Early Lessons in Leadership

by Sophia K. McKinley

Do you consider yourself a leader?

For most of medical school, I did not consider myself a leader. To me, leaders were people with big personalities and big visions, the kind of individuals who could inspire passion in large crowds or start political movements. I was a quiet-voiced student at the bottom of medicine’s hierarchy – surely not a leader, and in no position to lead.

My perspective on leadership changed dramatically while spending a year as a Zuckerman Fellow at the Center for Public Leadership at the Harvard Kennedy School. Every week I participated in three hours of leadership training in the form of small-group seminars with prominent individuals, workshops on practical skills such as public speaking and negotiating, and personal development sessions. Whenever anyone asks me what I learned over the course of the year-long leadership curriculum, I always identify the same three take-aways:

1. Leaders are made, not born

I used to think some people were leaders and others weren’t. Now, I see leadership as a skill that can be cultivated, practiced, and improved. This shift in attitude has meant that even when I don’t feel as if I am a leader, I still see myself as someone who can learn to become a leader. And, I am now on the lookout for opportunities to practice leading and to gain skills as part of a lifelong process of becoming an increasingly skilled leader.

I expect surgery residency will be full of opportunities to practice leadership skills. Oral presentations will be public speaking practice, and overnight call will serve as an exercise in prioritization and time management. Leaders need excellent interpersonal and teamwork skills even in tense situations—where better to deliberately develop these abilities than the operating room? No one expects newly graduated medical students to show up to intern year as fully formed surgeons. I now know it is just as unrealistic to expect myself to be a fully formed leader.

2. Self-understanding matters

Leadership is about influencing other people. In order to do this better, I realized I first needed to understand myself and my own behaviors. Through a variety of assessments including emotional intelligence evaluation and a 360 feedback process, I gained a greater understanding of how my actions were influencing those around me.

For example, I learned that I often concede what I want in order to avoid negotiation. But in surgery, being a leader often means effectively advocating for patients in difficult situations. Awareness of my tendency not to press my agenda means that in future conflicts, I can reflect on whether I am being assertive enough, or whether I am failing to identify collaborative, “win-win” solutions that satisfy all parties including myself. I now know that a key to my future success as a leader will be improving my negotiation skills. Yet gaining self-understanding isn’t just about identifying weakness—it’s also about understanding strengths. Nearly all of the individuals who provided me with feedback during my 360 evaluation commented on my written communication skills. I know that for me to be the most effective leader possible, I should capitalize on my ability to influence others through writing.

3. Leadership happens at all levels

Finally, I no longer believe that leadership is solely the purview of those at the top. While leadership manifests itself differently at different levels within an organization, individuals at every position in a hierarchy can exhibit leadership. One of the most common definitions of leadership is acting in a way that enlists the support of others towards the accomplishment of a common goal. A title that indicates authority or power is not necessary to engage in leadership of this kind.

Think of a situation during medical school, residency, or beyond in which a group of individuals at the same level were given a task or assignment. Even without adopting formal roles or titles, some individuals functioned as group leaders because their behaviors influenced others towards superior performance in task completion. And probably everyone has been on a medical team in which the individual who did the most to improve group performance was not the team’s most senior member. As I enter intern year and beyond, I hope to be the kind of resident who exhibits leadership by influencing others to better achieve common goals. What I do to exhibit leadership may change as I rise through surgery’s ranks, but no matter what level I am, there will be opportunities to function as a leader, even if that means leading by example to peers and more junior trainees.

Not everyone has the experience of participating in a formal leadership curriculum across a year, but everyone can reflect and seek feedback to gain better self-understanding of leadership strengths and weaknesses. We can all seek opportunities that will develop particular leadership skills, and we can consciously practice leadership in the setting and position we currently work and learn. Hopefully, when asked “Do you consider yourself a leader,” more women surgeons will affirm, as I do now:

“I am a leader.” 

~~~

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 currently interviewing for general surgery residency during the 2014 Match cycle.

Unconventional: Our Couple's Match Story

by Brittany Bankhead-Kendall, M.D., M.Sc.

Match Day 2012 was supposed to be the best day of our lives. Or one of them, at least. But it was so, so not. Monday morning my husband and I left our respective rotations around 11:45am and hopped into our SUV in the hospital parking lot in anticipation of the noon email saying we had matched. We wanted to celebrate that together. My email came: "Congratulations! You have matched to a one year preliminary position." I was devastated. But it got worse. My husband's email came: "We're sorry, you have not matched to any positions."

Can that happen? Did that just happen? I didn't think that was possible. Our numbers were right. We had plenty of interviews. We were matching Emergency Medicine (him) and Surgery (me). A difficult match, but not an impossible one. Right?

He was the better candidate, but we thought Surgery was the harder match. So at match choice #18, after all of our same city match choices, we listed a match-no match option. The thought was that in this certain city we chose, surely he could find something to do for a year. A big city, close to my family, lots of options. We assumed he would at the very least be able to find a preliminary surgery spot at one of the four hospitals in the area. Prelim surgery spots aren't hard to find, right?

We drove straight from the hospital parking lot to a McDonalds and hooked up the laptop and filled out his SOAP application. He applied to all the Surgery Prelim spots in my city (the NRMP will tell a couple, in a match-no match situation, the city of your match). Tuesday, Wednesday, and Thursday came; no interviews, no offers. Match Day came and went, we "celebrated" at home with our baby boy and my parents, and occasional tears.

Then we looked for research positions for the year for him. And... Nothing. We tried, we weren't even picky. But he was over or under qualified for anything we found.

Then one day, out of the blue, he got an email inviting him to interview across the country for a position in Emergency Medicine. He got the position. And yet we struggled with it. Was this a temptation that he should pass on? Was this a blessing? Was it great for his career at the expense of our family? Would we be able to survive without each other? Could I be a surgery intern, with our BABY, without him?

Ultimately, he took the position. We're tough. Yes, he and I are tough. But what I also mean is that we women physicians are tough. We're a different breed, I think. No one can tell us no. No one can put anything in our path too great to achieve our goals. No one can tell us we can't love our job and love our child. No one can tell us we can't do it without certain features of our home life lined up. We can do it.

It's hard every day. That I won't deny. It's hard being away from my best friend and confidante; the person I want to vent to and hug and go on dates with and share in our son's new milestones and that he finally says "Mama." It's hard being a "single" parent. It's hard knowing my son is not with his mom or his dad 24-7. It's hard when your child reaches for their grandmother for comfort when they fall and you are both standing there. And oh yeah- it's hard being a surgical intern, period.

But I'm blessed. We're blessed. Training looks different for everyone (we went to a school where our basic sciences were in the Caribbean; more on that another day). Life looks different for everyone. Just because it's different doesn't make it wrong or weird or not doable. We've learned a lot along the way, and talk about it a lot (when our shifts don't overlap, that is). I'll sum it up for you, in case it would help anyone else along the way . . .

1. Don't be too proud to apply to different locations if you're couple's matching. You'd rather be a doctor in a different geographical location than not-a-doctor in the same location.

2. Surgical preliminary spots aren't as easy to get into as you might think. I think that's the going rate for almost any residency these days.

3. There's lots of spots outside the match that you don't hear about unless you look for them in the right places. Look on your specialty's program director website (a good place to start) to see if there are open positions outside the match.

4. Don't panic if things don't go how you saw them. Where there's a will, there's a way. Don't let anyone tell you something isn't possible.

5. Family comes first, but deciding to be apart doesn't mean they don't still come first. Don't feel bad for choosing it. It doesn't mean you ranked them of less importance. It just means your story looks different.

6. Speaking of stories: Life looks different for everyone. You can use yucky situations for learning and growing, or for being miserable. It's a choice.

7. When you rank programs, go where you love. The rest will fall into place.

Of note- at the time of publication of this blog, my husband has an interview for an open PGY1 EM position that came available in late July right down the street at a phenomenal academic center.

Either way, we know what we've learned through all this.

Either way, we're good.

What obstacles have you overcome to achieve success? Do you have any words of advice for surgeons or aspiring surgeons who are going through a difficult time? Please share your thoughts in the comments below.

~~~

Brittany Bankhead-Kendall, M.D, M.Sc. is a PGY1 general surgery resident at Methodist Dallas Medical Center. She obtained her M.D. from Ross University School of Medicine, M.Sc. from Barry University in Biomedical Science, and studied Biomedical Science and Spanish at Texas A&M University. She enjoys being a surgical intern and mentoring medical students. In her personal time she enjoys spending time with her husband and son, interior design, international travel, and Texas Aggie football.

Internship: Ready, Set, Go!

by Callie Thompson, M.D.


Congratulations to all of you newly minted Doctors of Medicine! It is almost time to start your internships! You are probably trying to imagine what it will be like, and you are probably excited, nervous, scared, and maybe even a little nauseous.

This transition from medical student to doctor will be a big adjustment. But don't worry, you really can (and will) do this. I will start with a few general tips for how to succeed in your internship and then finish with some more specific tips that you will hopefully find helpful.

1. The patient comes first. Always. They are your North Star. When you lose your way, ask yourself "What is best for my patient?" and do that.

2. Be the doctor. I know, this one seems obvious, but you just graduated 3 weeks ago and now someone is calling you "Dr. So-and-so" and you feel both scared and like a total fraud almost all of the time. However, your patients and your team still depend on you. You are their "Dr. So-and-so" and you need to act like it. Have assessments, have plans and be willing and able to explain your reasoning for them.

And don't forget to introduce yourself as "Dr. (YOUR LAST NAME HERE)"--you earned it.

3. Always worry, but never worry alone. If you load that proverbial boat early, at least you won't sink alone. If someone on the floor is going south, assess them and then let your senior resident know. Immediately. No one expects you to be perfect; you will be learning and improving for the rest of your life, but we do expect that you will not keep secrets from us.

4. Never lie. Not to your seniors, not to your attending, and not to the patient.  I know that these people will be looking at you and wanting to hear "good news" but your only job is to be honest, to tell them the truth. Trust is what your relationships with these people is built on; lying, even once, can permanently damage that relationship and worst of all, put the patient at risk.

5. Utilize the nurses, but don't let them use you. The nurses can and will be your best friends. They have experience, and they can teach you infinite amounts. If they call and tell you someone is sick, listen to them. Don't let your ego get in the way. Everyone is on the patient's team. The flip side of this is that some people will take advantage of your "newness" and they will ask you to do things that seem wrong to you. If that is the case, don't do it. Politely tell them that you need to check with your senior, and check with your senior.  No one should get offended by that, as long as you remain polite and respectful.

6. Ask your senior residents and attendings for their expectations of you. There is nothing worse than finding out that you are falling short of expectations that you didn't know existed. Asking for expectations up front will lessen their potential frustrations, and yours.

7. Ask for feedback from your seniors and attendings. Don't wait for the end of a rotation to get an evaluation. That leaves you no opportunity to fix things and get better. Ask for feedback in the middle of your rotation (a great time for this is when you are finishing up a case) and then they will know that you were interested in improvement, and they will be able to recognize when you have improved.

And for the interns who are parents:

8. Set goals for yourself and your family. Make promises to yourself and your family about when you will study and prepare for your patients and when you will just be present for them. This is going to be an especially big period of adjustment for you, your partner, and your child(ren), but you'll get through it. Have patience with yourself and with them.

Now for a few specifics...

Must-use Websites & Apps:

1. NCCN Guidelines. The absolute best resource for guidelines for treatment of cancers. This site will help you immensely in clinic--and they have an app.

2. Up-to-date. Obviously.

3. Epocrates. Again, obviously.

4. ACGME case log mobile app. Immediately enter all of your cases after you complete them. Seriously, don't let them stack up. I had to enter an entire year's worth at one point, and it was obnoxious. Open the ACGME case log site on your iPhone (if you know how to do this on a non-Apple product please weigh-in in the comments below), click the rectangle with an arrow icon on the bottom of the page, and then click "add to home screen."

5. Twitter. Join twitter, follow people and organizations that you are interested in, and just watch. I have read more journal articles in the two months since joining twitter than I have in the prior two years. I recommend the Association of Women Surgeons, American College of Surgeons, Journal of Trauma, Annals of Surgery, NEJM, JAMA, and Journal of Burn Care and Research, but there are many more.

6. DrawMD apps. A perfect way to explain an operation to a patient.

7. Other useful (but potentially costly) resources include the SCORE curriculum (this will be an institutional license, so your program may not have it), the Gray's anatomy app, and SESAP 14.

8. Useful books (I like e-books because they are easier to carry around): Greenfield's Surgery, Zollinger's Atlas of Surgical Operations, and Operative Dictations in General and Vascular Surgery.

Organizing Your Day:

Pre-rounding, rounding, clinic, OR, afternoon rounding, sign-out. The schedule probably hasn't changed too much from medical school, except that you will be the one in charge of getting things done while still being in clinic and in the OR. Multi-tasking and triaging will be vitally important, but they can't really be taught. They are best observed and then applied in a trial and error manner until you find a method that works for you. I will give you this tip: discharge your patients before doing anything else (unless the something else is urgent). With computerized order entry, a lot of the discharge orders can be done the night before. This is also true for the discharge summary.
The big question is, what should you do when you get home from work? You should NOT start working again immediately. You should NOT study or read for the next day's cases. You SHOULD sit down and relax. Take a few moments for yourself. Eat some dinner. Maybe have a glass of wine. If you have a significant other or kids, spend time with them--see above. If you don't, make some plans with friends (co-residents make great friends) or give your family a call. Then, set a time (maybe 1-2 hours after you get home) to study, prepare for the next day, and/or check in on your patients.

What You Should Know for Every Case/Procedure You Do:

Prior to scrubbing in to a case or performing a procedure you need to know...

1. Your patient's history (including being familiar with their imaging)

2. The indications for the operation

3. The steps of the operation (including the anatomy)

4. The pitfalls for those steps

5. The general perioperative management

You may not be asked anything during the case but you should know these things all the same.
If you have a question or can't see during the case, ask politely if it would be a good time to ask a question or for you to take a closer look. Be okay if the answer is no because the patient comes first.
At the end of every case, talk with the senior resident and attending about the perioperative plan for the patient. You should know the plan for every drain/line, diet, pain management, and wound care. You should also know the criteria for discharge. (Hint: if you do this, you will almost always have an acceptable plan for the patient on morning rounds.)

Best of luck to all of you and congratulations, again!

For those of you who have already completed internship or at the tail-end of your intern year, do you have any additional tips or advice? What helped you out most during your first year as a new surgeon-in-training? Let us know in the comments below!

~~~

Callie is a resident in general surgery at the University of Washington. She will be entering her fourth clinical year at the end of June 2013 after completing a two year research fellowship. 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.