Early in the fall of my third year of medical school, before I’d ever stepped foot in an OR, a surgery resident told me, “Don’t ever let anyone tell you what you can’t do.”

At that point, I had no idea what I wanted to do.

For as long as I could remember, I’d planned to go into pediatrics. I’d always loved kids, and I can’t count the number of times people told me over the years, “I could so see you as a pediatrician!”

But my surgery rotation took me by surprise. Stepping into the sterile field granted me entrance into a new reality. Whether it was physical endurance and deep focus required to operate or the seclusion of the OR from the rest of the world, I found a parallel peace of mind in the cardiac OR to my favorite activity in the world: skiing deep in trees of Colorado’s backcountry.

From the sternotomy onward, the anatomical complexity of each open-heart surgery I scrubbed, particularly the creative repairs of congenital heart defects (CHDs), had me hooked. It fascinates me to watch the patient’s vitals undulate as the surgery and anesthesia teams work together to keep hemodynamics steady throughout the dramatic physiological changes of cardiopulmonary bypass, hypothermia, and cardioplegia. Most of all, I love when the heart lies still – when I can assist, and hopefully someday perform, the intricate stitching on the coronary arteries and valve annuli with needles hardly large enough to see.

Why, my entire life, had I told myself I could never be a surgeon? I wasn’t good with my hands, I’d always thought. But learning to suture reminded me of the repetitive technical practice of learning new songs on my harp or mastering a new crochet stitch. Maybe I wasn’t bad with my hands after all.

“You want to do congenital?” I remember one surgeon asking me, when I mentioned my personal interest.

“Just know, you might never find a job.”

“And if you do, it’s just about the most stressful job in the world,” another advised me.

I started to recede, as I continued to hear only negative feedback, trying to talk myself out of this dream. But then, at the end of the year, a neonatologist gave a lecture on CHDs during my pediatrics rotation.

“You really love this stuff, don’t you?” he asked me afterward. How could he tell? I had been wearing a mask.

“You had that spark in your eyes,” he remarked, when I came to his office for follow-up teaching. I told him how everyone had said a career in congenital heart surgery was impossible.

“Nah, it’s not impossible,” he said. I later discovered that this neonatologist, who took the extra time to teach me, had been cited in the Guinness World Records book three times for delivering the world’s smallest babies.

“If you have a passion for it, then you’ll do it,” he shrugged.

I remember hearing on a podcast, that, on average, women apply to jobs for which they meet 100% of the criteria while men apply to jobs for which they meet only 60% of the criteria. “In our society, from a young age, girls are taught to be perfect, while boys are taught to be brave,” the podcast host said. This message stuck with me throughout college and medical school, as I came to realize that I was my own biggest roadblock, holding myself back with my own fear.

I can’t yet know everything this challenging career will entail. But I certainly know courage is integral to become a congenital cardiac surgeon. In preparation, I let the wise words of Eleanor Roosevelt guide my daily life: “Do one thing every day that scares you.” With each layer of self-doubt I strip away, I’m discovering a whole lot more bravery than I’d ever known before.

I hope that in becoming a cardiac surgeon, I can serve as role model for all the other young girls who, just as I did, grew up thinking they could never become something like a surgeon, who didn’t even realize bravery was an option. I want every one of them to hear the same message that resident told me: don’t ever let anyone tell you what you can’t do. I’ll add my own two cents to her advice: don’t ever let anyone tell you who you are. You’re the only person who truly knows. Go be that person. Be brave.

References:

1. Ted radio hour interview of Reshma Saujani, the founder of Girls Who Code, referencing her Ted Talk “Teach girls bravery, not perfection”:
   Available from: https://www.ted.com/talks/reshma_saujani_teach_girls_bravery_not_perfection.

As a female first-generation medical student from an immigrant background, I entered medicine naively. At 10 years-old, I was confident in my love for the science of the human body and my goal to lead a life of service. Medicine was the only pathway that made sense. Through my research and shadowing experiences in high school, it quickly became apparent that the healing process was mental and emotional as much as it was physical, and a physician facilitates all three aspects. Therefore, aspiring to learn the art of medicine from Day 1, I entered an accelerated BA/MD program and found surgery to be where I belonged. I desired the satisfaction of using my hands to provide tangible fixes and became fascinated by cardiac anatomy, physiology, and the ingenious biomechanical engineering of it all. By the end of my preclinical years, it was clear that cardiothoracic surgery was my “perfect fit.” The field combines my deep-rooted passions for innovation, excellence in precise technical skill, clinical reasoning, multidisciplinary collaboration, complex problem-solving, and the privilege to care for the most critically ill patients. A CT surgeon builds trusting relationships with patients and their families and serves as a source of comfort during moments of uncertainty and fear. Having made my specialty choice, I was ready to find my place in the field, equipped with drive, passion, and the willingness to consistently work hard. What I wasn’t prepared for was the level of persistence, self-advocacy, and constant exploration it takes to fully understand the close-knit, collaborative environment of CT surgery and to build life-changing relationships with passionate, talented surgeons as mentors.

Coming from a small school with no home cardiothoracic surgery training program and limited resources, learning more about the field itself was a challenge. We had no CT surgery interest groups, our surgery interest group was unfortunately not very active at the time, and I had no personal connections or relationships in medicine. I finally got a true taste of the field when I rotated on my school’s singular cardiothoracic surgery elective at a neighboring hospital, where I met their one female cardiothoracic surgeon who became my first mentor in the field. I scrubbed in on every surgery I could with her from heart transplants to CABGs, no matter the time of day, and sought opportunities to follow up with patients in the ICU and outpatient clinic. Every experience only made me more confident in my specialty choice. My first piece of advice for students in a similar position is to aggressively seek out every opportunity available and to make the most of your experiences. Scrub into as many cases as you can, but also soak up any chance to interact with patients on rounds or in clinic. Be willing to learn in any scenario and from any individual. My knowledge of suturing techniques and the location of warming blankets comes from PAs, NPs, scrub nurses, perfusionists, and many more who graciously taught me these basic concepts.

Until I did my elective, I didn’t realize how important it was for me to see and hear from a successful female cardiothoracic surgeon. Instead of imagining what it might be like as a female in a male-dominated specialty, I felt seen and understood in having my first mentor as a role model. She taught me the necessity of resilience, the power of collaboration, the push to seek excellence, and the importance of creating an identity outside of surgery. She showed me that balancing a demanding career and a family life is possible without detriment to either. She was open about the challenges and the give-and-take required; it will seem nearly impossible at times. However, with support and delineation of priorities, the desire for a family life is not at all a barrier to being a successful CT surgeon. Women across the globe integrate their families and the demanding career of surgery every day. This brings me to my second piece of advice: be persistent in your search for mentors and intentionally create a large network of people as your support system. I cannot emphasize enough the necessity of mentorship in all forms. In fact, as an individual who entered medicine and surgery naïve to its foundation in tradition and close-knit environment, my progress has been built on mentorship every step of the way.

It’s also crucial to highlight that networking is an invaluable skill, especially for students without built-in mentorship opportunities at their home institutions. For me, the idea of walking up to or emailing a complete stranger to introduce myself and demonstrate my passion for CT surgery in an effort to seek guidance, was extremely foreign and daunting. Why would an accomplished and well-established CT surgeon take time from their busy schedule to talk with a random student? However, you’d be pleasantly surprised by how inviting and welcoming members of this small community truly are. So, push yourself to reach out to those who you admire, especially those who look like you and are in various stages of training; ask questions, share your concerns, and follow-up with meetings to cultivate your mentorships. Their diverse guidance will be vital in navigating the field and the training pathway. Personal relationships are vital in CT surgery; surprisingly often, faculty remember these brief interactions when you cross paths in the future. Additionally, as I’ve progressed towards the later stages of my medical school training, I’ve realized that a mentee can and should also be a mentor. In fact, it is our responsibility to pay it forward and mentor others seeking similar career pathways. Make it a priority to mentor younger students along the way, whether that be females interested but hesitant in pursuing surgery or high school students exploring their interest in healthcare. Teaching and mentorship are excellent ways to promote diversity and inclusion in CT surgery and medicine.

In my journey of exploring CT surgery, the internet also played a vital role. A simple Google search is how I discovered societies like Women in Thoracic Surgery (WTS), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgeons (AATS), along with their regional counterparts like the Southern Thoracic Surgical Association (STSA). By delving deeper, I came across funded scholarships, programs, and research grants specifically designed to foster early interest in the field. These programs serve as invaluable opportunities to learn about the future of CT surgery, make connections with various members from program directors to other like-minded medical students, start research projects, and facilitate questions. If you’re curious about the interview process, there are journal articles like “Integrated cardiothoracic surgery: Navigating interviews and the match” by Smood et al [1]. If you want to hear from CT surgery trainees, there’s the Aspiring CT Surgeons Blog by STS [2]. If you want to learn from pioneers in the field, you can watch/read past presidential addresses in the AATS archives [3]. If you’re trying to learn how to insert postoperative chest drains, go to CTSNet’s Step-by-Step Series [4]. Social media can also be a great way to stay involved and up-to-date with the field. This could be learning more about resident lifestyle at a particular program via their Instagram page or joining the discourse on Twitter about a new clinical trial. The opportunities are truly endless!

 As implied, don’t be discouraged if you attend an institution without a CT surgery division/department and local access to well-renowned CT surgery mentors. The tenacity, persistence, and self-motivation to create opportunities for yourself will serve you well in a demanding specialty like cardiothoracic surgery. Hold onto your passion for the field and let it drive you to grow as a student, mentee, and human. I will never forget the first time I was given the immense privilege of touching a newly transplanted, beating heart; I push myself to re-earn that privilege every day. We owe it to ourselves, our mentors, and most importantly, our entrusting patients.

References:

1. Smood, B., et al., Integrated cardiothoracic surgery: Navigating interviews and the match. J Thorac Cardiovasc Surg, 2021. 161(5): p. 1889-1895.
2. Aspiring CT Surgeons Blog – A Space for Trainees. 2023 12/12/22 1/21/2023]; Available from: https://www.sts.org/publications/aspiring-ct-surgeons-blog-space-trainees.
3. Keshavjee, S. Presidential Address: What’s Next? Presidential Addresses 2022 6/14/2022 [cited 2023 3/1/2023]; Available from: https://www.aats.org/resources/presidential-address-what-is-next.
4. CTSNet Step-by-Step. CTSNet Step-by-Step Series 2018 12/11/2018 [cited 2023 3/1/2023]; Available from: https://www.ctsnet.org/content-areas/ctsnet-step-step.

I was standing in front of the operating room case board as a third-year medical student. It was my first week on the trauma service during my surgery rotation. I was scouring the board, trying to find my next case. I saw Dr. Jason Muesse, one of my attendings from thoracic surgery, the service I had just finished rotating on. He knew I was interested in surgery and had enjoyed the thoracic rotation. He stopped to talk as he looked at the board. While standing there, we discussed the possibility of starting a research project and other ways I could stay involved. He recommended looking into Women in Thoracic Surgery. He had been mentored by female thoracic surgeons involved in WTS as a trainee.  

That night, I joined WTS and signed up for mentorship. I was paired with a cardiac surgeon named Dr. Rachael Harrison. She had gone to medical school at the University of Arkansas for Medical Sciences, where I was a student. At the time, she was a practicing cardiac surgeon a couple hours away. A few months after my conversation in the operating room hallway, I drove to shadow her in the hospital.

Dr. Harrison and I talked about extracorporeal membrane oxygenation (ECMO) physiology, applying for residency, the pros and cons of different training pathways, and starting a family as a trainee and surgeon. She drew pictures of the ECMO circuits in the ICU and let me try on her loupes in the OR. After a case in another OR hallway, I asked questions about her training pathway with an integrated program, practicing in a community setting, and her decision not to complete a fellowship. She described her training program, which had been tough but invaluable. She explained she wanted to focus on clinical practice instead of research, which led her to a non-academic practice. She had been at a high-volume transplant center during residency, giving her enough experience to bypass a heart failure fellowship on her way to being a cardiac transplant attending. We also got personal, and she talked about planning for and starting a family. She was open about the challenges as well as the rewards. She had a balance of her personal and professional life that I didn’t previously know was possible. 

Several months after shadowing Dr. Harrison, I applied for general surgery residency. At the end of my intern year at MedStar Georgetown University Hospital and Washington Hospital Center, I learned that Dr. Harrison had moved to MedStar Baltimore but was also practicing at MedStar Washington Hospital Center where she did heart transplantation and heart failure surgery. We reconnected, and when I was on my cardiac surgery elective, I had the chance to operate with her again. We caught up. There were many changes for both of us since we had last talked. Before a case, we stood in yet another OR hallway. She shared her perspective and advice with studying for and taking boards, developing clinical skills, and eventually finding the right job. 

A paper by Drs. Ourania Preventza and Leah Backhus published in Journal of Thoracic Disease in 2021 described the persistently unequal representation of women in thoracic surgery, especially in cardiac surgery. Given how few women are in the field, especially in leadership, it is not surprising that Dr. Harrison is still the only female cardiac surgeon I have worked with. I needed to see what the life of a female cardiac surgeon could look like. I am thankful for Dr. Muesse’s guidance and introduction to WTS, for Dr. Harrison’s example and mentorship, and for WTS for opening the door for these important conversations in three different OR hallways across three different states.

I’ve always wanted to be a cardiac surgeon. Even as a child, I dreamed that I would be a heart surgeon one day. As an adolescent, adults would ask me what I wanted to be when I grew up, and when I told them, they would invariably ask, “But don’t you want to be a mommy one day?” as if surgery and motherhood were mutually exclusive. It didn’t bother me then because I wasn’t thinking about children. I just wanted to be a heart surgeon, and if I happened to become a mother, then that would be fine too.

My passion for surgery grew as I did, but so did the breadth of my dreams. Not only did I want to become a cardiac surgeon, but I started thinking about becoming a mother one day, too. This new dream became even more tangible during my first year of Medical school, when I met my (now) fiancé. The way I saw it, I had two potential pathways ahead of me, each taking me in opposite directions but with equally fulfilling destinations. The only problem was that I couldn’t be in two places at once.

I began entertaining the idea of pursuing another, similar specialty that might have a better “work/life” balance, and I sought out a female mentor for advice and perspective. She was the first female that I had ever met in a procedural specialty, and she was a strong, confident, ambitious woman whom I began to admire. A few days into the experience I told her my story, revealing to her my passions and fears, hoping that she would tell me that I could make both of my dreams come true with a little elbow grease.

Instead, I got a very different message. According to her, she never would have accomplished all that she had if she had been burdened by a family, and I could never hope to be successful at both. Both my family and my career would necessarily suffer at the hand of the other. It was discouraging, but nothing I hadn’t heard before.

Then she said something that really jolted me, something that hovered over me for a very long time: She said that if I became a cardiac surgeon, my children would call the nanny “mommy.” She told me that my children would run to the nanny for kisses when they fell, that they’d cry for her when they had a nightmare. This shocking assertion, coming from my only female role model in a procedural specialty, breathed real life into the idea that I was doomed to choose between a family and my passion. I am ashamed to say that I allowed myself to be intimidated into setting my dreams aside. I started considering other specialties. I tried to love something else, but no matter how hard I tried to put cardiac surgery behind me, I kept circling back to it. My mind was open to the other possibilities, but my heart was not. I just couldn’t let it go.

I finally decided to begin my third year of medical school with a few weeks on a cardiac surgery rotation, so I could experience it for myself. On my second day, after a very long and complicated open aortic valve replacement, the fellow and I were about to wheel our patient up to the ICU when the patient suddenly went into tamponade and ventricular fibrillation. We emergently reopened his sternotomy to find a hole in his aorta where a stitch had ruptured. The fellow put him back on cardiac bypass while I performed an internal cardiac massage until more qualified help could take over. I held our patient’s heart in my hand. I kept it beating. We saved his life, but I was a goner. All my doubt and hesitation had evaporated, replaced with an absolute clarity in the truth that there is no other path for me. I am meant to spend my life holding hearts in my hands.

It was decided. I was (and am) going to be a cardiac surgeon. While this was no longer up for debate, it did leave me with another difficult decision, so I began questioning my future as a mother. Should I just not have kids? Should I expect my fiancé to give up his career as a corporate attorney to raise our children? How could I ask that of him? Would he and our kids end up resenting me? Do I just accept that the kids will call the nanny “mommy”? Which is worse: having no children, or having children who don’t know me?

But what if these are the wrong questions?

Why does this idea exist, that women can do whatever they want in their careers, just as long as they have a supportive partner and/or an army of nannies to pick up the slack? What if I don’t want to relinquish the joys of motherhood to someone else? What if I want to be both a successful surgeon and a devoted mother? Why should I have to choose? Why is this even a question? While both men and women struggle to balance careers and families, I can guarantee that my fiancé is not lying awake at night wondering how he is going to choose between his career and his ability to be a good father. The traditional standards required for earning the title of “good mother” are very different from those required to be a “good father”. Since the dawn of humanity, a good father has cared for his family by leaving the cave to bring back a mammoth for dinner, while the good mother stays home to care for the children. This system made sense when providing for the family meant wrestling a saber-tooth tiger, but not anymore. Families come in all shapes and sizes, and not one of us has the right to judge how another family makes it work. We, both as individuals and as a society, need to abandon the cavewoman’s standards and create our own, based on what is best for our individual families. I was really struggling with the choice between being a cardiac surgeon and being a good mom until I considered who I am as an individual. I realized that, for me, they are not mutually exclusive, but rather mutually inclusive. I know myself. I know that I am at my best in every way when I have something that I am passionate about that challenges me and keeps me very busy. Having a fulfilling career that I love will promote the best version of myself; my future children deserve that version. I want them to have a mother who cares about people and making a real difference in their lives, is inspired by what she does, welcomes a challenge, works hard but enjoys every moment, and loves them unconditionally. I owe it to them to give them that person, and I owe it to myself to become that person. For me, the way to become the best mother I possibly can be is to also become the best surgeon I can be.

This is the real world, and it takes more than good intentions to move mountains. I needed to know if it was physically possible. I reached out to female cardiothoracic and vascular surgeons, including some WTS members, who are also mothers to hear their stories. To date, not one of the women who actually has both a family and a successful career (and yes, there are many of them) endorses the unfortunate advice I was initially given.

They were all incredibly honest, and the truth of the matter is that it is tough. You don’t get to go to every ballet recital. You may need to interrupt your training to start a family. It all depends on you and your family. At the end of the day, each of the women I spoke to have become successful surgeons, leaders in their field, pioneers in research, teaching, and mentorship, and none have indicated that their families have suffered for it.

It’s true, many of them have had help. Hiring a nanny to babysit, drive the kids around, entertain them, and keep them out of trouble is of course a huge relief, but that is not all it is. Having a nanny is having another person to love your children and make them feel safe. It’s another person to cheer for them at soccer practice and applaud their A on that math test that they worked so hard to achieve. It is another person to wipe their tears when they fall and rebuild their confidence when they feel insecure. That can’t possibly be a bad thing. I was a nanny for 3 years for a family in which both parents were busy attorneys. I should have known better; I was all of those things. I still love them, and they loved me, but when they were sick, they always wanted their mommy.

Who you are and who you want to be are not binary. It isn’t a question of being a surgeon or a mother. Any working mother, no matter the field or specialty, from attorney to CEO to teacher to surgeon, is going to face similar struggles. Cardiac surgery might be considered one of the less lifestyle-friendly specialties, but every female doctor is going to face challenges. It isn’t easy no matter which specialty you pick. The choice is not between the easy path and the difficult path, it’s between the difficult path, the very difficult path, and all of the paths in between. Some extra challenges are worth it, some are not, but that is entirely up to you. Everyone has an opinion: other women, your mentors, your peers, your nanny, even the cavemen. Despite all of their opinions, YOU are the only one who actually knows what is best for you and your family.  For me, there is no being a successful surgeon or being a great mother. For me, they are one in the same.

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.

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, clinics, 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.