Residents in a Room

Episode Number: 42

Episode Title: Career Journeys

Recorded: September 2022

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VOICE OVER:

This is Residents in a room, an official podcast of the American Society of Anesthesiologists, where we go behind the scenes to explore the world from the point of view of anesthesiology residents.

You’ve got to capitalize on your senior partners, and leaning onto them for that assistance and never be afraid to reach out.

When you finally are the bottom line responsible person, to really take a safe and conservative path, even if it requires resisting people telling you to do otherwise.

Inevitably, something bad is going to happen. Do not beat yourself up over it. Learn from it. Grow from it. Move on and teach others about it.

DR. MARK HYLTON:

Well, welcome to the Residents in a Room, the podcast for residents by residents. Today we're bringing your special sponsored provided episode. I'm your host today, Dr. Mark Hylton. I completed medical school and residency at VCU Health, the Medical College of Virginia, located in Richmond, Virginia. And for the past two years, I've been an anesthesiologist with UMC faculty physicians at UNC Health in Goldsboro, North Carolina, as well as a per diem anesthesiologist with North American Partners in Anesthesia providing care at Riverside Shore Memorial.

So not too long ago, I was where you were as someone still relatively new to practice. I have a lot of questions and I'm thrilled to be part of an organization with so many welcoming and engaged colleagues who want to support my career journey. I'm joined today by two of my NAPA colleagues, Dr. Caroline Columbres and Dr. Ronald Bank, who are here to share some insights into navigating a career as an anesthesiologist. So to get started, let's learn a little about them. Caroline, tell us a little about yourself. Where did you train? Where do you currently work at? What's the most important step you took, big or small, that got you where you are today in your career?

DR. CAROLINE COLUMBRES:

Hi, I'm Caroline. I started my residency in Brooklyn at Maimonides Hospital, and I remember I when I looked for a jobs, I just wanted something that was easy. I was like, I'm just going to work for a couple of years, pay off my bills. I have a negative money in my account. And there was a hospital right down the street from my apartment, and I signed on right away. And I started as like a bright eyed, scared new attending. But 13 years later, here I am. I'm the chair of the department. I became chair in 2019. Before that, I was vice chair. Before that, I was the floor leader, clinical leader to run the flow on OR scheduling. So I kind of feel kind of like the ball boy on the New York Yankees who somehow rose through the ranks to become the coach. But it's it's been a fast 13 years. And I would say the one step that I took, big or small, was I allowed myself to be uncomfortable and put myself in an uncomfortable positions. And I was never afraid to deal with a very irate surgeon or, you know, you know, go into the, quote unquote, hard room or assign myself the hard room. You have to allow yourself to be uncomfortable to be a better, stronger and more confident physician.

DR. HYLTON:

Caroline, you just got to be the uncomfortable Miss Utility, right? That's what we do as anesthesiologist. We get into uncomfortable positions, but capitalize on it and we it just propels us forward in our career. So thank you for sharing that.

Ronald, what about your anesthesia journey? Where did you train at? What are you where do you currently work? And what's the most important step you took to reach where you are today?

DR. RONAL BANK:

Hi. I did my residency and fellowship at Johns Hopkins Hospital in Baltimore. I did a fellowship in cardiac anesthesia. And then immediately after fellowship, I came to my current position at the Inova Fairfax Hospital in Falls Church, Virginia, which is a huge quaternary care center, level one trauma center, huge adult and pediatric cardiac program and so forth.

I think the biggest step that I made was deciding to do a cardiac fellowship that really dramatically altered the course of my career. I've been the longest serving cardiac anesthesiologist now in this large hospital system, and I think having done a cardiac fellowship, it just prepares you well to do virtually any type of case, not obviously regional and that sort of thing. But in terms of sick patients, I'm also the chief of trauma anesthesia. We're a large level one trauma center. And I find that the cardiac skill set just kind of makes everything easier with respect to acuity and complexity of the patient and has dramatically altered the course of my career. Having done having done that now for so long.

DR. HYLTON:

Yeah, I agree with you, Ronald. I think going through training and getting those cardiac cases, they are the sickest patients. So usually don't get scared or get that uncomfortable situations always there. So that's awesome. Thank you for sharing that.

Let's jump into some more questions and we got to got to chat a little bit. For the new anesthesiologist plotting out his or her career path. What should be some goals that that they set in residency six months out, a year out, five years out? Sort of. what were some goals that you all said when you started your career and sort of planning your path.

DR. COLUMBRES:

For new grads, the most important thing like six months out, you need to be comfortable doing your own cases. I work with a lot of new attendings. You know, it's it's September. So I've had two new attendings starting since July. And just in a month, I can see the confidence they have. You know, just because I'm around when they start their first case as an attending and you have to you have to know when you need help. And I think that's like a very delicate skill because you don't want to seem like you don't know what you're doing. But if someone has a BMI of 65, do not be afraid to call for help. So it's good to see in my career just how that transition goes from like attending who's one month, one month out, two months out, six months out. So I think as a new attending, you just need to know yourself, know your skills, hone your skills and be confident in yourself.

DR. HYLTON:

Yeah, no, I agree with you. Ronald, what do you think about that? What do you think someone should like plotting out their career? What goals should they set at certain times?

DR. BANK:

Yeah, I think at the six month mark, I very much agree with what Caroline said. I think it's you're very book smart. However, you don't have the clinical experience. You also don't have the street cred with the surgeons. They don't know who you are. And I think one of the other important things is also to make sure that you tap into your more senior colleagues. If someone's trying to push you around, they're trying to push you into doing something unsafe. I think at that point in your career is particularly challenging because you just don't have the clinical experience that you develop over time, and you can be more hesitant to resist being pushed to do things that are unsafe. And it is I remember I think everyone remembers their very first night on call by yourself. It's all these years of training and there you are, finally, bottom line responsibility. But I think that those would be the things that I would offer for immediately out of training.

DR. HYLTON:

Yeah, I think you do. I agree with you've got to capitalize on your senior partners and leaning on to them to for that assistance and never be afraid to reach out.

DR. COLUMBRES:

Another thing, make sure you pass your boards, you know, like carve out enough time. Like don't take it lightly. Like everyone after they pass their in boards, you're like, Oh, I got this. And I'm doing anesthesia like 10 hours a day. Don't take for granted that the oral boards are are challenging and you need to prepare for them and carve enough time so that you're prepared.

DR. HYLTON:

Carve enough time and reach out to to your colleagues and back even to your residency program for oral board prep. Because I think we're all fortunate that where we trained or even currently practice if you're in an academic setting, there are oral board examiners right down the hallway or right down the street. And so you capitalize those opportunities to to practice because that's that's where you you get the skill set, the daily practice of anesthesia, plus some run or more questions. And the next thing you know, you're off sailing with with a pass score and you're now you're on to your career.

I think that leads into a good topic of what are some tips for successfully transitioning from residency to practice. I know myself now two years out, that transition of going to sitting in on case as the bottom line person with really no extra help other than maybe a partner to call versus transitioning to the anesthesia care team model. What are some tips that you all have for that successful transition?

DR. BANK:

Well, I think one of the tips that I have is to just basically be conservative in general with your medical management that I think in general, if you're faced with, you can it's not really what you can get away with. It's what's safe and what you can defend. And I think sometimes people get those things confused. But I think one very important thing to understand is that when you finally are the bottom line responsible person to really take a safe and conservative path, even if it requires resisting people telling you to do otherwise. And I think personally that that's very important early on because I really think the first few years of practice are the most challenging for a variety of reasons. But I think being conservative is one and I think one other that perhaps I should have mentioned earlier. I think just know how to do a good awake innovation. Don't be scared of them. I think one area people get hesitant and they take chances if they're not really facile with awake innovation. Once you take away someone's spontaneous effort, you're you've really got to be able to take that over. And I think that's one thing to learn as a resident and then as an attending, when you have people that are good at it really master that skill, it comes in handy off hours.

DR. HYLTON:

That is correct. Ronald. All doubt like the awake intubation is probably a very challenging aspect of our careers and we're we're leaned on that from our other physician colleagues and we don't always present and get that opportunity on a daily basis. So practice it when you can. Caroline, what's your thoughts on that? Some some successful tips?

DR. COLUMBRES:

I agree to be conservative because you always have to remember that the patient comes first. You just have to stand firm and trust your gut. And if you need help, reach out. But I think that's one of the hardest, hardest parts of being a new attending is like finding your voice sometimes because you don't have the experience behind you. But if you just keep in your head at the patient comes first and the patient's safety comes first. That should be like a good guiding light.

DR. BANK:

I think what Caroline said is, is just spot on. And the other thing I would say is it's not about your ego. In my practice, which I've been for a long time, if I don't get any given procedure after three tries, I'll just ask someone else to do it as soon as a qualified person is there, because it's really not about persisting with something in your ego. I can get the saline or this or whatever, but remember, like Caroline said, it's about the patient. They just want it done. And if you can't hit the IV, you can't hit the a line, get someone else to do it. It's not it's not about your individual pride, even though all of us doing this are pretty type-A folks. But I think that's another thing that's important to remember.

DR. HYLTON:

Correct? I totally agree with both you all. And as we talk about some challenges that we experience in our careers, what are some pitfalls that we might should keep an eye out for? You know, if we're in the interview process, we've accepted this job. We have some surgeons or administrators that are pushing back. What are some things we should look out for?

DR. COLUMBRES:

You just have to have this understanding that, you know, we don't have to be Kumbaya and hold hands and get along, but you have to be firm and you have to have medical based evidence behind you. And if you can defend your your decision, they don't have to like you, but they'll respect you.

DR. BANK:

Yeah, totally agree. And I would say another one is understanding how important citizenship issues are. I think sometimes people may not realize that I know where I train the surgeons had some big egos and I trained a long time ago when people acted in different ways. But I've seen a lot of great clinicians in different specialties get burned by citizenship issues, and they're extremely important. And it gets more important every year, meaning to be a good citizen, to treat people well, not to lose your temple, to be respectful, to treat your patients well. Another thing it's super important to realize is not that you want to practice medical, legal, defensive medicine, but if people like you, they're less likely to sue you. But also just be be nice, be collegial, be respectful. And it builds loyalty. It builds respect. And I think that's very important. And even if you're having a bad day or being frustrated, try not to act out or let that show because it really is very important and becomes, I think, more stressed in the team environment every year.

DR. COLUMBRES:

I feel also that like people will always remember, like the one bad thing if you lost your temper once but 100 times, you're cordial and respectful. They won't remember that. They'll always remember the one time you cursed. So it's it's something to keep in the back of your mind at all times. Just be a professional.

DR. HYLTON:

Professional team player. Nice. I think back, you know, my first couple of weeks on call and I get a 2 a.m. phone call from OB and all I know is my wife woke up beside me and goes, You were rude on the phone and I'm one of the nicest guys. I'm not that type of person, you know. And I go in like crying almost to to the nurse going, I'm so sorry you woke me up out of a dead sleep. And she goes, Dr. Hilton, I didn't even think nothing of it, you know what I mean? But you do. You have those times where you get frustrated and you don't even think about it. But, you know, like you said, be a team player, be nice, be cordial. And at the end of the day, things will go well.

DR. COLUMBRES:

And also own up to your shortcomings, because, I mean, the days are long sometimes and no one's perfect. But, you know, if you lose your temper, you can you could always go back and apologize. It's people are people.

DR. HYLTON:

Yeah. I was going to say, we're all human. We're not perfect. We don't make mistakes. But when you own up to it, it makes life a whole lot easier. And then at the end of the day, you can you can hang out with and be friends with your your colleagues outside of the hospital. You know that that's a thing we talk about.

You know, how can newer anesthesiologists like myself, for example, expand my skills? Right. Four years of med school, four years of residency, maybe a year or two of additional fellowships. So you got the clinical skills. And then outside of administrative skills, what are things that that new anesthesiologist can do to better themselves for the future and prepare them as they start their careers?

DR. COLUMBRES:

One thing I would advise is if you see the schedule beforehand, volunteer for harder cases or cases that are outside the realm of what you do. Just you could be more of an all around anesthesiologist. And another helpful thing, I would think, is also to volunteer to be on committees or like be like, you know, the quality committee or if there's an ERAS protocol that's being made, you could say, oh, can I be on? Can I get on that and see what that's all about? Just to get like another view of what goes on behind how the sausage gets made in the hospital and in the OR setting.

DR. BANK:

Now, totally agree. And I think going to clinical areas you might not know as well and having some more seasoned attendings attending sort of proctor you and also if there's a problem and you identify it, tackle it, just tackle it and figure out how to do it. I've had a number of leadership roles over the years. I went to medical executive committees now and some if you just find a problem instead of telling other people about it, if it's something that's not within someone else's immediate responsibility, tackle it yourself. Get to meet the people in other departments and in the administration and learn the system. And your name will become more well-known and you'll be looked at as a problem solver and people come to you and leadership opportunities build. And I think it's important relatively early on to start looking beyond the clinical realm at leadership opportunities within the hospital and even within our specialty. I think at some point it's important to look at advocacy within the ASA, understand the business of medicine. And also one thing that I should have mentioned earlier is your personal finances. I mean, you become financially literate early, understand the business of medicine and all the sorts of things that are all too frequently not taught in our training programs.

DR. HYLTON:

Yeah Ronald I definitely wanted to pick your brain today in regards to the advocacy and involvement in ASA. I know you and I did some stuff back when when I was in Virginia and so on that topic. Tell me, what did you how did you get involved early on in your career with advocacy groups and working with BSA and ASA.

DR. BANK:

Our group, we're right near D.C. and so I've always been a member of the BSA and ASA since the beginning of my career, but then I went a couple of times to the ASA Legislative Conference, which I would highly encourage everyone to do. And you learn quickly that if you are not at the table, you're on the menu. And what I've learned over the years of doing political advocacy is you've probably seen yourself. It's almost uncommon for actual practicing physicians to be on the Hill. They're used to seeing lobbyists and that sort of thing. When you're an actual currently practicing physician, people are very interested in what you have to say and it's very effective. So I think the earlier I think honestly going to the assay legislative starting with your state society but going to the ASA legislative conference, even if you can only do it once depending on where you live, is extremely valuable and you build great connections there.

DR. HYLTON:

I agree. I went to the legislative conference at one time and I was very amazed of the opportunity to talk to legislators, talk to their legislative aides, and even the lobbyists for our own societies, which is helpful. Caroline, I know you're your chairman or chairwoman, so tell me a little bit, you know, growing as a leader, building your CV up to promote yourself and get in the position that you are today in your career. How did you do that?

DR. COLUMBRES:

I said yes all the time there. Like anyone interested, like we need volunteers for to do this. Anyone want to be the floor leader or does anyone who wants the, you know, the thankless job of making the call schedule? I signed up for everything just so I mean, selfishly, so I could be in charge of schedule. But then I learned just what goes into like the care team model and how how so much goes into just scheduling people was amazing. And then, you know, my face was more prominent in the administration offices, so then I just kept on getting promoted, I guess. So that's my story.

DR. HYLTON:

Nice. And I think I would agree. You see, as people move up in their careers, it's if you're asked to do something and it's within your means to do it, you say yes, you do a great job at and next thing you know, your well continue to be well respected and the next thing that's asking to do more, do more. I caution because I it's a pitfall of myself, as I say yes, a lot too. And then I say yes too many times. And the next thing I know, I'm over here stressed out because like, how am I get all this done? Oh, I also have a family and a home life. And so you're trying to find that work life balance is challenging, knowing that the ultimate career goal is XYZ. If that's a chairman or woman of a practice, being president of the ASA, whatever it may be. So excellent. Thank you all for that.

How do y'all how should someone really ask or learn about some new opportunities clinically? You know, we mentioned, you know, you definitely lean on your senior partners. You're involved in some advocacy at the legislative conferences and going to your state levels. But what are some, what are some other ways you think we could you know, new grads, young residents get out there to to explore new opportunities within anesthesiology.

DR. BANK:

For residents, I think rotating through big centers like we have residents from the military, we have residents from a number of Virginia schools that rotate through our hospital. Depending on where you do your residency, I think go to a huge quaternary care hospital and look for opportunities to do really complicated cases. We're kind of an unusual hospital in that it's not a straight academic center, but we do heart and lung transplantation, pediatric hearts and all sorts of various, I just had a fourth time redo double lung heart transplant a few weeks ago. Literally. In a congenital adult. There's opportunities for residents to see those types of cases. We're interested in them in centers, in big centers, and I think that's a great opportunity. If, as a resident, try to rotate through places that do cases that you want to expand your horizons with.

DR. HYLTON:

I think you make a good point, Ronald. It's you know, I think residents should work with their program directors in their program to establish a connection at Inova Fairfax, though they may be at Georgetown or they may be at VCU and they may be down in North Carolina or even out West, but if you've got a connection, maybe you can come for a week during your during a rotation and still get that clinical exposure. Still countless clinical time, you know, not having to take a week, your week of vacation to go somewhere else, but I would say encourage residents to to work with that and explore those opportunities.

DR. BANK:

One other thing I would add, Mark, is that's the best job interview in the world. We've had residents rotate through and then later on they'll come looking for a job. We remember them, we work with them. It's you know, the interview is where you want to live and let's go to lunch. I mean, there's no better job interview than that. A lot of people end up places that they've rotated through. Something else to think about.

DR. HYLTON:

Yes, sir. Yes, sir. Caroline, what are some some top three things you wish you learned early in your career?

DR. COLUMBRES:

I would say, number one is inevitably something bad is going to happen. Do not beat yourself up over it, learn from it, grow from it, move on and teach others about it. Because I'm like very tight by and perfectionist. So obviously if there's a bad outcome despite your best efforts, I mean, I remember I was like for two weeks, I was couldn't sleep, couldn't all I want to do was talk about it and how could I have done something different to save this patient? We had our … and there was nothing I could have done. But just that is something that I wish, like looking back, I could have told myself, like, do not beat yourself up so badly over bad clinical outcomes. And also to set boundaries. As I said earlier, I said yes to a lot of things, but you have to do it in a way that is good for your mental health, for your family, and just for your well-being. So that work life balance, it's very, very hard. But you could say no and you could say like, you can email me and I'll answer it tomorrow, but I'm not like after 7:00, that's like family time and I'm unreachable. That's the way it is. So it's set healthy boundaries. And a third thing is work. Should it be work? This is a career, right? So learn to love. This is like a science. Like what we do is artful because I see a lot of my new attendings, I want them to learn to love their job. If you're happy in your home life and translates to being happy in your job and the key to a happy home life is boundaries. You know, like don't let your work consume, you know?

DR. HYLTON:

That's a very great point, Caroline. Very great point because I think early on we do get into that pathway that we may not set those boundaries because we want to get that advancement, early career advancement, you want to do this, want to do that, and then you find yourself going, Oh, oh, I'm too much, I'm too much. And then it does reflect back at home and reflect back at work. So you got to find that good balance.

Ronald, how about yourself? I mean, what do you think are three things you wish you learned early in your career? Because you've had a very long career, you're saying greater than 20 years being at one place, I mean, being at Inova. I mean, you've probably seen it transition to a much bigger hospital that may have started and probably Inovas been it's probably expanded tremendously over the past year or so. What are three things you you wish you learned earlier in your career then as a transitioned on?

DR. BANK:

Yeah, a couple of things I've already hit on. I think the importance of not letting your ego get in the way and the importance of you're basically having a high EQ not just a high IQ in terms of citizenship and the importance of understanding personal and business financial literacy early on. A couple of things I hadn't touched on that I wish I had known more about early on was the ability and the existence of really good formal leadership training and good and training and human factors and how to operate under stress. It's always struck me as odd, like I do outside of work, I've done a fair bit of work in a something called tactical medicine, where you're working with different agencies in a different environment to provide medical care and different environments outside of the hospital. In this instance, in a police or military setting. And these people are actually trained specifically in human factors and they're trained in how to manage stress and how to work in stressful situations, as are pilots and nuclear power workers. And we fancy ourselves a high reliability industry or high liability profession. But I think I wish I had known early on to look to some of this training and to better understand the human factors involved in what we do. And also the value of getting leadership training, formal leadership training early on. They're very valuable skills that frequently you're not even aware of the training for that until later in your career.

DR. COLUMBRES:

To that end, our company, our company has a special program called NAPA Select. And if there's someone in the group who shows leadership potential, then the chairs can nominate them. And it's a yearly course that teaches those critical leadership skills that and you meet other people within the company who are also trying to advance their career. So that's a good thing that NA{A has. And they do it every year and every year you can see the difference. When I nominate people, when they finish that that program just they their EQ is higher, their communication skills are better. And most of them have gone on to become really great leaders in other hospitals.

DR. HYLTON:

That is awesome. And I briefly heard about the NAPA Select Program and I think we're starting to see that and probably a lot of careers, especially within anesthesiology because you see we need physician leaders. And so you got to start you've got to find them early to to train those individuals and get them up to speed and then allow them to work their career path and through promotion and become great leaders in the field of medicine.

Well, Carolina, Ronald, we're, I think, wrapping up here just a little bit. I really do think both of you all for joining me this evening for this. An informative conversation. I really appreciate you both sharing your stories, providing some advice throughout your journey. You certainly give him myself, and I think we, all three of us have bounced ideas off that we can all learn from and think about.

I want to thank our listeners for joining us today for another episode of Residents in the Room, the podcast for residents by residents. However, I'm not a resident still I'm not attending. So I will say that those, you know, sponsored event tonight. But no, we appreciate everybody joining on. We'll hope you all listen again next month. And don't forget to share and follow us on social media. We appreciate everything. Thank you.

DR. BANK:

All. Thank you.

DR. COLUMBRES:

Thank you.

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VOICE OVER:

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