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).
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