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The Wisdom of CA2s · Style Points

0:09
Hello, anesthesia enthusiasts, and welcome back
0:12
to Style Points. We have a special episode for
0:14
you today, and it is one that has been three
0:16
years in the making. Longtime listeners may recall
0:20
Episode 7, The Wisdom of Interns. We sat down
0:24
with a class of graduating interns right before
0:26
they started as CA1s. They talked about emotional
0:30
growth, leaning on the class above them, and
0:32
learning how to tell sick from not sick. Then,
0:35
in episode 21, The Wisdom of CA1s, we brought
0:39
them back after their first clinical anesthesia
0:41
year. That time, we heard about the first case
0:44
where the attending walked out of the room, about
0:46
borrowing a little bit of style from every faculty
0:49
member they worked with, and about learning to
0:51
roll with the punches. Today is the third installment
0:55
from that same class. These residents have now
0:58
finished CA2 year and are a few weeks into CA3.
1:02
We're doing something a little different this
1:04
time as a bonus. We're going to play back part
1:06
of their intern episode and listen to their reactions.
1:10
Without further ado, I bring you The Wisdom of
1:14
CA2s. Thank you for staying a little bit later.
1:21
No worries. I mean, it's almost 930. I know.
1:26
It can't be too greedy. 9 .30 a .m. is a really
1:32
late time for you to be leaving as a senior.
1:35
I just want to make sure that we're not stressing
1:37
you too much. I mean, I've already talked to
1:39
HR about how this is unacceptable, but we can
1:43
worry about that another day. It's Monday soon,
1:46
isn't it? Pam on Mondays? Yeah, yeah. Okay. Just
1:49
wanted to double check on that for you. Garrett,
1:54
thank you so much for joining us today. Thanks
1:57
for having me. You've done a couple of these
2:00
so far. You've done the Wisdom of Interns episode
2:04
and you've done the Wisdom of CA1s episode. And
2:07
now this is the Wisdom of CA2 episode. So the
2:10
thing that I want to ask you first is, what did
2:13
you learn during your CA2 year? I think CA2 year,
2:19
especially at this program, you really learn
2:21
a lot. You learn to deal with, you know, the
2:25
adversity that comes with anesthesia, but that's
2:26
something that you're learning along the process
2:28
of your entire residency. But during our CA2
2:31
year with going to so many different locations
2:33
and working with different attendings, I think
2:36
I learned a lot about my actual anesthesia style
2:39
and started developing my own anesthesia style.
2:45
that I'm looking forward to as a CA3 and going
2:48
to be doing more cases and becoming even more
2:50
independent, being able to kind of tinker with
2:53
and use and adjust as I am moving one step closer
2:58
to being an attending. Is it easier to visualize
3:01
the type of attending that you're going to be
3:03
here shortly? I think in many ways, yes. I'm
3:07
very comfortable with the anesthesia, but also
3:10
now that I'm becoming a CA3 and doing some of
3:13
the more attending focused rotations, pretending,
3:17
doing the AOD rotation, seeing how much I don't
3:21
know about those different roles. It's also kind
3:23
of hard to see the steps that I need to make
3:26
to become an attending, but I think that's still
3:27
just the process of growing. I remember you as
3:31
an intern, and you've always been an excellent
3:35
resident in this program. What's the biggest
3:37
difference between you as an intern and you now?
3:42
I think... As an intern, I was portraying a lot
3:49
of fake confidence because it helps the patients
3:51
and it also, I feel like, helps the attendings
3:54
trust you a little bit better. But I think that
3:57
now that I'm a CA2, I have real confidence in
4:00
my ability and in my anesthetics. And I know
4:04
now that I know more, um, I realize how much
4:08
I didn't know and still don't know. So I think
4:11
that, um, whereas as an intern, you know, I portrayed
4:15
confidence, but was a little bit scared about
4:17
everything. I'm able to know what I should be
4:21
scared of now. And I think I'm, um, more like
4:24
cautious, but in a good way as a CA2 than I was
4:28
as an intern. So. You feel like you've faked
4:32
it and now you're getting ready to make it, I
4:34
suppose? Yeah, I think that's a summary of what
4:36
I just said, yeah. So you've worked with dozens
4:40
of attendings in our residency who all do things
4:43
in totally different ways. How are you deciding
4:47
what parts of that you want to keep for your
4:51
practice versus things that you might want to
4:53
discard? That's hard. And working with a lot
4:57
of different attendings here and at other institutions
5:00
as we do our away rotations, I find that I really
5:03
like trying to do things all different kinds
5:05
of ways and do new things so I can see if I like
5:07
them or see if I don't. A lot of it is from personal
5:10
experience, like how did that anesthetic go?
5:12
Is that something that I want to continue? Did
5:14
it actually make a difference that I found tangible
5:17
or that I saw for the patient? And then I'll
5:21
start incorporating those things. And I also
5:23
will lean on my mentors, attendings, and other
5:26
residents in the program and ask them, you know,
5:29
have they had similar experiences with these
5:31
other methods or what they like to do and kind
5:34
of use a little bit of all of that to see what
5:37
I like and formulate my own style. Is there anything
5:41
that you sort of thought about what this job
5:44
would be or what your career would be like that
5:46
you thought as an intern, but you think now might
5:51
have been a little bit misguided or you've changed
5:53
your mind about? I'm not sure. I think as an
6:00
intern, I didn't fully conceptualize or understand
6:06
all of the roles that an attending anesthesiologist
6:10
really encompasses in their day to day. I think
6:14
that as it was the next step in my learning to
6:18
learn how to perform operating room anesthesia,
6:21
I was kind of tunnel visioned on developing that
6:24
aspect of my professional career, but I didn't
6:30
realize all of the other things. For example,
6:33
just running multiple different rooms, the interpersonal
6:36
relationships and how important they are, the
6:39
AOD work and board running and other aspects
6:43
that an attending anesthesiologist performs.
6:46
And I think that's something that I'm going to
6:47
learn a lot more about this year. How does it
6:50
feel to be closer and closer to ready to graduate?
6:56
good in some ways and scary and others scary
6:59
in ways that didn't used to be scary. But now
7:02
that I'm, you know, thinking about those next
7:04
steps and being an attending anesthesiologist
7:06
and I know, you know, I'm happy to be starting
7:10
my career here at UC where I know the support
7:14
networks and. the people that I can always ask
7:17
for help when I need, but just that additional
7:19
level of independence is kind of scary to think
7:22
about that I don't have an attending to call
7:24
in the room. I'll still call the AOD or some
7:26
of the other faculty, but I am the attending
7:29
that gets called. So thinking about that's a
7:31
little bit scary, but at the same time, it's
7:35
exciting to almost be done. I'm going to play
7:39
for you a clip of you as an intern. or having
7:44
just graduated from your intern year and i'm
7:47
going to be curious about your reaction to this
7:50
hold on i'm interested too uh i'm garrett um
7:55
a few things i learned from intern year it's
7:58
hard because i learned a lot during intern year
8:00
but something i think that helped me a lot and
8:03
it's probably gonna help me going in the future
8:05
is just trying to be kind to and You know, as
8:09
friendly as you can with all of your co -residents,
8:11
even if they're not in your own specialty, at
8:14
the very least cordial. And also, even if it's
8:17
like a rotation that you're not too excited to
8:19
do, you know, trying to show up to work every
8:22
day, eager to learn and eager to help the team
8:26
as best you can. I feel like if you do that,
8:30
then the people that you're working with, your
8:32
seniors, your faculty, they kind of they notice
8:36
that and. it provides you a lot more opportunity
8:39
and it allows you to have, you know, a little
8:46
bit more independence than if you're not showing
8:49
up as eager to work. I've heard, you know, some
8:52
seniors that say, you know, I was on these rotations
8:55
I didn't really like, so I just tried to do the
8:57
bare minimum. But if you're expected to go to
9:00
work every day and you show up. giving your best,
9:03
then it really gets noticed and it allows you
9:05
to have more opportunities, more procedures,
9:08
which is something that I really tried to do.
9:10
When I was on my ICU rotations, they saw that
9:13
I was a hard worker and they knew that I was
9:16
interested in procedures and would seek me out
9:19
if they knew there was something that I wanted
9:20
to do because they valued the way that I presented
9:23
myself on a day -to -day basis. So I think that
9:25
that's something that was really valuable during
9:28
my intern year and something that I would recommend
9:30
doing for any incoming interns, regardless of
9:34
the rotation that you're going to be a part of.
9:36
So what do you think? What's your reaction to
9:39
that? I forgot about 75 % of what I said. That
9:45
was interesting to listen back to. I think that...
9:50
Yeah, some of the things that I mentioned as
9:52
far as coming in and treating people with kindness
9:54
is something that's kind of a part of my character
9:56
and always I try and do every day and give people
9:59
the benefit of the doubt. But it was interesting
10:02
towards the beginning, something that, you know,
10:05
I feel maybe it's the senioritis and I'm always
10:10
showing up to work. But something I could improve
10:12
on is working on that eagerness to come in every
10:17
day and continue learning. I feel like as an
10:20
intern, that was something that I had more of
10:22
than I do now. And it was interesting hearing
10:24
me talk about that and maybe something I could
10:28
improve on as I'm getting old and bitter. You
10:33
don't strike me as one of our more bitter residents
10:38
over the years. I've always thought you've come
10:41
to work with a good attitude. Well, thank you.
10:44
Lastly. I'm going to ask you the style points
10:47
question. What style points or points of personal
10:50
preference have brought you success in and out
10:52
of the operating room? I think something that
10:57
I may have said as a CA1 as well, but that I've
11:00
tried to continue doing for every patient as
11:05
I've progressed is when I'm thoughtfully developing
11:08
the anesthetic plan for any patient. Not just
11:13
doing things because that's how it's done here
11:15
or doing things because that's like the routine,
11:17
but actually trying to individualize and craft
11:20
the best anesthetic for a person that I can.
11:28
Treat them as if they're family, you know, as
11:31
if it's your family member there. And, you know,
11:34
focusing on patient -centered care and doing
11:35
everything with a purpose is something that I'm
11:38
being a little more thoughtful about as I'm continuing
11:40
to learn. Thank you so much for joining us today.
11:44
Absolutely. Thank you for having me. Are you
11:53
ready to get started? Yeah, let's do it. Morgan,
12:00
thank you for joining us. I'm excited to be here.
12:03
So tell me, what did you learn during CA2 year?
12:09
So I think the... biggest difference between
12:12
CA1 me and CA2 is that I had a child. Is that
12:18
why you weren't on the last episode? That is
12:21
exactly why I wasn't on the last episode. We
12:25
never got to making that up, but that's okay
12:26
because I'm here now so we can talk about the
12:28
whole experience. Yeah, so I spent most of CA1
12:33
year pregnant, working through the challenges
12:36
of that. including, you know, like thinking about
12:40
where I was in the operating room, what cases
12:43
I was assigned to, taking care of myself as well
12:46
as my patients, trying to study for basic. It
12:50
was a new adjustment. And I think the biggest
12:53
thing I learned in CA2, I started the year, I
12:56
got through most of the first rotation, most
13:01
of July, and then I went out with my baby. And
13:05
so I had this huge gap that allowed me time to
13:10
take care of myself and my family and then also
13:12
just see how my priorities changed a lot. And
13:18
so CO2, I think I... learned a lot about how
13:21
imposter syndrome works and working to overcome
13:26
that and try to see myself in different lights,
13:31
seeing that I am a mom on one side, that I'm
13:34
also a resident on another side and how those
13:36
two can mesh together at the same time and how
13:39
that can help me take care of my patients. So
13:44
it's been very interesting. It's separating my
13:51
time out. And so in a lot of CA2, it became very
13:58
clear to me that my time here needs to be completely
14:01
focused on education and taking advantage of
14:06
the times when my attendings are in the room,
14:08
asking them lots of questions and trying to expand
14:12
my knowledge from that perspective. And now as
14:18
I start CA3, I can see. So in CA2, I think I
14:22
missed out on a bit of being the senior for some
14:28
of the juniors when they started out. And so
14:31
I've gotten a lot more of that experience this
14:33
year. So I've been taking advantage of that and
14:35
seeing the things that I did in CA1 that I can
14:38
prevent them from doing. honestly helping them
14:43
like instill confidence in themselves. And when
14:46
I get to help them out in cases, it helps me
14:49
see the progress that I've made and the things
14:52
that I can continue to improve upon. This is
14:55
a big year. So you learned how to be a doctor
15:00
and you also learned how to be a mom. Yeah. And
15:03
how being a mom makes me a much better doctor,
15:06
actually. Tell me more about that. Yeah, seeing
15:11
before when I took care of patients, like I felt
15:14
like I was seeing them for who they were. But
15:17
now being a mom, I see them as if I was like
15:20
if I were their parent and how much more terrifying
15:25
it is, probably from their perspective, their
15:29
family's perspective, and just trying to really
15:31
take the time to talk with families and make
15:35
a better connection pre -op. I think it was something
15:39
that I thought that I was doing a good job before,
15:42
but now I can see where taking the time when
15:47
I first meet the patient to get to know them
15:49
and to get to know their family and really dive
15:51
into the things that they're nervous about can
15:54
be helpful. And then when I'm in the OR, just
15:57
it helps me talk to the patients a little bit
16:00
better, especially before they're asleep, because
16:01
that's always something that I feel like a lot
16:03
of us are not comfortable with at the very start.
16:09
Taking more time to like once the patient is
16:12
asleep to double check my positioning of the
16:14
patient, thinking more deeply about like, is
16:18
this a comfortable position? Would I want to
16:20
wake up with this tape all over my arm? Just
16:23
different things like that and making sure that
16:26
the patient is seen more as a complete human.
16:31
So you feel like it unlocked basically a new
16:34
level of empathy for you. Yeah. And with waking
16:37
up patients, too, just being able to more. I
16:45
don't really know what the what the correct words
16:48
are for it, but like as I'm waking them up, I
16:50
see them more as the patient who is being greatly
16:53
influenced by this anesthesia, like not getting
16:56
annoyed when the patient's thrashing around.
16:58
Like, unfortunately, I kind of see them like
17:00
a child waking up, seeing my child grow up like.
17:06
She is the opposite of like a stroke patient,
17:12
like a patient comes in, you know, they've lived
17:14
their whole life. They've been normal. And then
17:16
suddenly their neuro status is like completely
17:20
reversed. Right. So I watched my kid like learn
17:22
how to like she already knew how to breathe when
17:24
she came out. Thank goodness. But she learned
17:26
how to like use her arms. And then it was like
17:29
continued to develop. I saw her like start to
17:32
learn how to use her hands and her voice. And
17:34
so. you can kind of just view it in the opposite
17:40
light. Like patients coming out of anesthesia,
17:42
like they're regaining all of their control of
17:44
their bodies again. And so just trying to be
17:47
empathetic when you do have like the patient
17:49
that's thrashing or delirious and just taking
17:53
them for what they are and helping them out again.
17:57
I wonder if you'd be willing to listen to your
18:00
Wisdom of Interns episode and hear what you had
18:04
to say and see what you think. Sure. All right.
18:08
I'm Morgan. A few things that I learned during
18:11
intern year. One would be relying on the class
18:15
above me, especially like asking questions when
18:18
I felt like maybe things weren't going the way
18:22
maybe I had expected. And that maybe my experiences
18:25
weren't meeting what expectations that I had
18:28
for that rotation. And so just reaching out and
18:30
kind of getting advice or support, I felt like
18:33
was really helpful and kind of put things into
18:35
perspective. And then the other thing would be
18:39
feeling as an intern that every time you got
18:44
a call that you were expected to solve. the question
18:48
that was presented to you and fixing all of your
18:51
patient's problems, which is not possible at
18:54
some times. And so one of the things would be
18:58
some of the little recalls you'd get about like
19:01
a patient having a little bit of like a headache
19:04
or a little bit of stomach pain, something like
19:07
that, that after asking all the important questions,
19:10
making sure they didn't have any like red flag
19:12
symptoms. Just asking the patients, you know,
19:15
often they'd say like, yeah, I've had something
19:17
like this before. And, you know, especially if
19:20
it's like a headache, you could be like, well,
19:22
what do you usually do when you get a headache?
19:24
And sometimes they'd be like, I'll just like
19:26
sleep it off and drink some water. And you can
19:28
say, all right, let's try that first. You don't
19:31
have to always give them Tylenol. Or if you do
19:33
give them Tylenol, that might work and that might
19:36
be fine. And you don't need to go further than
19:37
that. And so it's okay to always just like take
19:41
a step back and not fix everything right in the
19:43
moment. So what's your reaction to that? I think
19:49
it's just me on the flip side of it. Like before
19:54
I felt like I was trying to know that I could
20:00
rely on those above me and trying to instill
20:05
that in. the people who are going to be the next
20:08
interns. And I think that's still true. It's
20:12
fun to be on a little bit of the opposite side
20:14
of it. I'm still very reliant on my attendings
20:17
at times. But being the CA3 who can now help
20:22
the interns and help the CA1s, just trying to
20:25
make sure that they feel the same psychological
20:30
safety in their work. There have been a couple
20:34
of times where I've... now been on elective and
20:36
been asked to go help some of my younger co -residents
20:41
and there was there's never a hesitation in me
20:45
to to not go help them it's an immediate drop
20:47
everything go help them teach them if there's
20:51
something to be taught or rightly just point
20:54
out yeah great job calling somebody you definitely
20:56
need help in here this patient situation is more
21:00
than your CA1 knowledge can usually hold. And
21:05
so it's been really fun from that aspect. And
21:07
I think just continuing along that path, starting
21:11
CA3, there's definitely topics that I know that
21:14
I want to work on, I want to get better at. When
21:18
I am going to be on GA, handpicking the cases
21:22
that I want to make sure that I'm good at so
21:24
that when I'm attending, I've been faced with
21:27
some of these difficult cases. know what to do,
21:30
know what to even just resource later, because
21:33
not everything's going to stick in my brain,
21:35
but being able to develop a strong foundation
21:37
now, I think will be really helpful. What are
21:41
you most worried about or conversely excited
21:44
about between here and graduation? I'm excited
21:48
to see how everything I've learned so far comes
21:52
together. At NCA2, we spend a lot of time at
21:57
other rotations. We go to some outside hospitals.
22:02
And so bringing back a lot of the things that
22:05
I've learned from those places, creating the
22:08
person that I want to be, creating the anesthesiologist
22:12
that I want to be, continuing to learn from my
22:16
attendings here and my co -residents. I'm just
22:19
excited to see who I end up becoming. at the
22:23
end of CA3, which is also terrifying, though,
22:26
because it leads right into being an attending
22:27
and being in charge of making those decisions.
22:31
And so I'm very nervous about becoming attending
22:34
someday very soon. But I'm trying to take that
22:37
in the perspective of instead of being like scared
22:40
about it and nervous about it and not wanting
22:41
to do it, instead developing what I can now while
22:45
I have extra support around me and just try to
22:49
nail down some more things. Yeah. Lastly, what
22:54
style points or points of personal preference
22:57
have brought you success in and out of the operating
22:59
room? I'd say like in the operating room, the
23:05
things, you know, I feel like I can recognize
23:08
when there's an emergency, when there's not an
23:10
emergency. I know when to ask for help, when
23:12
to not ask for help and not being afraid to just
23:15
ask for help and then not needing it, which is
23:17
always the best situation. But I think. especially
23:24
being in an academic setting where you're doing
23:27
procedures on patients who are not the average
23:31
patient, who have maybe had some other complications,
23:34
things that complicate your ability to do like
23:37
a normal central line or an arterial line when
23:41
they've already had so many and the same admission,
23:43
is trying to set yourself up for success. And
23:48
feeling confident before starting the procedure.
23:51
Anytime I have started the procedure and not
23:53
felt confident that I can do it, it doesn't go
23:57
well. I nine times out of 10 fail in that experience.
24:01
And so at that point, just asking the people
24:04
around you to maybe double check your work before
24:08
you get started or just ask like literally earlier
24:12
today, I was helping a case get started and I
24:16
was going to do an IV, something that. is very
24:18
simple to me at this point as a CA3, but I looked
24:21
at my colleague and I was like, do you think
24:23
I can put an 18 or a 16 in that? I think that's
24:25
an 18 and I should get an ultrasound for the
24:27
16. And they're like, I agree. I'm like, great.
24:30
So we, we also need an 18. So I put in the 18
24:33
there and then I went to the other side and got
24:35
in the 16, but it was like, I didn't feel quite
24:38
confident. And I knew that I wasn't going to
24:42
succeed if I probably would have put that 16
24:44
in there and I would have blown a vein and needed
24:46
to then do two more IV pokes. And so I think
24:49
just helping myself try to find that confidence
24:52
in doing my own procedures, but then translating
24:55
that to those that are going to be younger than
25:00
me. And like this weekend, I worked with one
25:03
of our CA1s and they were. quite nervous before
25:07
they were going to do an arterial line. And I
25:10
just looked at them and I was like, yeah, I've
25:12
been there. I have had those same feelings. And
25:15
so I was like, let's take a second. And they
25:17
were like looking around like, what's going on?
25:19
And I was like, I just wanted you to take a breath.
25:22
Like, you ready to do this? And they're like,
25:23
yeah. You could just see, you could just see
25:27
them relax a little bit that I was like, okay,
25:30
and now we're going to do it. And then they crushed
25:32
it. So it was great. Morgan, thank you so much
25:37
for joining us. Thanks. Thanks for having me.
25:45
Okay, you ready to get started? Yeah. AJ, thank
25:50
you for joining us. Thank you for having me again.
25:55
So tell me, what did you learn during your CA2
25:59
year? CA2 year is a lot. It's more responsibility
26:03
as a resident. You're no longer a CA1, so you
26:07
are entrusted to do bigger cases. You're entrusted
26:10
to do lines with a little bit less supervision
26:12
where the attending doesn't have gloves on supervising
26:14
you the whole time. So I think the big thing
26:18
that was learning and starting to learn is just
26:21
accepting more responsibility, taking on bigger
26:23
roles, whether that be on call, holding the phone,
26:26
holding the pager, doing the consult yourself,
26:29
or stepping up and asking to do cases. Because
26:33
as a CA1, you're just... kind of drinking out
26:35
of a fire fire hose early where you're just trying
26:38
to learn the basics of anesthesia and you're
26:40
put in whatever case is assigned to you but once
26:43
you get a good feel for what's happening i think
26:44
you have the opportunity to kind of start requesting
26:46
cases um and start trying a little bit different
26:50
things like by the end of ca1 you understand
26:53
how to do like a mac case but maybe trying something
26:55
different or a different medication or Being
26:58
more open to asking questions about what is an
27:00
attending like to do for specific things versus
27:03
like, how do I do this? So what do you think
27:07
the biggest differences between the intern version
27:10
of you and the you sitting here now? I think
27:13
confidence is the big thing. And early on, because
27:19
knowledge comes with time. We are in a field
27:21
where you gain. lots of experience. And through
27:24
that experience, you get more comfortable. And
27:26
then as you get more comfortable, your skills
27:28
improve. But having the confidence, one to step
27:32
up and do things as well as to ask questions.
27:35
I know there's a lot of times where you may have
27:38
questions, you might not even know what questions
27:41
you have, because you aren't aware. But at this
27:44
point, I think I'm very comfortable and confident
27:46
in my own abilities to just stop at any point
27:49
to ask like, Why did you do this? Or how do you
27:51
like to induce for a patient with specific hemodynamic
27:55
things? So I think that's a big part of it. I'd
28:00
like, with your permission, to play a bit of
28:03
your Wisdom of Interns episode. And I'd be curious
28:06
to hear your reaction. I'm excited to see what
28:08
that version of me had to say. So my name is
28:11
AJ Pagan. And some things I learned about intern
28:14
year. I think really investing in your intern
28:18
class is really important. We had a unique experience
28:22
where we had six people from where I went to
28:25
med school, UC, join our class. I wasn't necessarily
28:28
friends with them in medical school, but starting
28:31
residency, we've gotten very close. And I think
28:35
that's been a great experience for all of us.
28:37
And getting close, we've kind of built this friendship.
28:42
past just colleagues. We do lots of things together.
28:45
And then I think it extends into work where we're
28:47
always willing to help each other out, whether
28:50
that be on like an internal medicine rotation
28:52
or someone's getting swamped in the OR when we're
28:54
on anesthesia and we know that you're having
28:56
trouble setting up a room or something. And I
28:59
think just taking that extra step to get to know
29:00
each other goes a long way, both like academically
29:04
in your career and then outside of work. It's
29:07
always good to have a lot of new friends wherever
29:09
you're moving to. OK, so what's your reaction
29:12
to that? Pretty good answer. I think just kind
29:17
of stemming off that culture is everything. And
29:20
when you train and then when you go on to practice
29:23
is like establishing a culture of like it's a
29:27
team effort. We always say it. You're going to
29:29
hear it throughout any program or anywhere you
29:31
train, anywhere you interview. But actually having
29:35
a culture of cohesiveness and where everyone
29:38
works together. And when you ask for help, you
29:41
don't just get one person. You get a whole team
29:44
of people to come help you. And I think that's
29:46
something that our class, I mean, classes before
29:48
us obviously established and passed it down to
29:51
us. But it's something now as CA3s and, you know,
29:54
being with the new CA1s in the OR and then when
29:57
the new interns come by for their anesthesia
30:00
rotations, just emphasizing on what we do here
30:03
and what we do well here is the culture and how
30:06
if an emergency comes up or you have a question,
30:09
All of our phones are going off and there are
30:12
so many people that are coming almost too much
30:14
help when there's like five or six residents
30:16
show up when someone asks for help. I think that
30:21
it was really interesting hearing you talk about
30:23
putting your efforts and focus back in your classmates.
30:28
And now you're one of our chief residents. Could
30:33
you reflect on how. focusing on your classmates
30:38
transitioned into leadership? Yeah, I think whenever
30:44
you start investing in people and you starting
30:46
to get to learn more of the surface level, like
30:50
how I mentioned there, it goes a long way in
30:52
terms of just understanding the way they take
30:55
in like their why. I think that is like a big
30:57
thing in medicine. Big thing in anyone's career
30:59
is like understanding the why and why you're
31:01
interested in this, why you decided Cincinnati,
31:03
why you're interested in. specific fellowship,
31:06
because you really just get to learn more about
31:08
that person. And then taking that the step forward
31:11
is in the chief role is, you know, now that I
31:14
understand more and more about the class more
31:17
there, you can have more individual conversations.
31:20
And you're more comfortable discussing like harder
31:23
topics. Like, if, like, we have to change call,
31:27
for example, I feel very comfortable now going
31:29
up to one of my, honestly, friends at all at
31:31
this point, and saying, like, this is a scenario
31:34
and I was very open early on and we had such
31:36
an open relationship that now it's much easier
31:39
to have difficult conversations. And I think
31:41
that'll be something that I do moving forward.
31:45
What's something that as an intern, you had a
31:50
concept of, but turned out to be completely different
31:53
or that you've changed your mind about? That's
31:56
a good question. I think. I think early on intern
32:07
year, something that I had questions on or something
32:12
that I thought that was very important and necessary
32:15
at the time was like procedures and doing well
32:19
in those. And I always thought that like your
32:21
procedural competence related to like your intelligence.
32:24
And if you didn't get the IV or you. Didn't get
32:28
the airway perfectly or your line didn't go completely
32:31
according to plan. You thought the entire case
32:34
was a disaster. And in the grand scheme of things,
32:38
like you're attending or you're seeing your resident
32:40
probably doesn't even remember that because it's
32:42
the first couple of minutes of the case. And
32:44
then you just go ahead and did this bigger case
32:47
or any case that went completely according to
32:49
plan. But all you could fixate on is this one
32:51
little aspect of the case didn't go well. And
32:54
early on, I. It was pretty hard on myself, I
32:57
feel like, to be perfect when it came to that,
33:00
which, I mean, no one will be. Like, why would
33:02
you be good at lines when you've never done one
33:04
in an intern year you're not around? Especially
33:07
on internal medicine, you don't have the opportunity
33:08
to, you know, practice your skills. And then
33:11
coming to realize now and something I tell the
33:13
juniors when I'm doing stuff is no one will remember
33:16
this. I know you're going to be hard on this
33:17
on yourself, but talk with the senior resident
33:20
and be open because, I mean, I'm open about how,
33:23
like, early on I struggled with. specific things
33:26
and now they come pretty easily so and then just
33:29
being able to kind of laugh at yourself when
33:31
you can look back and say I wasn't good at this
33:34
or I did this mistake and now I get to teach
33:37
about it what are you excited about or worried
33:41
about between now and graduation I'm excited
33:47
to do To kind of just build upon things and have
33:51
like more open conversations with staff about
33:54
like little nuancy things that people like to
33:56
do. I think at this part I am comfortable doing,
34:00
you know, a very general case. And now it's just
34:03
kind of picking the brain of the supervisor to
34:07
say, like, what do you like to do in specific
34:09
scenarios? Because I know I've heard from lots
34:13
of people that first year of attending SHIP is.
34:16
Even worse than your first year or like your
34:18
CA1 year when you're just experiencing so many
34:20
different things that you haven't seen before.
34:22
So just trying to pick their brains on things
34:25
that they experienced as a first year or like
34:27
a relatively new staff. So you can be kind of
34:32
ready for all the different things that pop up
34:35
as an attending. Lastly, can you tell me about
34:38
your style points or points of personal preference
34:41
that have brought you success in and out of the
34:42
operating room? So early on, I focused on understanding
34:48
kind of the surgery around the case. So you can
34:51
kind of get your timing and cadence right when
34:53
it comes to like your anesthetic. So early on,
34:57
I would if I had just something simple like a
34:59
gallbladder, like just understanding how they
35:02
do the procedure. So when they're at X, Y, Z
35:04
step, you can anticipate where to go now. And
35:07
that's something I've kind of take moving forward.
35:09
And then the bigger thing I've done now that
35:12
I tell everyone to do is you have to have active
35:14
reflection time. Because going back to what I
35:17
said is we are really good at emphasizing the
35:21
little things that went wrong. But if you just
35:24
did a 10 -hour liver transplant and all you could
35:28
remember is your central line wasn't great, that
35:31
was a pretty good case. And so taking the time
35:34
to think of... what did I do that went well?
35:36
What did I do that I could improve on? And then
35:38
like, what will I learn moving forward? And like
35:41
physically saying these things out loud help
35:43
you think of to kind of get away of like the
35:47
possible one little hiccup that happened. And
35:49
then the rest of the case went completely fine.
35:53
AJ, thank you so much for joining us. Thank you
35:55
for having me. Brian, thank you so much for joining
36:03
us. Thank you. So first things first, what did
36:08
you learn during your CA2 year? I feel like CA2
36:14
year, at least for us here, is a good opportunity
36:17
to go to a variety of different health systems
36:20
and different anesthesia environments and just
36:23
learning the subtle things that are different
36:26
in each of those locations, whether it's at a
36:28
different hospital, if it's at children's, working
36:31
with kids. doing more ambulatory work. It's just
36:34
sort of our year that we get out of the regular
36:37
OR here at UC and see everything else. So there's
36:44
probably a different guy sitting in front of
36:47
me now than was sitting in front of me a couple
36:49
years ago. And I'm curious, what's the difference?
36:52
How have you changed? I don't know. I certainly
37:01
feel like, at least within anesthesia, I try
37:04
to just be much calmer than maybe I was starting
37:08
off. Early on, the little things seem big and
37:13
bad, and then eventually you feel like you've
37:16
seen a variety and you can kind of come with
37:19
a clearer headspace to when problems arise in
37:21
the OR. You've worked with a bunch of attendings
37:25
over time. Some attendings, I'm sure you've learned
37:30
stuff that you want to keep. Other attendings,
37:33
there's probably stuff that you want to discard.
37:35
How do you keep that straight? What do you think
37:39
is your methodology for deciding what you want
37:43
to keep? I'm always open to trying new things
37:46
when there's an attending that wants to show
37:48
me something new. I think what I decide to keep
37:52
versus just disregard if someone's showing me
37:54
something is often if there's... a logic or basis
37:59
behind it i tend to adopt it more readily versus
38:01
the i got burned once attitude where it may have
38:05
happened one time and if they think that a certain
38:09
intervention or doing something differently would
38:11
have changed that a lot of times it probably
38:13
wouldn't have but um when that's kind of the
38:17
mentality i tend to not hold on to it as much
38:19
um and i feel like when they're explaining why
38:21
they do certain things they can kind of they
38:24
kind of know whether which uh which realm they
38:28
fall into what do you do with situations where
38:32
you've been burned once uh i i usually try not
38:39
to deviate too much i just try to keep things
38:41
the same unless there's a clear like flaw leading
38:44
to it but if it's just like oh this bad thing
38:47
happened and it I don't know. I'm sure I'm adopting
38:52
some things where I got burned once. I'm doing
38:54
it differently now. But in my mind, I don't think
38:57
I'm doing it. There's probably some name for
39:02
that effect. Yeah. Willfully ignoring it. I am
39:08
going to have you listen briefly to the things
39:13
that you learned during intern year. And then
39:15
I'm curious what your reaction will be to that.
39:19
I am Brian Upton. I think the biggest things
39:23
I learned from intern year is just how quickly
39:24
you progress. So I think everyone starts off
39:28
pretty timid and uncomfortable with the amount
39:31
of knowledge that they have. But kind of there's
39:33
a point through intern year where all of a sudden
39:37
things just make sense. All of your training
39:38
kind of kicks in and things just start flowing.
39:42
And I think that's when a lot of people really
39:43
feel like they're getting into their rhythm.
39:45
So that was something I didn't quite expect.
39:47
I think for me, it came out of after doing one
39:50
of the ICU rotations, I came back to the floor
39:52
and like everything just seemed simpler after
39:55
that. I think a combination of having some ICU
39:57
experience, seeing sort of what the the edges
40:00
of physiology could be and then bringing it back
40:02
to patients that aren't to that extreme. And
40:05
it just kind of put everything in perspective
40:07
and was easier to manage at that point. So what
40:11
do you think? Yeah, I. still agree with everything
40:15
i said uh i actually think it continues on though
40:19
like beyond engineer just things uh you know
40:22
again once you get into anesthesia then it's
40:24
you know the things once you start seeing a number
40:26
of times i feel like you get to a point that
40:29
kind of it again it clicks you start seeing sort
40:32
of through everything in the bigger picture of
40:35
what's going on in the or um you know probably
40:39
happens sometimes later in ca1 year uh but a
40:43
similar perspective on just how the year unfolds
40:48
where you get comfortable with what you're doing.
40:51
What are you looking forward to between now and
40:55
graduation, which is just in a few short months,
40:58
it feels like? I mean, for the most part, I'm
41:01
enjoying what I'm doing. I'm just keeping on.
41:04
I'm doing fellowship next year. So looking forward
41:06
to sort of moving on to that next chapter. So
41:08
I've got a few. rotations this year that I'll
41:11
be doing in the more peds realm to try to better
41:15
prepare myself for the start of my fellowship
41:17
year. So lastly, what style points or points
41:24
of personal preference have brought you success
41:26
both in and out of the operating room? I think
41:29
just trying to have a rhythm with things that
41:32
you do, whether it's talking to all the pre -ops.
41:35
Roughly the same way, asking the same questions
41:38
in the same order. When you set up for a procedure
41:41
or for induction, having the same checklist when
41:44
you're getting to time to extubate. Again, having
41:47
a set standardized way to approach it. I've tried
41:52
to hammer down my routines that way, and I feel
41:54
like when things get chaotic, you just fall back
41:57
to what you know and that order of things, and
42:01
you tend not to forget things when you do it
42:03
that way. Brian, thank you so much for joining
42:07
us. Thank you. Nate, thank you for joining us.
42:16
Thank you for having me. So tell me, what did
42:20
you learn during your CA2 year? So much. It's
42:25
actually a great question because reflecting
42:27
on it, I think it probably went by the fastest.
42:30
Really? For me, at least. I think a big part
42:33
of that had to do with a lot of the external
42:35
rotations we did, the wide diversity and variety
42:38
of cases we did, as well as applying and going
42:41
through the fellowship process, which felt really
42:44
early, especially now post -match with a year
42:47
of residency left to go. And so it was definitely
42:52
a year where there were some new aspects, like
42:55
doing pediatrics for the first time, but then
42:57
going through and repeating a lot of rotations
42:59
like neuro, cardiac. OB, things like that. And
43:03
progressing and developing everything that you
43:06
learned CA1 year and sort of refining it and
43:09
advancing it. And now going into CA3 year, reflecting
43:14
on everything and thinking like, what do I polish
43:15
up on? Because now I should know how to do everything.
43:18
And kind of seeing the value in CA3 year and
43:23
having the chance to kind of become really well
43:25
-rounded before graduation. What are some of
43:28
the finishing touches that you're hoping to put
43:31
on before you graduate yeah i think um you know
43:35
anesthesia is a very technical specialty uh and
43:38
so one example would be like uh ob and araxial
43:42
skills um i feel like ca1 year was figuring out
43:46
what to do ca2 year was getting more reps and
43:48
getting more refined and i think for ca3 year
43:51
um fine -tuning that and really developing like
43:54
your style how you like to do things and like
43:57
why you do things i think that's developing that
44:01
why is sort of where CA3 year becomes fun. What
44:06
do you think the biggest difference is between
44:08
you and the intern version of you that did this
44:11
a couple years ago? Yeah, that's fun to think
44:14
about. I think the me now versus intern me, I
44:19
think intern me was just very excited and clueless
44:23
about everything and wanting to just kind of
44:27
take everything in and learn everything. I'm
44:30
not really having sort of a sense for like how
44:33
I do things or like what I like or don't like.
44:36
Whereas now I can I can say for sure there are
44:40
a lot of things like this is why I do it this
44:41
way. This is why I like it this way. And then
44:44
I think one fun aspect of that, too, is maybe
44:48
getting the point now where you sort of maybe
44:50
teach juniors that you have of your own students,
44:52
junior residents and things like that on what
44:55
you've learned and why you do things the way
44:56
you do. If it's OK, I'd like to. pull up your
45:00
episode from the wisdom of interns and we'll
45:04
listen to what you had to say about your intern
45:06
year. Yeah, that'd be great. My name is Nate.
45:09
I'm one of the residents at UC. And I'd say the
45:13
biggest thing I learned this year that I took
45:16
away from was how to advocate for myself and
45:19
how to advocate for others. I found that, at
45:23
least from my experience going through intern
45:24
year, there were several opportunities that came
45:27
up where there were things that maybe to me appeared
45:32
like they could be improved upon. And so I reached
45:35
out to my seniors, to my faculty, to discuss
45:38
ways that, you know, we can make things better.
45:41
And I feel that as an intern, sometimes that
45:44
can be intimidating or sometimes you feel like
45:46
that's not your place to do that. But I think
45:48
one thing that I definitely took away from this
45:49
year was that, you know, everyone has the opportunity
45:52
to do that, that, you know, it doesn't depend
45:54
on what year you are, if you're a junior or senior,
45:56
et cetera. I think that. That's really insightful,
45:59
and it's really hard to do when you're just starting
46:00
out as an intern, especially if you're going
46:02
to a location you haven't been before. What was
46:04
kind of your process when you saw something you
46:07
didn't think was right? What did you do to get
46:09
in touch with people that could help? Yeah, so
46:11
I think the first thing for me is trying to get
46:13
feedback from my peers immediately to see, you
46:16
know, if what I was feeling was out of the norm
46:18
or if, you know, things are par for the course
46:21
and maybe that I was just experiencing sort of
46:25
the status quo. And if something was unusual
46:28
or if we feel like, you know, the experience
46:30
is something that is not in line with what it
46:33
should be, then I would reach out to my seniors
46:35
to get their feedback on it. And then depending
46:38
on that process, then going up to faculty. And,
46:41
you know, here I would say I'm very fortunate
46:43
that I have very supportive seniors and faculty
46:45
and staff, and I always feel empowered to be
46:47
able to bring things up. So in terms of advice,
46:51
I would say, you know, for any prospective students,
46:53
definitely look at programs where you can feel
46:55
empowered to do that, where you are comfortable
46:57
speaking and being able to advocate for yourself
47:00
and others. I definitely think that's important.
47:02
Are there any questions you think applicants
47:04
could ask when they're on the interview trail
47:06
to kind of get a feel for how receptive senior
47:09
people are at people advocating this way? Yeah,
47:12
absolutely. I think on the interview trail. It
47:17
was a good sign if the program themselves advertised
47:20
a system. So I know coming here from UC, that
47:23
was something that was highlighted, the feedback
47:25
system, you know, multiple residents, multiple
47:30
faculty talking about like there are ways to
47:32
escalate concerns. And so that's already a green
47:35
flag. You're on the interview trail and you see
47:37
that. If I don't hear anything about that, then
47:41
I begin to ask simply, is there a system for
47:44
feedback? Is there a system? Like if I have concerns,
47:47
is there a system in place to allow residents
47:51
to express their concerns? So I'm curious to
47:55
hear your reaction to that. Yeah, it felt honestly
47:59
a lot closer than it's been three years. Like
48:03
I remember my thought process and thinking through
48:06
actually those specific rotations and scenarios
48:08
that made me feel that way. um and that still
48:12
stand true um even you know now coming into the
48:14
final year of residency i still think that uh
48:17
you know every rotation every block even there
48:21
are things that can be improved upon um and i
48:23
think i think having a mindset of like trying
48:26
to continually improve uh the experience is really
48:29
important um especially now coming into the last
48:32
year of residency and looking back and thinking
48:33
through all the rotations i've gone through um
48:36
just thinking like My input and what I did to
48:38
kind of make those who came after me have a better
48:40
experience is really important. Whether that's
48:43
here at UC or at off -site rotations, I think
48:47
every little bit of feedback matters. And I still
48:51
feel that way about our program and how supportive
48:54
we are and how important we take feedback. And
48:57
I would still give that same advice to applicants
48:59
now to look out for that in a program and to
49:02
be cognizant of that as they're evaluating programs.
49:07
I'm curious if there's anything that you've really
49:10
changed your mind about since intern year. If
49:13
there's anything that you are maybe a little
49:15
bit misguided about or that you just feel differently
49:18
about. In terms of expectations, I don't think
49:27
I was necessarily misled in any way. It's kind
49:31
of weird to think because I think also me coming
49:34
in intern year or even finishing intern year.
49:36
I didn't really have any specific expectations
49:39
going to my anesthesia year. I think for me,
49:42
the big one was that I would be trained really
49:45
well and that I would have a very good experience
49:48
and develop to become a strong clinician, which
49:53
I think all those expectations have been met.
49:56
And so I think for me personally, with my professional
49:59
development and my personal growth, I would feel
50:02
like our program has really helped me achieve
50:04
that. And then one thing that I continue to advertise
50:08
and I continue to feel strongly about is the
50:10
quality of our people, especially our quality
50:12
of our co -residents. I can definitely speak
50:16
on my class and the class below me and even the
50:18
CA1 class now. We do a very good job of finding
50:24
people who are very connected and cohesive and
50:28
like -minded. And so it makes for a really fun
50:31
time, especially now. being a CA3 and working
50:36
with like CA1s where there is a little bit of
50:38
a gap, but still feeling very connected and even
50:44
forming like friendships that I wouldn't have
50:46
expected. So between now and graduation, what
50:52
are your goals? What are your thoughts? What
50:54
do you hope to accomplish? Yeah, that's a great
50:57
question. And that's one I've been thinking about
50:58
a lot, especially for me, where I am going into
51:01
a fellowship after residency. There's technically
51:04
another year of training beyond this before I
51:06
enter attending hood. I think for me, I want
51:10
to use the opportunity now until the end of residency
51:14
to basically be as well -rounded as possible
51:16
to do things that I know that I'm going to have
51:19
kind of a little bit of a gap in because I'll
51:22
be doing a cardiac fellowship. And so next year
51:23
we'll all be cardiac devoted. And so, you know,
51:28
I want to be cognizant about skills like OB,
51:30
PEDS. Um, and then some of the other general
51:33
cases where, uh, I really want to make sure I
51:36
feel very comfortable with those and feel like
51:37
I have a good background in those before I transitioned
51:40
to a fellowship where I'll be so focused on one
51:43
specialty, but then after I'm done, I'll likely
51:45
be kind of a mix of everything again. And then
51:48
being mindful to, to not feel like a year out
51:52
from now I'm deficient in things. Um, so those
51:57
are my, my personal goals and, you know, for
52:00
For my peers who are also going into fellowship,
52:02
I think they also share similar thoughts. So
52:06
lastly, before you go back to your cardiac case,
52:09
what style points or points of personal preference
52:13
have brought you success both in and out of the
52:16
operating room? Yeah, I think that's a great
52:18
question. And I think for me, at least, from
52:23
the feedback that I've gotten, I think two things
52:26
stand out. And that one is preparation. And what
52:31
I mean by that is really taking ownership of
52:33
your patients. So since the start of CA1 year,
52:36
my mindset has always been like, this is my case.
52:39
This is my patient. Like, even if I'm the junior
52:42
resident, even if I have no idea what's going
52:44
on, it's my first day in the cardiac ward and
52:46
I don't even know what bypass is. Like, this
52:48
is my patient and I'm here to take care of them.
52:51
And everyone around me, my senior, the fellow,
52:55
the attending, they're there to help me facilitate
52:57
taking care of this patient. But I think having
53:02
that mindset of really taking ownership of the
53:05
case, taking ownership of the care of the patient,
53:07
and thinking just right from the beginning, like,
53:10
you know, if it was just me taking care of this
53:12
person, what would I want to do? Or how should
53:15
I go about it? I think that puts a lot of onus
53:17
and responsibility on the person. And it makes
53:19
you think about questions to ask. Because when
53:22
you think like, okay, if everyone leaves the
53:24
room right now, is this me? What do I do? I think
53:27
that really sparks a lot of good questions. Like,
53:30
how much of this medicine should I give? Is there
53:33
anything I should look out for? What is an emergency
53:35
in this case? And I think that's really brought
53:40
a lot of success to my time in residency. Nate,
53:45
thank you so much for joining us. Thank you for
53:47
having me. That's it for this episode of Style
53:52
Points. When I think about this mini -series
53:55
of episodes, it makes me nostalgic in a certain
53:58
kind of way. For me, one of the great benefits
54:01
of a career in academic medicine is witnessing
54:03
people develop and change during their residency
54:06
and eventually become fully -formed anesthesiologists
54:09
who people trust with their lives every day.
54:12
I hope that this series of episodes together
54:15
provides a bit of that magic for you. Eventually,
54:18
if any of these residents want to sit down with
54:21
me one more time down the road, We may do this
54:23
again. If you're new to the show, episodes 7
54:27
and 21 are in the feed. These are the same voices
54:30
all the way through residency. Please consider
54:33
leaving us a rating or a review. That's what
54:36
helps other people find the podcast. And you
54:39
can reach us at stylepointspodcast at gmail .com.
54:43
Take a deep breath. Open your eyes. We're all
54:47
done.