Latest / Style Points / Under the Mask with Ben Fedeles

Transcript

Under the Mask with Ben Fedeles · Style Points

0:10
anesthesia enthusiasts, and possibly people who
0:12
are pretending to be anesthesia enthusiasts.
0:15
My name is John Crow, and you're listening to
0:17
Style Points. Today on the podcast, I have special
0:20
guest Dr. Ben Fidelis, who will be chatting with
0:23
us about imposter syndrome. Before that, I'll
0:26
hand it over to my co -host, Nate Moore, to talk
0:28
about this month's RSI. Thanks, John. I'm really
0:32
excited to introduce Dr. Veronica Takugang today.
0:35
She is an anesthesia intern here at UC, but she's
0:38
not new to Cincinnati. She grew up in the city
0:40
and her first job was at Graders. So we'll be
0:43
seeing if she still has any free ice cream connections
0:45
after the show. Veronica will be teaching us
0:47
about inhaled anesthetics. Welcome, Veronica.
0:50
Thanks, Nate. So the course of general anesthesia
0:53
can be divided into three phases, induction,
0:56
maintenance, and emergence. The majority of general
0:59
anesthetics administered today use inhaled agents
1:01
during the maintenance phase. And while most
1:04
adult cases use IV agents for induction, pediatric
1:08
patients commonly receive inhalation inductions
1:10
to avoid awake IV placement. For these reasons,
1:14
it is important to understand how inhaled anesthetics
1:16
work. Let's first think about how these agents
1:19
get into the body. Inhaled agents start as a
1:21
liquid but are turned into a gas by a vaporizer,
1:23
then are swept into the lungs along with the
1:26
fresh gas flow from the ventilator. Note that
1:28
the patient does not necessarily receive the
1:30
concentration set on the vaporizer of inhaled
1:33
anesthetic. The actual composition of the gas
1:35
mixture depends on three factors, fresh gas flow
1:38
rate, the volume of the breathing system, and
1:41
any absorption by the machine or breathing circuit.
1:44
So the greater the fresh gas flow rate, the smaller
1:47
the breathing system volume, and the lower circuit
1:50
absorption, the closer the inspired gas concentration
1:52
will be compared to the fresh gas concentration.
1:56
Things that affect the uptake of inhaled anesthetics
1:59
include solubility in the blood, alveolar blood
2:02
flow, and the difference in partial pressure
2:04
between alveolar gas and venous blood. So how
2:07
do we know that our patients are getting enough
2:09
inhaled anesthetic to keep them deep enough through
2:11
surgery? One factor we use to ensure our patients
2:14
are adequately anesthetized is the MAC, or mean
2:17
alveolar concentration. MAC values are standardized
2:20
such that getting one MAC of a given agent prevents
2:23
movement in about 50 % of patients. The amount
2:25
of each agent needed to achieve one MAC is different,
2:28
and these values decrease with age. For example,
2:32
a healthy 40 -year -old needs to receive 2 .1
2:35
% of sevoflurane to achieve one of MAC. However,
2:38
the MAC decreases about 6 % with each decade
2:40
of age, so the same patient at 50 will only need
2:43
1 .97 % of sevoflurane to achieve one MAC. Modern
2:47
OR monitors will automatically calculate the
2:50
patient's current MAC percentage based on the
2:52
amount of anesthetic agent the patient exhales,
2:55
but not all will automatically adjust the MAC
2:57
based on the patient's age. So be mindful of
3:00
what one MAC really means for the patient in
3:03
front of you. Inhalation anesthetics include
3:06
nitrous oxide, halothane, isoflurane, desflurane,
3:10
xenon, and the most commonly used in the developed
3:13
world, sevoflurane. Each agent has its own unique
3:16
properties that cause variable effects on each
3:18
organ system, so it is important to take that
3:20
into consideration when formulating an anesthetic
3:23
plan for a patient. Nitrous oxide is an NMDA
3:27
receptor antagonist that is relatively inexpensive.
3:30
It rapidly diffuses from the blood into air -filled
3:33
cavities, which can be dangerous in instances
3:35
such as air embolisms or pneumothorax. Nitrous
3:38
oxide can even diffuse into the tracheal tube
3:40
cuff itself, increasing the pressure against
3:42
the tracheal mucosa. However, it has very fast
3:45
onset and offset, which can help with quick wake
3:48
-ups. Halothane used to be a common anesthetic,
3:51
but has fallen out of favor. It has been associated
3:53
with liver damage and can cause direct myocardial
3:56
depression leading to low blood pressure, which
3:58
can be exacerbated in patients taking beta blockers
4:01
or calcium channel blockers. Halothane can cause
4:04
hepatic dysfunction and in extremely rare cases
4:06
cause halothane hepatitis. Isoflurane is a pungent
4:11
agent that is relatively soluble in the blood,
4:13
resulting in slightly slower onset and offset
4:16
compared to Sivoflurane. At higher concentrations,
4:19
it can dilate coronary arteries, leading to a
4:21
theoretical coronary steal of blood away from
4:24
maximally dilated ischemic lesions. However,
4:27
this has not been observed to result in clinically
4:30
significant effects. Sivoflurane is relatively
4:33
insoluble in blood, making it an excellent choice
4:36
for smooth and relatively rapid induction and
4:39
emergence in both kids and adults. It is the
4:41
most commonly used inhaled agent in the developed
4:43
world and has a good safety profile and is inexpensive.
4:47
Desflurane has very low solubility in the blood,
4:50
causing very rapid induction and emergence from
4:52
anesthesia. However, it is also an extremely
4:55
potent greenhouse gas. For this reason, many
4:58
centers have moved away from desflurane use.
5:01
It's also extremely pungent and can cause airway
5:03
irritation, making it a poorer choice for inhalation
5:06
inductions. Xenon is an odorless noble gas that
5:09
has very fast onset and emergence parameters.
5:12
Like nitrous oxide, it is an NMDA inhibitor.
5:15
It has very little effect on cardiovascular,
5:18
hepatic, or renal systems and may actually be
5:21
protective against neuronal ischemia. Unfortunately,
5:24
cost and limited availability have prevented
5:26
its widespread use, so the use of xenon is mostly
5:29
limited to test questions currently. I hope this
5:32
brief overview of inhaled anesthetics helps you
5:35
breathe easier next time you are faced with a
5:36
problem on a test or in the OR. It's not like
5:46
I'm talking national secrets. This is my opinion
5:49
about a topic that you approached me about. Yeah,
5:52
that's true. And interestingly, I get to see
5:56
where the downloads come from for my podcast.
5:59
Oh, use the metrics. And one of the places that
6:03
has. i would say an abnormally high amount of
6:06
downloads is washington dc i don't know why hmm
6:10
all right maybe it's the fbi yeah i don't know
6:12
yeah exactly or maybe there's just maybe it's
6:15
just the podcast culture and and uh traffic sucks
6:18
and dmv oh yeah that's that's cool you know it's
6:21
it's just hey we we are progressive young listeners
6:24
who you know this is how we consume our information
6:27
because we're stuck on the metro or the traffic
6:30
for 90 minutes. Yeah, that's great. For the five
6:34
-mile commute. I imagine I could probably sort
6:37
all of my listeners by where the traffic is the
6:39
worst. Oh, that's interesting. Yeah. Well, Ben,
6:45
thank you so much for joining us. Thank you for
6:47
having me. I really appreciate it. I feel honored
6:49
to be offered this opportunity. I knew that you
6:53
wanted to give your little spiel right up front
6:56
since you are a very important person. Oh, I
6:57
don't know about important, but I am a person.
7:01
Similarly, all of the views expressed are my
7:04
own. Nothing here that I state reflects any endorsement
7:09
from the Department of Defense, Department of
7:11
State, United States Air Force, United States
7:14
Air Force, School of Aerospace Medicine, or any
7:16
of the alike. This is my opinion as a student,
7:21
as a scholar, as a, you know, I call myself a
7:23
professional. Someday I would hope to have. A
7:29
similar disclaimer. I'm one of those people that
7:31
gets up in front of people and says, well, I
7:33
have no disclosures, but if anybody is willing
7:35
to pay me, then that would be great. Yeah. Here's
7:38
my bank account. Although I guess I could add
7:41
advertisements to the podcast, but I haven't
7:43
done that yet. So I don't, I don't have any sponsors.
7:45
That's okay. If you want to be a sponsor on the
7:48
podcast, please contact me at styleboyspodcasts
7:51
at gmail .com and we would be happy to be paid
7:56
by you. That's a great plug. So I want to start
8:01
with one of my get to know you questions. Great.
8:03
Which is my dinner question that I asked during
8:07
my residency interviews. I asked it to a lot
8:10
of people yesterday when they were coming in
8:11
to interview for our program. If you could have
8:14
dinner with anyone in the world, could be somebody
8:16
from the past or even from fiction, who would
8:18
you have dinner with and why? So my initial reaction
8:23
would be. if I could have a dinner party, it
8:28
would be both sets of my grandparents. I, some
8:32
of them passed when I was young and some of them,
8:34
uh, unfortunately had, um, you know, just decline
8:38
in the mental capacity as I got older. And I
8:41
think I would just have such a lovely dinner
8:46
getting to know them now that I have kids now
8:49
that I had some military experience that I have
8:54
had. time in this world and been able to to learn
8:58
a little bit more about them you know as growing
9:01
up as a kid i i love my grandparents but you
9:04
appreciate people differently as as you pay you
9:08
know you pass through different phases of life
9:09
so i think that would be my my dinner party um
9:12
from my personal level And if I'm going to get
9:18
a bonus separate, maybe a lunch, I would probably
9:22
say Dolly Parton. Thank Dolly Parton. Just a
9:25
wonderful, kind soul. Who's, you know, that's
9:31
perhaps the safest answer. Oh, OK. All right.
9:34
All right. She's just she's just, you know, an
9:39
amazing individual, a philanthropist who has,
9:42
you know. broken ground and barriers over time
9:46
and has been you know with us so dolly parton
9:49
man i i think that i would leave lunch with dolly
9:54
parton feeling like inspired and hopeful that's
9:58
right she's just wonderful and um in so many
10:03
ways so i don't know anyone actually i probably
10:06
don't know anyone who who couldn't get behind
10:08
that answer and if yeah if um if you do then
10:12
You know, we can throw it on later. Yeah, right.
10:14
Exactly. The reason why we're here today is to
10:18
talk about something that is near and dear to
10:21
you, which is talking about imposter syndrome.
10:25
What about imposter syndrome drew you in? Why
10:29
are you interested to talk about it? Absolutely.
10:32
Great question. imposter syndrome is is especially
10:37
prevalent in medical training we're in a high
10:39
stakes environment where we all want to do well
10:43
we have a passion a calling i hope to take care
10:46
of our patients and our decisions our management
10:49
our job day -to -day has very dire consequences
10:54
and impact also on conversely on the positive
10:58
side through that we often have quite a bit of
11:05
pressure on our shoulders. That's, you know,
11:08
some of it is self -imposed and certainly some
11:11
of it is external. Talking about imposter syndrome
11:15
is important because of the prevalence in this
11:18
environment and the impact it has on us. I believe
11:24
that, you know, at some point in almost everyone's
11:29
medical career, they'll have some symptoms, some
11:33
signs of imposter syndrome, whether it's full
11:36
-blown feelings of fraud or just inadequacy,
11:41
you know, it's certainly, you know, if it hasn't
11:45
hit you yet, it probably will at some point.
11:49
Whenever I saw that you were giving a talk about
11:52
imposter syndrome at the Ohio Society of Anesthesiologists
11:56
meeting, which is where I first saw that this
11:59
was something that you were interested in, I
12:01
have to admit, I thought that you were probably
12:04
the least likely person that I know that I would
12:09
imagine would have imposter syndrome, which is
12:11
why I was excited to talk to you about it partially.
12:15
I remember when you first came to the department
12:17
a few years ago, and the way that you were described
12:20
to me was sort of as the opposite of somebody
12:24
who might be struggling with imposter syndrome,
12:26
just as a... superb clinician and somebody who
12:30
always has a good head on shoulders, very professional,
12:35
solid guy. So tell me, what is it about that
12:43
description that you don't feel applies to you
12:45
or that you struggle with? Great. First of all,
12:49
thank you. I feel honored that people perceive
12:53
and describe me that way. I think it's really
12:56
through some self -discovery and my own vulnerability
13:00
that I've discovered. Sometimes I feel like I
13:04
don't know the answer and the truth is a lot
13:07
of people don't have all the answers all the
13:09
time. It's not until we have this self -reflection
13:14
and this acceptance of who we are and we're all
13:18
human, we're all striving to be the best versions
13:21
of ourselves. If we fail to recognize and we
13:26
fail to normalize and label it, I think we do
13:31
all ourselves, we do each other a disfavor. We're
13:35
all professionals and we all suffer from these
13:36
things. And it is, I think, you know, one of
13:40
my jobs is to normalize this and say, hey, you
13:43
may, this is your perception of me. And I do
13:46
feel like I've had wonderful training. I show
13:49
up every day ready to work. I do all the things
13:52
that. you know, we should do. But at the same
13:55
time, I still am far from where I want to be
13:59
and we're all striving for it. But if I'm doing
14:01
it, certainly everyone else is too. So let's
14:04
back up a little bit. I'd love to hear more about
14:07
your background, your intro to medicine, your
14:12
pathway to being part of the Seastars. Tell me
14:16
more about all that. Absolutely. So I took a
14:22
non -straightforward approach to medicine. I
14:24
always knew I wanted to go in the medical field.
14:28
But when I graduated from undergrad, I knew I
14:30
wasn't quite ready yet. The decision to commit
14:33
to medicine was, it's a big one, right? You put
14:37
that as your priority. You know, I feel that
14:40
our profession is not one to be taken lightly
14:42
and it's not just, oh, it's the next path because
14:45
I don't know what else to do. That shouldn't
14:47
be the answer in my book. I took a few years
14:53
off, didn't know quite what I wanted to do in
14:57
the interim. I did a little bit of business consulting.
15:01
I spent some time actually working in the agricultural
15:05
industry. One of my great grandfathers was a
15:09
farrier in the cavalry. And I was like, oh man,
15:14
that's a pretty cool piece of family history.
15:16
So I went to... the West, went to fair school,
15:22
learned how to shoe horses, moved back to Florida,
15:26
did that for a little while, realized it was
15:28
backbreaking work. And then I managed a show
15:33
horse barn, did some importing and sales and
15:37
management of in that arena, you would say. And
15:43
then I was like, okay, I'm ready. I'm ready to
15:45
go back, ready to hit the books, ready to hit
15:47
the lab. You know, let's continue this on. So
15:50
that was about a four -year hiatus. Did some
15:55
post -bac work where I was down in Florida at
15:57
the University of Florida. And applied for medical
16:01
school. I did not get in the first time, which
16:03
is not an uncommon thing. Neither did I. And
16:07
here we are. And got in on the second round.
16:15
Did my training at University of South Florida
16:17
in Tampa, Florida. Went on to do residency. Joined
16:22
the military during medical school because this
16:24
was also something near and dear to my heart.
16:26
Come from both grandfathers were in the Army
16:30
Air Corps. And I also wanted to continue on that
16:33
tradition. I think at that point we were solidly
16:37
almost into a decade of our overseas involvement.
16:44
again another discussion whether right or wrong
16:46
but that was the state of affairs and i felt
16:48
a calling to help those who were doing work to
16:52
try to make the world a better place or at least
16:54
you know that was all of our where our heart
16:57
was went through the hpsb program managed to
17:04
get civilian training all the way through. So
17:06
did residency at University of Maryland Medical
17:08
Center in shock trauma in Baltimore, and then
17:11
did a critical care fellowship at Vanderbilt
17:13
University and had an outstanding group of mentors
17:16
at both places, especially Vanderbilt. Graduated
17:20
in the midst of COVID, towards the end of COVID
17:24
from fellowship. Came here as my first duty station.
17:28
Again, very, very lucky to come to an institution
17:31
with a heritage. and a high volume of sick patients
17:37
to work in the OR, to work in the ICUs, to continue
17:41
to do ECMO management, retrieval, transport,
17:46
and so do my Air Force job, which is to work
17:52
at our C -STAR Cincinnati Center for Sustainment
17:55
Training and Readiness, where our job here is
17:59
to prepare and validate. members of our CCAT,
18:05
Critical Care Air Transport Team. That's the
18:08
final portion of their pipeline. It's a two -week
18:11
course, which is both instructional, but it's
18:13
really assessment validation in order to take
18:16
care of critically ill patients downrange and
18:20
transport them basically a flying ICU. Sometimes
18:23
it's back of pickup trucks. Sometimes it's rotor
18:26
wings. Sometimes it's fixed wing and just preparing
18:28
for what's next. All sounds really amazing. And
18:33
I fortunately had the opportunity to go see some
18:36
of the Seastar simulation stuff with Jesse when
18:39
I had him on the podcast too. And I had no idea
18:43
how much really cool stuff you guys have. Oh,
18:46
it's amazing. I really feel lucky to be part
18:50
of it. And that's what my job also is when I
18:54
deploy as well. So what deployments have you
18:58
been on? Managed to have a deployment that was
19:03
supposed to be six months and turned into a seven
19:05
and a half month deployment in East Africa. It's
19:09
part of a special operations team out there.
19:12
And without getting into details, we had a really
19:15
large area of the continent to cover and provide
19:20
medical support. We were the asset to mitigate
19:24
risk and to take care of, you know, our brothers
19:27
and sisters and our... partner nations that were
19:31
doing the work mostly anti -terrorism work okay
19:36
so through all that uh you're clearly have an
19:42
incredible cv uh everyone around you respects
19:44
you very much when did you first start to recognize
19:48
imposter syndrome in yourself absolutely and
19:52
the way i think of imposter syndrome too is is
19:55
a spectrum right there's people that certainly
20:00
have full -blown imposter syndrome where they
20:02
feel despite objective evidence of their knowledge
20:06
and performance that they are a fraud and that's
20:10
really really tough to be in that position because
20:12
in my mind or thinking about a fraud is someone
20:15
who does who isn't something who doesn't have
20:18
the skills that they they actually have in their
20:22
armamentarium i feel that most of us manifest
20:28
imposter syndrome in inadequacy or underpreparation
20:34
or feelings of underpreparation despite adequate
20:37
preparation or data that we've done the job,
20:40
done the work, and we're capable. And that's
20:44
really where it was for me. It's like, hey, you
20:46
know, I am the line. I am responsible for these
20:52
patients, for this job, and... Am I good enough?
20:57
Is this, you know, so many people are looking
20:59
at me. Do I have what it takes? Was this something
21:03
that you started to feel in medical school or
21:07
residency or more as an attending? What do you
21:09
think? Sure. I believe it was towards the end
21:12
of residency until to being a junior attending.
21:16
I think for me, it was more the reality of the.
21:21
application. And we're lucky enough not to work
21:24
in silos. We have a great group of colleagues
21:26
here that always back each other. You ask for
21:27
help and you end up having to kick people away
21:29
because you have so much help. But for me, it
21:32
was towards that period where I'm the one making
21:36
decisions. And again, this is the impact of these
21:41
decisions, the nature of our job. We see those
21:45
decisions and the downstream effects of those
21:48
pretty quickly compared to other areas of medicine
21:52
where you're seeing someone every four months
21:55
for titration outpatient blood pressure medication
21:57
right where we have a dangerous job or make critical
22:01
decisions and we do it in a very very short amount
22:06
of time with sometimes limited data points and
22:08
that's that's high stakes that's a lot riding
22:11
on that i feel some of my Self -reflection is
22:15
healthy concern and respect for that responsibility.
22:19
And I think part of it too is making sure that,
22:21
you know, some other people you can show up and
22:25
have a bad day and it doesn't have much consequence.
22:27
But if one of us shows up and has a bad day,
22:29
well, it's a bad day not only for you, but some
22:32
other folks too. This is really true. You know,
22:36
when you think about other areas of medicine,
22:39
when an internal medicine doctor sees a patient,
22:45
and decides to prescribe a medication, the pathway
22:49
for the medication getting to the patient is
22:51
very different. For that internal medicine doctor,
22:54
he will go back to his computer, he will type
22:58
in an order, or he will tell one of his residents
23:02
to type in an order, one of his APPs. That order
23:05
goes in, and it goes to the pharmacy, who double
23:09
-checks it, makes sure that it's correct. And
23:12
then after the pharmacy, it will typically be
23:16
dispensed by a nurse. And if it's a high -alert
23:19
medication, then that gets double -checked again
23:22
by the nurse and it's given to the patient. For
23:28
us, it's very different. We see something on
23:31
the monitor that we don't like and we have to
23:33
push a medicine. We open the OmniCell, pull out
23:38
the medicine, draw it up, and give it immediately
23:40
into the patient's IV. There's not... Usually
23:44
you need double checking. You're right. I think
23:46
that that sort of dramatic responsibility is
23:52
a weighty thing that we have to deal with. I
23:55
agree. You hit the nail on the head and we can
23:58
talk all about the safety systems and everything,
24:00
but I think the emphasis today is really on how
24:04
do we handle those pressures, those stressors,
24:09
and still have the confidence. in our skills
24:13
in our knowledge in our training in our previous
24:18
repetitions in order to provide the best care
24:23
and not let that stand in the way of thinking
24:26
as clearly as we can in those situations did
24:30
you have any sort of event that made you say
24:34
to yourself you know imposter syndrome is something
24:37
that i want to talk about To my colleagues, I
24:40
want to share my experience because that's a
24:42
vulnerable thing that you're doing to put yourself
24:46
out there and say, look, this is who I am. I
24:51
mean, spoiler alert, I think everybody has some
24:54
degree of this. I certainly do myself. I feel
24:57
that way all the time. But what event or mindset
25:03
change pushed you over to the idea of, you know,
25:06
I'm going to put together a talk about this?
25:08
Absolutely. I think two things. One, in my personal
25:13
life, I've realized that I struggle to be vulnerable,
25:19
whether that's with my wife, with my friends,
25:25
my family. And I realized this also extends to
25:29
my professional life. So in this personal sort
25:34
of quest to be more me or at least get in touch
25:38
with myself and connect with those around me
25:43
people I love my colleagues my patients that
25:48
that's this is a critical portion of that is
25:52
is having the self -awareness that hey I have
25:55
these feelings too and you know what you probably
25:57
do too but let me go first let me let me share
26:02
with you my story let me share with you my feelings
26:05
and maybe then you won't feel as alone either.
26:11
When residents ask me questions that I don't
26:16
know the answer to, which is more often than
26:19
I'd like to admit, I think, in the beginning
26:25
when I was a junior attending, I very much felt
26:28
like, oh, I have to know the answer to this,
26:32
and I would feel very terrible. if i didn't know
26:36
and so i would often deflect or say something
26:39
like well why don't you look that up yeah right
26:43
something like that but i've started trying to
26:47
say you know i don't remember let's look it up
26:51
together let's let's both learn and i think that
26:54
that's a little bit freeing it's it's helped
26:57
me be a better teacher and probably be a better
27:00
person to be more vulnerable like that even though
27:03
it's hard It is hard, but you also realize that
27:07
when you can be honest with yourself and honest
27:09
with others, it feels so much better. That weight
27:14
is lifted off your shoulders and it's okay not
27:17
to know the answer. And I think part of my critical
27:19
care training made that easier because, you know,
27:23
in the ICU, the patients are so heterogeneous.
27:27
They don't read the studies. We're like extrapolating
27:30
information. You have all these people and you're
27:32
trying to Make assessments, integrate information,
27:36
make the best decision. And then, of course,
27:38
it's a dynamic environment. So it's the ICU training
27:43
and fellowship helped me in the OR, not just
27:47
from a clinical standpoint, but from the fact
27:49
that it's OK to say you don't know. And that's
27:52
why you have a team or you have resources in
27:54
order to, you know, arrive at the right answer.
27:58
And sometimes it's. Not knowing it on the tip
28:02
of your tongue is an okay thing. Do you think
28:05
that being in the military helped you with your
28:09
mindset in terms of imposter syndrome? Did it
28:13
make it more challenging? What do you think?
28:17
That's a good one. I think it's a mixed bag.
28:19
I think the environment in which I practice medicine
28:24
certainly... amplified those feelings at times
28:29
when you're the sole three -member medical team
28:33
in this area relied on by you know layers and
28:39
layers of folks you feel that pressure for sure
28:42
and I think that drives you to to train to prepare
28:45
and to know these things and through the training
28:48
preparation the reps you realize that you actually
28:54
do have it I think also in the military, there's
28:58
quite a bit of experience, inexperience. There's
29:02
quite a bit of variety in levels of intelligence,
29:08
application of that intelligence, right, and
29:10
skill set. And seeing that variety, I think,
29:16
was helpful. In medical school, everyone is a
29:19
super achiever of some sorts. We've made it to
29:22
this level. You know, everyone is. board certified
29:26
in the pursuit of board certification. They're
29:29
well read, they're well published. And I think
29:35
that is not necessarily a true representation
29:38
of life in general, right? We surround ourselves,
29:40
we spend most of the time working hours at work
29:43
around these, you know, super smart people. And
29:46
that sometimes can be challenging. that comparison
29:50
and those things that can also be very supportive
29:52
if you have a resilient culture. But I think
29:55
it also sets yourself up to, you know, feeling
29:58
that way a little bit more different, a little
30:00
bit more frequently than maybe in other settings.
30:05
So what do you think we need to do to have a
30:09
culture that's a little bit more resilient, that
30:11
supports people like both of us who struggle
30:16
with these feelings? So, of course, you know,
30:20
you and I were at the Grand Rounds yesterday
30:22
with Dr. Amy Henson out of Boston Children's,
30:24
who's wonderful. Yes, absolutely. Who primarily
30:28
spoke to us in this joint Grand Rounds about
30:31
burnout and resilient culture at the divisional
30:37
and department levels. So plug for her. But imposter
30:41
syndrome is a part of that. And I look at that.
30:47
I look at the. burnout and the resiliency in
30:53
culture of an institution or a divisional level
30:56
as kind of like the strategic overarching framework.
31:00
The things that I try to share with my residents,
31:06
my colleagues are more on the tactical or individual
31:08
level, like how can I own this? And I think the
31:13
change starts when we, as teachers who are responsible
31:18
for residents, who interact with nursing anesthetists,
31:22
who work with fellows, with all sorts of different
31:25
levels of folks. If we demonstrate this vulnerability
31:29
and we provide our trainees and those around
31:34
us with a safe space to share their feelings
31:38
or to come to us with questions, concerns, challenges,
31:41
I think that's where we build it from the ground
31:44
up. So I think there's two ways of doing it from
31:46
the top down. Super important, but also it is
31:48
our responsibility to own a piece of it. And
31:51
that starts with yourself. One thing that helps
31:55
me to understand things better is specific examples.
31:58
I wonder if you'd be willing to tell a story
32:01
or two about situations where you felt like you
32:06
did right by our trainees or by somebody else
32:10
you were with and being vulnerable, talking about
32:13
a situation. where you might have felt like you
32:21
did it right. Absolutely. The example that comes
32:26
to mind was in the ICU, which is a perfect place
32:29
to not know the answer and still be okay with
32:32
not knowing the answer. And it was a complex
32:34
patient who had multisystem organ failure and
32:37
some complex things going on with the... social
32:44
aspects of his life. And at this point, it's
32:47
pretty straightforward, challenging, but pretty
32:50
straightforward what we needed to do from a medical
32:53
standpoint. But when I said, I don't know if
32:56
this is the right thing to do for the patient,
32:59
this bristled the hair of some of my consulting
33:03
colleagues. We're discussing about mechanical
33:08
support devices and durable options for a patient
33:12
and multi -system organ failure that started
33:14
as heart failure. And I think having a discussion
33:19
in front of everyone, meaning trainees, medical
33:23
students, multidisciplinary team, and saying,
33:27
hey, there's more to this. We need to not make
33:32
decisions for someone else, which we can. Talk
33:34
about paternalism another time. But to really
33:37
say, hey, there's a lot of conflicting data and
33:39
I don't know what to do with it. It's real easy
33:42
to look at endpoints and target endpoints of
33:45
certain things, organ function or what have you.
33:48
But it's different to look at the big picture
33:53
and say, I'm not sure what's right or wrong.
33:56
And we need to figure this out together as a
33:58
team because I don't know the right answer. And
34:00
just being saying, you know, this decision. my
34:03
feelings in front of surgeons in front of you
34:07
know several other attending teams i think showed
34:13
you know my colors to my team that it's okay
34:17
that you know when the person in charge of my
34:19
team doesn't know the answer and just owns it
34:22
and that's okay i don't need to fake it or or
34:24
make these decisions quickly or without without
34:28
deep thought I have been in situations before
34:33
with some of my senior residents, and they will
34:38
ask me a question about a plan that we have for
34:41
a patient. And I'll say something like, well,
34:48
I don't really know. What do you think we should
34:52
do? But I've noticed that they don't actually
34:55
believe me when I say that. Oftentimes, I say,
35:00
yeah yeah okay but what what do you actually
35:02
want to do it's like no what i'm telling you
35:05
the truth i i don't actually know what the right
35:09
thing to do is here and i am seeking your input
35:13
as somebody who's also done this before you know
35:16
that's a great way of doing it i think we often
35:22
you know as a trainee you have this great advantage
35:25
of working with different attendings on a daily
35:29
basis see how different things are done you you
35:31
are in a unique position where you're collecting
35:33
all this data collecting different approaches
35:35
you have the ability and then graduate from training
35:40
and you're practicing an or on your own or overseeing
35:44
two three rooms sometimes four running together
35:47
and unless you actively seek out colleagues actively
35:54
talk to your surgeons about his or her approach
35:58
and have these discussions the further you get
36:02
out the more alone you might end up feeling and
36:05
then the harder it is to reach out so having
36:07
uh i think it's a very valid question not to
36:11
flip it on the learner saying oh well teach me
36:13
what you know where this is part of your mock
36:16
oral exam but rather like what have you seen
36:19
has worked in the past oh you're on your neuro
36:21
rotation and it's month two it's been three months
36:25
since i've done this beach chair position? What
36:29
are your thoughts? And having that as an honest
36:32
conversation is great. One thing that I've found
36:39
is that patients really want you to be confident
36:44
in whatever you do. But you also have to balance
36:49
that with the humility of knowing that you don't
36:53
know everything and that you might not. be right
36:56
all the time what do you think the best way is
36:58
to balance the confidence and the humility i
37:08
believe that the answer when a patient asks me
37:11
about these things is to promise them or to impart
37:15
in them that i will do everything i can to take
37:19
care of you the way you deserve the way the dynamic
37:24
situation calls for. That's not to say I may
37:28
not know an answer to along the way, or it might
37:30
be a real time dynamic decision. But I can clearly
37:36
say when I wake up, you know, I'm prepared, and
37:39
I'm confident that I will do my best to take
37:42
care of you the way you deserve. Some of those
37:45
other things you can figure out along the way,
37:47
you can look up, you can speak to expert colleagues
37:51
who've done this, you know, longer. who are smarter
37:54
than me but i i have no problem telling a patient
37:58
i'm confident in being prepared to take care
38:01
of you the way i'd take care of any family member
38:04
so it makes sense separating the the intent from
38:06
the actual individual minutia of the medical
38:13
decision making that is actually something that
38:16
i like to share with patients a lot as a way
38:20
to build rapport but it's also part of my actual
38:24
underlying philosophy, which is helpful. I say,
38:27
well, I'm telling you this information or I'm
38:31
presenting you with this plan, but this is the
38:33
exact same thing that I would do for my family
38:35
member because I treat my patients as if I were
38:39
treating my family member. That's just my underlying
38:42
ethos about treating patients generally. And
38:45
so I find that that can sometimes help patients
38:48
buy into your plan. Like I really am. doing the
38:52
best thing i can think of for you and this is
38:53
this is the best thing that we can do i'm sorry
38:56
we do have to start that arterial line while
38:59
you're awake that's i i know that's not going
39:03
to be fun or comfortable for you but i would
39:06
also be doing this if it was my family member
39:08
in the same situation 100 and i think two things
39:12
kind of came into my mind as you were sharing
39:14
this and one is this is not a substitution for
39:20
training, preparation, reading, and doing all
39:24
the things we need to do in order to deliver
39:26
the best evidence -based care to that patient
39:29
in that situation. But it's layering it saying,
39:32
I can't possibly know the thousand permeations
39:38
of what may happen, but I have the training to
39:40
fall back on how to assess and intervene appropriately.
39:45
So let's say that you could go, back in time
39:49
and talk to a previous version of yourself give
39:53
him advice when you're struggling with feeling
39:56
like a fraud or that you don't belong what what
39:59
would you tell the past version of yourself what
40:02
would you say to make him feel better it's a
40:07
great question i wish i could i would say the
40:10
stress about not having what it takes is inappropriately
40:17
placed meaning you work hard you read you prepare
40:21
trust in that process trust in yourself and reach
40:27
out because everyone else is you know having
40:31
some permeation of these feelings along the way
40:34
and reaching out for assistance for help for
40:39
knowledge for support is never a sign of weakness
40:41
it's a sign of strength to know what you need
40:45
and how to get it and whom to get it from. How
40:50
do you think that your perspective on imposter
40:52
syndrome has changed over time? I think that
40:58
over time, my perspective has changed to this
41:01
is not a me problem, but this is a problem common
41:05
to folks in the medical field, to medical trainees.
41:09
And part of my job is... to support those around
41:15
me who may have challenges who may have intermittent
41:21
periods where they feel like they don't belong
41:24
or despite evidence of high performance and well
41:30
thought out plans and preparations you know struggle
41:33
lastly I want to go over what you feel like your
41:38
style points are, whether or not it has to do
41:40
with imposter syndrome specifically. What style
41:44
points or points of personal preference have
41:46
brought you success both in and out of the OR?
41:52
Good question. I'll tie this one into imposter
41:56
syndrome. And I think more about vulnerability
41:58
is over time, especially like over the past,
42:04
you know, six, eight. you know 10 years we've
42:07
spent so much time on the focus of others in
42:12
medicine and for many of us that was still informant
42:18
you know formative years of your life from a
42:20
mental and emotional development position i feel
42:25
like it's important for everyone and this is
42:28
sojourn that i'm on myself is to to become re
42:33
-acclimated with yourself you know what makes
42:36
me me what are what are my important values that
42:41
i hold near and dear that i'm willing to you
42:44
know my hill to die on right and you know if
42:49
you haven't had those that insight and that self
42:53
-reflection over the past years because you've
42:55
been busy reading you know bearish and critical
43:00
care medicine and everything else that in order
43:03
to provide the care and the calling that we all
43:07
feel or else we wouldn't be here. Sometimes we
43:10
forget that, you know, we're people behind that.
43:13
And it's critical to focus on that. And I think
43:16
that's, you know, whether it's five minutes here
43:19
or there, long weekends, self -reflection, self
43:23
-exploration, getting into a meditation practice,
43:27
however that works for you. You know, time will
43:32
turn, you know, whether or not you're ready for
43:35
it. And don't miss out on the opportunity to
43:38
know yourself. And I think that's, I think that
43:41
ties in. And it's probably one of the other parts
43:43
about imposter syndrome is just being vulnerable
43:46
and being self -aware. And then you realize the
43:49
feelings I have maybe aren't truly imposter syndrome.
43:52
It's just pressure, right? And expectation. But,
43:57
you know, we're people at the end of the day
43:58
and humanism is a real thing. And we owe it to
44:02
ourselves to not only know ourselves, but to
44:04
connect and support and love one another. But
44:07
if you don't know yourself, it's really hard
44:08
to do that for someone else. Well, personally,
44:12
I've had a really nice time connecting with you.
44:15
Thank you so much for joining us, Ben. I feel
44:17
honored. Thanks for being here. That's it for
44:23
this month's episode of Style Points. Anecdotally,
44:26
I've heard that the immediate and permanent cure
44:28
for imposter syndrome is leaving a five -star
44:31
rating or review for this podcast. It can also
44:34
help other people find the show. Genuinely, though,
44:37
I appreciate everyone who listens. I also want
44:41
to share that with the last episode, this podcast
44:43
has been downloaded over 10 ,000 times in total
44:46
over the last couple of years. Not really sure
44:49
what that means, but at least my mom thinks that
44:51
that's pretty neat. Lastly. Take a deep breath.
44:55
Open your eyes. We are all done.