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Match Points with Dustin Tsitouris · Style Points

0:10
Hello, anesthesia enthusiasts, and welcome to
0:13
this month's episode of Style Points. Today,
0:15
we've got an episode geared towards one of my
0:17
favorite groups of people, medical students applying
0:20
to residency in anesthesiology. Even if you aren't
0:24
a medical student, though, I'm hoping that this
0:27
episode provides you with an inside look at what
0:29
it takes to become an anesthesiologist. Before
0:32
I invite my fellow associate program director,
0:34
Dr. Dustin Satoris, on the podcast, I'm going
0:37
to turn it over to Nate, who will be introducing
0:40
this month's RSI, which of course stands for
0:43
Resident Selected Information. Thank you, John.
0:46
Delivering our RSI is CA1 resident Anne Burgess.
0:49
Anne was a college burn ball champion, which
0:52
she described as an incredibly dangerous game
0:54
of hockey without ice skates. If a burn ball
0:56
trauma victim rolls into your ED tonight needing
0:59
ventilatory support, you're in luck because Anne
1:01
is going to teach us about ventilators. Welcome,
1:03
Anne. The learning curve for new trainees is
1:06
steep in the operating room as well as the intensive
1:09
care unit, especially when throwing around terms
1:11
like BCAC, SIMV, SBT, RISB. What do they all
1:16
mean? How do I use them? Learning how to navigate
1:19
the modes of mechanical ventilation can often
1:21
feel overwhelming. So let's get into it. The
1:24
goal of mechanical ventilation, in very simplified
1:27
terms, is to provide oxygenation and ventilation.
1:30
Patients may require mechanical ventilation for
1:32
a whole host of reasons. from routine general
1:35
anesthesia in the operating room to dire respiratory
1:37
failure in the ICU. Regardless of the reason
1:40
for requiring mechanical ventilation, the basics
1:43
of vent management forms an important backbone
1:45
of our practice in anesthesia. Some of the variables
1:49
that we can manipulate when programming and adjusting
1:51
the ventilator include the FiO2, positive end
1:55
-expiratory pressure, otherwise known as PEEP,
1:58
respiratory rate, and tidal volume or inspiratory
2:01
pressure, depending on the ventilatory mode.
2:04
FiO2 and PEEP will generally be adjusted to achieve
2:06
oxygenation goals. Respiratory rate and tidal
2:09
volume comprise minute ventilation and will therefore
2:12
be adjusted to meet various ventilation goals.
2:15
There are a couple of main themes within ventilator
2:18
modes. We tend to use either volume or pressure
2:21
as an independent variable, meaning you can decide
2:24
to set either the volume or the pressure you
2:26
want delivered, and the ventilator will figure
2:28
out where to set the other one. At the same time,
2:31
there are modes that account for patient effort,
2:33
and those that do not. Volume -controlled ventilation
2:35
delivers a set tidal volume with each breath.
2:38
This is great for ensuring consistent tidal volumes
2:40
and therefore a consistent minute ventilation.
2:43
However, the mean airway pressure is generally
2:45
lower than it is with pressure -controlled ventilation,
2:48
which can lead to less effective oxygenation.
2:51
Pressure -controlled ventilation delivers a breath
2:54
until a set pressure is reached. This helps limit
2:57
barotrauma, but tidal volumes can vary, leading
2:59
to an inconsistent minute ventilation. However,
3:02
mean airway pressures are higher in this mode,
3:05
resulting in increased alveolar recruitment,
3:07
therefore increased oxygenation. Note that both
3:10
of these modes have control in the name. This
3:12
means that the ventilator has full control of
3:14
the patient's breathing. If the patient tries
3:16
to take a breath on their own, the ventilator
3:18
will not allow it. This is great for fully sedated
3:21
patients or paralyzed patients, but this can
3:23
lead to coughing, bucking, more formally known
3:26
as ventilator dyssynchrony, if the patient tries
3:29
to take a breath of their own while in these
3:30
modes. In contrast, pressure support ventilation
3:33
is entirely patient -triggered. Each breath is
3:36
supported with a preset driving pressure. This
3:39
is a great mode for ventilator weaning, but can
3:41
also be dangerous if a patient stops initiating
3:44
their own breaths. Assist control is more of
3:46
a hybrid mode. Every breath is supported, whether
3:49
initiated by the ventilator or the patient. This
3:52
mode can be tacked onto volume control and is
3:54
very common in ICUs as it will deliver a set
3:57
volume when the patient's initiated a breath.
3:59
but also have a backup minimum respiratory rate
4:01
if the patient is not breathing at a rate greater
4:04
than what is programmed on the vent. Synchronized
4:06
intermittent mandatory ventilation, SIMV, also
4:10
combines mandatory breaths with spontaneous breathing.
4:13
It will deliver a fixed volume when the patient
4:16
does not initiate a breath, but in contrast to
4:18
assist control, it will only provide pressure
4:20
support to patient -triggered breaths. Choosing
4:23
the right mode depends entirely on the patient's
4:25
lung mechanics, mental status, and underlying
4:28
pathology. Other variables, like type of procedure
4:31
or patient positioning, may also contribute towards
4:33
choosing one mode over the other. So when do
4:36
we know that it's time to stop mechanical ventilation
4:38
and extubate? We look at a couple different areas
4:40
when considering extubation, especially in the
4:42
ICU, including lung mechanics, mental status,
4:45
and the patient's overall clinical picture. A
4:48
spontaneous breathing trial, or SBT, is the clinical
4:51
test that is used to assess a patient's readiness
4:53
for extubation in the ICU. In order to perform
4:57
an SBT, Patients will typically need to be on
4:59
minimal ventilatory settings. This varies from
5:02
institution to institution, but tends to be an
5:05
FI below 30 or 40 and a PEEP of 5 to 8. The SPT
5:10
is typically performed by the respiratory therapist,
5:12
and they will place the patient on pressure support
5:14
for at least 30 minutes. The SPT can be stopped
5:18
earlier if the patient isn't doing well. We then
5:21
look at a few factors to decide whether the patient
5:23
can be extubated. Typically, we will assess the
5:26
patient's ability to maintain oxygenation by
5:28
looking at the SpO2 or formal blood gas. In order
5:31
to assess the patient's ventilation, we will
5:34
calculate their RSBI or RISBI. The RISBI is the
5:37
Rapid Shallow Breathing Index and is calculated
5:40
by dividing their respiratory rate by the tidal
5:42
volume. If a patient is breathing fast and shallow,
5:46
their RISBI will be higher. This tells you that
5:49
the patient may not be quite ready to be extubated.
5:52
We typically use a threshold of 105 as our upper
5:55
limit of an extubatable RISB, although some recent
5:59
evidence may suggest that the trend in RISB may
6:01
be more indicative of success than one standalone
6:03
value. It isn't a perfect measure, but does provide
6:07
some objective information about a patient's
6:09
chance of success post -extubation. Ultimately,
6:12
the decision to extubate does not rely solely
6:14
on the SBT in your RISB. Patients must also be
6:17
awake, following commands, clearing their secretions,
6:20
and be able to protect their own airway. Pristine
6:23
lung mechanics on its own does not guarantee
6:25
that they are safe to be without a protected
6:27
airway. Hopefully this helps give you a foundation
6:29
for discussing these patients and demystifies
6:32
the black box that is a ventilator. Happy venting
6:35
and SBT -ing! And we are actually both associate
6:45
program directors here at the University of Cincinnati
6:48
as well. We're here to talk about applying for
6:50
anesthesiology residency. But first, Dustin's
6:53
going to give us some of his pro tips about how
6:55
to remove a ring from your finger in the perioperative
6:58
period. Dustin? All right. Well, thank you for
7:00
having me. So that's a little bit of a story
7:04
based on what happened when I was running. the
7:07
board the other day for the hospital that we
7:10
work at. And all of a sudden, my hand started
7:12
swelling. And what started out as a casual idea
7:19
to potentially remove my wedding ring that I've
7:23
had on for 16 years turned into a relatively
7:26
emergent situation as my finger began to swell
7:29
pretty rapidly. But, you know, thanks to... John
7:32
Crow and a few other of my helpful associates,
7:36
we were able to use an emergency ring cutter.
7:40
And then ultimately, we used, I think, four or
7:43
five different emergency ring cutters. Yes, that's
7:45
right. And then to my dismay, a very large bolt
7:49
cutter to finish the job. But all is well. I
7:53
live to fight another day and do not have to
7:55
apply for disability. So that's good. Thank goodness.
7:58
I did think that. we were going to have to prep
8:02
one of the ORs for you at one point in time.
8:05
I remember the, you know, I initially wanted
8:07
to save it, and we tried the little trick where
8:10
you put the... The floss wrap. Yeah, the floss
8:13
wrap around. And I think you only get really
8:16
one shot at that because it's pretty aggressive,
8:20
and it starts to, the swelling cascade a lot
8:23
more. So when that didn't work, it was, the writing
8:26
was on the wall. We have a lot of people that
8:29
are pretty good at removing rings. In fact, we
8:30
have to do that to prevent burn injuries to people's
8:33
fingers in the perioperative period. That's why
8:35
we have people take off all their jewelry. But
8:37
despite all of our expertise, this one was a
8:40
particularly challenging one, I feel like. Yes,
8:43
but again, you know. I can still see on your
8:47
finger where. Oh, there's no escaping. There's
8:49
no escaping the fact that I've been married for
8:52
so long. Happily, I must say. But yes, the swelling
8:57
is still there, but it's healing slowly but surely.
9:01
Well, I'm glad. Well, what we're actually here
9:04
to talk about today is applying for anesthesiology
9:07
residency. Dustin, how long have you been an
9:10
associate program director? So I've been an associate
9:12
program director since 2017. And then even before
9:18
that, I was involved with the process as a chief
9:23
resident. the year before that or a couple of
9:28
years before that, actually. And then and then
9:31
again, like probably many of the people listening,
9:33
I was involved on the other side as an applicant.
9:37
So, you know, that's something we always we all
9:41
share. So we all have hopefully you're not so
9:44
far removed that you don't remember what it's
9:47
like. And I think that provides. you know, a
9:51
lot of structure to hopefully provide a lot of
9:55
structure to the talk today. Do you think that
9:57
it's easier or harder than it was when you were
10:00
applying for residency? It's harder. And I think
10:07
it's gotten a little more competitive, for sure.
10:10
I think there is definitely a larger eye on anesthesia
10:15
as as a great specialty. And a great career that
10:19
people have tapped into. And I think like everybody
10:26
else, you look at the applicants, if you're privy
10:29
to them and you say, well, man, I don't know
10:31
if I would have been able to match at this point
10:35
in time if I was going up against all these wonderful
10:38
applicants. Yeah, it's really kind of humbling
10:41
when you're going through all of these different
10:43
applications that are dramatically better than.
10:47
At least mine was probably not yours, but they're
10:49
definitely a lot better than mine. And thinking
10:52
to yourself, wow, it's really kind of a privilege
10:54
to get to pick out the people who we get to interview
10:59
and who we get to ultimately match to our program.
11:03
Right. Absolutely. And I think the big kind of
11:07
overarching thing to remember as a medical student
11:09
or anybody involved really is that, you know,
11:12
by and large. Everyone's already made it to medical
11:16
school. They've already had success in medical
11:18
school. When you're applying to residency, you've
11:21
already realized such great successes in your
11:24
life that it's just inherent to the process that
11:29
you're going to be presented with a ton of wonderful
11:33
people who've done wonderful things. And that's
11:37
ultimately a great thing for the specialty because
11:40
we're all going to be colleagues someday. So
11:43
let's put yourself in the shoes of a medical
11:46
student who's maybe a second or third year medical
11:49
student somewhere in there. And they have just
11:52
decided anesthesiology is definitely the thing
11:55
for them. Maybe they spent some time shadowing
11:57
you and they figured out that's who I want to
11:59
be when I grow up. Where do you go from there?
12:02
How do you build a CV? How do you make it so
12:07
that you are? Someone who the program directors
12:11
will look at and say, that's the guy that I wanted
12:13
our program. So finding mentors is really important
12:19
and finding people that that have gone through
12:22
the process that could be students that are that
12:26
are. above you that have just done it it can
12:29
be faculty at your home institution it can be
12:31
people at other institutions but certainly finding
12:34
mentors i think is the first step really asking
12:37
as many questions as possible and getting a really
12:41
good understanding of what the specialty is really
12:44
like not only as a trainee but also as a faculty
12:47
member eventually so that's the step for that's
12:50
the first step and i think from there you really
12:54
want to look at all the different things that
12:58
make your application whole. First off, when
13:02
we're talking about mentors, how do you find
13:04
a good mentor? What kind of person would you
13:07
be looking for? What kind of characteristics?
13:09
Do they have to be an anesthesiologist, do you
13:11
think? I don't think they have to be, but certainly
13:14
that helps because they're going to be keenly
13:16
aware and understanding and understand the specialty.
13:22
It needs to be somebody who you potentially see
13:27
yourself in or who you jive with, somebody who
13:32
you get along with, somebody who you can tell
13:35
maybe has your best interest at heart and is
13:38
not doing it for other reasons. That's the first
13:41
step. And then you're going to have a better
13:44
outcome, I think, if you pick somebody in anesthesiology,
13:47
because that person is going to understand the
13:50
process. Yeah, I've found that to be true as
13:54
well. I've definitely had some My mentees talked
13:58
to me before about other mentors' advice that
14:01
they've given, and I've thought to myself, oh,
14:03
wow, that's actually not correct. And I can tell
14:07
them definitively that it's not correct because
14:09
I'm an associate program director. I'm the one
14:12
who's looking through the applications and can
14:14
help pick things out. That doesn't mean that
14:17
you have to have somebody who's a program director
14:19
as one of your mentors necessarily, but it definitely
14:22
does help to have somebody who's... gone through
14:24
the process themselves i think i agree with you
14:26
yeah we i think uh earlier on we had some people
14:31
here at our home institution who had been advised
14:34
by somebody who wasn't in anesthesia and i think
14:37
fortunately they found some people in our department
14:40
and we were able to kind of give them the correct
14:43
information i remember some of those stories
14:46
distinctly so what makes an anesthesia application
14:49
stand out If we're looking through hundreds or
14:53
even thousands of applications, what's going
14:56
to make someone stand out? The last few years,
14:58
it has been thousands. It has been. Yes. So I
15:01
think what you have to remember is when you're
15:05
presenting an application, just like any other
15:07
marketing professional. you become a marketing
15:14
professional for that small period of time, right?
15:17
And my wife is a creative director, so I know
15:20
this uniquely well. But really what you're doing
15:24
is you are telling a story. Just like somebody
15:27
might be telling a story about a product, you're
15:30
telling the story of your life and your professional
15:34
life. And there are a few key things that you
15:38
have to hit, but really providing a well -rounded...
15:42
story is the key to having your application get
15:46
noticed. So I'll go into some like specifics.
15:49
Please do. First off, academics, you need to
15:57
do well in your classes. And it's important that
16:01
you have kind of handily handled the rigors of
16:07
medical school. Residency doesn't necessarily
16:11
get any easier, nor does being a junior attending.
16:15
So, you know, having that where you confidently
16:19
complete a medical school is a really good thing
16:22
to see. Letters of recommendation. Having good
16:27
letters of recommendation is great. Now, what
16:30
does that mean, right? A good letter of recommendation.
16:32
It means somebody who knows you well, somebody
16:36
who has some insight into your character. and
16:40
potentially has some more than surface -level
16:44
interaction with you, ideally over a long period
16:47
of time. So for some people, that's an anesthesiologist.
16:51
For other people, that's a pediatrician or maybe
16:55
an advisor that you had all through medical school.
16:59
It can be anybody, but it's going to be... best
17:08
if you have at least some letters of recommendation
17:10
from an anesthesiologist. I've read through,
17:15
again, thousands of these letters of recommendation.
17:18
They fall into a few categories that I've seen.
17:24
Would you agree with me that about 85 % to 90
17:27
% of letters of recommendation are almost exactly
17:31
the same? Yeah, they follow a cadence. So they
17:34
follow a little bit of a cadence. And you got
17:37
to think that if you are a faculty member who
17:41
is writing a lot of these, there has to be some
17:44
type of kind of prescribed way of doing it so
17:48
that you hit all the points, hit all the high
17:50
points, the style points, if you will. And then
17:53
you want to make sure that you are. speaking
18:01
the language that is going to resonate with the
18:06
people reading the application. So who would
18:09
be a good example of somebody who could write
18:12
a great letter of recommendation? And maybe what
18:15
are some characteristics of some letter writers
18:17
that you don't think would do as good of a job
18:21
writing a letter of recommendation? That's a
18:24
great question. So I can give you a personal
18:27
anecdote. So I had a letter of recommendation.
18:29
And while you're not, you know, you waive your
18:32
right to see your letters of recommendation.
18:35
But I'm very confident that one of my best letters
18:38
of recommendation was from a pediatrician that
18:42
had a pretty prominent role in the patient safety
18:48
sector at Cincinnati Children's. Now, I had no
18:54
interest in being a pediatrician, and you know
18:56
me very well, and that's not where my aptitudes
19:01
are necessarily. I like being a dad, but I don't
19:05
like being a pediatrician. Me too. Yes. And so
19:09
I'm confident that that was a great letter. I
19:13
had great interactions with this person. We had
19:15
talks outside of just medicine through my two
19:19
months that I was there. And I had him all two
19:22
months. So that's a pretty long period of time
19:24
as a medical student. So I think that that is,
19:27
you know, again, longitudinal interaction with
19:30
something beyond just surface level academic
19:35
interaction, I think is great. some people who
19:51
were newly diagnosed with ALS. And it was quite
19:56
an emotional thing to be there while these people
20:00
were being told that they had this disease process
20:04
that's ultimately terminal. And being there through
20:10
those situations, talking to the patients through
20:13
those situations, and the professor had seen
20:15
me in those kind of critical situations, I think...
20:19
Helped him write a really nice letter for me.
20:24
Absolutely. That's a I mean, very parallel type
20:27
stories. You know, you're going to get letters
20:30
from the chairman of the department oftentimes
20:33
or a program director of your home institution.
20:36
The chairs write all those letters personally
20:38
by hand. I understand. Yes. With papyrus and
20:41
a quill pen. Yes. But no, it's you know, it's
20:45
a kind of. something that sort of has to happen
20:48
and it needs to be there um that does that's
20:51
not to say that some of them aren't personal
20:53
some of them can be very personal that's true
20:55
but you have to you have to imagine how many
20:58
uh those people are writing so um you know you
21:04
still got to go through the motions and get those
21:05
letters if you're applying but um you know finding
21:09
at least one or two letters from somebody who
21:12
knows you really well is really the key Also,
21:15
you definitely need to have some anesthesia letters
21:17
as well. I think it's probably a red flag if
21:20
you don't have any letters from an anesthesiologist.
21:22
100%. 100%. Because that shows that you have
21:28
done some due diligence in actually talking to
21:33
somebody in the field. So let's move to personal
21:37
statements. Yes. This is always a very challenging
21:40
issue with personal statements. One of the things
21:44
that I wanted to offer to whoever is listening
21:46
is I remember writing my personal statement,
21:49
went through a whole bunch of edits. I thought
21:51
that it was great. I submitted it. I got into
21:53
residency. But when I was advising people and
21:58
editing their personal statements years later
22:00
as a program director, I kept coming across some
22:03
of the same themes. This is a little bit too
22:05
cheesy. You're not putting enough of yourself
22:07
into it. And so what I eventually did is i looked
22:10
back at my own personal statement and i i was
22:15
somewhat unsurprised to find that it was just
22:18
as bad as everyone else's oh yes hindsight is
22:24
20 20. and so what i did was i i saved my old
22:28
one i edited my old one uh knowing that it isn't
22:33
for anything now but i made it much much much
22:37
better from perspective of a program director.
22:40
So I have a before and after that I'd be willing
22:44
to share with anybody who is listening to the
22:47
podcast if they want to see the example of what
22:50
a normal personal statement looks like versus
22:53
what I think a pretty decent personal statement
22:55
looks like. So if you're interested in that,
22:57
you can just email me at stylepointspodcast .gmail
23:00
.com. That's very interesting. I remember writing
23:04
mine and thinking it was good at the time. I
23:07
haven't done what you've done and looked back
23:08
at it. I'm sure it's horrid, but it was just
23:13
cheesy. I did take a chance and really not mention
23:16
anesthesia. It was really all about playing soccer,
23:22
which actually does become somewhat of a theme
23:24
where people talk about something that was big
23:28
in their life growing up or whatever. personal
23:33
anecdotes about interactions with medicine, maybe
23:36
from the patient's side, or pivotal cases that
23:43
they experienced that maybe were like a thunderclap
23:45
moment where they decided they wanted to do anesthesia.
23:48
I see that a lot too. Yeah, I've seen a lot of
23:52
different themes and personal statements. People
23:54
will draw out extended metaphors about how anesthesia
23:59
is like sailing a boat or like climbing a mountain.
24:02
I think that's fine. I think that falls within
24:04
the 85 % to 90 % of personal statements that
24:07
are, again, sort of like letters of rec. They
24:09
fall into kind of certain categories, whether
24:12
it's telling a personal medical story about how
24:15
they became interested in anesthesia or in medicine
24:18
in general, which was mine. I had my back surgery
24:21
back when I was 15 or 16, and that was sort of
24:25
what I have come to view as more of a turning
24:28
point in my life that pointed me towards medicine
24:30
and ultimately anesthesia. Or, you know, you
24:34
can draw upon whatever experience in your life
24:37
has brought you to where you are. The one thing
24:40
that I definitely recommend to people in their
24:42
personal statement is read it out loud to yourself.
24:46
And if you think to yourself, I sound really
24:49
cheesy and I don't like how I feel when I'm reading
24:52
it out loud, rewrite it. Try again. Yeah, don't
24:55
be afraid to start over. Yeah, use more natural
24:58
language like... you would actually tell somebody.
25:01
Don't use words in your personal statement that
25:04
you don't use in real life is something that
25:06
I will often tell people. That is very, very
25:08
good advice because ultimately, again, you're
25:11
trying to tell a story and someone needs to be
25:14
able to read your story and needs to be able
25:16
to remain involved and interested in what you're
25:21
saying. One thing that's interesting, I think,
25:23
about personal statements that we should probably
25:25
mention is AI. Oh, yeah, for sure. And chat GPT
25:30
and the like. In the future, I'm sure that this
25:35
is going to become rampant and identifying it
25:38
as going to, I will bet, be much more challenging
25:42
over time, that it's going to be challenging.
25:45
So figuring out a way to write your personal
25:48
statement such that it is absolutely guaranteed
25:55
that you are. writing it yourself and not having
26:00
an AI -based program write it, I think is going
26:04
to be good. The converse is if someone finds
26:07
out that you are writing it with an AI -based
26:10
program, I think that that would be a major red
26:12
flag. I think so too. But I think that what a
26:16
lot of people are using AI for is not necessarily
26:19
writing the entire thing and submitting it as
26:22
is. They're using it... As more of a mentor,
26:24
as a creative editor, somebody who can put things
26:28
in a little bit better language. You know, after
26:30
all, as medical students, we're not really trained
26:32
as creative writers or marketers. We're trained
26:36
as medical students. That's right. So I think
26:40
it's reasonable to use resources at your disposal
26:42
to use AI to help edit things, to help give you
26:45
ideas. But doing the whole thing for you, I think
26:49
it's just going to come across as extremely generic.
26:52
100%. I think the best prescription I have for
26:56
personal statements is just be radically honest,
26:59
not just with who you're writing it to, but with
27:01
yourself. Why are you really interested in it?
27:04
What is driving you? Where are you coming from?
27:07
The best personal statements that I have read
27:12
have just been radically honest. get to the heart
27:16
of why that person wants to do anesthesia. I
27:19
think one other thing we should mention is the
27:21
last paragraph, which has been more frequently
27:24
co -opted than ever. Can you talk about what
27:27
the last paragraph of the personal statement
27:29
should be, whether it should be personalized
27:31
per program? It seems like this is something
27:32
that is being taught, but I'm all for it. The
27:36
last paragraph seems to be some type of tie -in
27:39
where you tie in your experiences to to what
27:45
you want to do in residency and potentially in
27:48
your career. And it also gives you an opportunity
27:54
to personalize it to whoever you're applying
27:57
to. And I see that not infrequently where people
28:01
personalize it. And that's actually a really
28:04
powerful tool that you can have because you're
28:06
like, just, you know, everybody's human. And
28:09
when someone is personalizing it seemingly to
28:12
you, That is something that you gravitate towards.
28:15
That's a very common human emotion is, oh, they
28:19
like me. I like them too. So that's a nice thing.
28:25
Is that what you were getting at? Yeah, I've
28:28
seen a lot of personal statements over time,
28:31
and I've seen a definite trend towards the personalization
28:35
of the last paragraph. You know, with the signaling
28:37
now. there's really only about 15 programs that
28:42
people are applying to very seriously. And with
28:47
those 15 programs, you know, if you're applying
28:49
to 50 programs, I think it's pretty impossible
28:51
to write a personalized personal statement to
28:54
50 programs. And fraught with potential error.
28:58
Yes, with catastrophic error. If you accidentally
29:02
copy and paste the wrong thing, it can be a...
29:07
That's a kill shot. Yeah, that's that's bad news.
29:10
But seeing why the person is interested in your
29:14
program beyond just, oh, your program has a lot
29:17
of liver transplants. And I think that that's
29:19
really great. OK, that's fine. But if they have
29:22
a real reason why they want to come here, for
29:25
example, you know, I really like your program.
29:28
And, you know, my sister lives here in Cincinnati
29:32
and I. grew up just across the river, or I have
29:36
a specific reason why it's not just your program,
29:39
but it's the city, it's the culture, it's everything.
29:42
When you have something more compelling like
29:44
that, I think that can really help you out. I
29:48
agree with that. I think that it's your chance
29:51
of tying it all together. The one last thing
29:54
I'd like to say about personal statements is
29:57
what I ask myself after I read one is, Or not
30:03
what I ask myself, but what I want to hear after
30:08
I read it is, man, I have to meet this guy. I
30:11
have to meet this girl. Absolutely. That's the
30:14
key is I want to meet this person. Like, listen
30:18
to this story. I need to meet this person. And
30:21
that's all you're trying to get across in the
30:23
end of the day. You've got to get to the next
30:25
stage. Yeah, absolutely. So it's not just about
30:29
the personal statement and the letters direct.
30:31
We also have to. Do well in your classes. And
30:35
let's talk about the importance of step scores,
30:37
too. We don't have a step one score anymore to
30:41
look at. That's that's gone away. No. And honestly,
30:44
the objective data that we have when you look
30:50
at dean's letters from medical students or from
30:52
medical schools and everything, a lot of things
30:56
have been going to much more of a pass fail type
31:00
system. there's a lot less objective data. And,
31:03
you know, chiefly step one being away is a good
31:07
example of that. But this makes it pretty onerous
31:12
when you're trying to compare people across different
31:14
institutions. So, you know, I hate to say it,
31:20
but I think that the elimination of step one
31:23
has put a huge burden on students. to do really
31:29
well on step two because that's the only one
31:31
with an objective score attached to it and while
31:35
previously uh you know if you did less than your
31:39
best on step one but everything else in your
31:42
application uh pointed to you being a stellar
31:45
student but you just had a bad day which can
31:48
happen we're all human right um well you had
31:51
a chance to redeem yourself on step two that
31:53
no longer exists right so um I think it's a little
31:57
unfortunate how it's being done now, but it does
32:02
inherently show the importance of kind of really
32:09
studying, playing the game, and doing very, very
32:12
well on step two. What about class rank? What
32:15
do you think? Class rank is more of an objective
32:21
longitudinal. That's another thing to say, actually,
32:24
is that even though you might be pass -fail in
32:27
your classes with what you get on your transcript,
32:31
that doesn't necessarily mean that the school
32:33
itself is not keeping track of people in terms
32:37
of putting them into quartiles or quintiles or
32:40
whatever. I think we do look at that, and I think
32:42
that that's important. It demonstrates kind of
32:45
longitudinal achievement and achievement in other
32:48
disciplines. I really like it when people do
32:50
really well. in subjects that are not anesthesia.
32:56
That means that they're trying their best through
33:00
all facets of their education and really trying
33:03
to kind of suck the marrow from the bone no matter
33:08
where they are. And I think that that's extremely
33:11
important and shows a lot of character. Yeah,
33:14
I agree. It's really nice to see when you can
33:17
see demonstrated across their application and
33:20
all the different facets. This person was trying
33:22
hard no matter what situation they were in, even
33:25
if they were on a rotation that they should have
33:29
no reason to care deeply about. It's just the
33:32
type of person that they are. It's part of the
33:34
story. That's right. So let's talk about one
33:39
other thing in terms of. The application. One
33:44
of the things that I've seen on people's applications
33:48
recently and has gained more importance with
33:51
the elimination of step scores is the research
33:54
aspect of it. How do you do research in anesthesia?
33:58
How do you make that part of your application
34:00
stronger? Is it important? So like most good
34:06
questions and most. stellar answers. It depends.
34:10
But no, I think research is important. It's not
34:14
something that is mandatory. I will say that.
34:18
When you're looking at extracurriculars, and
34:20
research, I think, is included in that. Research
34:24
can be everything from clinical research to bench
34:28
science research to quality improvement projects
34:32
to patient safety research. There's a lot of
34:35
different avenues that you can take that you're
34:38
institution might be involved with that you can
34:42
also get involved with. Certainly, you know,
34:47
checking the box is less important than having
34:50
a tangible position or a tangible experience
34:57
within that body of research. So now I know medical
35:01
students don't have all that much time, right?
35:03
So you don't have all that much time to be involved.
35:06
But with the time that you do have or over a
35:09
longitudinal period of time, I think that that's
35:10
kind of more important. And certainly you'd like
35:14
to get something out of it in terms of a publication,
35:16
whether that be a poster presentation or an abstract
35:19
or something. We certainly look at those things
35:22
and see if people are. involved with and contributing
35:27
to the anesthesia literature and to the academic
35:31
nature of anesthesiology over their short career.
35:37
One of the things that has become more important
35:41
over time is finding ways to separate one medical
35:44
student from another. Now, if your college of
35:48
medicine has decided we're not going to give
35:50
grades to anybody, we're not going to rank anybody,
35:53
we just think that... Everyone is wonderful who
35:56
graduates from here, and that's what we're going
36:00
to put forward. It makes it very hard to tell
36:03
one medical student from another, and it makes
36:05
it very hard for those medical students to show
36:09
that they're the kind of person who is going
36:12
to blossom in residency. So one of the things
36:16
that we look at is how much have you done in
36:21
terms of your publications now? It's become more
36:24
and more important. Do you need to be excellent
36:26
at doing research to be a great anesthesiologist?
36:29
No. But it sort of is a replacement for effort.
36:37
Do you need to know all the stuff on step two
36:41
to be a great anesthesiologist? Also no. But
36:44
it sort of describes how much effort you're willing
36:49
to put into things by studying hard for that
36:51
test. And it describes how much effort that you're
36:55
going to put into things if instead of having
36:57
one case report, you have maybe 10 or you've
37:02
done multiple posters and you've gone to multiple
37:05
conferences. It just shows the amount of effort
37:08
that you're willing to put into things on top
37:10
of getting good grades, getting good step scores,
37:13
everything else. Yeah, I totally agree with that.
37:15
I think that that's a good way of saying it.
37:18
Overall, when you're looking at an application,
37:20
how long does it take you to go over one of these
37:23
applications? It's a trick question because there
37:32
can be things in your application that make me
37:36
look at it for a very short amount of time. Certain
37:39
potential red flags, which we can get into later,
37:42
actually. Let's do red flags now. You want to?
37:44
Yeah. Okay. All right. So some red flags would
37:48
be, you know, failing your board exams altogether.
37:54
Sure. That's usually a red flag. Is it possible
37:59
to get over that red flag? It is. I think almost
38:03
everything is, you know, nothing's insurmountable,
38:08
completely insurmountable, but certainly it can
38:11
create an uphill battle for you. Sure. So that's
38:15
one thing. We can go extreme. Felony convictions.
38:21
Sure, yeah. If you are a felon that has taken
38:26
a lot of drugs and killed people, I think that
38:29
that's probably not a— It's tough. It's going
38:31
to be an uphill battle, as we say. It's going
38:33
to make it harder to get into anesthesia. That's
38:36
right. There are some things that you might not
38:42
think about, like risky behavior. Oh, okay. demonstrated
38:48
risky behavior such as say you're a climber a
38:54
rock climber but you only like to free solo oh
38:58
yeah that does sound dangerous it's dangerous
39:01
it's it it shows uh potentially too dangerous
39:07
for uh for a field that is you know rooted in
39:11
patient safety and anticipatory awareness and
39:15
ensuring that we are kind of actuarially responsible
39:19
for risk in the operating room. Climbing a high
39:23
mountain without safety gear is sort of the opposite
39:26
of the way that anesthesiologists think. Yes,
39:29
that's exactly true. So those are kind of things
39:33
that you just need to at least think about. An
39:37
incomplete application. So an application that
39:40
is put together haphazardly is a complete red
39:43
flag. don't have your letters of recommendation,
39:46
don't have a personal statement. Your personal
39:49
statement is in many different fonts with lots
39:51
of grammatical errors and spelling errors and
39:56
a CV that is not formatted correctly. All of
40:02
these are like low bar things that everyone should
40:05
be able to do, that there are resources there
40:07
to do. And to your point, there are even... If
40:10
you don't have personal resources, there are
40:12
technological resources available to you that
40:14
should kind of go without saying. Yeah, absolutely.
40:18
You shouldn't be the only pair of eyes on your
40:21
application. In fact, there should be multiple
40:23
pairs of eyes from you, your mentors, your friends.
40:29
You should be making sure that nothing sticks
40:31
out and nothing is strange. That's right. And,
40:36
you know, back to your first question, when you're
40:38
looking at all this stuff, you know, you get
40:40
really good at being able to look through this
40:43
very quickly, right? And a lot of the programs
40:45
that you submit them to organize it in such a
40:48
way that allows people to kind of get an overarching
40:51
glance very quickly, which is nice. That being
40:55
said, to truly go through an application, you're
40:59
reading the personal statement, reading the letters
41:02
of recommendation. literally clicking into people's
41:06
transcripts and looking through their grades
41:08
and things like that. This can take 10, 15, 20
41:12
minutes per person. So it's an arduous task.
41:16
And if you're really doing a holistic view of
41:21
someone, as we do, you really have to look at
41:25
everything. Because the key is to try to find,
41:28
if there is an admonishment somewhere, you have
41:31
to find the outlier. You have to find out if
41:33
the admonishment is the real story or if that
41:36
is the outlier. Right. I've spent sometimes up
41:41
to an hour looking at somebody's application
41:43
before because there is something like a red
41:46
flag, but there's also things that just make
41:49
you want to interview the person as well. You
41:52
know, maybe somebody took a year off of medical
41:55
school for some reason and that's reflected in
41:57
their transcript. I want to find out that story.
42:00
Why did they have to take that time off? What's
42:02
what's going on with their lives? Does that make
42:04
them a threat to not be able to complete residency,
42:09
for example? Which is what we're looking at in
42:12
the end of the day is right. The ultimate goal
42:14
is for us to recruit people who will ultimately
42:18
be successful in completing residency, attaining
42:22
board certification and becoming a productive
42:24
member of the anesthesia community. I totally
42:28
agree. One of the things that I've. try to emphasize
42:30
to people who are filling all this stuff out
42:33
is the three characteristics that I think that
42:36
program directors look for. And you can also
42:38
chime in with what you're looking for as well,
42:41
or see if you agree with me. We're looking for
42:44
people who will work hard, will pass their boards,
42:49
and lastly, won't cause any issues during residency.
42:55
Domestic strife, if you will. Well, It could
42:58
be that it could be a lot of different things.
43:00
You know, I've heard of residents who get felony
43:03
convictions during their residency or who have
43:06
to drop out for a variety of complicated reasons,
43:10
which is never great. We're here to help people
43:14
succeed at the end of the day. Yeah. And I mean,
43:17
we're all people and, you know, people make mistakes
43:22
and the goal is to. you know, get through with
43:25
as few mistakes as possible. But, you know, ideally,
43:29
you know, part of, you're going to find a residency
43:32
program that will support you when you're down
43:35
just as much as they're going to support you
43:37
when you're up. I think we actually do a really
43:39
good job of that. I'm very proud of that is that
43:41
we, we have our residents backs. And I think
43:43
that that's extremely important. But yes, to
43:48
your, you're absolutely right on the money with
43:52
that. let's talk about away rotations should
43:56
people do away rotations uh sure why not next
44:03
question no i'm just kidding uh so away rotations
44:05
are uh it's a double -edged sword right um if
44:10
you don't have a good anesthesia rotation at
44:14
your institution then you should absolutely do
44:16
an away rotation uh to get uh the full monty
44:20
if you There's really a couple reasons to do
44:25
one. If there's a particular program that you
44:27
are very, very interested in, then that's a very
44:31
good reason to do an away rotation there. If
44:34
there's a rotation or an away program that offers
44:38
you a learning opportunity that you would otherwise
44:40
not get that you think is going to make you a
44:45
better clinician, that's a good reason to do
44:47
an away rotation. I don't think people think
44:49
about that as much. But I think that that is
44:51
a really good, whether that's transplant or trauma
44:55
or some other type of niche thing. I think that
45:00
that is a good way to do an away rotation. But
45:02
you have to remember when you do an away rotation,
45:04
that is effectively a month -long interview.
45:11
I've talked to medical students who are on their
45:14
away rotation. They have expressed to me as I'm
45:19
mentoring them and such that they're really nervous
45:21
about the interview that they have coming up.
45:24
But I tell them not to worry about the interview.
45:28
The interview is right now. It's already happened.
45:33
For better or worse. Right. Everyone has already
45:36
formed their opinion of you because you've been
45:38
here for a month interacting with us. One 15
45:41
-minute slot a week after your away rotation.
45:46
likely not going to make a huge difference no
45:48
it doesn't uh what i will say though is that
45:51
somebody who does an away rotation does a stellar
45:54
job on their away rotation and then absolutely
45:57
mails it in and doesn't give any um it doesn't
46:03
place any importance on their actual interview
46:05
their actual one -on -one time with different
46:07
faculty members um that's in some ways a little
46:10
bit of a red flag yeah i i agree with you i i
46:13
think that uh That's pretty rare to see that.
46:17
Almost never. But you shouldn't take for granted
46:20
any opportunity you have to put your best foot
46:23
forward. Sure. What tips do you have for people
46:27
who are on their away rotation? How can you succeed,
46:29
stand out in a positive way? Talk to the residents.
46:36
See how they can be an advocate for you. Find
46:43
out. It's very apparent which teaching faculty
46:46
are in and around the residence. Latch on to
46:50
them. Go talk to the residency program coordinator
46:53
and say, hey, which faculty really enjoy being
46:56
with med students? And seek those people out.
47:01
It's important to get as many stories about the
47:06
program as possible. Like it or not, this whole...
47:11
We're talking about how we look at applicants,
47:13
right? But it's just as much applicants interviewing
47:18
us as it is us interviewing applicants. Oh, absolutely.
47:23
And by and large, the way the residency match
47:25
is structured, people are in an advantageous
47:30
position. And it gives deference to the applicant.
47:35
And they're choosing us as much as we're choosing
47:39
them. You know, it's important for somebody who's
47:42
on an away rotation to get the full story about
47:45
the program that they're at, too. Yeah, I totally
47:48
agree. That's definitely one thing that I would
47:52
go into my interviews thinking about is not just
47:56
that I'm being interviewed by the program and
47:58
they're going to ask me what my favorite tree
48:00
is. That was actually a literal question that
48:03
I got on the interview trail. What is your favorite
48:05
tree? Yeah, if you were a tree, what kind of
48:07
tree would you be? Interesting. Yeah, I know.
48:12
I'm not much of an arborist, so that isn't really
48:15
my field of expertise. But I think that a lot
48:19
of places will ask you kind of oddball questions
48:22
just to try to get a sense of who you are, what
48:28
you're thinking. Speaking of which, I have a
48:31
question for you. Go for it. If you could have
48:33
dinner with anybody, it could be somebody who...
48:37
is from the past or even from fiction who would
48:40
you have dinner with that's a very good question
48:44
and i know this question well because i know
48:46
you asked this to people or have been known to
48:49
in the past uh don't don't give away all the
48:52
secrets i won't give away all the secrets so
48:54
um uh it would be my my grandfather on my mom's
49:02
side um i never met him He was the only grandparent
49:06
I never met. He was the one that, ironically,
49:10
people say I'm the most like. And I would love
49:14
to meet him and hear his story. Family is important
49:18
to me, and I think that there would be no better
49:23
person to have dinner with. So whenever I ask
49:29
that question during interviews, A lot of what
49:32
I'm looking for isn't necessarily that you can
49:35
come up with some more interesting historical
49:39
figure or person that you really want to meet.
49:42
And that piques my interest. It's not a guess
49:45
what I'm thinking. What I really am trying to
49:46
do is find out what you care about. And what
49:49
you were just telling me is that you care about
49:52
and place emphasis on your family. That's one
49:54
of your values. And I think that that's good
49:56
information for me if I was picking somebody
49:59
out for the program is to find out. what their
50:02
actual values are so yeah that's that's why i
50:06
asked the question absolutely um one of the biggest
50:09
things that that i look for uh when people are
50:13
applying and especially when they're interviewing
50:16
is is and we talk about this as a sense of grit
50:21
right sense of grit um what does that mean it
50:26
can mean a lot of different things it can mean
50:28
that you've you know in the face of adversity,
50:31
it can mean that you just have a wonderful sense
50:35
of self -control. There's a lot of different
50:38
ways of defining it. But it's one of those things
50:43
when you know it, when you see it. And that's
50:46
always a big plus when you see that for people.
50:50
Yeah, I seem to recall there was an application
50:53
where I saw that... somebody's house or apartment
50:57
had burned down in the middle of medical school
50:59
and i i saw that they they told a little bit
51:04
of that story and they still didn't miss any
51:09
time in medical school and kept going through
51:12
their rotation and did well on their rotation
51:14
wow i don't think i could have done that that's
51:18
that would be an example of something that shows
51:21
grit that being said if dustin and i find a lot
51:23
of applications where their houses burned down,
51:26
I think we'll probably look at that with statistical,
51:30
statistical, uh, statistically impossible. Um,
51:34
I remember one where somebody, um, the first
51:37
sort of two sentences of their personal statement
51:40
was something along the lines of like, you know,
51:43
like I was seven and it was my job to, you know,
51:48
retrieve, uh, the bread. And to do that, I had
51:52
to run across, uh, an active like war zone right
51:58
every day and i'm like oh my god my problems
52:01
are so insignificant it's just like a complete
52:05
um it's just a complete other solar system of
52:08
life um and it's great to hear those type of
52:11
things it's great to hear those stories um and
52:14
that was he could have written uh like actually
52:20
i can't remember if it was a he or she i think
52:21
it was a he but he could have written about anything
52:24
else for the last and those two paragraphs or
52:27
those two sentences already made me want to meet
52:29
that guy right yeah absolutely that's that's
52:32
a heck of a hook it was a good one um so there
52:38
are some people who are going through the couples
52:41
matching process where they're trying to both
52:43
match to the same city or maybe they're applying
52:47
to different specialties but they're trying to
52:49
match into the same place and they have a Something
52:53
in place for that with a couples match where
52:55
people can end up going to the same place or
52:58
they can try. Do you have any advice or recommendations
53:01
for people who have gone through that? It definitely
53:05
adds a layer of complexity. You kind of have
53:09
to do a little more research as to the competitiveness
53:14
of both fields at that point that the people
53:19
are applying to and figure out. Who's driving
53:23
the bus? Because in some ways, if the competitiveness
53:32
is completely disparate between the two people,
53:35
one person is going to really be the one that
53:41
is the key driver of where they're going to be
53:44
getting interviews. So that's kind of the first
53:47
sort of step is to figure out how competitive.
53:51
Each applicant is in their respective specialties
53:53
and how, when you combine those two, what the
53:59
probability is that you're going to be successful
54:01
in matching. And then you have to do a lot of
54:07
legwork as to where you need to apply, what programs
54:12
are potentially located close to each other so
54:17
that you aren't separated by, 2 ,000 miles. That
54:23
technically wouldn't happen with a couples match
54:26
or shouldn't happen. But that is the... I think
54:32
that's where you start is you have to really
54:35
have a good understanding and a lot of self -reflection
54:38
on your competitiveness and realize that you
54:41
might have to apply to more programs just by
54:45
definition because of the added layer of complexity.
54:48
As somebody who went through the... couples match
54:51
myself, I can confirm that it does add a layer
54:54
of complexity. We had a big colorful spreadsheet
54:56
that we used to keep track of everything, and
54:58
it's hard. Everything tends to run together.
55:01
It's expensive, too, to travel around, but the
55:04
good news is for now that COVID has sort of made
55:08
everything virtual, so it's a lot less of an
55:12
arduous task to get to all these destinations.
55:14
Although I think we might be getting back away
55:16
from that eventually again. It's up in the air.
55:21
It's up in the air. We'll see. We'll find out
55:23
which way the wind blows as far as that goes.
55:25
I understand both sides of it. I understand and
55:28
sympathize with the fact that it's an expensive,
55:30
stressful process for the applicants and that
55:34
a virtual component is extremely helpful from
55:39
a financial aspect and from a logistical aspect
55:42
when you're potentially on a rotation that is
55:44
hard to get away from. But I also understand.
55:48
how important it is to see places in person,
55:51
you know, walk, touch, feel, be a part of that
55:55
institution. Even if it's for a small period
55:57
of time, you can really get a good sense as to
56:01
the camaraderie, collegiality, and general themes
56:05
that run through a place. So what do you think
56:07
about second looks then? Is that sort of the
56:10
middle ground that people can go and see after
56:14
their interview is already done? Well, that's
56:17
become our middle ground, and I think it's a
56:19
good one. I think you should – if you go to a
56:22
place in the virtual space, go, quote -unquote,
56:28
and you love it, you have a great interview,
56:31
I think you owe it to yourself if you're really
56:34
considering spending four or more years of your
56:38
life at a place to go see the city, go see the
56:42
institution. If they offer a second look, you
56:44
need to try to be there. if you're serious about
56:47
it. There's no reason to go on every second look
56:49
because, again, that's too arduous of a process.
56:53
But if you are dead serious about going to a
56:57
place, going on a second look is important. Yeah,
57:03
absolutely. Should people be concerned about
57:07
the way they present themselves at second looks?
57:11
Is a second look another interview? Can I move
57:13
them up or down on the... On the rank list? Well,
57:17
I can't speak for every institution because I
57:20
don't know how other people do things. But the
57:24
way that I think is the correct way to do it
57:29
is to already have all your decisions made, already
57:32
have all your lists completed so that it is not
57:36
something that can move you up or down a list.
57:40
or change someone's opinion or outlook on you.
57:44
And I think that's for two reasons. One, you're
57:47
just there as a guest. And two, not everybody
57:50
might have equal resources to come do a second
57:55
look or have the availability to do it. And just
57:59
because someone wasn't able to do it doesn't
58:02
mean they didn't want to and certainly means
58:05
we shouldn't hold that against them. Let's wrap
58:09
up here and get your style points overall. What
58:13
style points or points of personal preference
58:15
have helped you throughout your career? And maybe
58:18
we can even say through the application process
58:22
and through becoming an anesthesia professional.
58:26
The best thing that someone can do and the thing
58:32
that's been most useful for me is No matter what
58:39
the circumstance, always coming into work, trying
58:44
my best, being a team player, and trying to get
58:51
the most educationally and professionally out
58:54
of each situation. I think that oftentimes a
58:59
question that we will get in the interview process.
59:04
with people who don't have any frame of reference
59:06
really is like, what do you look for in an applicant?
59:09
And I always tell people I would look for the
59:13
same things that I would look at for an anesthesia
59:16
resident as I would look for as a manager at
59:19
a bank or a front of house representative at
59:23
a restaurant. And that's someone who is a team
59:27
player, someone who tries their best. Someone
59:33
who operates with professionalism and puts others
59:38
before themselves, puts their patience above
59:41
all else. And if you do those things, you're
59:45
going to be successful. What did your wife say
59:49
when you told her that you had cut your wedding
59:52
ring off at work? She looked at it and said,
59:55
oh, great. Is this like some type of... uh, omen
59:59
or foreshadowing event. And, uh, you know, mind
1:00:03
you, we've been together since we were 17. We
1:00:06
met at blockbuster video. If people who are listening
1:00:08
even know what that is. Um, wow. But it's a stupendous
1:00:11
situation. Um, and, uh, I told her that I already
1:00:18
had a, uh, like a silicone ring in the mail,
1:00:22
uh, to, to appease the situation. And, um, It
1:00:28
ultimately was fine, as I knew it would be. Good
1:00:32
deal. Well, Dustin, thank you so much for joining
1:00:34
me. Thank you for having me. Thanks for tuning
1:00:39
in to this month's episode of Style Points. I
1:00:42
really appreciate you taking the time to listen.
1:00:44
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1:00:57
As always, you can contact me at stylepointspodcast
1:01:00
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1:01:05
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