A message to medical interns, in the midst of a pandemic [PODCAST]

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“Ultimately, our job is a difficult one. It’s hard to take usual comfort in heartwarming statistics or hollow promises of prosperity when you find yourself loving and grieving your patients. I have found there is comfort and an impenetrable hope that comes from this; this is the life-hack for training: Seek the welfare of the program, the institution, the city where you have found yourself. For in its welfare, there you will also find your welfare. As you start, finish, or continue your training, let the foundation of your vocation be marked by the virtue of hope rooted in doing the little things with great love. This rhythm will help you not only in the transition to or from training, but will also allow you thrive in the wake of this pandemic.”

Sumner Abraham is an internal medicine physician.

He shares his story and discusses his KevinMD article, “A letter to medical interns, in the midst of a pandemic.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Sumner Abraham. He’s an internal medicine physician, and he wrote the KevinMD article “A letter to medical interns, in the midst of a pandemic.” Sumner, welcome to the show.

Sumner Abraham: Kevin, thanks so much for having me. It’s funny to think that I thought maybe the pandemic would have subsided, but we’re still definitely in the midst of it, just as much as we were when this article was published. So thanks for having me.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and your journey to where you are today?

Sumner Abraham: Yes. I’m a primary care physician in Oxford, Mississippi. I did medical school at the University of Mississippi and my training at the University of Virginia, and served as a chief resident there. Now I’m back in Oxford, Mississippi, doing general internal medicine, and I’m also an associate CMO of Reliance Health Care, which is a health care solutions company. I teach a bioethics course at the University of Mississippi, a class on death and dying, which has been very interesting in the midst of the pandemic. And I also work at a local hospice agency, which is where a lot of my passion and my work really lies.

Kevin Pho: So we are now speaking in the second week of November, and we are on the cusp of another wave of the coronavirus pandemic. Tell me a little about what you’re seeing, and you could choose which role you’re seeing that through.

Sumner Abraham: I think two things are becoming abundantly clear. The first is that the anxiety and the mental toll that this is taking on patients and physicians is very real. I think it was easy at first: The novelty of a disease or the excitement of the doomsday prepping gave folks a lot of adrenaline. I think what you’re seeing now is that this is very difficult for everybody in lots of different ways. I feel like I’ve done a lot more counseling and therapy and practice in the last several weeks than I ever really dreamed of doing, which has been fun, but it’s clear that the mental toll on patients and physicians alike is very real.

The other thing that we’re seeing is the really cool opportunity, particularly as telehealth has started to come to be. That’s where the work with Reliance Health Care, a health care solutions company with the goal of trying to keep rural hospitals in the Deep South open and profitable, has been really interesting: to see how telemedicine has been life-giving to those local institutions.

Kevin Pho: All right, so let’s talk about that KevinMD article now, “A letter to medical interns, in the midst of a pandemic.” For those who haven’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Sumner Abraham: Yeah. One of the things that we did serving as a chief was obviously recruit and try to have a robust class of incoming interns. Something that was very clear talking to fourth-year medical students, soon to be our interns, on Match Day was the profound sense of disappointment that Match Day was abnormal and that they didn’t know what the transition was going to look like. I was unsettled by that, because when everybody transitions to training or to a new job, there is a sense of disruption, and the pandemic just amplified that a little bit.

So I wanted to essentially have a peek behind the curtain: things that you are not taught in medical school but are vital to your job and to transitioning to a full-time position, how to think through those, and how this pandemic is actually going to highlight those aspects of your work that are the most life-giving and rewarding, despite it seeming to be some sort of disruption.

Kevin Pho: Now tell me some of those tips. Not only for the medical students transitioning to be interns, but you yourself were a chief resident transitioning to be an attending. So what are some transition tips that you offer, especially during the pandemic?

Sumner Abraham: One of the things that I’ve tried to remind myself every day is this idea of learning how to act amid uncertainty, not in spite of it. Whether it’s medical school or your residency training, you’re trying to make decisions based off of a likelihood ratio or the certainty that a disease might be present. But I think one of the most powerful things you can learn, and that I’ve learned and am still trying to learn in my practice, is that I’m actually going to be the best physician that I can be when I’m acting in the midst of that uncertainty and holding that. I think that is vitally important.

I think another thing that is talked about all the time is physician burnout and what that is. One of the things I talk about in the article is this idea that maybe what we’re the most frustrated by is that things are not what we really expected. It’s hard for us to make sense of all this hard work that I did to get me to this point, and you arrive at that destination and it’s disappointing because it’s not what you expected. And it is to lean into that, and for that not to be frustrating to you; really, what makes our work meaningful is this admission that our work is always a work in progress. Even just the term “practice,” I think we take that for granted. I think that’s something, especially when you’re learning a new disease and it’s easy to get cynical about donning and doffing the PPE and some of the anxieties that come with taking care of a new infectious disease. I think that this admission that our work is always a work in progress is important.

And then, two, I think patient stories, right? It’s so easy to overlook, and it sounds cliche, but the story of the person who’s in front of you really is the only way to keep pressing in and to continue to care for the next patient in the best possible way. That takes time, trying to fight against this idea that time is the enemy and that you’re racing against the clock. But a little, you know, one open-ended question can go a long way. So I think this idea of narrative medicine is as important as it’s ever been.

Kevin Pho: So on this podcast, I’ve talked to several medical students, especially fourth-year medical students, and one of the things that they regret was that essentially a third to a quarter of their last year of medical school was wiped out because of the pandemic. Now they’re interns, and I was wondering if you could give some actionable tips or scenarios that they may encounter during their first six months of internship that can help ease them through the transition in the midst of a pandemic.

Sumner Abraham: I often think about those first months of nights, where you’re working a lot of nights and you’re making a lot of little, minuscule decisions: replacing potassium, giving a Lasix dose, helping patients sleep with any sort of medication. I would actually try to encourage people to look at every EMR that you’re looking at, every patient chart, as if that is a patient and their patient story, because that makes it a lot easier to give that next dose of Lasix, to give a Tylenol, or anything like that in the middle of the night. I think that’s vital.

I think the other thing, too, is just saying that your job is a difficult one, and I really think that the way to navigate the difficulties of what it means to practice is to seek the welfare of the hospital, of the city, of the community, of where you are. Because I really do believe that in its welfare, there you will find your welfare. I think it’s really easy to have everything be about your work, but getting to know the custodial staff and the nurses and the people who are helping the hospital go is really going to be valuable for the rest of your training, and I think it’s a good practice to have for the rest of your career, no matter what discipline you’re going into, but really investing in the people and the place of where you are, even though it may be a foreign place.

Maybe it’s a place you’re not excited about being. Maybe it’s a place that you’ve always wanted to be, but you’re not getting to experience it because everything’s locked down in the midst of a pandemic. But still, that hospital, that institution, your residency program, all the GME community: Investing in that, I think, is where you’re going to find your welfare.

Kevin Pho: So like you, I’m an internal medicine primary care doctor myself, and one of the biggest transitions for me was just having a lot of experience with outpatient problems right out of residency. I felt more comfortable dealing with an MI than I did with a skin rash, for instance. How was the transition for you? Because you’re within your first few months of being a primary care internal medicine attending, especially in the midst of a pandemic. How has that transition been for you?

Sumner Abraham: Yeah, you’re spot on. I think our graduate medical education does focus a lot on inpatient medicine. I do feel like I had a lot of exposure with that at UVA, and I’m so thankful for my training there. But again, I think it’s holding that uncertainty. You can order some labs in the hospital and they’re back the next morning; you check labs every day, whether or not it’s the right thing to do, because that’s just the easiest thing to do next. But I think it’s sending the patient out, maybe to see them in three months, and really having to trust that.

And I think it’s being honest with your patients: “Hey, I’m going to tell you how I’m thinking through this. I’m a human being just like you are, and I want so desperately to care for you as a whole person. But also, I may have to pick up the phone and call you and say, ‘Hey, I wasn’t really thinking through that the right way.'” I think just having the humility to say that your work is always a work in progress, I think it’s OK to share that with your patients. I’ve found that they’re very appreciative of that and just appreciate that little piece of vulnerability. But certainly, holding the ambiguity in the outpatient setting is very different than the safety net of training. So there are times that I miss it, but I think I’m growing a lot more in practice.

Kevin Pho: We’re talking to Sumner Abraham. He’s an internal medicine physician, and he wrote the KevinMD article “A letter to medical interns, in the midst of a pandemic.” Sumner, is there something that you know now that you wish you knew back eight or nine months ago, before the pandemic started?

Sumner Abraham: Yeah, I’ve really thought a lot about this word, lament: this idea that I can see a tragedy or an injustice or an infectious disease that is taking over the world and be honest about that, that it’s terrible and that it’s difficult and that practicing evidence-based medicine without any evidence is impossible, but then also to hope. Being able to be honest and really name what’s happening while also still having a positive outlook and some hope is something that I’ve really wrestled with, but I do think that it is the antidote to this feeling like you’re drowning in the midst of this.

I think that if I were to really lean into that concept as a trainee, I would maybe have been more fulfilled at times. You see these profound social injustices as a trainee, and it’s really easy to get down about that and really easy to just be sad. But also think that you can simultaneously hope for a better health care system or a more equitable health care system, and you can do that at the same time. I think this pandemic has really just been a pressure cooker for that idea for me: that I’m going to be a better physician if I learn that, and that is to simultaneously cry out and be truthful about some of the hardships that we’re facing, but also to really remain hopeful about what there is to come, because there is profound opportunity amid this disruption.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Sumner Abraham: You know, I just think that it’s really easy to find a lot of this idea that statistics can kind of be heartwarming. I think I close out my article with that. Or that there are a lot of hollow promises that I feel drugs and therapies can offer. As I go and see patients this afternoon, and as hopefully all the listeners go and really care for people, just what a cool job we get to have, to really come alongside people and walk through life with them.

I think just zooming out and having that 10,000-foot perspective, even in the midst of cases soaring and our health care system being as overwhelmed as it has been this whole entire year, there are people in front of you and there are patient stories, and to lean into that and to take, you know, two or three extra minutes with each patient and just learn about their life, their hobbies, what makes them tick, and what their goals are, because I think that will sustain you not only now but also in the future.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Sumner Abraham: Yeah, Kevin, thank you so much.

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