Sub-internship Success: A How-to Guide

by Callie Thompson, MD and Jane Zhao, MD

For those who are not familiar: A sub-internship is a rotation that a medical student does, in their fourth (and last) year, in which they are expected to function as an intern. We lovingly refer to such a person as a sub-I, sub-intern, or acting intern. Usually, at least one of these rotations is done at an outside institution. And typically, this is considered a month long job interview.

What follows are our tips/suggestions for a successful rotation.

Keep in mind that these are general guidelines, and that each medical school will have slightly different expectations of their surgical sub-interns.

Away rotations: Only do a sub-internship at a place that you might want to train at for residency if you are ready to work, work, work. This is your chance to knock the socks off the people you are working with. You need to show them how good you are and they need to come away from it thinking "we want her/him in our program." Because of these odds, many attendings and residents will tell you that the underwhelming returns of matching at a program where you have completed an away rotation are not worth the amount of money and effort you pitch in.

On the other hand, do an away rotation if you want to take advantage of the opportunity to gain some perspective on how residency programs may differ and which characteristics of a program you absolutely need and which you may be willing to sacrifice when push comes to shove, e.g. location, demographics, prestige. Furthermore, obtaining a letter of recommendation from an away rotation is a great way to gain invitations to programs that typically only interview regional applicants. This holds especially true for those who stayed in one location from undergraduate and medical school and have a desire to move elsewhere for residency.

Another word on away rotations: Do not ever turn down an away rotation you applied for at a hospital where you would like to interview for residency. Turning down the opportunity to visit a program for a month after you have taken the time to apply for it and after the program has taken the time to approve you is the single quickest way to blacklist yourself from the program when interview season rolls around.

Scheduling and letters of recommendation: Generally speaking, the earlier you schedule your sub-internship the better because most students take advantage of this time to also ask for letters of recommendation from faculty members they work with. Make sure the faculty member knows you, make sure they are going to say something good about you, and give them enough notice so that they aren’t rushing to meet a 48 hour deadline. Thus, July, August, and September are prime months. Keep in mind that if you schedule your rotation in the midst of interview season, you may have to request numerous absences, which will detract from your experience and even possibly reflect negatively on you. Scheduling a sub-internship earlier in the school year also provides faculty who have worked with you a greater level of comfort to advocate strongly for you if programs use a democratic process to create their rank list. This comes in handy if you absolutely need to match to a particular program or city.

Choosing the site of your rotation: Numerous programs request a letter from either your medical school’s chair of surgery or program director. If you haven’t had the chance to meet with either of them during other occasions, you may want to figure out which service they belong to, and try to rotate through there.

Given that a good surgeon should also have a firm understanding of medicine, a strong letter from a respected attending from a different department such as internal medicine can also go a long way in making your application shine, so if you have enough time, it certainly would behoove you to attempt a sub-internship in medicine.

A sub-internship is also a great chance to try out a particular surgical subspecialty you might be interested in pursuing further down the road, e.g. colorectal, trauma and critical care, or pediatrics. If you end up falling in love with it, you now have a stronger incentive to match to certain programs, or if you end up hating it with a passion, you have saved yourself from years of potential misery.

Set yourself up well: This starts by developing a full understanding of the dynamics of the system setup and the people on the service you will work with. Will you be working on a high-volume service with fast turnover? Will you be working on one where the norm is one to two elective cases every other day? Are the attendings known for their Socratic style of teaching? Do the residents go out of their way to include students in the work up of patients? Play to your strengths, particularly if you are trying to obtain a letter. Some sub-interns’ strengths come out in chaotic situations, when their reliability and collected composure are a sweet breath of relief to ragged residents working in a hectic environment. Some sub-interns love being pimped and shine best when being grilled with question after question while their classmates stare gape-mouthed and hopeless. Do you rock at presenting and working up patients? Are you better with procedures? Figure out how your strengths will complement the needs of the service you are joining, and make sure you choose and prepare accordingly. For better or worse, your performance will be evaluated subjectively, and it doesn’t take much for a poor impression to be wrongly formed of a usually wonderful sub-intern or a positive one of an otherwise average sub-intern.

Eliminate distractions: This is your opportunity to take on the responsibilities of an intern. Help manage the list. Know every patient. Unlike your third year clerkship, you do not have assignments or a shelf exam to worry about during your acting internship (disclaimer: this is not true at every medical school). Plan out your year to avoid having to work on your personal statement, ERAS application, away rotations, scheduling interviews, or study for the USMLE Step 2 during this time. You can take full advantage of the freed up time to play an active role on the team and gain more hands on patient care experience.

Presentation: If you are expected to give a presentation (many rotations require them), get started on it early, and identify both a resident and a faculty member to advise you. Be sure that you already have an idea in mind before you speak to them and get your presentation done early enough that they can help you make improvements if need be.

Prioritizing: A real intern probably spends more time on the wards than in the operating rooms, while a third year medical student gets the best possible snapshot of what it’s like to be a surgeon by being in the operating room whenever possible. What’s a sub-intern to do? As a fourth year medical student, you are somehow expected to find the happy medium between both.

Some pearls:

You need to be able to function like an intern which means you need to have a good idea of how to manage your time and balance multiple patients at a time. You aren't a third year student anymore, so you need to carry more than two to three patients at a time. Ideally, you should know the entire service, just like the intern does. Even if there is a third year medical student on your service, you should know everything about their patients too without stepping on their toes.

In the mornings, do your best to help the third year medical students and interns collect vitals and pre-round on patients. Chat with the nurses and ancillary staff for events that occurred overnight.

For rounds, you will most likely follow steps for success that won’t have deviated much from your third year clerkship: Carry marking pens, suture removal kits, gauze, tape, and consent forms in your pockets. Split up patients with the other medical students on your team, and take down dressings on all patients who are postop day two. Have a penlight at the ready to shine on the incision for your resident to have better visualization. Propose alternative treatments for patients who appear to quickly be running out of conventional options. And so on.

Go into the patient’s room with the senior resident or fellow, and gain a sense of what the plan for that day will be. You have no idea how helpful you can end up being when you run the list with the other junior residents later or when you spare the time to follow up on labs and imaging while the rest of the team is occupied handling tasks that only they can do with the MD or DO behind their name.

The intern may not be able to make time to be in the operating room, but you do. Since you are a sub-intern and not an actual intern, your priority is to get the most of your undergraduate medical education. However, you should be demonstrating your ability to be an intern in less than a year so don’t ignore the floor work. Also, not helping the intern and going to the OR the entire time will be noticed and not in a positive way since that isn’t really the function of a sub-I.

When you do go to the operating rooms, first (as always) you must know the patient you are operating on. Help roll the patients into and out of the rooms. Retract. Answer questions about anatomy, pathophysiology, ethics, or whatever else the attending or resident wants you to answer. Drive the camera. Again, this part won’t be much different from when you were a third year medical student. Let third year medical students have opportunities to scrub into cases you have seen before. If you desperately want to be involved in a case, and there are two students, ask the attending if both of you can scrub. Teach the third year medical student basic skills, and share opportunities to do procedures in the operating rooms and by the bedside with them. You had great residents and sub-interns when you rotated through that made surgery rock your world. Now it’s your turn to pay the favor forward.

If the team is short-staffed, your priority is to take care of the floor patients or clinic patients depending on where your are assigned. If you are done with your tasks on the floor, then make your way to clinic (even if you weren’t assigned), and see patients and present to the attendings. Come up with plans for the patients. Look out for your third year medical students and have them present to you before they present to the resident/attending, and help them polish their presentation.

Be proactive rather than reactive, and let your residents know what you are up to, especially once you have completed a task. If you ask if you can do anything to help, they will invariably reply, “No thanks. You really don’t have to. Seriously.” So if you see that they have a million and one tasks to complete, take the initiative to tackle a task within your ability that doesn’t put patients at risk, and provide your upper level with the completed result. That is the difference between a stellar, unforgettable sub-intern and one who is great.

Ask for help when you are unsure, and take advantage of this time to ask questions that may seem silly or dumb. Now is the time. While it sometimes may not seem to be the case, you shouldn’t be expected to know everything about surgery. Residency is after all a training process. It’s better to clarify what you don’t know now, rather than wait later when you have actual responsibility over patients.

Remember, not always knowing the answer is forgivable. What’s important is being reliable and teachable. Surgery is one of the most exhausting specialties out there, and not everyone has the physical or emotional fortitude to pursue the field. This has led to a phenomenon where even 80 hours per week are sometimes perceived as not enough. Thus, we don’t think we’re remiss in stating that a honest hard worker of above average intelligence is often preferred over a genius who can’t be relied on, a statement true for most walks of life but one that sub-interns should particularly take to heart.

Read: Just because you don’t have a shelf exam to prepare for anymore doesn’t mean you should stop studying. Read up on your patients. Find relevant articles. Create treatment algorithms and cheat sheets.

There are some folks who function well on three hours of sleep. If you are not that type of individual, give yourself permission to crash when you return home in the evening. Instead, set aside time early in the morning to jot down notes about the patients who will be operated on for the day. Be smart about it. If there are too many cases for you to scrub into, and you’re pressed for time, then concentrate on those whom you know for sure you will be operating on. For those patients, know the following:

o pertinent details from patient’s history, labs, and imaging

o indications for the operation

o crucial anatomy and steps of the operation

o possible short-term and long-term complications

o important details of perioperative management

Hopefully, if you have read up about each patient prior to their operation, then as the rotation goes on, you will be able to anticipate the general management and time course of all the patients on the service during their post-operative stay in the hospital.

Share what you have learned with the other medical students on your service. It helps guide their studying and cements the knowledge further in your mind. Remember the big picture. By helping others, you indirectly improve the care of those patients who will be one day be treated by other members of your team.

Pay it forward. Take the third year medical students under your wing. Teach them how to tie surgical knots. Share with them stories of your own frustrations and triumphs from your time as a third year. Remind them to eat. Buy them coffee, or share a granola bar. Help them with their presentations. Let them know when it is okay to text the upper level and ask, “is there anything else I can do to help?” which we all know is universal student code speak for “may I please leave?”

Lastly, if you really want to stand out, give the sub-intern and third year medical students who will trade you out for the next month a heads up about what to expect once they come onto service. This will make not only their lives easier but also relieve a weight off the shoulders of your upper levels. Your patients may even benefit from safer care.

You will impress everyone if you show them how helpful and kind you are to others, even when it doesn't directly benefit you.

In conclusion: what does it take to succeed as a sub-intern? If you can in anyway make the service run as smoothly as possible and life better for the residents then you can be rest assured that you’ve done a good job.

Did we miss anything? Let us know your own suggestions for sub-internship success in the comments below.

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Medical students, click here for more information on how to succeed on your third year medical student surgical clerkship.

Surgical interns, click here for advice on how to build the foundation for future success by starting off intern year the right way.

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Callie Thompson is a chief resident in general surgery at the University of Washington. Callie aspires to be a burn and trauma surgeon and a translational scientist. Her research interests include genetic variations and their associations with the development and outcomes of disease and illness. Callie is married to an internist and has three children ages 1, 3, and 7.

 







Jane Zhao is a general surgery resident at the University at Buffalo, State University of New York. She obtained her medical degree with a scholarly concentration in Clinical Quality, Safety, and Evidence-based Medicine from the University of Texas Medical School at Houston and completed her undergraduate studies in Medicine, Health, & Society at Vanderbilt University. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award and chaired the AWS Blog Subcommittee from 2013 to 2014. Her interests include healthcare social media, quality improvement, and public health. She can be followed on Twitter.

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The Importance of Mentoring

Last month, the Healthcare Leadership Tweet Chat (#HCLDR) invited me to participate as guest moderator to discuss The Changing Face of Medicine. You can read the accompanying blog post here. 

The weekly Tuesday evening #HCLDR chat engages a diverse community made up of patients, medical students, doctors, surgeons, residents, nurses, healthcare executives, and many others with a shared interest in healthcare leadership. Some international colleagues also joined from Europe, the Philippines, and Australia.

For many Tweeters, it was also the first time joining the #HCLDR Tweet chat. We were very proud to have the support of the American Medical Women’s Association (AMWA) and the Association of Women Surgeons (AWS).

The #HCLDR platform resulted in an engaging conversation on the importance of diversity in medicine. One question we discussed was how can we encourage women and other minorities to pursue careers in medicine/surgery or any non-traditional field?

Among the many excellent responses, a common theme emerged of the importance of mentoring.

Another important factor is to expose students to careers in medicine and surgery early. "Building the pipeline" can be achieved through personal interactions and through support of outreach programs and organizations. One of our AWS members recently wrote on her experience in showing young students what she does daily as a surgeon on The Power of a Stitch.

Demonstrating that diversity is important to the organization and showing students that doctors are also people they can relate to are other important aspects of mentoring. 

 

How do you find mentors? We previously tackled the topic of finding a Mentor in our Lean In Book Review, which you can find here.  A quick recap on working with mentors: 

1.            Be mindful of the mentor’s time

2.            Strangers can be mentors. Don’t be afraid to seek out someone no matter how much you admire them.

3.            “Excel and you will get a mentor”

4.            Have more than one mentor.

What has your own mentorship experience been like? Have you been a part of an organized mentorship program? How can mentoring be fruitful endeavor for faculty?

If you have not downloaded the AWS Pocket Mentor you may do so here. You can also read our AWS blog post for good advice passed down from our mentors.

Featuring 2013 ACS Surgical Forum Excellence in Research Award Recipient: Nicole Tapia, MD

General Surgery Resident Nicole Tapia, MD was honored a Surgical Forum Excellence in Research Award at the 2013 American College of Surgeons Clinical Congress held in Washington, D.C. Her work entitled "PACT Project: Standardized Resident Hand-off Implementation Improves Hand-off Quality" was also chosen as one of the top three resident presentations at the American College of Surgeons South Texas Chapter Meeting held in Austin, Texas during February 2014. The Association of Women Surgeons is proud to present Dr. Tapia’s work—in her own words—on the blog.

Standardizing Resident Hand-offs to Improve Hand-off Quality

by Nicole Tapia, MD

Morbidity and mortality conferences allow us to review our complications and ask ourselves if it was preventable, how it happened, and what we could have done differently to achieve an alternate outcome. There is usually a lesson to be learned during discussion of the adverse patient event, and a new best practice can develop as a result of such dialogue.

I have come to believe that the question of “what could I have done differently” is applicable to many realms of surgical life – struggling in the operating room with a new task, juggling management of a surgical team as a senior resident with both junior resident and attending expectations, and even balancing home and resident life. Recently, my institution offered an Advancing Clinical Excellence (ACE) in Health Care research grant which challenged residents to propose a study to improve health care delivery. They asked us to approach health care with a unique resident perspective and hypothesize and test our ideas.

Brainstorming with another research colleague and my research mentor, we agreed that a current hot topic which is omnipresent in resident work-life is the unintended consequences of the ACGME work hour requirements. In particular, our residents and staff have noted challenges that come with increased patient handoffs as we transitioned to a night-float system. We all agreed that anecdotally, we thought quality of patient care was likely worsened by this change.

Our research group determined that to test and study our hypothesis and improve handoffs, we needed to focus on verbal communication of patient information, as we work at several hospitals with varied electronic medical records and wanted our approach to be independent of a computer system. We set out to improve patient handoffs using a three-pronged approach: (1) determine current limitations and shortcomings of patient handoffs, (2) develop an ideal handoff, and (3) test the new handoff comparing subjective and objective quality measures.

Utilizing a focus group of residents and surgical staff to determine current limitations as well as the ideal handoff, everyone agreed that patients should be discussed based on acuity -- communication of events and plans of the sickest patients should occur first. This should be followed by in-depth discussion of the newest admissions, then changes to the current patients. Finally, a task review for the on-coming shift would be reviewed in top-down fashion. We developed a mnemonic, PACT (Priority, Admissions, Changes, Task review), to help our residents remember this discussion based on acuity.

Measuring pre- and post-PACT implementation, we found that with PACT implementation, residents had lower incidence of incomplete tasks and lack of patient knowledge on morning rounds, decreased discrepancy between junior and senior handoffs, and senior residents reported junior residents were better able to handle emergencies.

We were encouraged by our findings, but in true reflective fashion, thought we could further improve our handoffs. One limitation we found was that there were considerable interruptions during the handoff process. Additionally, we found that although residents were discussing the PACT content, they preferred to discuss patients based on list order – organized by patient location – rather than true acuity. Achieving complete buy-in to the new process has not been without resistance, even though our outcomes were excellent with improved handoff practices. As a result, we developed a second iteration of the handoff process (PACT 2.0) to address these limitations, and we are testing it head-to-head with our current PACT system, in a randomized controlled trial. We are currently analyzing the results and hope to report soon on our outcomes.

As a previous research resident and now third-year clinical resident, I have witnessed the junior residents transfer care of their patients with improved communication and feel confident that the night float residents have better knowledge of the patients on their census as a result of the work we have done so far. We introduced the PACT handoff system to our interns at orientation this past year and intend to do so again when they show up in late June. I feel privileged that through a unique grant opportunity at my institution, we were able to review our handoff process and ask ourselves not only what we could do differently, but also, were able to institute change.

Our experience has made me curious: How does your program do handoffs? Do you do handoff training?

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Nicole Tapia, MD, is a general surgery resident in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine, currently in her third clinical year. She recently completed two years of research, focusing on trauma and resident education. Nicole hopes to be a trauma surgeon at an affiliated academic center, where she can work with residents and medical students.

Compassion: Lessons from Roshi Joan Halifax

by Mary Brandt, MD

It’s not often that a talk completely changes the way I think about something.

I’ve been thinking and speaking about compassion fatigue for many years. I recently had the privilege of hearing a wonderful talk by Roshi Joan Halifax. She made a strong and convincing case that “compassion fatigue” is a misnomer… and that we should think about this in a very different way.

We can never have too much compassion nor can true compassion result in fatigue. 


Photo credit

Empathy and compassion are not the same thing.

Empathy is a necessary prerequisite for compassion, but compassion goes beyond empathy. Empathy is the ability to be with someone who is suffering, to be able to feel what they are feeling. Compassion, on the other hand, is being for someone who is suffering, being moved to act and find a way to relieve their suffering.



Link to Roshi Joan Halifax TED talk “Compassion and the true meaning of empathy”

Self-regulation is the key to being able to remain compassionate and this skill can be taught.
We all respond to situations of suffering with “arousal”, a state that varies in intensity depending on the severity of the suffering, and our own memories and experiences. How you respond to this state determines whether you can stay present, effective and compassionate. Roshi Joan Halifax offered the mnemonic “GRACE” as a way to teach this skill to medical students, residents, physicians, nurses and other health care professionals.

G: Gather your attention. Take three deep breaths. Be present.

R: Recall your intention. We choose careers in medicine to help heal the sick and to reduce suffering. It’s not easy to remember this intention when we are overwhelmed. But, in the moment we are faced with a human being who is suffering, we must let our own response (and the demands of the day) go and remember why we are here.

A: Attend to yourself. Being able to detect what is going on in your own body is the same “wiring” you use when you feel empathy. After gathering your attention and recalling your intention, pay attention to what is going on in your body. Watch your breath, feel where there is tension, pay attention to sensations.

C: Consider what will really serve. Moving from empathy to compassion is defined by considering the actions that will relieve suffering. Really consider the person and the situation and decide what is most likely to improve the situation.

E: Engage ethically.

“Developing our capacity for compassion makes it possible for us to help others in a more skillful and effective way. And compassion helps us as well.” Joan Halifax



Photo credit

This post originally appeared January 13, 2014 on Dr. Brandt's website Wellness Rounds

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Mary L. Brandt, M.D. is a professor of Surgery, Pediatrics, and Medical Ethics at Baylor College of Medicine and a practicing pediatric surgeon at Texas Children’s Hospital. She is involved in education on a day-to-day basis in her clinical work. She also thinks about medical education on a bigger scale through her work as Vice Chair of Education of the Michael E. DeBakey Department of Surgery and Associate Dean of Student Affairs at Baylor College of Medicine. She actively blogs and tweets.

A bit of kindness

by Amalia Cochran, MD

The following is an excerpt from an email I recently received from a mentee:

“I love, love, love surgery, but even as someone who has thrived in this environment, I now acknowledge that there are some aspects of the culture of surgery/academics/surgical and medical education that I am deeply unsettled by and wish very much to change. I see fellow students, residents, fellows, young faculty transform from being full of zeal and goodwill into angry, bitter, jaded people, and it’s absolutely disheartening to see. What’s more infuriating (to me because of the wrongness of it all and because I’m such a fixer) is that those who have been negatively affected and are the very ones capable of enacting positive change because they’ve “been there” sadly become the very ones who perpetuate the indignities of the broken culture, and they don’t even recognize that they’re doing so.”

Her important question that she asked me, and one that I found incredibly wise, was, “Did you ever struggle with this during your training or see this among your colleagues? Or even now?”

I asked her if I could answer this on the blog, and she graciously said yes. It was important for me to do so because I feel obliged to make some confessions related to her concerns.

The biggest one? I had many days during my residency when I was so tired, so broken, so frustrated that I wasn’t a nice person. While I was able to focus on doing the right thing for my patients, I could be and often was impatient with students who needed nurturing and staff who were still learning too. I was so Hell-bent on my own survival, on not making mistakes, on not showing any shred of evidence that I might not be able to succeed as a surgeon that I had no qualms about running over people. I nearly quit surgical residency during my PGY2 year because I didn’t like what I was my self becoming (then was nurtured by some VERY kind mentors who managed to help me hang in there).

I attribute a significant portion of my behaviors when they weren’t outstanding to sleep deprivation and not having a functional set of skills for coping with my chronic exhaustion. I also attribute some of my less-than-ideal behaviors to the surgical culture in which we were supposed to prove that we’re tough and don’t have flaws. Reality check: I may be resilient- I far prefer that word to “tough”- but I do have flaws. Sometime around my 40th birthday, I became okay with that.

• I want to believe I was asked about this topic because I’m seen as someone who is generally patient and supportive. A few key lessons have helped me get back to this place, one in which I think I existed prior to my 7 years of complete exhaustion and chronic stress.
• We’re all struggling. Every one of us is, in one way or another. That’s not a source of shame, it’s a source of humanity.
• If those moments in which your lesser self shows up are rare, people believe you when you apologize for your behavior.
• We are all learning, ever hour of every day. That’s what we’re here to do in a teaching environment.
• As someone in a position of leadership, my team and those around my team rely on me to set a tone. I don’t want that tone to be one of nastiness, blaming, and negativity because I want/ need a high-achieving team. Therefore, it’s up to me to be supportive, to be patient, to take a deep breath before reacting, even when my gut wants to say, “WHAT were you thinking?!?”
• When people are intimidated, their ability to think critically is impaired. Working in an ICU, I need everyone around me to be a critical thinker. Kindness does much more towards that end than bullying.
• If all else fails, go for a walk with the dog. Dogs are masters of this moment being the very best moment ever and that influence is contagious- particularly on a snowy day if one has a Siberian Husky in their life (as I do).

If nothing else I wrote tonight resonates with you, it’s my hope that a picture of an incredibly happy husky will help you pause and be a bit kinder.

This post originally appeared March 24, 2014 on Dr. Cochran's website Life in the Wild West

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Dr. Amalia Cochran is Associate Professor of Surgery at the University of Utah.  She is heavily involved in undergraduate medical education, serving as the Surgery Clerkship Director and the Director for the Applied Anatomy track for 4th year medical students at the University of Utah.  Her research interests lie in surgical education and in clinical outcomes in burns.  She is completing her term as Vice President for the Association of Women Surgeons. 

A Recipe for Success: One Surgeon's Story

 by Minerva Romero Arenas, MD, MPH

 

There are two questions that students frequently ask me about becoming a doctor. One is, “What did you do to become a doctor?” and “How did you stay motivated?” I often tell students attending the Tour 4 Diversity in Medicine (T4D) that becoming a doctor is like running a marathon. The pathway to medicine is long and challenging; I jumped through a lot of “hoops” (prerequisite courses, examinations, extracurricular activities, letters of recommendation, interviewing, etc.) just to get to medical school. At this point, I swear if their eyes get any wider they will come out of their socket. Then I tell them about the time I have spent in residency, research, and fellowships – and overwhelming is probably a gross understatement.

There are many factors that contribute to a person’s success – especially the success of a doctor. In my own personal path, I credit my success to at least four essential factors.

My family has been one of the main sources of strength and motivation. Like many immigrant families, we moved to the United States to pursue the American Dream. I was 8 years old when we moved, but since that young age I knew that my family (yes, I mean my parents, tías and tíos and abuelita) wanted better opportunities for our family. While my family never pushed me to be anything in particular, they always supported and encouraged me to pursue higher education – an opportunity they did not have. When a situation challenges me, I think back to how fortunate I am to have a loving and supportive family and any doubt is erased from my mind.

I also credit my mentors – yes, more than one – with a large part of helping me succeed. Some of them were professors who helped me stay on track and grow academically. Others were instrumental in helping me develop leadership and life skills. Yet others were research mentors or clinical mentors who helped figure out my interest in these fields. Even now as I am in my surgical training, I continue to keep in touch with some of these mentors and have even gained new mentors who are helping me grow and develop as a surgeon-in-training and future leader in healthcare.

I also found motivation in programs that helped me remember why I wanted to be a doctor. In college it was when I worked in certain clinics or doctors. In medical school, student-run clinics, organizations that connected me with other students and doctors who shared similar backgrounds or interests such as ending health disparities. In fact, even now that I have become a doctor and am completing my surgical training I still find it refreshing to remember why I chose this career in the first place. This is part of the reason I joined Tour 4 Diversity in Medicine. Talking to students about my love of surgery, or helping patients, or my research – it always help make me feel more
motivated.

Lastly, I tell students the most important factor in achieving success is the one that nobody else can help you with: hard work. There have been many people who have provided guidance, support, and opportunities that helped me achieve my dream of becoming a doctor. However, I know that my own effort helped me earn the respect and time of my mentors and make the most of the opportunities that were provided. Most importantly it has given me a source of pride and confidence that will continue to make me a successful person and surgeon.

This article was originally posted on February 5, 2014 on the Tour 4 Diversity website under the title "#T4DWest Day 2: A Recipe for Success – One Surgeon’s Story"

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Dr. Minerva Romero Arenas is a general surgery resident at Sinai Hospital of Baltimore and is completing a research fellowship at The University of Texas MD Anderson Cancer Center in Houston, TX. She obtained her MD and MPH from The University of Arizona, and studied Cellular Biology & French at Arizona State University. She is also involved in mentoring and public policy. On her personal time she enjoys spending time with friends and family, especially when it involves good food.

Interview with Dr. Diana L. Farmer

by Lauren B. Nosanov

Dr. Diana L. Farmer, an internationally renowned fetal and neonatal surgeon, is Chair of the Department of Surgery at UC Davis Health System, where she oversees more than 250 faculty, volunteer clinical faculty, post-doctoral fellows, residents, students, and staff who provide highly skilled, specialty services in bariatric, burn, cardiothoracic, gastrointestinal, plastic and reconstructive, oncology, transplant, trauma and vascular surgery. A recognized leader in pediatric surgery, Dr. Farmer is known for her skilled surgical treatment of congenital anomalies and for her expertise in cancer, airway, and intestinal surgeries in newborns and for her investigations on the safety and effectiveness of providing spina bifida treatments before birth.

At a recent American College of Surgeons Chapter meeting, I was fortunate enough to attend a Women in Surgery luncheon featuring Dr. Farmer. Among the topics she discussed was the journey she took from the beginning of her career to her current position as Chair of Surgery at UC Davis. She had a great deal of wisdom and advice to offer for surgeons at all points in their professional life. Below she shares some of these insights.

Q: You have taken what some would consider an unusual path through your career. What do you consider to be the most crucial turning points that have brought you to where you currently are?

A: Following my husband to match our careers allowed (forced) me to spend three years in the Lab. My resident surgical oncology lab time (two decades ago) working on adoptive cellular immune therapy for cancer, has proven to be unexpectedly valuable in my career as a pediatric surgeon now working on stem cell therapies for children’s surgical diseases.

Q: What roles have mentorship and networking played throughout your career development? 

A: In the early days, mentorship and networking were less formal, and I would define it as functioning more by observing people who served more as role models than mentors.

Q: Does being a woman affect the way in which you approach your position as Chair of Surgery? If so, how?

A: I don’t think that being a woman affects my approach to the Chair job. It’s a very maternal/paternal kind of job in a very big family!

Q: What advice can you provide to our younger members looking to have a successful career in academic surgery?

A: Follow your passion, “lean in,” don’t be afraid to try things and fail.

~~~

Lauren Nosanov is a fourth year medical student at the University of Southern California Keck School of Medicine. She spent a year before her last year of medical school as a Dean’s Research Scholar, dedicating her time to clinical research in the field of Trauma and Critical Care. Having loved surgery from the very beginning, she is excited to start her General Surgery residency in a couple of months. She is passionate about issues surrounding surgical education, mentorship, and finding a balance between motherhood and medicine. Outside of medicine she enjoys practicing Taekwondo and spending time with her husband and children.

Why I Started Tweeting and Blogging

by Sophia K. McKinley

For years, I limited my participation in social media: my tendency is to untag all photos of myself on Facebook, and as recently as six months ago I had never visited Twitter.com. I do have some experience writing personal travel blogs, but the main purpose of those online posts was to communicate to an audience of one (Hi, Mom) that I was safe and sound despite being thousands of miles away from home. If you had asked me a year ago why I wasn’t more engaged with the online community, I would have responded that I was too introverted and private, or that I had nothing worth sharing with other people.

Today, I have a Twitter account and have written blog posts for both the Association of Women Surgeons and the Association of Academic Surgeons. I’ve even explored options for launching a personal website, though instead of describing which remote destination I’ve visited, this website will outline my research interests and link to my Twitter feed.

It sounds implausible, but I began to overcome my hesitation to develop an online presence through an old-fashioned essay writing course. The instructor, Nancy Sommers, embraces a philosophy that everyone has a story to tell and that the world is better off when those stories are shared. The essays my classmates wrote were fascinating not because they were perfectly polished, but because they were genuine and authentic. Their stories were interesting and full of meaning, and I found myself thinking this might also be true of my own life. I was forced to reconsider my assumption that I had nothing to contribute to a larger conversation.

The next experience that pushed me to become more active in social media was hearing a talk by Dr. Mary L. Brandt at the Women in Surgery Career Symposium in San Francisco. Dr. Brandt provided an outline for creating an online presence and reviewed useful applications for tweeting and blogging, but the most important thing I learned was that the online world is still dominated by written language. Previously, I thought that the kinds of individuals who shared frequently online would be extroverts who easily navigate cocktail parties and always have a snappy verbal reply at the ready. I’m most confident when communicating through writing, so viewing tweeting and blogging as forms of writing made these activities less daunting.

There continue to be moments when I cringe at the thought of other people reading my tweets and blog entries. Sometimes I wonder if I am oversharing, or if I’ve only added noise to an already crowded internet. What keeps me stepping outside my comfort zone and hitting that “tweet” button one more time is the overwhelmingly positive feedback on what I have already transmitted into cyberspace. Just a few tweets and blog posts have led to productive face-to-face networking opportunities with other medical students, surgical residents, and even leading surgeons.

I may never stop untagging photos on Facebook, but I now consider Twitter and the blogosphere as additional writing venues within my professional life. Whatever hesitations you may have about establishing an online presence, I’d urge you to be courageous and dip a toe into the social media waters. Not as warm as a Balinese beach, but that’s a post for a totally different blog.

~~~

Sophia is a dual-degree M.D./Ed.M. student at Harvard Medical School and the Harvard Graduate School of Education. She received the 2012 Association of Women Surgeons Patricia Numann Medical Student Award and spent a year as a Zuckerman fellow at the Center for Public Leadership at Harvard Kennedy School. Sophia is passionate about medical education, and she hopes to be an academic surgeon who brings educationally-sound innovations to surgical training. Her clinical interests are gastrointestinal and minimally invasive surgery. Sophia is in the process of applying for general surgery residency for the 2014 Match cycle.

Creating your own academic timeline

by Christina Cellini, MD, FACS, FASCRS

This topic came to me during a grand rounds given by a well-known surgeon in his mid-career - henceforth will be referred to as “WKS”. I had just returned from my second three-month maternity leave in two years and was looking forward to hearing about what advice he had to give.

That morning WKS gave a talk about how he advanced academically starting from residency to his early attending years that eventually led to his promotion to associate professor. His talk was very informative, and he made a really big deal about being present for your family while trying to achieve your goals. All in all it was a thoughtful presentation. However a few things caught my attention and highlighted how everyone’s situation is unique.

One piece of advice given was that one should constantly “be writing papers” and even to “get up at 4 am before work” to write in order to fulfill that goal.

4am??? I thought back to what I was doing at four A.M. that morning. Oh right… I was nursing an infant. I’m certain that’s not something that ever stood in his way of writing papers. Oh well, no time for paper writing this morning. Maybe tomorrow.

His next piece of advice was to take advantage of all the wonderful scholarships and traveling opportunities that are catered towards young attendings under the age of 45 . He showed lovely pictures of him and his family frolicking around a foreign country that was many time zones away.

I thought- wow! I didn’t know about these awards. I should think of putting something together. Then I thought of the logistics- I don’t think I’ll be able to leave my tiny children away for that amount of time. And since these days I need to plan about an hour in advance to take both kids out to a trip to Target…. maybe in about 5-7 more years. But then I’ll be too old for these scholarships!

Finally he mentioned being involved in society meetings and to bring family along so that you can take advantages of the opportunities there while your spouse and kids go and do fun things in the area. See- you can work and spend time with your family as well! I thought- that might be doable. I did have to skip the last 2 of my society meetings because I was either too pregnant to fly safely or did not have the resources to travel with an infant. Let me ask my husband how he’d feel about watching the girls in a strange place for a week while I do my surgery thing. I texted him- I got back “absolutely not”. Apparently dealing with two cranky, nap-less, off schedule children by himself while I do my own thing most of the day was not my husband’s idea of “family fun”. He encouraged me to go alone. Now don’t get me wrong- my husband is awesome and takes care of the lion’s share of child rearing and is supportive of my career- but I couldn’t blame him for not wanting to sign up for that.

WKS had a number of great ideas that worked for him to achieve academic success so quickly in his career. I am certain there are many young surgeons - both men and women- who can achieve that as well. However, WKS had a personal situation that allowed him to flourish early on. He was able to follow the typical academic timeline that usually consists of publishing 2-3 papers/year, obtaining some sort of early career development grant or funding in the first 5 years as a means for future funding, active involvement in the ACS and specialty societies - all in addition to growing one’s clinical practice at the expected pace. With this timeline one can usually expect promotion to associate professor within five years or so. I know that I will not be able to keep up with that timeline. My path to promotion will likely take a few (or more) years longer than others. Occasionally I get antsy about it when I perceive that my peers are advancing faster than me or that I am in some way “behind”. However, I have been lucky to have colleagues and mentors that understand my need to slow down for my family and are supportive of an “extended” academic timeline to academic advancement.

Now, if you can breastfeed and write scientific papers at the same time go for it! If not, I suggest the following:

1) Take some time to really think about what your future academic goals are. Make them very discrete, not ambiguous. Also, take the time to write them down.

2) Prioritize the goals and create a timeline to go with them. Give some real thought as to how you might go about achieving these goals. Again, the more specific you are, the more likely you are to realize them.

3) Share your academic timeline with a more senior colleague or mentor. Doing so may help you identify potential opportunities or pitfalls in your strategy that you may not have considered. As always AWS members are available to help- and have likely been in your shoes at one time or another!

4) Periodically look back on what you have written and adjust as necessary. Do not feel bad or guilty if it takes longer than you thought. Try not to fall into the “keeping up with the Jones’s” trap that can be prevalent in surgery (I know I have on more than one occasion). Take the time to write down and reflect on everything that you have accomplished up to that point. Remember no accomplishment is too small! As long as you remember what’s important to you and keep your eye on the prize you will no doubt be able to balance your personal and professional life and accomplish what you have set out to do.

Readers, how have you adjusted your own professional timeline to achieve both personal and professional goals in a reasonable manner? Share your thoughts below.
 

~~~

 

Dr. Christina Cellini is an Assistant Professor of Surgery and Oncology at the University of Rochester Medical Center in the Division of Colorectal Surgery. After obtaining her undergraduate and medical school degrees at Cornell University she trained in general surgery at the NewYork Presbyterian Hospital-Weill Cornell Medical Center. Following residency, she completed a fellowship in Colorectal Surgery at Washington University in St. Louis. She recently completed a Masters in Medical Management at the Simon School of Business at the University of Rochester. She lives in Webster, NY with her husband and 2 children and enjoys running and snowshoeing in her free time. Dr. Cellini serves on the AWS communication committee.

Pregnancy during Medical School & Residency

by Callie Thompson, MD

I have read a lot of discussions about “the right time” to have a baby during a career in medicine and most of them come to the conclusion that there is no right time. I don’t think that is really accurate. The more correct answer would be that the right time is entirely dependent on you and your situation. I feel well prepared to write this blog and give this advice because I have been pregnant during both medical school and residency (twice).

In chronological order, I will start with pregnancy during medical school. The first two years of medical school are typically spent listening to a lot of lectures and studying almost all of the time. The third year is usually heavy with clinical work and spending a lot of time in the hospital. And the fourth year is usually a few sub-internships and a lot of light rotations at your home institution. So, where would a pregnancy, birth, and caring for an infant fit in there? Again, it really depends on your situation. You have to weigh the physically demanding state of gravidity with what you will need to be doing at that time. If you are concerned about being on your feet all day, then maybe being pregnant in the first two years would work best for you. You also have to take into account the demands of a newborn/infant. If you need a lot of time to study or are not great at multitasking, then having a newborn prior to taking your USMLE Step 1 might not be the best idea for you. No matter what you decide, you must have a viable option for childcare in mind. I suggest that you do this prior to even becoming pregnant because you will need help.

Regarding taking time away from school, there are no universal rules as to how much time can be taken. This will be school dependent. You just need to make sure that you can fulfill the requirements to earn your degree. Some people choose to take an extra year and make medical school a total of five years to allow them to have their child. I do not think this is necessary for everyone and you are going to know your capabilities best. Don’t let someone push you into a 5th year just because others before you have chosen to do that.

Pregnancy in residency is a bit trickier because of the American Board of Surgery requirements for General Surgery Certification. I had a baby during clinical R3 year and another while I was out in the lab. From a time-off perspective, having a baby during your lab years is much easier. If you are NIH funded through a training grant you can have 6-8 weeks, though some lab work can be done from home so the actual time you get to spend with your newborn can actually be longer than that depending on your research. Having a baby during your clinical years requires a good understanding of “the rules.” The ABS states that:

“To be eligible for ABS certification in general surgery, the following must be completed: At least 48 weeks of full-time clinical activity in each residency year, regardless of the amount of operative experience obtained. The 48 weeks may be averaged over the first three years of residency, for a total of 144 weeks required, and over the last two years, for a total of 96 weeks required."

“For documented medical problems or maternity leave, residents may take an additional two weeks off during the first three years of residency, for a total of 142 weeks required in the first three years of training, and an additional two weeks off during the last two years of residency, for a total of 94 weeks required in the last two years of training.”

Translation: You can average your time over the first three years so, in theory, if you didn't take any other time off for three years, you could have a 14 week maternity leave. Similarly, if you didn't take any time off for vacation during your last two years, you could have a 10 week maternity leave.

In actuality, that isn't possible. For instance, you would have to know that you were going to get pregnant and have a baby during third year so that you could forgo a vacation in your first 2 years. And if you did that, you would surely go insane. So if you did take the regular 3 weeks of vacation a year, you could have an 8 week maternity leave during the year you did have the baby—as long as you don’t take any other vacation that year. A baby during the last two years is even more difficult because of the time constraints. Also, keep in mind that none of this accounts for the possibility of medical problems during the pregnancy and any time off that may need to be taken. None of this is meant to dissuade you from pregnancy during residency (see above where I state I did it twice) but knowledge is power and you have to be prepared to extend your training if you are unable to meet the ABS requirements. This is most important during the last 2 years because they have to be done in succession so if you were to get pregnant, become ill, and need extra time off during your 4th or 5th year, you may be required to start over at year 4.

This blog could end up being very long so the last topic that I will include for today is when/how to tell people when you become pregnant. I advocate telling people when you feel comfortable. For some people that is the minute you find out, for others it is after the first trimester. However, I would not wait much beyond the first trimester because arrangements will need to be made, either to your schedule if you are a student or for coverage from your co-residents if you are a resident. I also would also advise you not to tell anyone else before you tell your Dean or medical school adviser (for students) or your program director (for residents). It is best to give big, personal news yourself, and in person.

~~~ 

Callie is a resident in general surgery at the University of Washington. She completed a two-year research fellowship and is now in her fourth clinical year.  Callie aspires to be a burn and trauma surgeon and a translational scientist. Her research interests include genetic variations and their associations with the development and outcomes of disease and illness. Callie is married to an internist and has three children under the age of 7.
 

Sexism & Surgery

by Amalia Cochran, MD, MA, FACS, FCCM

How many of you saw this great piece from Emily Graslie a couple of weeks ago? 

 

I loved this video for a couple of reasons. One is obvious if you are familiar with her work- Emily’s video series from The Brain Scoop is a terrific, user-friendly approach to science. The other was that I honestly empathized with the comments that Emily included in her video, as I suspect many of us do, and I loved her approach to dealing with sexism and science. She’s no-nonsense about it and addresses the issue head on.

I thought back to my first encounter with sexism in medicine, going back to high school. Our family’s physician, upon being told that I was leaving for college at the end of my junior year under an early admission program with intent of going to medical school, simply commented, “Well, I guess it’s okay for women to be physicians these days.” No, he wasn’t joking. No, he never treated me again (nor my mother). I’ll admit- this was almost 30 years ago, and with the entry of more women into medical school many things have changed. Or have they?

Plenty of research shows that female medical students often experience gender discrimination, and that this occurs most commonly on their surgical clerkships. Women medical students are more likely to experience gender discrimination during their surgical clerkship than are their male counterparts and are more likely to perceive sex discrimination, typically from male attendings and male residents. My own recent work has shown that female surgeons and residents are more concerned about the presence of sex discrimination in the workplace than are their male colleagues, and that they perceive this discrimination as a barrier to advancement in academic surgery. Clearly this problem isn’t just one of the 1980s; it persists in modern-day medicine.

Stories of incidents can be gathered easily enough from many sources; in one night on Twitter I was able to acquire stories ranging from colleagues or patients refusing to address a woman physician as “Doctor” to women being told they are “too nice” to be a surgeon, or being told that they are allowed to do more in the OR because of their looks. While the overt sexism remains, many institutions are starting to consider the role of “implicit bias,” those subtle behaviors and actions that manage to undermine the leadership and credibility of any minority group. Yes, women surgeons are still a minority group.

So back to where we started, with Emily Graslie’s video. We have a problem still, and what we need is a solution. We can start by speaking up when we hear sexist comments- particularly those of us who are a little more senior and have less to lose than our younger colleagues. We can also work within our institutions to increase awareness of implicit bias in hopes that this will have a durable impact. And, as Emily Graslie stated, “We need to make sure we’re making it possible for people of all genders to feel acknowledged for their contributions and not feel held back by something as arbitrary as their genetics or appearance.”

How have you experienced sexism? And, perhaps more importantly, how have you dealt with it when you have either experienced it or witnessed it?

This post was originally published on Dr. Cochran's blog, Life in the Wild West.

 

~~~

Dr. Amalia Cochran is Associate Professor of Surgery at the University of Utah. She is heavily involved in undergraduate medical education, serving as the Surgery Clerkship Director and the Director for the Applied Anatomy track for 4th year medical students at the University of Utah. Her research interests lie in surgical education and in clinical outcomes in burns. She is Vice President of the Association of Women Surgeons. Follow her on Twitter. Visit her blog. 

There’s Something In the Water

by AWS writer, Denise Harrigan

Often-invisible but highly influential, second-generation gender bias often impedes women’s ascent to top levels of leadership. The Harvard Business Review intends to expose it.

Fifty years after women were first admitted into Harvard’s MBA program, the September 2013 issue of The Harvard Business Review (HBR) examines the status of women in the business world. The cover alone – with a silhouetted female profile and the words “Emotional – Bossy - Too Nice ” -- reveals that women are floundering, not flourishing.

The bottom line is that only four percent of Fortune 500 companies have female CEOs, and 50 of those companies have no female board members. According to Adi Ignatius, editor-in-chief of HBR, women remain “distressingly underrepresented at the top levels of institutions.”

The HBR focus is not on the numbers -- those numbers, in recent years, have been documented to death. The goal, according to Ignatius, is “finding practical new solutions to a seemingly intractable situation. Closing the leadership gap is a formidable challenge. But there’s no excuse for accepting the status quo.”

The issue, part of the Harvard Business School’s global effort to accelerate the advancement of women leaders, features major articles on persistent gender bias and inclusiveness as a mission and moral imperative.

Unfortunate Legacy

The article “Women Rising: The Unseen Barriers,” by Herminia Ibarra, Robin Ely and Deborah Kolb, examines undercurrents that impede women’s progress and identifies second-generation gender bias as a major but rarely acknowledged impediment.

Where first-generation gender bias involved the deliberate exclusion of women, the second generation “erects powerful but often subtle and invisible barriers for women that… inadvertently benefit men while putting women at a disadvantage.”

Insidious

As a result of second-generation gender bias, unspoken cultural perceptions about women often carry more weight than job performance. Perhaps the most insidious belief is that men are natural leaders, and women are followers.

“In most cultures, masculinity and leadership are closely linked,” the authors report. “The ideal leader, like the ideal man, is decisive, assertive and independent. In contrast, women are expected to be nice, caretaking and unselfish.”

Linking leadership with common male behaviors suggests that women are not cut out to be leaders. It can also create a double standard. Assertive men, for example, are admired – and promoted. Assertive women are advised to “soften their sharp elbows.”

As a result, many women waste professional energy trying to project the perfect image -- not too pushy, not too nice. According to the authors, some employ voice coaches, image consultants, and branding experts “to manage the competence-likability trade-off— the seeming choice between being respected and being liked.”

“But the time and energy spent on managing these perceptions can ultimately be self-defeating. Overinvestment in one’s image diminishes the emotional and motivational resources available for larger purposes. People who focus on how others perceive them are less clear about their goals, less open to learning from failure, and less capable of self-regulation.”

Leaders Are Made, Not Born

Leadership is not an innate gift – it’s a skill that requires practice. More often than not, men are given opportunities to practice this skill. The workplace, still predominantly led by men, instinctively grooms men for leadership positions, creating stepping stones where men can practice leadership skills.

According to the authors, “Women have fewer opportunities to develop leadership skills and seem less inclined to create these opportunities for themselves.” By nature or nurture, women often gravitate to behind-the-scenes positions, and their efforts fade into the blur of teamwork.

Internalizing Leadership

“People become leaders by internalizing a leadership identity and developing a sense of purpose,” the authors observe. “Internalizing a sense of oneself as a leader is an iterative process. A person asserts leadership by taking purposeful action—such as convening a meeting to revive a dormant project. Others affirm or resist the action, thus encouraging or discouraging subsequent assertions. These interactions inform the person’s sense of self as a leader.”

In the wake of positive affirmation, “a person’s leadership capabilities grow. Opportunities to demonstrate them expand. High-profile, challenging assignments …. become more likely. Such affirmation gives the person the fortitude to step out-side a comfort zone and experiment with unfamiliar behaviors and new ways of exercising leadership.”

Well-Meaning but Off Center

The authors of “Women Rising” acknowledge that many companies attempt to level the playing field for women. “Many CEOs make gender diversity a priority, set aspirational goals for the proportion of women in leadership roles”…. and invest in building “a more robust pipeline of upwardly mobile women.

“But then, not much happens,” according to the authors. “The solutions to the pipeline problem are very different from what companies currently employ. Mentoring and leadership education programs are necessary but not sufficient.”

Deeply Conflicted Culture

“These approaches don’t address the often fragile process of coming to see oneself, and to be seen by others, as a leader. Integrating leadership into one’s core identity is particularly challenging for women, who must establish credibility in a culture that is deeply conflicted about whether, when, and how they should exercise authority.”

Call It by Name

Since second-generation gender bias “can be subtle, subconscious, assumed but not articulated by both men and women,” the authors recommend that employers begin to address it by simply naming it.

“Second-generation bias does not require an intent to exclude; nor does it necessarily produce direct, immediate harm to any individual. Rather, it creates a context—akin to ‘something in the water’—in which women fail to thrive or reach their full potential.

“Without an understanding of second-generation bias, people are left with stereotypes to explain why women as a group have failed to achieve parity with men: If they can’t reach the top, it’s their own fault for failing to be sufficiently aggressive or committed to the job.”

Alternative Reality

By identifying and addressing second-generation bias, however, companies can finally move toward gender equity – and an executive suite that “doesn’t look or behave like the current generation of senior executives.”

“When women recognize the subtle and pervasive effects of second-generation bias, they feel empowered, not victimized, because they can take action to counter those effects,” the authors promise. “They can put themselves forward for leadership roles when they are qualified but have been overlooked. They can seek out sponsors and others to support and develop them in those roles. They can negotiate for work arrangements that fit both their lives and their organizations’ performance requirements.

“Such understanding,” the authors conclude, “makes it easier for women to ‘lean in.’”