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In the Trenches: The Daily Grind of Family and Academic Medicine

In the Trenches: The Daily Grind of Family and Academic Medicine

Автором Jason Profetto и Emily Dewhurst

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In the Trenches: The Daily Grind of Family and Academic Medicine

Автором Jason Profetto и Emily Dewhurst

229 pages
2 hours
Sep 26, 2017


This book is about family and academic medicine. It’s a memoir of sorts with story-telling and reflection, as well as a slice of life advice. The stories are true and accurate, with patients’ particulars omitted of course. I talk about both positive and negative experiences and how they contributed to my growth and learning as a person while winding my way through the medical system. Some chapters are concise, others more detailed.

I encourage medical and non-medical people to read this book. It’s my hope it will shed light into our profession, and what we actually encounter on a daily basis. I should clearly state how fortunate I am to be in medicine, at the same time acknowledging how challenging the daily grind can be.

The title is a metaphor to describe what it feels like sometimes to walk a day in the shoes of a family and academic physician. I hope not to be overly cynical but rather honest, not jaded but genuinely reflective, not a pessimist but a realistic optimistic.
Sep 26, 2017

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In the Trenches - Jason Profetto



It Ain’t Easy

A female patient of mine came to see me one morning at 7:30 a.m. to discuss fatigue (I sometimes start appointments that early if it is convenient for my patients). Essentially the long and short of it, she was tired and gaining weight. My initial thoughts? Functional: She doesn’t have a medical issue per se, but rather she had a functional problem.

Functional problems rule the medical world, but what are they? Simple really … they arise out of a patient’s lifestyle (mainly) that is causing a concern. Think about an individual’s lifestyle; their patterns of sleep, nutrition, exercise level, stress, work or school schedules, family, etc. These are prominent pieces of our lives that affect us and how we feel. Not enough sleep? Too little exercise? Eating poorly? Arguments with your spouse? Foggy … Weight gain … Stress … They’re all functional problems.

Statistically, many individuals, especially those who are middle-aged or older, are more likely to have a functional problem, and that is exactly where I started; or at least where my mind started. I haven’t even described the point at which I started to speak to my patient, so I hope you appreciate just how complex the thought process is during an observation to determine why a patient initially comes in. That is why it’s paramount to first listen to an individual before a doctor begins to make deductions, with potential bias, cognitive distortion, and error.

After some further discussion I successfully determined that she was otherwise completely well; no respiratory, cardiac, gastrointestinal, or genitourinary signs or symptoms that would make me worry. We did blood work to look at the different medical causes of her fatigue, with normal results. I completed several physical exams; normal. She followed up to see me and repeat testing and blood work were carried out—again normal.

I advised her that the issues were mainly functional; she was stressed, sleeping poorly, not eating properly, and needed to start exercising more.

Three months later she returned to see me because now her right arm is tingling. The fatigue she noted was still there and perhaps worse. A neuron in the back of my brain was also tingling and a flag went up. Did I consider neurological causes? Nope.

One week later, a MRI of my patient’s brain showed multiple white matter lesions, suggestive of a demyelination problem. In this instance, it was MS. Even worse, I missed it. Let’s get this correct; I dismissed it.

What’s the point of such an incriminating story? Simple: It ain’t easy. This whole game of playing doctor is challenging and complex, especially as a front-line clinician. So why does one wish to get into this field to begin with? That is where we go next … back to the beginning.


In the Beginning

My father is a physician, a family doctor. He graduated from McMaster’s medical school in 1983, and went to complete further training in a family medicine residency program. Thirty years later, he is still practicing. Some call this commitment, others discipline, and most recently I think the scholars are agreeing on grit as the overarching theme for such success.

The running joke in my family is that my mother is the brilliant one, and while my father is still quite smart, he is the beloved donkey because he is such a hard worker. I don’t think my mother has ever had her IQ tested, but I can quite confidently tell you that it’s at least two standard deviations above the mean, when compared to others in North America. I believe three standard deviations above the means is what constitutes a genius, and she is probably pretty close to that.

That said, I’ve always thought about being a doctor too. In elementary school, it was a far-stretched aspiration, but an aspiration nonetheless. It wasn’t until the latter part of high school though that my ambitions started to materialize. Then I really began to look at medicine more closely as a career and started to plan my road ahead. I think this is a valuable point to highlight; our future goals are never guarantees, yet reflect what we are capable of doing by putting in place the appropriate and logical steps in order to optimize our chances and create opportunities. Then, if and when an opportunity should arrive, it is at this point that we try to solidify our goals and successfully complete the application cycle.

As I neared the end of high school, I thought about the different potential undergraduate degrees I would pursue to facilitate my path to medicine. It was incredible really (and still is to the present day) how often poor advice is provided from those who have gone through university to those wishing to apply.

I was particularly interested in anatomy, human physiology, and sport. After a bit of research, the program which provided the most for these areas of science, in my opinion, was kinesiology. So I decided to pursue kinesiology as an undergraduate degree prior to applying to medicine.

I remember vividly the day that our high school class found out which university programs we were accepted to and would be pursuing in the following academic year. When I told my friend, Evelyn, that I would be entering kinesiology at McMaster, she looked disappointed and told me, to which I quote, Ah Jason, kinesiology isn’t a good degree; you can’t do anything with it afterwards.

For a moment I felt dejected, yet motivated simultaneously. Firstly, why would someone actually say that to me? I could never imagine saying that to someone else. Personally, I would rather be positive and encouraging. Secondly, I loved the comment and embraced the criticism. I thought to myself, finally, a chance to prove others wrong.

I Just Want to Get Checked    by Emily

It’s funny and also quite intimidating when patients use phrases such as Well, I just wanted to get checked. They have a concern regarding their health and they present it to their physician with the goal of either having a problem fixed or of relieving their anxiety. There have been a great number of times during my medical education that I have examined a patient and truly had no idea what I was looking at or feeling. Just a quick look in the ear and I’m supposed to say, yep, looks great, that is definitively a normal tympanic membrane (eardrum). This I say when I have seen maybe thirty tympanic membranes in my short time as a clinical clerk.

I often worry about my limited experience when I think about my eventual transition from clinical clerk, to resident, and onwards to independent physician. Over the years I am sure that I will gather the useful knowledge which will allow me to competently assess my patients and address most of their concerns. But what about those pieces of knowledge that seem to slip through the cracks, the ones that I definitely should know at my level of training, but just don’t? Surely I’m not the only person to experience this phenomenon. Surely there are some doctors out there who just don’t know how to examine a tympanic membrane, but do so anyway, confident on their quick glance that it looks normal enough.

So I come back to the idea of just getting checked. I hear this so often from patients, I’d like a full blood work-up, just to check, or Can you do a full physical examination, just to check? I find it challenging to explain to patients that my full physical examination is still not all that comprehensive. In fact, some physicians use portions of the physical examination as more of a therapeutic tool than a diagnostic one. Even if we aren’t looking for something specific, patients actually feel more satisfied with their visit to the physician when we physically touch them, simply because we have checked.

But what about those things we don’t cover on a general physical examination? What are we inevitably missing, or frankly not looking for, that our patients are falsely reassured about?


Just Starting

In 2006, I started at McMaster’s medical school, at which time a man named Michael G. DeGroote gave the school millions of dollars. So the school was renamed after him: The Michael G. DeGroote School of Medicine, McMaster University. Too complicated … I prefer McMaster’s medical school.

McMaster is innovative. It is the home of evidence-based medicine, problem-based and self-directed learning. We have limited exams and lectures and focus on newer, more creative ways to learn and retain information.

What I found more interesting about medical school though was not related to the academic rigor involved in doing well, but rather how complex and difficult some of my fellow student colleagues were. I witnessed first-hand the overly competitive, anti-altruistic, and at times, contemptuous manner with which students treated one another. How could we have worked so hard to come so far and yet even at this successful destination, we still didn’t truly appreciate the value and role of collegiality and collaboration?

If you believe this is an uncommon and rare situation, you’re unfortunately incorrect. During my medical school days I witnessed it many times. Although I believe it happens much less now than in the past, regrettably it is still a problem.

Medical students will strive to obtain certain elective rotations and clinical experiences to help optimize their chances of obtaining a desired specialty or family medicine residency. There exist certain specialties that are historically known to be so competitive that one needs to dedicate countless hours to research and electives, and then schmooze with the powers that be and/or with those who will make final decisions on who gets in and who stays

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