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PRS Resident Chronicles
Monday, February 03, 2014
Trauma "Chief"

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

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.