The Five Things I Learned in Residency

by
  • Kotecha, Mona, MD
| May 29, 2012

I think my overwhelming desire to teach anesthesiology to residents stems from both narcissism and masochism. The narcissist in me feels so passionately about the profession that I attempt to leave some sort of trail of this passion behind. The masochist in me wants to be uncomfortably hungry for knowledge most of the time. Nothing is more humbling than when a first year resident backs me into a corner with a series of questions about an anesthetic approach, the last of which I can only answer with, “because I said so.” Teacher, student…student, teacher. We’re all the same in academics.

I had the fortune of being taught by legends of anesthesiology at the University of California San Francisco (circa mid 2000’s, but for my sake, don’t do the math). And in the past few years I have worked with some of the brightest people in all of medicine: residents in anesthesiology. Every day—with humility—I attempt to teach one something meaningful. My lessons are simple, because they are distilled from the lessons I learned from my own attendings.

There are five.

The first is to approach your profession with a “say yes” attitude. During the fatigue of my internship at an inner city hospital, the beeping of the consult or admission pager filled me with dread and worry. “Blocking” consults or admissions was an accepted approach towards practicing medicine. I take the opposite stance now. When consulted for help by an interventional radiologist, an electro-physiologist, or anyone else, I regroup and put on a “just say yes” smile. I ask residents to memorize these words: “Thank you for consulting anesthesiology; we are so glad to help. You absolutely DO need our services.” (Admittedly, they sometimes look at me like I’m crazy.) Once I viewed the add-on list as an overwhelming burden. Now I see it as opportunity: to advance the visibility of our profession, to take ownership of a patient’s peri-operative experience, to keep another patient safe from harm, to secure our profession’s future.

Residents: Just say yes.

The second is to, “know more.” The simple act of knowing at least one thing “extra” about the patient’s history, I believe, instills surgeon confidence, elevates our professional status and distinguishes us as peri-operative doctors. This lesson I learned when a particularly meticulous attending asked me what the patient’s gastrin level was during a gastrectomy in a Zollinger-Ellison patient. Why don’t you know, she said? It’s 900, she announced disappointedly. I dropped my head in shame. Perhaps the gastrin level didn’t matter too much. But the echocardiogram results, glucose level, EKG, and that little piece of history about the vocal cord polyp probably does matter. So I try to know about it. Except in the most extreme of emergencies, I insist that a resident do the most thorough chart review, history and physical possible, because I want them to gather as much information as they can to best deliver tailored anesthetic care.

Residents: Know more; don’t know just “enough.”

The third is to respect yourself and your work. This lesson was actually taught to me by a surgical intern, who at 2 a.m. on call during my residency performed the most painstaking subcuticular xiphoid to pubis closure I have ever witnessed. He was a proud doctor who approached this closure with a zen-like focus. In stark contrast to his behavior, only a few weeks prior to this event, I myself had frantically attempted to gain IV access in an 80-year-old hip fracture patient under the drapes, upside down, in the dark, because a particularly enthusiastic orthopedic surgeon convinced me it would be “efficient” to position and start the case while I obtained adequate access. I didn’t have the self respect this surgery intern did. In reality, we should insist on adequate working conditions during the periods we need them most. Quality care depends on our self-respect. 

Residents: Respect yourself, and what you do.

The fourth is to do the hard thing, because it’s usually the right thing. “Are you going to leave this patient at the 11th hour so you can go have dinner? Is that really the doctor you want to be?” asked an attending bluntly, as I prepared to hand off a marathon case just as we crossed the finish line. Yet again, I put my head down in shame. In fact, performing the best patient care often involves cancelling personal plans, missing dinner, slowing down a rush to the O.R., delaying the case, moving it to the main hospital, refusing to transfer care just yet or annoying somebody on the team. Cursory to this lesson is to resist what I call the “probably approach.” If I tell myself more than twice that I should “probably” do something (e.g. put in an a-line, awake fiberoptic the patient, etc.), then I do it. Because “it will probably be ok” is not good enough for our patients.

Residents: Do the right thing, even when it’s the harder thing.

The fifth is to use your senses: all of them. One of the finest anesthesiologists I know sits curled near the machine, the precordial stethoscope in his ear and his hand on the breathing bag because, “I just can’t feel connected to the patient if I stare at the monitors,” he says. He sits down to intubate, “so I can feel closer to the airway.” I ask residents to touch (What does the pulse feel like? Where is the cricothyroid membrane?), listen (Is that a cuff leak you hear, or stridor, or gurgling?), smell (Is that sevoflurane? Could the vaporizer be leaking?), look (Not at the monitors—at the patient’s skin, the surgical field). During an episode of mild hypoxemia recently, I quipped to the resident, “Well, since all else has failed, let’s examine the patient together.” As we listened carefully to the lungs and examined the surgical field, we diagnosed a small pneumothorax from an unanticipated surgical complication. It’s amazing what you can learn when you examine the patient, we decided together.

Residents: Engage your senses; your patients deserve all of them.

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