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This is Residents in a Room, an official podcast of the American Society of Anesthesiologists, where we go behind the scenes to explore the world from the point of view of anesthesiology residents.
Do you have that passion. If you're doing that through your career, could you be happy?
There's a lot of new material that comes out in journals and elsewhere. And I still read about those cases.
In the first couple of years out of residency, I think your biggest role should be to figure out how can you contribute to that group?
DR. MADA HELOU (HOST):
Hello, everyone, and welcome to Residents in Room, the podcast for residents by residents. I’m Mada Helou, the Program Director at University Hospital’s Cleveland Medical Center. Today I'm going to be leading the Program Director takeover of your show. I'm here in the house with some fellow Program Directors. Can you all please introduce yourselves?
DR. ROBERT GAISER:
Yeah. This is Robert Gaiser from, Program Director at Yale University.
DR. MICHELLE PARRA:
I’m Michelle Parra, Program Director at the University of Iowa.
DR. JACK BUCKLEY:
I'm Jack Buckley. I'm the Program Director here at UCLA Medical Center.
DR. HELOU:
I thought we could talk about expectations today. Once residents are in your program, what can they expect from you? What are your responsibilities towards them? And maybe what aren't your responsibilities, so much?
DR. BUCKLEY:
I mean, I think my primary responsibility is, most of us go have the goal of being a mentor to the residents, to be available to the residents, to kind of answer questions, to kind of guide residents through the process. You know, I think one of the biggest things we can do is just to help make sure the residents understand that they're making the progress they should, you know, because unfortunately, with anesthesia, we don't get the same feedback by watching our peers struggle, so a lot of times residents don't realize that everyone is struggling along with them. And that's one of the things I try to do as the Program Director, especially the junior residents, is just to kind of help, you know, them understand that they're making the progress they should.
You know, I think what the question is, what are not our responsibilities? I, I think the biggest thing is, I'd like to think that all residents, you know, you are now physicians. You're adults. You don't need me to guide you through every step of the way, meaning like how to study, like what to study. And obviously, I will tell you my perspective on the big picture, but I'm not going to be telling you day to day, you know, you need to be reading a textbook. I, I go with the belief that you're well past that.
DR. GAISER:
Yeah, so, we will make sure they get a superb education. We will make sure they get a superb clinical experience. We expect them to be full participants in this. We expect them to be prepared. We'll make sure they get a chance to do things together, but not every weekend. And they need to maintain their own social calendar.
DR. PARRA:
I think residents can expect us as Program Directors to be sounding boards and to be their advocates. I think they can consider us as resources. I think it might sound cliché, but people kind of have to do the work themselves to get the benefit out of it. And I think, you know, most residents do come into residency training knowing that it's going to be rigorous, that it's going to be hard. And that's where we can show up as their advocates, as their sounding boards and point them in directions of resources if they need them. But we cannot do the work for them.
DR. HELOU:
I definitely agree with that line of thought. Any time that I discuss this, both in interview season, or just in orientation for my new residents, I always tell them the journey is easier when the goal’s in sight. The goal is to become excellent physicians, to take care of patients and do the best possible job. And so when that goal is in mind, rights and responsibilities become very clear. It's our duty to provide them with a wide clinical experience and a good education. It's our responsibility to provide them with feedback and suggestions on ways to improve. However, it is their duty to recognize that residency is incredibly hard, that it takes a lot of hours, and that becoming a good physician will entail a lot of busy nights on call, heavy work weeks. And despite that, we can still find a way to manage our time efficiently and maintain a reasonable social life. But it's going to be hard. And so I think that once that attitude is kind of taken upon the resident, everything suddenly becomes easier because it's all about the expectations.
So that being said, we can move on to doing a little bit of myth busting. Are there any common misconceptions that residents have when they come into programs that we can bust today?
DR. PARRA:
I think one of the underlying myths that maybe isn't verbalized from residents coming into programs is a perception that a program is something that’s static. There's an absolute to the training. I'm going to do this, that and then this. And I think one of the things that I've tried to be very open with our resident group about is that a program is a living, breathing organism. And we're going to adapt and we're going to change and we're going to chase and sort of modify as needed. That would be one of the biggest myths I've encountered.
DR. GAISER:
Yeah, I, I share similar thoughts. I think, you know, I, I use the term whenever I speak to the candidates, when there's one question I always hear is, are there going to be changes? And I, I tell them, I hope there's going to be changes because you are going to change. And if you're changing, the program should change. It, the program evolves.
I’ll throw out a couple of others. As an obstetric anesthesiologist, I would be amiss not to mention that epidurals do not slow labor. Epidurals do not cause cesarean deliveries.
Another myth I'd like to bust is that doing questions alone will guarantee you to pass the Boards. You do need to supplement with reading. Questions are awesome, but in doing questions alone will not have you pass your Boards. Those were the ones I wanted to make sure are out there.
DR. PARRA:
Bob, I absolutely agree with you about those questions. I think that is a big myth and a fallacy that we should just make sure that is loud and clear right now, that that is not going to help you become a great physician, anesthesiologist, or pass your Boards.
DR. HELOU:
That I'd like to bust is I feel that when I interview a lot of medical students, many times they bring up work-life balance in terms of residency training. And I just would like to clarify what that means in the context of the four short years that residents will be training to become anesthesiologists.
I definitely believe in having enough time off to maintain sanity, to be happy, to do all of those things. I was somebody who always made time to do something fun every week that I was in residency, no matter how much call I was on. But true work-life balance is not something to be searched for in a residency. It's something to be earned over the course of time. And so when we take our Hippocratic oath, it's an oath to our patients to do the best possible work. And in order to do that, we need to undergo rigorous training. And so once we undergo that rigorous training, work-life balance can then become the first and, and prime priority. But there's only so much work-life balance that we can earn and residency in four years while still becoming good physicians. So that's the myth that I really, really, really wanted to bust.
So is, is fellowship the right choice for everybody? What are the advantages and disadvantages of doing a fellowship and what does it take to obtain a fellowship in a really competitive specialty? I know those were kind of a lot of questions, but we can break it down to, to whatever you guys would like to start with.
DR. GAISER:
So your question reminded me of another myth. And the other myth is that a good In-Training Exam score makes you a good fellow. There is too much emphasis on In-Training Exam scores with fellowships. That is something that needs to be addressed.
I think, with the advice I ask residents when considering fellowship is, do you have that passion? If you're doing that through your career, is it, could you be happy? I, being obstetric anesthesia, haven't taken care of a child since 1992. It's a long time. You know, my private practice colleagues do get a chance to take care of kids sometimes. Once you do the fellowship, you kind of stay in that area, you get, you know, in general and stuff. But I haven't done a cardiac case since 1992, but I found what I love doing and when you love it, it's, it's great. And the nice thing about fellowship, it's a chance to really explore the literature and become a real expert in a specific area and I've really enjoyed that.
So in essence, it's to thine own self be true. If you have that interest, and boy, you see yourself in 10 years and you'd be quite content not taking care of a child. Not, if it's cardiac, not doing another caesarean delivery, not doing another craniotomy, then you know you’ve found your passion and follow it. Go ahead and do the fellowship.
DR. BUCKLEY:
Well, I think it's a, this is an important question because fellowship, depending on how it's used, can actually be detrimental to residents. So when you're applying to a program and ultimately training at a program, you want to know, are the fellows there for your benefit or are they competing with you for cases, procedures and those type of things?
So, for example, at our program our fellows virtually always work with residents, but the fellows are not there to learn how to do an intubation, they're not there to learn how to do arterial line. They're there learning the big picture of how to be a liver transplant, how to be a cardiac attending. But not every program does it that way. So it's important to kind of see like what is the role of the fellows? And like I said, are they there for your benefit or potentially to your detriment if they're competing for procedures or cases with you.
Going to the next part of the question is how do you decide if you should do a fellowship? And you know, I think this one kind of comes down to, like, what your goals are. You know, if, if you if your goal is to take care of little tiny babies in the NICU, you then you should do a fellowship. But I'd like to think that in most anesthesia training programs, you'll get enough training to be a, a good practicing anesthesiologist. You just have to decide for yourself, is there something you want to specifically focus on? And for some job markets, doing a fellowship can be advantageous. But it, it's unfortunately very specific on the job market in, in fellowship. So it's a little hard to answer in the global sense.
And in deciding how to get a fellowship, you know, a lot of this kind of comes down to also the specifics of each fellowship. Some fellowships prefer research. A lot of it is actually just word of mouth. So working with an attending who actually ends up knowing other attendings in that specialty can actually be very helpful. So having your attendings reach out on your behalf seems to make a bigger difference. But it, it's fairly similar to like just applying for residency. It's a lot of the same processes. What I tell our residents is just be a good, hardworking resident. You know, do all the things that you should be to be a great physician, and that'll help you get your fellowship, because then many attendings will be able to advocate for you.
DR. PARRA:
I think one of the questions of what does it take to obtain a fellowship in an especially competitive subspecialty is that intense desire and passion to not just practice that specialty, but also bring evidence based medicine into your practice. I think that concentrated time in a fellowship really does give you, and afford you, that opportunity to build yourself in that particular field.
DR. HELOU:
At this juncture, my opinion might be a little bit personal. I, I do encourage my trainees to do fellowship. Really, the, the disadvantage in my eyes might be less earning potential for a year. But the advantage is that even if you end up doing general practice, there is an area of expertise in your back pocket that you have and that can make you a, a valuable asset to the group that you join. And it also, I think, helps us advance the field, like Dr. Parra was saying, in terms of bringing evidence based medicine and ex, expanding the field and really just staying leaders in the field of anesthesia. I feel that fellowship does, does help with that in the future of our specialty.
But that being said, there are a lot of my residents who choose not to do fellowship, who join private practice and our postgraduate surveys say that they are very happy and they're doing very well. So I can see it both ways, although I do encourage my trainees to obtain one.
So along those lines, because our specialty continues to evolve, the importance of lifelong learning is essential. Do you have any advice for your residents on how to develop habits that support the kind of ongoing education that keeps us up to date about trends and innovations in the field?
DR. PARRA:
I think the habit of attending meetings, either in the subspecialty or the ASA is incredibly important. That's where a lot of the ongoing education happens. And networking, even if it's if you're in a private practice group to touch base about what are the things that other groups are doing? I think the lifelong learning can happen intensely at those meetings. I also think that there's something to be said for picking up a journal in the specialty and reading it. I unfortunately am still a classic reader of the physical journals, as more than online. So I always, you know, encourage residents to just continue to pick up a journal, whether it's in the subspecialty or AMA or anesthesiology, to see what's relevant, to see what people are doing, to continue with those experiences of the lifelong learning and make it something that you incorporate on a continual basis.
DR. GAISER:
Yeah, I think, you know, the reading if you started early, reading every day. And, and I, I can't stress the importance of the lifelong learning. The only way I can think of this is if I were to tell you my first anesthetic as an attending after completion of my residency and my fellowship was I would have administered thiopental vecuronium and turned on the n-fluorine, and for my opioid use, either morphine or fentanyl.
If you don't develop the lifelong skills, the specialty will pass you by. The advances in the specialty, just in my career, is just amazing. So one thing I think, the important thing is, is to make sure you read, go to meetings, journals. I, I am a big fan of Twitter. I, I enjoy learning about various things, but I do go to the original source to verify anything that's common there. And I think that's the most important thing, you know, is if you hear something, verify it from a source, go see that article, because what you sometimes will hear is a person's interpretation of the article and you might come away with a very different interpretation. I'm a big fan of going to the original source.
DR. BUCKLEY:
Well, I think the biggest focus on this is, you know, you want to continue to do things that help advance your practice. You know, one of the biggest mistakes I've seen people make sometimes is they fall into the trap of I'm going to do x anesthesia and just kind of maintain at that level. In the first couple of years out of residency, I think your biggest goal should be to find, you know, looking at your first group and figure out how can you contribute to that group? Whether it's, you know, doing specific types of anesthesia that other people don't want to do, maybe it’s getting involved in, you know, QI, or different aspects of you know, find a niche that you find interesting, but it also makes you advantageous to your future group. And I, I think learning more about that than others can really make you valuable. So that's, that’s kind of what I recommend, is just find something that is important to you and, you know, others aren't doing.
DR. HELOU:
What I've done is that a lot of the habits that I had as a trainee, I maintained as an attending. So I still look up articles related to my patients and I read about it as if I were a trainee. There's a lot of new material that comes out like Dr. Parra said, in journals and elsewhere. And I still read about those cases and I print it out. It helps that I'm in an academic center. I give it to my residents to read. But I would imagine that even if I were in private practice, as many of my private practice colleagues do do, we still look up our patients.
And something else that's helped too, post graduation, is I have a lot of group chats with some of the friends that I was in training with, both in my class then one or two years ahead of me, and we discussed challenging cases together and new articles, very helpful during COVID pandemic preparation, especially in my role as an in, intensivist. And so staying in communication with colleagues, even in a casual way over group text and especially in meetings, and then continuing to look up patients and reads, I think would be my, my main tips.
So in addition to all of those things that we mentioned and, for staying up to date and lifelong learning, there are also some newer postgraduate certifications that seem to be helpful in our specialty. Doctors, can you describe some of the options, some of the requirements, the benefits for the various certifications that are out there, like POCUS or FASA or business training, et cetera?
DR. GAISER:
Yeah. So one is, all of you will become Board Certified, and used to be you would get Board Certified, you did it once and you never did anything again. Now you must maintain your certificate. That involves questions with critiques and articles, so a chance to learn as well as required CME and as well as quality improvement patient safety activities.
I'm also a big fan, I think all anesthesiologists should work towards becoming a Fellow of the American Society of Anesthesia. It's a, proving that you're involved in education, you're involved in advocacy, and it really is a, a true mark of distinction that academic as well as private practice can strive for. And it just shows that you've made that commitment to continued learning.
DR. PARRA:
I think all of these postgraduate certifications are evidence of the broad footprint that anesthesiologists have throughout the hospital. Certainly incorporating new technologies with POCUS certification and being leaders within the hospital system and getting business training, things like that are just evidence about where the footprint of anesthesiologists are throughout the institutions. And I think that that's imperative as we kind of build our careers, and what that looks like in anesthesia can be incredibly unique.
DR. HELOU:
I definitely agree with all that was said. I think that all of the certifications are helpful and I always tell the residents the more you have, the better. I would say the ones that are an absolute necessity are becoming involved in the American Society of Anesthesiologists, particularly as a Fellow, showing that dedication, that commitment to other anesthesiologists across the country and also coming together so that we have a voice in the future and in the leadership of our field. I think that's key. And I tell my residents that it's an absolute requirement, both in training and after training.
I would say that definitely leadership training is another key and important aspect, whether or not doctors end up in traditional administrative roles, we all lead our own initiatives, whether it be at the bedside or with a small team of caregivers, and honing that skill set and really learning to interact with our teams in a humble manner that engages them is key for patient outcomes. And I think that that type of training is definitely very fruitful.
And outside of that, basic ECHO training is something that we offer our residents the opportunity to do as well as POCUS, and I think that that can fall more in line with clinical interests. But again, the more the better.
So we talked about diversity in maintaining lifelong learning. We'll move on to talking about diversity of the workforce. How important is it for you to maintain a diverse workforce and how do you support diversity amongst your residents once they have matched into your program?
DR. BUCKLEY:
Well, I mean, this is one of the areas that we've devoted a significant amount of energy to in the last few years, and I think it's extremely important. It comes down to we actually are getting involved with a lot of the high schools and going to some of the high schools that higher, that have a higher percentage of underrepresented in medicine, high school students. So by going to as early as the high schools, I think that can be very helpful because it doesn't really help if anesthesia programs just fight over the small number of URM candidates. I think what we ultimately need to do is increase the number of candidates in medical school as a whole, which will ultimately help us down the road. So that's one of the things we're doing.
We're also very involved in our local medical schools with the same goal that by providing mentorship, especially to some of the URM candidates, we can guide them through the whole process of getting into a residency. And I think that's also been very valuable because we all know that for everyone that helped us choose our specialty, a lot of times, you know, it was just having a good mentor and having a good mentor can really make you, can kind of convince you to choose a given field. So that's one of the things that we're trying to do with the medical students.
And we're also very involved in, with the different, different societies, whether it's the Latino Medical Student Association, the SNMA. We have residents and faculty that participate in those different associations because by going into those associations, I think it's another way for us to get people to apply to anesthesia and maybe not another field.
Once residents are actually here at UCLA, we have a very active EDI committee. And I think this is important because it helps residents that are either interested in EDI or are actually URM candidates find a support system. And the support system includes residents, CRNAs, some of our administrative staff, but also faculty. And I think that's actually been shown to be very helpful because whenever you come to a new program, you want to find a good support network. And, that, you know, we want to do that as many different ways as we can.
DR. PARRA:
I think it's imperative that we as programs seek to diversify the workforce and our, and get support organizationally and departmentally to do that. I think the more that our specialty can, and our programs can represent our broader and bigger roles, the better we are at providing patient care. I think, you know, this is something that has gotten a lot of publicity lately, but I think it's something that as Program Directors, we're in a unique position to certainly influence and advocate for. On a programmatic level, we've changed the way that we look at applications. I think a more holistic view of applications, making sure that our interview faculty and Chief Residents all go through implicit bias training is important. And I think once underrepresented minorities or diverse residents come into the program, the real support needs to be there and the foundation for building their careers needs to be there as well.
DR. GAISER:
Yeah, I, diversity is critical to health care in the United States. And, you know, looking at anesthesiology, you know, maternal mortality is definitely higher in the black population. If you look in pediatric anesthesia, black children are less likely to get pre-medications. So there are possibilities of biases that need to be addressed within the specialty. This only will occur when we diversify the workforce. I'm extremely committed to it. We are working hard. And one of the things that we want to expand to next is to partner with community, because I do think the, the pipeline needs to be there and to show those in high school that it is possible to become doctors and effect the health care of the population.
DR. HELOU:
I definitely agree with that. It all starts in strong community pipeline programs, and that's where really we'll have the biggest applicant pool. So we definitely encourage our residents to participate in programs like that, to really increase the number of applicants to the field of medicine in general.
I would say that in our roles as Program Directors, you know, we go through the applications that we receive. And so a couple of things that we do is that after we've sent out about half the invites, we go back over the demographics to make sure that we have adequate representation and kind of tailor the remainder of our invites in a direction that ensures diversity, at least in the interview pool.
We also do have unconscious bias that is offered through our Leadership Institute at the hospital and is free to all health care providers in addition to our own interviewing team. I definitely agree with Dr. Parra in taking a holistic look at applicants. We certainly make sure that we kind of try to take into consideration all the factors of an applicant's life that have led them to be where they are. And we definitely take all, all aspects of the application into consideration in that regard.
Some of the things that we've done more recently is we've spoken to some of our graduates from underrepresented minority groups and roped them back in to represent our organization in places like the SNMA and other venues. I will say that COVID kind of disrupted our SNMA project, but I had a, a resident at least flying back from D.C. who was an alum to help me market the program, but that kind of, that didn't work. But there's a lot that we're doing to try to get creative. And at the end of the day, I would encourage all applicants to apply. We can only pick from the pool that we get, so, so please shoot your application far and wide and give us the chance to get to know you.
So that brings us down to our very last question. And this one is going to be about surprises. What has surprised you the most about the role of being Program Director?
DR. BUCKLEY:
I, I, since I was the Associate Program Director for a long time, I knew a lot of the, you know, day-to-day kind of what the tasks were. So that wasn't a surprise. But one of the things I did wonder when I first took on the role is, am I truly going to enjoy this? Because it is a significant amount of work, and the biggest surprise is, I really actually like being the Program Director. You know, the day, every day with the different things where I'm meeting, you know, with the residents or the faculty and just kind of working to make the program even stronger. It's surprisingly been a lot of fun. And that's the one thing I, I was hoping I would like it, but I was a little worried until I actually took on the role. Would I truly want to do this? And my hope is that I’ll want to do this for a long time.
DR. GAISER:
I get worried because my response is going to sound cliché in that I, I am surprised at how happy I am and how much I enjoy it. I never anticipated liking it as much when I first took the position. One of the things that I constantly hear is the average lifespan of a Program Director is five years. Going on year 17, I can tell you it really is a great job. And much like I focused on the resident and on happiness, it's OK for you to be happy after residency and find the job you love. And it's a great career.
DR. PARRA:
I agree. It's an incredible career. I think one of the things that has surprised me the most about the role is how incredibly personal it is. But on the other side of that, you also you know, you take personally the failures of the program or things that could be improved. And I think I kind of got the hint of that based on going through a residency and interacting with my Program Director. I don't think it became as personal as when I became Program Director. I realized how incredibly personal that role is.
DR. HELOU:
I would have to agree in that I, I think what surprised me the most was just the amount of impact that we as Program Directors have on our trainee's lives. I really didn't realize that so much until I became into the role and started hearing things like, I ranked this program because of you, or I was a med student when you were rounding in the ICU and I thought, I want to round like that one day. And I really realized that I set an example for others and I can impact others in the most positive of ways. And so it really led me to work even more on myself so that I can continue to impact lives very positively and continue to be a very positive and happy influence on my residents’ life and just the ability to partner with them and help them overcome their challenges and be the best possible version of themselves. That's a real privilege. And I think I just came to the full understanding of it only after I had been immersed in the role for some time.
DR. GAISER:
And, and I like what you said, the concept of role model. I think that's so important. We are really the role models for the faculty and role models for the residents. And again, that was a surprise to me too.
DR. HELOU:
In a way, it was a nice surprise, I guess, because it just reminds us and energizes us to continue to better ourselves, because our self-betterment leads to just more positive energy and betterment of the group. So, so I like that. It's, it’s led me to really work on myself way more intensely, too, the sense of kind of responsibility.
It's really, honestly been a great conversation today as well. Thank you all for joining us. I'm Mada Helou and this was Residents in a Room, the podcast for residents by residents, or for today's episode, by Program Directors. Join us for more episodes soon. Thank you.
ALL:
Thank you.
DR. GAISER:
It was really nice. I look forward to seeing you virtually or in person.
DR. HELOU:
Thanks.
DR. BUCKLEY:
All right. Take care. Have a good one.
DR. PARRA:
Bye, guys.
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