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PRS Resident Chronicles
Monday, February 03, 2014

by Raj Sawh-Martinez, MD

This past summer third year residents across the country began a rite of passage, and will be referred to for the first time as a “chief residents”.  The residency process is long and arduous, with one of the biggest challenges being the transition from a junior resident ‘worker-bee’ (1-3 post graduate years) to the ranks of senior resident (4-6 post graduate years).  Traditionally, interns (first year residents) man the surgical floors, second years see consults and are the front line in the intensive care units, and third years start the process of learning how to become full fledged surgeon in charge of all aspects of patient care.   

Plastic Surgery training is chock full of firsts and major landmarks.  Every surgeon will likely be able to recall the joy of matching into Plastic surgery training, their first terrifying day as a surgical intern, the gratitude of thankful patients, the sorrow of families experiencing loss, and the bonds formed with faculty and co-residents.  These memories are seared into our minds because they involve such major transitions, steep learning curves, and incredible personal sacrifice. 

In most programs, junior residents rotate through various surgical subspecialties the first 3 years of training(1).  As a third year resident rotating at one of our affiliated hospitals, I faced the challenge of becoming the senior resident on the trauma service.  For the first time I became a resident leader of the surgical team, taking responsibility for decision making as I learned from the attending surgeons.  I set the time for morning rounds, assigned case coverage, made clinical decisions for patients, learned increasingly complex procedures, taught junior residents and students, and took on the responsibility for all that happened on “my service”.

"You have instinctual responses for each issue in isolation, but are now faced with making key critical decisions simultaneously. " 

From one day to the next, your fellow residents, one or two years your junior, are asking you to make the decisions – “Which antibiotic? What pain medication regimen? May we advance their diet? Do they need an NG (nasogastric) tube?”   These are standard questions that you likely know the answers to because you know clinical guidelines, the surgical attending’s preferences and the management of daily clinical situations.  These make you feel confident about being in charge - “I can do this!” you exclaim to yourself, being lulled into a false sense of security.

It all seems to occur suddenly and nothing you’ve done before has prepared you for your next day.  A full trauma (a patient in critical condition) is paged overhead; you remind yourself you’re waiting for the completion of a CT scan on a tenuous patient in the ED; your intern is concerned about a sick patient on the floor and bursts into the OR, as you debate the exact placement of your next stitch as your attending holds suction on a bleeder.  You have instinctual responses for each issue in isolation, but are now faced with making key critical decisions simultaneously.  Employing your skills in triaging clinical situations, you have to allocate resources, manage your team and make the best decisions for the lives that may hang in the balance.  These are the tasks that make up the daily grind of your teaching faculty mentors, who guide you through every step and make it look easy.  Franzblau et al (2) outlined the keys to successful mentorship relationships, emphasizing the importance for us trainees to seek out help.  Something you become comfortable with very quickly!

As we learn how to become the “chief” of a surgical team, all our insecurities are laid bare.

As surgeons, we train in gradual, supervised experiences, handling complex and stressful situations that are part and parcel of our training.  We climb the developmental ladder from unconscious incompetence, attempting to achieve unconscious competence that enables master surgeons to handle adverse events and manage new complexities(3).  We all come to these situations and experiences with our individual set of strength and weaknesses, and grow from them, becoming professionals to whom our fellow human beings entrust their lives. 

Although we all become capable, there is a distribution of excellence.  This bell-curve of achievement affects us all, and even varies day-to-day for each us.  That is the necessary price of education.  As we learn how to become the “chief” of a surgical team, all our insecurities are laid bare.  We are all the more aware of the gaps in our knowledge and ability in dealing with complex clinical decisions, surgical skill, team management, and conflict resolution – a profoundly humbling experience. 

The transition from junior resident to senior resident, from 2nd year to 3rd, is said to be one of the most challenging.  We finally start to see the tip of the iceberg that encompasses the talent and exceptionalism that our surgical leaders exhibit.  Our insecurities and failings drive our work ethic, passion, and desire to achieve in order to offer solutions to those in need.  They fuel our need to read and stay abreast of achievements by leaders in surgery throughout the world, on display through PRS and PRS GO. 

In future posts, we’ll explore tips and stories from plastic surgery leaders on their educational journeys, and lessons learned from their experiences undergoing these transitions.  Dr. Rohrich’s May article on ‘High-Performance Teamwork’ gives us a great start on the discussion and pearls to achieve excellence in leadership(4). 

Below you’ll find links to incredible stories of leadership under fire as PRS remembered JFK’s legacy and his untimely assassination in the November issue(5).  You’ll also find references to key articles exploring leadership in plastic surgery(6).

References:

1. The Education of a Resident  Noone, R. Barrett   Plastic & Reconstructive Surgery. 132():4S-8S, July 2013.

2. Mentorship: Concepts and Application to Plastic Surgery Training Programs.  Franzblau, Lauren E.; Kotsis, Sandra V.; Chung, Kevin C.  Plastic & Reconstructive Surgery. 131(5):837e-843e, May 2013.

3. Climbing the Ladder from Novice to Expert Plastic Surgeon.  Weber, Robert A.; Aretz, H. Thomas.  Plastic & Reconstructive Surgery. 130(1):241-247, July 2012.

4. So, How Do You Do High-Performance Teamwork?  Rohrich, Rod J.   Plastic & Reconstructive Surgery. 131(5):1203-1204, May 2013.

5. The Assassination of JFK: A Plastic Surgery Perspective 50 Years Later. Rohrich, Rod J.; Weinstein, Aaron; Stokes, Mike  Plastic & Reconstructive Surgery. 132(5):1373-1376, November 2013

6. A Day in the Life.  Rohrich, Rod J.  Plastic & Reconstructive Surgery. 131(6):1437-1438, June 2013


Friday, January 24, 2014
by Andre Alcon
 
Op•por•tu•ni•ty (ä-pər-ˈtü-nə-tē):
1. A favorable juncture of circumstances
2. A good chance for advancement or progress

Students pursuing a career in plastic surgery have a long checklist to complete before going on to residency. Though we don’t like to think of our lives as a lengthy list of accomplishments and accolades, it’s easy to get lost in the numbers of it all. Sometimes we push ourselves so hard that we miss taking advantage of those inconspicuous, everyday opportunities that can shape our future in profound, unforeseen ways.

For instance, several months ago I was at a PRS conference grabbing lunch when a colleague approached me to go to the beach for the afternoon. I was hesitant to miss the afternoon lectures, but decided to go anyway. An hour later, I was surfing with a couple of down-to-earth, fun guys I had met just twenty minutes ago. I quickly discovered that they were PRS residents from a program I’ll be rotating with during my sub-I’s next year. Pretty lucky, right? I never planned on going to the beach that day or meeting PRS residents along the way, yet experiences like these could have a significant impact on my future.
 
As I thought about similar experiences I’ve had in the past, I realized that serendipity has played a much larger role in my life than I gave it credit for. Interestingly, these seemingly random, sometimes non-academic experiences have been just as important to my career as the ones I’ve worked for months or years to attain. Thus, I thought it might be worthwhile to share some of my thoughts on opportunity. Was I just lucky or is there something I’ve been doing to help bring about these “favorable junctures of circumstances?”
 
I wrestled with this concept for weeks as I tried to put into words something meaningful about opportunity. My friends and I sat around the dinner table discussing the elements of opportunities and how they come to be. Maybe it’s attitude. As I’ve matured, I’ve learned to be more comfortable in unfamiliar situations and as a result I’ve been able to take advantage of some incredible opportunities that years ago would never have happened because I was too shy to pursue them. Could it be curiosity and a passion for life? My eclectic array of interests-athletics, cooking, traveling, art, history, and many others-has enabled me to form more substantial relationships with those around me. In turn, these people have become my friends and mentors who have provided me with more opportunities than I could have ever imagined. 
 
Ultimately, we came to the conclusion that although there is no universal algorithm or formula for creating and recognizing opportunities, we must remember the value of continuing to do the other things we love in life. We all have interests and hobbies that we with we could devote more time to, but with the demands of being a medical student, we often have to put them on the back burner. However, I’ve found that when I have taken the time to pursue some of these interests, ironically, they’ve opened up a number of doors for me that have had a substantial impact on my career trajectory. One day, that trip you take to Italy could be the nidus of an incredible relationship with a mentor and future colleague. Or your passion for cooking could turn into a long dinner conversation with the department chief who also happens to share an appreciation for the culinary arts. It’s happened to me.  Plastic surgery demands a lot and we have no regrets about the sacrifices we make to get to there, but don’t forget to set aside your checklist from time to time to appreciate other things in life. You might be surprised by what happens next.
 
 

Tuesday, January 21, 2014
by Justin Perez
 
Interview season is in full swing. Along with the excitement of checking your phone for ERAS invites comes the stressful thought of, “how am I going to get through this?” For what it's worth, I’d like to share some of the challenges of this process (and ways to circumvent those challenges) to ease the burden of this potentially hectic and expensive time of year.  
 
Set a budget:
Once your ERAS is in, set a travel budget. Going to interviews is costly, but fortunately the financial aid office at my home institution offers loans to cover interview expenses. I had to confront the projected cost of interviewing early on (and I’m glad I did!) by providing my financial aid office with a well-outlined affidavit of my projected costs.  For those of you applying next year, meet with your financial aid adviser and educate yourself regarding your school's protocol for funding “the trail.”  Might not be the most fun conversation you've had all year, but better to face these financial facts sooner than later. Be aware that as a plastic surgery applicant, your ERAS and interview travel will likely cost more compared to your peers— this is normal, so don’t panic!

That said, there are many ways to pinch pennies.
 
Keeping Down Costs:
Book flights early! Tickets will be cheaper and you’ll ensure their availability. Some interviews will be back to back, and depending on the region of the country you’re in, there may only be one precious flight that can get you to the next city in time for your interview. Chances are you’re not the only one trying to make it to those two interviews, so secure that seat early. Also, be aware that airlines offering cheaper airfare may have pricier cancellation policies and hidden carry-on baggage fees, so look into this before booking.

Choose your hotel wisely.  You’ll be tempted to “name your price” for a less expensive hotel that is further away.  This is not always worth it. By the time you factor in additional cab rides to and from social events/interviews, you may end up spending close to the amount you would have for the closer hotel anyway. The hotel recommended by the residency program is often the safest bet. These hotels are close to the hospital and typically offer a negotiated rate. Plus, you’ll be wiped out from traveling all day, so a bed that’s only steps away from the social event is clutch when all you want is to catch some Z’s and be sharp for the next day’s interview.
Make friends on the trail! One of the best parts of this process is meeting your future colleagues, and you’ll definitely bond over the stresses and joys of the interview trail. Plus, you can share hotel rooms, cabs, Uber rides, late night pizzas, and interview stories with one another.  If you happen to have a rental car, ask around to see if anyone else needs a ride to the airport and help out your fellow applicant. Don’t accept their ”money for gas,” but instead ask that they pay it forward to the next applicant who needs a lift!
                                                                     
Make Yourself Portable:
The airport will become your second home, so make yourself as travel friendly as possible. The PRS and PRS Go apps are great ways to stay current on the literature and save some room in your messenger bag. I’d advise that you get an external battery to re-charge your dying phone on-the-go; they’re inexpensive and compact! Consider downloading airline apps to avoid check-in lines. You can check-in from your cab on the way to the airport and pull up a digital boarding pass for a more stress-free departure. Take cell phone photos of all important documents (i.e. baggage claim tickets, car/hotel confirmations, interview schedules, etc.) to have a second copy in the event that you lose them or the internet bails on you. Lastly, try the TripIt® App; it condenses all your travel itineraries into one.
 
Traveling with the Appropriate Attire:
Garment bags that convert into duffle or roll-on bags are a great addition to your travel repertoire, allowing your suit to stay relatively wrinkle-free without having to carry a million separate pieces of luggage. Gentlemen, keep a spare tie handy on interview day. A coffee streak running down your tie isn’t a good look, but a quick step into the bathroom for a fast change can be a life saver.  Seek out one-hour dry cleaning in cities where it’s available, and don’t forget to pack a sewing kit for those loose/missing buttons!
 
Follow the Sub-I:
Sub-I's can be a great resource on interview day. Not only will they know their way around the institution and public transportation, but they can give you the scoop on program details that didn’t necessarily make it onto that residency overview PowerPoint. Many sub-I’s will freely give out their cell phone numbers in the event that you have questions later on. Seize that opportunity.

Meet as Many Residents as Possible:
Attending the pre-interview social not only demonstrates interest in a program, but also gives you the opportunity to see the residents in a more laid back setting. Bear in mind that this whole process (even having a few drinks with the residents) is an interview, but try not to be intimidated by this fact. It gives you the opportunity to get to know a program’s personality, show them YOUR personality, and gather honest opinions from the house staff. Plus, networking with residents may lead to cross-institutional collaboration down the line (stay tuned for co-authored blog post by Anup Patel and myself!).  Remember, all of the residents were in our shoes not too long ago and are more than willing to help you hash out your thoughts and feelings between interviews and match day.
 
Most importantly, BE YOURSELF and enjoy the journey! Come March we’ll all appreciate the memories, lifelong friends, and challenges “The Trail” brought us.

 

Thursday, January 16, 2014

by Anup Patel, MD, MBA, and Ajul Shah, MD

During my time at the University of Florida, I took a summer job teaching economics to the Gator football and basketball players. Besides the pay, the experience also proved to be a fun-filled time solving real-life business problems by applying microeconomics as well as developing great friendships. Jeremy Mincey, a defensive end for the Denver Broncos, was impressive not only because he guaranteed that he would make the NFL during his junior year, but also spoke passionately about becoming an entrepreneur by developing his own production company. He has done both. His production company, Mr. Mince Production, has launched several top-selling albums, and on Sunday he will line up against Tom Brady and the New England Patriots.

With Sportscenter flashing highlights in the background, Ajul and I this past Monday were reviewing the cases for the next day. On the screen, Jeremy swam past the offensive lineman and tackled Philip Rivers, recording his first sack of the day. Although his play sparked the Broncos defense, Ajul noticed that as the highlight ran, Jeremy’s finger flexed as he grabbed the quarterback’s jersey. Immediately (and shamefully as he considered how nerdy it sounds), Ajul’s thoughts moved to the possibility of a flexor tendon rupture, as he was conditioned to think when thinking of flexion against forced hyperextension.  He then asked me: “The NFL players have trainers on the field. But how do you think NFL players select a hand surgeon outside of what happens during the game?”

The question immediately led back to Jeremy. We had an opportunity to sit down with him and discuss aspects of football and hand surgery. Admittedly, this is one player’s viewpoint, but we hope to have a publication on this important topic from a group of NFL players in the near future. The following consists of our conversation with him and his responses to a series of questions we asked.

Jeremy began by telling us that he was very surprised to find himself playing for the AFC Championship game this Sunday. He had been praying for the possibility to hoist the Vince Lombardi trophy in New York City, but could not believe the moment was so close at hand. When we asked him who was the best quarterback he has played against, he said,” I have to go with my main man and captain of our team Peyton. I still remember when he lit us up when I was playing for the Jaguars.”

We then spoke about our interest in hand surgery and possibly writing a manuscript on how NFL players seek out opinions for hand injuries. Remembering the moment that Jeremy almost sustained a “jersey” finger injury, we asked for his thoughts on finding a hand surgeon. Immediately, Jeremy stated, “nearly all of my injuries in the NFL have been hand-related.”



He went on to tell us that he has sustained right metacarpal fracture of his ring finger that was treated with closed reduction, a right scaphoid fracture that was treated with casting, and a left capitate fracture that required surgical intervention. When seeking out surgical opinions, he sits down with his agents and the closest of his NFL friends to see whom they have visited for a particular injury. Once he has a few names, he himself investigates the surgeons thoroughly. He learns their educational background, including where they trained, their feedback from other players, and their research on that particular injury. He finds that most players want a surgeon who will be there for them as this is “crucial for the healing process.”

Because of his background as a Florida Gator and his current starting spot on the Denver Broncos, our conversation ended with the inevitable “Tim Tebow” question. We asked Jeremy what advice Tim had given him for Sunday’s grudge match against the Patriots. Jeremy made it clear: he is a huge Tebow fan and that “he (Tim) owes me a phone call, especially since we are part of the Gator nation.”

We completed the conversation by telling Jeremy we were rooting for him to flash the bling that comes with the Super Bowl Ring, and we were excited to work with him on a possible Plastic and Reconstructive Surgery manuscript. Stay tuned for this paper and if Jeremy, Peyton, and the Broncos will be visiting the Meadowlands for Superbowl XLVIII.


Wednesday, January 15, 2014
by Jacob Unger, MD
 
The holiday season is upon us and with it comes a time for reflection, for family, and for giving thanks.  This thanksgiving I was lucky enough to get to spend some time with my extended family and refocus on those important aspects of life as well as spend some time contemplating my future.
 
I was surprised at my own
nerves for my first case
 
When I look back on the past 5 months of training it is easy to see the progression in both thought and technique that have occurred.  It seems like just yesterday that I was writing about the anxiety and excitement of starting my 5th year of training with the all-consuming role of Chief of the Parkland plastic surgery service. Yet, here I stand, now with multiple chief rotations under-my-belt, and starting to think about fellowship opportunities and even possible first jobs. While I may be able to see how I have progressed over these last few months, the opportunities for improvement are always present as well showing me how far I have yet to go.
 
Recently, I was able to perform my first case that I booked through our Chief Resident Aesthetic Clinic.  This is a wonderful opportunity where the 5th and 6th year integrated residents (and 2nd and 3rd year independent residents) are allowed to see cosmetic patients solo in the faculty clinic space and create operative plans based on these patients’ desires.  We then present our plans to faculty, find an OR date that is mutually agreeable and perform said surgery, with continued follow up in our individual clinics. I was surprised at my own nerves for my first case. While it was a procedure I had been a part of and even performed numerous times, the fact that this patient had chosen to trust me with her surgical goals and had given me the honor of determining and carrying out the best plan in my opinion was both humbling and exhilarating!
 
But, it is moments like these that allow you to both realize how much you have learned, as well as how much more there is to discover
 
Fortunately, the procedure went well and the patient is pleased with her result. But, it is moments like these that allow you to both realize how much you have learned, as well as how much more there is to discover. You quickly see how much more efficiency there is to achieve, and how elegance does not come as easily as it seems when watching the masters that surround me in my training program.
 
As I reflect on the past year I realize how lucky I am. I am thankful for my family, for my training, and for my future. The hard work that all of us as physicians put in to our education, our training, and our patients has a clearer light at the end of the tunnel as we get closer and closer to reaching the end. While I have more training ahead of me, I am thankful as well for the future opportunities to learn and improve my craft before the day comes that I am truly ultimately responsible, with no sage advisor over my shoulder.
 
This thanksgiving I am just so thankful; Thankful for those who educate me, those who support me, and those who love me. I can only hope to be as inspirational to my family and to future generations of plastic surgeons as my mentors have been to me.
About the Blog

Plastic and Reconstructive Surgery

PRS Resident Chronicles” is the official Resident blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit this blog to follow the unique journeys of several young doctors as they go through residency in their respective Plastic Surgery Programs across the country.

We want to hear from Plastic Surgery Residents across the globe as well: how do you use PRS in your residency? What are some of the challenges you’ve faced and successes you’ve had? Join the on-going conversation by commenting, and if you think you have a potentially interesting-enough entry to be a unique blog post, email us at prs@plasticsurgery.org.

Bookmark the “PRS Resident Chronicles,” subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your journal; have fun, be respectful, get engaged and interact with the PRS community.

Keep in mind that the views and recommendations presented in this blog do not necessarily indicate official endorsements or opinions of the Publisher, PRS, or the ASPS. All views are those of the authors and the authors alone.

Rod J Rohrich, MD
Editor-in-Chief

Contributors

Andre Alcon is a fourth-year medical student at Yale University where he is starting a one year research fellowship in tissue engineering with the department of plastic and reconstructive surgery.

Ashley Amalfi is currently a fifth year Plastic Surgery Resident at Southern Illinois University School of Medicine. She attended the George Washington University and received dual degrees in Fine Arts and Art History. She returned home to attend The University of Rochester School of Medicine and Dentistry in Rochester, NY. Ashley met her husband, a urologist, during her training at SIU. She enjoys yoga, reading, travel and cooking in her free time.

Jordan Ireton is in her first of six years at the University of Texas Southwestern Plastic Surgery residency program.

 

 Anup Patel, MD, MBA, is a resident in the Yale Plastic and Reconstructive Surgery Program. He co-founded Cents of Relief, a 501(c)3 nonprofit, that empowers victims of human trafficking through health and educational initiatives including those related to reconstructive surgery. Along those lines, he has interest in surgical burden of disease and healthcare policy. He has been selected to serve on the American Society of Plastic Surgeons Board of Directors as resident representative.

 

Justin Perez is a fourth-year medical student at Weill Cornell Medical College. Born and raised in Reading, Pennsylvania, Justin moved to New York City to attend Fordham University, where he graduated summa cum laude with degrees in Biology and Spanish Literature. His academic interests include tissue engineering and wound healing, the topics of his current research. His hobbies include theater and biking.

 

Raj Sawh-Martinez, MD is a current resident at the Yale Plastic and Reconstructive Surgery program.  He grew up in Yonkers, NY and completed his undergraduate work in Neural Science at New York University.  He graduated from the Yale School of Medicine in 2011.

Ajul Shah, MD is a graduate of University of Texas Southwestern Medical School and is now a resident in his second of six years at the Yale Plastic Surgery residency program.

Jacob Unger, MD was raised in New Jersey on the shore. He attended Tulane University for his undergraduate work where he rowed on the Tulane Crew Team and majored in Philosophy. He graduated Phi Beta Kappa, Summa cum Laude with honors and then attended New York University School of Medicine. When not working, he enjoys traveling with his wife, surfing, and skiing.

Former Resident Chronicle contributors

Eamon O’Reilly, MD LCDR USN is an active duty US Navy full-time outservice resident in his second of three years at the University of Texas Southwestern Plastic Surgery residency program in Dallas, TX.