CREATING YOUR DREAM

Many medical students I meet in the clinic or in the classroom, dream of an extraordinary career in medicine. They often ask: what does it take to realize this dream?

I had a somewhat atypical journey, taking a circuitous route from Internal Medicine to Emergency Medicine and then ultimately deciding to specialize in Family Medicine. However, whether in the Emergency Department (ED) or practicing Primary Care, I continually strove to be well informed and on top of what was happening in my discipline.

This included reading my specialty’s prominent magazines cover to cover every month and including more than thirty other medical journals.  Besides reading, I listened to four or five medical cassettes each month.  These cassettes were chosen to supplement my lack of knowledge in a particular area.  Among other things, I decided early in my career that staying current in my specialty is very important.  I still resonate with what Dr. Roger Hadley, the Dean of Loma Linda School of Medicine once told me, “It is not so important where you train as much as how you take charge of your learning.”

Another key to practicing good medicine is paying attention to detail and being thorough in everything you do to help patients. While I was teaching at Loma Linda Medical School, I would tell the students, “I want you to be uncommonly good at the common.” The common in your specialty may be extracting a gallbladder through a scope, handling an asthma patient in the ED or treating a diabetic in your clinic.  Whether doing a complete physical examination, a prostate, knee or thyroid exam these skills must be done thoroughly because they are basic and crucial to quality medicine.

Students also often heard me say, “Repetition is the mother of learning; the father of learning is testing.” As seasoned physicians, we test ourselves every day, whether we’re making a diagnosis or performing a procedure.

Long hours, difficult cases, and emotionally needy patients can drain the vitality out of young aspiring physicians (older ones too).  Having experienced the loss of enthusiasm for medicine myself at one point, I came up with an answer that has lasted for forty years.  I’d be the first to admit, this solution came at a time when I was utterly frustrated with medicine and patients.

I realized that as physicians, we can encourage, cajole, and persuade patients to be responsible for their health, but we can’t make them change.  I learned to deal with what I could control.  This led me to change my approach to patients and transformed me to deal with complex patients.  So follow me.

“Happy Hanna Healer” did not happen overnight, however.  Each day, I tried to connect with every patient in a more personal way.  I asked about their emotional and spiritual health as well as their physical condition.  The more I offered this deeper caring for the individual, the more I benefited from the experience and the life came back into my medicine.

A good physician is a key shaper of people’s lives and, in turn, our patients can inspire us to do better.  My patients gave me comfort when I was fatigued, and gave me the same advice I gave them about taking care of myself.  Don’t forget it is a mutual nourishing of each other. This type of relationship can be a barrier against burn out and prevent a loss of fervor for your profession.

In his book Outliers, Malcolm Gladwell proposes that it takes about 10,000 hours to become proficient at any profession.  That’s a long time and no way around the commitment to put in the hours to be successful. He concluded that would be a minimum of 3-4 hours a day, 20 hours a week for ten years. Based on his conclusions, it appears that all it takes is laboring in your specialty and a “tincture of time” to become a skilled physician.  That’s not exactly true.  Even if physicians put in a tremendous number of hours and labor long in their specialty, they can still be missing pieces to the “practitioner puzzle” and the making of a competent healer.

When my daughter finished her residency in Family Medicine, she asked me one day, “What do young doctors do when they don’t have a mother who is in the same specialty as a mentor?”  My response , “Some muddle along, others try to figure it out by going to the Internet, and others find a mentor that they can ask.” Much of our learning is machine driven and we have many resources at our fingertips such as MD Consult, but in no way can it answer all the issues that a young doctor will encounter.  For example: What do you do when a patient approaches you sexually?  This was a question I had dealt with and felt comfortable answering, but may not be so readily available in other places

By now, I suppose, you are asking a broader question.  What is it that creates a truly competent healer? This was the sort of inquiry I posed to eight faculty and alumni at Loma Linda University School of Medicine, where we have a wealth of experience and wisdom in our faculty and alumni. I wanted to capture and share some of that knowledge with students and residents.  With my tape recorder in hand, I selected a group of competent physicians in different disciplines on faculty and gleaned an array of answers that were fascinatingly varied and interesting.  They all came from many years of practicing their speciality.  At the end of this introduction, you can read the various interviews.

Having gathered this information I decided to extend an invitation to all our Alumni, who represents a storehouse of knowledge and many years of practical experience, to send in their most poignant lessons that they have learned over their 10-40 years in the “trenches.”  My hope is that we can get many of our Alumni, scattered worldwide, to expand this advice with their best gems.

In closing, I want to make one more suggestion to help you figure out your future “self”.  Interview someone you respect and who has had years of living (60-80). I like the idea of finding a maven.  This word is derived from a Hebrew word meaning “one who knows” or “one who understands”.  Find someone who embodies your ideal and spend some time gleaning ideas about successful living-find an alumnus.

Let us connect our graduates, as consultants, to our students and residents and everyone will benefit from the relationship.

Leonard Bailey, MD:  Pediatric Cardiovascular Surgery, Loma Linda University School of Medicine

Early training and becoming proficient:

Dr. Bailey graduated from Loma Linda University School of Medicine in 1969.  As a medical student in 1968, he spent a day at Stanford University with Dr. Norman Shumway when he was doing early heart transplants on dogs.  This had an important impact on Dr. Bailey.  With his general and cardiothoracic surgical training at Loma Linda University Medical Center and his subspecialty training in pediatric cardiovascular surgery in Toronto, Canada he was sufficiently trained to begin his profession.  In the mid-seventies during his training in Canada, he saw 15-16 babies with hypoplastic left-heart syndromes.  They all died.  He thought, “Possibly we could transplant these babies.”  Prior surgical attempts were failures.   When asked how long it took him to feel surgically skilled, he felt proficient in the mechanical parts of surgery after his training (5-7 years), and because of all the practice he got in the lab working on baby goats. Many a night was spent tending to the babies as their intensivist.  He spent a tremendous amount of time in the lab until newborn heart transplantation was second nature to him; he felt he could almost do the surgery in his sleep.  “That is how we prepared for the baby Fae pilot transplant.  We practiced the transplant surgery on baby goats hundreds of times in the lab before we actually did it for real. We also studied the neonatal immune response and how to manipulate it in the solid organ transplant setting, particularly as it related to cross species transplants.”

Regrets:

When asked what would he do differently now then he did in his early years.  Dr. Bailey wished he had documented more when he did his surgeries and procedures.  Many times his mentors and other residents would scribble on the chart a few words about the procedure and would be meager in their description.  “We needed to make it seem we were there at the surgery by our detailing.  This left us open to liabilities. We would put a chest drain in and put two words on the chart.  I would never do it that way again.”

Mentors and role models:

Dr. Bailey remembers two or three mentors that helped him become a better doctor.  He especially sought out Dr. Ellsworth Wareham since he had heard him give a presentation in the mid- sixties at his undergraduate college (CUC now Washington Adventist University).  His first exposure with Dr. Wareham, as a surgeon, was when he was showing Dr. Tom Zirkle how to close an atrial septal defect in the Loma Linda Sanitarium Hospital.  “ Zirkle’s instruction was simple steps done well and you had to do them well. He would never allow himself or anyone else to take a bad stitch.   He had absolute pride in what he did.”

Dr. Louis Smith, a vascular surgeon, is another mentor that taught Dr. Bailey to treasure the laboratory. Dr. Bailey felt he was a powerful influence in his life. Dr. Smith was exacting even when applying a dressing.  “He insisted that we cut dressing tape, not tear it jagged, so all bandages were neatly applied.  That is often all the family sees.  In surgery, Dr. Smith would tell me to put it back the way you found it.  Make your grandmother proud of you. “

When he went back East to Toronto in the mid-seventies, Dr. Bailey felt he was a “pretty darn good operator” because of the influences and encouragement of his mentors at Loma Linda University Hospital.  The surgeons in Toronto, Canada in his subspecialty did not need to teach him how to operate but rather how to understand and cope with the many variations that occur in pediatric cardiac surgery.  Dr. Bill Mustard, one of his mentors in Canada, was a “bloody genius” and in addition he was fun to work with.  You could not pick him out from the janitor because he we so unassuming.  Yet he was such a capable guy.

Reflections on his choice of specialty:

When asked if he would change anything about his choice of specialty, Dr. Bailey stated, “ he would not change a single aspect of his specialty and thought Nancy, his wife, was in full agreement. They both would have liked more time for intimacy and for raising their sons.  Such are the time constraints intrinsic to busy professional lives.   He feels his profession was a call to service.  “I ‘ve been so lucky to be engaged in this work, regardless the size of the paycheck.  Our bank account was never a driving force.  I think I have the neatest job.”

Dr. Bailey could not think of any real frustrating areas of his work.  He was asked how he would handle the death of a patient after surgery.   “ Beyond the grief, I would remind myself I did my best. That is all that is required.  You have to be able to sleep at night and get up in the morning with a smile on your face.”

In closing the interview:

Dr. Bailey would like young doctors to figure out what they want to do with their life and invest totally.

 

Fred Orr, MD:  Retired Chief of Radiology at San Bernardino County Hospital

Early training and becoming proficient:

Dr. Fred Orr graduated from Loma Linda University School of Medicine in 1968 and had one year of internship and one year of radiology. In 1970, he was part of the Berry Plan, a deferment program from the military during the Vietnam War.  After one year of radiology, he was drafted into the Air Force and became a Family Physician at Langley Air Force Base in Virginia.  During this time he saw patients but part of that time he read x-rays and did moon lighting in radiology at various locations to supplement his income.  When he came back to Loma Linda to resume his residency program, he had more experience then his colleagues and found that he was comfortable and efficient.  “What makes you feel comfortable when reading x-rays is having many x-rays that you see over and over again until it become second nature,” he said.  He feels it is pattern recognition and you see enough of them to feel comfortable.

After his radiology residency, he took added training in angiography and nuclear medicine at Loma Linda University Medical Center from there he became a staff radiologist at the San Bernardino County Hospital.  After nearly seven years, two in the military, extra work at moon lighting jobs, and completion of his residency, he was not afraid to tackle most anything in his specialty.   At the county hospital he set up an angiogram and ultrasound department.  He loved doing procedures such as arthrograms, myelograms, and any others that were being done at the time. The county hospital had a very large volume and the radiologist read 2-3 times what the average radiologist reads in a day. “ The residents that came from different programs were so slow and our program taught them to read faster and more efficiently.  I can look at a healthy chest x-ray in five seconds and feel comfortable with my diagnosis.”

Mentors and role models:

Dr. Walter Stilson, one of our beloved mentors at Loma Linda, taught him how to read chest x-rays.  “Everybody respected him, how accurate and fast he was.  He knew a lot and would teach you to be systematic and analytical.  He was very much into quizzes and cases.  You were put on the spot but he didn’t embarrass you,” said Dr. Orr.  Mentioning others that help him was Dr. Henry Gorman, who excelled at special procedures.  “We now call it interventional radiology.   He taught all the techniques correctly and carefully.    Dr. Dunbar was very approachable and was well versed in chest radiology.  Dr. Francis Toomy taught me mammography reading. That was when mammograms were ‘hocus pocus’ the films were poor and hard to read.  Dr. Douglas Smith taught me angiograms and was very much into detail and wanted me to be very particular about guide wires and catheters.  He was particular about air bubbles and all the details.  I learned to do them safely without causing a lot of damage.  When I was at the county and saw radiologists from other programs, I realize how well I was taught at Loma Linda.”

Suggestions to residents:

Advice he would give to other doctors, “do your own dictation.”  He feels when a resident watches his mentor do the dictation you miss out on the skill.  “When a radiologist dictates a large number of differentials and doesn’t commit to a definite diagnosis it means he doesn’t trust his diagnosis.”       He suggests when making a report be as specific and accurate so if you go back and read it you will know exactly what is being described.  Dr. Orr feels that the radiologist should intervene when inappropriate ordering is done.  For example: a physician ordered an MRI of both shoulders and both knees without a plane x-rays, all at the request of the patient.

Reflections on his choice of specialty:

Dr. Orr is very happy with his choice. “You need to know something about everybody’s specialty.  You don’t have the headaches of patients calling you at all hours of the night.”  He likes the idea of tele-radiology where you can read at home and can give 24- hour coverage if you choose. 

Roger Hadley, MD:  Dean, Loma Linda University School of Medicine and Chair, Department of  Urology

Early training and becoming proficient:

Dr. Hadley started his surgical residency in 1975.   When asked the question about how many years it took him to be proficient, he expressed, “ after five years of surgery residency, three years of urology, and one year of fellowship where he operated nearly every day,  even with all this experience, he felt like a beginner. “ He did not have the confidence that you only get after handling case after case and all the variations in your own practice. He felt that after ten years and certainly after twenty years he is a much better surgeon.  “You have seen everything and you can get out of trouble.  Experience is everything in surgery.  It is not just a technical problem.  To be an effective surgeon you have to have humility and courage.  It takes a balance of these two characteristics. You are always humbled by what can happen and the frailties of just being human. You will make mistakes both technical and mental just because you are human.  And when you think you cannot make a mistake you are no longer effective. There has to be respect, humility, and yet a certain amount of courage,” he said with much conviction.  Dr. Hadley has seen surgeons paralyzed because of what might happen. They will not operate because of fear.  He gave an example; when you operate around the femoral nerve and the vena cava you have to recognize the consequences of your action.  He wants to see a confidence in a resident so they will not be paralyzed.  Dr. Hadley has seen an intuitive resident with two years of experience that can trump a surgeon that may have practiced for twenty years.

Learning life’s experiences:

“ When I was a resident, I was more analytical than I was compassionate so I decided to go into Urology because of the male patient. “ Then something happened that changed him. “So much of what we are today are made up of small decisions.  I wanted to come to Loma Linda to be on staff and they needed someone that could take care of woman’s urological problems and that is what my fellowship was in.”  He relates a story while he was on rounds when a woman was looking at him and told him that he was afraid to touch her.  That was a wake-up call forever.  “It was not in me.  I had to teach myself to touch.  When I walk into a room, I had to learn to put my hand on their hand and make contact.

Suggestions to residents:

One advice that he would like to give to young applicants for residency is this.  “How good a doctor that you will become is dependent on your investment of yourself into your program for the next five years.  How engaged are you into your program and take ownership for your learning. Once you show yourself as a team player, problem solver, and making patient’s lives better you will make nurses lives better and your attending’s lives better.  They will embrace you and take you places that you could not imagine.   Don’t fret about where you take your training it’s  more about what you do when you get there.  After 40 years, I know who are the good doctors and who to send my patients to and it doesn’t matter where they took their training.”

Mentors and role models:

When asked about mentors, he particularly admired his grandfathers-Drs. Roger Barnes and Henry Hadley, one a urologist who was scientifically oriented and the other practiced family medicine in the inner city of Washington D.C.  They were both real inspirations; loving their profession and never complaining.  They were daily energized by what they did.  In medical school Dr. Lou Smith always guided him and a resident by the name of Tom Mitts gave him advice about going into surgery.  “Once I didn’t do well on one exam as a freshman and went to Tom and asked if it was worth it for me to study harder.  He advised me to put in more time and energy.  I took his advice, cranked it up a notch and turned it around.”

“When I got into practice and into a leadership role, I was helped a great deal by Dr. John Mace, Chairman of Pediatrics at that time.  He gave me good advice concerning older faculty members in his department of urology.  He told me I will not always have credibility.  Dr. Mace gave me advice and courage to face them.”

Reflections on his choice of specialty:

When asked if he was happy with his choice.  He responded unequivocally, “I made the right choice.” If he were to choose another profession, it might be a racecar driver or he thought it might be challenging and fun to be in charge of building a major highway project with it bridges, interchanges and overpasses.  He would love to organize and to figure out how to move this dirt to this spot and all the details involved. He related the story of the contractor that fixed the freeway after the Northridge earthquake and rebuilt it in 23 days sooner than agreed.  Dr. Hadley is fascinated with systems.  He feels that being a doctor is a lot like an organizer of a project.

Final wisdom about his specialty and the changes in medicine:

When asked if there are “headaches” in his specialty?  He felt interstitial cystitis (painful bladder) patients were difficult to manage.  “ I now have gray hair and confidence and tell them what they need to do.”   This is what he said, “they need to change their life style and that there is not an operation or a pill that will make them better.”   He felt he had enough experience that he was not overlooking any other problems.   He would like all young doctors to be able to feel comfortable about their doctoring and put the responsibility back on the patient to take charge of their health.  “Seek early in your career to gain the confidence to tell the patient to take control of their own lives and say it in a compassionate way so that patient knows you are listening.  It is hard to do that right out of residency because of your youth and lack of experience.”

When asked about changes in medicine, he remembered fifty years ago when Medicare was introduced into medicine, the doctors were telling us that this is going to be the end of the golden years of medicine.  But now we can do so much more for our patients then my father and grandfather could do.   “It is the best time to be in medicine.  If a patient has prostate cancer and a kidney stone we can make them stone free and pain free so much better now because we have much better tools to work with.”

David Wilbur, PhD in physics from Berkeley and Medical Oncologist at Jerry Pettis VA Hospital.

Dr. Wilbur has been practicing his specialty since 1976.  “ It took many years to get comfortable with the practice of oncology.  The technology and the drugs are always evolving and must be delivered empathetically to patients with complex powerful and subtle emotions.”

Learning life experiences:

“ I had to learn to be concerned but not to assume personal responsibility for bad things such as progression of cancer.  My job was to offer options and information about possible outcomes with them.  I had to learn not to feel guilty when treatment didn’t work. Over time I learned to put many patients in charge of their own therapy. I was their advisor. I learn to put the majority of patients in charge of their care.  Give them the options, give them the pros and cons, and I would help them with their medical decision.  A few patients didn’t want to make their own medical decision so I would help them.  Decisions at least shared by the patient is less likely to lead to emotional upset if the hoped for benefit isn’t obtained.”

Suggestions to residents:

“ If I were advising young oncologists about what I have learned over the years, I would say I have gotten more conservative about treatment.  If you treat patients who are too close to dying from their disease, it may look like you caused their death.  Some patients want to try therapy-‘Even if it will kill me’.  When they can’t get out of bed because of weakness you probably shouldn’t treat them, you are likely only pushing them down the banana peel a little faster.   There are exceptions such as some patients with breast cancer or hematologic malignancy. I remember a patient with extensive lymphoma who arrested during his oncology evaluation.  With the help of an initially reluctant surgeon we resuscitated and intubated him and got him to ICU.  The surgeon was upset that we were intubating him because he thought he had terminal lung cancer, we told him it was lymphoma, he said go ahead.  The patient went home after a month in ICU and lived a year or so mostly out of the hospital.

Changes in his specialty:

When asked how had his specialty changed over the past twenty-five years, Dr. Wilbur said “ we cure more patients with diseases like lymphomas and give them more remissions.  Testicular disease is another one that we can cure even with metastatic disease.  We cure early prostate cancer depending on the type with either surgery or radiation but this is stable over the past thirty years.  We have more hormone options then years ago.  With breast cancer we have more adjunctive therapy for early disease but with metastatic disease we almost never cure them but improved palliation has extended survival.  Some people feel we over diagnosis and up to 25% would not die from their cancers but there is a lot of controversy in this area.”

Mentors and role models:

Dr. Wilbur doesn’t remember any particular mentors that guided him.  In his training in New York there was young Catholic attending that he enjoyed and was approachable.  He was bright and well informed.  Some leaders in his profession such as Larry Einhoven, M.D. in testicular cancer and Charles Moertel, M.D. have earned his respect.

Reflections on his choice of specialty:

He is happy with his choice but considered radiological oncology or nuclear medicine because of his physics background. “I wanted the patient contact and I liked the people I deal with.  I do enjoy my patients.  Some of them I have taken care of for a decade or more. Many tell me they feel better after our visits.”

Areas of difficulty in his specialty:

When asked about an area of difficulty in his specialty.  He couldn’t think of any but he dislikes oncologist that don’t take the time to communicate with their patients.  “Some don’t take the time to explain the side effects or other treatment options.  Some don’t keep decent records and taking care of their patients is potentially made more difficult.”

In closing:

The issue of death and dying was discussed and Dr. Wilbur had not found that religion made it easier for the patient to face death.  “ The religious patient was often anxious maybe because they were unsure of whether they were ‘saved’ or not.  The atheist seemed to accept their dying as part of life,” he said.

 

Kathleen Clem, MD: Former Chair of Emergency Medicine, Loma Linda University School of Medicine

Early experience and proficiency:

Dr. Clem has been practicing emergency medicine since 1993.  When asked when did she feel proficient in her specialty, she feels that initially you can never feel fully comfortable because you do not know what will come through the doors of the emergency department, but after a few years you can quickly determine whether the patient is truly sick or not and have a solid plan to provide care within minutes.  “ As a new graduate from a residency, I learned the most and the learning curve was the steepest because I was seeing patients on my own and you didn’t have supervision.”  After her residency she felt capable with the technical skills and doing all the procedures but it was more of the judgment.  “In emergency medicine the patient comes to you undifferentiated and to sort through all the facts and bits and pieces takes time and skill.  I think that was the hardest thing for me was to find the nuances and not miss the critical parts and not to over react to thing that are thrown at you.”

Reflections on lessons learned:

One of the aspects of medicine that she learned over the years was how important it is to give emotional support to the patient. “ I knew it was important to be caring, I am a Loma Linda graduate and knew about whole person care.  But I didn’t realize how important it is provide emotional support.  I thought you needed to be a stellar diagnostician and find out what was wrong and fix it.  But so many times in medicine you can’t fix it, but you can always convey that you care about what is going on in their life. This work is so valuable.  In emergency medicine you can’t fake it.  I am always working on a greater capacity to care.  I just didn’t know how important that was when I first finished residency.”

Mentors and role models:

Dr. Clem has had multiple mentors in medicine.  “All of my attending mentored in their own way, it was a combination of many.  I had life mentors along the way.”

Satisfaction with her specialty:

When students ask if she misses continuity of care, she said she doesn’t.  She feels she has a gift and opportunity to help patients in a time of life crises, even if momentarily.  She has developed the skill set to provide the healing touch and think through the possibilities for them.  “This is my substitute for the lack of continuity and I have a great deal of career satisfaction.  Suddenly you are intertwined in their lives and family.  I consider this a privilege the more and more I do it.  I was unaware of this when I started.  When there is a death the Emergency Department.  I identify with the patient’s family especially if their ages are the ages of my family members.”

She loves what she does and has learned to take care of the unwanted of sociality the unwashed, drug addicts, prisoners, and the unloved.  “ We have the ability to provide care for all kinds of patients and are proud to do it.  In the Emergency Department (ED), we don’t always learn about our mistakes because of the lack of follow-up so if I don’t learn about my errors it would be hard to improve my practice.”

Changes in her specialty:

“Emergency medicine has changed significantly over the years; especially, in the amount of work-up that is expected to take place before the patient is admitted.  The amount of diagnostic skill set is much more than it used to be.  When we call an admitting service they would like us to have a diagnosis and a differential with the appropriate labs and radiographic studies. Sometimes I feel we should have a ‘pretty bow’ tied on the patient’s head before we call them.   When I started emergency medicine, you were expected to give life saving measures and get the labs and x-rays started, but now, they want the diagnosis nailed down and a clear idea as to what is to happen next.”   She feels that if this doesn’t happen the admitting team feel as if you haven’ t done your job.  “We are pressured to order more by the patients who have limited or no insurance and can’t pay for service outside the ED.  This ties up our emergency room when the patient can’t afford primary outpatient care.”

Starting out, she did not know that she had to learn to collaborate with other physicians as much as she does. She found this to be such an important part of her job that she enjoys and finds very satisfying.  She learns from other colleagues in medicine.  She tries to understand their perspective for the common good of the patient.  “ Fifty percent of all the patients admitted to the hospital come through the ED and you have to learn to communicate with other physicians. Twenty-five percent of the time, I get a consult for the patients.  It is so rewarding to put our heads together to manage the patient.”

Suggestions for residents:

Dr. Clem decides each day what is important in her life and she, especially, feels that her personal life matters.  “And if your personal life is not in order you cannot be a complete physician.  If you have someone that you are suppose to love and care for, you are not excused from it because you are in training or a busy attending.  I decided this before I started medical school.  If you have a person to love, it is your duty to love them more than medicine, patients, and excitement for yourself.  It is the only way your marriage is going to survive.”   She has been married 40 years and has two daughters. As a parent and a busy ED doctor she feels it takes a “village”.  She had live-in help during medical school and residency.  Dr. Clem picked the things to do that mattered to her family.  Her family didn’t care who did the laundry and cleaned the house but they did care that she made the cupcakes for their birthdays to take to school.  “If it matters to your family, then do it.  My family kept me sane.  My daughters are better people because both parents made contributions to society.”

In closing:

Dr. Clem would like all young doctors to be good role models of Emergency Medicine. “ It is so important to enjoy your job if you don’t then you need to fix it or add enough good things so it counters what you can’t change. In addition, I would like the resident to lean on the side of the patient, keep them safe.  This sometimes puts us at odds with the administration, sometimes our peers but if we fail to take care of our patients no one else will either and we will have violated our sacred oath and our ability to provide whole patient care.” 

John Mace,  MD: Professor and Chairman of Pediatrics from 1975 to 2003, Pediatric Endocrinologist.

Early experience and history of his growth:

Jokingly, Dr. Mace tells people that he went from janitor to chairman of pediatrics in 3 years. This occurred after the sudden death of Dr. Chinnock, the first chairman of pediatrics. In 1975 there were 7-9 physicians in the department of pediatrics. During the 28 years as chairman, Dr. Mace also practiced his specialty of endocrinology.  His favorite area in his discipline was in growth problems- short stature, and growth hormone deficiencies.  He has been practicing for 46 years.  When asked how long it took him to feel proficient in his specialty after residency, he said, it took about five years and he thought he had seen the majority of problems that he would encounter in pediatric endocrinology.  “Nothing teaches us like experience. You can read about it for ever, but when you do it, that is when you really learn.”

Suggestions to residents:

“If I was giving advice to students and residents, I would suggest that young physicians learn to focus on the child and not just the parent.  Learn early to connect with children. I would start out with a question. What kind of work do you want to do when you grow up?  It established a bond with the child.   The parents appreciated that I was also interested in their grades and by asking, often times, their child was motivated to improve them.  Almost uniformly the next time, I see the child their grades have gone up.

We can do more than just treat their short stature. I feel it is just as important to address the social and emotional needs of my patients as to solve their medical problems.  My degree of satisfaction with my work occurs when I know they are doing better in all areas of their lives.  Young physicians are pretty ‘disease oriented’ and need to include the social aspects of the child’s life.”

Mentors and role models:

When asked about mentors he brought up Dr. Lyn Behrens, who he recruited to the pediatric department.  She functioned as Vice-Chair and every week they would meet to go over everything; from finances, to what ever came up as a problem. She would keep minutes.   “She helped me realize the importance of documentation.   She was good with the staff and would address their problems.   When I left as chairman, we had over 90 faculty members and I had recruited all of them.” One of the best mentors he ever had was Dr. David Hinshaw.  Whenever, Dr. Mace had a serious problem and needed help sorting it out, he would go to him.  “Some of the best advice he gave me was this.  The enemy of excellence is not poor or bad behavior but mediocrity.  The average person is hard to get out of your system.  I never recruited anybody with out thinking about that.  It made you look at them a little harder.”

Reflections on his specialty:

He was absolutely happy with his choice and would have done it again.  “ I truly get up in the morning and enjoy going to work.  You should feel called to do your work.”   He doesn’t like handling bone problems, he feels he doesn’t know it as well as he should and all the enzymes involved, because they are always changing.  “Most of Endocrinology is so easy because you can measure every hormone accurately. There is less of a problem with the real diagnosis.  Unlike the olden days when you had to get 24- hour urine samples and you weren’t sure the urine was collected accurately.  There used to be a lot more clinical decision making, now it is, what should I treat them with.”

Difficulties in his specialty:

The child with diabetes can be difficult because of social problems and lack of support.  Dr. Mace found that some of his young diabetic controlled their diabetes better when they accepted Jesus as their Savior and became more responsible. With the introduction of computers there is more of a problem with proficiency and he has more difficulty looking at the patient. “ His colleagues in general pediatrics are dealing with more complex social problems than ever before because of the complexity of our society and the addition of computers slows them down.”

In closing:

The best advice that he could give a young pediatrician entering a residency is this: In order to give good patient care, you must care for your patient in a multitude of ways; hold their hand, cry with them, and look them in the eyes.  Don’t be ashamed to shed a tear.  “ I was taught and I think it was wrong to have no emotional connection to my patient because you would lose objectivity.  I had to get past that. Our ability to heal is helped by the relationship with our patient and their trust in us.  Patients are motivated to get well quicker when they know you are supporting them.”

When he is on rounds, Dr. Mace does his best to demonstrate this by sitting down with every patient.  “ It doesn’t take that much time to pause at the bedside, always try to make the patient feel you have time for them.  Those are little things that have a whole lot of meaning.”

John Jacobson,  MD, Professor of OB/GYN at Loma Linda University School of Medicine, Section Chief  of Reproductive, Endocrine, and Infertility(REI)

Early training and history:

Dr. Jacobson graduated from Loma Linda Medical School in 1970.   After a year of internship, he went to the “mission field” of Okinawa, Japan. He was privileged to have time to learn the language, and his Japanese experience was a rich one, allowing cultural immersion in an endlessly fascinating country. He grandfathered into family medicine after 4 years of practice in Japan, as Family Medicine had just become a specialty in 1969.  He returned to the U.S. after 5 years in Japan, settling in rural West Virginia with two fellow Loma Linda graduates, where he practiced for an additional 6 years.  In Japan he learned how to do surgeries such as appendectomies, gallbladders, hernia repairs, tonsillectomies, and Cesarean sections.  During his time in West Virginia, he realized he especially like doing OB. His three-man group did about 20 deliveries per month.  In 1982, he decided to come back to Loma Linda to take a residency in OB/GYN.  After completing a residency in 1985, he started working at the San Bernardino County Hospital for six years.  He also served as an itinerant endoscopist, providing minimally invasive care for woman at Riverside County Hospital.  He also provided pelvic support surgery for both Riverside General Hospital and San Bernardino County Hospital.

Dr. Jacobson learned pelvic support surgery from Drs. McGill and Jerry Benzel.  They very much had a mission field mentality with a “can do attitude”. “I became their pelvic support surgeon for the next three to four years.”

Mentors and role models:

In 1994, all four Loma Linda-based  reproductive endocrinologists left over a period of six months.  Dr. Bill Patton, a medical school friend and trained Reproductive Endocrinologist, was asked to come back to Loma Linda to head the section.  He asked Dr. Jacobson to join him.  Dr. Jacobson had learned to do vaginal ultrasounds in his work at the county hospitals and had provided infertility care for many patients while working in Japan, Dr. Patton expanded his knowledge in the medical part of REI.  At this time he was also doing research with Dr. David Baylink in selective estrogen receptor modulators (SERMS) and osteoporosis.  Dr. Jacobson did the ultrasound monitoring of vaginal endometrial response in Dr. Baylink’s studies.  To keep track of his patients in this area, he decided to develop a computer program for REI.  There was nothing available in this area with the support of his department head, Dr. Alan King,  Dr. Jacobson began to develop and code a comprehensive clinical REI electronic medical record.  Dr. King gave him time to develop the program.  His most effective coding took place at a friend’s place on the beach in the isolation of the North Shore of Oahu.  Over the course of a year, he spent six weeks in Hawaii, and had a working system in place in the Loma Linda Center for Fertility by 2002 .

Suggestions to residents:

When asked about the advice that he would give a young resident in OB/GYN, Dr. Jacobson explained that he had eleven years of practice in family medicine so he was on a different plain then most of his fellow colleagues which gave him an advantage.  “There is something about the totality of medicine that gets lost when we focus on our subspecialty early in our career.  Loma Linda talks about taking care of the “whole person” but it is more than that.  It is being aware of the different systems and how they interact for example how something in metabolism affects something in infertility.  “I had a leg up with the years in primary care.  I never thought that was time wasted.  Medical knowledge is ‘pretty generic’, you can go to the internet and get the information.  What you learn as a practitioner is how to relate to people and be a better listener.  I am a much better interviewer.  How to draw people out and make them comfortable.  We talk about sensitive issues.”

Other mentors:

Another of Dr. Jacobson’s mentors was Dr. Alan King.  “He was very kind.  He was always hurting himself and would come into the surgical suite and instruct me with his arm in a cast and tell me how to do these radical cancer surgeries.”

Dr. Patton taught him how to approach an infertility patient.  “Our worldview, our skill set and our attitude toward patients are so similar. Our practice patterns and philosophies meshed well, though we didn’t practice together until we’d been out of school 25 years.”

Difficult areas in his specialty:

When asked about areas that are difficult and that he may want to avoid, the diagnosis of chronic pelvic pain quickly came up. “It is non-specific and emotional.  The pain clinic has been a real help once you rule-out any organic disease.”

“My infertility patients are a nice group to deal with even though there are deep emotional issues concerning their inability to have children.   We have learned how to optimize therapy for patients with infertility problems; for example, we only do three ovarian stimulation cycles with intrauterine inseminations before proceeding to In Vitro Fertilization (IVF).  As we perform the initial procedures, we learn about the couple’s potential going forward.  We make specific recommendations to our patients; when to continue fertility treatment and when to stop.  In some situations we encourage them to think about adoption or about using a surrogate.  Maybe an egg donor is the best option.  I give them straightforward information.  This is a process that has an end-point.  We won’t continue it forever.”

Changes in his specialty:

How has his specialty changed and how has he adapted? “We have so much data that we do not know what to do with it.  Comprehensive chromosome screening is one area of much change.  It is an exciting time to be in infertility.  Our goal is to help couples create families.”

In closing:

His best advice is to be a good observer.  Most of us don’t learn when we are talking.  We get better as we get older.  Learn to be a good observer and a better listener

Every fall and winter thousands of fourth year medical students travel hundred of miles for an interview as they seek their idea residency.  A survey done by the National Residency Match Program found that the interview is the most important tool used in ranking candidates, more important than clerkship grades or USMLE Scores. Seniors in the United States have a median of eleven interviews in the student-ranking program.  If you do an internet search, you will find thousands of results that are devoted to the interviewing process and numerous questions.  It can seem overwhelming.

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ABOUT THE AUTHOR

Dr. Barbara Orr ’70 is a loyal supporter of Loma Linda University School of Medicine and truly believes in the mission of this institution. Since October 1972, she has worked at Loma Linda University, initially as assistant director of the emergency department and then as a founding member of the family medicine department. She was the medical director of the faculty clinic for 10 years and then the predoctoral director of family medicine for nearly 12 years.

ACKNOWLEDGEMENTS

Roger Hadley, M.D. ’74
Montri Wongworawat, M.D. ’96