This piece was originally published in the January/February 2022 issue of the Tarrant County Physician. You can read find the full magazine here.
Welcome to 2022! This is going to be our year. Things are going to be better. So long, COVID . . . Oh wait, maybe not. Doesn’t this all sound a little too reminiscent of the start of 2021? As I write this, we are in the beginning stages of a new variant, Omicron. There is still much we do not know about this variant, and hopefully, by the time you are reading this, it will have turned out to be not as bad as the last one.
Thinking back to the start of 2021, we were elated to have new vaccines to fight off and end the COVID pandemic. Many of us in healthcare were racing to sign up to get our shot and show it off on social media. We finally had some armor to protect us in this fight, and soon enough it would be available to protect our families, friends, and patients. Yet the conversation quickly turned to, “It was made too quickly,” “You can’t mandate that I get the vaccine,” “I am healthy; why do I have to get the vaccine?” or “It is all fake news.” So now, here we are, entering the “terrible twos” of the COVID pandemic. If there is one thing that has been demonstrated during the COVID pandemic, it is that the innate trust in physicians, medicine, and science is, unfortunately, no longer so automatic. We as physicians must continue to be voices for science and for medicine who, at the end of the day, want the best health outcomes for our patients.
As we enter the terrible twos of the pandemic, I encourage my physician compatriots to be the voice that our patients and our society need to hear. Whether that is in your day-to-day interactions with patients, conversations with family and friends, or in public venues, we must continue to be the voice of medicine. Ways to amplify that voice exist within our own county, state, and national medical society. Those of us in medicine often focus on what makes us different, but now more than ever we need to focus on what brings us together.
We are all tired and exhausted from this fight, and more than once I have heard others as well as myself say, “Can’t we just go back to how it used to be?” Unfortunately, I hate to say, COVID is with us for the foreseeable future. Yet, those of us in medicine went into this field for a reason. For me, that reason always comes down to my patients. I want to provide the best care to optimize the health and well-being of my patients. During these terrible twos, I call on my colleagues to remember why you embarked on this journey of medicine, and when you see a colleague struggling, help them to remember why they came to this profession. Not only can we be the voice of medicine to our patients, but we can also be the voice of support and camaraderie for our fellow physicians.
As we embark on this new year, I want to say that I support you as a fellow physician, and I look forward to the amazing work that you all contribute to your patients and to our society. Thank you for what you have done and what you will continue to do.
This piece was originally published in the January/February 2022 issue of the Tarrant County Physician. You can read find the full magazine here.
When Dr. Shanna Marie Combs was a little girl, she knew when she grew up that she wanted to be a doctor and a ballerina. Not a doctor or a ballerina – she wanted to dance and practice medicine. So that’s what she did.
The combination might seem odd, but when the OB/Gyn, who is a self-declared science nerd, ended up seeing multiple orthopedic surgeons throughout her childhood to manage dance-related ankle complications, the interest came organically.
“I was seeing orthopedic surgeons at the age of 12,” Dr. Combs says. “They all wanted to operate on me, and I would push back and be like, ‘No, I need another option.’” She laughs as she remembers her juvenile determination. “It came to the point I would have orthopedic surgeons print out journal articles for me.”
While her interest in medicine only grew as she did, Dr. Combs realized that she should pursue dance first if she wanted a real shot at both of her passions. After all, professional dancers have limited careers, and Dr. Combs was facing an even bigger challenge with her stressed ankle.
“I used to joke that medicine was my backup career for ballet,” Dr. Combs says with a grin.
She pursued a Bachelor of Fine Arts in ballet at TCU while taking all the necessary prerequisites to apply for medical school. Even though she wasn’t ready to take that step, she wanted to be prepared. It was a hectic time – she always took the maximum number of hours and had to take her science classes in whatever order they were available to work them around her dance classes.
After graduating, Dr. Combs joined the Ballet Theater of New Mexico in Albuquerque, where she had danced in high school. While there her life revolved around ballet – she performed, worked with students, and even managed the studio’s front desk.
Dancing was fulfilling, and Dr. Combs looks back on that time fondly. She created a special bond with her “ballet ladies,” one that holds strong these many years later. Still, the time had its challenges. Money was tight, and she ended up taking another job as a physics lab tech at a community college.
Dr. Combs was also physically feeling the impact of constantly dancing, so after a couple of years of performing professionally she decided it was time to move on to medical school. It was at that point that she hit a snag in the plan; she didn’t get accepted to the places where she had applied.
“I kind of had to have a real heart-to-heart with myself as to whether or not I actually wanted to do this again,” Dr. Combs says. “But ultimately, I was like, ‘No! You want to be a doctor.’ So I retook my MCATs and applied broadly and got in.”
She attended medical school at the University of New Mexico. Based on her childhood, she had thought she might go into orthopedics or perhaps pediatrics, but when she began her third-year rotations, she found she was drawn to obstetrics and gynecology. No one was more surprised than she was.
“I said I would never do OB/Gyn as a first-year med student, and here I am, as an OB/Gyn,” Dr. Combs says. “I did not understand the scope of what an OB/Gyn does, and probably my first day on the rotation I was like, ‘Oh, I kind of like this.’ So I fell in love with the field.”
It has been her passion ever since. She completed medical school in 2008 and began her residency in obstetrics and gynecology at JPS. She finished the program in 2012 and then began working for JPS Health Network in private practice as well as in education for the residency program.
Her love for teaching and education led to her involvement in the curriculum development of the TCU and UNTHSC School of Medicine, and she ultimately became the OB/Gyn clerkship director at the new medical school. Though Dr. Combs recently left that position, she is continuing to work with students; it’s one of her favorite roles as a physician, to prepare the next generation of doctors.
“When you work with students, I always say you can learn what to do and what not to do, and I always wanted to be somebody where they hopefully learned what to do in working with me,” Dr. Combs says. “I’d always loved teaching, so once I discovered that, oh, I can teach in medicine too, I kind of continued that in residency working with medical students and residents who were below me as I moved up and ultimately into education and working with students.”
In spite of her focus on education, Dr. Combs has maintained an active private practice. Last year she transitioned to Cook Children’s Physician Network, which has been an amazing opportunity to marry her love of pediatrics and OB/Gyn, two fields of medicine that rarely intersect.
“A lot of gynecologists won’t see kids younger than 16 or 18,” Dr. Combs explains. “There was definitely a need; it’s totally blown up. And I love it. I can’t tell you how many times women have brought their daughters and been like, ‘We’re so glad you are here.’”
“[Dr. Combs] has taken on the awesome task of advocating for female teen and young girls’ health,” says Dr. Hannah Smitherman, a pediatric emergency medicine physician who is one of her colleagues at Cook Children’s. “It’s a niche that many shy away from . . . Teens are struggling with the stressors of a rapidly changing and conflicted world. Dr. Combs is there to help support these children, soon to be adults, through their often very personal medical issues.”
Currently she sees any patient between the ages of 0–22 that needs gynecological care, but the bulk of her practice is made up of teenagers. “I love taking care of my little ladies,” Dr. Combs says. “I try to provide a very safe place.”
Recently, after displaying quite a bit of anxiety during her appointment, one of her young teenage patients came out to Dr. Combs as lesbian when they talked privately. It was something she had been afraid to tell anyone.
“As they were leaving, the patient kind of hangs back a little bit and she’s standing next to me,” Dr. Combs says. “And I’m like, ‘What’s up?’” Her voice is hushed as she reenacts the moment.
“And she said, ‘Can I give you a hug?’ My heart just broke. I just got the impression that she felt heard and supported . . . Stuff like that – it’s the best part of the job.”
Dr. Combs says there is one simple answer when it comes to organized medicine: “Do it!”
“As a medical student, I got involved in the New Mexico Medical Society and the AMA as well, and I remember talking with colleagues and fellow students,” Dr. Combs says. “They were like, ‘Ugh! I don’t want to deal with that stuff.’”
While she understands the hesitation physicians might feel, especially those just beginning their careers, she believes that it is critical for them to be involved in anything that impacts medicine.
“Am I a businessperson or a politician? Absolutely not,” Dr. Combs says. “Would I rather just practice medicine? Absolutely! But all those outside influences affect how I can practice medicine, so I’ve always wanted a seat at the table to kind of influence those decisions and choices.”
And if you feel underrepresented by an organization, Dr. Combs believes that is all the more reason to get involved.
“You can stand on the outside and throw stones and say, ‘They don’t speak for me,’ or you can say, ‘They don’t speak for me; I need to join that organization.’ Because the only way it’s going to change is if more membership gets involved.”
Dr. Combs tries to encourage medical students to participate just as some of her mentors encouraged her. One of those mentors, Dr. G. Sealy Massingill, who is an OB/Gyn practicing in Fort Worth, interviewed Dr. Combs when she applied for a JPS residency spot, and when she joined the program, he suggested that she participate with TMA and TCMS.
“I encouraged her to seek out opportunities in the community and feel grateful she chose to become involved,” Dr. Massingill says. “Her commitment to equity, diversity, and access to care have been drivers for her.”
Several years ago, Dr. Combs participated in TMA’s Leadership College. Since then, she has served on the TCMS Women in Medicine Committee and Publications Committee, and on the state level, the Membership Committee and Maternal Health Congress, as well as one of the AMA alternate delegates.
Now, she is ready to lead TCMS as she begins her term as the 2022 president. Dr. Demequa Moore, who is also an OB/Gyn taking care of patients in Fort Worth, says one of Dr. Combs’ greatest strengths is that she is driven by her deep care for others. “[She] has always practiced with empathy and compassion,” Dr. Moore says. “She continues to seek opportunities to learn and improve the health of her community.”
As Dr. Combs looks back over her career, a physician of particular influence comes to mind: the late Dr. Tracy Kobs. Dr. Kobs worked with JPS residents in the operating room when Dr. Combs was in the program, and she strives to emulate him as both a physician and educator.
“The more I learned about him over time, the more I respected him,” Dr. Combs says. “Operating, you want to get in, you want to do the job correctly, and you want to get out. And so when you’re working with learners you have to be very patient because they’re learning, and he never got frustrated or upset when things were taking too long or anything like that. He was always so patient . . . with the breaking down of steps. And even working with students now, teaching them how to do just basic knot tying and suturing, a lot of the mechanics I learned from him I bring to teaching with students.”
She is grateful for the cheerleaders she has had along the way, and her parents have been chief among them. They supported her at every step she took and challenge she faced.
At one particularly memorable moment, the family was driving back to Texas from Colorado when Dr. Combs found out she had passed her board exams. Her mother insisted that they had to celebrate immediately, so they pulled the car over so they could dance for joy.
“I love my parents,” she says, a big smile crossing her face. “I have to say, I’m very blessed.”
When she isn’t busy teaching, seeing patients, or attending meetings, Dr. Combs enjoys traveling with friends and family or spending time with her dogs, Duke and Poppy, and her partner, Mike Bernas.
While she has enjoyed her varied career and life experiences thus far, Dr. Combs looks to the future with anticipation because she sees it centered around her work as a physician, something that over the years, she has realized is more than just a passion.
“At the end of the day, I call it a calling,” Dr. Combs says. “You know, you hear people talk about their calling to ministry and things like that, but to be a physician has always been what’s at the center of me.”
This piece was originally published in the November/December 2021 issue of the Tarrant County Physician. You can read find the full magazine here.
The church bus let me off in front of the house. It must have been after a Wednesday evening service because it was dark. I started to walk toward the house when I heard “Angela, Angela.” It was my mom quietly calling to me from her car across the street, my little sister and brother in tow. I did not know at that moment that my dad was inside the house wreaking who knows what kind of havoc. My parents had been separated for a couple of years after my mom had all she could take of his drunken rages and unthinkable actions. One time we returned home to this very house in Oak Cliff, Texas, to find all of our windows broken out and a note on the kitchen wall (held there by a large butcher knife).
Let me back up for a minute. My dad was a brilliant man who had a heart of compassion and was an excellent teacher and patriot – when he was sober. The problem was that we rarely saw him sober in my early years. The thing about kids and their parents is, no matter how messed up a parent is, the trauma of losing them is greater than the pain endured by any disease or affliction they bring with their presence. For several years I would ask my mom if “Daddy” knew where we were and if he had called. I was sure that he just couldn’t find us. This feeling only got worse when we moved out of state. My mom met another man, and I knew he was there to stay when she told me that she was pregnant. That was one of the saddest days I can remember. I did not even know what abortion was at the time, but my mom could not afford to travel to California to get one (the year was 1973). I would not see or hear from my biological dad again until I was 19 years old.
One thing I knew was that I could not let my new little brother grow up without a dad. The pain of that loss was all I could bear as a child and I could not let another child, my brother, suffer in that way. So I kept quiet in the midst of abuse for years. I knew that I had to because mom would leave, and she would not be able to support us without him. I also knew my little brother would be as devastated as I was when I lost my dad. Yes, my stepdad was also an alcoholic. Both of these men have passed, my dad at 53 years of age and my stepfather at 69. I was at my stepfather’s bedside after the stroke that was likely a result of years of alcohol and tobacco use. He and my mother had divorced years earlier, thank God. I had forgiven everything and kept in touch, hoping he would find the same self-forgiveness and peace that I had found at 19 — you see, he also grew up as a child of abuse.
My mom was a little checked out (okay, a lot checked out) during the “Vegas years.” Though my stepdad was able to do a lot of construction work to support us, my mom struggled with a different addiction. My mom, who has likely never really been drunk or high, was a gambling addict. What does an abusive stepdad do when he wants the freedom to abuse his step kids? He tells his gambling addict wife to go to the casino and even gives her money for the little adventure. As soon as I was old enough to physically get out of the house, I would run away, stay out all night, miss school. My mom would ask me for years to come why I just spun off the rails at about 15 years old. She was concerned about my behavior and sent me to stay with my aunt in New York one summer and then for a semester in 9th grade. I met a boy there; he was cute. Right after I graduated from high school, I continued staying out all night. Mom told me that if I stayed out all night one more time, I could pack my bags and take them with me. I took Mom up on that offer, probably that day. I bought a bus ticket to New York (at 17) and informed the cute boy that I was coming to stay with him.
I worked as a dental assistant to help us pay the bills; there weren’t many as we mainly lived with his parents. Sadly, he also struggled with some issues that hit a button with me and led me out of the relationship ten years after I met him. I am grateful for all that I learned from his family; I did not really know what family was supposed to look like until I spent time with his. They were wonderful people who taught me things I had not learned at “home.” Do not misunderstand, my mom loved all of her kids very much, but she was dealing with her own childhood and adult struggles which took the focus off of anything other than keeping us physically safe (which would only happen while we were in her sight). Now I was an adult, out on my own, volunteering with my ambulance corps, working as a surgical dental assistant, going to college – just in a very unhealthy relationship. But what was a healthy relationship? It would be years before I knew, if I actually do know. We will leave my relationship struggles between me and my very capable counselor. Let’s get back to the casualties of war.
The pain of that loss was all I could bear as a child and I could not let another child, my brother, suffer in that way. So I kept quiet in the midst of abuse for years.
My mom and stepdad moved back to Texas. It’s funny how unsustainable it is when you tell your husband that you’re making the mortgage payment and you’re really putting it in the slot machines. It doesn’t work well with car payments either. They had an opportunity to buy a small home on a pretty lake near Caldwell, Texas. It was the town where we had gone to visit my grandparents when I was a kid. Things were seemingly okay with my mom, stepdad, and youngest sibling, my half-brother. Then things got rocky between my mom and stepdad, and my little brother dealt with the breakup by running with a crowd that was likely not the best. By the time he approached his teen years he had dropped out of high school and had started having kids. I remember his first daughter being born when I was in med school. He and his girlfriend began having problems and drugs entered the picture. At some point one of those drugs was meth. My mom has spent so many years trying to make up for the years lost with her oldest three kids by being a doting mom to her youngest and to his kids. At present my brother still struggles with meth. His oldest daughter, who ran track and got many awards before graduating from Caldwell High School, is now an addict who might not be alive as I write this. I really do not know. I am not allowed to mention my youngest brother to my other family members (except Mom) as we have all lived too many years waiting for that phone call from the police, hospital, or morgue.
You can take so much and then you just check out due to helplessness in the situation. We have all been casualties of addiction of various sorts, yet we fight on. My sister is a very good nurse and has been the best mom to her college student daughter. My sister does not drink or dabble with any of the substances that wrecked our family. My brother (the clean one) has a sheep farm, is a carpenter, a loving husband and father, and has also kept his house clean from any of the things that wrecked our lives. I am here writing this article, hoping my mom will not be too hurt as she is doing the best she can to try to save the life of her granddaughter this week. Literally, doing whatever she can to get her arrested so that she will not die in a drug house (weighing about 100 pounds, covered in sores, mind almost gone, and threatening to “fix herself” in her own way). Oh, don’t worry about the resources available – my niece has already been visited by the police and MHMR this week. There is nothing they can do.
The thing about meth is that it does not take its victims all at once; it slowly makes them and everyone in their lives casualties every single day. I wish I could give a hotline or support group info, but the only thing that I can do is pray. And I do, we do, pray. We have all come to terms with what addiction has done to our lives. We have made peace with the actions of others and regret how our own actions have hurt those around us, but we continue on in the midst of a bad dream and find joy in any area that life offers. As you go out today, remember that there is not a specific background that defines a physician, or an individual. Often, we assume that doctors only come from privileged environments, but many of us have a different story. Yet, I am the sum total of what a physician is, and so are you. We are changed, we are impacted, but we are not defined by our pasts. You never know who around you is a fellow casualty of war, doing their very best to enjoy one day at a time. God bless you all – it has been my honor to serve as your president.
A note from our committee meeting seemed to resonate with me. One of our editors asked the group to describe the tone of this edition of the Physician. They were asked to clarify the rhetorical question. The point made was that this edition of the magazine read more like a collection of biographies than a medical journal. Are we physicians compiling and writing a medical journal? For over a decade now, I have worked with this committee to help produce this magazine. I don’t know if I’ve ever really thought of it like I do perhaps the New England Journal of Medicine or JAMA. Such magazines are usually filled with double-blinded studies, research into this and that, and critical analyses of the science of the day. Our journal seems a bit different.
The President’s Paragraph tells of a rocky childhood and challenges overcome. In reading this, we are reminded that as physicians, we all have stories that define not only who we are personally, but also the lives we lead professionally. We are not automatons or angels with all the answers. We are humans who aspire to be more for the betterment of all of humanity. We are not brilliant white sheets flowing in the wind. Rather, we are tapestries with amazing, intricate stories. The beauty of these tapestries is reflected in the practice of our trade. Because of our own complexities, our patients connect with us, and so bonded we weave the physician-patient relationship. Through the experiences of our own pain, we are able to relieve their pain, alleviate their suffering, and embrace our collective humanity.
The student article also speaks to fighting through stigmas and strife to achieve a goal, an almost unattainable dream. Humble beginnings define the immigrant and minority community biographies. The idea that a poor student from a third world country with nothing more than the shirt on his or her back could somehow immigrate to this country and then in a generation that individual’s progeny are successful professionals and entrepreneurs, physicians even. This idea would sound impossible back in their homelands. Like our student though, many physicians have lived through this dream. We were told that the obstacles were insurmountable. We may not have been recognized as being able to be something more than our station, our family’s station. We may have been told that we don’t belong. We may not have had the means to support ourselves and our families. And yet, we endeavored to persevere. Some students may have been discounted. Despite this, we fight on. We work harder. Become stronger, wiser. We work so that we can achieve this solitary goal of the betterment of the lives of our patients.
The feature article speaks to our connections. They are not always palpable, but they remain very real. For some of us, the physician-patient relationship comes easy. We are able to effortlessly bond with our patients. We acknowledge our collective humanity, forging solid connections. The relationships we have with our families and our friends often remain more evasive. And so when these relationships cross into our professional lives, we often celebrate them. The article celebrates the human connection, the love and respect we have for our fellow man, and then the love we have for our friends and family. Every day in our practices, we celebrate the physician-patient relationship. Inevitably, we celebrate our patients and the love we have for them. Many of us agree that medicine is an art, not a pure science. We weave our tapestries together with our patients. We often speak of professional distance, but this really does not apply well to medicine. We often cross our patients with loved ones, and vice versa. We take care of our patients just as we would our own families and flesh and blood, to the point that our patients often become our family in their own right.
We take care of our patients just as we would our own families and flesh and blood, to the point that our patients often become our family in their own right.
These are the issues which are woven into this month’s edition of the Tarrant County Physician. If you read back, you will readily recall that these are the issues that are found throughout every edition of the journal of the Tarrant County Medical Society. In every sense, the articles that are published for your perusal are our collective biographies. They are the words of our TCMS Family. These are the stories of the physicians of Tarrant County. We have always asked our membership to contribute to the magazine, and we have never been disappointed. All of you have beautiful tapestries to share with all of us. I continue to encourage you to share your stories with our committee. After all, in answering the initial question, this is not a medical journal. We always appreciate and publish any scientific contributions by our member physicians and will continue to look forward to doing so. If you have any articles or studies or research that you have done which you would like us to consider publishing, please send them in. And if you think your story, your biography, your words can be shared, then please send these in as well. The Tarrant County Physician is a direct reflection of our membership. All of us have amazing, interesting, intricate, and beautiful stories. Every time you read my own articles, I share my own biography with you. I hope that y’all will continue to share your stories with me and all of us in your TCMS Family (you can do so by sending them to editor@tcms.org). My name is Hujefa Vora, and this is Our Last Word.
This piece was originally published in the November/December 2020 issue of the Tarrant County Physician. You can read find the full magazine here.
“I can only wait for the final amnesia, the one that can erase an entire life.” —Luis Buñuel
There is little doubt that my wife will outlive me, likely by decades. Her father lived to the age of 100, and we celebrated her mother’s 101st birthday last month. There is no substitute for good genes. Her father’s memory remained sharp until he laid down one afternoon for a nap and didn’t awaken. He had been quite a baseball enthusiast as a young man—his grandsons loved to hear him tell about the time he met Babe Ruth. In his final years, he avidly watched any and every sport on television and knew every player and their current statistics in several of the major sports. His wife, however, has followed the more familiar scenario of progressive dementia with increasingly poor short-term memory over the past three years. At this moment, she is sitting across the room from me, and she just asked for the third time in five minutes what the temperature is outside. It is sad for me to see this happening to one of the three most wonderful women I know.
I am all too familiar with dementia from my own father’s last few years. He had been a brilliant chemical engineer and remains one of the most accomplished people I have ever known. It was painful to witness his decline. I once watched him read and reread a typed letter on a well-worn piece of paper. Each time he did so, his smile faded and his eyes filled with tears before he sadly put the letter down. Within a few moments he had regained his usual happy demeanor and was about his business until he noticed the letter lying where he had placed it. He picked it back up and reread it with the same sad results. After observing this cycle several times, I peeked at the letter and saw that it was from his primary care physician. It read, “Dear Mr. Black, you have been diagnosed with dementia . . . . .” I disposed of that letter very quickly, and my father never realized it was gone. His memory loss progressed inexorably from short-term to include even long-term during his final year, resulting in a peaceful but oblivious state of total amnesia. It was no longer possible to pursue a meaningful relationship with him because we shared no common ground and could discuss only the environment around us at that moment. We could no longer revel in family memories. He recognized no photographs and could not even recall personal food preferences. Toward the end, we visited him—not for his sake, for we realized our visit would have no significance to him after we left—but for our sake, because it would be of significance to us.
In his 1985 book, The Man Who Mistook His Wife for a Hat, the late neurologist, Dr. Oliver Sacks, recounted the story of “The Lost Mariner.” Jimmie G. had developed amnesia due to Korsakoff syndrome. He could remember nothing of his life since the end of World War II, including all events that had taken place more than a few minutes earlier. He believed it still to be 1945, and although he behaved as a normal 19-year-old, Jimmie was, in reality, nearly 50. He was completely incapable of accomplishing anything noteworthy because he could not build one memory upon another to form a progressive narrative. His life had been frozen in time, in 1945. It was a living death.
Is there a better explanation of what makes life meaningful than Memory? Without memory, life cannot possibly be more than a moment-to-moment existence. In his memoirs, the film director, Luis Buñuel, wrote, “You have to begin to lose your memory, if only in bits and pieces, to realize that memory is what makes our lives. Life without memory is no life at all. Our memory is our coherence, our reason, our feeling, even our action. Without it, we are nothing. I can only wait for the final amnesia, the one that can erase an entire life.”
“Generations from now, their descendants will know about them, but they won’t know them.”
I am noticing that my forgetfulness is slowly increasing. Doorways have become amnestic devices; as I pass though one into the next room, I find I have suddenly forgotten the reason I came. I am on the hunt for ways to stave off memory loss.
Which brings me finally to the point of this essay.
The movable printing press was invented in China around 1040 AD using porcelain type, but Gutenberg had the immense advantage of an alphabetic language when he introduced the metal movable-type printing press in Europe around 1450. Suddenly information could be much more easily recorded than ever before, and the past could now be remembered by means other than oral or hand-written accounts. Within 50 years, over 9 million books had been printed, accelerating the dissemination of ideas in the early Renaissance. What defines the Modern Age if not the ability to more thoroughly record and recall past actions and discoveries? And how much greater of an invention is digital storage, which can “remember” and make instantly available entire libraries of information.
My father lived out west, and I was able to visit him about three times a year. At the time we celebrated his 90th birthday, my mother had recently passed away, and my father had plenty of free time. I asked him if he would do me a big favor, and he agreed. Knowing he had led a very interesting and eventful life, I asked him if he would please write his autobiography so his children, grandchildren, and future descendants could always know what a great man they had as an ancestor. He agreed to have at least one chapter completed by each time I visited, and while I was there, I typed what had he had written into his computer. After the 16th chapter, he declared that he was done. I had the book printed and bound, along with the diary that my mother had kept the last two decades of her life, and each of their living descendants received a copy. This book has become a priceless remembrance of two noteworthy lives, more meaningful to me than to my children, because I knew both of my parents so well that I seem to hear them speaking the words as I read them. For the next several years, my father spent much of his time reading and rereading his autobiography, reliving in his mind, I am sure, the halcyon days of his youth and productive adult life that he would otherwise have been slowly forgetting.
About that time, I was talking with a friend and former college roommate. His 100-year-old father, a former physician, was living with my friend and his wife at the time, and I asked my friend what his father was doing with his time. “Oh,” he replied, “most of the time he just sits and reads the autobiography he wrote 10 years ago.” With the brain, as with a digital storage device, sometimes a hard copy is helpful to have on hand for when the primary device begins to fail.
Although a written autobiography won’t assure you of immortality in an eternal sense, it will give you an opportunity to achieve immortality in this life and assure that the memory of your existence will long outlast you. Begin writing it now while your experiences are fresh in your mind; small bits of your personal history may be eroding away even as you are reading this. It was labor intensive for my father to write the words by hand and then to type them into the word processor. It is so much easier these days with recording devices everywhere; my iPhone will even transcribe voice-to-text while I am driving, and I can edit later. I can’t imagine the process getting any easier than that, since thought-to-text technology, to my knowledge, is not just around the corner.
Throughout their last years, my wife and I interviewed her aged parents. We quizzed them about what life was like as they were growing up during the ‘20s and the years of the Great Depression. We learned of their lives as newlyweds during World War II and as they raised their children during the mid-twentieth century. We added to what we already knew of them as empty nesters. We compiled our notes into biographies of them before and after they became a couple. A century from now my father-in-law’s descendants might still read about him growing up in a town with no paved roads and few automobiles, about his visit with Babe Ruth and his stint in the Army during WWII. They will read about his wife’s parents, who were immigrants from the Ukraine; her reputation as the best golfing, bowling, and tennis partner in the area; and how she and her future husband met on a blind date. But it just isn’t the same as my parents’ accounts; they are altogether too brief for such long and noteworthy lives. Most importantly, they lack a personal touch. I don’t hear their voices when I read their second-hand stories. Generations from now, their descendants will know about them, but they won’t know them. Don’t allow that to happen to you. For a future reader to hear your voice rather than that of your biographer, you must write your story yourself. It is your opportunity to have The Last Word.
1Oliver Sacks, The Man Who Mistook His Wife for a Hat, [New York: Simon & Schuster, 1970]
2Luis Buñuel, My Last Breath, [London: Virgin Books, 1983], p. 4-5.
This article was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.
Sometimes you just need to grab a cup of coffee, sit under a tree, and contemplate nothing at all. Years before I started coffee blogging, I remember watching an episode of 60 Minutes where a segment was on “living into your 90s” by Leslie Stahl (the episode aired on May 4, 2014). I was still a toddler in my appreciation of coffee, and this episode was one of the things that propelled me to look further. Some of the commonalities that these 1,600 nonagenarians shared were physical activity (average 45 minutes a day, but at least 15), moderate alcohol consumption (those who had one to two drinks a day lived longer than those who did not drink), and coffee consumption of one to three cups a day (not more). At that time, I clung to the coffee part of the study. Now, I am realizing how far behind I am in alcohol consumption.
As the story goes, coffee was first discovered in Ethiopia by a goatherd named Kaldi. He played music for his goats each day and they would come running to follow him home. One day they did not come, so he went looking and found them playing, bleating, butting heads. He wasn’t sure what was going on but noticed they were eating leaves and berries from a plant. They refused to come for hours, but they made it home eventually. He was concerned the plant might be poisonous, but the next day the goats ran to the same area and started eating from them again. Kaldi, after seeing that the goats were not ill from the plant, decided to try it himself. That is how Mark Pendergrast tells the tale in Uncommon Grounds. The Ethiopians got creative with how they consumed this energy-giving substance that heightened alertness, a very desirable property, and thus the coffee drink was introduced to the world.
Coffee was first traded to the Arabic people by the Ethiopians. Arab Sufi monks would drink coffee to stay awake for midnight prayers. Coffee was banned more than once in that society in the 1500s, but this did not discourage people from drinking it privately. The business of “coffee growing” got quite political, and because growers tried to keep their sacred plants from being shared, there were coffee beans and trees that were smuggled from one country to another in the 1600s. The beverage was becoming popularized in Europe, and in the early 1600s it was an exotic drink used by the upper class. By the 1650s it was being sold on the streets in what sounds like coffee trucks, offering coffee and other beverages. The first coffee shop to open in Italy was reportedly Caffè Florian in Venice in 1683. This café became a place of “relaxed companionship, animated conversation, and tasty food.”1
The properties of coffee make this beverage magical—I mean, medicinal. I appreciate that reflux can be exacerbated by coffee with relaxation of the lower esophageal sphincter, and that it can keep susceptible people awake at night. However, I would rather focus on its healthy properties. Studies have been done that suggest coffee can lower the risk of cancer of the prostate, liver, endometrium, colon, and mouth.2 It is also recommended for nonalcoholic fatty liver disease because it can possibly decrease fibrosis. Caffeine comprises two to three percent of the coffee content and is present as a salt of chlorogenic acid. Tannin comprises another three to five percent. The antioxidants in coffee fight inflammation, which Rubin and Farber taught me was the basis of disease.
There are 70 species of coffee (Coffea), but the two main ones that are cultivated are Coffea arabica (75 percent) and Coffea canaphora (25 percent), and there are multiple thousands of varieties or varietals. The plant is indigenous to many countries, including Ethiopia, Brazil, Mexico, Guatemala, and Vietnam. I have tried coffee from many countries and a couple of my favorites are Costa Rica and Rwanda. I really like that Rwanda has a large female-run co-op that was started in 2009 when 85 female coffee farmers pooled their resources to form the Gashonga Cooperative (fair trade certified). I first fell in love with the body and flavor of this single-origin coffee at Oak Lawn Coffee Company (sadly, it is now closed), where they served the tasty espresso from a Denver roaster, Commonwealth Coffee Roasters. I even traveled to Denver to get another sip of this juice from the gods only to learn that Commonwealth was one of a handful of similar excellent coffeemakers: Allegro, Sweet Bloom, Little Owl . . . (perhaps just read my blog on that Denver trip at coffeebyangela.com).
To sum it up (I think Allison is knocking on my door), coffee is healthy for most people when consumed in moderation. It contains antioxidants, caffeine, and tannin, among other natural chemicals. It has done more to bring people together in this country than anything I can think of, even music. I believe that it staves off diseases and can even contribute to a longer life.2
Also, I just like it and I think it tastes much better than beer. So, cheers, and I hope we can enjoy a cup together soon!
References
1. Pendergrast, Mark. Uncommon Grounds: The History of Coffee and How It Transformed Our World. New York: Basic Books, 2010.
by Catherine Colquitt, MD Tarrant County Public Health Medical Director
This article was originally published in the November/December issue of the Tarrant County Physician. You can read find the full magazine here.
With local hospitals and emergency responders struggling to meet the space and staffing challenges brought on by the COVID-19 Delta variant, monoclonal antibody infusions (and subcutaneous injections when applicable for REGEN-COV) are being used to treat early COVID-19 infections. These are effective options in persons who don’t require hospitalization for COVID-19, aren’t hypoxic (or, if chronically O2-dependent, aren’t needing to augment their percentage of supplemental O2), or even as postexposure prophylaxis for persons at high risk for severe disease and poor outcome if they contract COVID-19 after an exposure.
The science underlying the development of the three monoclonal products granted Emergency Use Authorization (EUA) by the FDA capitalizes on the importance of the COVID-19 spike protein as a means of host cell entry. When viral particles are tagged by SARS-CoV-2 monoclonal antibody therapies, the monoclonal antibody-tagged viruses can’t enter host cells and replicate.
The mRNA vaccines, encoded for the COVID-19 spike protein and currently in wide usage, target the same essential viral spike protein by stimulating the host to transcribe the spike protein mRNA. They mount an immune response to that transcribed viral spike protein which the host’s immune system will then remember and repeat (anamnestic response) when COVID-19 viral particles present the spike protein to the now-vaccinated host’s primed immune system.1
Three SARS-CoV-2 monoclonal antibody formulations have been granted EUA by the FDA, though the first monoclonal SARS-CoV2 product (the coformulation bamlanivimab and etesevimab) is no longer authorized in the U.S. because of the decreased susceptibility of Beta and Gamma COVID-19 variants to it.2 Two combinations remain in use— the coformulation monoclonal casirivimab and imdevimab (REGEN-COV), which binds to nonoverlapping epitopes of the spike protein, and sotrovimab (XeVudy). Both are given under EUA’s for mild to moderate COVID-19 infections in persons 12 years or older weighing at least 40 kg and at high risk for severe COVID-19 infection. REGEN-COV use in postexposure prophylaxis is also granted under its EUA for COVID-19-exposed persons not yet fully vaccinated and for persons who are vaccinated but regarded as unlikely to respond well to COVID-19 vaccinations.3 Locally, only REGEN-COV is in use at present.
Comorbidities to consider in deciding who to refer for SARS-CoV-2 monoclonal therapy after onset of mild to moderate illness (early is best but both products are approved through day 10 after symptom onset) include:
Age 65 and older
BMI over 25kg/meter squared
For 12 to 17 years old, BMI over 85th percentile for height and age
Pregnancy
Chronic kidney disease
Diabetes mellitus
Immunosuppressive disorder or treatment
Cardiovascular disease, including hypertension and congenital heart disease
Chronic lung disease, including COPD
Moderate to severe asthma
Interstitial lung disease
Cystic fibrosis
Pulmonary hypertension
Sickle cell disease
Neurodevelopmental disorders such as cerebral palsy or other conditions “conferring medical complexity such as congenital abnormalities and genetic or metabolic syndromes, and medical-related technology dependence such as tracheostomy, gastrostomy or feeding jejunostomy, mechanical ventilation, etc.”4
Data supporting the use of both SARS-CoV-2 monoclonal products currently in use is persuasive if primary outcomes of all deaths and hospitalizations through day 29 after administration of the products is the measure. For REGEN-COV there was an absolute reduction in death and hospitalization of 2.2 percent and a relative reduction of 70 percent in the treatment group versus placebo. For XeVudy, using the same primary outcome measures of all-cause mortality and hospitalization through day 29, the treatment group experienced a 6 percent absolute reduction and an 85 percent relative risk reduction compared with the placebo group.5
Some special considerations for the use of SAR-CoV-2 monoclonal products:
Variants: So far both products are rated as efficacious against variants available to test, including Delta and Mu, though this is a rapidly changing field of study.
Vaccinations Against COVID-19: Contraindicated in the 90 days following monoclonal administration due to theoretical concerns regarding a blunted immune response to COVID-19 vaccination.
Monitoring After Infusion: For one hour in a health care setting.
Drug Interactions: None so far identified.
Pregnancy: Monoclonals can be used in pregnancy and should certainly be considered when a pregnant woman has additional risk factors (beyond pregnancy alone) for severe COVID-19 disease.
Reactions to SARS-CoV-2 Monoclonal Products: Injection site reactions (pain, redness, swelling, pruritus, injection site ecchymosis) in approximately 1 percent and infusion related reactions such as urticaria, pruritus, flushing, pyrexia, shortness of breath, chest tightness, nausea, vomiting, and, rarely, anaphylaxis. In general, the REGEN-COV current dose of 600mg of casirivimab and 600mg of imdevimab is significantly better tolerated than the previously higher dosed formulations.
Lactation: No data yet available.
Hepatic impairment: No dose adjustment needed.
And please remember – COVID-19 monoclonal therapeutics are not a substitute for COVID-19 vaccination!
Locations of Tarrant County Infusion Centers:
JPS Urgent Care Center
1500 S. Main Street, Fort Worth , Texas 76104
Call 817-702 1451 for appt.
North Central Texas COVID-19 Regional Infusion Center
Additional Infusion Center resources are available at www.tarrantcounty.com or by phone at HHS Protect Public Data Hub (1-877-332-6585 in English and 1-877-366-0310 in Spanish).
This article was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.
by Rachel Marie G. Felix, OMS-II
If everything I’ve learned in medical school thus far, my favorite realization has been that I love people. Given the fact that we live in a society rooted in individualism, becoming aware of this fundamental truth of mine was not as straightforward as it sounds. Especially when being part of the medical field, where there is constant pressure to compete, accomplish extremely taxing feats, and be the best all-around people we can possibly be at all times. From a young age, those who pursue medicine are conditioned to hyper focus on their individual accomplishments. However, through guidance from my extraordinary mom, support from my childhood loved ones, and interactions with my incredible classmates, I’ve come to truly understand my “why,” and it’s all for the community.
With a jam-packed schedule and overflowing course material, during the first few weeks of medical school I knew I had to take time to contemplate who I was and what I wanted from life, or else I would risk losing myself to the grind. And from deep reflection and unlearning during the Black Lives Matter movement, I realized that I thrive when I am able to contribute to the joy and wellbeing of those around me.
What came from living daily in this truth was life altering. I found myself soaking in every conversation shared with my mom and truly learning the depth of her selflessness. I challenged myself to go on a medical mission trip to help those with limited access to healthcare and was overwhelmed by both the support from my family and friends and the gratitude from those we were able to serve. I would even go to campus completely open to meeting new people and end up having such enjoyable conversations. This would lead to sessions of vulnerability and genuine connection, leaving me feeling enriched by the opportunity to appreciate the different sides of each classmate-turned-friend.
As I made a point to cherish each interpersonal opportunity, I realized just how fulfilling every day can be when we immerse ourselves in community. Yes, we can say we show appreciation for our communities through volunteering or even through our careers, but intentionally showing how much we care for one another as a regular practice is a lifestyle that I highly recommend. While there are many outside influences that can cause us to get caught up in our own worlds and participate in a zero-sum game, the truth is, there is abundance in the shared human experience. We are each beautifully complex and different beings with something unique to contribute to one another. So when one of us wins, we all win.
Conversely, we all hurt when one of us hurts. As made obvious by the pandemic, a flourishing community depends on the health of its people. So dear reader, I hope you are able to appreciate the unparalleled opportunity we have to positively impact those around us as healthcare professionals. Moreover, I hope you see how valuable both you and your patients are in creating a thriving community and allow every interaction—inside and outside of the clinic—to reflect that.
This article was originally published in the July/August issue of the Tarrant County Physician. You can read find the full magazine here.
I remember working as a medic in New York and New Jersey and loving what I did all day, every day (and many times all night). When I got “the call” to go to med school, I knew that it would be years before I could do anything clinical—at least eight years. My first procedure was at 14 years old at Southern Nevada Memorial Hospital (now University Hospital), when a surgeon let me round with him on a patient and told me to pull the tube straight back. I pulled out a chest tube at 14. Where do you go from there? Well, the day I went back to taking food trays to rooms and getting the nurse when a patient needed their bedpan to be emptied. After high school, I started taking dental x-rays, and I took great x-rays without even using the rings and film holders. I spent those moments in the darkroom praying and soaking in the blessing of the esteemed opportunity that I had been given as an almost dental assistant. Those x-ray skills thrust me into a career in dental and then oral surgical assisting.
When life brought me back to my home state of Texas, I got my first job as an oral surgical assistant. Dr. Robert Thomas Perry hired me after looking at my résumé, which was handwritten on a 11-by-14-inch sheet of legal paper. Full disclosure, when he asked for my résumé, I did not know what that meant; he explained that it was a list of my experience. I was just about 21 years old by then, so he was an early inspiration for me. We would drive to remote sites to perform oral surgeries and I would read board review material to him for hours and hours as we drove from College Station to Corsicana and Huntsville. I learned so much about oral surgery from these hours of drives, which always included a stop for Blue Bell ice cream.
Dr. Perry and his wife, a CRNA, were very well liked in the community, though he struggled to establish great referral patterns from the general dentists. While he was away doing his oral surgery training, two other oral surgeons, Garrett and Gray, had set up practice. Their winning personalities and ability to network between Bryan and College Station proved to be a barrier to Dr. Perry getting much business in this good ole boy country. Dr. McElroy did send us patients. Dr. McElroy is known to have left Thanksgiving dinner for an emergency; he even showed up at his office to meet a patient with a severe toothache one Christmas Day. That patient was one of my relatives (I got him on multiple holidays). Dr. Perry had me credentialed at both local hospitals and one in another town. At St. Joe’s in Bryan, I went through a week-long orientation in the OR, watching various cases so that I could assist Dr. Perry there—I knew all of the instruments he used and when he used them. I didn’t just see oral surgeries; I had a front-row seat for everything that was happening in the OR that week. I remember watching a vag hyst (in horror) and then a breast biopsy where they had to go ahead with a mastectomy right then, after the frozen section came back positive. I was a high school graduate dental assistant, and I was in the OR.
You think it’s difficult to get someone to take a statin? Try telling them you’re going to put a tube down their throat.
I first started assisting Dr. Perry in the OR when he performed orthognathic surgery that included down-fracturing a maxilla. I was so happy and fulfilled in my work. I had arrived. When the local hospitals stopped using CRNAs in the mid 80s, Dr. Perry had to move his family back to Ohio, where he had trained. Sue, his wife, was actually the breadwinner. Dr. Perry once had a farmer pay him with a side of beef (tractor accident). Another elderly woman paid him by making fabric holders for his surgical instruments. He was not the only oral surgeon that I worked for who depended on the income of their spouse to stay afloat. After crying every day for two weeks over having to leave Dr. Perry due to the imminent practice closure, I moved back to New York, where I had lived right after high school. I went to work for another oral surgeon there and I also joined my volunteer ambulance corps.
I was a trainee at the South Orangetown Ambulance Corps when I took my EMT course and then immediately followed with my medic course, which I studied at White Plains Hospital. I worked in Rockland County with my ambulance corps and in Westchester County as part of my medic class. I remember being in Yonkers, where the medics put on bulletproof vests at the beginning of their shift. I drove around White Plains looking for an address where there was a patient with a GI bleed. The police kept telling me to step it up (the patient was bleeding out from varices). Basic Life Support (BLS) transported the patient before I arrived as I was not familiar with White Plains, having lived in Rockland County and only commuting to Westchester. I remember once, when responding to a cardiac arrest, we found upon our arrival that the husband had coded, too. I had to decide which code we would care for, and which one would have to wait for the second unit to arrive.
One time I regretted having taken this career path—it was in the moments before arriving on-scene at an accident involving a train. Thank God for my partner, who also worked for NYC EMS at the time. He was a calm and reassuring voice as we worked with the PD to locate the body parts. This was important, because when daylight came there would be parents driving kids to school and the carnage would be seen in the light of day. There was the time that I dropped my partner at a call with the volunteers (we worked as a pair from a fly car, which is used to carry equipment, and would split up as needed). I arrived at a scene where the wife called about her husband, who was unresponsive. I had to speak to the wife in a calm, reassuring way as I dragged her husband by the feet from the foot of the stairs to the middle of the living room floor where I would intubate, put on the monitor, start an IV and work the code until another BLS unit arrived to transport him to Nyack Hospital. An awake intubation on someone in distress from severe congestive heart failure is an exercise in coaching a patient. You think it’s difficult to get someone to take a statin? Try telling them you’re going to put a tube down their throat.
I knew I wanted to go to med school, but it wasn’t to be in New York, and I didn’t apply anywhere else. While working in White Plains I met fellow medics George Kiss and John Brebbia. They were both students at Saint George’s University School of Medicine. I also knew Dr. Stuart Rasch, an ER doc at Nyack who was an SGU grad. I applied. I got in. I went. I continued to work as a medic per diem during my breaks from school. I worked for several companies at one time—Mamaroneck, Portchester Rye, and Larchmont, which were volunteer agencies with paid medics, and Rockland Paramedic Services and Clifton-Passaic MICU in Passaic, New Jersey. The relationships that I made still endure. The experiences that I had continue to keep the paramedic in me alive. I miss days when I would arrive at the home of an elderly person having an MI or pull up on the scene of an MCI (mass casualty incident). The other day I was talking to a close friend on the phone, and he mentioned in passing that his dad was short of breath. The last time someone mentioned that in passing (in the pulpit at a church), they ended up in the cath lab getting stents the following day. This time it was a friend, and I knew his dad. I calmly asked, “Do your parents mind if I come over?” Though it was late at night, they agreed. I got dressed and went over and did a medic questionnaire and exam which led to an ER visit and hospital stay. Though the family is thankful that I was there, I am even more thankful, because they allowed me the opportunity to remember life when I would wake up and be excited to go to work every day, all day (and many times all night).
Imposter syndrome and how the little monster brings us down.
by Ashley Brodrick, OMS-III
This article was originally published in the July/August issue of the Tarrant County Physician. You can read find the full magazine here.
“Am I really cut out for this?” A question most medical students have asked themselves time and time again. Imposter syndrome is this little monster in the back of our minds that tells us we are inadequate; it grows every week, with every test, and with every medical encounter. It tells us we are destined to fail. It tells us we are never going to make it, we are never going to learn, and we are never going to be good doctors. This little monster puts doubts into our minds about our ability to be successful physicians. If you are lucky enough never to have been visited by this little monster, I applaud you.
Medical school is this arduous four-year journey that tests us mentally, physically, emotionally, and sometimes even brings us to our breaking point. Why is medical training so taxing on our emotions, leaving us feeling empty, drained, and questioning if we are made for this career? Medical school is competitive by nature, with a national acceptance rate of 43 percent. This means you must be the “best of the best,” graduating with extraordinarily high GPAs, and performing well on the MCAT. Don’t get me wrong, being a doctor is no easy task. You are responsible for another person’s life, something that I consider to be a tremendous honor. However, at what point do we start to take a step back and reconsider this competitive atmosphere that we have fostered for so long and look at applicants on a holistic level and not just a statistic on a sheet of paper. I can tell you I would rather have a doctor that understands my concerns and listens to me than one who scored in the 99th percentile on their standardized exams but never questions their diagnosis. I would rather have a doctor that IS questioning their diagnostic and treatment decisions for me—not because they don’t know the proper protocols, but because they care about getting my treatment right for me as an individual. M
I am no stranger to imposter syndrome; however, this little monster did not visit me until my second year. My first year of medical school was the year I thrived, leading me to believe that maybe I could make it through without letting that little monster get the best of me. My grades were above average, I was making friends, and I was becoming more confident in my ability to talk to patients (even if it was standardized and following a script). The real challenge for me came during my second year, when my self-doubt started setting in. I was having difficulty connecting the dots and putting everything together. My classmates seemed to be following the right path, understanding how the different diseases connect across organ systems, whereas I felt like I was stumbling every step of the way. Each block presented a new challenge and fed that little monster even more. While I could understand the information and explain it flawlessly to my friends, it was just not coming together on the tests. This inability to perform well on exams did a number on my mental health. You don’t realize how deep into a hole you are until you turn around and realize you can no longer see any light, making it impossible to escape. Each day I would wake up with my heart racing, but you know what I did? I told myself this was normal; this is what medical school is supposed to be like. Stressful, hard, and exhausting, it takes everything out of you along the way, while proving to everyone that you are the “best of the best,” having the highest level of education, being in the top 0.29 percent of the population. The one thing I did not tell myself was that medical school did not have to be this way.
Medical school puts you in a bubble, one that is hard to escape. You are surrounded by medicine 24/7, and during my first two years I found it difficult to talk about anything other than medicine when I was with my friends and family. Every time I went home it was always, “How is school going? Any recent tests? What are you learning now? Making good grades still?” It was never, “How are you handling everything? Is there anything you need help with?” I knew they were trying to show an interest in my education, and genuinely wanted to know what I was learning, but I did not have the energy to go into detail. So, I found myself falling into the same routine of saying, “School is going well, just the same every day. I spend 10 hours in the library and when I get home I take Sadie on a walk, then sit on my couch and watch TV until I do it all over again.” This wasn’t always the case. I was hanging out with my friends, going to dinners, TV show watch parties, doing normal adult things, but whenever I would tell people about this, I would be hit with, “Shouldn’t you be studying? How do you have time for all of that?” I decided it was not worth it to try to please everyone and explain myself, so I shut down and didn’t tell anyone outside of medicine what was going on in my life. To some degree I felt this fed that little monster even more, because I was not sharing all the extraordinary things I was learning. I was not sharing how I was learning to properly perform a physical exam on patients. I was not sharing the complex pathology behind diseases and how to treat them. I was not sharing how I was developing my communication skills with our standardized practice patients. I was not sharing how I was constantly being uplifted and supported by not only my classmates and friends, but also my professors and faculty advisors. Looking back, I think the main reason I decided to suppress and not discuss was because of my imposter syndrome. I felt that if I started to talk about a subject and got one thing wrong, then my months of learning proved nothing, showing that I didn’t belong in this field.
I had this grand idea in my mind of what my clinical years in school would be like, but the pandemic added hurdles and setbacks, which further contributed to my imposter syndrome. I’ve spent most of my third-year rotations online— 60 percent, to be exact—which has left me questioning if I really am ready to begin my residency. I’ve never witnessed a code, never rounded on in-patient care, my note writing skills are lacking, and frankly, I just have not had the experience I feel is necessary to graduate medical school. Thus, imposter syndrome is in full effect for me right now. I made it halfway through my third year when I realized I was just getting to my first full in-person rotation. Thankfully it was OB-GYN, the field I have fallen in love with and will be applying for in the 2022 residency match. I felt comfortable taking a gynecologic history, performing PAP smears, delivering placentas, assisting in the OR, and even having the incredible opportunity of catching a baby. Now, as I am nearing the end of my third year, I realized I had the expectation that I would know so much; however, I feel like I know so little and find myself looking forward to the day when it will all come together. When I look around at my other classmates, I realize I am surrounded by people who were at the top of their class, and while I am one of those people, I still find myself feeling inadequate. I still find myself wondering how they can connect the dots on their rotations and see the big picture. I still find myself wondering how they know what questions to ask. I still find myself wondering simply how they make it look so easy. The one benefit of spending most of my clinical time online is it has allowed me to have time for self-reflection. This year has allowed me to foster relationships with my friends in ways that would not have been possible with a full work schedule. This year has allowed me to make myself and my mental health a priority. Most of all, this year has shown me the amazing support system I have cheering me on every step of the way, especially during the hard times.
So, while I try my best to contain this little monster, there are days when it breaks free from the room it is kept in, and I sometimes am still unable to contain my feelings of being inadequate. When these days come, I’ve learned how to work through them. I remind myself of how far I’ve come to get here. I remind myself of the years of education and knowledge I have gained on this journey. I remind myself of the countless individuals who have supported me, encouraged me, and helped me on this path. I remind myself of what lies ahead, and while it is a long and arduous road, it is one I am happy to be on. Sacrificing the best years of my life to being confined to the library, where I am studying and absorbing an overwhelming amount of information, has been worth it to me. Some might ask why, and the only answer I can give is that whenever I am asked what I would do if I wasn’t in medicine, I honestly do not have an answer. So, this is how I lure the monster back into its room—by reminding myself of my worth, my perseverance, my triumphs, and my successes throughout this journey.
Part of me is curious if it is the competitive culture of medicine that contributes to imposter syndrome, or if it is the self-doubt we carry in ourselves because of how difficult the road is to becoming a doctor. My biggest question going into my fourth year is how do we combat this? How do we tell medical trainees that it is okay to have these doubts; that they are normal, and that you are still learning and absorbing everything around you? How do we tell them that medical school is hard, but you don’t have to endure it alone? I think the answer to these questions is acknowledging that everyone experiences imposter syndrome at least once, and it is okay to have these doubts. It is okay to take a step back and say, “Wait a minute, was that the right call? Was that the right diagnosis? Should I have treated my patient’s condition in a different way?” Acknowledging this monster allows us to not become complacent in our careers, ensuring we are doing the best job that we can. This is a big part of the reason I chose to pursue medicine—the constant educational and learning opportunities, the inability to ever become complacent in your job. My time in medical school has opened my eyes to the type of physician I want to be. I want to encourage and reassure the medical students I will one day work with that it is okay to not know the answer to everything. It is okay to ask questions out of curiosity, even if the answer is something that I view as common knowledge. It is okay to be nervous, it is okay to be scared, it is okay to simply not know things. Medical students are exactly what they are called: students. Here to learn, here to observe, and here to take in everything around them. They should be able to do this without fear of humiliation or being deemed incompetent. I want to be the type of resident that shows my students that I too suffer from imposter syndrome right there with them, and that with the right tools and strategies, it is possible to cage the monster.
My challenge to this generation of physicians is to look back on your time in medical school and think of a resident or preceptor that showed an interest in your education and made you feel like you belonged. Do you think you could have survived that rotation without their help? If you find yourself answering “yes,” I give my applause to you, but if you find yourself answering “no,” hold on to that thought, remembering it for when you have students of your own.
We don’t have to be alone on this journey. We should work together to normalize the conversation around the mental exhaustion medical school creates in individuals. We should work together to lift and encourage our peers. We should work together to ultimately say it is okay to have imposter syndrome, but here is how we can deal with it before it becomes something greater than we can contain.
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