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Interview With Dr. Saul Hymes - Pediatric Infectious Diseases Specialist

Thursday, September 5, 2013

I recently connected with Dr. Saul Hymes on Twitter and immediately got the idea to do an interview (it's the journalist in me). Two of my greatest interests in medicine are Pediatrics and Infectious Diseases and I was lucky enough to find someone who works in both fields simultaneously! Dr. Hymes graciously agreed to answer any questions I might have and responded to my long list with some fascinating, touching, and informative stories about his experiences as an ID doc. If you're interested in becoming a doctor or in going into Peds ID in particular then definitely take the time to read through the transcript because there's nothing like getting advice from someone who has been through it already. As always, any questions or comments are welcome!

1.    Please tell us a little bit about yourself – where do you work, what field of medicine are you involved in and what are some of your non-medical interests?

I am an Assistant Professor of Clinical Pediatrics at Stony Brook Children's Hospital/Stony Brook University School of Medicine in the Department of Pediatrics and more specifically in the Division of Pediatric Infectious Diseases. As a Pediatric ID specialist, I perform consults on children with infections--and that is absolutely as broad as it sounds: everything from cellulitis from MRSA to Lyme Disease to HIV to infectious complications of a bone marrow transplant and everything in between. In addition to inpatient and outpatient clinical work, I conduct clinical research on antibiotic use and bacterial infections, and I teach med students, residents, and fellows. I love my job, but when I'm not working I like to read--especially sci-fi/fantasy, I sing off and on in a choir, I blog at http://infectious-ideas.org, I tweet (@IDDocHymes), and I try to keep up with my wife and my two children, ages 5 years and 17 months. It's a busy life!

2.    How did you decide you wanted to be a physician?

I sort of always knew I wanted to be a doctor and I have no idea really why, as nobody in my immediate family is a physician. I have always been interested in science and biology in particular, and was weighing as early as 9th grade the pros and cons of a research (PhD) career vs. going the route of an MD. But more than that, I think it came down to my own models: I had a great couple of pediatricians myself who left a serious impact on me--George Lazarus and Barney Softness, both based in NY City where I grew up. Dr Softness even nurtured my interest and let me shadow him when I was in high school & college and helped answer my questions about why he had chosen pediatrics. It's always important to have good role models in a career and these two pediatricians were incredible ones! Once I got to college at the Univeristy of Chicago, I knew for sure and from there it was just a question of navigating the med school application process…oy, what a pain!

3.    Can you discuss your medical school experience briefly? What did you find most challenging/rewarding while going through the process of learning to become a doctor?

I had an interesting medical school experience. I attended Columbia University's College of Physicians and Surgeons in NY and while I got an amazing education and was incredibly well-prepared for residency, I also felt like a bit of an outsider. Many of the students were single and I was in a serious relationship with the woman who later became my wife, and was living with her rather than alone in the dorms. So it took me some time to navigate the balance of school and home socializing and find my niche of friends. That's an important thing to think about in choosing a med school--if you're older and married or even have kids, you may not want to be at a school filled with young singles…or you may--just keep this in mind.

Otherwise, medical school, for me was probably the same as for everyone--it was hard! The first two years were a ton of memorizing, some brutal, brutal exams, and a lot of stressing over grades once they were introduced in second year. Third year was hard because of the huge amount of knowledge you thought you'd already learned, but now need to relearn in a whole new way in order to actually apply it to patients--it's like taking a boggle cube, shaking it up after you've already found all the words, and then having to find the same ones all over again. But once things started to click, it was amazing. I was finally taking care of patients, which is why we all want to do this in the first place! This of course brought its own challenges--knowing something or not wasn't just a question of an exam question--it was answering a patient’s question about their med, or telling the resident the newest lab. Getting it wrong had major consequences and while you always double and triple checked, the importance of what you are doing really starts to be felt. And then 4th year was wonderful, as I could finally do things only related to pediatrics, and I chose some wonderfully fun and educational electives, including Pediatric ID.

4.    When did you realize you were interested in pediatric infectious disease? What drew you to that field?

I always knew I wanted to do pediatrics--that's what I went to med school to become--a pediatrician. I've loved babies and kids for as long as I can remember and once I got to med school, other than a brief dalliance with OB and psych, I continued to think pediatrics all the way. On OB, I realized I liked taking care of the babies more than the moms and almost contaminated myself and the patient by trying to turn my non-sterile back on a c-section to look at the baby once or twice…and on psych, I liked the patient's childlike minds, but I missed the actual children, as well as the actual organic medical problems.

I was first interested in "peds ID" as we call it during my second year micro class. I loved the infections--the bacteria in particle were fascinating, the antibiotics and how they worked and how resistance worked--this was all super-interesting to me. So knowing I was doing pediatrics, when the time came in 3rd year, I chose a 4th-year elective in pediatric infectious diseases. It was everything I'd hoped it would be. The patients were sick, yet treatable; we had the time to think and make differentials and puzzle through pathophysiology of an infection, rather than rush to make snap decisions as one does in the ER or the ICU; we saw patients everywhere in the whole hospital so we had to know a little (or a lot) about everything in the world of pediatrics--I loved specialties with this kind of general knowledge base that didn't focus on only one organ or part of the body.

However, when I got to residency at Mount Sinai, I was drawn to heme-onc--they too were sick, complicated, interesting, but very often treatable. And I liked the longitudinally of their care--the hematologist-oncologists were these patient’s doctors for years. They got to have their cake and eat it too, being specialists while still having years of longitudinality in their patient-physician relationships, just as I'd admired in my own pediatricians. Ultimately, though, when I did an elective early in second year of residency, I realized I liked the sick inpatients with their infections far more than the healthier outpatients just moving along the chemo protocol. What I liked heme-onc for was, in fact, the infectious diseases. And so I decided to do a fellowship in that instead, ultimately back uptown at Columbia, and the rest is (recent) history.

5.    What kind of cases would a doctor working as a Pediatric ID specialist come across? Is there any one patient in particular that impacted your development as a physician?

We sort of work on everything and everybody, as long as what they have is an infection. So as an example, a recent list of inpatient consults might be: a patient with Staph aureus bacteremia and a septic hip whose team needed antibiotic advice; a neurologically devastated ICU patient with persistent staph bacteremia and probably endocarditis; a 3 month old with persistent fevers that nobody could figure out the source of; an ER patient with Lyme disease; a 19-year old with a chronic toe osteomyelitis from Stenotrophomonas, an intrinsically highly-resistant bacteria; a baby born to a mother with HIV; a new onset lymphoma patient who the team worried also had a superinfection of one of her cancerous lymph nodes.

And a recent list of outpatient clinic patients might be: a teen with Lyme disease, a 6-year old with recurrent fevers; a 2-year old with MRSA colonization and recurrent boils; post-hospital follow-up of a10 year old with osteomyelitis; a travel visit for vaccinations for 3 siblings in one family ages 1, 3, and 7 all there prior to travel to Bangladesh; a mother whose husband was anti-vaccine but she wasn't sure and wanted data and advice on vaccines for her baby.

The one patient who impacted me most as a physician was a teenage girl I took care of with HIV/AIDS. She acquired HIV perinatally but in the days before routine newborn screening, so she was not diagnosed until age 8 and, for a variety of reasons including psychosocial ones, had a lot of trouble once she hit the teenage years with taking meds and following physician instructions. At age 17 she began to lose weight and have chronic abdominal pain and fullness; a CT scan showed she had huge abdominal lymph nodes and biopsies and blood cultures confirmed the diagnosis of disseminated mycobacterium avium (MAC). Already noncompliant with one part of her regimen, she did not take the anti-mycobacterial drugs we prescribed either and ended up dying after nearly a year of intermittent hospitalizations and attempts to get her on board with treatment. Her death was not a good one--we had known she was incurable for some time and had tried to do hospice care, but her mother would not agree. In the end she died in some degree of pain in the hospital, rather than at home, comfortable, with loved ones around--the "good" death we had all been trying to help her have. I learned more from this one patient--about HIV, about treating recalcitrant infections, about connecting successfully with difficult patients and families, about my own abilities to cope (see below) than I did from any other before or since.

6.    How do you deal with the emotional fallout from handling a difficult case or the disappointment of a negative outcome?

That is a fantastic question, and one without an easy answer, because everybody handles it differently. To some extent, we all go through the classic 7 stages of grief described by Elizabeth Kubler-Ross (worth reading about if you're going into medicine!), some of us more quickly than others. That means at various times I'll blame myself, or be angry at the parent or patient for making a particular decision, or yes, even deny that the outcome was bad--sometimes we tell ourselves that the patient was going to die no matter what so what we did or didn't do doesn't matter.  But ultimately, if there is a bad outcome or a difficult case that doesn't go the way we want--even if it's just that you fail to connect with a patient and they switch doctors but no bad outcome occurs--it's always hard and also always a learning experience.

For me, the important thing is to keep perspective and try to separate my life from work as much as I can. So I go home, I hug my wife and kids, I call my folks--I use the natural support structure of family and friends to help me stay grounded and realize that while, yes, this was a horrible thing for the patient or their parents or even us, their doctors, it does not need to rule my life. Of course if or when a patient dies it is a horrible experience. The department often holds a debriefing session for students and residents and fellows and even attendings involved in the case. And people cry and talk about it. And people get angry and upset. We are only human. Ultimately, having a good support network and a way to decompress--see a movie, play basketball, go for a run, drink some wine--allow you to move past it, go back to work, and learn from any mistakes you may have made. Those are mistakes that you or anyone else involved in the outcome will never make again!

7.    What do you enjoy most about teaching?

There are two things I really enjoy about teaching med students, residents and fellows. The first is the ability to give back to the system that produced me--I became a doctor thanks to brilliant teachers and mentors and so the least I can do is try to be 1/10 as good as they were. It gives me joy to see a student finally understand how MRSA is resistant to methicillin, or a resident truly 'get' why it is so important to be aggressive with antibiotics early in sepsis, or a fellow analyze a piece of basic science literature and apply it to their own research. In all of these moments we who teach see echoes of ourselves at the same stage and it is awesome to see somebody else trying and enjoying following the career that we've chosen and that we love.

The second is that I always learn when I teach. Learners at all levels--from premeds shadowing to fellows about to graduate--will always ask questions you never thought of, or reframe a problem in a way you didn't see it. Or they'll simply ask you something you don't know the answer to. And it's important to maintain humility and openness about that as a teacher--if I need to look something up myself, I'll say so. Sometimes I'll make the student or resident look it up and report back so they can learn from the exercise (I already know how to do a literature search but they may not), but sometimes I'll open the text book or go to UpToDate or another online resource and we'll both learn the answer right there. And learning is one of the most fun things there is!

8.    Is there anything important you’d want to tell a student who was interested in pursuing a career in your field?

I would say first, regarding medicine in general, you should be sure it's what you really want to do. I know that's trite and clich├ęd, but it is a long road and there are many other careers in the health sciences that are equally clinically rewarding like nursing, or being a PA, that are shorter easier, and cheaper re: cost of education. If you want to teach, if you want to do research, overall if you want to become a leader in the field, I'd say get an MD/DO--become a physician. Regarding pediatrics, you have to love kids, and you also have to love and relate to parents--you need to be willing to deal with nervous, anxious wrecks who think their kid (who may not be that sick) s dying, or who are confrontational, or tired, etc. And that's not to judge--I've been a parent of a sick kid in an ER and that's how I am too! But there's an added mystery to pediatrics--your patients can't always tell you a history that's as good as what an adult might give. So you get to use your brain more, your physical diagnosis skills, and you get very good at generating interesting differential diagnoses. Finally for pediatric ID, I would say you need to be a bit of a nerd. We tend to be a kind of nerdy, intellectual specialty. Most of us do research because we like to, but also because it's expected--there isn't a lot of clinical money in ID and often grants are needed for salary support or at least research is needed to convince your boss you're worth spending money on :-) And of course you need to love and be fascinated by the bugs! Overall, a career in medicine can be very rewarding, but never forget what it is--it is a job, and ultimately only a job. Even the greatest job in the world can never be more than partially fulfilling, and the rest comes from everything else. Make time for family, for friends, for life. Yes you can work hard, but find time to play no matter what field you choose or you will burn out faster than an old light bulb. And, a doctor who never lives in the world around them will never be very good at relating to patients--being well-rounded is ultimately one of the best traits a physician can have, because at the end of the day, the patients don't care what your board scores were or what school is on your diploma--they care if they like you.


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