By Tracy Wallowicz
Director, ECFMG Exchange Visitor Sponsorship Program and Compliance
Welcome to Journeys in Medicine. ECFMG is thrilled to launch this new blog developed to profile the physicians, institutions, and experiences behind our Exchange Visitor Sponsorship Program (EVSP). With each post, Journeys in Medicine will highlight the accomplishments and contributions of a current or former exchange visitor participant and/or feature a host teaching hospital that is taking a unique approach to resident education resulting in an enhanced experience for exchange visitor (EV) physicians.
You may wonder why we are launching the blog and why we are doing so now. The answer to both questions is quite simple. We feel strongly that the contributions of current and former EV physicians to health care around the globe cannot be underestimated and should be shared. While in the United States, these doctors hone their skills and share their medical expertise while engaging in valuable cross cultural experiences and enriching their communities. Upon completion of U.S. training, many make significant impacts on health care in their home countries. We look forward to sharing their stories with you.
Below you find our inaugural blog entry. It marks the first time that I am sharing the very personal story of my unexpected and profound interactions with two exchange visitor (EV) physicians.
THREE PERSPECTIVES, ONE PERSONAL STORY
As we kick-off our blog, I want to introduce you to two EV physicians that I got to know last year through a personal, not professional, experience. Although I have been with ECFMG for more than two decades and visited dozens of academic medical centers over the past twenty years, it wasn’t until my son fell ill with a rare and complicated disease that I had a front-row seat to the incredible work that takes place in teaching hospitals. His amazing health care team included two very special neurology residents who happen to be EV physicians. Getting to know these talented residents marked an unexpected and humbling intersection of my professional and personal lives.
My son, Jon, was a strong and energetic 19-year-old college freshman when he fell ill in April 2017. His symptoms started with fatigue and some numbness and tingling in his extremities, but it was finals week and we attributed those early symptoms to the chaos of closing out his first year of college. Because he was hundreds of miles from home, I was not with him when, on a Sunday afternoon, he and a friend Ubered to a hospital about a mile from campus after he experienced a worsening of his symptoms. Dr. Suraj Rajan was the neurology resident on call charged with evaluating Jon in the emergency room. Dr. Rajan called me shortly after Jon’s initial evaluation to let me know that he “checked six of the seven diagnostic boxes” they typically look for when diagnosing a patient with Guillain-Barre Syndrome (GBS) – a disease that I had never heard of and that my family now (not so) affectionately refers to as “geebs.”
What followed that first conversation with Dr. Rajan was nothing short of terrifying. Roughly 48 hours after his emergency room admission, Jon was admitted to the hospital’s Neurocritical Care Unit. The disease continued to rapidly progress despite the medical team’s best efforts and early intervention. By his fifth day in the hospital, Jon was completely paralyzed from the neck down, including paralysis of his breathing muscles. Unable to breathe or eat on his own, Jon was first intubated and, about two weeks later, had a tracheostomy and feeding tube inserted. Each day, his health care team visited multiple times to evaluate his progress, or lack thereof. Outside of the unbelievable nursing staff, it was Dr. Rajan and another resident, Dr. Alexander Mirzoev, who most frequently talked with us and monitored Jon’s condition. In those early weeks, it was also Dr. Rajan and Dr. Mirzoev who seemed to have the unenviable task of delivering what seemed to be an endless string of bad news. Jon was not the typical GBS patient. He had a rare form of the disease with an unusually poor prognosis. However, our family was constantly fortified by the care, kindness and skill with which these two physicians, and many others, approached Jon’s treatment.
After close to four weeks in the hospital, Jon was life-flighted to a hospital closer to our home. Sometime in those early weeks, I came to learn that Dr. Rajan and Dr. Mirzoev are EV physicians. Literally waking up every day in a teaching hospital provided me with insight into the daily activities and contributions of EV physicians that I could not have gained otherwise. The professionalism and interpersonal skills specifically demonstrated by Drs. Rajan and Mirzoev illuminated and made real for me the exchange visitor experience. As a result, Jon’s battle with GBS was not only an intensely emotional personal experience, but professionally transforming as well.
Today, I better understand the incredible talents, sacrifice, and dedication of the EV physicians we serve. I had already known the level of academic and professional achievement and personal initiative that it takes for foreign nationals to secure U.S. residency positions. What I had not fully grasped was the impact that these physicians have on the families they serve during training, and the personal challenges and sacrifices that may stem from that dedication. I am surer than ever before of the importance of the Exchange Visitor Sponsorship Program, the value of these trainees to our health care system, and the impacts they have, both in the United States and around the globe.
Below, Dr. Rajan and Dr. Mirzoev provide their insights into Jon’s battle and a window into their exchange visitor experiences. Before encouraging you to read our shared story in their words, I will let you know how the story ends. After several months of progression and regression, frightening days and long nights, and stays in three different inpatient facilities, Jon slowly began to show consistent signs of progress. (I clearly remember the first time he was able to lift his hand and wave his fingers at me in greeting. It was literally the best thing I’ve ever seen.) Eventually, Jon re-learned how to do the things that most of us take for granted every day such as hold a fork, sit up, write his name and stand. In preparing our family for potential outcomes, caregivers at each facility had cautioned that full recovery might not be possible and that, as a family, we should be prepared for permanent deficits. However, Jon was very determined; he made it an early (and somewhat unlikely) goal to swing a golf club before the end of that summer and return to school that fall. Miraculously, he was able to do both! He was tired emotionally and physically, walked with a cane, and had continued numbness in his feet, but he did it. Today, he is fully recovered. Jon’s recovery is a testament not only to his will but to the diligent care of so many – including Drs. Rajan and Mirzoev. Jon’s battle with GBS transformed my family and me – but in none of the ways we initially anticipated.
As you might now guess, telling the stories of exchange visitor physicians and the programs that host them is something close to my heart. To our future Journeys in Medicine contributors: I look forward to reading your important stories. To our readers: I hope that you find this window into the exchange visitor sponsorship program compelling and transformative, as my own experience has done for me.
IN HIS WORDS: DR. RAJAN
By Dr. Suraj Rajan
Jon’s case was special in many ways. He came into our ER on that fateful evening when I was on consult calls for neurology. Dr. Chris Schiener had recently given us a noon-lecture on Guillain-Barre-Strohl syndrome. The gastrointestinal and upper respiratory infections that provoke the inflammatory reaction prior to GBS are more common in spring and summer. We had also had many discussions on the variants of GBS that may present with subtle differences from the typical GBS. So when Jon, a tall and fit young man, came into the ER complaining of his seemingly “minor” symptoms, it invoked the memory of several previous cases we had had. I am glad that we were able to make the diagnosis within 30 minutes of seeing him, and cerebrospinal fluid was obtained that night itself and he was started appropriately on intravenous immunoglobulins. It is a rare and fatal disease and not many people know about it. There are not many blood tests or imaging findings specific to the entity. A high index of suspicion from the providers, combined with a thorough clinical exam hunting for the subtle but well-established neurological signs is the key to diagnosis. The role of meticulous follow up and documentation of exam findings goes beyond just diagnosis. Scores ascribed to exam findings can determine how the patient will do in the immediate future and in the long run. These features make GBS a favorite of neurologists.
The General Neurology teaching service at Miami Valley Hospital, under Dr. Christopher Scheiner and later under Dr. Cassandra Milling directed Jon’s care. Jon’s case was one of the worst GBS that we had seen in ages. Despite doing everything by the book, Jon went on to complete paralysis with minimal movements of his face and eyes spared. He had to be intubated and hooked to a ventilator for weeks, as the nerves that moved his breathing muscles had quit working.
Our multi-award winning neurocritical care unit (NCCU) team under the supervision of nurse Beth Larsen left no stone unturned to ensure his comfort during these hellish days. After weeks of his initial therapy, when it was time for him to be transferred to inpatient rehabilitation, the NCCU social workers worked hard to make the transition as smooth as possible.
In the course of this fight, the medical team became close to Jon’s loving family. One of the things I learned from the U.S. style of medicine is that the old-school style of paternalistic medicine has no role here. We are taught to be educators and patient advocates. It’s not just the patient fighting against the disease. It’s all of us – the caregivers, the family, and the patient as a “team” that fights.
As a resident in training, I also learned from Jon how to be a trooper and fight. Months after I graduated and moved on to Johns Hopkins University for Postdoc training, I received texts from my old colleagues telling me how Jon walked into the clinic! Jon’s family tried to educate themselves on GBS, and understood the clinical rationale behind our every step. They were aware of how nerve-pain can be a part of the disease, but were very understanding when it came to avoiding addictive medicines. They supported Jon through his arduous physical therapy rehabilitation. Without them Jon wouldn’t walk.
Like many international physicians, training in the U.S. has been a dream for me. Being the most technologically advanced medical system and a very innovative society makes this training the best in the world, hands down. I feel that it has not only made good doctors of me and my fellow trainees, but also prepared us to take on leadership roles in the medicine of tomorrow. My door to all this was opened by the ECFMG and its Exchange Visitor Sponsorship Program, for which I cannot thank them enough.
IN HIS WORDS: DR. MIRZOEV
By Dr. Alexander Mirzoev
Our journey with Jon was extraordinary; from horror, to relief, and exemplified the tenacity and teamwork among healthcare staff and family.
My colleague Dr. Rajan admitted the patient, for a reason that most would have ignored, especially in an athletic 19 year-old. Jon noted the slightest decrease in exercise stamina, yet after careful inspection, other signs and symptoms pointed to very early acute inflammatory demyelinating polyneuropathy (AIDP, or Guillan-Barre syndrome). This occurs when the immune system mistakes the insulation layer of nerves for infection. Unsurprisingly, this often occurs following viral or bacterial infection. The irony is that the stronger the immune system, the milder the actual infection, but the worse the post-infectious reaction. Within hours, Dr. Rajan obtained testing and started treatment. However, the symptoms still worsened to the point of paralysis, as commonly occurs. Jon was transferred to the critical care neurology unit, intubated, eventually receiving a tracheostomy and feeding tube. It was determined that Jon had one of the rare subtypes, with the worst outcome.
Before leaving every evening, I checked on Jon. All of his limbs were decorated with a variety of splints and orthotics, and I made sure to remove them for the duration of my examination. Albeit brief, I wanted Jon to have a break. Also, the 2017 Stanley Cup playoffs were always on TV, and we bonded over hockey (being both Canadian and Russian, it was only natural). I connected with his parents and grandparents about shared cultural interests, as they found out about my deep passion for classical music and previous piano career. During his 4 week hospitalization, both staff and family underwent an extraordinary experience. I will forever cherish this unique and humbling encounter. We fostered the hope and perseverance necessary to overcome such a terrifying disease. As a testament, after 4 months, he was virtually back to himself and off all medications.