Hospital Medicine, Teaching and Working at Baylor

Erik: This is the Baylor College of Medicine Resonance podcast. I am one of your hosts, Erik Anderson.

Erin: I'm Erin - I'm a writer for this episode.

Eileen: I'm Eileen - I am a writer and sound engineer.

Erin: Today we have the treat of talking to Dr. Zaven Sargsyan. He is an educator and a physician here at Baylor College of Medicine and he actually went to Baylor for med school, so it's really nice to get to talk to him about how things have changed, and how he practices medicine, how that allows him to teach his students better. We wanted to talk to him about his job as a hospitalist. A lot of times when we think about doctors practicing there's like a lot of different ways that doctors are interacting with patients. It could be in the clinic; it could be in kind of the inpatient wards. So, I think hospital medicine is very unique because physicians are just at the bedside with the patient talking to them; usually the patients who are there are admitted. They get a very broad kind of understanding of who this patient is and they're kind of the chief point of contact for these patients.

Eileen: Yeah, so I think the one huge thing about hospitalists is that you said they're the chief point of contact. So, they're kind of like the captain of the team and coordinating between all of the different specialists when you're admitting a patient from the ER who has renal failure and CHF and you're trying to balance how to treat one and treat the other. It really is the hospitalist who kind of comes in and looks at the picture as a bigger whole, and then we'll talk to nephrology and cardiology and what other specialties are needed so that they can all work together - versus other people on the team are just coming at it from sort of a single perspective looking at their piece. 

Erin: I think it's important when we think about the differential diagnosis. We, I feel like, we even as high school college students and pre-meds hear that term and even in med school it's always, ‘what is the differential?’ Like, what are the top three things on your differential and to think about what really is a differential diagnosis. It's not just these three things that are on your head, but it's really thinking through everything that it could possibly be, thinking about the patient as a whole picture, all their body systems together, and then narrowing down and ruling out what it could be.

Eileen: Right, and so an ideal person to do that really is a hospitalist. I think hospitalist is actually fairly new. I could be mistaken on that but in the past, people's primary care physicians would be the admitting physician for their hospital stay and a lot of times primary care physicians now are so busy and have so many patients that they don't really have a chance to work on the wards. So instead of being admitted to a PCP, you get admitted to a hospitalist. So, most people now who are admitted into the hospital will be assigned to a hospitalist and so like you said they can kind of think about all of the different systems - what could this possibly be - and then start narrowing down from there. 
Erik: Yeah definitely and I think Erin and I have had him lecture, and you can definitely see his personality. Like I can just see him being a fantastic doctor and having great bedside manner just because it seems like he's a very caring and empathetic person. And I think that's the kind of person that you need also as a hospitalist because like they're probably going to also be interacting with the patient the most.

Erin: Yeah, I think obviously Dr. Sargsyan's experience as a hospitalist makes him a fantastic teacher just to help med students think about everything that could possibly be going wrong with patients. Even in pre-clinicals when we're just learning from textbooks just to get in the habit of thinking about the patient and everything that the patient represents - all the body systems. Again, and not just, you know, single best answer type things that we're trained usually. 

Eileen: And I think yeah, usually in class it's, you know, what's the one best answer and which answer fits the most you know – a, b, c, or d. But in the real world and in medicine it's important to be able to come up with a broad differential to think of everything it could be, and then equally important to be able to narrow that down and figure out, A) what's most likely and B) what's most dangerous potentially.

Erin: So, yeah just to introduce Dr. Sargsyan he, as I mentioned, went to Baylor College of Medicine for medical school and then went to Massachusetts General Hospital for his residency in internal medicine and then came back after three years, where he practices as a hospitalist at Ben Taub and the VA. Yeah, we're really excited to talk to Zaven Sargsyan today.

[Music] 

Erin: Alrighty, so we are here with Dr. Zaven Sargsyan and we just wanted to ask you to tell us a little bit about yourself first - introduce yourself.

Dr. Sargsyan: Thanks for having me. Introduce myself professionally or personally?

Erin and Eileen: Both, yeah little bit of both.

Dr. Sargsyan: Sure, so I'm from Armenia originally - I spent most of my childhood. And then my family - my parents and my sister - moved to Houston when I was 11, and I’ve been here most of my life since then. I went to high school here, I went to undergrad, and medical school at Baylor. I really enjoyed Houston and becoming a Texan and everything. I'm married - we just had our first kid, uh two and a half months ago. He's doing great and consuming most of our brains and hearts these days in a wonderful way, so that's that. And then work-wise, I do hospital medicine. I work at Ben Taub, the safety net hospital here, and the VA clinically, and then I'm involved with the residency and some stuff at the medical school and really love my job.

Eileen: Great, so I know you said that you went to undergrad in medical school here in Houston and then I believe you went to Mass Gen for residency. So how did you end up back in Houston? Did you always know that you wanted to come back?

Dr. Sargsyan: I did actually. So, it was hard enough for me to decide to even go anywhere just because I loved my experience here at Baylor as a student, and I was also just very grounded here with family and stuff. So, I always kind of knew I’d be back to my personal and professional home.

Erin: So, what's it like to kind of be back where you were in school, and then now you're in attending?

Dr. Sargsyan: It's really cool. It's fun, I mean I think first there's just a sort of an emotional connection to the institution and the experience of all the students and that just feels nice and makes everything um kind of more valent and fun. And then in practical terms it's kind of cool to have some notion of what the experience of the students is like. Even though things have changed, you know, a lot of things kind of stay the same culturally and logistically. So, I feel like I maybe can relate a little bit better than if I was sort of new to the institution.

Erik: I was going to ask - you said some things have changed. Anything that's like striking in particular?

Dr. Sargsyan: In terms of what has changed? No, I mean the curriculum has actually, hasn't undergone a major reform since I was a student here, which wasn't that long ago. I was here from 2007 to 2011. I think a lot of that, you know there's always sort of an ebb and flow of the people at any given institution, so a lot of my attendings I rotated with have retired or moved on and there's sort of a new crop of people. But the students are sort of as I remember them - just great people, really bright people and I would say the sort of core identity of Baylor has stayed true. 

Eileen: If you could go back you know 15 years and you're at the beginning of starting medical school, do you have any advice that you would give yourself as a student at Baylor? 

Dr. Sargsyan: Honestly, I think I was a very happy student, and I don't have a problem with having regrets, but I don't happen to have too many regrets about my sort of MO and choices as a student. I think I would definitely tell myself that you know that everything was gonna work out beautifully and maybe to worry a little bit less. I think that can be applied to every student. I’d probably want to sleep more, and then I would tell my earlier self to read more like fiction and non-medical things. Only like at the very end of medical school and like in the fourth year did I start reading more like I used to, and I realized that was a big way to stay sane and enrich yourself in other ways that I think as a student you sort of have this pressure where like if you're going to read something you want to read your books or notes or whatever, right. But I think there's a lot of benefit to kind of stepping away and staying more broad in your horizons.

Eileen: I think I’m definitely going to steal some of that advice. 

Erin: It's interesting that you talk about that, because I think the curriculum committee and you know LCME in general is trying to promote that. Erik and I right now are on surgery rotation and they're having us do like a narrative medicine aspect in our inter session, and I think just like getting to know your classmates kind of in a different light, and also getting to think about medicine and literature in kind of a different way. You're right, it's all about keeping your horizons broad.

Dr. Sargsyan: That's great to hear and actually I would say that is a big way in which the curriculum and the culture has changed. I think there's a lot more of that in the curriculum as well as in the sort of informal kind of background or hidden curriculum of the students and stuff. A lot more awareness and discussion and learning about, you know, social determinants of health and communication skills and things like that that I think weren't as much a focus when I was a student here. So, it's been a great change, I think. 

Erin: Yeah, so you are kind of a director or associate director I think for IM residency.

Dr. Sargsyan: Yeah, I’m one of the associate program directors.

Erin: Okay, how has that been, getting to decide who gets to be in the program, who doesn’t, like, how do you pick your residents and how do you know who's going to make a good clinician?

Dr. Sargsyan: I mean that's really - so overall the role is something I really enjoy, and I think recruitment is part of the job and selection. But it's not necessarily the most fun part of the job. I think actually mentoring the residents while they're here and thinking about the curriculum and how to help people develop into the best and best prepared clinicians and professionals they can be is the more rewarding part of the job. I think interviewing students and sort of going through the process of selecting, recruiting, is really important too. And it's tough and we do it as a big team. There's a lot of people who both participate in interviewing, advising. I think we're lucky to just have a really great crop of applicants and people who are interested in medicine, in the program, and we really love the residents we end up matching and having the opportunity to work with and train. But it's always, you know, your question about how do you know - it's really tough and I don't think anybody has figured it out. I think a lot of the metrics that people look at don't necessarily reflect the qualities that, you know, for example a patient would love to have in their clinician, right. You try to discern sort of who might best fill that role and also be a good match for your program in particular. But it's always a little bit of guesswork and again you just hope that everybody you interview is going to be more than qualified and whoever ends up matching and showing up is going to be great.

Erik: Well that sort of naturally leads in right to our add-on question.

Erin: You know, with all the hot buzz of Step One now being past fail, I mean that used to be like basically the biggest metric for residencies.

Erik: Or so they told us. I don't know, maybe you can speak to that.

Erin: Legend has it, yeah, how do you feel about the whole pass/fail thing and you know, how do you adjust how to select students?

Eileen: Yeah, because now so many medical schools are pass/fail in their pre-clinical curriculum they've really emphasized to us that Step One is the score that residency directors look at so if you don't have that score how are you thinking that you'll probably adjust?

Erik: Yeah, and just to explain to those who maybe don't know what Step One is too if there's anybody in college or before listening to this. Step One is basically the MCAT of residency, I think that's probably fair to say. It's a test that people generally take after a year and a half or two years and is sort of the culmination of all your pre-clinicals, and has been used as a metric to whether you should get it into a certain specialty. 

Eileen: So, the testing never stops. You got the SAT, you got the MCAT and then Step One which as it implies, is just the first.

Dr. Sargsyan: I think that's a question with a very complicated answer. I'm trying to think about where to even start. I think it's very it's actually very much on students minds I think, and it's been one of the biggest probably, sort of, news and what will be one of the biggest changes in medical education for a long time, believe it or not. So just by way of background. So, as you guys said USMLE step one is, that's the US medical licensing exam, right, step one. And the fact that it's labeled as such implies that there's subsequent steps. So, there's a step two CK - clinical knowledge, which is also a multiple choice knowledge based exam. And then there's a step two clinical skills which is an entirely simulated patient exam, and that one has always been reported as pass/fail. And then step three of the licensing exam series is usually taken during residency. And actually, historically USMLE step one was never meant to be a discriminatory exam to aid in applicant selection for graduate medical education. It was meant to be just a licensing exam for the state licensing boards to say okay, this person is qualified to practice medicine just, you know, along with the other steps. And over time it was sort of evolved to be used in this in this way in you know along a scale and to play, as you guys said, one of the biggest sort of determinants of selection, especially for more competitive specialties. And again, it was never designed to be such an exam and I think when it has been studied there's no convincing evidence that there's a strong correlation between how you perform on step one with your subsequent sort of qualities as a physician, as a colleague. So, it was always problematic for it to be used in that way. Additionally, I think over time we've realized too that the test has created really an undue burden on medical students in terms of the emotional stress, in terms of some of the kind of bias it creates in potentially closing opportunities for certain individuals who don't have as many resources to take the courses or buy the books or allot the time, or whatever it might be. Against individuals who may not be as good as test takers but again are just as good or better as clinicians, communicators, etc. And one sort of personal beef I've always had with it is that it tests the, in my opinion, the least important kind of content of medical school, which is the pre-clinical, the basic sciences rather than the more kind of practical, real life clinical knowledge. Even if you were going to sort of use a knowledge based test to prioritize in that way. So, you know, people including myself spent dozens and hundreds of hours memorizing chemical structures and sort of various details about microbiology and other things that I have since long forgotten. And I actually, this has never been tested but I really think that if you were to take all of the practicing physicians in the US right now and have them take USMLE step one, they would fail it. Which is ironic right it's like the licensing exam and presumably the longer you've been practicing, the more prepared you are to continue to be a doctor, but you would you would fail step one. Whereas I don't think that's true about step two ck. I think most doctors would pass step two ck, but they would fail step one. So again, why is it being used as this sort of discriminatory, most important big test of your life supposedly. I think one of the other challenges is all medical schools, all course directors, periodically and really continually should be reassessing their curriculum, right. Things change, the practice of medicine changes, and you always want to think, how can I better teach my learners, prepare them for their eventual careers in practice. And the fact that this test was such a critical point of achievement for students, it actually shackled medical educators in from focusing on what really matters in preparing the best future physicians. And it informed a lot of the curricula the medical students had to sort of choose and teach to, because if you don't prepare your students to pass step one or really rather to excel at step one, you are limiting their opportunities for postgraduate training. So, in my opinion, from the perspective of someone who just cares about high quality medical education, I feel like a lot of curriculum medical schools have been liberated have been unshackled to actually think about how to best create the best physicians rather than the best step one takers. And I think that that should be great news and that should be celebrated for everyone. Now as a program director, yes, we're facing new challenges. And especially with the problem of overapplication for residency that most specialties have unfortunately suffered from, we just get too many applications to be able to thoroughly review each one and discern the qualities of the applicants beyond objective, easy, number based things. And the step one was used traditionally to screen a lot of applicants and to at least create one kind of filter through which to get started and narrow down the field. But if you take a metric that wasn't that good and get rid of it, it might make your job harder, but maybe it's still a good thing. So even from that perspective I'm actually not sweating it too much. Maybe we'll have to rely on step two more, but hopefully we'll also just take a more holistic approach to reviewing applicants and what they have to offer. So anyway, I think across the board I'm overall optimistic that it's definitely a positive step and that the challenges will be met in turn. Sorry that was a super long answer. 

Eileen: It's so helpful, and as a future applicant for residency, very reassuring to hear. So, speaking of residency have you ever considered doing any sort of sub-specialty within IM and if not, why, and if so, what would it be?

Dr. Sargsyan: In the last 10 years, I've probably seriously wanted to do every internal medicine sub-specialty fellowship, which was a good sign that maybe I shouldn't do any of them and that I'm a generalist at heart. I think I really love my field of general internal medicine and I feel like on a given day sometimes, you know, if it's the content you're interested in of a sub-specialty, right, well then when you have a patient with myocarditis that you that you're taking care of then you're involved with the content of cardiology, right, and you can get to be a cardiologist of sorts in the moment. And then the next day you may have an onslaught of people with respiratory complaints and lung diseases; well then, you're getting to learn and apply your knowledge in that field. So, I just really like the breadth and the fact that you get to constantly be learning and getting better and working with the sub-specialist to collaborate and both take care of that patient on a given day but also to learn from them and be more prepared for the next patient.

Eileen: Yeah, we were actually just talking about how it is that sort of being the generalist gives you that 30,000 foot view that you can see something you might miss if you're only focusing on one specific system or one aspect of the patient.

Dr. Sargsyan: For sure.

Erin: So, you're an academic hospitalist which means you get to work with residents, and students, and maybe even high schoolers, shadowers, the whole totem pole. What is your favorite part about working with medical students and what is your least favorite part, or maybe more frustrating part about working with us? 

Dr. Sargsyan: So many things. I love working with all trainees, but I think it's such a privilege to work with students who just bring a new fresh perspective and haven't been sort of mixed into the into the sausage yet. I mean I think you just get sort of acculturated and indoctrinated into the clinician side of things so quickly that you very much lose touch oftentimes with more experience with the patient experience side of it. I just never cease to be amazed for example how much I learn about medicine every time I have even the smallest or most trivial experience on the patient side either as a patient or a family member or whatever. And I think that that's a perspective that medical students often bring to the to the team. They just, they're often able to empathize with the experience of the patient more than those of us who've been just doing it for longer day in day out on the doctor's side of things. So, I think that that's a great privilege. And then I just, I love learning and I love watching learning happen and it's just, seeing a student get better at a skill on a daily basis literally or to apply something immediately that they learned the hour or the day before. It seems like a simple kind of everyday, mundane thing, right, that learning process but for me it's just really just a joy to observe and to be a part of. So that's just why I like the academic environment in general, but for students that learning curve is even steeper, so I think it's even more sort of drastic, salient version of that process.

Erik: It's good to hear that because I know that there have been times I've felt - you know and I think you probably remember being a medical student - you ask a question that you think is stupid and maybe outside the box, and most of the time it probably is, but maybe there's that one time that like, ‘oh yeah that's actually a good point!’

Dr. Sargsyan: Erik that not the exception. I would say that that happens on almost a daily basis where there's so much dogma in medicine and you just take so many things for granted that aren't necessarily true or don't necessarily make sense. It's just inertia, it's habit right, and yeah. I can't say how often I say the words, ‘you know what, like, that's, I've never thought about that, but that's such a great question. Yeah, I don't know why we do that.’ And those questions come from students not senior residents. 

Eileen: That's really fantastic to hear as a medical student. I'm also curious if there are any particular challenges you have working with us.

Dr. Sargsyan: Challenges, yes, lots. I think teaching in general and including teaching medical students is a very elusive art. and I think if you find it easy all the time, you're probably not paying enough attention. But I think for me, that sort of that intrinsic challenge of the fact that every learner is different, and they start in a different place, and they have sort of different needs and learning styles, and the interaction is so complex in so many ways. I think that challenge is a positive one where it just makes things interesting. It makes a job always, always difficult and always something to aspire to do a little bit better. You know earlier when you asked what are your least favorite things, I think that's a slightly different question and I'm trying to think of something more negative about the experience. And I guess the only thing is level of interest among some senior students who maybe have differentiated themselves into a certain field, and when they're rotating on internal medicine, sometimes they may not realize just how relevant everything is to every other specialty. I think that's the only situation where if I ever get frustrated it's sort of like, wishing I could be better at motivating people to stay engaged even if they think what surrounds them is sort of less relevant to them. But maybe they're right, maybe it isn't.

Erin: Can you just tell us a little bit more about what a day in your life looks like, maybe from academic and also, what you do outside of work - any hobbies, leisurely activities...

Dr. Sargsyan: Sure. My job is such that my days are actually very different from each other. So, oh yeah, I can for example just look at my calendar from yesterday. So, I currently am not on service meaning that I don't have any clinical, any patient care responsibilities, so a lot of what I'm doing is you know sort of academic work, teaching, things like that. So yesterday in the morning I had a one-hour workshop that I led for residents, and then I had a couple of hours off, so I went back home and played with the baby, went for a run. And then in the afternoon I had another lecture, a new conference talk, with the residents, after which we had a residency meeting. And then in the evening had a drink with a colleague and caught up on some academic work and stuff like that. And then this morning I was completely off and this afternoon I’ve had some more classes and meetings and things like that. Tomorrow I don't have anything scheduled at all, so I'm just gonna relax, and then next week though, on Monday, I start with one week straight of working every day in hospital taking care of patients at the VA and the following week is again sort of more flexible, kind of on and off. The week after that I’m working at Ben Taub with residents and students on the wards so it's very variable. Yeah, it's a little bit of kind of clustered more dense duties, and then more flexible time and time off. 

Erik: so that actually brings up a good question of - how is that determined? And I've thought about this with respect to just all the faculty that come and teach us, too. It makes me wonder - do you have a set amount of time that you are supposed to, as an academic physician, do you have to do some duty like whether it's teaching, or whether it's being a program director, or have some part in a curriculum? Or is it kind of up to you to determine?

Dr. Sargsyan: that is really, it's so variable. Yeah, I think the career paths and job descriptions within what may seem like a single descriptor of academic medicine can be just vastly different. So, for example there are Baylor faculty members and fantastic clinicians and educators who see patients. And when they're seeing patients in their clinics or on wards, they often have residents who come and work with them who see patients with them. Sometimes students will rotate through those rotations and they do a lot of teaching in a clinical setting. But that's what they do - they love being doctors, they love being teachers when the learners come to them, and they're exceptionally good at it. But they don’t feel the need nor have any kind of pressure necessarily to go to teach at the medical school or to give extra lectures or to do research or anything like that. And I think that's a very worthwhile calling right, I don't know if you guys agree but that sounds pretty good to me actually, and we need people to do that. There's other people who are more involved at different levels of medical education who, in addition to doing that or instead of doing as much of that, may spend more time giving lectures or participating in certain or well-defined sections of the curriculum. So, for example, one of the things I do at the med school is I am a small group facilitator for the PPS course, which is like the first year kind of introduction to clinical skills course. And that takes up most my Wednesday afternoons and it's kind of a discrete, defined educational role that I really really enjoy, but that I have been given opportunity to do and that I really like but that I don't have to do if I don't want to, you know, I could stop doing it. There's other people who are predominantly more researchers and they may spend 80 of their time and their salary, you know 80 of their salary, is sort of dedicated to protect their time to do research.

Erik: I guess that's sort of my question - is that determined like the year before? And I mean we don't have to obviously get in the specifics of who's going to make more if you work on here and here, but your salary does depend on like if you're spending most of your time doing this thing, then it's going to affect it?

Dr. Sargsyan: Yeah, I mean I would say that most people within an institution and within a practice field like within a specialty - it's not that your salary is determined by how much of what you do. It's that the breakdown of your time is determined by your interest as well as by your demonstration that your time and the institution’s resources are well spent. So, for example if you protected 80 of my time and gave me 80 of my salary to do basic science research, that would not be a good choice because I don't have the right skills to do that and I wouldn't be a productive scientist. 

Erik: Well and I think you'd have to supplement it with your grants. Yeah, but I hear you that's - it's a long way off for most of us but to be thinking about because everybody's asking, ‘oh do you want academic medicine or private practice?’

Erin: I have no idea about that yeah like logistically.

Erik: But that's the thing. None of us really know how any of this stuff works.

Dr. Sargsyan: I think it's, I think that's okay. I think it's good to be asking these questions and to have a general sense of the lay of the land. But I think it's hard enough to, you know most people go to medical school because their primary goal is to become a physician. And that's a hard enough task and a worthy enough calling to really focus 99% of your effort and energy and time on doing that as well as you possibly can. And you can explore some extra interests whether it's teaching or scholarship or leadership, administrative work, health policy, whatever it might be, and potentially with an eye of having incorporating that into part of your career. But it won't be at all “too late” for you to work on those interests and skills at a later time. So yeah, I don't think you have to have figured out exactly what you want to be doing 10 years from now when you're a medical student. That's just my opinion. 

Eileen: I think it's really interesting. I hadn't necessarily considered how different the skill set is for someone who is teaching in clinic kind of on the job versus someone who's teaching in a lecture hall versus someone who's doing kind of a hybrid of both, which is maybe more like what PPS is. Can you talk a little bit about how you have to adjust your teaching style for each of those different settings?

Dr. Sargsyan: Yeah, you definitely do. I think it's, they are different skills. There are some principles that overlap and apply to all of them, but giving an auditorium lecture is so different from teaching a small group interactive session, from teaching in the simulation lab, from teaching in front of a patient. You have to realize that those are different skill sets and different performances and considerations and everything and be reflective about the components and the determinants of your quality as a teacher in each of those settings. And that's why like if you do - the Baylor faculty here have a wonderful program that’s called a Master Teacher Fellowship program. It's a two-year kind of longitudinal curriculum that a lot of faculty take advantage of and as part of that there's discrete sessions - there's workshops about how to refine your large group presentation skills. And then there might be a different session about how to teach at the bedside, there might be a different session about small group teaching, and yeah, the conversation is very different in each of those.

Eileen: I think it's also challenging in medicine because there's not always necessarily one right answer. On the test there usually is a “best answer” but in life it's not always that way. So, we were wondering if you could tell us a little bit about how you teach your students to sort of walk through the process of figuring out what's going on and a little bit about what a differential diagnosis is.

Dr. Sargsyan: Man, so first, before talking about differential diagnosis, I just want to say a few words about diagnosis, period. And this may be obvious, but diagnosis is at least half of what you do as a doctor, what at least internal medicine, that's our core task, that's our core procedure, right. Because the body breaks in a million different ways but the symptoms or the abnormalities that each of those illness entities, each of those diseases causes, a lot of times is the same. Like you could have a million reasons why you're short of breath and people don't walk in through the hospital door or the clinic door and say, ‘doctor I have hemophagocytic lymphohistiocytosis,’ they like walk in and say like ‘I’ve been tired lately.’ And to go from symptom to diagnosis is an incredibly important and challenging thing, because if you don't know which disease entity is causing the problem then you have nowhere to start to figure out how to make the patient feel better, and live longer, etc. And it's incredibly challenging and the data speaks to that in terms of how common it is to have diagnostic delay, diagnostic error. I think it's a huge part of what doctors and internists think about how to do and how to do better and it's a huge part of the sort of long game curriculum of what you learned to do as a clinician. As a result, I can't give you a very satisfying short answer the rest of the way there. But I mean to speak to differential diagnosis though, that's basically, that is the differential diagnosis - is the list of possible diagnoses, list of possibilities to explain a patient's symptoms or abnormalities, when there is not yet a firm diagnosis. And kind of a key concept there is that there's almost always actually some diagnostic uncertainty even if you think that you've recognized a pattern, that you think you know what's going, on just based on what the patient told you based on the physical examination and labs. There's very often and, statistically you're going to run into this, where you were wrong with that impression, and there was you know a less common disease or something presenting atypically that tricked you and in fact it was something else. So that's why it's always important to construct a differential diagnosis to say okay, what do I think this is most probably, but importantly if it's not that what else could it be. Because if you don't think of those alternate possibilities again, you don't have a good chance of making the correct diagnosis. So, I think in terms of how I like to teach those concepts again is to emphasize the complexity and uncertainty inherent in the process. To always emphasize the importance of creating a differential diagnosis and sort of that kind of paranoid humility that you're bound to be proven wrong on most days. And to try to stay ahead of that and then there's you know a lot of kind of complicated approaches to how to approach the differential diagnosis in terms of creating it. You know, using different systematic approaches, frameworks, schemas, for a given complaint or in general. And to always try to develop your own processes realizing that again it's an extremely complex and lifelong skill to work on.

Erin: Wow, thank you, very well said. So, we know that your wife Dr. Sherman also works with you. Can you talk a little bit about what it's like to work with her? Do you get tired of each other, do you get frustrated?

Dr. Sargsyan: So, the answer to this question would be I'm sure very different. People are different, relationships are different, and then the working relationships are different, too, but we absolutely love it. We actually have like very similar jobs so it's not just that we work in the same place but were we're often on the same ward. We're often in the same meetings and discussions and stuff, for us it's really nice like spending time with each other and we enjoy spending even more time with each other at work. And then I think just the mutual sort of understanding of what our jobs are like as well as just being an ally, as sort of a second opinion. We feel very lucky. Like a lot of the, probably most talks that I give for example, have been like torn apart and rebuilt by Steph like at home, and they're so much better for it. And it's been really nice for us.

Eileen: Do you ever have to sort of set a rule when you're at home that, we're not going to talk about work anymore? 

Dr. Sargsyan: yeah, but I think it also just happens naturally. I think most of the time we enjoy talking about our work. We're very passionate and we don't necessarily get tired of it too much and if we do, we just naturally transition to something else or something else will sort of catch our attention naturally. Maybe it's also, maybe we also don't run into the problem because we don’t, we're not big complainers, so a lot of times when we're talking about work it's in a positive light where we're either debriefing and talking about something good or trying to brainstorm and troubleshoot so we don't tend to kind of get bogged down or get tired of it as much.

Eileen: I think that's kind of the dream to have a job that you love doing and you want to talk about it. You’re interested by it. I'm sure also with a two and a half month old at home you have plenty else to focus on.

Dr. Sargsyan: Exactly right, so that's the kind of thing that like naturally will just take your attention and your priorities and turn it upside down. And so yeah, we do have to be very conscious though if there's a third party, so then we definitely obviously tone it way down from our normal sort of dinner making banter.

Eileen: What do you guys like to do just for fun around Houston?

Dr. Sargsyan: We both like to spend time outside, so we'll run around a neighborhood, walk or run to different coffee shops. We like spending time there, throwing a frisbee, I don't know, we kind of treat the neighborhood park as our personal sort of backyard. Yeah, I like the kind of casual existing-in-the-world scene of Houston. I wish it was a little more terrain-y, a little more mountainous.

Eileen: Yeah, I do wish Houston had a little more nature for us. 

Erin: Well, thank you so much Dr. Sargsyan. It's been an absolute treat getting to talk to you and just hearing about your life and about your journey through medicine. I think it's safe to say that we have a lot to learn from our educators and I think it's always really amazing when the educators include the students in the learning and there's kind of this like lifelong process of learning and growing together in medicine. And I think you really exemplify that and yeah, we're just really thankful to be able to talk to you. 

Dr. Sargsyan: Thanks Erin, Erik, Eileen. Thank you for having me, and this was a lot of fun.