Latest / Behind The Knife: The Surgery Podcast / Parental Support: The 5-in-6 Pathway - Flexibility in Surgical Residency Training

Transcript

Parental Support: The 5-in-6 Pathway - Flexibility in Surgical Residency Training · Behind The Knife: The Surgery Podcast

• BTK_5_in_6 === [00:00:00] Hi everyone. My name is Kara Button. I'm a general surgery resident at Bain Medical Center and I'm behind the Knife Surgical Education Fellow. Today we're focusing on flexibility and surgical training, specifically a program known as the five and six. This option allows residents with approval from their program and the A BS to complete five years of residency training over six calendar years. Unlike traditional research time, the extra year is spread out over five years, creating more flexibility for residents who may need time for family, personal, or professional reasons. I'm honored to be joined today by two incredible guests. Dr. Joe Bisky is the president and CEO of the American Board of Surgery, and is held a leadership role with the A BS since 2009. During her time there, the five and six became a formal policy. And I am also joined by Dr. Bridget Olson, who is one of my co-residents, a PGY four at Maine Medical Center, and a current participant in the five and six, Dr. Bisky and Dr. Olson, thank you so much [00:01:00] for joining us today. My pleasure. Thank you. We're excited to be here. We are especially excited to have Dr. Bisky back with us. She joined behind the knife in 2021 to discuss the family leave during surgical training after some recent changes in the a BS parental leave policy and today we're re-engaging in that dialogue as we further explore the five and six pathway. Dr. Bisky, to get us started, can you give us a quick overview of the baseline training requirements for general surgery? Really in terms of how much time can a resident be away from clinical training without having to extend their time and residency? Sure. So, um, the, the short version or the core version is that there are 52 weeks in a year, and for a year to count it has, you have to work for 48 of those weeks. So four weeks away from clinical work. That should include anytime that you spend at a conference. Anytime you spend doing research, anytime you spend doing [00:02:00] interviews it's often interpreted as being vacation, but it's actually time away from clinical service. And that came about because of the. Kind of outcry in the, you know, in the 2005 to 2010 era when program directors and fellowship directors were saying that surgical residents weren't adequately prepared. So I don't think that, uh, we agreed with that, but we did wanna be able to compare apples to apples and oranges to oranges. So we really clarified the guidelines around what is a week off, how much time is it, what counts and what doesn't? 'cause we found a pretty wide discrepancy between people. Allowing residents to take weeks off for interviews and weeks off for research. We're like, we wanna understand exactly what this is and have people talk to us if there's any exceptions. So that's the baseline. And then the, you know, sort of accommodating life events. There are several leaves. There's an additional four weeks that can be used twice during your residency. Once in the first three years. And once again, in the last two years, we kind of lumped them differently because of the difference in leadership and learning. [00:03:00] That occurs in the different parts of residency. And that can be used for sort of a major family event for caretaking, for a loved one. We've had people use it for a sick parent, sick spouse, sick child for parental leave, for personal illness. So at that point, you're up to eight weeks if you were gonna take it all as a block. That we also allow extension of training through August. So that's an additional eight and a half or nine weeks to accommodate people who need more than that and still want to finish sort of on time. And then the last is we do allow averaging from year to year. So if you. Needed, you know, extra time off in your second year, you could take a little less time of your four allotted weeks in your third year. So there's actually quite a, quite a few pathways and it's, you know, up to the program program director and the person involved to figure out what is gonna work for them. And then of course, my favorite, which is the five and six. That's actually my favorite of all of them. I think it's the most flexible. And I think [00:04:00] particularly since we're talking about supporting surgeon parents, it ain't all about the pregnancy and the new baby, you know? So five and six is the one that allows you to then say, and then when the, you know, the baby's a month old, I'm gonna have more time with 'em, or I'm gonna be able to stagger time off with my partner because I, I think that that's a more realistic look than saying, oh good, I got eight weeks off for parental leave, which is, by the way, kind of short anyway. I definitely can agree with that. Thank you so much for putting the timing and training into context. This can be a really confusing subject, especially for, for trainees who are trying to navigate parental leave or time off for any reason in residency now launching into the five and six in particular, I'm curious about the history of the five and six and, and how did all of this get started? Especially since this was before the changes to the formal parental leave. Policy. I think there alwa, first of all, there were a growing number of women in [00:05:00] residency. So the issue of parental leave was coming up a little bit more frequently. There was also a little bit of a social change where the non birthing parent also might be interested in leave, and that was not a thing in surgical culture prior to, certainly prior to this century in any way. And then a, a growing drumbeat from program directors from me, from. Other people in surgical leadership that you have to kind of be prepared to acknowledge that life is going to happen during those, you know, critical years of whatever, 27 to 32 or 26 to 35, that range of time that you'd be foolish not to think that people are gonna have children, people are gonna get married, their siblings are gonna get married, their parents are gonna die. You know, all kinds of things can happen that consume time. And for us to just let every one of those events be an unexpected catastrophe, how do we deal with this? Seemed very shortsighted. So I was in favor of, you know, a, a rule that would allow people to take flexible time off. And, you know, I think you, I think you know that there was [00:06:00] always probably some option to do that, but it wasn't written down and it wasn't formalized. Which led to only sort of program directors of longstanding who might have a contact at the board or who had successfully managed this time before they might know enough to call and ask for special dispensation for a trainee who needed additional time off. That to me, creates an in-crowd and outrow and I really. Uh, if I, you know, that's one of my true norths if you can have more than one, um, is, is to try as much as possible to make things transparent so that everybody has access to the same information. So I didn't feel comfortable with the idea that it was like, this isn't a problem. They just have to call. 'cause I didn't think that everybody would know to call. So I wanted to have a rule in place and that became the five and six, you know, published on the website, disseminated in the program, director's new letter a fact, uh, that happened in 2011 and that year we had one person take advantage of. Well, it's good to know that even the first year you had one person formally take advantage of [00:07:00] something that I'm sure a few people had taken advantage of, but there were probably a lot of residents who didn't know that this was an option. So that's really great that the word got spread around. Now speaking of we're getting spread around Dr. Olson, I'm curious as to how you learned about the five and six and how you decided on taking this training pathway. Yeah, so in my spring of my intern year, I remember talking to my then program director, Dr. Whiting, and I was mentioning to him that I. But I wish I had more time to reflect on my job, I think is initially how I put it and, and how I wanted some time for research, but I wasn't sure I wanted to have to leave to go do it. And that at the time was pretty common at our residency that most people did not stay to do a research year or two. And he, he said, oh, I think you should do the five and six. I think it would work. Great for [00:08:00] you. We've had one resident do it previously and, and she had used two six month blocks. And uh, and that's how I ultimately decided on it. I told, you know, my family and my brother who's a. Psychiatry, re resident. I remember him saying like, you'd be, you'd be mad not to do this. This is the way to make residency an enjoyable, more normal experience. And I said, okay. And I did it and it was great. So what had you heard from other residents before about the five and six? Because I'm sure as a resident this can be confusing in terms of how do you arrange your schedule and how do you keep track of what you're doing, your rotations, how did you approach that? I talked to the resident who had done it before me, and she had some great advice, which I've told the resident who has done it after me, that you definitely need to be somewhat regimented [00:09:00] with your schedule because your, your schedule is gonna. Span over two scheduling chiefs most likely. And so it does get confusing for people of, oh, is she a early three, a late three? What has she already done for rotations in her in the year, the academic year prior when she was a, starting her third year? Things like that. So she gave me advice on how to manage that, which is just being. You know, having a spreadsheet and, and knowing exactly what I've done and tying up all the weeks and months that I've spent on different rotations so that I can, at the beginning of the, each academic year talk to the scheduling chiefs about, you know, what, what I've already done, what I'm expecting for this following year. And, and that worked. That's worked really well so far. I actually, I wanna just jump in there 'cause it sounds like you really took ownership of helping other people understand what you were doing, which I'm sure not everybody absolutely can do that or does do that, and I'm sure that that made it more [00:10:00] successful and less stressful for you and the people around you. You sort of showed up with the information that they might be wondering. They didn't, maybe they didn't even know to ask. They were just sort of uneasy, you know, when you showed up on a new rotation. So I think. You know, we should have an FAQ that says how to, how to make this work and have a little summary about that. I like that approach a lot. Yeah. I think so much of residency is having to show up at a certain time, but a lot of it is being in charge of your own education and I think this really allows you to, to do that because you do have this kind of nonclinical time that you can use to further. Further study, further do whatever, and you get to decide. And then with that comes the responsibility that this is, you know, more work for the scheduling chiefs. It is more work for your program directors. So I think on the flip side of being more on top of what your schedule is, really helps balance out that that workload. Now, Dr. Bisky you know, Dr. Olson was just telling us about how she's [00:11:00] divided up her time, and we know that there's the requirement for the number of rotations that you have to have for a chief year, but are there other regulations about how time has to be divided between years in the five and six, or is it really up to the resident and their program director? Other than the fact that when you are on, you have to stay on, you know, you can't do a half day, you can't do and call, then call that halftime. You know, it has to be, if I'm on rotation, I match the rotation of the rest of the hospital, whether it's calendar month or four weeks or whatever. You're there, you're full time and you're doing that, and then when you're off, you're. Off. So that's really the only rule. And you know, as Bridget said, some people take blocks six months on, six months off. Some people take the entire year. Some people, uh, we've had more than one person do every other month. And then we've had people do any, any kind of mixture in between. And we've also had people not take the whole 12 months, they just graduated, you know, really off cycle. They needed more than the extended training that went into, that goes into August. They [00:12:00] needed four months or something instead. So some people take, uh, lesser time, but the rules are, it's really supposed to be. Pretty easy and, and also easy in that we don't ask you what you're doing with it. It's not, you know, as is obvious from British story, it's not only parental leave, it's for space time reflection, adventure, special interest, special life event. You know, my dream was that someone would say, I want, I, I wanna use it to climb Everest. Hasn't happened yet, but I still have a little bit more time. Could still happen, but I really wanted it to be for the things that might happen to you, both good and bad, and in between. In those years of your life, so easy, easy. When it comes to the rules. We don't say, well, why? Tell us why. Tell us what you're gonna accomplish. We just say. Make sure when you're on, you're on. Well, to any mountaineers who are out there listening, uh, I know that Dr. Bisky is, uh, supporting you if you, uh, have some, uh, mountaineering endeavors. And I should say that my schedule for, for the listeners and people curious about it [00:13:00] is that I'm, I'm do, I did my intern year in normal. Mm-hmm. And then I'm doing my chief year. Full and the three years in between those two, I'm stretching out over four years. So I have three months of nonclinical time during my second, third, and fourth year, which has been lovely. You started off saying that we have to have 12 months of chief rotations and you know, you know you can do chief rotations in your fourth year as long as there's a. Or you can do non chief rotations in your last year as long as there's an accommodating or balancing chief rotation in your fourth year. Now, what exactly is your fourth year if you're in five and six is a little confusing. And so to that, I would say the board is actually way friendlier than people think. So you could just call, you know, the program administrators particularly know how to reach the staff. That helps 'em. They have a very close relationship. And it's a, and the program directors are, they're free to reach out to me. They're sometimes surprised that they actually get me, but we, you know, we like to work through that stuff [00:14:00] together 'cause we wanna make it work. And we definitely don't want people to have some elaborate schedule that actually doesn't work. So when things are confusing, it's completely fine to reach out to the board office and we'll get you to the right person. Wow. It was really great to hear not only is this a flexible program, but it's really one that is resident specific. Mm-hmm. Where it's truly flexible in terms of timing and to make sure that it's the best fit for that particular resident. Now, I think one thing that can be kind of confusing is there's the American Board of Surgery and then there's the hospital that the resident works for. Dr. Bisky, can you talk a little bit about how the American Board of Surgery might support this program, but then what does the A BS have to do with the actual hospital? Who's employing the resident? Yeah, that is a, that is a complicated problem, and it's really, as far as I know, medicine writ large is the only field that still has this very dense interface between education and work. And so the hospital is really on the work [00:15:00] side. I mean, they, they do get funds for education, but really they're your employer. The HR rules of your work flow through the hospital. Um, and you're also bound not just by the hospital, but by the state and perhaps the city that you work in and the, you know, local environment and, and, uh, laws and regulations. There. We are really on the education side. Our question is, did you learn what you needed to learn during your training to be a safe surgeon? And so the five and six pathway is. You can finish your training in this period of time and you'll still be admissible to our exams because we believe that you will still, you will still be able to learn the stuff that you needed to learn. And actually, I said still be able to like maybe even better, but in any case, you'll still be, you'll be able to do it in that period of time. And it's really for the hospital to decide what they wanna do about paying you and what your category is. Are you still a trainee? Are you related to them at all? But selective, not every program can do it. Not every program wants to do it. It's a little easier I think for the larger programs, the. Are moving residents in and out of research [00:16:00] years or extra education years. A little tougher on a program that only has a few people. And there are a lot of things like that. The international rotations. Some programs can do it, some programs can't. Some programs can manage flexibility and training, which is really changing rotations specific to residents. Some can't and some can, some can manage five and six and some can't. So we, we opened the door to it. We try to make it easy for the program directors. We do share what we've learned from the people who've already taken it about how people managed it, but really it's to the hospital and the program directors to figure out if it's doable or not. And Dr. Olson, I'm hoping that off that you can give us some, some real life examples of how did you make this work with, uh, the hospital. How did your employer adjust to your schedule? Yeah, so you know, from my end it was actually fairly easy. Dr. Whiting, the then program director, spoke with the Dean of Education and the DIO, and they approved that I become [00:17:00] a 0.75 FTE resident, and they basically allowed me to have an extra year of benefits that were not discounted. I'm still allowed to do public service loan forgiveness. I still get all of my normal benefits, but instead of getting paid a full-time equivalent, I get paid, you know, basically three quarters and I still get paid every two weeks, uh, even when I'm off because it's discounted. Some people have elected to only get paid when they are working. I think that's much more difficult for accounting and, and that's not what I chose to do. And then also. You know, certainly that's a pay cut. Um, moonlighting impressively makes up for it quite quickly, which is a little painful. But, uh, it does, and to me, time was worth so much more than that small amount of salary that I was losing. So it, it all balanced nicely. [00:18:00] Now, has there ever been a situation in which you are in your nonclinical time at time where you're not supposed to be at the hospital and you've gotten called into work, and how would you have handled that? No, I have not. I have had people ask if I can take a shift for them under the medical malpractice. It's. Was suggested to me, not formally told to me, but suggested that I not particularly not operate when I'm on my o nonclinical time. So I'll occasionally take moonlighting shifts, but I do not take shifts for residents where they would need to be operating, which is at Main Med, pretty much all of the shifts. So I have said, no, it is, it is sometimes difficult for me because I do have a lot more time and I often feel like I. Want to help out, but that was something, the person who did the five and six before me had encouraged me [00:19:00] to be really specific and disciplined on my nonclinical months that I was not to be in the hospital unless I was moonlighting. It sounds really important, the need to set boundaries not only for you personally and for what you're doing with your time, but from a medical malpractice, pers protection standpoint and from a financial standpoint too. So I think a, a take home for our listeners who are considering this is know what the rules are within your hospital in terms of what your pay can be like, what your benefits will be like. What your malpractice insurance will be like and what the culture within your program is going to be to make sure that you're not having an expectation for you to be there when you're not supposed to be there. So I think that those are probably some key considerations that you just brought up with that. Yeah, and I think, Bridget, you took risk with this. You know, you, you prolonged the period of low income after medical school. You delayed the time that you could take a fellowship or take a full-time job. You took on burden as [00:20:00] well. In electing to do this, you took responsibility for that. So, uh, if that bolsters anyone else's fines a little bit, it's not just like you're just hanging out at home and you're getting all the benefit and you know they're taking all the burden. You took burden as well. Yeah, that's fair. And I, I do think that it's an important skill of setting boundaries. And I think while the schedule of the five and six might not be what my schedule is as an attending. The lessons that I've learned and how to create a life that I'm really happy with, I think will progress into my life as an attending. And I, I hope it prolongs my career because I've learned how to be in medicine, in surgery and still protect my personal life and still do all the life events and be present for them in a way that I think, I think will have long-term effects. It makes me very, very happy and it's very, very pleasing to hear, and as your friend and and co-resident, I certainly get to say that you bring a lot of [00:21:00] that positivity and that perspective to our program, which is incredibly helpful. So having people like you involved in a team to be able to lift everyone up is is truly wonderful. I would like to talk a little bit about kind of the, the next steps in your career. 'cause we talked about some of the implications it has, you know, financially about someone extending their training. But one question that people might have is, well, what is this gonna do? If I'm trying to apply for fellowship, how is this going to affect my fellowship application? Will I still be able to be kind of on the on cycle application? And what are some examples of what that looks like from the previous resident who did it in our program? Matched into fellowship on a non, on a off cycle. She had done her six months where she ended her chief year in January. So that is a different, I'd say it's a different example from mine where my fourth year, apart from starting in March of the, you [00:22:00] know, the, what other people would have as their third year, my fourth year is really. In continuity. I have a few months here and there. I think on the other side of that is that doing this program allowed me to do some awesome research that I was really excited about, and I got to do it over this three, four year period. So to me it seems so much more rich because I got that time to really invest in it and understand the research. One of the advantages of five and six, instead of trying a shorter. Shorter amount of way if you just commit upfront to taking 12 months off over time, theoretically, when you're gonna finish, barring unexpected events, and it's, I'm gonna say several times a year, we get a contact with the program director saying, we have residents who had a bicycle accident. They're gonna miss six weeks, we wanna use the leave. Fine. And then a couple months later, we gotta, actually, they came back for two weeks, but now they're out again. So we are gonna use the other two weeks. And also can we extend their training into the end of July. [00:23:00] Did we mean? Did we say July? We meant the end of August, but it limps forward and you can imagine how disruptive that is to the program, how distressing and demoralizing it probably is to the trainee themselves. How much time consuming and distressing for the program director. And sometimes it's better to just step up front and say, wow, this unexpected in this, my example, negative event happened. Let's just take everything off the table and concentrate on getting well. Yeah. Um, and if we're well a little bit early, then we'll contact the board and ask if we can shorten the five and six. And that'll be, that'll work out as well too. So I, I like it for that reason. It's sad to see the kind of limping forward. Trying and failing efforts. And so you should know, you theoretically know when you're done or we're done, and I think five and six facilitates that, which might help with Fellowship to link it back to the original topic. And one thing I also wanna bring up, because I, I think her story is just so awesome and showing what is possible during a surgical residency is that. The resident who did the five and six before me actually had two children during residency, and so [00:24:00] she, she used the two six month blocks in order to have time with her newborns, and then she matched into some fabulous vascular fellowship, and she's a absolutely phenomenal surgeon and person, and she really felt like it. It allowed her to have somewhat of the best of both worlds. She got that delicate time with with her kids and she progressed her career and is now done with fellowship. And listening to her talk about her five and six experience definitely inspired me, despite knowing that I might not have kids during it, but still being able to have time to do. So many life events that we really gloss over in residency and we say, oh, well, we'll take a weekend to get married. Well, it's a big thing and if you can, you know, if you can have the time to really fully be present. And I think what people will see when they get out of residency and something research [00:25:00] residents have always known, and I've found in my nonclinical months, is that there is a, there's a. Kind of space opening in your brain that happens when you have these months off where you are thinking about what you want and what you need in a way that when you're in residency, you really, you know, clinically you can't because you have to do these, these hours and focus all in on your patients. And having a step removed really allows you to think, what do I want out of life? Is this, is this fellowship decision really right for me? You know, all these different things that when you don't have the space to process them appropriately, it's much harder to make long-term decisions that are in your best interest. So I felt like her talking about how much it gave to her really. Was an impetus for me to, to take a chance and do it despite having people say, well, you're gonna miss a full year of being an attending and having the salary that it comes with [00:26:00] that and, and, you know, fellowships are gonna look down on you for taking time off. And I had to say, you know, I think this is in my best interest and I think this will make me a great surgeon in the long run and have a long career. And I have to stick to my gut about how I feel when I think about having a month off. And all that I can get accomplished in that, in that time and be excited to go back to work On the flip side of actually having the time to be, to look forward to, and you know, I, I tell Kara knows this, but at week three of my four weeks nonclinical, I get a little itchy. Like, I'm like, okay, like what are we, when are we doing stuff again? Come on. You know, I, I, I, I miss the OR and I get back to the or so. So yeah, I think that's beautiful what you said, especially in regards to career longevity because we spend, you know, for a lot of us, our twenties, early thirties and early forties and training and being able to see [00:27:00] beyond that and see what your career can be and what you want it to be, I think is really important when you're putting all this time and taking care of other people to be able to have the space to dedicate to your patients when you make it through training. Dr. Beke, do you have any advice for residents who are considering the five and six from, from your position? Well, I am a really big fan of the five and six for all the reasons that Bridgette has brought forth for allowing yourself space and time to be a parent as opposed to just drop a baby and come back to work, to explore things, to think, to refresh your enthusiasm for your career. I think the self-advocacy is so important, and it is funny how residents don't have that because they advocate for their patients. They're really good at it. Other, uh, specialties might say were too good at it. And it's a, it is the same skill. I actually thought that being a surgeon made me a better parent 'cause I was better able [00:28:00] to advocate for my kids than I would've been had I not, but I had to learn it. The pathway was advocate for your patients. Advocate for your kids and then advocate for myself. Those are the, that was like the sequence that I learned it in, so I think that it's valuable that way. I know this is sort of the boomer look back comment, but life is longer than it looks like from where you are and you will not know care or remember that residency took a year longer when you're 50, 55, 60. I actually. Was not really pre-med or not, certainly not a committed pre-med in college. And I had to do an extra year of school to take all of the pre-med requirements and the time. It was like a catastrophe. My friend, my friends were like, you are, you know, you're gonna take a your school. How are you gonna do that? How are you gonna pay for that? You know, you're, who's gonna hire you after that? You're just like an, you're not even gonna get a degree. And it was like all this catastrophizing about it. And I literally, now that my friends have kids who are taking five or six or seven years to go to [00:29:00] college. And they all are heartbroken, and they're like, oh, I'm just so upset. He can't come, he can't get his feet under him. He is changing paths. And I'm like, oh yeah, you know, it'll probably work out. And I get home before I'm like, oh. Oh gosh. I did that too. I forgot to tell them I need to call them and tell them it was probably gonna work out. Okay. So the timing seems so awful, and I know there's the burden of debt and the desire for time, but in the great scheme of things, it really is so worth it to take advantage of the gift of time, which doesn't come that often, not likely to get it during your. Job. And if you do get it during your job, you're gonna have to ask for it. You're going to have to advocate for yourself. You're going to have to say, I want this, or I need this, or, we have to work it out in such a way that I can, I can do this. So I think just don't short, don't short yourself. If you have a reason to need time off, make sure you get all the time off that you need. Yeah, and I think I'll, I, I probably won't. Care in the long run that I had an extra year, but I certainly will care that I had a nonclinical month off when I got married and I was able to plan the wedding without a lot [00:30:00] of stress and I was there for parents and family and I got to remodel my brother's bathroom when he moved into a new house with my dad. And that was an absolute blast. So there's, there are so many things that we can. Welcome in life and embrace in life that we probably wouldn't if we didn't have the time and space. I'm just thinking back to when I had my daughter in the five weeks off that I had, after I had her, and the five and six was offered to me as an option, and I knew that it was a really great option and I had seen people who were so successful with it, but it wasn't the right option for me. I was really grateful to have been offered that because it meant that my program was looking out and saying, Hey, you know. It looks like this might be something that would be interesting to you that would benefit you, not only personally, but professionally. And I think that's a really, really important lens for a program director to be able to say, you know what? Your pathway might not look the same as somebody else's, and that's okay. And in fact, that's encouraged [00:31:00] because we want you to be successful at the end of the day. And I think knowing what's going to make you successful personally is really important. That's a really good story that was offered and you chose not to take it, but they recognized your. Your autonomy, your personhood. You're not just a widget. Yeah, I like that. I really like that. It's just an option and we should all have options. One of these other questions that I have here is, is there anything else that we haven't talked about that you would want a resident or a program director or an institution to know specifically about the five and six or any questions, especially Bridget, that you've been asked about the program that we haven't addressed already? Something that. Kara brought up in the past is sometimes when I go to conferences, people, people ask me about it or, or I bring it up that I'm doing this five and six pathway, and unfortunately for them, most people don't know about it. Kara watched me kind of stumble my way through describing it before [00:32:00] I came up with a script that I used. So I think if there's any people listening who are worried that they're gonna be met with. Something less than excitement for the program. I'd say that Everyone I've talked to and explained it, they're like, oh my goodness. If I had been able to do that when I was a resident. I, that would've been incredible. They're just enamored by the fact that it's a possibility now, and so I now say, you know, I, I'm a part of the five and six, which is approved by the American Board of Surgery to be able to take your five years of training stretched out over six. And I use my nonclinical time for personal as well as research purposes. That has made it much better than watching me stumble. The lovely Dr. Button has. It is an interesting, first of all, that is a very good elevator speech, you know, uh, for it. I like that a lot. The, uh, I'm surprised when I go around and give grand rounds and sometimes it sort of updates from the board. Sometimes it's a [00:33:00] little burnout or personnel personality focus, in which case I talk about leave, and often it is at a training program. And I'm shocked at how often people had no idea how many options for leave there are. And then I'm not sure. Why they don't know. And then I just, while you were talking, I just realized, you know, when I started at the board, there were 150 training programs. There are now 350 training programs. So actually more than that, there are, so that's a lot of new program directors, even without turnover and the program directors can turn over pretty fast. And so a lot of them may just not know. There's a big book of rules. So back to the advocacy. If you need to take leave, maybe I encourage you to do research about what's available. And then from the flip side, I heard, uh, Doug Mink, who's been a big advocate for sort of quality of life during residency, gave a talk once and it was about how to receive the news that a resident wants to take leave. And he said it's two steps. The first meeting should be nothing, but that's fantastic. This is great news. [00:34:00] Good for you. So happy for you. Yay. Let's talk again in a couple weeks. And then the second one is more like, what exactly are we talking about here and how, how you and here are your options. And, but he said the first one should have no kind of action items out of it. It should just be, receive it with nothing but joy, which I really, um, found inspiring and. You know, I, I have staff that, I have staff that goes out on leave too. So I try to, I try to do exactly that. Yeah. That's great advice. That is wonderful. And I think this, this talks too as well, that the idea about policy and culture going hand in hand, that a change in policy can promote a change in culture and a change in culture can promote a change in policy. And I think that that's what you see with the five and six that. It was always behind the scenes, but now it's out in the open. More people are learning about it more. More people will take advantage of it. We had a resident after me decide to do it for, again, very different reasons. Has older kids, middle school age, and wanted time [00:35:00] with them when, on summer vacation, when they went back to school and Christmas break when they, when they're off for a couple weeks for a break. There's many different ways to use it. And also like, you don't have to have kids, you don't have to. I was, you know, a single person who had family nearby, but really no other reasons that I would take it for a personal or a family reason. And I met my now husband on my fourth day off of my first nonclinical nonclinical block. So. Life happens and I'm really glad that I had, uh, you know, a month or two months to be able to get to know him because if I had gone right back to residency and been in my super focused all in mode, I don't know if I would've given, given that relationship the, the time and the, you know, input that it needed. So, and I think, I think you asked about advice to program [00:36:00] directors also, I think for programs to be able to take advantage of it. They need to have flexibility built into the schedule. So if every resident is doing exactly every rotation, then the work aspect comes into play very heavily, right? Every, the rotations, the services count on this number of residents to match that number of attendings, to match that number of cases, to match that number of apps or whatever. So any change in that. Is, has a terrible ripple effect and causes headaches for everybody. And that's been a sticking point for, for years, for any kind of change or time off that we wanted to create. And, uh, if you just throw in a couple of undefined elective months, every year, every couple of years, then they have the space, at least from the work aspect, from the service aspect. To make changes like that. So the sort of more forward thinking, proactive programs realize that themselves, I didn't think of it myself. I figured that out from them. So it's not impossible if you have it, if you have a little bit of flexibility already built into the schedule and then you just have an opportunity to take advantage of it [00:37:00] when somebody wants to take any degree of leave. Mm-hmm. Yeah, and I'll say our program is pretty small. We, we. Our four years we're four per year. We've now expanded to six, but my class is still four and, and we've actually found it, I mean, I hope I can speak for my program director, but it seems like to me that it has been actually less disruptive than having a resident leave for research and come back because I'm still around for most of the time. I'm just kind of randomly not there and, and so I'm in the call pool. Most of the time versus having a resident leave for research and then come back. It's especially been less disruptive. Before we wrap up, I was just wondering if you have any closing remarks for our listeners. Sometimes we lose sight of how incredible this job is, and I find that, you know, some additional time has really allowed me to fall in love with surgery all over again [00:38:00] because I have the space and the time to do so. So if anyone's thinking about it, I highly recommend it. I'm always happy to chat with people about it. And I think from my perspective, just to acknowledge that both of you, um, are sort of in a vanguard of change, it makes it easier for people who follow behind you to do whatever their creative. Slightly different thing is. Just looking at the first couple years that we had five and six, it was single digits. One person, three people, five people. And the last couple years it's been 15, 15, 13, and it'll get to be more. I'm quite confident about that. And you open the door, you know that if you can't see it, you can't be it. They can see you doing it so that they're willing to take a chance as well. And so are the program directors and the rest of the residency. So I just wanted to acknowledge that about both of you, and thank you for that. Dr. Baki and Dr. Olson, thank you so much for joining us today.