WTS Medical Student Perspective

In this section, we proudly feature articles and contributions written by medical students interested in thoracic surgery.   Any students interested in contributing to this featured section of the WTS website, please inquire via email to mbantonoff@mdanderson.org.


Dispelling the Myths: What I learned from the 2017 STS Conference
Brienne Ryan, MS2

Brienne Ryan, MS2

As a 2017 WTS Scholarship recipient, I was granted attendance to the 2017 STS conference in Houston, Texas. Whether chatting casually with fellow medical students or listening to questions posed at the formal resident’s luncheon, it became evident that students considering a career in CT surgery share some common apprehensions. Below I discuss some of the common concerns expressed by my peers and what I learned in reference to these concerns from speaking with attendings and residents as well as listening to presentations.

Fear # 1: The field is dying

If you are interested in CT surgery, you have probably been told at some point that it is a ‘dying field’. First and foremost, the field of cardiothoracic surgery is extensive. When I am told CT surgery is dying, I have to remind people that the thoracic cavity contains more than the heart. Cardiothoracic surgery treats a myriad of pathologies including lung cancer, esophageal cancer, congenital defects of the heart, trachea, esophagus, etc. I have witnessed procedures for esophageal diverticulum, rib fractures, chest wall resections, achalasia, mediastinal cysts, aortic dissections and so much more. As a medical student, I am continually amazed as I learn more about the breadth of the field. It is true that the volume of specific cardiac procedures such as CABG have declined and several interventional procedures are used more frequently. However, the use of interventional procedures does not automatically negate the job of CT surgeons. For example, during the conference, Dr. Joseph Bavaria (2016-2017 STS President) presented a recent STS study showing that among those surgeons with TAVR programs at their hospitals, 77.5% perform TAVR procedures as part of the heart team, and 83.7% of cardiothoracic surgeons jointly shared responsibility with cardiologist for TAVR referrals (1). Additionally, cardiovascular disease will remain the leading cause of mortality and morbidity for the elderly, an age group whose population in 2050 was projected to double, according to the 2010 government census population estimates. Most importantly, as of 2014, the median age of active US thoracic surgeons was 54 years, with 29.1% of surgeons aged 60 or older (2). The number of newly trained CT surgeons will fail to match the pace at which older surgeons are retiring, leading to a failure of the CT surgeon supply to meet the future demands of the expanding and aging US population. Evidence points to the fact that cardiothoracic surgery is an innovative and thriving field, which will have continued demand in the future.

Fear # 2: CT surgery has a horrible work-life balance:

It is no secret that CT surgery is a demanding specialty that requires a lengthy training process. On par with other surgical specialties, residents can expect to work 80+ hours per week, with long shifts, brutal call schedules and little sleep. However, it is important to remember that training is temporary. Once an attending, I learned that the balance between personal life and work can be obtained albeit it may require some adjustment. One of the most interesting pieces of advice I gained was during the mentor-mentee dinner. It was a large group, consisting of several female thoracic surgeons and a mix of medical students and residents. When the question of work-life balance came up, one of the surgeons shared a unique perspective. Instead of calling it a work-life-balance, she referred to it as “work-life integration”. She would occasionally take her kids rounding with her to meet her patients and by doing so, her children were better able to understand the importance of her job, thus being more accepting in those moments when she could not be there. Coincidently, that same night, it was one of her children’s birthdays. She had planned around the conference and they had celebrated at an earlier date. However, despite the previous celebration, she was adamant that she be home before midnight to ensure that she could wish her child a real “happy birthday”. It may be less of a balance and more about integrating the relationships and priorities.

Balance between work and life does not always mean balancing work and motherhood, and I think it is important to add this in. Often when the topic is broached, it veers to the subject of children when in reality, not every female surgeon aspires to have both. So to those who have reservations of work-life balance that have no relation to motherhood, I will add that several surgeons discussed having hobbies outside of medicine. One surgeon mentioned raising chickens, another talked about her most recent trip to Asia and another, about their passion for boating. Whatever work-life balance means to you, it appears to be attainable while being a successful CT surgeon.

Fear # 3: I will be the only woman training in my program

To quote a current integrated resident, “get used to being in the boy’s club”. That might very well be true but the number of women is increasing in the field by the day! One of my favorite moments at the conference was attending the WTS reception and having the opportunity to converse with so many driven women working towards their goal of becoming thoracic surgeons. According to an article written by Mara Antonoff et al., the first females (3) were board certified in 1961. By 1980, the number had increased to 10. Over time, it has continued to grow with the number of women board certified in thoracic surgery exceeding 270, as of 2015. According to the AAMC’s most recent Report of Residents, women make up over 24% of the total active residents in the integrated thoracic programs. As Dr. Antonoff et al. stated, the presence of women in the field is stronger than ever. Although it is true that you may be the only female in your particular training program, it shouldn’t be a fear. Be ready to channel your inner Nina Starr Braunwald.

Attending the STS conference provided an invaluable experience to learn about the field and gain a more accurate insight into the future of CT surgery. I am thankful to WTS for giving me the opportunity to further explore my future specialty.

References

  1. Bavaria JE, Prager RL, Naunheim KS, Allen MS, Higgins RSD, Thourani VH, MacGillivray TE, Boden N, Sabik JF III, on Behalf of the STS Executive Committee, Surgeon Involvement in Transcatheter Aortic Valve Replacement in the United States: A 2016 Society of Thoracic Surgeons Survey, The Annals of Thoracic Surgery (2017), doi:10.1016/j.athoracsur.2017.03.055.
  1. Ikonomidis JS. The Society of Thoracic Surgeons Thoracic Surgery Practice and Access Task Force: 2014 Workforce Report. The Annals of Thoracic Surgery. 2016;102:2118-2125.
  2. Antonoff MB, David EA, Donington JS, et al. Women in Thoracic Surgery: 30 Years of History.Ann Thorac Surg 2016;101:399-409. 10.1016/j.athoracsur.2015.11.014
 

The Challenges: Married and Motivated in Med School, by Brienne Ryan
Brienne Ryan, MS2, Jacobs School of Medicine (SUNY Buffalo)

Brienne Ryan, MS2, Jacobs School of Medicine (SUNY Buffalo)

My interest in cardiothoracic surgery began after attending a cardiovascular health seminar at UB School of Medicine, coincidently my future medical school. The seminar engendered a fascination with the anatomy of the thoracic cavity and the various ailments that can impede its function. After finishing the month-long seminar, my aunt gave me a small key chain – it was a beautiful crystal display with a three-dimensional laser image of the heart inside. Nearly a decade later, that small heart remains on my desk, a simple reminder of my goals. As I continued in my academic career, I flirted with new interests. After all, whenever I would mention cardiothoracic surgery to someone I would be told how it is a dying field, with a long and demanding residency (Didn’t I want a family or kids?). Despite these dissuading opinions, my interest did not waver. James S. Forrester, M.D, author of The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives, put it beautifully when he wrote, “Complex in structure yet simple in function, yet so perfect in performance, the heart is truly Nature’s engineering masterpiece”. I felt a kinship with the heart and its incessant persistence. And so, my romance with the thoracic cavity continued, growing more ardent the deeper I delved into the field. As a second year medical student, it finally feels as if my aspiration of becoming a cardiothoracic surgeon is coming into fruition – but this is not without challenges. As a married female medical student interested in a demanding, male-dominated specialty, I thought it would be constructive to discuss some of the challenges I’ve faced on my path towards this goal and provide insight into how these challenges can prove advantageous.

One such challenge that my husband and I faced arose when I was accepted to a summer research program out of state. It was an invaluable opportunity to spend an entire summer on the thoracic service, at an institution with a rich history in both cardiac and thoracic surgery. It was difficult and financially straining to spend more than two months apart in separate states, but was the most rewarding and educational experience I have ever had. For those weeks, I was immersed in thoracic surgery, going on rounds, scrubbing into cases, attending weekly conferences and getting to converse with leaders in the field. I woke up at 5:30 am to get to the hospital for 6:30 rounds, and sometimes scrubbed in for most of the day, squeezing in meals and bathroom breaks during the turnover time between procedures. Nothing could be better. Although days typically lasted 12+ hours, I was constantly energized because I was doing something I loved each and every day. I discovered the complexity and versatility of thoracic procedures, igniting a new interest beyond cardiac. One of the most important lessons I learned over that summer was to say yes! If someone asks you to do something you have never done – do not hesitate, just say YES! You may have an embarrassing moment or fumble on your first attempt, but each new endeavor is a learning experience and an opportunity to gain new skills. Because I was enthusiastic and eager, I was granted the opportunity to do things reserved for third or fourth year medical students. My inexperience was overshadowed by my willingness to learn and improve. However, with the joy and excitement of this new experience also came a bit of guilt.

Feeling like you may not be a good partner is something many females who choose demanding specialties will experience. It was my first real taste of this and at times, it was hard. On week days, we barely spoke. I would leave the hospital at 6:30 or 7 pm (later on some days), and would need to spend the evenings prepping for the next day’s cases or working on my research project. We would have short conversations as I stood on the subway platform, almost always less than 5 minutes and disrupted by the loud rambling of the approaching train. Conversations later in the evenings were underwhelming as I was normally exhausted and barely contributing to the discussion. The second important lesson I’ve learned from trying to balance marriage with career ambitions is that my choice of profession will probably not allow me to be a traditional wife, but that does not negate my ability to be a good one. Comparing oneself against the “traditional” or societal constructs of marriage can illicit feelings of underachievement or negligence. I’ve been asked numerous times if my husband is okay with my choice of specialty. While unintended, this question, in and of itself, can be discouraging to prospective female applicants because it insinuates existence of a reason for a spouse to reject your choice, such that it necessitates spousal approval. I can honestly attest that none of my female peers aspiring to be pediatricians or family physicians have been asked this. And although I do not particularly like that question, I understand why it is so frequently posed. Surgical careers, especially cardiothoracic, are demanding and time-consuming. I can relate to the strain it can have on relationships and I have yet to even enter the most challenging parts of my training. However, this should not dissuade females from entering the specialty. During that summer, a current thoracic surgeon and WTS member was kind enough to meet with me and discuss her experience in the field. She acknowledged that it requires quite a bit of planning and prioritizing, but it is more than possible to be a wife, and parent, and successful surgeon. Even so, it is vital to remember that despite the pressures you may feel, none of these roles are obligatory. You, alone, know what you are capable of and decide for yourself what constitutes a fulfilling life.

And therein lies the third and most important lesson I’ve learned from these challenges; accept who you are. I am a workhorse and I thrive in environments that challenge me. Twelve hour days seemed too short when I was spending each and every day in the OR. I could not imagine having a career other than surgery because what little I’ve experienced has impacted me in a way no other specialty has. I truly believe I was built to do it and in acknowledging that, it makes the challenges of balancing marriage and future career worth it. So the most important advice I would give to female medical students is to try – do not avoid a specialty just because you hear of a horrible lifestyle or grueling residency. You may just miss out on your calling as a result.

 

 


“See one, do one, teach one”: a timeless recipe for success, by Jackie Olive;  
Jackie is a senior undergraduate student at Rice University, where she is studying Biological Sciences and Policy Studies. She will be attending Baylor College of Medicine in Fall 2017 and is interested in a career in cardiothoracic surgery. Jackie hopes to keep writing throughout her life, and she currently blogs at jackiekolive.com

Jackie is a senior undergraduate student at Rice University, where she is studying Biological Sciences and Policy Studies. She will be attending Baylor College of Medicine in Fall 2017 and is interested in a career in cardiothoracic surgery. Jackie hopes to keep writing throughout her life, and she currently blogs at jackiekolive.com

 
I am always on a quest to be helpful. For this reason, a life in medicine has always made perfect sense to me. Since elementary school, I’ve dreamed of a future that would hold opportunity after opportunity for me to help other people become healthier and happier. As I’ve now shared in some of the triumphs and defeats that characterize work in the medical profession, I also hope to help others become even just a bit more grateful for good health. It is our universal blessing, and too often an overlooked privilege.I believe that my early interests in surgery were truly cemented in high school. For many years, I performed music for therapy in an Alzheimer’s assisted living facility in Pasadena, CA. It was almost unbelievable to help these individuals reconnect with their memories and surroundings through the music I sang and played. But I left each day frustrated and aching, knowing that these cognitive revivals were only temporary. I wanted my hands to be capable of more! It was around this time that I knew I had to become a surgeon.When I came to Rice, I only vaguely knew of Houston’s cardiothoracic legends. I remember walking through the DeBakey Museum and later the Texas Heart Institute one day as a freshman. I listened to my own heart beat furiously yet still felt a strange sense of belonging. I hope to work with them one day, I thought to myself. I didn’t expect that this day would come sooner rather than later.Thanks to a lot of persistence and even more generosity on their end, I have many mentors who undoubtedly serve as my best resource. Without them, I would be nowhere. I cannot insist enough that mentorship is the recipe for success and is of utmost importance in the field of surgery. We must rely on each other for support when the demands of surgical training make us feel as though we cannot go on. Surgery is perhaps the most traditional of medical specialties, relying on hierarchy and deference to help sustain its culture of rigor and prestige. And most importantly, the nature of the work that we perform on the operating table, for our patients, requires us to be humble and to seek the guidance of others with more experience and wisdom. My first piece of advice is to seek out mentors often and to treat everyone as a potential mentor. In medicine, I have found that you can and will never know enough.My first ever mentor in cardiothoracic surgery used to buy me breakfast after rounds at a small private hospital in the San Gabriel Valley back at home. He personally wrapped me up in sterile garb before operations and laughed when I ended up looking like one of the burritos we had just eaten.My first mentor in Houston, with whom I still work, always pushes me to be excellent. Our lab studies a novel method of cardiac regeneration, and it is through this research that I have been able to test my hand at surgeries in murine models. It is riveting to navigate the miniature anatomy with my scalpel, and ultimately gratifying to successfully complete these procedures. There is no room for error in scientific endeavor, and certainly none when human lives are at stake. I fondly remember as he walked around his office during the second time we met, showing me photos of his surgical mentors. Then he sat back down at the table from where I was watching him intently, and told me “you’re going to be excellent, Jackie.” I don’t expect anything less from myself.This past summer, I interacted closely with several of my current mentors as they met with and operated on patients. I fully immersed myself as part of two surgical teams at Baylor St. Luke’s, and by the second day on the services, immediately departed from the notion that surgery was glamorous. The activity itself certainly was collaborative and very much rewarding when our teamwork saved lives. But being present at the start of rounds, through six to ten hour surgeries, to post-op visits was exhausting. I had romanticized a career in the field without accounting for just how much time and energy it would take to develop it. Three times I slept in my car instead of going home. Once I remained scrubbed for 11 hours of an “elephant trunk” operation, finally stepping out of the OR and at that moment realizing my bladder was about to burst. Another time I naively felt relieved as an overwhelming calm pervaded the trauma bay minutes into the team’s assessment of a boy my age who was brought in after a gun fight. He died one minute later, and I listened to his mother’s sobs as I stitched up one of his wounds.Although I’d like to think I’m a resilient individual, I credit my mentors for helping me get through the summer. They instructed me on causes and symptoms, CT scans, anatomical structures, transplants and aortic repairs, and how to communicate with patients and in surgery. They coached me on what I would need to do in medical school and how to be a whole person when surgery will occupy so much of my life going forward. At times they even explained how I should be feeling because my head would begin to swirl from all of the conflicting emotions. And often they simply did their jobs in silence, affording me the opportunity to observe without interruption. Some of these moments were the most valuable of my summer.It was during these moments that I also learned how to be my own mentor. I meditated on my own strengths and weaknesses, how I did this thing right but could have helped out more with that. I got to know myself better, and in doing so, became a better student and person. We are most capable of caring for others when we strive to be the best versions of ourselves. We are unlikely to burn out. We are more attuned to how we feel and what is around us.

My second piece of advice is to be a mentor. I know that as a student I cannot teach surgeons anything about how to operate or care for patients, but by working hard and being respectful, I may inspire them to be good teachers. I am not yet in medical school, but I have some exposure to the field and a blossoming perspective on the things I’ve witnessed and sometimes even done myself. The cornerstone of medical education “see one, do one, teach one” inspires my continued efforts to write and answer queries from other students. Social media has served as a special platform to offer any tips I have to my friends and others I’ve actually never met in person. I am overjoyed that I can already be helpful in this field without a professional medical license!

It becomes even more important for women to look for mentors and be mentors since we are underrepresented in surgery. Honestly, I am sometimes intimidated by the preponderance of men in my specialty of interest. However, I am always encouraged by the overwhelming support of my male mentors. I had the great privilege of meeting Dr. Denton Cooley a few months before he passed away, and he too renewed the faith I constantly work at having in myself. I will always remember that he said he was luckier when he worked harder. But he wasn’t referring to luck as a random outcome, rather a consequence of preparation meeting opportunity. Providing our patients with the highest quality care requires hard work and serious investment in personal relationships. At all stages in our careers, we must seek mentorship, be mentors, and encourage others to do the same.


Learning Begins at the End of Your Comfort Zone
Caitlin Harrington Brown
M.D. Candidate, Class of 2017
Oregon Health & Science University School of Medicine

Caitlin Harrington Brown, MD Candidate Class of 2017

Caitlin Harrington Brown, MD Candidate Class of 2017

Surgeons are like professional athletes. They commit years to rigorous training, and spend hours preparing for a specific case, and then before they know it, it’s game day. All that pre-game prep is all well and good, but it’s what happens on game day that actually counts.  Every patient and case is different. Surgeons are prepared for the unknown in a very high stakes environment because they are trained to be problem solvers and be clutch in a crisis. They use their knowledge and their technical skill to fix complications, even if it’s the first time they’ve seen that particular problem. Their ability to operate when facing the unknown does not mean they are comfortable – it means they are competent and confident.

As medical students on a surgery rotation, we have been told that a large part of our attendings’ and residents’ analysis of us is their assessment of our decisiveness. We are seeing things for the very first time, and they are looking for us to apply our knowledge to an unknown situation and confidently make an educated choice.  When you first experienced this, it felt uncomfortable, right? Maybe it still does, and there is a reason for that! Making an educated guess feels like we are unprepared, probably because we spend the first two years being told exactly what to study for on an exam, and then suddenly find ourselves on clerkships where any question is fair game at any time. It’s hard to prepare for this, and if we don’t know the answer, it feels awful. But like with all things in surgery, there is a reason why our teachers put us in this position. Beyond teaching us the information we need to be competent doctors, they are also training us to be comfortable with being uncomfortable. It feels bad in the moment, but that will feel nothing like how it will feel when we are trying to control bleeding for the first time on our own. These situations require us to remain calm and decisive in the moment. If you ever feel like a “deer caught in the headlights” with a question on rounds, imagine how you will feel when a patient’s life is in your hands and you have minutes to assess the situation and fix the problem! It is imperative to get used to this feeling. Luckily, as you move through your rotation and gain exposure, you start to feel more comfortable. It means you’re gaining confidence. But we should be wary of that too! Feeling comfortable means we have learned something – past tense. It does not mean we are actively learning. Instead, we should aim to consistently push ourselves outside of our comfort zone. If we can learn to handle and even thrive in this discomfort, we will get more out of every day we have left as students, we will train ourselves to be more competent residents, and eventually, we will be better prepared for the real game day – when we are in charge of an OR.

There is another element to feeling uncomfortable during our medical school education – when we get feedback. Hearing that we were wrong, or maybe even worse – “just okay” – is hard to swallow. It is natural to feel upset… it’s because you care and are used to being successful.  But here is the thing – you shouldn’t feel upset for getting negative feedback. You should be grateful because someone has taken an interest in your education and wants to help you become a better physician. A helpful way to look at this is to imagine that you are teaching a child how to draw an anatomical heart. Can you imagine a situation where you would have nothing constructive to offer them to help them do a better job? No. The only circumstance in which you would not provide some kind of advice or feedback, would be if you were not invested in their education. In The Last Lecture, Randy Pausch said, “A coach yells at the kid he thinks can improve, but the coach will not yell at the kid who he/she knows won’t.” If you are not getting negative feedback as a student on your surgery rotation, ask for it. If your resident is correcting you and testing you, then they are doing you a service because they are pushing you to be better. They care about your education, and more importantly, they care about the patients you will eventually be in charge of caring for. Yes, it will feel uncomfortable and in that moment, you will not like it. But rather than let it get you down, pay close attention to their message and use it to help you be a better doctor. We have a very, very short time before the responsibility becomes our own. Capitalize on the wisdom and experience of everyone around you, as much as you can, and be wary of only receiving positive feedback. Although it highlights the things you are doing well, it doesn’t always help you improve.

There are moments during medical school that will give us a taste of what it’s like to be a resident. A meaningful example from my personal experience was on my sub-internship when I got to first assist on the same operation twice in a row. The first time through, my attending instructed me with every step – where to place the ports, what instruments to ask for, etc. The second time through, he asked me where I wanted to place the ports, and if he gave me any instruction at all, it was because I forgot to ask for an instrument or because I made a decision that he disagreed with. He gave me the illusion of autonomy, which was exceptionally fun and challenging. However, the real gift he gave me was the opportunity to learn just how mindful I needed to be during the first operation, to be able to operate without prompting during the second operation. What a valuable lesson to learn so early in my education! When I wasn’t mindful enough and required prompting, I felt disappointed in myself. I was grateful for that lesson though – to feel what it’s like to not know what to do, to have to rely on my attending for answers – I didn’t like it, and the next time I get the chance to do the same procedure twice, I will remember that experience and capitalize on what I took from it. In fact, I will be able to get more out of every opportunity I am given in the future because of what I learned. The real key is that, although it’s a more tactile and active learning experience to first assist, you don’t have to wait for those moments to test your surgical decision making. Every time you watch an operation, ask yourself what you would do next and then see what your fellow does. Listen to the feedback your attending gives to the fellow with each step and use it to correct your own thinking. Pay attention to every detail – how much tissue do they take per bite, what plane of tissue are they dissecting, what surrounding structures are they being careful to avoid? Learn from their successes and mistakes. THAT is being mindful. Go to the simulation lab with one of your residents to practice your laparoscopy/thoracoscopy skills. These habits will give you the best chance to capitalize on every opportunity you get in the OR – your attendings will be more willing to give you chances because you’ll be more efficient, and you will be able to focus on the finer details of the operation earlier in your training.

An attending whom I deeply admire for his purposeful and thoughtful operative skills once told me that he was given the feedback during a case as an R2 that “he wasn’t listening, and he wasn’t learning.” His attending had watched him do the same case a few times, and did not see enough progression.  He said that feedback stuck with him throughout the rest of his training as a general surgery and cardiothoracic resident. He never wanted to give that impression again, and thus, he became extremely mindful in order to improve with each opportunity. Being uncomfortable and receiving negative feedback during our training – these are commonalities we share with the surgeons we respect the most. Take comfort in that fact, but don’t take so much comfort that you become complacent and stop pushing. Don’t let the worry that your resident thinks you’re doing a poor job distract you from the opportunity to improve. Instead, demonstrate that you heard their message by making the changes that were suggested to you. Most importantly, think beyond your rotation grade because that is not the reason you should be busting your tail to do well. The real reason is that at the end of medical school, you will become a surgical intern, and then one day a chief, and then a fellow, and then finally, a cardiothoracic surgeon. The safety net will be gone from beneath you because you will have become the safety net – for your fellows, residents, and most importantly, for your patients. Yes, your partners will help you in a crisis, but ultimately, the buck will stop with you. You will own your complications. The weight of that responsibility is so heavy that in order to enjoy this job… to truly love it… you have to be great at it.

So take every moment in your education that forces you into the unknown and welcome it with open arms. Savor the feeling of being uncomfortable and let it sink in. Be mindful of what goes wrong and why, and imprint the lessons you learn into your brain forever.  Realize that medical school is actually a safe place to be bold, to make yourself vulnerable, to ask important questions. Hold yourself to a standard that goes beyond impressing the attendings on your team or scoring well on your rotation of the moment. See the bigger picture.  This is how we earn the right to have this job. This is how we become ready for game day.

See below for our inaugural medstudent contribution, also written by Caitlin Harrington Brown, entitled “Lessons Learned.” 


 

Lessons Learned
Caitlin Harrington Brown
M.D. Candidate, Class of 2017
Oregon Health & Science University School of Medicine

Caitlin Brown, OHSU MD Candidate, Class of 2017

Caitlin Brown, OHSU MD Candidate, Class of 2017


I am a second year medical student at Oregon Health & Science University School of Medicine. I started medical school with an interest in cardiothoracic (CT) surgery, and that interest was quickly confirmed by early exposure to the field in the fall of my first year. For the purpose of this article, I have chosen the five most important “lessons” I have learned in my exploration of CT thus far. These lessons are the products of a careful analysis of the past year and a half of my life, during which I have attended weekly surgeries, clinic, tumor board meetings, M&M conferences, fellowship teaching conferences, weekend rounds, and simulation events with the perspective that medical school is the beginning of my training. This exposure has allowed me to learn technical and clinical skills and experience moments that will stay with me for the rest of my career. It has also helped me to recognize that for all that I have learned in the past eighteen months, my experience, knowledge base and technical skills have not yet begun to penetrate the surface of what I will need to excel in this field. Thus, it is in my best interest to be humble, work hard, listen, read, be grateful, and squeeze every drop of wisdom I can out of the CT surgery team at my school. The five lessons below have become my “guiding principles” in this journey.

  1. You can learn to operate without actually operating: Medical students interested in CT surgery want to do things – learn to open, put in chest tubes, learn to close, etc. We recognize that the knowledge, skill, and restraint necessary to perform at an attending level takes years to develop, and we are eager for that process to start immediately. As a result, it is very easy for us to feel frustrated when we are not the ones cutting, sewing, or assisting. It is important to realize, however, that even when we are not right in the action, there are still a million things that we can learn simply by watching. Going to surgery regularly allows us to absorb more and more with each exposure, from the surgeon’s actual technique to more subtle details such as the way they utilize retractors, camera angles, or assistants. We can witness how our mentors react when things do not go as planned. We can learn about the clinical decision making that brought our patient to the OR. We can learn how new information discovered during the course of an operation, such as the results of a frozen lymph node biopsy, can change that decision making. We can learn how to read and interpret imaging studies, how to set up the room, position the patient, and how to work with the team. The possibilities are endless! One of my mentors recently said to me, “Learning basic techniques will come easily… that is not what makes you a great surgeon. What makes you a great surgeon is knowing where to cut, when and why, and why not.” This is key! Surgeons are purposeful – every movement and every decision they make comes from a place of reason. As medical students, we need to learn the purpose of each step and each decision, we need to watch how our attendings handle their instruments, how they fix problems, and ask “why” every single time the question pops into our heads. The great thing for us is that this does not require us to be operating. It requires that we are present, attentive, inquisitive, curious and observant. This is the training that we can start now, when we are scrubbed in but perhaps outside of the action.
  2. Find a mentor who will invest in your success: As medical students, we are tasked with the job of giving everything we have to learn the practice of medicine in order to become excellent at what we do. Our hope is that when we show up to take on this challenge, there will be CT surgeons that will serve as extraordinary examples of what we should become. Everyone in this job is busy, and thus, the most we might ever expect is to be taught through example alone. If, however, we can find someone who is willing to help us foster curiosity, passion, interest and excellence, it takes what can be an impersonal and challenging journey and makes it one that is personal, inspired and profound. The important thing to remember is that mentorship of medical students is a selfless act on the part of the attending, and thus we need to do everything in our power to earn and re-earn (and re-earn) the gift of their focus, teaching and time. How do we get these incredibly busy and focused surgeons to invest in us? I have found that it is important to both demonstrate and vocalize passion for the specialty. Demonstrating passion means that we show up (all the time) and show up prepared. One of the CT surgeons at my school said to me early on, “There are two things that exist in surgery: results and excuses. Be the one who gets results.” This beautiful pearl of wisdom applies to everything, but in terms of mentorship, I take it to mean that we need to consistently ask for opportunities to learn, and when we get those opportunities, show up prepared as if we are interviewing for a job. The goal is to never be in the position to say that we do not know something that we should know at our level of education, especially if we could have looked it up, read it in the patient’s chart, or searched pub-med before the case. Once we have established a track record of work ethic and dedication with our mentors, it will become appropriate for us to discuss specific goals for future learning. This is an excellent opportunity to vocalize our passion, given that we have already demonstrated our commitment over time. The ultimate goal is to establish a trusting relationship with our mentors that respects their effort and time, and allows us to gain access to their wisdom and experience.
  3. Everyone is a resource.   While sitting in the OR before a cardiac case during my first year of medical school, my very wise attending turned to me and said “Caitlin Brown. I’m going to tell you something that will make your life as a medical student easier. Every time you come into the OR, it’s like you’re walking into a stranger’s house. Would you walk into a stranger’s house and not introduce yourself? No. That would be weird. That would be rude. So… Caitlin Brown, whose house is this? This is the scrub nurse’s house. So when you walk through those doors, the first thing you do is introduce yourself, tell them your level of education and write your name on the white board.” This little pearl of wisdom got me thinking. As a first year medical student, I was the least experienced person in the room, which meant that every single person around me probably had some bit of advice that would help me become a more useful medical student in the OR. From that day forward, I made a habit of actively engaging every single person on the team, whether that person was an attending, scrub nurse, sub-intern, resident, PA or fellow, in order to maximize my learning. I asked them to teach me if they felt that they had something valuable to point out. As a result, I had a lot of support from the entire team, which certainly broke the ice and made learning comfortable. I learned ten times the amount in one visit with so many teachers around.  One caveat to this is realizing that everyone in the OR has a job to do and it is NO ONE’S singular job to teach medical students, especially if we are not on service. To ease the time burden that teaching us might take, I have found that it is important to learn how to help the people around me. I try to get to the OR early so that I can pull up the proper imaging studies. I ask the scrub nurse and circulator if I can be useful in setting up the room. After a case, I scrub out, and do whatever tasks I can to help transfer the patient safely to the PACU. The greatest time burden of all rests on the residents and fellows. If we want them to take the time to teach and help us learn, we really need to make an effort to make their lives a little bit easier. That may mean printing them a copy of the list for morning rounds, pulling their gloves in the OR, helping position the patient, or assisting them in tasks on the floor. At this stage in our education, our presence is a privilege, not a right. The more helpful we can be, the more our team will be willing to engage us and the more we will learn.
  4. Ask for constructive criticism from your mentors constantly. You might be the best medical student in the history of all medical students, and there will still be a lifetime of learning ahead of you. Recognizing our weaknesses is not always an easy task because we are seldom aware of the big picture, especially during our preclinical education. We do not have the roadmap yet to see where we will need to be in terms of knowledge, technique and understanding. Fortunately, our mentors do. They have been through what we are going through. They have figured out many tricks of the trade to make an operation easier, safer and more efficient. Surgeons are mindful and proud creatures – I guarantee that they operate in a particular way for a very specific reason and they could tell you why it is the best way to approach the task. Will we automatically operate as efficiently and precisely without hours of repetition, observation and guidance? No. We are babies when it comes to surgery. Simple tasks will be challenging. So how can we improve? Ask for their criticism constantly. This is different from the real-time criticism we are guaranteed to get when we make a mistake. I am talking about having a conversation with the attending after surgery or clinic and directly asking, “What could I have done better? What are my weaknesses?” If we make an effort to request honest feedback with each interaction and use it to change our technique and understanding, we will maximize our progression. Another thing to be aware of is the danger of compliments. When an attending surgeon tells us that we did something well, we feel incredible, and there is certainly some value in hearing this positive reinforcement. However, this can also give us a false sense of accomplishment and can slow our progression. When my mentor says, “Caitlin, you did a good job”, I force myself to hear “Caitlin, you did a good job for a medical student” to remind myself that until I am as competent as my attendings, it is not good enough.
  5. Geek out, and be proud of it. We will be told by many attendings and fellows that this job is hard and there are easier ways to make a living. This is true. It is extremely important to get the big picture of what life is like as a CT surgeon so that we understand what we are committing ourselves to. If you do not like the work hours as a medical student on rotation, you will hate the work hours when you are a resident. It is not just the work hours that make this job hard – it is the fact that sometimes doing everything you can for a patient will not be enough and that will rest on your shoulders. You will experience hardship, pain, and suffering. You will be away from your own support system constantly and sometimes unpredictably, making emotional hardships and personal pain even more daunting. We need to be informed and do our research before choosing any specialty, particularly this one. However, if at the end of a long and complicated day in the operating room, you find yourself eager to do it again the next morning, follow your heart. If you discover that the feeling you get during a cardiac or thoracic case is unlike any other feeling you have ever experienced in medical school, follow your heart. I call this particular phenomenon “geeking out”. It is how you felt the first time you saw a beating heart. It is how you feel every time you see a beating heart. You feel alive. Inspired. Passionate. Curious. You forget you are hungry. You forget you are tired. You lose yourself in the moment so that time flies by and stands still at the same time. If you geek out, then please, please, please geek out with pride. Never let the people around you dampen that enthusiasm. Other people might not get it, but it does not mean that the joy is not real. It is real. And loving something that much is what life is all about.
Caitlin Brown, MS2

Caitlin Brown, MS2