Knocking on Opportunity's Door, Part 2

I recently published a narrative about my research experiences in high school and college. In that article, I naievely demanded scientific experiences that would be successful as measured by metrics such as authorship and publications.

http://science.sciencemag.org/content/354/6310/382

As I look at laboratories around me, I see some PIs that care most deeply about the underlying theories of their work at the expense of publishing, some that care most about getting even preliminary work into print, and every spectrum in between. I am probably not the only one who feels conflicted about where the "right" place is to fall on that spectrum. In any publication, there are some theories that are more tenuously supported by the data and others that are more justified. How do we balance the need for concrete achievements like getting a paper published versus continuing to gather scientific evidence.

This recent analysis of scientific productivity (Sinatra et al. Science 2016) shows that publications are directly tied to chances for scientific impact, and that the impact is independent of where the investigator is in their career.

While these findings seem to support the 'publish or perish' mentality in academia, I wonder how the results would shake up if there were a direct comparison between clinical investigators and basic science investigators.

Clinical investigators as a category publish a large quantity of case studies or observational papers that serve a general purpose of sharing information and connecting with other clinicians over medical developments or observations in a rapid manner. However, it also contributes to a glut of papers in each field that may or may not actually advance the field. While clinicians learn to distinguish the types of articles that are reliable resources, and everyone knows where they need to publish to create an impact, how do the rest of the articles contribute to one's career? To the field?

Is it worth spending my time on case reports that I can churn out this year, or work on building a project of impact that won't be fruitful for another 5 years? I wish I could demand myself to focus on the goals that would benefit the field and my career the most. The harder part now, in contrast to my concrete demands in high school and college, is that I no longer know exactly what those goals should be. I and numerous others in my position can only guess. Let's ask Sinatra et al to publish a follow up study, shall we?

Burnout Science vs Medicine

We spend a lot of time in medicine talking about "burnout." Since it's not an official psychiatric diagnosis, the diagnosis straddles a murky state between "worked to the bone" and depressed. I did learn that there is an ICD10 code (Z73) that can be used for charting purposes. In comparison, burnout in academic research seems rarely discussed. This recent review of mental health literature amongst postdocs (written by one of my co-interns!) suggests a significant proportion of depression, and a google search shows many forums discussing burnout in this population as well.

I found one blog that talked about the first commenter in this blog about burnout who wrote:

"Burnout is caused when you repeatedly make large amounts of sacrifice and or effort into high-risk problems that fail.  It's the result of a negative prediction error in the nucleus accumbens.  You effectively condition your brain to associate work with failure."

I would rephrase this to say that burnout occurs when you have worked your hardest but have not achieved successes that are meaningful to you, personally. 

Different people have different rewards. The newborn nursery is a place where I always feel like I am at risk for burnout even though it runs on a leisurely 7am-5pm schedule, everyone is extremely kind, and the moms and babies are a delight. Every day I dread going. Despite all the lovely things about the newborn nursery, all I can feel is the weight of the paperwork for the high volume of babies we see every day. For me, the reward of a busy workday is an interesting case that I can learn from and increase my patient repertoire (which rarely happens in a nursery where the babies are almost all healthy or have very minor complications). For the attending physians in the newburn nursery, if their personal reward is getting to know a family in a highly emotionally charged time of life, they would not run the same risk of burnout.

The corollary to this theory of burnout is that if we can fit aspects of work that supercharge us into our workday, we will be able to prevent the problem. People feel that if they build in enough time outside of work or have great vacation days, they will avoid burnout, but I think that's simply not true. I'm reflecting on the ways I will structure my days to prevent burnout.

1. Schedule short term projects. I mentioned in a prior post about scheduling both short term and long term projects. Perhaps I have learned to inherently build this into my day?

2. Identify an interesting topic early in the day.

3. Go to teaching conference.

4. Spend extra time to learn about a family.

Regardless, the ability to keep projects going is counted as a success in itself in my book. In a long day, where I feel like I haven't been heard and have just been following other's orders and doing the medical paperwork along with it, it feels like a success to have connected to a collaborator, to have identified some new samples, to have written a new paragraph in my paper. It's funny because I'm not sure that if my life 100% revolved around science, that I would psychologically perceive those things as successes and register them the same way. As paradoxical as it sounds, I think that the extra time I give to pursuing projects makes my day to day life more enjoyable.

Reflections on A Big Heart

This week, I diagnosed a young boy with leukemia in the ED. He came in with his parents, sent by their primary care doctor because he had been coughing for a month and the doctor was concerned about his heart size on his chest X-ray. I met the family before we had even loaded the film into our hospital system. We laughed about the show our patient was watching on TV and I did an exam with pleasant chatter with the family. He was alert, playing, breathing comfortably. I walked out of the room reassured, and told the attending he had no problems with his heart. The attending, however, was clearly more worried than I was - "maybe he has a faint murmur, maybe I hear an extra sound in the heart. Let's worry about this."

Ten minutes later, everything went downhill the moment we saw the X-ray. Nothing was wrong with his heart, but there was a large, terrifying thing in his chest. Thirty minutes later, our phones started ringing off the hook with the laboratory calling to report back critical laboratory values on the blood samples we had sent. We sent the patient for a CT scan, and shortly thereafter I called the oncology team for help.

The look on the parents faces when I prepared them for the bad news was one of disbelief. They couldn't understand anything I said - their lovely, healthy boy's life was going to be turned upside down in the course of an evening.

As the data rolled in, there was one part of my brain processing it medically, scientifically, even. That part was interested and eager to know what the data is and what it meant, thinking already about the next data pieces that we needed and the next steps to take. There was another part of the brain saying "fuck" with every new abnormal lab value, each one trickling in with anticipation as the abnormal values are verified by the laboratory before release. The next thought is, "what am I going to tell this family?"

I also have a vague sense that I feel a decrease in mental capacity, analogous to trying to do a high concentration task after having a small bit of alcohol. I think to myself that I should be careful because I still have a full panel of patients I am simultaneously caring for in the ED. The mild bronchiolitis in the next room seems unimportant in comparison, but I still need to focus that they get the right care and to avoid a judgement error simply because their neighbor is becoming a high acuity situation.

Hours later, when it was time to send the patient up to the oncology floor to start treatment for leukemia, the mother reached out and hugged me. I couldn't help but feel that it was because I must have looked like I needed a hug too.

I've been thinking about the scenario, the diagnosis, and the hug. It feels unsatisfying having delivered a diagnosis and sending them out of the ED for care. It feels wrong that we traversed from point A, health, to point B, diagnosis, together, and now I'm no longer needed. I want to visit them, but that would be selfish. I am certainly not family, they have much larger issues to deal with, and they are in capable hands. I console myself with the idea that this was a time for me to expand my repertoire of experiences, to practice skills in human connection that I will certainly need again, and to recognize the mental toll of an emotional experience that I am still working through.

Getting the Most Out of Your Shift as an Intern

My personal take on the topic of time management during intern year is based on this amazing blog I read a while back about fixed-schedule productivity. The premise is that you decide how many hours you are going to work (for him - 9 hours a day, 5 days a week; for an intern - 12-14 hours a day, 6 days a week), and then fit everything you are going to do into it.

For me, it's unreasonable to get everything I need to get done in life during the hours while also being an intern. My goal, instead, is to fit time in for menial tasks, errands, emails, phone calls during the day so that it frees up my time outside of work for thinking, creating, and developing things that are important to me! Here are my personal tips for fitting tasks into the busy workday.

Pre-round in half the time.

Ever notice that you pre-round faster when you have more patients, because you simply don't have more time? Well just pretend that rounds start 30 minutes earlier. Then you get an extra 30 minutes for yourself every morning. Not quite achievable every day, but I'd say 50% of days work out.

If I can get this time in the morning, it's most productive for me to write/answer emails where I'd like the other person to get back to me that day. I also like to use it to plan out what else I might be able to get done during the day depending on how busy the service looks. If there's an interesting patient, I get bonus time to look into the primary literature.

Create your own time.

Try to set aside a 30 minute block in the afternoon. I like spending an hour after noon conference catching up with patient related tasks, and then take this "own time" afterwards. Because interns are constantly bombarded with requests, it's a very conscientious effort to leave anything that is not time-sensitive or critical to patient care for 30 minutes later. That means all progress notes and non-urgent pages and non-urgent orders. In return, I actually can respond to email, flesh out an outline of a grant, or read a journal article.

Set tasks for yourself.

I have an Asana (online and app based productivity scheme) where I keep a running list of to-do's (and have a set timeline of recurrent to-dos). During a few minutes downtime, I can quickly check my list to see if I can take care of anything on it. Not all tasks are amenable to shift work. I'm this far down in this blog post during the first draft on hour 7 of my 10 hour ED shift. I'm enjoying blogging so far because it doesn't take a lot of mental capacity and I can add to a post during down time after I've created a general outline.

Set expectations for others on the team.

If the service looks light that day, I'll remind the attending first thing in the morning that we may be able to round quickly enough to get to senior conference (for us, a very educational conference at 10am that interns often cannot get to because of timing). On services where interns prepare the signout, I start preparing it about 30 minutes before, and allow at least 10 minutes for printer mishaps. If someone else besides the residents (i.e. attending, NP, etc) need to be at signout, I remind them via page or in person 30 minutes before so that they are there on time. Since the intern typically leads signout, I feel like it is up to us to lead the the process with minimal chatter (chatter after signout, please)!


How did I do this week?

I sent in applications to 2 small resident grants, started an essay for another site, and contacted 2 resource banks to look for samples for my research study. Since I wrote the majority of this post during my ED shift on Thursday, I just spent 20 minutes polishing it up today and now I'm ready to share it with you!

How To Do Postdoctoral Research During Residency

In numerous discussions with advisors and physician scientists, the vast majority told me not to try to do postdoctoral research during residency, MD/PhD program directors included.

You need to focus on your clinical skills.
You won't have any time.
What's the rush, you will always have your skill set and can come back to science later.
I simply would not advise it.

Why do so many physician scientists dole out this advice with such certainty?

There is not a control group of physician scientists who tried and failed. There are no patients that have suffered adverse outcomes because a resident was instead working on their research project. Of the residents who are in specific research residency tracks, more about those tracks in this online piece, they seem to have great success in terms continuing their research work.

I think the reason why the idea that research during residency is a bad idea is prevalent is simply because the majority of physician scientists did not do it. But what if they had? And what about all the MD/PhD's who decided not to return to the laboratory because they felt they no longer belonged there after residency training - what if they had too?

Advice from mentors who attribute their success to research during residency

In my time at Harvard, I have met exactly three of such physician scientists. They currently run exciting, productive labs and are role models and mentors. And notably, they they started their labs at the ages of 34, 38 and probably 33 (I can't find exact numbers on the third). In a time when average age of first R01 for MD/PhDs is 44.3 years (NIH Physician Scientist Workforce Working Group Report 2014), that's no small feat. Some trainees see this and feel that those accomplishments are superhuman and cannot serve as a model,  but perhaps it was their expeditiousness to embark early on their research career that was the outlier. I have distilled their advice to me into guidelines that serve as my own template:

1. Find a lab before starting residency. 

One of these mentors set up postdoctoral interviews alongside residency interviews, and another used a fourth year elective to rotate through a potential lab out of state. Many PIs that you contact for a postdoctoral position at this stage will express a mixture of confusion and skepticism, but those are not the people you want to work with anyway. The key is to define your goals clearly and spell out your timeline for them.

2. Set up realistic short term and long term project goals.

One person set up a bank for samples from patients with dementia, in which he collected samples over his entire residency period and propelled his early work as a PI. Another looked for isolated case studies of a particular phenotype he was interested in that contributed to his larger scientific story. Regardless of the project, the key is to make sure that you see all the pieces fitting in together to craft a cohesive story for your career. For example, I am writing up a case study of an already solved genetic family in the laboratory while also collecting a cohort of patients with a specific phenotype for which I want to understand the genetics. The small successes will keep your momentum going.

3. Find nooks and crannies in your time and make them count.

Compared to a time when they did research without intern work hour restrictions, our current situation is quite cushy. I don't recommend taking tremendous amount of time in addition to the 80 hour workweek, but instead maximize time during the week. One faculty member said he would work on grants during night call if patients weren't getting admitted, and during downtime even if they are. In the afternoons, schedule one phone meeting every week because you can cram the time for your progress notes, the least useful of all, into 30 minutes less time.

4. Get help and collaborate.

Sometimes that means finding multiple collaborators to carry out a few time intensive experiments that you cannot. Sometimes that means finding grant funding for a student or technician, or partially commandeering an existing clinical coordinator. People are more willing to help out than you might think as long as your tasks are carefully planned and don't waste time.

4. Advocate for your own time.

This tidbit is my own addition, and the ways to advocate will depend on your program. For example, my residency program often has research studies about residents which we are expected to go to, but in reality all research studies are voluntary. We have clinics where we shadow specialists and the resident is not involved in patient care - on those days I bow out no later than 5pm regardless of the clinic schedule.

5. Find mentors who believe in you.

How will you know? I know because when I tell them I am a postdoc, the people who believe in me don't try to help me define when and how I should be doing my postdoctoral research, they simply try to help me achieve it.