Infectious Disease, week #2

Day #6:

A person with a history of E. coli sepsis (blood infection) who now has findings on a brain scan suspicious for abscess, but could also represent tumor. Abscess is more likely, so we will treat with antibiotics for 4 weeks, scan their head again, and see if there has been any response.

A person with an infection of the skull bone behind the ear on the right side, recovered, had a stroke, had a portion of skull removed to accomodate swelling, had the skull replaced and now appears to have developed an infection of the skull bone behind the left ear. Cultured the drainage and tested the susceptibility of the bacteria. Antibiotics recommended, person is recovering.

Day #7:

A person who had their hip replaced, had an infection in that hip, had the replacement removed and a new one inserted, had another infection, had the second replacement removed, now has no hip on that side and is undergoing treatment to clear... infection. They fell and now their knee is swollen too - blood from the fall, blood clot, or spreading infection? Likely from the fall. Continue antibiotics, check inflammatory markers and use ultrasound to rule out clot.

A person on dialysis with endocarditis and known brain abscesses. We helped identify the organism, choose antibiotics and he is undergoing pre-surgical workup. Kinda grumpy.

Day #8:

A Chinese immigrant who is coughing up blood. They have a lung disorder that can cause episodic blood, but there is also concern for tuberculosis (which is endemic in China). More likely to be their underlying condition (based on physical exam) - testing confirms. We set them up with pulmonary follow-up.

Day #9:

A person who arrived in liver failure due to purposeful overdose who continued to have fevers despite antibiotics. Given chest x-ray, more likely drug fever or chemical pneumonitis, but will treat with a short course of antibiotics to rule out aspiration given their altered mental status and vomiting on admission.

Day #10:

A person who has cancer and no immune cells due to chemotherapy now has a fever and trouble breathing. Chest imaging is suspicious for fungus. Lots of antibiotics started until we can clarify the nature of the infection.

A person with multiple antibiotic allergies who has an infection of the inside of the nose. There is always a concern that if inadequately treated, an infection like this will spread backwards to the brain. Broad antibiotics were started until we can grow the bug in culture and narrow them.

Still following:

The endocarditis patient from last week who has vegetations on their pacer leads. They went to surgery and had their pacemaker removed. Labs are still negative, so a 4-6 weeks course of broad spectrum antibiotics before a new device can be placed. Still unclear what their lung findings are: septic emboli vs pneumonia.

The patient with ulcerative colitis who had a blood infection and a clot in their arm... the clot was not surgically removed and they cleared the bacteria from their blood. Was discharged to complete antibiotics at home.

Gosh darnit, they like you!

On Jan 21st I was part of a team of finalists representing Ross
business school in the Kellogg biotech and healthcare case competition. One week prior we had been given a dilemma
surrounding the issue of infant HIV diagnosis in a poor African nation. We had to come up with a pilot program for a new point-of-care testing method and justify our strategy. There were thirty-six entrants, of which 11 finalists were chosen. Each finalist team had 1/2 hour to present their solution.

We won. Felt awesome.

If you can believe it, I did power calculations and threshold sensitivity analysis. I used formulas in excel. I could feel the rust falling off the mental gears I used 10 years ago in my undergrad business degree. It felt really good to be doing something a little different than the past 3.5 years.

It was so much fun, in fact, that I am pursuing the idea of doing a three month project with one of the professors in the Ross business school as an interdisciplinary elective. I'll know more next week on how feasible that is.

Emergency Dept: week 4

Monday: chest compressions and a resident too busy to staff with me
Tuesday: no cath for you, more abdominal pain
Wednesday: just had his nose done and now it's broken, back pain, allergic reaction
Thursday: it's not your shunt but we'll scan you anyway, can't stop pooping
Friday: exam (that doesn't count)

Emergency Dept: week 2

Monday: Lupus, vomiting blood, strep throat, passing out.
Tuesday: Multiple orbital fractures, pelvic exam and a cheerleader with the flu.
Wednesday: Tech shift - peripheral IVs, appendicitis.
Thursday: Splints x3. Asthma. Oops, the baby ate mommy's pills.
Friday: Stitched up a chin, a forehead and an ear.
Saturday: Biliary colic, drunk, drunker and drunkest.
Sunday: off

Heartbreak cardiomyopathy

This month I had a patient with an interesting and rare condition called TakoTsubo Cardiomyopathy, also known as "broken heart syndrome." It involves myocardial stunning after a highly stressful event such as the death of a spouse or a natural disaster. Basically, you are so overwhelmed that you literally go into heart failure. The physiologic mechanism is incompletely understood, but leading theories revolve around catecholamine release. Thankfully, the significant majority of people recover their full heart function in days to weeks. It is most commonly seen in Japanese post-menopausal women, however it has been described in the US and Europe as well. It can be accompanied by an NSTEMI (heart attack) and frequently QT prolongation (repolarization abnormality - sorry, I don't know how to translate that better without a tutorial on EKGs).

It gets its name from Japanese octopus traps. Why? Because this particular heart failure displays what we call "apical ballooning." Basically, the upper and middle parts of the ventricle contract, but the apex (the point) of the heart does not. That means that blood, which is ordinarily squeezed from the bottom of the heart towards the top, is now being simultaneously pushed up and down. the down-going blood has nowhere to go so the tip of the heart balloons out (see diagram).

My patient began recovering heart function very quickly, but her QT prolongation was impressive. Almost write-it-up-in-a-journal impressive. Thankfully, that also resolved quickly. We never got a good sense of what her precipitating event was, but I suppose all stress is relative.

Welcome to M4!

One whole week into my fourth year you may be wondering, what have I done with myself? Well, I am starting the fourth year much the same way I started the third year: studying for a USMLE exam.

This week I have covered cardiology, dermatology, GI, endocrine, biostatistics and some infectious disease. I am reading, highlighting, making flashcards and doing lots of practice questions. Fun fun.

However, life is not all work. I had a lovely day and night out (we started a little early) after completing third year: there was sangria, there was gin, there were pancakes the next morning.

I've also been helping to orient the rising M3s, which is a nostalgia-inducing process. It really makes me realise how far I've come in the last year in terms of my comfort in talking to and evaluating patients. It also points out how different the focus in teaching is now - I spend much more time thinking about details: drug choice, dosing, treatment length, etc - whereas before it was about having a workable list of potential diagnoses. A lot of what I struggled with at the beginning of my third year is assumed knowledge in the fourth. My review books don't even bother to classify antibiotic types, for example, it's assumed I know azithromycin is a macrolide that acts on the 50S ribosomal subunit and has good efficacy against gram positives and atypicals. The new questions is: how much and how many days worth for a patient with strep pharyngitis in a COPD patient?

In an effort to stay balanced while studying, I've joined a tennis clinic. I had my first practice yesterday and got a little sun (oops) as well as losing half a toenail jamming my foot in my shoe on some abrupt directional change. Worth it. I'm horrendously inconsistent at the moment, but I hit a few aces and a couple of solid put-away shots. I'm considering joining a USTA team this summer, but I'm not sure I'll have time with the sub-i's etc.

Motorcycle lessons start next week and I'm now involved with admissions for the medical school too - so hopefully those will yield some good stories for a post. In the meantime... nose to the grindstone to (hopefully) pull out a good Step 2 score.

I called it!

Warning: this post involves some bragging. Let me state that I frequently get things wrong (thus, still in training), but that's not as fun to write about.

How clinic works: The attending sends me in to each room ahead of her to get a history and perform a physical exam. I then briefly present the patient to her as well as any recommendations I have. She then finishes the appointment with the patient (I'm in the room too).

I go in to see patient X who is supposedly here for a routine physical. I ask her how she's been feeling lately and she says "my optometrist said it was important I keep this appointment." On questioning I discover that she is having positional headaches and some intermittent nausea, but otherwise feels well. She denies any vision changes.

On physical exam, patient X had bilaterally blurred optic disc margins (papilledema), full visual fields to confrontation, but otherwise appeared well.

If you're in medical school, make your diagnosis now...

During my presentation I state that idiopathic intracranial hypertension is at the top of my differential, but that a mass lesion should be ruled out. I state that papilledema merits an MRI but that ultimately a lumbar puncture should be performed. My attending smiles at me, pats my hand and says, "please don't be offended if I disagree with you, that's a pretty rare thing to find."

We go in together to see patient X. My attending examines her and begins counseling her. Guess what turns out to be at the top of her differential? Guess what test she wants first? Yup. I may have given myself a mental pat on the back.

When I grow up...

A big focus in life at the moment is answering the question: What kind of doctor do I want to be? Unfortunately for me, I am currently undecided. Here's where I am:

Internal Medicine (likely fellowship in cardiology or critical care)

Pro: Some patient continuity, variety, acute care, flexible lifestyle

Con: Not heavily procedural unless I go into the cath lab

Total time: 3 years residency + 3 years fellowship

General Surgery (likely critical care fellowship)

Pro: Very procedural, the OR is fun, prestige, variety, some patient continuity

Con: Not sure I love GI problems, tough lifestyle, required lab year

Total time: 7 years residency, with fellowship as one of my research years

Pediatrics (likely fellowship in cardiology or critical care)

Pro: love the patient population, patient continuity, flexible lifestyle

Con: not procedural (again, unless cath lab), limited places to practice

Total time: 3 years residency + 3 years fellowship

I've ruled out anesthesiology for lack of patient continuity. Plus, if I'm going to be in the OR, it's going to be my OR. I would likely match in any of these, though surgery would be toughest. Current plan: subi in each, await my surgery grade and see where we stand.

ps note the M4 schedule has been posted on the sidebar, for those who are curious.

I feel dirty

I am on rotation at another hospital at the moment and one of our lecturers failed to show. Instead, I got to bond with some of my fellow students (for whom this hospital is home). One of them had a great horror story...

She was evaluating a patient in the ER who came in with priapism (a prolonged erection). Draining the organ was attempted, with no success. The student's attending then told her to "milk it." After some hesitation, she did as she was told. Another attending came by and asked her what on earth she was doing?! Turns out the first attending had been joking. The patient went on to surgery.

Stating the obvious

According to my textbook, "the basic principles of hepatic resection are complete removal of the lesion without patient death."

Don't want to set the bar too high there...

MIS: the last surgery

Ok, so it was technically the second to last surgery, but the true last one wasn't nearly as unique.

The picture is not my patient, but the operation was the same: repair of a rather large primary umbilical hernia. He literally had a basketball-sized hernia filled with bowel and omentum hanging off of a 8cm x 8cm fascial defect. We managed to reduce the hernia completely, placed some synthetic mesh to bridge the defect, covered it with some muscle flaps, then closed fascia, deep dermis and skin. For those of you up on your hernia repairs, he did not require separation of parts to achieve repair nor did he necessitate a full laparotomy. We only extended our incision 2 inches above the hernia sack (the defect in the picture must be larger since his sack extends to the xiphoid). We did remove quite a bit of skin, as you can imagine.

The operation was complicated by a difficult foley placement. I thought it was just my technical error... but I was vindicated when my chief couldn't pass the catheter either and we had to call urology. They managed a foley with the assistance of a flexible scope, which revealed a significant stricture in the urethra.

In slightly less medical terms: a hernia is a weakness or hole in one of the connective tissue layers separating two compartments in your body. In this case, the hole was in the abdominal wall where your belly button is. It was about 8cm in diameter. The man's intestines had crept out of the hole and were right below his skin in the big ball hanging off of his belly. We cut open the skin, pushed his intestines back into his belly and put some mesh over the hole to prevent his intestines from getting out again. We then pulled his abdominal muscles over the mesh to strengthen the repair. Sometimes when we pull the muscles, they don't close properly because they can't reach each other. If that's the case, we cut them free from other muscles on your sides (separation of parts) so that they can move more centrally and cover the hole. Since the hernia stretched the skin, we cut off some of the extra skin and stapled the incision closed.

Inguinal hernia

On Friday I assisted a laparoscopic bilateral inguinal hernia repair. For those of you uncertain where the inguinal area is, feel your hip bones at the bottom of your stomach. Draw a line from each hipbone to where your pubic hair starts. That's roughly the location of your inguinal ligament.

The surgery provided the best view of that anatomy of the lower anterior abdominal wall I have seen to date. Better than anatomy lab without question. I can't find a phenomenal photo of it, but this one isn't bad. There is a normal weak point in the abdominal wall in that region, called Hesselbach's triangle (the HT in the picture). The vessel that borders it is called the inferior epigastric (not labeled) and a hernia medial (in HT) is called a direct inguinal hernia whereas a hernia lateral to the vessel is called indirect (through the internal inguinal ring, labeled IIR in the picture). Two important anatomic regions lie near Hesselbach's triangle, making the surgery technically quite challenging. My attending affectionally refers to these as the triangle of doom (inferior, where the femoral vessels run) and the triangle of pain (lateral, where the genitofemoral nerve runs). During the surgery he would constantly yell out which triangle we were near when our instruments got too close (which was often, it's a tiny space). "Watch out for DOOM!" "Beware PAIN!"

It was a quick, interesting case to observe; a good start to the morning. It was followed by (yet another) anterior abdominal wall reconstrution.

Professionalism

We has a small group lecture on Friday to discuss professionalism. Our facilitator was supposed to have us discuss what professionalism means to us and how we think we learn it, but instead the conversation became a reflection on the tenor of the interactions we have witnessed over the last year in the hospital. We all agreed that by-and-large the demeanor displayed towards patients was very professional. Not always warm and fuzzy, but at a minimum, respectful. The few occasions we witnessed something less were generally in the context of extreme burn out.

What was more interesting is that we witness a lot of unprofessional interaction between medical professionals. The doctor-nurse relationship has been beaten to death in many forums, but it also exists between consulting and primary teams, between different specialties and between levels in the hierarchy. In particular, medical students can be the target of unprofessional, disrespectful behavior; most commonly from non-physicians on the care team. There is something about wearing a short white coat instead of a long one that signals to nurses and scrub techs that it's ok to abuse you or ignore you at will. Maybe it's because in a few months when we graduate we will be their bosses. Maybe it's because we have zero power to retaliate. Maybe it's because we're new and young. Whatever it is, we have all experienced it.

In the end, having a collective bitch session was very therapeutic. We are at a stage in training in which we have no autonomy, no choices, long hours and constant evaluation. Being able to complain to others who understand and don't recoil with a look of disgust at our temporary lack of compassion and empathy was very freeing. And the truth is, everyone else in the world complains about their job, their coworkers and their customers at times. Is it so surprising that we, as (future) physicians, would need to as well?

Vascular: the final surgery

My last day on the vascular surgery service was spent in the OR on an exceptionally engrossing case. It was a thoracic aorta to celiac/SMA bypass. Basically, we anastamose (attach) a bifurcated graft (tube that splits in two) proximally to the thoracic aorta (above the diaphragm) and distally to the celiac trunk and the superior mesenteric arteries (one leg of the graft to each artery. This means it's attached once to the aorta, splits, and then each leg attaches to one of the arteries). The patient was suffering from mesenteric ischemia (bowel that wasn't getting enough oxygen) due to atherosclerosis. Two of the three arteries supplying the gut were completly occluded, so those are the two we bypassed, improving blood flow to the gut and hopefully reduing his pain.

The attending was Dr. C, an eccentric Spaniard who is both an exceptional technical surgeon and an enthusiastic teacher. He would step back every 10 minutes or so during the dissection to describe the planes of anatomy he was crossing, ask a few reasonable questions and then have everyone stick their hand in and feel for key structures. The incision was along the ninth rib space in the retroperitoneum, just below the diaphragm. We dissected through the diaphragm to access the thoracic aorta; then through the pleural space while strategically collapsing the lung. This provided a beautiful view of the heart contracting, which is really quite captivating. This lateral incision also allowed us to leave the kidney alone, though we did have to mobilze the pancreas. Once the graft had been sewn in and we were closing, we reinflated the lung. It was pretty nifty to see the lung inflating and deflating with each breath while we closed the diaphragm. Dr. C let me close the skin, which involved no small number of subcuticular stitches (yay).

In the end, I really enjoyed my month on vascular. It almost makes me think I would enjoy being a surgeon, so we'll have to see how MIS goes. I wonder if the novelty of being inside someone would wear off and it would become tedious? You don't really follow your patients and you take care of such a compartmentalized portion of their health. On the other hand, you get to operate. The trouble with liking everything is that it becomes awfully hard to choose.

180 degrees

I had an amazing day on surgery, which is unexpected but welcome. There was a blizzard overnight, the new interns were starting and I was on call so I was geared up for a long, rough day. Instead...

1. I presented patients on rounds and the fellow liked my plans

2. I pulled drains and changed dressings before the OR (it's fun to do things)

3. I did the electrocautery to open the patient's groin (in the OR)

4. I got to close the groin alone

5. The uptight fellow looked at my closure and said "you've got skills."

6. I actually had a 45 minute lunch

7. We did a helpful teaching session on trauma and I managed to not interrupt

8. I was sent to consult a patient because I knew more about the procedure than the intern

9. The uptight fellow had me do the entire add-on I&D while she supervised

10. The uptight fellow gave me unexpectedly positive feedback

11. I was paged while in the OR by another attending

12. I was sent home at 8pm on a call night

I should probably stop calling her the uptight fellow since I actually sort of like her now. Since I'm less scared and we've both gotten used to each other, I feel like I can relate to her somewhat. I feel like I've seen a little of her human/personal side rather than just her all-business/work side.

Medical funfact #249

We use protamine sulfate to reverse the effects of the blood thinner heparin. One potential side effect exists for males who have undergone vasectomy...

Protamine is made from salmon sperm. Usually, the (human) testicles reside across a special barrier from the rest of the body, much like the brain. If this barrier was damaged during a vasectomy, some of the protamine could cross it. The human immune system would then mount an allergic reaction to the non-human sperm proteins.

And for the beauty pageant contestants out there: no, protamine cannot get you pregnant.

Sunday call

There is nothing quite like a morning amputation to make your day feel productive. By lunchtime you have already rounded on all the patients, redressed the wounds, updated the orders, written progress notes and removed a person's limb. Call it macabre, but that's a lot of to-do list items checked off.

Amputations feel so satisfying because you can physically see the work (unlike a stent or graft where all the work is interior). They are also extremely quick surgeries; you bove through the skin/muscle, saw through the bone, clean up the edges and sew a skin flap. Done and done. From induction to reversal, taking off this guy's forefoot took one hour. And yes, they let me cut through some bone. There was a lot more spatter than with the above-the-knee I did last week. This time I had blood spray on my goggles and mask (cool).

The picture is an x-ray s/p (after) a transmetatarsal amputation. People lose their forefoot and have special shoe inserts that help them with ambulation.

There is another guy on the floor at the moment who had a bypass graft done earlier this week. It's a high risk graft, which means there is a strong likelihood the graft will clot off. More of a when than if. To extend the life of the graft we put the patients on coumadin. Well, this guy really doesn't want to take it in case it causes some nausea. SERIOUSLY? How is this a decision? Take the coumadin +/- a anti-emetic and keep the leg for a few years vs. don't take coumadin and lose the leg in weeks. He has to think about this?

Tidbits

1. Standing in the OR holding a freshly amputated leg (above the knee) and putting it in the disposal bag. When you take something off the table, you have to call out. Examples include: knife down, needle back, etc. Handing off the leg, I stated "one partially used limb for pathology."

2. Putting stitches into a femoral artery graft. They have to be perfect because you don't want the patient bleeding from the graft-artery junction (anastamosis). The attending let me throw the last 4 to close the anastamosis. The needle we use is less than a millimeter thick and 1cm long. We took the clamp off and... my sutures held!

3. A patient on the thoracic service was bleeding through his dressings after having an emergent bilateral fasciotomy (two big incisions in each leg, left open) earlier that morning. The interns were busy dealing with a patient having a heart attack so they sent me down to do the consult. The fellow and attending agreed with my plan and had me present to the primary team. The nurse didn't want to touch the dressings so I redid the surgical bandages (more complicated than just some gauze), stitched his central lines in place, then answered the wife's questions. Basically, I acted as the consulting resident from vascular (quite a promotion).

4. Putting a Foley in a man with a penis that is permanently fibrosed in the erect position.

bad days

I'm coming to the conclusion that when choosing a specialty, you need to choose the one where even the bad days are somewhat fun. I don't mean bad as in the previous post where you're emotionally drained; I mean bad as in technically the sh*t is hitting the fan. An example of one of these painful days...

I got to the unit at 5:30am for pre-rounds, as usual. I checked in on my patients and took down the dressings, as usual. We rounded as a team and I re-dressed the wounds, as usual. There was no morning conference so I headed down to the OR early to put in the patient's Foley and watch anesthesia place the central lines. The planned surgery was an open (cut the abdomen open, rather than inserting a catheter though the vessels) abdominal aortic aneurysm repair. It should take 4-5 hours. I was scrubbing with the uptight fellow and one of the old Spaniards.

The case began and he was a little wetter (oozing blood) than expected, but otherwise the dissection to the retroperitoneum was uneventful. We were able to clamp infra-renally (good) and got proximal and distal control of the arteries near our anastamosis sites. We began grafting to the aorta, but the clamp appeared through the posterior wall. This means the aorta had torn, so we had to reclamp, higher, and get control of the bleeding. We managed to get the graft on, but the patient was still bleeding. We discovered the aorta had torn proximal to the clamp. We attempted to mobilize the aorta and sew the tear closed, but it continued extending. It look 3-4 hours and a supra-renal clamp to repair the tear. We turned our attention to the iliac anastamoses, and one of these also proved problematic with excess bleeding. We finally closed the belly to find he had stopped urinating and had stooled all over the OR table. At this point he had lost just over 13L of blood.

We did dopplers of his feet to check for pulses and found one limb to have absent pulses and pallor. We prepped for a thrombectomy, to extract the presumed clot released when we came off the aortic clamp. Once in his groin, we found very calcified arteries and insufficient forward flow to float a catheter down the leg. We immediately converted to a femoral to femoral bypass graft. We opened the other groin and reheparinised him. The bypass was completed uneventfully and his groins were closed. At this point, he had another 2L of blood loss.

The whole operation took 14 hours (I was allowed to leave at hour 12) and ended up being really rough on his kidneys (suprarenal clamp) and having a very long aortic clamp time (no fresh blood to the legs -> tissue loss -> also bad for kidneys). He's stable (for now) in the ICU. The point (long-winded, yes) is that this was a tough case where everything was going wrong. This is a painful surgery, even for a surgeon. In fact, the attending that started the case was not the one who finished it. If you can still find some fun in this kind of day, then maybe the OR is the place for you. Me, well, I did not find so much fun in this. But there are rough days in the ICU I get some rush from. Where the fight is energizing as well as draining. So I don't think I'm a future surgeon, but I think I earned some respect from them for standing in that OR for 12 hours with no food/water/peeing/sitting.

We all fall down

Well, I suspected it would happen, but surgery broke me. On Friday night I was reduce to tears. Or more accurately, collapsed sobbing on my bedroom floor. It was, in all honesty, a pathetic sight and a definite low-point. How did this happen? Well... Friday actually started out quite well. Rounds went relatively smoothly since we had the relaxed fellow. Then it was off to clinic with the nice attending. The first two patients didn't show so I was able to grab a coffee and tend to some email. I managed to see six patients and write their notes before leaving for seminar, prompting Dr. E to tell me I was "ready to be a fourth year." So yeah, the day started out fairly well. Seminar should have been a hint. It was about our future, a topic that always give me a little spasm of fear: will I be able to match to geography I like given my Step 1 score? Am I going to get stuck doing primary care in Idaho? A classmate approached me during seminar to tell me that the uptight fellow had scrubbed on some cases at the VA with him and spent the time in the OR asking my fellow student pointed questions about ME (unprofessional!). He couldn't say anything nice (what?) so he lied and said he had never been on service with me (thanks). I got back to the conference room after seminar in time for afternoon rounds. When the other students on vascular got back they made it clear I shouldn't have left without them (they left without me last week). Off to teaching rounds with the over-enthusiastic attending who pimped JUST ME on surgical abdomens, but felt the need to stop halfway through to tell the whole room that I was defensive and arrogant and should get that under control (unprofessional!). After teaching rounds the two medical students on vascular cornered me to have a frank talk about how I interrupt too much. I then took some staples out of a woman's abdominal wound and was allowed to leave. I got out of the hospital into the freezing air and tears started sprouting. Trouble is, they started freezing in my eyelashes as I walked. Yes, I froze my eyes shut crying on the walk home.

So let's reflect: yes, the "constructive" criticism I received is grounded in truth. My board scores are my fault. I am defensive, but not out of arrogance. I hate getting things wrong because I'm terrified. I probably do interrupt too much, but could that conversation possibly have waited until the next day given they had just watched me get humiliated by an attending? Not to mention that I have not committed the cardinal sins of throwing another student under the bus or claiming all the good surgeries?

End result: I don't have skin thick enough to be a surgeon. Nor do I want to. I do take it personally when people criticize me; because I care. I care that I'm good at this and that I am respected. I don't want to become the kind of person who can humiliate another person in public just because they can't talk back for fear of their grade. It does not help my learning. Being a good teacher is about motivating and empowering, not belittling and intimidating. Surgeons seem to confuse fear with respect.