Residency Diary: Intern Year Part 2 (March-May)—Teams in Residency

March 2019: Mentorship in Metabolic Bone

One of the most memorable rotations of my intern year was a rotation with Dr. Jones (names changed here and throughout), an attending deeply involved in osteoporosis, orthopaedic oncology, and fracture care. Dr. Jones has a love of everything orthopaedic, and his enthusiasm for tackling any orthopaedic problem, from “bread and butter” orthopaedic injuries to complex cases, is contagious.

During the rotation, I worked one-on-one with Dr. Jones, helped run his in-patient service, operated with him, staffed his consults, and saw clinic patients with him. The rotation was, in many ways, the purest form of the mentorship model in residency training.

The breadth of Dr. Jones’ practice is one of the many reasons why his rotation is so memorable. In the first week alone, I remember caring for a wide spectrum of patients—a child with chronic recurrent multifocal osteomyelitis, a middle-aged woman with bilateral atypical femoral shaft fractures, and an older man with a massive blastic metastatic intertrochanteric lesion. In particular, I remember the first day on my rotation when we met an otherwise healthy pregnant woman with a large sacral osteosarcoma. Despite the fact that Dr. Jones has 40 or more years on me, I remember struggling to keep up with him as we ran around the hospital, consulting with radiologists, oncologists, and fellow orthopaedic surgeons to devise a plan to help the patient. Indeed, his desire to tackle the problem and do right by the patient was unstoppable.

While the patients and their diagnoses were fascinating, and the learning was superb, what really sticks out is Dr. Jones himself. I am fortunate to be in a residency with many great mentors and rotations that offer superb learning experiences. Yet the rotation with Dr. Jones had a more fundamental impact on me. It changed how I view orthopaedics, and more importantly, how I envision myself as a future orthopaedic surgeon. I will never match Dr. Jones’ charisma, but what I do hope to emulate, as best I can, is his limitless passion for orthopaedics. But what I do hope to emulate, as best I can, is his limitless passion for orthopaedics. Everything I did and witnessed on his rotation—hustling non-stop around the hospital trying to help a patient or discussing the fifth femoral neck fracture of the week with as much enthusiasm as the first—stemmed from his inexhaustible love of orthopaedics. His rotation reminded me that practicing orthopaedics is a privilege and a joy—a helpful reminder amidst the grind of intern year.

April 2019: Senior Residents as Role Models

It was 5:30 PM on a Sunday, with another weekend trauma call almost completed. As my last trauma call shift before PGY2 year, I was finally feeling comfortable managing the more straightforward trauma that came through the emergency room. Alongside the third-year resident on call, I had reduced a prosthetic hip dislocation, aspirated a possibly septic knee, and reduced a pediatric both bone forearm fracture, among other things.

While preparing the patient list for 6 PM sign out, my pager went off with a new consult. It was a decision I had faced many times before—let the consult wait until after sign out or see the consult first and risk giving a poor sign out with an unfinished list. I decided to see the consult and run back to finish updating the list before 6 PM. But before I could go, the my third-year resident stopped me.

“You stay here and make sure the list is perfect,” she said. “I’ll see the consult on my own, so we can both go home after sign out.”

The other resident could have worked on any of her other responsibilities and left after sign out while I would stay to see the consult. It was a small but significant gesture, a confirmation of what I have learned time and again this year from my senior residents—residency is a team sport. While our responsibilities are different, we still operate as a team to care for our patients. Sometimes that means the third-year resident will help out the intern, so we can give a good sign out to the oncoming team, leave no consults pending, and go home together.

That third-year resident, like other senior residents I’ve worked with, was a great example of who I hope to become: A resident who provides an appropriate amount of autonomy and guidance to the interns and junior residents, but also understands that leading a service is best approached as a team working cohesively, rather than as individuals with discrete and exclusive responsibilities.

May 2019: Reflections on General Surgery

As an orthopaedics intern, I was less than excited at the thought of spending 3 months on general surgery rotations. Stepping away from orthopaedics meant that I would be thrust into the world of acute abdomens, small bowel obstructions, and gallstones. Moreover, the time spent on general surgery would eat away at the (relatively little) time I had to learn orthopaedics.

While some of my fears did come true—the long hours I spent on general surgery definitely impacted the time I had available to study orthopaedics—general surgery turned out to be a good rotation.

First, I can safely say that general surgery taught me many of the fundamentals of how to be a better intern, which I have carried forward in my recent orthopaedic rotations. Some skills I learned on general surgery were directly relevant to orthopaedics, like managing complex wounds and conducting primary surveys on trauma patients. Others were basic skills I’m glad I now know, like placing IVs in trauma situations and adjusting blood pressure or diabetes medications. Of course, a few “skills” were simply part of the general surgery experience, like disimpacting patients and unclogging nasogastric tubes. Even those were valuable in their own way by helping me become more comfortable with polytrauma patients who have many acute medical problems. Most importantly, general surgery taught me how to manage a large list of inpatients with a variety of conditions that, until I rotated on general surgery, I would have struggled to manage on my own.

Second, general surgery taught me about the importance of inter-disciplinary care. Over the course of 3 months, I had the opportunity to work with dozens of general and subspecialty surgical interns, not to mention the many other residents, attendings, physician assistants, nurses, social workers, care managers, and other providers that all contributed to patient care. For example, discharging a patient to rehabilitation after a bowel resection was a concerted effort requiring discussions with social work regarding insurance authorization and rehab approval, co-management with other consulting teams, and mobilization with physical therapy—all tasks that were mine to coordinate on a daily basis. Forgetting even one of those could delay the patient’s discharge for a day or more. On top of all that, there was actual medical care to be done, as I quickly learned how to titrate anti-hypertensive meds, insulin therapies, and bowel regimens.

There was a surprisingly challenging learning curve to navigating the hospital’s care teams. Even a relatively standard procedure could turn into a momentous challenge. For example, a “straightforward” angioplasty could quickly go awry if the patient had a complication from the procedure, an unrelated new medical issue arose during the hospitalization, or insurance issues prevented a streamlined discharge. Yet the process of working with the many care providers in the hospital gave me a newfound appreciation for the complexity of care we provide as well as the importance of interacting professionally with everyone in the hospital.

Lastly, I am grateful that the general surgery and subspecialty interns I worked with will be my colleagues for the next 4 years of residency. Given how frequently our services interact, I look forward to working with them on our mutual patients, not simply as residents in a large hospital, but as a team coming together as colleagues.