“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Tuesday, February 20, 2007

You are not in training be a resident ...

"Wisdom is not a product of schooling but of the lifelong attempt to acquire it."
~Albert Einstein

In my residency, we had an attending that was particularly hard on the younger residents. He was of the old guard. He was a yeller and a thrower. He struck fear in most of the residents and hatred in others. He was my mentor. My respect for him and understanding of his method developed over time and with some frustration. What I learned from him is that residents need to be pushed a little and encouraged in their development. Not that I agree with his tactics, but I do understand and fear can be a great motivator.

When I was a 3rd year (PGY-4) orthopaedic resident, for 2 weeks I was the acting chief of the service while the chief was on vacation. I still had the fear in me from when I had being yelled at, as a lower level resident, for not placing a spica cast on correctly, or couldn't get the locking cap on the CD instrumentation. He comes to the scrub sink as I scrub for a spine case and he asks me, "When do you start thinking?" I said to him, "I am not sure." I mean what else do you say to that. "I think all day and night, I worry about you yelling at me in front of the nurses and saying how I have no operative skill." In my mind, I am thinking, "When am I not thinking?" As I talked to him more, I began to understand his motives. I began to understand his question. What he wanted to know was, "when do begin to think like an orthopaedic surgeon? When do you stop thinking like a resident, and start treating patients as if you are treating them? When do you develop the skill of evaluating the patient, reviewing the studies, and come up with an exact plan for treatment?" My mentor's way of helping you to develop the necessary skills was to prevent you from making the mistake, mostly by fear. He described it as, "if every time you come around a corner you see a tiger, you stop going around that corner." I disagree with teaching by fear, but I understand its effectiveness.

In July, we will have a new batch of residents. They will come in bright eyed and eager to learn. They will begin their internship with fear of making a mistake. The first call night will be filled with doubt and insecurity. They will aspire to be better, to treat patients well, and to be good physicians. They will complete their internship and make their way to their intended specialties. Ours is orthopaedics, the best of course and most important of all. They will look to their peers and attendings and aspire to be more like or less like them, depending on their experience. Your ultimate goal in coming into orthopaedic residency is to become an orthopaedic surgeon. So why do so many residents act as if they will always be a resident?

Although my mentor taught by fear, he did not discriminate. He treated you according to your year. As a 1st year (PGY-2) orthopaedic year, he was relatively lenient on you. You did the floor work and simple cases. You didn't know enough to be dangerous. It was the 2nd year (PGY-3) that he gave the hardest time. He felt they were a problem. They had enough orthopaedic knowledge to treat most basic things and not enough to know when they were over their head. So, it was that resident that was his "whipping boy." Nothing could be done right. It was a hard year. My ego took a big beating. As a 3rd year (PGY-4), he started to ask you what you thought. What was your plan? And as a 4th year (PGY-5), he treated you more as a peer. He allowed your input in developing a treatment plan and follow-up care, with some guidance. This helps you to develop you thought process. As you developed more skill, he allowed you more freedom.

Today, I still remember that day and they impact that it made on my perception of my own resident education. So to this day, when a resident calls me or presents a patient in clinic, I ask, "so what is the impression and plan?" What I am looking for is a thought process, any thought process. It is better to have a wrong thought than no thought. That is why I am here, to correct that wrong thought. So, when you are speaking with your fellow residents about a case or discussing it with your attending, ask yourself, how are you thinking?

“The greatest barrier to success is the fear of failure.”
~Sven Goran Eriksson

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