When I was a resident ......

"Destiny is not a matter of chance; it is a matter of choice. It is not a thing to be waited for; it is a thing to be achieved." ~William Jennings Bryan

with permission from Med
Sketches by Kimberly Wong

When I was a resident …..  These are words I dread saying as I refer back to a situation or an experience that somehow relates to today.  I am sure those who have heard or have said these words probably feel the same way I do.  It brings up memories of sitting in the car with my father listening to him drone on about some past experience and how it is applies to me and my life.  He would lay those words of wisdom on me as if they were so important.  I, in turn, would blow him off, using those sophomoric words, such as, “you don’t know what I’m going through”, “things have changed”, or “you have no idea how difficult my life is.”  Now, as I look back and remember all those words and sayings, I realize how wise they all were.

with permission from Med
Sketches by Kimberly Wong

A quote I commonly use when discussing experiences with students is by Gustave Flaubert, “there is no truth only perception.”  Nietzsche says it in a different way, “There are no facts, only interpretations.”  We evaluate everything through the lenses of our past experiences, belief structure, and current position.  When we see something today, we refer back to a pattern in our life that is similar and compare.  We take that and compare it to the situation at hand.  It is important to understand that memory is funny and it changes every time we access it.  It is influenced by more recent events, thoughts, and experiences.  

Residency today has changed immensely.  The amount of information a medical student and resident is expected to consume grows exponentially.  There is increased rigor in testing or quantifying a student’s retention of that knowledge.  Yet, the number of hours to acquire this has been restricted.  In my view, this has made residency much different than when I started almost 20 years ago. 

I am here revisiting my blog voice.  I want to give you my perspective today.  For those who have read my blog posts before, welcome back and I hope you will see some maturity in my thoughts.  For those who are new to me, welcome to my perspective.

A lot of us grow up and we grow out of the literal interpretation that we get when we're children, but we bear the scars all our life. Whether they're scars of beauty or scars of ugliness, it's pretty much in the eye of the beholder. ~Stephen King

WELCOME

"There will come a time when you believe everything is finished. That will be the beginning." ~Louis L'Amour 

For my previous followers, I thank you for coming to the new site; for the new follower, I welcome you.  Those who new me from before, I was known as someonect in the blog world and Staff on orthogate.  I have written many blogs on topics in the past ranging from how to get into a residency to problems with residents today.  I had also posted many of my random thoughts.  In the version 2.0, I plan to revisit some of these thoughts, as well as, update many of them.  I hope this will be helpful to many.  Thank you for visiting and please come again.  Welcome to The Attending Perspective.

"Every new beginning comes from some other beginning's end." ~Seneca

The "Arte Y Pico" ... My First Blog Award ... and I got 2

If thou desire the love of God and man, be humble, for the proud heart, as it loves none but itself, is beloved of none but itself. Humility enforces where neither virtue, nor strength, nor reason can prevail.
~Francis Quarles

This year I have been honored with 2 awards that I don't know if I deserve, but have received them none the less. Every time I am given a compliment or an award, my first instinct is to say, "I am not worthy," or "so and so is better." A wise person once told me, instead of trying to be humble, just say thank you. So, Thank you.

I thank the residents for awarding me the Resident Teaching Award for 2008. I am particularly proud of this award.

I also thank my 2 blog friends, Make Mine Trauma and Chrysalis Angel, for awarding me the Arte Y Pico blog award.

Make Mine Trauma

Someonetc at Orthopaedic Residency. He cleverly incorporates everyday challenges and situations as a mirror into the challenges of training ortho residents as their attending. He is constantly striving for more creative, motivating and successful methods of teaching.

Chrysalis Angel

Orthopedic Residency – This blogger actually found me one day, and I’ve been the one reading him ever since. Occasionally he disappears and then reappears out from behind his work and home life, balance is essential you know. I hope he comes back to write more often, I’m going to be especially interested in what he has to say now.

The rules of this award are as follows:

1. You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.
4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.
5. To show these rules.

So as part of the rules, here are my chosen blogs:

1. Midwife with a Knife - This OB/GYN who specializes in maternal fetal medicine bring her insight about medicine, teaching, and life. Through her blog, she shares her personal struggles.
2. Musings of a Dinosaur - This is a well written blog by #1 Dinosaur, a family practice physician. His wisdom and experience in both medicine and life permeates his writings.
3. Medical School of Hard Knocks - This is a relatively new blog started this year. It is written by a medical student, CSTEW. He bring his humorous insight in tho the medical student mind.
4. Hurricane Jill - This former general surgery resident, future neurosurgeon, and now pharmacist consistently writes her humorously honest prose about her day to day life and struggles.
5. Crzegrl, Flight nurse - Crazygirl or Emily is an awesome flight nurse with a wicked sleeve. Her blog continues to evolve. She is a little crazy and maybe even zany. Her blog is no different. She is also military, Hooah.

Humility is the embarrassment you feel when you tell people how wonderful you are.
~Laurence J. Peter

"Sorry about Michigan" ...

Do not dwell in the past, do not dream of the future, concentrate the mind on the present moment.
~Buddha

Life is always throwing us curve balls. In medicine, it is easy to get caught up in work. Medicine consumes. As I have said before, I am a grunt. I work. I teach. I mentor. It is my work persona. Outside of work, I am a husband, father, friend, and blogger. Balancing these roles is very difficult. Often, one overshadows the other.

Over the last few months, I have been engrossed in medicine. My long days at work brought on by emergent surgeries, OR delays, and over booked clinics. Mentoring keeps me in the office answering the questions and concerns of residents and medical students. Administrative meetings for the residency, medical school, or hospital, fill my lunch hours and evenings with bad coffee and cookies. Mentally fatigued, I come home to a family starved for attention. The dog needs to be walked. My daughter needs to tell me about her day. My son needs to be read a story and put to bed. Then there is my wife who wants to share with me what the kids are doing, changes she wants to make on the house, vacation plans she has for the future, and things friends and family are doing. There were days that I don't think I had anytime for myself.

Last week started like every other week. Monday was a long clinic day. Tuesday was a long OR day because of OR delays. Wednesday kept my head spinning with OR, clinic, OR, Clinic, and then a consult that changed my week and probably helped to bring me back to humanity. I was consulted on a patient that is well known to me and the hospital. His disease is chronic and likely fatal. Studies were ordered. I reviewed them and realize that he needs surgery, a big surgery. I sit down with the patient and his father. We discussed the options and our goals. Mom was not present because of another family emergency. After going through the options and expectations, they elected for surgery.

Wednesday night, I was on call at the adult hospital. I was up all night. Thursday long OR day and I was on call at my little hospital, luckily did not have to go in. Friday, surgery day, we had a pre-, post- op spine conference, I gave Grand Rounds to rheumatology, and then went to clinic. The case was in the afternoon. OR was ready. All of the implants were available. Anesthesia was informed of all of the problems and they wereready. Pre-operative plan was done. I was ready.

I walked out to talk to the patient and his parents. Mom was there apologizing for being out of town dealing with a family tragedy. I explained the planned procedure to the mother and she understood. At the end of my discussion, my patient said to me, "dude, I am sorry about Michigan." He is a Notre Dame fan. Although he struggles to be like other kids, he was at ease here. He has been in the hospital more than he has been in school. He knows that he has a disease that is likely fatal. He and his family have come to terms with this. Now, it is about quality of life.

We went back to the OR and anesthesia places lines. I visualized my plan. My mind's eye showed me the procedure, step by step. I was ready. After lines were placed, we positioned the patient. At that moment, a wave of emotion came over me. Tears filled my eyes. I didn't want to make a mistake. I questioned whether I was doing the right thing. I didn't want to be the person that shortened young man's life. He trusted me. His family trusted me. Never before have I doubted my own skill. So, I composed myself, re-centered. I said a prayer and ask for guidance.

In the end, the case went flawlessly. My breathing became easier. I spoke with the family. They were sitting comfortably smiling and joking. I explained that everything went well. They were at ease. They were dealing with this big surgery and a family tragedy, yet they were comfortable. Their family was centered.

There are times when I feel sorry for myself. Whether I am working too hard or have too much family responsibility, my life is never as hard as my patients life. Dealing with death and dying requires strength of character and is by far more emotionally draining than anything I ever encounter. I wish I had the spirit of my patient. Today, I am going to follow his lead. It is time to re-balance. It is time to get out of myself and back to life. To my friend, I say thank you for your wisdom and GO BLUE.

The price of anything is the amount of life you exchange for it.

~Henry David Thoreau

All they need is calm assertive leadership ...

Pathetic/benign
Accept it/undermined
Your opinion/your justification
Happy/safe
Servant/caged
Malice/utter weakness
No toleration - Invade
Committed/enraged/admit it
Don't condescend/don't even disagree
Destroy/decay/Disappoint/delay
You've suffered then, now suffer unto me.

Obsession - take another look.
Remember - every chance you took.
Decide- either live with me
Or give up - any thought you had of being free

SLIPKNOT - The Nameless

We just got a new dog, a Rhodesian Ridgeback. She is a beautiful dog. She is both sweet and feisty. She is a puppy and, as such, has all the puppy traits. To break her of all these traits, we attend puppy class and read all sorts of opinionated books on puppy training. We have even watch, on occasion, Ceasar Millan . What I have learned is that dogs have a pack mentality. They look for a pack leader, and try to improve their position within the pack. As I work on my own family pack and being the pack leader within my home, I couldn't help but recognize the similarities of the dogs' approach to a pack and residents' approach to residency.

It is July. The month that all residencies have the transition. The Spring residents are experienced and polished. They understand their roles and are comfortable their position. This is in total contrast to the Summer residents. They have yet to figure out their role. Like dogs in a pack, they are all jockeying for position. As an attending, I am suppose to be the pack leader. I find humor in this battle for position. Sometimes, they challenge one another. On occasion, someone in the pack challenge the pack leader. How the pack leader approaches this confrontation determines his/her status in the pack and can not be taken lightly.

In training my dog, I have learned some training techniques that are different from when I had my first dog. The choker chain seems to be out. There is no more rubbing your dogs nose in their accidents. Now, the trend is crate training and the kinder gentler pack leader. The overall goal is still to assert your dominance in a less painful but assertive way.

As a residency pack leader, I can't follow Ceaser Millan's fulfillment formula of exercise, discipline, and affection. Although it would be fun, the ACGME may frown on it. Ceasar does have some advice that can be parlayed into residency education. He recommends setting rules, boundaries, and limitations. Along with being consistent and fair, these can be effective techniques in teaching/training adult learners.

In the past, if a resident would question or challenge his/her attending, s/he would be handed an embarrassing beat down comparable to a WWE smack down. Many would use their favorite tools of fear and humiliation. In the new age of the educator, things have changed. Socratic questioning is losing favor and may go the way of the choker chain. Although the techniques have changed, the ultimate goals have not. As a dog trainer, our goal is to have an obedient dog that follows commands, doesn't make a mess of the house, and is kind to others. As a physician educator, our goal is to produce a competent physician/surgeon who has the needed skills, is considerate of others, and understands his/her limitations.

Calm assertive leadership is Ceaser's recommendation to the pack leader. Following this rule is tough. When the puppy nips at your toes or the resident questions your treatment method, you just want to smack them, figuratively speaking. I like to tell my residents, "my pimp hand is strong." I know this is not the way to approach it, but the urge is there. In the end, I have to fight that urge and smile. Instead of the physical punishment, I have to use guidance, reinforcement, and occasionally a treat. Eventually, they will learn, and if they don't, I could always just take them to the pound.

“Patience and perseverance have a magical effect before which difficulties disappear and obstacles vanish.”

~ John Quincy Adams

I am the boss of me ...

Invictus

William Ernest Henley

Out of the night that covers me,
Black as the Pit from pole to pole,
I thank whatever gods may be
For my unconquerable soul.

In the fell clutch of circumstance
I have not winced nor cried aloud.
Under the bludgeonings of chance
My head is bloody, but unbowed.

Beyond this place of wrath and tears
Looms but the horror of the shade,
And yet the menace of the years
Finds, and shall find me, unafraid.

It matters not how strait the gate,
How charged with punishments the scroll,

I am the master of my fate;
I am the captain of my soul.

We are well into another July. Like all of the previous years, nothing seems to change except my age. The residents switch over and ascend to their new status: interns to residents, juniors to chiefs. Everyone is in their new role, but my role stays the same.

In this new academic year, I continue in my role as surgeon educator ... lecture, clinic, surgery. I am a team player. If my partners as for help, I am there. I have a difficult time "dumping" on others, instead "I suck it up". Again, I am a team player.

I try to model for my residents what I feel are good characteristics of an orthopaedic surgeon. Giving them insight into errors I and others have made in both thought and technique. I model characteristics I hope that they will pass on to those behind them and utilize in their practices. It is my way of giving back in homage to those who spent that time on me.

Today, I sit in my office after 7 waiting for a case and I am not on call. Why? I feel it is the right thing to do for the patient. On the other hand, my all of resident have gone home. I guess I can't expect that they too would feel the need to stay, but I can still hope.

So, I continue to model.

“Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.”
~Albert Einstein

Fly on Little Wing

“Fear of failure must never be a reason not to try something.”

~Frederick Smith

You know it is hard for me to resist a challenge. So, when my father-in-law asked me if I wanted to climb Snowdonia, I said sure. I am reasonable fit. I can put on some hiking shoes and walk up a mountain, no problem. I think I forgot I have a little fear of heights.

I looked up from the bottom of the mountain. The top was cloud covered. There was a chill in the air, a few clouds, but no rain. I put on my gear and away we went. We were the first on the well traveled. There had been many before us.

Like many journeys, it is hard to imagine how hard it will be. We rely on those before us to lead the way. Educational journeys are no different than physical ones.

The path residency is well worn. At the beginning, the end is hard to see. We are given a glimpse of the end by those ahead of us. For the most part, we feel prepared. Our gear has been packed.

We walked to the base of the mountain at a brisk pace. The mountain streams flowed into clear lakes. Barely breathing heavy, we reached the beginning of the difficult climb. My father-in-law led the way. This wasn't his first time. I needed his wisdom to show me the way.

In residency, it is important to be given guidance. Those with wisdom should guiding you way through the difficult tasks. Although the books and literature give you some perspective, they do not give the whole story. Those colored pictures by Netter do not give you an idea of how to place retractors or set up a room. Most technique books fail to give you all of the information needed to go through a procedure smoothly. This is when your guide comes in handy.

Walking up the mountain, it was clear to me I would not be physically challenged. Although it was steep in areas, it was not physically hard. I quickly over took my guide, bounding forward far ahead. As I looked back to see where my partner was, the reality of what we were doing hit me. We are climbing a F%#k#$g mountain. What was I thinking?

As the years go by, it is common for learners to feel that they have surpassed their educators. With more experience and confidence, the learner may question his/her educator's rationale for a specific treatment. They may feel there s a better way, but lack the experience to know all of the positives and negatives of the treatment they have chosen. It is only when they are allowed to go forth with their choice or to complete a procedure without much educator input that they see their inexperience and the holes in their education. With their errors in thought or technique brought to light, the learner and educator can work together to improve and in the end succeed.

My heart beat faster. How am I going to complete this task? I adjusted. I found ways of decreasing my fear and improving my chance at succeeding. Keeping my head down and pushing forward, I overcame my fear and made it to the top. I completed the challenge.

With every other step forward, there may be a step back. But it is only with being self critical, that we can grow. It is only with acknowledging you weaknesses, fears, and errors that you can improve. It is important to continue to push forward, always taking into account your limits.

As I smile for my summit picture, I had the scary realization that I wasn't done. I still had to walk down.

For all of you graduates, remember this is not the end, only the beginning. Your education has just begun. This is only the first peak at the beginning of your career. As you begin in your journey, here are a few words to remember: stay self aware, listen to you gut and your patients, you can always be better, and always do the next right thing.

So, with my task only partially completed, I grabbed a hold of the mountain and walked down.

“Courage is not the absence of fear, but rather the judgement that something else is more important than fear.”
~Ambrose Redmoon