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Wednesday, May 13, 2015

Bullies and cool kids

“I wish that I could be like the cool kids.
‘Cause all the cool kids they seem to fit in
I wish that I could be like the cool kids
like the cool kids.”

Echosmith

Medicine can be like middle school at times. Much like seventh grade, it's a combination of development, swagger, and perception. The early bloomers ascend to the top while the others settle wherever they can fit. It isn't always fair, actually.

Someone deems a person “good” which, in the medical field, is like the equivalent of being considered “cool.” Sometimes it's a faculty member or a colleague. Other times it's the nursing staff or junior group of admirers. What happens next isn't too far of a cry from junior high. Opportunities come. Shortcomings are quickly forgiven or even not noticed at all. And if a person is in the cool camp, life is good for the most part.

Now.

In full transparency, I will share that my experience in residency was from the perspective of a person placed squarely in the cool camp. I remember when it happened, too. I was on my very first rotation as an intern and was signing out a late patient to my attending because my co-intern was in clinic. As I reached the end of my oral presentation and marched through the assessment and plan, my attending stopped, cocked his head sideways, and squinted 1 eye.

“Remind me of your name again?”

“Kimberly Draper, sir.”

“And Kimberly where did you go to medical school again?”

“I went to Meharry Medical College, sir. In Nashville, Tenn.”

He jutted out his lower lip and gave me a slow nod. Then gestured for me to carry on with the rest of my plan. And that was that.

That attending was a key person on the faculty and a program leader. And I could tell that in that little glimmer of a second, he'd sized me up. The rest of our interactions were positive and he always seemed eager to teach me for the remaining time we had together.

Sure. I worked hard as an intern and took pride in the lessons Meharry had taught me prior to starting residency. But I quickly began to realize that sometimes my lot in trainee life was better because of my position as one of the cool kids. Or rather, the good ones.

As time marched on, I started to recognize a few other things, too. I started noticing that the cool kids are often privy to some conversations about the not-so-cool kids that aren't so nice. And I guess since I wasn't too cool in middle school, I've always felt a kindred tie to those who haven't been given a golden ticket. For that reason, those mean words always made me uncomfortable. But like any immature person who has found solace in the cool camp, fear of messing up a good thing can be a mighty muzzle.

This got me thinking about an experience I had in residency. I had a co-intern who'd worked with me in the NICU during our first few months of internship. Sujata (name changed) was this very petite, soft spoken, and nervous young woman of Indian descent. She had a rather thickish accent but mostly it was her apologetic and anxious nature that drew the most attention to her. And that attention wasn't good, either.

Nope.

Sujata and I were on the same team that month and worked shoulder to shoulder on some very sick infants. In our extensive time together, I rapidly discerned that she'd been completely misunderstood. Not only was Suji highly competent, she was also smarter than anyone else working in the unit that month. That said, when the time came for her to defend her management or answer questions, with a tiny shake of her head she'd disappear into soft, mumbling apologies. It was awful.

Suji became my friend that month. Over that year, she looked out for me, too. Whenever I was on call in a unit or a tough rotation, without fail, she'd slide a Tupperware dish into the resident lounge refrigerator with “Kim” written on a piece of masking tape stuck on top. Suji knew how much I loved her authentic South Asian cooking and never missed a chance to allow me to try whatever new recipes she whipped up. I appreciated that. And mostly I appreciated her.

But.

One day I was hanging out in the resident lounge waiting for sign out. In walks 2 “cool kid” senior residents, 1 of whom had already been chosen to serve as a chief resident the following year. Brent, the rising chief, plops down in a chair and groans loudly.

“What's all that about?” I laughed.

“It's about the painful night I have ahead of me in the PICU.” He plunged his hands into his hair and acted as if he was pulling it out. When I wrinkled my nose and looked puzzled, he clarified it for me. “Dude. Did you see who I'm covering tonight? I'm going to be up all frickin’ night.”

As soon as he said it, I knew who he was speaking about. He was referring to Suji.

“Maybe she will be sort of helpful, Brent. You never know. She's gotten some more experience over these last few months.” That's what the other senior resident said which I would have called him defending Sujata but won't since he was cackling the entire time.

Brent squinted his eyes and stared at his co-resident as if he'd just spoken the most asinine words in the world. “Dude. Did you say helpful? Sujata? Phsssssshhh. That chick is like an accessory nipple, man.”

That line caused them both to explode in laughter. The other senior. while gasping to catch his breath, howled out loud. “An accessory nipple? What the hell? I don't even … .bwah ha ha ha ha … Wait, man. You gotta clarify on that one.” He was already doubled over as he probed on this wicked 1-liner partly because anyone who knew Brent knew that his quick-witted humor was unmatched, even when he was being mean.

“Why an accessory nipple?” I asked, trying to look as genuinely perplexed as possible even though I wasn't. I knew that whatever he was getting at wasn't good. So I suppose this was my milquetoast attempt at a quasi-defense.

Brent propped his clogs on the dented up coffee table and leaned back on the chair. He was already chewing a big bite of the apple in one of his hands and nearly spat it all over the room when he added, “It's a perfect description. An accessory nipple is useless and just in the way. And most of the time embarrassing.”

And that? That was all she wrote. The laughing could no longer be contained. Brent literally fell on the floor and his co-senior began running in circles while screaming hysterically. And I just sort of sat there with this weird expression on my face which probably was some bizarre cross between uncomfortable and amused. You know, that way you look when you snicker at something terrible that you see on social media.

But even worse was the fact that Sujata was my friend. I didn't defend her. I just sat there like someone watching a mugging in the street and feeling too scared to act.

Yeah.

On the way home I thought about the little babies that I'd seen in the newborn nursery with those extra mammary glands or accessory nipples. The parents pointing at the 1, sometimes 2 little brownish peaks and asking if it was some sort of pimple or birth mark and me trying to explain through embryology that it was a “normal variant.” Every single time, they'd look at me in horror as I tried unsuccessfully to reassure them about the random satellite teat that their sweet baby hadn't ditched in utero. Yup. Useless and just in the way. And most of the time embarrassing. Pretty damn accurate description.

And this was the metaphor someone used to describe my friend as I sat by silently and allowed it. I'm still not certain why I didn't speak up, either. I'm ashamed of it even today.

Anyways.

I guess I am thinking about this today because I was talking to Isaiah about bullies yesterday. He asked me if anyone had ever bullied me. Quickly I told him “heck Yes!”, reflecting on my awkward middle school years. Then he hit me with another question that got me thinking. “Did you ever stand by and let somebody get bullied without standing up for them?”

He sort of pulled the wind from my chest on that one because instead of wandering back into high school or 6th grade, my mind squarely landed on Suji and residency. That “accessory nipple” line was one of many very, very mean things I heard about her without defending her. And so. I was honest. “Yeah, actually. I'm not so proud of that either.”

“Were you in 4th grade?” Isaiah pushed.

I twisted my mouth. “Honestly, son? I was a grown up. And some people who thought I was cool decided one of my friends wasn't. I was too scared of not being liked to speak up.”

“As a grown up?”

“I know, right? I should have known better.”

“Did your friend know that you weren't sticking up for her?”

I hate it when Isaiah's old soul rips the covers off of me. “Um. I sort of don't think so. Which I guess is the part that I've always felt bad about.”

“Were you saying mean things about her, too, when she wasn't there?”

“Not so much. But sometimes I laughed.”

Isaiah immediately looked disappointed in me when I said that part which sucked. “That's kind of being 2-faced, mom.”

“Yeah, you're right. It wasn't cool.”

“No, mom. It wasn't.” It looked like he felt bad for giving me such a rough time so he added this to make me feel better. “But it's good when you think about something a long time and then realize a better thing to do. Like, now you tell us to always choose kindness.”

I smiled. “Yeah. I guess you're right about that. And you know? It's good to let your kids and friends learn from what you did wrong.”

“Yup!”

And with that, he ran off to build Legos.

The part Isaiah isn't seeing is the part of me that now fights for everyone around me to feel like a cool kid, especially my medical students and resident learners. In all these years I've never shaken Brent's stinging words: ”Useless and just in the way. And most of the time embarrassing.” I don't ever want to feel that way nor do I ever want someone else to feel that way in my presence. Man, I don't.

Yeah.

I've not gotten it all fully figured out. And Lord knows that I still have my days where I don't advocate for folks like I should. But I'm better than I used to be. And what I know for sure is that the real secret to being a cool kid is believing that you don't need to be.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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