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The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Arman Shariar, talking about medical training so far.
[00:00:09] Dr. Shahriar: I also... I think I just have this idea in the back of my mind about the type of doctor I want to be in 20 years and I think I'd want to be the type who would feel comfortable getting up on a plane if somebody doesn't look well.
[00:00:21] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. Today, we continue our series talking to people in various stages of medical training to hear about their experience.
I'm Adam Cifu, and today I'm joined by Arman Shahriar. Arman is a third-year internal medicine resident at the University of Chicago. He came to us from the University of Minnesota. And three years prior, working as an engineer and internal consultant in the medical device industry, working in Minnesota, Columbia, and Brazil.
Outside of work, he's an avid runner, soccer player, and soccer fan, but we won't talk about that. Arman, thanks so much for joining me today.
[00:01:18] Dr. Shahriar: Sure. Thank you for having me.
[00:01:19] Dr. Cifu: So tell me a little bit about kind of the present stage of your career. You're a resident of internal medicine at the University of Chicago. Maybe first tell me a bit about your journey to get here. You know, what sent you on the road to medicine to begin with and then internal medicine after that?
[00:01:35] Dr. Shahriar: Sure. Yeah. If I had to summarize, I had a little bit of a non-conventional path to medicine but I think in this day and age, I'm not really sure what that phrase means anymore.
[00:01:45] Dr. Cifu: True.
[00:01:46] Dr. Shahriar: So I grew up in Minnesota in an Iranian-American household. I spent the majority of my childhood sort of between cultures. And I was a pretty average high schooler. Didn't really know what I wanted to do when I finished, so instead of going to college I decided to take a year the cheapest way possible and I went to Ecuador and did a year of teaching everything, like a small class there, I lived with a host family, became very close with my family there, who I'm still in very close contact with today. And kind of discovered my love for working with people one-on-one. Fast forward, I came back to Minnesota. I ended up doing my undergraduate in biomedical engineering at the University of Minnesota. My senior year of college, I was studying for the MCAT and I was approached by one of the upperclassmen in my program who presented kind of a unique strategy engineering hybrid-type job. So I took that and fast forward a couple of years, which gave me opportunity to save some money, but also learn a lot about healthcare and the healthcare system, I ended up doing six months of scribing at a federally qualified health center, which got me more in tune with clinical medicine. I applied to med school.
[00:02:59] Dr. Cifu: Got it. Got it. Do you think already, I know you're... I mean, right now you're not early on, but at the time kind of going into medical school, maybe we talk about your medical school education.
I mean, you have had a much broader experience it sounds like, both culturally and within medicine than most students starting medical school. Did you notice that kind of in your work in medical school, among your peers in medical school?
[00:03:26] Dr. Shahriar: I think, you know, it's always in the back of your mind, but I do think one of the interesting things about medical training is its general linearity. It's very different than, I think, other industries and forms of professional development. We are forced to follow a linear path that's defined by time points, rigid time points. I think there's very little deviation from graduation times currently. You know, med school is four years, residency in internal medicine is three years. Fellowships are time-determined. So it makes it difficult to, I think, incorporate a lot of your life experiences but it definitely changes the way you view things. So in the background, it's always there, but I think in terms of training, you know, you kind of... You buckle up and you ride the same roller coasters.
[00:04:16] Dr. Cifu: Yeah. Do you think in reflecting on the sort of experiences in medicine, maybe outside of the usual trajectory that I've had, which admittedly is actually, I think already sounds like less than you've had, but I, on the one hand, think that some of those experiences shaped the kind of doctor I am now, even whatever, 30 years later but I'm not sure if maybe what they did is they just sort of... The reason I enjoyed them is because they underlined what I was already bringing into medicine. Maybe it's hard to separate that. What do you think?
[00:04:53] Dr. Shahriar: Yeah, the experiences have changed my perspective, I think, Ecuador, certainly. The few years I was working, you know, I had other financial obligations. I kind of accepted I'm going to take a little bit of time off and, you know, they were valuable for their own reasons at the time but the year in Ecuador kind of taught me, well, A, I gained a whole appreciation for a culture other than mine. I grew up in an Iranian household in Minnesota and I was never really able to see where my parents grew up in Iran. So I always had this like yearning for other cultures, but it's not a huge Iranian community in Minnesota. So I became very close and grew in appreciation for Latino culture, which has been invaluable because now I have a... Not preference, but I like seeing Spanish-speaking patients. People feel more comfortable when you can speak Spanish with them and that's definitely changed, at least, demographically, the patients that I attracted to my primary care. But it's hard to imagine a... You know, I don't know in a parallel universe, had I jumped right into med school, would I still be interested in all the same things? Would I have gone and ventured and learned about all the same things that I learned on the job? It's hard to say.
[00:06:02] Dr. Cifu: And then tell me, you know, you're doing internal medicine now, and I know your plans for the future, but when you were in medical school, why did that appeal to you? Sort of what made that right for you as a, at least first step in the career?
[00:06:17] Dr. Shahriar: I don't have a solid answer to this question because it takes a lot of thinking, you know, why did I make this choice? I think the best answer is that most things interest me, so I think the best answer for why did I choose internal medicine is to not commit myself to a specific niche right off the bat. I think some degree of niche or expertise is inevitable, but this early in the game, I wasn't really ready to do that. I also... I think I just have this idea in the back of my mind about the type of doctor I want to be in 20 years and I think I'd want to be the type who would feel comfortable getting up on a plane if somebody doesn't look well.
[00:06:51] Dr. Cifu: My father was a psychiatrist and whenever that happened on a plane and I would sort of look at him, and he would just like wave his hands like, "No. Don't say anything."
I love it. It's interesting. I mean, I always think one of the great things about a medical degree is that the options of what you can do with it are enormous. And kind of every decision you make narrows that a little bit, but I do think that internal medicine still keeps things remarkably broad, maybe for longer than a lot of other subspecialties.
[00:07:23] Dr. Shahriar: Yeah. Yeah, definitely. And I've noticed that. I think now, two and some years into training, you get random questions from everybody. And the frequency and the depth of the questions has increased over time. And I feel, you know, initially, I feel I'd be googling things quickly and looking things up, but now I feel more and more comfortable giving people basic types of advice which I probably otherwise wouldn't you know, if I was doing these all day.
[00:07:49] Dr. Cifu: Right, you're not sad that you can bow out of the questions with that excuse. So you're a resident, tell me what your life is like, and maybe tell me, is this what you expected, you know, as you were applying to residency and thinking about internship and residency, did it sort of live up to expectations?
[00:08:09] Dr. Shahriar: Yeah. So what is life like or work like as a resident? We rotate a lot. So we're always changing what we're doing. It keeps things interesting. It keeps you on your toes. We rotate between the hospital, the ICU, general floors, consulting teams, clinics. So we see everything. Inpatient hours can be long, but we have a nice schedule, or we have planned time off, and we have certain blocks where we get weekends.
The job, I think, in a nutshell, is just chaotic. A lot of rotation which is good and bad. In terms of expectations, I think yes and no. Things have panned out the way I expected. I think discussing the unexpected things is a little bit more interesting. So you know, a couple of examples of unexpected realizations or things about residency that weren't really on my radar. My stance... One of this is a little specific, but my stance on call schedules, which is a pretty hot topic in residency, the main debate being whether we should continue to have 24-hour or 28-hour calls where residents are admitting patients and stay in the hospital until the next day, or if we should eliminate them altogether. My stance has evolved a little over the course of residency. Our program still has 28-hour calls on certain rotations. I came in completely against it. I think for political reasons. It obviously makes a great headline. You know, why are we sleep-depriving residents? But on the job, you realize in certain instances that you know, it doesn't really seem that different to do it either way.
A great example is you're in the ICU. It's 5:30 p.m. A really sick patient is coming in. The night team shows up at 7:30. You're admitting them. There's a lot to be done. There's, you know, four to five hours of initial work that needs to be done. Right. If I tack that onto the current time, it puts me at 10 30 p.m. So clearly some of this needs to be handed off.
So really, in that situation, it's balancing, prioritizing handoffs and what actually needs to be done right now. Often times I'll find I'm still in the hospital until 10 p.m. I have to come back the next morning at 5 a.m. So it's not like I got this remarkable sleep. Whereas if we're on an old schedule and I'm in the hospital for 28 hours, I would have admitted the patient, stuck with them. You know, things start winding down around 10 or 11 p.m., winding down or declaring themselves. And then I'm able to get a little bit of rest. And I know that patient better than, you know, someone I'd be handing them off to.
[00:10:48] Dr. Cifu: So actually let me just chime in on that.
I'm obviously, you know, an old guy, so I'm going to be old school and be like, "Oh, everybody should work really long hours." I do think that a lot of the changes probably underlining some of the things you said, have actually made it more difficult for current trainees because in my environment, which had a whole lot of things wrong with it and was overly abusive and blah, blah, blah but it was sort of impossible not to learn a lot of things because you were just there all the time. And I think that, I'll just say, you know, your generation of trainees actually have to be a little bit more deliberate, you know, about thinking about cases and learning from cases. And you know, maybe you guys, because of what you do before medical school, makes you, you know, better at that kind of deliberate practice than us, who are, you know, I think, less mature and less worldly. It's a difference, I'll just put it that way.
[00:11:45] Dr. Shahriar: Yeah, it's definitely... I try to think about parallel ways of doing it, and I don't think the literature does it justice, because there is so much nuance that you just can't measure. You know, like this example that I gave, I don't know how you'd capture what's going on through my head at 5:30 p.m. with a checkbox on a survey.
[00:12:05] Dr. Cifu: Absolutely. And I think also, you know, the important endpoints in any sort of educational intervention study, right, are so vague. And probably lots of them don't pan out for 30 years, right? And most of the people who are going to do poorly are going to do poorly, almost no matter what. And the people who are going to do terrifically are going to do terrifically, no matter what. And so you're making little changes into the, you know, mean resident. Mean as far as average, not nasty. We don't have any of those here.
[00:12:38] Dr. Shahriar: And then I think another unexpected thing was the friendships you form in residency. I obviously came in knowing we'd be in a cohort and you know, you'd make friends, but the strength of the friendships is definitely... You know, there's stronger friendships than anticipated. I think a lot of this is driven by the bonding you do through difficult experiences. For most of us, it's our first time facing death and dying regularly on a, you know, daily, weekly basis. So it brings a lot out of you. And the only people you can really talk to about that are other people who are also going through it. So that's been eye-opening.
[00:13:17] Dr. Cifu: Unless you want to lose friends and talk to people who don't want to hear about it, right?
So, tell me, you know, thinking about, I mean, medical education, postgraduate medical training is certainly far from perfect. I think you've alluded to some of the issues. Certainly, the fact that we tend to train every budding physician exactly the same way while some people need more time. Some people need less time. Some people need more time on specific things than other people. Are there things at this point that if, you know, someone made you medical education czar, that you would say, "Huh, this would be something that I'd probably kind of go after early."
[00:14:00] Dr. Shahriar: So I think a lot can be improved. I'll start with learning has become asynchronous, for the most part. People learn how to interface with knowledge sources, and they do their learning on their own terms, through their own mechanisms, which can be highly effective. I think it would be nice to incorporate some kind of structure to the asynchronous learning. Our program does a good job of at least giving us set periods of time where we don't really have obligations, but everyone knows that time is just a placeholder for, you know, spillover from the other periods where you do have obligations, but it would be nice to come up with a crediting system, I think, for time we spend doing learning outside of what's required.
The only time I really feel like I get credited for learning I do on my own is, you know, when something comes up in the hospital, and I do something different or new that I have learned about through some mechanism that wasn't offered through conventional means. And then an attending or somebody senior to me will comment on it. You know, that's a sort of feedback. So I think that can be improved.
I think knowledge management is another area where I see a lot of room for improvement and that is how do we... You know, with how much information is evolving, how do we interface with information? How do we store information? How do we train ourselves to retrieve things from various sources that are kind of extensions of our brains. I think the best doctors in 30 years are going to be the ones who best know how to interface with technology on top of being good clinicians you know, the old-fashioned way, for lack of a better term.
[00:15:40] Dr. Cifu: That's so interesting. I think that is going to be... It's going to be a big change because we're going to have to quote-unquote know less, right? There's absolutely no reason to be able to, you know, figure out creatinine clearance in your head, right? Where it should just sort of show up on Epic. My worry is always that as we don't teach students and trainees that, what are we going to teach in their place? And how are we going to be creative about sort of figuring out like, so what do they really need to know? And let's spend the time we have to do a better job teaching that because I think there's the temptation that, okay, well if we cut all this out, we can just get people, you know, into independent practice faster but maybe you just have people who've kind of grown less.
[00:16:32] Dr. Shahriar: Yeah. It's almost what is going to define the value of the physician in 20 to 30 years.
[00:16:38] Dr. Cifu: Right.
[00:16:40] Dr. Shahriar: And I don't have a great answer to it. I think the human aspect is always going to be there. So I don't know if there needs to be more of an emphasis on how we treat people and interact with people, because I don't think people's need for talking to a human being about their health is ever going to go away, but in terms of you know, where do we draw the line? What do people actually need to have stored in their brains versus what can they access with their fingertips? I don't have a great answer, but I think at the core teaching critical thinking is probably the best thing we can do because then you know, it empowers doctors to make those decisions on their own.
[00:17:17] Dr. Cifu: Yeah. Yeah, it almost feels like we're going to have to kind of reevaluate the whole medical training system every few years as things change so quickly with the availability of knowledge, with artificial intelligence, to like check-in, like, so how are we doing here? You know, are we still doing a good job doctoring? Which, of course, is nearly impossible to measure. And if we're not, what are we losing in the current atmosphere that we need to attend to a little bit more deliberately? Interesting. Interesting points. So what are your next steps? What do you see ahead for you? You're a third-year resident, so you'll be leaving the nest relatively soon. What's next for you?
[00:18:04] Dr. Shahriar: I have a primary care service obligation. It's part of how I paid for medical school through a government program, through the National Health Service Corps. So I'm currently looking for primary care or primary care adjacent jobs at qualifying facilities to be determined where and what exact type of job but some exciting options I think are on the table. Thereafter, we'll see. I think I could see myself in primary care long-term. I can also see myself gravitating towards some kind of specialty, but we'll see.
[00:18:40] Dr. Cifu: I always think there's so much in... No matter what you do, there ends up being so much, you know, sort of outpatient primary care, that even those...
I don't want to tip my hand too much. You know, even those who subspecialize, I think benefit so much from a really rich sort of outpatient foundation. That's probably a great thing.
Well, Arman, thank you so much for taking time out of a day off to talk to me for a little while.
And thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Institute webpage.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.