely slammed starting at 6 that night. So, the tacos sat in the fridge for a while. We got to eat them about 13 hours later at morning report.
It's difficult to describe what it feels like to be awake for 36 hours on a night call. You can't even acknowledge that you're tired because you have to go take care of people. There's no one else. You're it. But afterwards, when you get off your shift, the exhaustion hits. That's why it's so crucial to take care of yourself after that--sleep, eat well, and use your time off to recharge."
...But it's all worth it when they get that big save:
"We had a patient come in who had a 500-pound magnet fall on his chest when he was at a construction site. He had ruptured his trachea starting in his neck and extending all the way into his chest. We had to do a clamshell thoracotomy, which involves opening both sides of the patient's chest. That's a very uncommon, highly invasive procedure that serves as a last resort, and it's a tough recovery. But we had to do that to repair the whole length of his trachea. Afterwards, during his recovery, he had prolonged oxygen saturation in the low 60s. At that point you start worrying about permanent brain damage. A few days later, he woke up, completely fine. No brain injury, went on to have an excellent recovery. Those cases are always amazing and humbling, since the odds are so slim even for a marginal recovery. At that point, you kind of just look at the other people on your team and say, 'Hey, nice save!' Then you move on to the next case."
Oluyinka Olutoye, MD, PhD
On training in Nigeria and seeking something different:
I did my undergraduate medical training in Ife and internship in Lagos. It was similar to a transitional internship here, where you rotate through all sorts of services. The difference with the medical system in Nigeria is that, by the end of your internship, you're expected to be an independently functioning physician. That's because after your internship, you may be posted by the national service to any location in Nigeria, in places where you might be the only physician for hundreds of miles. So the expectations are different from here, where you're almost expected to enter specialty training. In Nigeria, you have to be able to take care of emergent situations, do c-sections, surgery for bowel obstruction, some more bread and butter stuff but from many different specialties.
After my internship, I had a desire to continue my post-graduate training. I wanted to go somewhere with a lot more opportunities in that regard, so I came to the United States. I always wanted to do surgery, but as a foreign medical graduate, it can be difficult to get into a surgical program right off the bat. So I started in pediatrics, which made perfect sense because I knew I wanted to do pediatric surgery in particular. Then I got into a combined program with five years of general surgery training and two years of research, in Virginia. That's when I got my PhD. I focused specifically on the topic of fetal wound healing, which led me to exploring the field of fetal surgery.
Fetal surgery is a relatively new field, an evolving field. It is closely linked to the advancement of technology--the more things develop, the more we can see, the more we can fix. Oftentimes, with pediatric surgery, you wish you could do something sooner. For a while, we had the ability to detect certain anomalies in the womb, but we did not know how to operate until after birth. Now, we're beginning to pioneer methods that allow you to help earlier. But again, the more you know, the more you can do, the more new questions arise. It's exciting. It's the cutting-edge, the forefront of innovation in medicine.
On the need for openness in medical practice:
It is an incredible privilege to be involved in the lives of people who are going through such a vulnerable time. When you have kids, when you're pregnant, oftentimes you have very little control over the situation. Sometimes you just have to wait and see. Many people are very used to having everything planned out and laid out in front of them, and to be told that you have a fetus with an anomaly can throw things into a tailspin. So I consider it a privilege to be able to guide them through that process.
It's important that we make it clear that we don't have all the answers, we can't always 'solve the problem.' A lot of it is acknowledging the uncertainty. You have to be open and frank about it. It's a big problem if you over-promise and under-deliver. Being frank about what you know and don't know makes it a team effort as you go forward with the family.
It's the most challenging part of my job, and it's also the most rewarding. It's realizing that these families are coming to you at a very vulnerable time, and that puts a weight on you because many of them are coming to you hoping that you have the answers. And you know full well that you may not have those answers. But then you can always be there to offer support in a time where it seems that the bottom has fallen out of their world. In my experience, the outcome, whether it is desired or not, is almost always better if the process is open and transparent. Some people might not consider that process 'medicine,' but that's simply not true. Instead, that process is what makes medicine an art at times. Compassion, care, and empathy are at the foundation of practicing medicine, right alongside scientific knowledge and reasoning.
On the scrapbook:
This was made by some of my residents a few years back. It's full of christmas cards, pictures, and notes given to us by patient families. We still get christmas cards every year from a lot of them. It's wonderful to look at because it's a powerful reminder of purpose. People are at the heart of medicine, on both the giving and the receiving ends.
Jennifer Christner, MD
Dean, School of Medicine at the Baylor College of Medicine.
She had a passion for teaching anyone and anything...
When I was a resident, I found that I loved teaching. People on my service would call me 'The Mom.' I really enjoyed taking the new medical students or interns under my wing and showing them the ropes. By the end of my residency, I also knew that I wanted part of my job to involve something outside of the clinic because I was so interested in education.
My first job at the University of Toledo, I had an amazing boss. After my first year, she seemed to notice that I really loved teaching, so she recommended that I apply for a fellowship in teaching and learning in medical education. I was accepted, and that program changed my whole world. I loved it. When I got done with that, I became the associate pediatric residency director at Toledo.
The program involved a lot of education theory, different assessment techniques, faculty development, all in the context of medical education. A lot of us who were in the program entered it because we already had a lot of gut instincts about teaching certain ways. But we learned how to really define those instincts, as well as develop specific skills that are proven to help teaching.
...but found she had plenty to learn, too:
A typical exercise [in the fellowship program] involved getting videotaped while you taught, then reviewing your own film. I'm a pediatrician by training, so we're very comfortable being near our patients and their families and such. But I soon realized that was not the most normal thing in other scenarios. One time I reviewed a video where I kept scooting closer to this student, and they just kept scooting away every time. I didn’t notice during the encounter, but it looked so silly on tape! And it was like, 'Oh, personal space, that's a thing for a lot of adults, I have to be mindful of that.' Of course it's uncomfortable to see yourself doing that, but it's extremely helpful for becoming a better educator.
She can, and will, design a curriculum for just about anything...
I love novel assessment techniques. When I started out at the University of Michigan as the clerkship director, a lot of our residents and students would often email patients back and forth. That still happens now, of course, but there's a lot of other communication methods that weren't available back then, too. So I said, 'Why don't we put together a curriculum on how you communicate via email with patients?' So we had simulated emails sent to students, then we would have them respond. We would have faculty grade them with a rubric, then we also had the patients and patient families grade these emails. It was fascinating to notice the differences between how the two groups graded their emails. Many things were assessed similarly, but there were a few things that were incredibly different. Some faculty felt that something should be said this way, but then parents would note, 'That sounds condescending and demeaning.' So then we got to develop ways to kind of align those things.
...because new knowledge demands a new paradigm:
The simple fact is that medicine is a vastly different field than it was 100 years ago. We have a constantly, rapidly expanding amount of knowledge. Back in the day, you could rotate through all these different specialties and feel very well rounded in your education. Now, if you do that, even though you are getting a great variety of experience, much of it will never be used again in your practice, especially if you specialize. So, we have to wonder, is it time to start thinking that we don’t need every person to be pluripotent, that they don't need to see every single thing, that they might need to start specializing even earlier? Because the reality is that you simply can't know everything. Of course, I can't be certain that these are the solutions, but the questions must be asked.
Ultimately, I believe medical education needs to be flexible. There will be people like me who are pretty sure they want to go into something like pediatrics, so there are some rotations where I did things that I really did not need to do because I never ended up doing them again. But then some other people definitely need a longer exploratory period to figure out what they want.
Peter Hotez, MD, PhD
Professor, Departments of Pediatrics and Molecular Virology & Microbiology
Dean, National School of Tropical Medicine at Baylor College of Medicine
U.S. Science Envoy for the Department of State
He's spent much of his life studying tropical disease...
"I actually knew from a pretty early age that I wanted to study tropical diseases. Part of it probably came from an early love of maps and travel, which I combined with a growing passion for biomedical science. As an undergrad at Yale, I got my feet wet by working in a lab studying African sleeping sickness. I then pursued an MD/PhD at Cornell, where I became enamored with the concept of developing vaccines for these tropical diseases. I started with developing a hookworm vaccine, which is now, some 30 years later, going through clinical trials in Africa and Brazil.
I came here with the desire to start the nation's first School of Tropical Medicine. Houston was the perfect place--there was the Texas Medical Center, with the Baylor College of Medicine, Texas Children's Hospital, and huge interest in biomedical research. Texas is also an epicenter of tropical diseases in the United States. There is a great deal of poverty both in and outside of its urban centers, immigration from all around the world lands in Texas, and the climate often allows for tropical disease to remain endemic if it arrives."
...which means he's had to wrestle with the many societal forces that produce it.
"When I first came here, I was focusing on developing interventions in the world's poorest countries. But now we're realizing that there's a great deal of disease to be addressed amongst the poor living in wealthy countries, such as Chagas and leishmaniasis. The majority of the world's poverty-related diseases are not found in the world's poorest countries. Rather, they're found in the poor living among the wealthy, in some of the world's richest nations. We're seeing an important shift in the concept of global health. This older concept of developing vs. developed nation is slowly being replaced by an understanding that many economies are growing quickly but leaving behind large portions of their populations.
We have to recognize that disease is not simply a biomedical problem. We can't solve these issues with new diagnostic tools and vaccines alone. We have to recognize that the modern forces of urbanization, human migration, and economics are at play."
He's still in the lab, but he's found a second calling as a diplomat...
In 2015, I took on the role of serving as the US science envoy for the White House State Department. When you think of science as something that seeks to develop these humanitarian interventions, there's a lot of need for building scientific discoveries into foreign policy. The State Department has asked me to help develop vaccine production capacity in the Middle East and North Africa because this region has recently become a hotbed of disease discovery and spread. In addition to forces like urbanization and climate change, human conflict proves to be one of the other major drivers of disease because it not only produces massive human migration but often creates a great deal of poverty at the same time. Zoonotic disease (diseases spread by insects and other animals) has increased, and there's even been a resurgence in polio and measles.
There's this concept of 'vaccine diplomacy' inherent in this endeavor. Beyond the ability of vaccines to dramatically improve the health of a community, there is the opportunity to improve relationships with other countries and to help one another develop economically through cooperation in developing vaccines.
...and he wants others to join him, too:
Physicians have to get more involved in public discourse. 9% of Americans have heard of the National Institutes of Health. Federal funding for the NIH has flatlined for the last decade. And, of course, you have raw scientific facts being denied and politicized by certain demographics. The absence of many physicians from public discourse has contributed to these issues, and we can't just let it keep happening. People are getting diseases that haven't been present in America for decades because a whole industry of pseudoscience has developed. Certainly some members of the scientific community have been vocal in their resistance, but we need more.
I can speak from first hand experience and say that science and science-based diplomacy can produce great healing in this world, and I also know that ignoring or not promoting it can produce terrible consequences for all members of society.