Baylor College of Medicine

Fun Times with a Fungi




Erik: So anyway now the bureaucracy is out of the way if you have any questions for us - If not, I've already hit recording on our end and I'm recording video and audio. But the video will not be a part of it.

Hamill: All right

Jason: So what was your career journey? I guess as a doctor

Hamill: As a physi-?

Jason: As a physician, as a teacher, as a - yeah - as a residency director, like what was that Journey?

Hamill: Well, so I went to medical school at Wayne State University in Detroit and then I stayed there and did my training as a resident and I ended up being a chief medical resident there. So I got the opportunity to teach for that year, which I really enjoyed and then I went off did my fellowship in infectious disease at University of Wisconsin and I actually did three years. Normally the fellowship would be too but I did three there. The third year was mostly in the lab. I did have the opportunity to do some teaching there. I taught, for instance, the endocarditis block, you know, our lecture for the medical students and micro, so I got to do it there. And I actually - one of the kind of memorable Grand rounds I did, there was the – I took care of the first patient with HIV in the state of Wisconsin. And he was a patient who was admitted to the VA there. And so, I gave Grand rounds, the first Grand rounds on AIDS at the University of Wisconsin. So, you know, I thought that was kind of cool. I still have the handout from that.

Hamill: Then I came to Houston in 1985 Dr. Musher actually, you know, interviewed me for the job and I heard that was kind of memorable because that he picked me up. I had never met him before, you know, and he picked me up at this dumpy Hotel on Holcombe and his big blue Chevy. I don't know if you guys have seen that Chevy convertible that he drives – an old Chevy with a white convertible – he still has – 1950 something. You know, I like the people, Dr. young, Dr. Musher I met at the time. Kind of my wife and I wanted to change so I came here. I told her when we came down and be five years here and we've been here now thirty, you know, so we liked it here. You know initially when the reason I came to the VA was that when I first started, the VA was a nice opportunity because you could see patients, you could teach, you could do your research, and nobody really bothered you, you know. And back then, you know, things weren't near as strict as they are now, in terms of, you know, you didn't have to round every day without staff and those types of things. But I did enjoy teaching and I, you know, I tended Morning Report quite frequently then, and I spent three years as the associate chief of the medical service while I was at the VA and I was, for a long time, the chairman of the curriculum subcommittee, for the Residency program. And then in 2006, the person who is charge of the Residency program ahead of me, Dr. Levy decided he wanted to go over the dark side and join the law profession (he'd been going to law school at night). And so, I was put in charge as chairman of the recruitment committee for that position. But then Dr. Greenberg was the acting chair of the medicine at the time. And I told him well, you know, I sort of would like to apply for the job so he made me step down as chairman the committee ultimately I was chosen to run the residency program. You know, I'm glad I did it. I had been involved prior to that with a group called the mycosis study group. And so, we did a lot of studies for fungal diseases. And at the time, you know, this was early on in the HIV era, we saw a lot of patients in Houston with cryptococcus, histoplasma, and HIV. So we were one of the highest enrolling centers in the country and a lot of different studies particularly for cryptococcal disease but you know as therapy started coming out for HIV and stuff, those patients became fewer. And so it became much harder to do those studies and things. I think the transition to the educational program was kind of a natural one for me. I still get, you know, to do my fungal things and still get to participate. People still call me for all the complicated fungal infections – I mean, I got an email yesterday from one of our former trainees who has a patient over at MD Anderson, who had some questions about, so I still get to do that. But I also get to teach and kind of run The Residency program too.

Erik: Well, I'm curious because, I actually went to Wisconsin for undergrad and I'm from Illinois, so also from the Midwest and I'm always kind of interested to hear what attracted you to, you know, the VA and then Baylor specifically that, you know, you felt like maybe you - I don't know if there's anything you felt like you couldn't find in the Midwest or elsewhere on the coast or something.

Hamill: Well, you know, we liked Wisconsin; Madison was a nice place to live. No, my wife is still mad at me for leaving there; she thought it was Heaven on Earth, you know, because she had grown up in Detroit, her dad was a fireman in Detroit. She had grown up in Detroit, so leaving, Detroit was like, great for her. But, you know, because of Wisconsin was so nice, people wanted to stay there, and there were no jobs. A lot of the guys who had finished the fellowship program ahead of me were working in ER's and stuff because they couldn't get an ID job

Erik: Really?

Hamill: Yeah. And you know Madison is kind of a small city, you know. It's not like Houston is and it's not a very diverse city, right?

Erik: Definitely

Hamill: And so, you know, I think just Houston offered a lot more opportunity for my career and Madison did at the time. And that was borne out, I think about by my career trajectory. I couldn't have done the type of research I did at a lot of other places with the support I had here, and the diversity of the patient population that we had here. Very few places in the country have that, and even the ones that do – I don't think everything's not as concentrated together as it is here. So it makes, you know, getting around pretty easy and it makes life pretty easy because you don't have to, you know, run all over town. The other thing about Houston the medical center which I think is kind of unique is the fact that you can live so close by. I still still living a pretty nice part of town in a lot of major medical centers, you can't do that. So for the first four years I lived here, I actually rode my bike to work every day because I only lived a few miles away. And I'd still I have a ten-year-old car that only has 48 thousand miles on it because I hardly drive

Erik: Even in the heat you'd bike in, huh?

Hamill: Well, back then – Houston wasn't as bike friendly back then. So the reason I quit was I actually got hit by a car.

Erik: Oh my goodness. Oh my sorry to hear that.

Hamill: But, so there are a lot of opportunities here to do research. You know, the Infectious Disease section I think a Baylor is always been very strong, you know, and good colleagues at the Infectious Disease community here in Houston is good. It's very collegial, maybe a little unlike Cardiology or something.

Erik: Gotcha
Jason: Sure, yeah, what was one of your most difficult patient cases

Hamill: Couple different things – I think one of the disease's I think that's really difficult to manage is coccidioidomycosis. And I have a patient actually, I'm following in the clinic right now, I think is was one of the most difficult ones I've had. He's a young man who had been diagnosed with cocci when he was in the service in California, about three or four years ago, and at that time, he had pulmonary disease, CNS disease, cervical spinal disease, thoracic spinal disease, and he had to have thoracic surgery, spinal surgery, and was treated in California. And then he came here and he been off medicines for a while and he relapsed. And when he got here, he had exacerbation of his cervical disease and he developed hydrocephalus. And so he had to have a surgery for his hydrocephalus and we treated him with high-dose fluconazole which is sort of the guideline directed therapy for his meningitis. Well, he was on 1200 milligrams a day and all his hair fell out, and he got upset from that. So that's one of the side effects of fluconazole. And you know, I have some friends out in the Arizona, who deal with a lot of this. I talked to them and ultimately we started him on posaconazole, and so far he's been doing pretty well on Posaconazole. But, you know this is a difficult disease to treat will never be able to cure him with the present drugs and he's got to be diligent about making sure he takes his drugs. So that's a tough one to treat.

Erik: So is the main reason that it's tough just because we have better azoles and antifungals to treat the other diseases where it's just not there?

Hamill: Well, yeah, just the ones that the ones we have just aren't effective for cocci. I mean, so far right now, cocci meningitis is considered an incurable disease and it's complicated even in patients who you can manage them, you know, you never cure their CNS disease. So there are still at risk down the road for hydrocephalus. I've had three patients now who I follow – we don't see a lot of cocci here, but I've had three patients of the few we've seen who've required shunting or some other Neurosurgical procedure for management of the hydrocephalus because it's such a common complication. So it makes it difficult to manage. And it's a very humbling disease. And then some of our HIV patients early on in the HIV era – it was very depressing, you know? And because we didn't have great drugs for these patients. If we had the drugs available back then – if we had the drugs we have now back then, we would have done a lot better with HIV because they took their medicines, you know. Early in the HIV era, we didn't have a lot of knowledge about the pharmacokinetics, for instance, of AZT. When that one that was our first drug available patients would wake up every four hours at night to take their medicine because we thought the half-life was short, you know. And they did it, they set their clocks. They got up at every 4 hours at night to take it and they did fine. But then they got after 20 to 40 weeks, they all got resistant, and we just bounced from drug to drug to drug like that. But ultimately, we had nothing to offer them. So it wasn't until we could get combination therapy and we could actually start curing these. And I have two patients right now – or one, at least (I had two and then one died last year). But back in 1996, we got combination, they were on their death beds, but both of them – they were alive for years afterwards after we were able to get the protease inhibitors.

Erik: When you talk about HIV gets me to think, because I mean I know you said that you were in your fellowship when HIV was kind of first being realized and coming into the scene so I guess it probably didn't get you to go an infectious disease because you're already doing it. But did you feel like that sort of endemic caused more people to go into infectious disease? And I'm asking this question because of COVID, I'm wondering if we're going to see a bunch of people who want to be infectious disease doctors because you know it's everybody's you know it's the thing sort of to learn more about and treat.

Hamill: Yeah, you know I think it probably was. It's what's interesting – we had the graduation virtual graduation for our ID fellows the other night, and Dr. Fauci actually had put together a video for all the graduating ID fellows in the country. And so they showed it at our virtual graduation the other night and he brought up an incident that happened back in the early 80s. Dr. Petersdorf, who was at the University of Washington and was a very well-known ID doc then, had given an address at the Infectious Disease society meeting saying that there were too many ID doctors back then, and that they'd all be culturing themselves and treating them because there were just too many of us. Well, I mean that was literally in the doorstep of HIV. Then since then, you know, we've got leaked layers disease, we've got SARS and we've got MERS, we've got covid. And you know all these new diseases that people wouldn't imagine back antibiotic resistance and infection control is tough, global health. So I think, yeah, I think probably HIV did have an impetus for people to go into ID back then because a lot more people; we have a lot more women have now too, you know, which I think is one of the nice things about the field because I think – we graduated six fellows this year and all of them were women. So I think it's been a nice opportunity for women, unlike some sub-specialties, like Cardiology which are very heavily male dominated, you know, ID's allowed women to come in.

Erik: They're going to think you're coming at – you have a vendetta against cardiologists. I'm just joking.

Hamill: It's not as interesting of a subspecialty as ID.

Jason: We both remember – I mean, we're one of the few students who actually attended the lectures. I did want to ask though, why is it that you still put up with teaching us medical students?

Hamill: Well I wondered – I got the evaluations yesterday actually from the last, you know, the last group actually. You know most of them were recorded from the year before – I only gave 2 in person. And, several times over the course of the years that I've given these lectures, the students complain about the TV lecture. Because they say that, what I tell them, they don't believe – they don't believe it. And what I tell them is has to do with BCG vaccination, you know? And the public health response to that and what I tell them is what's in the guidelines, but they don't like it because they think it's discriminatory. And I got one of the, one of the evaluations yesterday, said, well, what he said, was, what's not in their ID first aid book, or whatever the dumbed down version of the book reviews. Well, I'm sorry but it's not the public health response, you know BCG is pretty well laid out, you know you ignore the BCG status when you do PPD testing, or when you do T-spot testing nowadays. That's the way it's supposed to be done, but these books and their thought is well that's discriminatory. Well, it's not and it kind of – it's a little bit irksome right when the students are bellyaching about that when they don't really know the data. And then the other comment that they got this time was, well, I was teaching them stuff that only ID fellas need to know. So, I'm teaching them the ID that they're going to see when they get in the clinic. Because if I teach them, they will be seeing it and they don't know because they haven't been the clinics yet, but you guys have now or you will be you will see these things. So that's the one thing that bothers me about it. I do miss not interacting with the students in class – I like that better? I don't, I don't like giving Zoom lectures because it's fun to interact with students so that's why I do it. And I'd like to round on the ward still, you know, a lot of program directors around the country don't round because they don't have time to do it. But I don't like that because you don't get to interact with students. And you know, I like clinical medicine, so I want to continue that, and I think I have something to impart to you. There's, you know, there's been this movement for hospitalists to do all the rounding in medicine now in general medicine. The man who actually got me interested in joining the mycosis study group used to be the chief chair, chief of general medicine over at UT. He was actually a pulmonologist Jorge Cirrosi. He wrote an editorial in annals of internal medicine a few years ago because he still rounded on general medicine and he was 70 something. We still have something to offer, we have some insights, you know, we may not be able to get the patient out of the hospital as quick as maybe a hospitalist does, or something, but I think we have some history and some insights and like this, you know, that that we can give you guys that they may be beneficial in an approach to Medicine still, because we've seen a lot more than you guys have.

Erik: Definitely, definitely. I didn't realize that there was a move for hospitalist to do all the –  most of the rounding.

Hamill: Oh yeah,  and that's the way it is at a lot of places. You know if you but I mean, if you look at who's running a been table now, it's mostly the hospitalists. Dr. Greenberg and I were the only ID people, I think, now who rounded on general medicine there. Several of the Endocrinologist did, and I think one or two of the nephrologists. But mostly, that's all it is. And at the VA, you have more of the subspecialists, but there are moving away from that as well. But that's nationally, that's the trend. But I enjoy it and I think we still have something to add.

Erik: And I think Jason, correct me if I'm wrong, but were you also trying to ask about like the fact that the years, because when Jason was saying he attended all and I attended most I did watch them all, you know in some manner, but some of them I did stream. And I think we're also curious just to know as somebody who's been teaching a long time and has seen streaming become more of a thing, like, do you like that, or are you indifferent or do you despise it?

Hamill: Well, I don't despise it but I, you know, I like I said, I enjoy interacting with the students. I'd rather they'd be there than often in the Netherlands, you know. You know, when I went to medical school, I had a big class (there were 256 of us). Most of us went to class, but not everybody did; we had a scribe service back then that you could pay for. We all paid for it just to augment our notes, but most of us went, but I went to socialize with my friends, you know. The way our medical school is set up, we had a we were broken up into 16 person labs, you know and so, you know, that was your social unit. I mean we had potluck dinners, and picnics, and we went on vacations together and stuff, you know, that's why I went to, that's why I went to classes. But yeah, I don't, you know – you sit at home and you look at zoomed all day long, I mean I hate it right now. Excuse my language, ha ha, I hate this. Yeah, everything Zoom right now. I am sitting up here in my office. I come here every day, our house is under construction right now, you know, so I can't stay at home. My office is a mess and stuff, so I got I come up to work, well several days. I'm the only one up here, you know, and it's lonely. And that's not the way medicine should be.

Jason: For sure. I definitely feel that the like I went to class mostly to see people.

Erik: Yeah, yeah.

Hamill; And I think it's helpful too because, you know, you can ask questions and people come up afterwards and stuff to talk, you know.

Jason: It doesn't take like a, you know, six emails to get one question and you can just ask it and, you know.

Hamill: So I miss that.

Jason: Yeah, for sure. I guess, I was wondering how is it different from teaching like us medical students compared to residents? Is it different is it not different? It's a little different because, you know, there's a different level of sophistication. But you know, I've had medical students who are phenomenal or better than the residents, you know, so it's not a hard and fast rule when I round on infectious disease service I do like to have a fellow on the service with me because you can talk about a little bit more sophisticated topic, you know. And so for me, that's good because then they challenge you a little bit, but on the whole I think, the way I do rounds, it's good because I think we can address certain aspects of different patients at different levels, right? And so, it's always good to make us think about the basics, but you can get a little more sophisticated. You know, there's, you know, there's that RIME acronym, they, you know, you guys are familiar with RIME

Erik: I don't think so.

Hamill: Okay, so theoretically, that's how we should be, evaluating you guys, putting you on the RIME scale. R is reporter, I is interpreter, M is manager, and E is – I don't know teacher or explainer or something like that. So yeah, as a first, you know, when you're on your first clinical rotation as a medical student, you guys are pretty much reporting what you find. It's very satisfying to me to see a student start to be able to interpret the values and certainly manage it, you know. They tell me the patient has hyperkalemia, they know to give kayexalate, and insulin and glucose and what have you.

Jason: We talked about fungi, I guess a lot in the lectures too, so why are fungi your favorite class of microorganism?

Hamill: Well, because they call cause cool diseases, right? So, you know, right now, a lot of the stuff, there's a lot of stuff out there about COVID, you know. But, I find it boring because, you know, I mean, I know there's a lot of things that can happen to patients with COVID, you know. I mean, besides having respiratory things, they have GI things, they have hematologic things, they have thromboses, blah blah blah. But I don't know; they don't have these weird skin lesions like people with fungi get, you know. And they don't have all these weird manifestations. And there's not cool epidemiology like there is with fungi, right? The epidemiology is really neat. The other reason I like it is because nobody else does. So, I can see myself as an expert so people will come to me with questions because you know I've dealt with it and that's where my expertise is and stuff. You know, and it's kind of cool that, you know, you see these diseases that have weird manifestation and they are – sometimes they can be very difficult to manage. And I think we don't – sometimes people, I don't think look at the little bit deeper into these diseases. For instance with cocci now, I think it's becoming pretty clear with cocci that if somebody has a very bad cocci infection that there's something wrong with their immune system, and people don't think that way. They think well, he's got bad cocci and we got to treat it. But I think we're finding now more and more that there's something wrong with their immune system. So actually, in the New England Journal of Medicine last week, they had a case description of a child who had disseminated cocci and had a bad infection and it turned out they ended up treating the patient with some of these immune modulating drugs, as well as interferon gamma, and the kid actually did very well. And then they genetically, they looked at him and he had truncation of a gene that allowed for – that caused the decrease in the interferon gamma production. We don't look as carefully into those things as we should in those patients. So I think anybody that has disseminated cryptococcosis, histoplasmosis, coccidioidomycosis, who doesn't have something obvious – we should, we probably ought to be investigating them because they probably do have something wrong with them. A lot more sophisticated than we can usually get.

Jason: Yeah, so fungi, pretty cool.

Hamill: Yeah, they are.

Jason: Yeah, kind of different. No, definitely – I when I was learning it I definitely felt like the clinical manifestations are like, very different from like bacteria. I feel like bacteria were like, very like, clear. Like a lot more clear out of in, like, a picture of what, what they did, but fungi really were like kind of all over the place with clinical manifestation

Hamill: But I think you know, a lot of times if you take a good epidemiologic history and patient you sometimes get some clues, or look at their underlying illnesses.

Jason: Hmm do you have a favorite fungus? We've talked about cocci a lot.

Hamill: Like yeah, I like cryptococcus. I think is probably my favorite. I mean if you can if you effectively treat somebody with cryptococcus you can help them a lot. It's probably not the most interesting in terms of its clinical manifestations but it's the most satisfying to treat sometimes

Jason: And then, okay, the next question I have is kind of fun one: as a residency director for like so many years, how have you seen students suck up to you?

Hamill: I don't know. I don't think they suck up a lot. Occasionally there will be a student though you know who want to talk, come in and talk you know, more than the typical. It's clear they want to stick around or something, but it doesn't happen too much.

Jason: Okay. Okay, cool. I mean it's like I feel like I've a lot of times, like, especially during lecture like okay, like no one really liked knows like your title or whatever, like, during lecture and be like, oh yeah, like, by the way, like Dr. Hamill is like the residency director and then they're like, oh like now he's like actually listen to him and I was like – what the, like why would you not listen, you know, why won't you listen to him before?

Hamill: That's right.

Jason: Why don't you attend his lecture, like you know, a six of the classes is attending his lecture? I don't really get it but it's fine.

Hamill: Does that give me more credibility or something?

Jason: I don't know. I don't know, it's fine.  Anyway, that's just a fun question. I guess after practicing, like medicine and teaching for so many years, what do you say is the most rewarding part of your job, either the medicine or the teaching?

Hamill: You know, I think just seeing how you guys mature over the years, you know? I mean, I've seen a lot of students come and go now and a lot of residents going go, and I always get sad, you know. We had our graduation two weeks ago for the residents, you know. We see them; unfortunately, we didn't this year, but most years we see them packed into a room on the first day, you know. They sort of have this deer in the headlight, look, you know, there's nowhere to go. But, you know, I usually round at Ben Taub in the end April-May, you know, of each year. And when I have a third-year resident running a ward team then, it's very satisfying to see how well they've done. You know, I would trust most of them implicitly with my life, you know, because they've done a great job and I think that's the most satisfying thing to see them come very raw and over just three years, you know, work very hard, work with a lot of camaraderie with a group, you know, and become just very, very competent physicians. That that to me is tremendous. We put out a lot of good physicians. Then to see them go on, you know, a lot of, you know, my residence now are, you know, they're faculty here and stuff, to see them being successful and stuff like that, you know, it's just very satisfying.

Jason: I mean, there they literally is a new class of interns, they're starting like what next Wednesday, right?

Hamill: They start Friday, but they're here now.

Jason: They're here right now?

Hamill: And just before you got on, I was just finishing up our bootcamp online. But we had a camp today with them. Yeah, I met him all, we had a drive-through in front of the McNair building on Thursday and Friday for them to pick up their white coats, and so they're all in town and a next Friday I think they start.

Jason: So they have the same look, the headlight.

Hamill: Yeah, yeah, although you can't see them all in one room.

Erik: Has COVID changed anything about how like it's going to be structured or is it going to be pretty much the same way?

Hamill: Well, you know, I mean, it has changed the orientation completely, right? Everything is online now. We had our orientation yesterday morning, it was all online. All the Baylor, orientation's online. Except for you know we have to do a donning and doffing gown thing for them, you know? And we certainly are doing the n95 Mask fitting now. And yeah, you know we have to have them socially kind of separated in the team rooms and stuff, which to me is unfortunate because you guys have been through medicine, right? I mean, you know how it is when you're in a team room, you sort of through osmosis you pick up things, right? A little things you know, how you put this order in? What is this low potassium mean? What is it? And we don't we're not going to have that because kids are going to be scattered around a little bit more, so I think it's going to be detrimental to their education. So I do really hope that we get through this thing pretty fast. Actually, myself and Amy Angler. I don't know if you guys know Amy, she just graduated from the medical school. She's gonna be one of our interns. She and I were interviewed yesterday by a woman from the Houston Chronicle. There's going to be an article in the chronicle I think this week or next week about the interns starting in this era. Look for that.

Jason: So I guess, what has been like the least rewarding part of the most frustrating part of your job?

Hamill: Well, I think the amount of paperwork over the years, and the amount of regulatory things that have occurred, you know. I feel bad for the residents because we're just – we're always hitting them up with, you know, you got to do this training and that training and stuff that they never had to do in the past. This year was particularly bad because, you know, three of the four hospitals that they train at all had CMS things. And so they had to do a tremendous amount of training that really was duplicative but all three hospitals required it, right? And so they had to do it on multiple occasions for all. Plus you know, they have ACGME surveys, and they got to do duty hours. They have to do training on compliance and they got to do ethics training and human research, and HIPAA, and I mean, there's just a huge amount of training that they didn't have to do before. For all this training, they could be taking care of patients, and they could be getting so much more out of it. So that bothers me and then all the paperwork, that's involved nowadays. The other aspect I don't like, is that just in case there are disciplinary problems, you know. We don't have many of those, fortunately, but we do have some remediation issues occasionally with residents and that's very unpleasant because as a whole these kids are pretty good and yeah but sometimes people just can't put two and two together, you know. Yeah that's just not satisfying.

Erik: Well I've heard a lot of – we've interviewed quite a few people who have sort of been around long enough to see the paperwork build up and have said, similar things. But I've also talked to some people who have said, you know, doctors have always had a lot of paperwork to do it just you just used to handwrite it. Are you talking specifically about like EMR stuff? Or - because like notes in general, you've had to take since the beginning, right?

Hamill: I think the paperwork burden is more the regulatory documents.

Erik: Gotcha.

Hamill: So, when I trained, obviously all the records were handwritten. I don't think that was optimal. The hospital where I did my residency at the time, had the largest inpatient oncology population in the country, bigger than MD Anderson. And so we would see patients, that would have a chart about 2 feet high.

Erik: Wow.

Hamill: And you had to go through the chart every time these patients were admitted and calculate how much doxorubicin they had gotten, so we'd stayed below the 250 milligrams per meter squared, you know. So you might spend hours going through the pages of this chart, trying to find that. Well, the EMR certainly facilitated that type of stuff. But on the other hand, it's taken people away from the patients and patient's rooms because they're sitting in front of computer because there's so much a data available there that they sit there and get it all, instead of being with a patient. I think that's the major thing that that I don't like about the EMR and that's been commented on. You know we had Robert Wachter or who's the chair at UCSF and he wrote that book, the digital doctor. It's a good book but one the pictures he has in there, one that the daughter of one of his patients had drawn his back is to the patient looking at the record, you know. I mean that's been an unsatisfying component of this medicine these days.

Erik: Definitely.

Jason: Even as a med student, I feel like I can just be, like, in the mornings, I'm like, I can be in front of the computer, like the entire morning up till it rounds and like, forget to see the patient. I have to like, time myself, like, okay, I just could spend like 20 minutes and then anything that I don't get in the 20 minutes, I just going to see the patient and then I can come back to, it's fine. I don't have to get like every single little thing. But yeah, that's definitely something that I've noticed, like even for me like oh my gosh, is like so much stuff in the morning. There's all these new labs like all these new all these new tests.

Hamill: You know, some of the residents couple years ago, it applied for one of these ACGME grants, back to the bedside grants, and had developed this program to, you know, interview patients about things other than their medical issue, you know, where they live, how they grew up. If they were a veteran where they would Branch the service they were in and do they see combat or something. But that's sort of been curtailed now because of this COVID thing because you can't get everybody in the room now, to listen to those stories, you know. Which is unfortunate because that program was highly liked by the residents. It's unfortunate that this whole issue is sort of taking us away from the bedside again. We want to minimize our exposure to these patients. I had an attending when I was on a fourth-year student for infectious diseases. He was a world-renowned infectious disease expert, but he was a jerk. But one of the things he told us was you never sit on the patient's bed and you never touch patient except to examine them. Subsequently he went all over the off, the dark end to the dark side. It's one of those people that gave a massive infusions of vitamin B12 and you know chronic fatigue syndrome blah blah blah stuff, but he was just wrong, you know, you touch patients, she said in their bed, you talk with him. That's how you connect with your patient.

Jason: I remember – it was during one of your lecture, you had said this kind of like – I don't know, it was in response to a question and you said almost subconsciously, like, "sometimes it's nice to touch your patients". I forgot what the response – what the context was. I just remember you saying that? And yeah, I yeah, I definitely remember that though.

Erik: There was – I actually saw lecture of, I think it was another physician from UCSF doing like a TED talk about sort of the healing touch of like just even just like a pat on the shoulder or like, you know, just human contact.

Hamill: Yeah.

Jason: Especially now during covid, especially the patients who have covid. It's like I feel like I'm sure like nobody touches them; we're gowned up and like have goggles and like

Erik: can't see their loved ones.

Jason: Yeah, can't see their loved ones.

Hamill: It's like they're lepers right?

Erik: Last question or last two.

Jason: Yeah, maybe like last question. I guess how have you seen medicine change over time?

Erik: We've already talked about EMR. But yeah, but any others?

Hamill: I think part of it is, you know, like the hospitalist movement. I mean there's good and bad for the hospitalist movement. It clearly is more organized and stuff, but there is too much of a push nowadays to get patients in and out of the hospitals. You know, I remember, when I was a resident, you know, we rotated through the VA to, you know, and back then, the patient in the hospitals were in big ward's, you know. You didn't have individual rooms and so you might have 20, 24 patients in a room. Well, at the VA, you know, these guys were all vets, you know? And a lot of more World War Two vets. So they'd sit around telling War Stories all day long and they never wanted to leave the hospital? They didn't want to be discharged and they stayed around for months and months, you know. But, you got to see the natural history of disease to, right? You got to see things work out. Nowadays patients are kicked out of the hospital so quickly that you don't get to see the stuff. So five, six, seven years ago, I was running on general medicine in July and we admitted a young man from Kingwood who had a family normal guy, you know? But he was admitted with aseptic meningitis, he wasn't real ill, you know, we thought maybe it was West Nile, but all the testing came back negative as he was being discharged. I asked the house staff will get a typhus antibody on him. Well they didn't and he got discharged and he was supposed to come see me a couple months later, he never did, but this was July, he showed up in January. He was fine, but I got a typhus antibody then. Well, his IgG tighter was off the wall. So the house staff and students, never knew that, right? Because I didn't remember who they all were and stuff. And yet I found out what that guy had, you know, and it helped me because down the road, I've seen more patients like that. So five, six years ago, we had one of the guys who's head of General medicine that you at San Francisco VA, who's Gupreet Dhaliwal. And if you guys get a chance, you should Google him and see some of the stuff he's written. But he came as the visiting Professor Chief residents at the end of the year, we get to invite a visiting professor. And he was the visiting Professor, so his lecture was from good to great. And we talked about was what you guys need to do, is you need to keep a list of all the patients, you see, then periodically go back in the record and find out what happened to them because you certainly don't know when they leave the hospital and when you find out about that then that's what makes you great. Because you found out you seen what happened to your, either to your therapeutic intervention, or your diagnostic things and that's what that case sort of demonstrated to me. So that's been I think one of the major problems with medicine and DRGs and stuff like that trying to get patients out of the hospital and not being able to see what happened to them. Unless you make a real concerted effort to do. Then if you make that effort, you're going to learn a lot more.

Erik: That's pretty interesting. I didn't think about that, the longitudinal course of patients, you really miss out on it.

Jason: Literally one of the patients that we have right now, we suspecting like an autoimmune cause, but everything's being done outpatient. We're trying to get her out.

Hamill: Yeah.

Jason: In the clinic and everything's been done outpatient. I'm like, I really want to know – she's got like elevated ESR; that's the one test that's come back already. Everything else like we're just we're going to discharge her and then follow up. You know she's gonna have to follow up outpatient. I'm like I am dying to know like what she has actually.

Hamill: Well that's why you got to write down her name, medical record number and then find out what happened to her because then you'll learn something.

Jason: Yeah, yeah

Hamill: Either you're on the wrong track or you were on the right track.

Jason: I guess, last question. So what do you see in the future of medicine?

Hamill: Well, you know, I don't think, I think there will be more of a telemedicine impact on medicine, but I don't think it will be to the extent that it is now. I mean, I think we'll come up with a vaccine for this COVID thing, or treatment or both. And I and so we'll get through this. There may be other pandemics in the future. But I think what this has taught us is that we can respond pretty quickly and that the scientific Community can come up with treatments and stuff like that, so, I mean this will be short lived. But telemedicine, I think we'll have a more impact. I think we will unfortunately probably move more and more away from the bedside, less into inpatient medicine, more to outpatient medicine because we can do so much more as an outpatient work people off. I'm hoping that people will still see the intellectual challenge in medicine and not, you know, not get too cookbook-y about it because sometimes we seem to see that. But I still want people to enjoy it. You know, like I do. I'd like to see the regulatory environment not get so burdensome so doctors don't want to practice. Because you know, I mean I've enjoyed my career, and I want young guys like you guys to enjoy your career, and I don't want to have people make it so burdensome or so difficult that it's like a job and not a, you know, a hobby or something.

Jason: That is the dream for the job to be something that we really love and really enjoy.

Hamill: But I think you can do that, I mean. But you got to you got to take an effort to make it what it is.

Jason: Definitely, definitely.

Erik: Well yeah. And I mean do your point of what you said earlier about how you you like teaching because you think you have a lot to kind of teach us who have not seen nearly as many things as you, I think that's absolutely true and that's one of the reasons we were really happy when you decided to be interviewed by us, we really appreciate and we do think you have a lot that we can learn from. So we really appreciate your time, we know that you are busy, so thank you.

Jason: Appreciate you teaching us also all about the even the diabetic feet. Yeah. And we're not just saying that because you're the residency director, okay.

Hamill: You know I tore this thing out today. Can you see that? Oh drinks. Yeah. Oh man you got we have two new faculty members starting at the VA in July. Two of our fellows and ID section and I want one of them to get interested in diabetic feet. As they're saying here, you know, in the last 20 years, there's been no change in Canada, absolutely no change in the incident to diabetic amputations for diabetic feet. Whereas other things, you know, have improved a lot, so we need some work on diabetic feet.

Jason: Yeah, some new innovation. Yeah, yeah, alrighty. Well yeah, thank you so much once again.

Erik: Yeah. Thank you.

Hamill: Have a good day.