Residents' Corner

ICE-TIME AND SURGERY

from left to right - Caroline Scott with her brother Ian and her sister Katherine

Caroline Scott grew up in Toronto, then attended Cornell University in Ithaca, New York for undergraduate studies in Biology and Society. She chose Cornell for its excellent Biology program and for its Varsity Hockey team. "I wanted science and ice-time". She went with her cousin to Ithaca and found "it was great fun, though Varsity athletics is a full time job". She continues to play hockey now with the Orthopaedics Division in the men's league. "I play Tuesday night with some of the orthopedic residents and staff, and Wednesday with The Bipolar Bears team, that includes anesthesia, plastic surgery and family medicine friends from medical school. It keeps me in touch and gives me a great workout."

She likes trauma, sports medicine and pediatrics, all recent rotations in the orthopedics competency-based curriculum. Her mother is an orthopaedic surgeon at Scarborough Grace Hospital. She enjoyed the reflective writing elective with Mount Sinai psychiatrist Allan Peterkin. "The project was to illustrate CanMeds roles based on experiences as a medical student – how I advocated, managed etc. I got more out of my rotations because of these writing assignments."

She enjoys international research and travelling. "It has made me a better resident in my own Toronto setting." She also enjoyed studying HIV medication counseling in Zambia. She focused on the counselors and the barriers to their success like communication and compliance problems. "If there is no transportation, no alarm clocks, and no feedback on CD4 counts from lab data to motivate them, patients are less compliant." "I lived on the University campus and then travelled in Africa to Zambia, Ethiopia and Tanzania with my cousin." Her current residency research project involves a needs assessment of low cost imaging technology in low resource settings. Her field work will be in Uganda. This is a continuation of her supervisor Maryse Bouchard's work. She has studied the effects of sleep deprivation, including studies in which she participated as a subject. She learned "not to pull all-nighters," which, though commonly misconceived as virtuous, are not effective for study or for patient care. "There isn't a simple solution to the patients' need for 24 hour care and the harmful effect of sleep deprivation on resident performance."

M.M.

MICHAEL MACKECHNIE - INTERNATIONAL SURGEON

Michael MacKechnie in Barcelona -Parc Gruel

Michael is a second year resident in the department of orthopedic surgery. Born in Seattle WA, he grew up in the United States, Great Britain, and New Zealand before arriving in Canada. He attended York University and graduated from medical school at McGill University.

His enthusiasm lies in the field of global health, an interest which first started with his work with the Canada International Scientific Exchange Program (www.cisepo.ca) where he spent twelve weeks in Jordan working with Jordanian, Israeli and Palestinian groups, with a special focus on performing hearing screening in newborn babies. Michael went on to work with the Canadian Association of Medical Teams Abroad, where he was a translator for an orthopedic surgery mission to Quito, Ecuador. He has been mentored in many of his international endeavors by Arnold M. Noyek, ENT surgeon at Mt. Sinai Hospital. Arnold is a very active and internationally engaged surgeon and humanitarian, the founder of CISEPO, and a wonderful mentor to generations of young doctors.

Michael became interested in orthopedic surgery as an undergraduate student when he watched orthopedic surgeons in Ecuador. These doctors enabled people who had spent years without the ability to walk to return quickly to being active members of their communities. In many cases these patients were from the Ecuadorian Amazon jungle, and had been unable to leave their houses for years.

Michael's research interests include international health education. He is presently working on an education video to teach fracture reduction and casting which he hopes will be widely available in North America and the developing world. The technology boom has made interesting new methods of teaching available around the world.

Michael is also the recent recipient of a Health Volunteers Oversees Orthopaedics Traveling Fellowship. He will use this award to spend four weeks on orthopedic assignment to Malawi in early 2013. He is grateful for the support and encouragement of his faculty, especially program director Peter Ferguson, and his co-residents.

Michael plans to use his six months of research time in his third year of residency to examine the possibility of creating an orthopedic surgery residency program in Botswana. He will work with Arnold Noyek, Georges Azzie, and Lucas Murnaghan at the Hospital for Sick Children.

Following the teaching of Arnold Noyek, Michael also has an interest in ways that international health can work towards peace building in conflicted areas such as the Middle East. "It's Maslow's hierarchy of needs - people first need food and shelter and health; they next need safety, then work, all before they can start to actualize their true potential, and work for peace."

He is close to his parents and three younger siblings, all in the GTA. His parents run university programs teaching English as a Second Language, and appear to have transmitted their nomadic allele of the traveling gene to Michael. He is in a relationship with Lauren, a Masters student in pediatric nursing. He runs, golfs and plays intramural soccer and basketball. The latest book that he has read is the biography of cancer- "Emperor of all Maladies" by Siddhartha Mukherjee and "Theodore Rex", a biography of Theodore Roosevelt. He also enjoys the Spanish literature of Mario Vargas Llosa.

M.M.

Professionalism in Practice

DEALING WITH DEATH

As an eager medical student, I had prepared myself to tackle the physical and emotional hurdles that would await me during a general surgery residency. I was anticipating the complex knowledge base and intricate technical skills that I would have to try and master. I had a plan to maintain a good work-life balance despite the challenging schedules and heavy work load that required long work hours. I felt that medical school had helped me cultivate the skills and qualities required to provide patient-centred care, to honour ethical principles and to act with professionalism. However, I was not prepared to be comfortable with death.

One month into residency, I had my first experience with dying. Mr. S was a 60 year old male who was scheduled for an elective esophagectomy for esophageal cancer. Unfortunately, in the operating theatre, he was found to have an inoperable tumour as there was evidence of tumour encasement of the aorta and right atrium, which was not evident on recent imaging. Our thoracic surgery staff informed the patient and his family about the intraoperative findings and recommended getting palliative care involved. While the patient had come to terms with his prognosis, the family was optimistic and reluctant to give up hope. As a result, the patient gave in to his family's wishes and requested a consult with medical oncology to discuss the role of chemotherapy.

While recovering from this unfortunate surgery, his health rapidly declined. He required a gastrostomy tube for nutritional intake. After only a week in hospital, he developed a bronchoesophageal and a bronchopleural fistula. As a result, he developed a right pneumothorax and severe pneumonia. Treatment was initiated with a chest tube and broad-spectrum intravenous antibiotics. It was becoming evident that his cancer was rapidly progressing and that no medical or surgical treatments could rescue him. I was on call the day his fistulas were diagnosed. Together with the thoracic surgery fellow, we prepared for the family meeting. Our goals were clear; we were to update the family on the clinical status of the patient, the options available, and the expected prognosis. We were going to discuss code status, palliative care involvement, and end of life issues. We had cleared our schedules to allow for ample time with the family and reserved the quiet room designated for such meetings. The fellow I was working with allowed me to take the lead and begin the conversation. Soon into the conversation, the patient's daughter began to cry. She squeezed the hands of her mother, who began to weep and tremble uncontrollably. Upon witnessing their emotional burden, I was unable to continue. I froze. I felt a lump in my throat and that my eyes would soon well up with tears. I knew that if I continued, they would be able to sense my sadness. I needed to maintain my composure so that the focus would not shift to me. But I was no longer in control.

Luckily, the thoracics fellow was with me. I watched with amazement and awe as he communicated with ease. He demonstrated empathy and compassion without becoming overly emotional, and demonstrated a high level of professionalism. Whether knowingly or unknowingly, he used all of the nonverbal and verbal communications skills we were taught in medical school. He made appropriate eye contact, demonstrated active listening, used reflective statements, and summarized appropriately. In a calm and steady voice, he used his medical knowledge to explain why further interventions would be futile. He wasn't afraid of the silent pauses. He gave them time. He remained composed and patient while answering all of their questions, and repeated his responses multiple times using various terms until he was sure they understood. He went beyond the ethical principles of informed consent and patient-centred care by understanding their vulnerability, experiences and fears. In doing so, he was able to earn their trust. The family was confident that he was putting their loved one's best interests first. And so, he was able to ask the difficult questions surrounding palliative care, comfort measures and DNR status. He used layman terms to emphasize the concepts of patient autonomy and advance directives. From this conversation, the family realized that any medical or surgical efforts would be prolonging death and they accepted that comfort care would be in the patient's best interest.

At the end of five months into residency, I had another encounter with the discussion of death. Mr. W was an 83 year old man with known metastatic colon cancer involving the liver and lungs for which he was receiving chemotherapy. He presented to the hospital with a high-grade bowel obstruction with marked dilatation of his cecum to over 13 cm secondary to a colonic stent failure. On admission, code status was established and he was deemed DNR. While in hospital he underwent stent replacement via interventional radiology, which was initially thought to be successful. However, while I was on call that night, I was paged to assess Mr. W for SVT with a heart rate ranging from 170-200 and increasing oxygen requirements on nasal prongs. He was otherwise asymptomatic. After ordering routine investigations for tachycardia, I checked the stat chest x-ray. I was surprised to see a moderate amount of pneumoperitoneum. I reviewed the findings with the senior on home call and we decided to order a CT scan of his abdomen. The CT scan confirmed a perforation near the distal site of the stent placement with moderate free fluid and extraluminal air. Given his clinical status, age and comorbidities he was high risk for surgery and the outcomes were poor given his end stage cancer. It was almost certain that he would require a stoma. However, the patient's wishes were uncertain as he was confused. Since I was the only one in the hospital that night, my senior resident asked me to communicate the findings to the patient's wife and discuss the patient's wishes, including the option for surgical management, the high risk of requiring a stoma, and to confirm code status, while he informed the staff surgeon on call.

At first, I was nervous. I was afraid of how the wife would react and how I would respond to her questions. This time, however, I was armed with some experience. I recalled my encounter during thoracics and the salient features that helped the fellow break bad news. I made sure I knew all of the medical information, options and outcomes. I was prepared for the silent pauses and the emotions and uncertainty that would ensue. I remembered how important it was to be empathic and to gain an understanding of the patient and family's wishes, fears, and concerns. And I realized that even though there wasn't a fellow by my side, this still wasn't a discussion I would be having alone with the family. The senior resident and staff would discuss the prognosis further in the morning. Social work, the hospital chaplain, and the family's minister would be available for addition support and guidance. With this knowledge and experience, I was comfortable and I didn't lose control. This encounter came full circle for me when at the end of the discussion the patient's wife commented on how much she appreciated the time, care, and ‘good bedside manner' that I provided.

Most surgeons remain uncomfortable with death, as it is an outcome they might equate with defeat (1). However, evidence suggests that students do as their teacher do (2). And so, with positive role models, professionalism surrounding ‘breaking bad news' can be taught. Dealing with the concept of death and dying is still not second nature to me, nor should I ever want it to be. It is not a routine practice since it is a unique and extreme situation that each patient and their family are faced with. It requires compassion, empathy, good communication and a mutual understanding to reach common goals for the patient. With the excellent mentorship I received, I am now more comfortable in my role as a physician and as a professional during these trying times.

Nathalie Wong-Chong,
PGY1 General Surgery

REFERENCES:

(1) Gruen RL, Arya J, Cosgrove EM, Cruess RL, Cruess SR, Eastman AB, Fabri RJ, Friedman P, Kirksey TD, Kodner IJ, Lewis FR, Liscum KR, Organ CH, Rosenfeld JC, Russell TR, Sachdeva AK, Zook EG, Harken AH: Professionalism in Surgery. J Am Coll Surg 2003; 197; 4; 605-08.

(2) Christian F, Pitt DF, Bond J, Davison P, Gomes A: Professionalism – Connecting the past and the present and a blueprint for the Canadian Association of General Surgeons. Can J Surg 2008; 51; 2; 88-91.

[This is a well described example of the role of near-peer mentoring. Junior residents often miss the chance to observe these emotionally charged conversations or stumble through them unmentored. M.M.]