Residents in a Room

Episode Number: 67

Episode Title: Year One Pitfalls

Recorded: August 2024

(SOUNDBITE OF MUSIC)

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 anesthesia residents.

Don't worry about the textbook reading, you know, just for knowledge. You should be focusing on the patient and planning for that specific surgery if that.

That main character energy, if you will, when you walk in the room and know that you're there to take good care of the patient and as long as you prioritize that.

Every attending has different ways of doing things and you have to kind of figure it out, and it's hard to do, and you're still getting your feet wet.

It's okay if you feel like you need a breather. You know you should take it. There's a reason you're feeling that way inside. Quantity does not always equate to quality.

DR. JOSHUA CADWELL:

Welcome to Residents in a Room, the podcast for residents by residents. I'm your host for today's episode, Joshua Cadwell. I'm a CA1 of Cornell. I'm just finishing my second month of CA1 year. It's been great. Exciting, challenging. I'm here to represent new residents, many of whom would welcome help and advice on navigating their critical early years. My fellow residents on this panel are a year or two ahead of me and are here to talk about their pitfalls and give advice. I'm excited to jump in here from everyone, so let's meet everyone.

DR. VARINA CLARK:

Hi everyone! My name is Varina Clark and I am a CA3 at UCLA.

DR. KATHERINE DAVID:

Hi everyone! My name is Katherine David. I'm a CA2 at Grand Strand Medical Hospital in Myrtle Beach, South Carolina.

DR. CLAYTON SWEENEY:

And hi everyone, I'm Clayton Sweeney, I'm a CA2 here at the Medical College of Wisconsin in Milwaukee.

DR. CADWELL:

Awesome. Drs. Clark, Davis and Sweeney, it's amazing to meet all of you. And we have a good variety all across the country, which is awesome. So when you were asked to join a podcast about year one pitfalls, what came to your mind first? Was there something specific that tripped you up in the first year?

DR. DAVID:

I can jump in on this one because I am fresh out of CA11 year. I think when you first start, you know, personally I barely knew how to intubate a patient that first month in July. I had very limited exposure to anesthesia as a medical student, so every single case feels like a mountain that you're trying to climb. I remember wheeling a patient back and I thought, okay, can I intubate this patient? Can I start an IV? And then you surprise yourself and you do it, and then you're like, oh my gosh, what do I do next? You're just kind of staring at the patient with the tube in, and you're just so happy that you did it, but you have to start anticipating what your next steps are. So I think when I think about CA1 year, it is really anticipating those next steps, developing a full plan. One of the pitfalls, I think, as the year goes on, is you get a little comfortable doing the cases that you're used to. It's just really important not to get complacent in all of that.

DR. CADWELL:

Awesome. Thanks for all that advice. And I it actually reminds me of intern year when, you know, everyone knows you're an anesthesia intern, so everyone assumes you know how to do all these things already. But it's a quite a big change when you actually show up as CA1 and you have no idea how to place an IV. Or maybe you place like a few, like like my experience, but. Right. Yeah. Um, does anyone else have any any thoughts on this question?

DR. SWEENEY:

So I completely agree. Early in VA1 year, just like Catherine said, we're trying to master the airways properly dose meds and even just understand workflows. But while we're treading water in this new deep end, we kind of come across some really cool anesthesia topics. And that's what our attendings get passionate to teach. So I was inundated with like well vetted and high impact articles and only had time to really skim them. Unfortunately, I didn't have like an organizational system, so many of these articles just got lost, like an email folder kind of named references to read later. I'm still not through that folder. But one of my one of the things that I recommend, or what I have now is an outline. You can do it based off like ABA keywords or your favorite text. I downloaded my preferred textbook into a notes app, and I attached the articles next to the specific chapters. That way, the next time I'm reading about Neuraxial anaesthesia and get to a section on test doses, I have this well vetted article, and I remember this conversation that my attending was trying to have with me, and doing it digitally also allows you to search keywords that I feel like we get inundated when we're trying to focus on the easy stuff.

DR. CADWELL:

Awesome. It's great, great advice.

So there's a lot of things that we find difficult in early residency and throughout residency. Some common stuff, large amount of information we feel like we need to learn. This is definitely true in early CA1, when you don't even know what a dominate is and you've never given it before, you need to figure out what these things are. And then another thing that I noticed is just adapting to different styles of practice, because every attending has different ways of doing things, and you have to kind of figure it out, and it's hard to do, and you're still getting your feet wet and you still don't know how to get a get a good view, for example and when you're intubating. So in your opinion, what is the hardest thing about residency, especially those early years? And is it something you're prepared for? And did these early challenges surprise you?

DR. SWEENEY:

So you brought up practice variation or changes amongst attendings. And I completely agree. That's one of the hardest things that I had to get used to. I do appreciate one of the attendings that I had in training stated to me that as trainees, we all deserve a reason our attendings practice the way they do. And so I encourage us all to start asking why some of those reasons are like outcome evidence. Others are time or practices based on price. Others might be where that attending trained or their patient experiences. While not all the reasons are evidence from randomized controlled trials, I still think it's important to have those reasons shared. The variation is really frustrating as an early CA1 and it makes everything hard. But as a CA two, it now kind of keeps everything interesting.

DR. DAVID:

Yeah, I have to agree. It brings to mind actually one of my co-residents today said in a single case, she had three different attendings come in and tell her three different things about how the case should run. And it just made me laugh because that is the epitome of your CA1 year. You make your own plans, your attending agrees with the plans, but things always change. You know, patients may come in and your whole plan has to go out the window. So it is hard. You're constantly adjusting. You just have to kind of go with the flow.

Another thing that, not that it's hard about residency, but it's something to really challenge yourself with, is the accountability of what you are doing. Um, we're no longer just medical students. We are in the operating room. We have a voice. And I think sometimes it's hard for us to remember that we are a voice in the operating room as a resident, but you are the one behind the drapes, taking care of the patient, making sure they are safe. You are responsible for someone's life and your actions matter. So we we have our attending that we can look to for guidance. But you should start thinking to yourself as an attending, what would I do for this patient? How would I manage them? The quality of the care you are giving is really important.

DR. CLARK:

I think, as everyone had mentioned before, CA1 year can be quite taxing as well on our mind and on our body. And one of the things that I took for granted was, um, prioritizing wellness and prioritizing my mental health and wellness. Um, you know, waking up early every morning, getting in there to set up, preparing for your patients so that you can give high quality care is so important. But then also coming home and taking care of yourself, yourself is also as important. And so one of the things that I sort of let fall through the cracks was prioritizing my mental and physical well-being during CA1 year. And so if I had any recommendation for folks, it would be to, you know, prioritize also what things make you happy, what things keep you going, how to create that energy for yourself to be able to give that the best patient care the following day. Um, it's really important and will sustain you throughout your following years as well.

DR. CADWELL:

I really appreciate those thoughts. As we all know, it's pervasive in medicine, not just anesthesiology, not just residency, but wellness and burnout and work life balance. All these things are hot topic right now, as medicine just tries to figure out how to grapple with all of these things. So just a question for all of you. In order to manage work life balance, how do you find time for friends and family? How do you find time for yourself to do these things, like like you were mentioning Dr. Clark. Have you learned something about taking care of yourself while going through residency that you could give us advice on how to do?

DR. CLARK:

Yeah. Um, for me. I love to dance and so carving out time on the weekends that I'm off, my golden weekends, is finding a cool dance class or hanging out with friends and family. It's it's really hard to find that time, I would say on a daily basis, but really being proactive and creating a schedule and letting folks know, you know, this is my schedule for the next four months, where can you fit me in? Really is helpful. And also, I'm a new mom. And so, you know, some of that time now is dedicated to my daughter and being again as proactive as possible so that I'm carving out that time to spend time with her. And I think, you know, as long as I said before, as long as you sort of set up yourself for success by being proactive and taking deep breaths and taking it day by day, it will sustain you.

DR. DAVID:

First I want to say congratulations, Dr. Clark. That's awesome.

DR. SWEENEY:

Yeah, absolutely.

DR. CLARK:

Thanks.

DR. DAVID: Um, going along the same lines with Dr. Clark was saying, I think, you know, it's really important to continue your hobbies and make your priorities an actual priority. Have events to look forward to. Showing up for yourself allows you to show up for other people. My first couple years of medical school, it was really about, you know, just reading the books, doing the practice questions. But once you get into the clinical years, you start to learn that you may have a little bit more time. And, you know, I started listening to more podcasts, reading more books, finding time to practice meditating, not saying I'm anywhere near capable of still doing that, but, you know, trying different things and seeing what you like and what you don't really like and figuring out where to fit those into your either daily schedule or weekly schedule. Just carving out time for yourself. You are learning a lot in residency, but I think it's also important, these are really formative years, just as a person too, so you need to learn about yourself as well.

DR. SWEENEY:

Yeah, I would second that. I'm I'm a 36 year old with a wife and four kids. So my experience may be an outlier when compared to most residents. My wife is a physician assistant. She has her own busy clinical responsibilities. But I think it's important to take time to also celebrate in small ways. So too often, residency dictates our schedules, and we find it hard to attend big events and have large, pre-planned celebrations. We have to do a months in advance, but planning to bring easy takeout food to a park for a picnic with coresidents, or even getting together for hospital cafeteria ice cream in the work room, that can mark a day as important. I'm actually a really strong proponent that the CA1a after they have their first solo case, they get together with other first time soloers and they go out to celebrate that. Such an incredible achievement. I remember going to a local resident with my co resident and friend Ryan, and we were toasting to our patients surviving our inexperienced anesthesia, and thought that was fun.

DR. CADWELL:

It's actually funny. I met in our residency and our intern year, we do a month in ICU at Memorial Sloan-Kettering, and I was just toasting with a few of my co-residents like a few like a month or two ago about these patients surviving our intern knowledge skills and how to manage three pressors and A lines and all this stuff. Okay, so we all have heard the term imposter syndrome, and it's definitely real. And I think we've all experienced it in some way or another. Did you or do you struggle with the fear of failure. And do you think it fades later in residency? Or is it something you just kind of get used to and learn how to manage?

DR. SWEENEY:

Yeah, I, I would absolutely say that imposter syndrome is real. It will ebb and flow. It fades when you have a string of cases that you hit out of the park, and you'll start feeling like you belong in the operating room, and then your patient will have an intra op complication that you weren't anticipating, and you'll feel like an imposter in the room again. And especially early in the early season one specialty rotations will humble you too. Even after spending a month in the heart room and having done three liver transplants, I still feel inadequate in those rooms. Um, but I remind myself that training environment in the last, you know, three years for the anesthesia residency, uh, and I see the presence and knowledge of my attendings bringing into those rooms. And I realize, you know, as I gain knowledge and experience through residency and early practice, that that I can belong in their role.

DR. DAVID:

Yeah. Just going off of what Dr. Sweeney said, I think imposter syndrome is very real. There are some days where that voice is just a small whisper, and then there are other days where it feels like it's written in big print on your forehead. Um, you learn to redirect that voice in your head as you grow in your residency and your training. Um, we are in training for a reason. We're not supposed to know everything right away. And everything we do takes practice. And it's Repetition. It's about learning and adapting throughout the four years, which make you a better provider.

DR. CADWELL:

I appreciate all that advice. I know for me, like early on in like the first couple weeks of CA1 year, it was just really difficult kind of going from the end of intern year where you kind of have an idea of how to manage some basic medicine to not knowing what's going on again. So I really appreciate your advice.

DR. CLARK:

Yeah. I was just going to add that, you know, at the end of the day, negative thoughts may start to accumulate and may accumulate to the point where you have that imposter syndrome. But as we were saying before, it ebbs and flows throughout the years. When you become a new attending, it will come back again. And so it's just important to stay calm and support those positive emotions. Give that main character energy, if you will. When you walk in the room and know that you're there to take good care of the patient. And as long as you prioritize that every day, getting through those hard cases, reflecting on those hard cases and just being revitalized to, you know, again, be present for your patient for the next case, and the next case is really what it's all about.

DR. CADWELL:

Awesome. Thanks. So if you could go back in time and give late med school you, like, maybe like the sub I's that are all of us are probably working with a lot this summer. Or maybe the interns or CA1s some advice about surviving residency. What would it be?

DR. DAVID:

I think going back to the wellness, it's it's really okay to rest. Just because you're doing something doesn't mean you're moving forward. Um, we're all told that we need to constantly be reading and we need to be, you know, doing those practice questions and just constantly taking in information. But just because you're doing those things doesn't mean you're actually absorbing any of the information if you're burnt out. You don't want to start your training as a CA1 or even as a medical student in your sub-i already burnt out, because you're not going to gain the experience that you should be getting through all of those sub eyes or the rotations that you're doing as CA1. It's okay if you feel like you need a breather. You know you should take it. There's a reason you're feeling that way inside. Quantity does not always equate to quality.

DR. CADWELL:

Also, I really appreciate that. So going into CA1 year, I mean you're used to like all the question banks and resources that you have in medical school like your world, etc.. And now going into C one year we hear about all these new resources like True Learn Dave Miller. What are some resources that you have all discovered that have helped you really cope and manage better and really start learning anesthesia?

DR. SWEENEY:

So fortunately, in residency, there are people you know that are going through similar scenarios as you. So I kind of focus on like the coping that we all need to achieve. Um, so reach out to your peers, those people that you know that are going through it. Um, they can understand the intricacies of the scenario you are in better than anyone else, and therefore they can be better listeners.

Here in Milwaukee, we have this SOS peer support system. And in fact, one of our chief residents, Dr. Paul Otto, who's going to present at it at the annual conference this year. Gut in short, residents, attendings, techs, each role, the hospital, they have representatives that are trained to responding to poor patient outcomes. And there's a system where this network gets activated automatically when there's adverse events that happens. So within a day, someone reaches out that's at your level and that's outside of the hierarchy and can just be there to listen and help. It's a phenomenal program and highlights, you know, that our peers are really wonderful resources when we're coping and they're aware of all of our challenges.

DR. CADWELL:

Awesome. It's a really good point, and I really do lean on my peers and my co-residents a lot. And my class, especially of getting through intern year and now CA1 year, I really appreciate that. Um, does anyone have any, like, academic resources we should use to start really learning content in addition?

DR. DAVID:

There is a textbook. It is a textbook that goes through a lot of surgeries. It's by Jaffe. It gives a basic outline of what the surgery entails and the steps the surgeon takes. And then it will give you a basically an outline of the anesthetic that you could use. Obviously, there's many ways to do anesthesia, but this is a nice little guide to follow in order to help you set up your anesthetic plan. It was very useful as a CA1. I just have the PDF just saved on my desktop, and it's even helpful now that I'm doing more pediatric cases, things I'm not really used to. You know, just opening it up, looking up the keywords, and it gives me a basic outline of what I need to be doing for the next day.

DR. SWEENEY:

I would absolutely second that book. It was recommended to me early on in my CA1 time, and it really helped me develop those plans, just as Dr. David was mentioning.

DR. CLARK:

Yeah, I definitely use that textbook as well for preparation for the cases for the day. And then also the question banks are helpful to review and prep for the board exams, but then also just content, just reading through the questions answers specifically and getting a sense of what you know anesthesia is all about, especially when you're brand new to CA1 and you haven't had a lot of sub-i experience. It's really helpful as you go along in your career, and you will use that resource again for your future exams. Um, and then just seconding what Dr. Sweeney was saying in terms of coping, I think having those mentors and having good fellowship within your program and outside helps you to cope through, you know, board exams, cases, laughing about your your Pitfalls. Thinking about future cases that maybe you could do something different. Really having that support system and that fellowship helps throughout your career.

DR. CADWELL:

Awesome. Well, it sounds like I have a textbook I need to buy after we're done recording today. I appreciate all your help with that. So we have all these resources that we have access to. How do you incorporate study time into your daily schedule?

DR. SWEENEY:

I think that's a really important question, especially in early CA1. And getting back to what Dr. Clark was saying earlier, just kind of about how tired we all are at the end of the day, um, after working on this new arena. There is a bit of guilt that comes with being exhausted at home, but feeling like you should be reading or studying. I even had trouble sleeping early in CA one year, but now I know I should have given myself more grace. And there's in those first few weeks, and even maybe those first few months of CA one year, the cognitive load is already really so high. Don't worry about the textbook reading. You know, just for knowledge. You should be focusing on the patient and and like the Jaffe book, planning for that specific surgery and focusing on the actual tasks that you as a resident, need to complete. Eventually those things become more habit and they take less cognitive load. And that's when you start realizing that you aren't exhausted in the evening and you have more time for yourself. And and ultimately, that's when the discipline needs to start slowly picking up and and opening those textbooks.

DR. DAVID:

I second what Dr. Sweeney just said. I think back to when I was studying for my basic exam. All CA1s that in June. And you start your CA1 year doing your True Learn questions so you can take your in-service training exam. And then you take your in-service training exam and you say, okay, I can just relax for a little bit and then, lo and behold, it's time to start studying for your basic exam. And you do carry guilt when you go home and you're exhausted and you, you know, maybe you need to make dinner or take care of your pets or your kids or, you know, whoever's at home. But just carving out some time for yourself and then giving yourself that grace to say, you know, maybe tonight's not the night that I stay up to read this textbook. But every day that you do read up on a patient and the case and the anesthetic plan, you are studying for those exams that are coming up. It's just real life application of the things that you need to know. Because going back to medical school and your your intern year or your first two years, you're studying and you're absorbing things that are read in textbooks, but now you're applying it in real life, and that's just the rest of your career. So giving yourself that grace to say, I may not have read a textbook today, but I took care of 4 or 5 patients and they all taught me something different, should be enough to help you rest easy at night. Which is a lot to say because I know it's very difficult to do that, but it is important to just reflect on that too.

DR. CADWELL:

Awesome. Thanks so much, Dr. David. That's definitely something that I've noticed when I get home after, especially these long days or days that you're on call and you do feel that guilt about not studying or not doing a question bank? So I really appreciate that advice.

DR. DAVID:

Absolutely. And, you know, we we do live in an age where we do a lot of mindless scrolling on social media. And I, at least personally, I've seen just the growth through my training is, you know, if you have a few minutes between patients, there is always a True Learn app. Just open the app and do a few questions. And that's how you get your numbers in and the reps of questions on true learn. And that is a really you know, you think you're not absorbing it, but you you are. You learn from that too.

DR. CADWELL:

Awesome. Uh, yeah. So earlier, Dor. Sweeney, I know you were mentioning helping your co-residents cope. I know Dr. Clark also talked about this. So what do you guys think CA1s can do for each other to help you thrive in this first year?

DR. CLARK:

I think CA1s can support one another by checking in. Sometimes it's just a hey, how you doing in the hallway or do you need anything? I remember one time I was pulled from one case to another, and one of the seniors actually just got me a coffee and it made my day. And so I think similar to what Dr. Sweeney was saying in terms of just taking bite size, um, bite size of things. It's like it's just the little things that matter throughout the day. That where you can feel like you have a family by being supportive, by being there, by checking in, by scheduling ice cream or pizza, you know, on a Friday night, if everyone is off from work or, you know, it's those little things that really build, build community and can really help out your fellow classmates.

DR. DAVID:

I agree. I feel like we all spend so much time in the hospital, but it is nice to just meet up every once in a while, go get that food together, and doesn't have to be a whole ordeal every time. But just checking in here and there throughout the week, seeing how they're doing. I have a co resident who's really great about helping out in the operating room as well. If he has some downtime, he'll come in and say, hey, how can I help? If if we're inducing he's handing things over and just making things more seamless. And I think that's a really great way to help support each other. And at work, too.

DR. SWEENEY:

Yeah uh, I consider much of life a team sport. Um, so when I check in, I have a move on nights, if I'm working nights and I'm lucky enough not to be in a case, you know, starting at 5 a.m. or something like that. Uh, I look at whichever resident is setting up the biggest room, like the art room, the delivery l room. And I just go in there and help set up. Uh, just telling jokes while laying out a central line kit or preparing infusions can make that mundane task really fun. And I hope it takes a little bit of stress off their timing of the complex setup, and helps them be more successful in that case.

DR. CADWELL:

Those are all great suggestions and I really appreciate all your thoughts on that. So as you know, we're going into late summer, early fall, and for medical students, this is a really stressful time, especially those fourth years that are putting in their ERAS applications. Um, what advice would you give to these fourth year medical students that are applying about choosing a residency that supports their well-being as they go forward in these next few years?

DR. CLARK:

I cannot stress that enough, choosing a residency that really supports your well-being, I think my department does an amazing job at doing so in so many ways. Mentors, scheduled events, non-scheduled events. Um, just really getting a culture of well-being and support is really important. And it's sometimes hard as a medical student, especially when you're interviewing and trying to get a sense of what the community is like via zoom, virtually. Um, but talking to residents to sort of gauge what their experiences are like, do they hang out with one another? Do they, you know, enjoy going to the office to talk to their program director? Do they feel supported? Those are some things that you can start to ask or start to get a sense of as you navigate through this process of applications and settling in on a residency program. And I will say that residency is hard. No matter where you end up, no matter what specialty you're going into. So finding a place that you feel can support you is going to be really important. Life comes at you fast and hard sometimes, and it's not always planned or pre-planned. So really having that sense of community has really helped me personally through all of my challenges and all of my celebrations as well.

DR. CADWELL:

I couldn't agree more with you, Dr. Clark. As going into these early years of residency, people in my class and also my seniors have just been so helpful and helping wellness by, you know, offering the support and celebrating the wins as well. Like you mentioned. We we often lose sight of those as we go through these long hours of early residency. Does anyone else have any more advice for the medical students?

DR. DAVID:

Yeah. You know, it is very difficult to pick the right residency program, and obviously there's only so much we can do before the match takes over. But I also think geographic location is so important. I got very, very lucky in the fact that I, I do really love the people in my program, and we do hang out out of the operating room and out of the hospital very frequently, and I do feel supported. However, my family is all in the southwest and now my training program is in the southeast. And sometimes you do think, would it be easier if you were closer to family? Now that's going back to what I said about priorities too. Is it a priority to you or to be near family or, you know, specific people or in a specific region? I think as students, we put a lot of weight on the program and what people's opinions of programs are. But I think we need to sit back and reflect on what we want out of our training, but also the next four years of our lives too.

DR. CADWELL:

Awesome. Thank you for that, Dr. David. I couldn't agree more as well. Just choosing a residency is not as easy as it sounds. It takes a lot of work, a lot of talking to the residents, really trying to get an idea of the programs. Yeah. So like I said earlier, we've been talking about the hard parts of residency, especially those early years and things that challenge us early on, but it's not all bad. I don't know about you guys that have had a lot of really great days in residency with my co-residents, with my program. So I have a question for all of you. So what happy surprises have you found along the way in residency, and what are some things that you learned through these surprises that, beyond the clinical aspect or the clinical as well?

DR. SWEENEY:

Yeah, I was recently a senior resident to a new CA1, I guess a case really stuck out to me. We were tasked with just a straightforward incision and drainage of a essentially a painful flare up that a patient was having, and it was so painful that the patient had trouble moving her arms an inch, much less letting the surgeon assess the site. But within a few minutes of this new CA1 and I starting our work, we could position the patient for optimal surgical exposure, and the surgeons started to dive deep and explore the wound. You know, watching those surgeons and seeing that patient's hemodynamics just train track across the anesthetic record. It's extremely rewarding. The CA1 looked at me with a smile under his mask and he said, man, we have a cool job. I'm always proud to provide that opportunity for intervention toward an improved patient outcome. And while we're only a piece of the larger healthcare team, it feels good to be essential in providing that opportunity.

DR. DAVID:

I like what you said, Dr. Sweeney, about that CA1 thinking how we just have such a cool job. I have found myself saying the same exact thing to myself countless times. I think one of the coolest things is just reflecting on your own growth through all of it. It's gratifying to see how much you learn within a year, and how you're able to safely take care of a patient and improve their outcomes. And just seeing how happy they are, you know, if you're relieving their pain or just relieving their anxieties, you're helping the patient. But it is such a gratifying feeling as well.

DR. CADWELL:

These are all really great thoughts and I really appreciate it. This and everything else has really been great. Um, so one last question before we wrap up. Leave us with one word. One word that you would use to describe the first year of residency is particularly CA1 year.

DR. SWEENEY:

Camaraderie.

DR. CLARK:

Exciting.

DR. DAVID:

Whirlwind.

(SOUNDBITE OF MUSIC)

DR. CADWELL:

Well, I do agree that so far that's been there's been a lot of camaraderie, a whirlwind of information, people, and it has been exciting too. Well, thank you all again for this enlightening conversation. I really enjoyed learning from you all and I'm sure everyone listening did too. And to our listeners, don't forget to share and like residents in a room the podcast for residents by residents and join us again soon. Thank you.

VOICE OVER:

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