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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 Nihar Rama talking about medical training so far.
[00:00:11] Mr. Rama: Part of being a good physician is, you know, being able to reason through all the different possibilities for something, but probably more than anything, being able to communicate effectively, work effectively in a team, but really make your patients feel like regardless of you having the answers or not having the answers, that they're receiving, you know, high-quality care.
[00:00:41] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence. On this podcast, we speak to patients and doctors, and today, trainees, about all aspects of excellence in clinical medicine. Today we're starting a series talking to people at various stages of medical training to hear about their experiences so far.
I'm Adam Cifu, and today I'm joined by Nihar Rama. I'm going to skimp on my introduction since that will be part of our conversation. Nihar grew up in Ohio. He did his undergraduate work at the University of Cincinnati, where he graduated with a B. S. in Medical Sciences. He's presently a third-year medical student here at the Pritzker School of Medicine at the University of Chicago.
Nihar, thanks so much for joining me.
[00:01:24] Mr. Rama: Thanks so much for having me.
[00:01:25] Dr. Cifu: I literally pulled you off the wards of your medicine rotation for this, right?
[00:01:29] Mr. Rama: That's right. That's right. I showed up with my stethoscope and everything ready to auscultate.
[00:01:34] Dr. Cifu: So just tell me a little bit about kind of your route into medicine.
How and when did you decide on this career? Were you the kind of person who, like, decided in sixth grade based on absolutely nothing or was it a more conscious deliberative decision?
[00:01:50] Mr. Rama: Yeah, yeah, it's a good question to start with I think. You know, like a lot of people, medicine's kind of always been on my radar. I think that as a kid growing up I was always kind of in awe of doctors. I think I saw them as the people that those who were suffering, those who were in need would go to and be healed. Certainly, as I grew up that impression was changed a little bit by personal experiences that I had, personal experiences of some of my family members.
In particular, both, you know, my mom and I having chronic migraines and being chronic migraine sufferers. And there was this kind of interesting duality that I noticed that physicians had in my life and my mom's life where on one hand, they very much fulfilled that initial vision that I had, they were the people that we would go to in times of stress and times of suffering but on the other hand, I think I started to appreciate how much harm they could cause and how important it was to actually be a good doctor, to do a good job in terms of your clinical practice. And there were physicians who I felt did better at that than others. And I think as I got a little bit older and started to solidify my interest in clinical medicine, pathophysiology, as well as social sciences, I really wanted to be that doctor who was a good doctor for my patients and I felt like I could rely on my own experiences with migraines to be that person who could relate to my patients.
[00:03:20] Dr. Cifu: Do you think... I mean it's interesting listening to you because I think like a lot of people, you know, your view of medicine sort of starts a little bit idealistic, right? These are the beneficent people who give their lives to the care of others, right? And it sounds like, actually, maybe a little bit earlier than some, you got a sense for the complexity of it. You know, that the doctors are people and not only can they do good, but as you say, you know, they can do harm if they don't think about it. As you, I don't know, went through college and I know it's uncomfortable to like talk about classmates, and I don't want to put you in any weird position, but as you went through your sort of entry into medicine in undergraduate years, did you feel maybe not ahead of people, but sort of a different view of that given your interaction with medicine you'd had?
[00:04:15] Mr. Rama: You know, I never really felt like I was ahead of other people. I think I just brought a different perspective to it. And I think the perspective that I brought is somebody who had been a patient in a lot of different settings myself. Someone who in one way really understood what it meant to suffer, really understood what it meant to deal with pain, really understood what it meant to feel like the team that's supposed to be caring for you is not listening to you.
And so I think perhaps earlier than others, I appreciated the importance of a physician being willing to admit when they didn't know things and having some humility because, you know, again, I think as a kid, I saw medicine as a very black and white type of picture. There were clear diseases that had clear answers. And the more I trained, the more I realized that's just not the case. And I think part of being a good physician is, you know, being able to reason through all the different possibilities for something, but probably more than anything, being able to communicate effectively, work effectively in a team, but really make your patients feel like, regardless of you having the answers or not having the answers, that they're receiving, you know, high-quality care.
[00:05:24] Dr. Cifu: I like your comment that you know, you've already suffered. It's like, you can say to your attending, "You can't hurt me." You're just like, "I'm not your attending. I could hurt you." Tell me sort of, you know, you're, I guess, more than halfway through medical school. You know, you've already had some clinical experiences, you're getting sort of deeper and deeper into it this year, what's medical school been like for you so far? Is it kind of what you've been expecting? Is it, I don't know, living up to expectations as far as what you've learned and what the experience has been like?
[00:05:58] Mr. Rama: Yeah, yeah, I think my expectations coming into medical school were that it was going to be one of the hardest things I've ever experienced. And I think that's been true in some ways.
I think I've really had to find the balance between giving myself to my studies, giving myself to, you know, my patients, but also taking care of myself as a person. And, you know, it's been interesting seeing a lot of the kind of revolutions that are taking place in medical education more broadly because I think 20-30 years ago, the emphasis was really not on these kinds of conversations.
You know, I think the first couple of years of medical school for me were definitely the years that I was more kind of book-heavy. I was very much studying but I think that modern medical education does a good job of getting you involved clinically pretty early. I think what's been interesting in my third year is, you know, how it's lived up to my expectations of what I thought third year was going to be. I very much envisioned third year is that time where I could fill into the role of, you know, an intern on a team, be that person who's taking on a patient, really taking ownership, trying to help my team out in any way I can.
And I think that the skills that I fostered the first couple of years of medical school, skills in terms of being efficient with parsing through information, skills in terms of communicating effectively with classmates, with professors, being able to show, you know, my clinical knowledge. A lot of those have really come into play during the third year as well but there's also skills during third year that I think I didn't really get a chance to demonstrate the first two years. And a huge part of that is just interpersonal interaction. I find that as a third-year medical student, so much of what you can do to be, you know, a good team member for your patients, but also a good team member for your other teammates, is just having social and emotional awareness.
Knowing when something is appropriate, knowing, you know, when to step up and maybe when to take a step back. And that's a hard balance to find. I'm still working on it.
[00:08:08] Dr. Cifu: Right, and I think it's a hard thing about, you know, medical education in general, right? Because the ideal is that medical school admissions look for these kind of multi-talented renaissance people, right? Who are both sort of academics and humanists and so forth but then at different times during medical school, you need to sort of express those qualities differently, and that can be really challenging. And then eventually, you know, hopefully you get to use them all but they're not all useful to your success in medical school, right? And I do think maybe at times some of those qualities atrophy as you go through the experience. But it's good to hear that you... It sounds like you kind of remember like, "Oh, these are important qualities that I need at this point in the training."
[00:09:02] Mr. Rama: Yeah, I mean, I think a huge quality that often gets forgotten about is just empathy. You know, like taking the time to listen to a patient, taking the time to take a patient's concerns seriously.
And I think drawing back to what we were just chatting about, because I grew up as a patient in a lot of settings, I feel like I am constantly reminding myself that you really have to listen to the patient. You know, the patient's telling you what they're concerned about. And I've definitely already seen a couple of cases where a patient's concerns are ignored, you know, early on in the hospital course or during a clinic visit or something like that. And later on, those concerns manifest themselves more overtly with the disease process.
[00:09:44] Dr. Cifu: So it's interesting, you're sort of... I always refer to it as indirect empathy, you know. You're using your own experience to improve your empathy with patients.
So, you know, somebody comes in with heart failure, I assume you haven't been hospitalized with, you know, end-stage heart failure in the past, but you do know what it's like to be sick, to rely on other people, to have people have to listen to you and understand what you're going through. And it sounds like you are quite consciously pulling on those experiences already in your patient care.
[00:10:17] Mr. Rama: I'm certainly trying to. You know, I think there's certain clinical situations that are easier to relate to than others. You know, we were just chatting, I'm on my hematology and oncology time right now, and I find that a lot of these patients that are suffering from disseminated oncologic processes have a degree of pain, a degree of discomfort that I just haven't personally experienced.
But I think from a human perspective, I can relate to their need, their desire to maintain some semblance of self despite suffering. I think from a human level I can relate to their desire to get back to their kind of baseline and not allow their kind of identity as a patient to become an overwhelming aspect of self. So I try to keep those front of mind and think about it any time I'm coming up with a plan for a patient, you know, how are we going to try to get this person back to who they are fundamentally?
[00:11:13] Dr. Cifu: I'm always interested in what we can do better in terms of training, kind of across the whole breadth of training. And this is part of the reason that we're doing this series. I recognize that you have basically like zero perspective on your medical education, right? It's not like you're looking back on it with 10 years of patient care experience. But for you personally, you know, what has sort of worked well for you? Maybe what would you change, even at this early stage that you think maybe you struggled with, maybe you felt like, "Ah, I didn't get out of that what I should have got out of it," or maybe what was intended for you to get out of it?
[00:11:47] Mr. Rama: Yeah, I think there's a few things. I mean, certainly when I think about things that have gone well, I think about me as a student trying to be proactive and getting feedback from my team, trying to get feedback from my patients. Recognizing that the clinical care we provide is actually more than just the medical team, it's also all of the interdisciplinary team members.
And so I think the opportunities when I can actually get feedback from those people and get a sense of, you know, how can I communicate better with you as a physical therapy colleague or as a social worker are the times where I can really take better holistic care of my patients. I think I'm trying to work on finding the right level of confidence, and balancing, you know, being confident with being humble because I think, you know, a number of attendings, a number of residents have certainly expressed that when you as a student feel confident in your assessment and plan for a patient, that that actually reflects well on you because it reflects that you've been doing reading. It reflects that you're being thoughtful about the patient but I also think it's appropriate for students to have some level of kind of doubt. You know, like this is often the first time that we're doing a lot of this stuff. It's the first time that we're actually managing a patient in a very complicated setting, and so I'm still working on trying to be confident while also expressing, you know, I don't have all the answers and even though this is what I think is going on, it very well may not be the case.
[00:13:21] Dr. Cifu: I love some of those things and as I think about, you know, how to improve care and training, the feedback thing is so important. You know, we say over and over again, you know, you can't get better, right? Unless you're getting feedback on what you're doing well, what you're doing poorly but so often feedback gets to like, a student asking the attending who's grading them like, "How am I doing?" You know, and it's all sort of mixed up and like, "What grade am I going to get?" And you know, what's formative feedback, what's summative feedback? It's really great to hear about, like, okay, how can I get that kind of formative feedback from people who are, in a way, peripherally involved in my education, but who are really important, right? That infectious disease consult that you give them a snippet about in the case and may never hear from you again. You know, really being kind of mindful in how they received the information is so important.
And the confidence is such a tough one, right? Because on the one hand, nobody expects you to know anything, and the beauty about being a clinical medical student is that you have all these buffers that you can call on help and say, "You know, I'm just a student," but we totally know if two people walk in the room with patients and they have exactly the same knowledge and they're providing the same plan, a patient's going to feel so much more cared for if they hear about it in a, "Look. We know what's going on. This is what we're doing. You know, these are the uncertainties which persist," than the person that's like, "Uh, I don't really know," you know. And so it's good to think about that even as you're learning how to do it.
[00:14:59] Mr. Rama: Yeah, yeah. I mean, I think that, you know, in front of patients especially, you have to be careful because I've also heard of situations and tried to stay out of situations where you as a medical student are overconfident and then express a plan to a patient that actually could have been better saved for a separate setting or maybe wasn't the right plan.
Another part of that I think is, you know, just the potential to cause harm as I was kind of talking about and as a student, you certainly can harm patients if you're not careful but you can also harm patients by kind of failing to be proactive in their care. So that balance is I think really difficult to find.
[00:15:43] Dr. Cifu: Yeah, I think students do bring more to the care of patients than we really give them credit and it's seldom, you know, the brilliant diagnosis, right? But so often it's actually taking the time, it's listening to them. It's either in the relationship, which then transfers to the relationship between the patient and the entire team, or maybe it's, you know, the extra 15 minutes that actually some important information comes out, which tends to get lost in the like hubbub of, you know, the admitting day or something like that.
[00:16:19] Mr. Rama: And you know, when I think about kind of the implications of this for trainees, I think about how schools look for students, how they try to recruit students. And I think there's a lot of characteristics that are important for being a clinical medical student that are often not identified during the medical school selection process.
I think the peers that I look up to the most are the peers that are you know, willing to take the extra time to sit with a patient to really understand them, to build that relationship which is just really difficult to assess during a medical school selection process. The peers that I respect are those peers that can actually take a very complicated concept and distill it into simple yet, you know, comprehensive information for a patient and actually sit with them, try to, you know, help them understand it, take the time to do the teach-back.
And so I guess I wonder, you know, how do schools actually assess undergraduate students or assess students even earlier for these types of characteristics? I don't have a great answer for that, but I think the earlier people can get exposed to the clinical setting, the earlier people can see that these things actually make a difference.
There are more time people will have to foster these types of skills.
[00:17:40] Dr. Cifu: I do think I always compare medicine admissions to, you know, the job search in the tech industry, right? Where, you know, many of those jobs have multiple interviews and then a day of, you know, sort of basically skill-testing and you know, we're not near that.
And you think of what we're accepting people for. Sure, designing algorithms is an important thing, but you know, taking care of people is pretty important too. And I wonder if we'll ever both invest the time in evaluating the students and invest the time in figuring out like, what are the evaluation tools which would be best at predicting, you know, who's going to do really well in the future.
Not that we do a bad job now, but I guess there's always some room to improve. We're lucky that we get good people applying to medical school, that we can at least figure out if they're smart and can do the work, and then, you know, we sort of hope for the best.
[00:18:42] Mr. Rama: Yeah, I mean, I think that most students are probably, you know, pretty smart and able to do the work but as I mentioned, I think the things that are actually more important are how do you jive with the rest of the team? How do you connect with patients? And I think there's always some inherent personality differences that exist. Some people naturally get along with one patient better than another. And that's also true within a team, but I think broadly as a student, you know, trying to identify one's emotional flexibility or interpersonal flexibility, how well they can jump from one setting to another and adapt from, you know, the flow of pediatrics or the flow of OB/GYN to the flow of medicine and surgery. It's difficult to do. It's difficult to do.
[00:19:27] Dr. Cifu: And I think it's true that our kind of natural patient empathic stance, you know, each individually probably works with, I don't know, 85-90% of people and the other 5-10% of people, 10-15% of people, you know, you have to put on a little act, right? You have to be something different for it to work. And part of what you learn in medical school is like what act works, right? And there are a couple of percent that, you know, you're never right for. And that's fine, no doctor's right for every patient, but it is part of the learning process, and it's great to hear you, you know, talk about being aware of that already.
So anyhow, I wanted to thank you so much again for taking the time out and running away from your team for half an hour to talk to me this afternoon. Before we finish up today, a quick addition about this year's National Clinical Excellence Award. As you know, the Bucksbaum-Siegler Institute for Clinical Excellence at the University of Chicago is dedicated to fostering compassionate doctor-patient relationships and advancing clinical care.
Each year, the Institute recognizes extraordinary healthcare professionals through the National Clinical Excellence Award. To learn more about the award and nominate a deserving clinician, please visit the Bucksbaum Institute webpage. That's bucksbauminstitute.uchicago.edu.
Thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Bucksbaum Institute webpage.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.