Residency Diary: Fifth Year—Fracture Chief

September 2023

It’s my last day as fracture chief. The fracture service at New York Presbyterian Hospital is the pinnacle of trauma training in our program. As the fracture chief, I oversaw a team of junior residents, managed everything from bread-and-butter trauma to geriatric trauma to complex polytrauma, and monitored interactions within the fracture team and between other teams in the hospital.

Maybe it’s a stretch, but being fracture chief has been a lot like being a parent. Both have been accompanied by a mix of emotions: excitement, anxiety, bewilderment, joy, and a little fear. Both have involved late nights and early mornings. Both required patience and adaptability. Both have been extremely satisfying. It’s hard to compare the pride I felt the first time I heard my daughter say “banana” to the pride I felt looking at the post-reduction radiographs of my intern’s first distal radius reduction, hearing how my PGY2 handled a hard night of consults, or seeing my PGY3 get incrementally better with every tibial nail we did.

Like many other experiences in residency, or parenting for that matter, imposter syndrome crept in from time to time. I remember being an intern and observing my fracture chiefs, awed by how they could speak confidently about patients, plans, and procedures. I remember wondering how I would ever reach that point. If I did, would I be as confident (and competent) as they were?

Over the last several weeks, I’ve wondered if I achieved that goal or if I fell short. There were some days when I felt like I was handling everything smoothly and happily told myself “Yes, I can do this!” On other days, I was unsure about a patient’s plan or uncertain about the next step in a procedure. These were the days that made me question, “do I belong here?” Do I really deserve the title the junior residents call me – “chief”? On those days, I had to remind myself that I had 4 years of residency (including 16 months of orthopaedic trauma) behind me. With those 4 years came hundreds of firsthand experiences that collectively taught me what to do, what not to do, and when and how to ask for help. I had learned, through my own moments as a PGY1, 2, or 3—including moments of triumph and failure—that in the event I was not sure, I could figure it out.

One fortunate consequence of my own imposter syndrome was that it helped when junior residents came to me with their own struggles. It was early in the year, after all, and they were still getting settled into their respective roles. Some common themes emerged: they wanted to be better, they felt like they had so much to learn, they wondered if they belonged, or if they were behind their peers.

When the junior residents talked to me about their own struggles, I was quick to offer that they were not alone. I was right there with them, out of my element and wondering if I was good enough. I also reminded them that I faced the same challenges they did when I was in their shoes. The intern struggling with time management between seeing consults and triaging inpatient tasks? I struggled with that, too. The PGY2 grappling to reduce a midshaft humerus fracture with a coaptation splint? I grappled with that as well, and I did my fair share of repeat reductions. The PGY3 learning the differences between a loose screw, an appropriately tight screw, and an overtightened or stripped screw? I had trouble with that also, and I still have difficulty with it.

These conversations were admittedly not a surprise because I felt the same anxieties and frustrations at various points in residency too. I vividly remember for the first few months of intern year, feeling like I was struggling more than my peers and wondering if I was “cut out” for this type of work. Several months later, as a new PGY2, I remember the anxiety that came before a 24-hour call shift, where I dwelled on all the hypothetical consults I had never seen before. Transitioning from PGY2 to PGY3, I again went from being confident in one realm (the ER) to less confident in another (the OR). Thus, when the junior residents brought up these concerns to me, it wasn’t necessarily surprising. We’ve all been there, I told them—some people just talk about it less than others.

In June, I was fortunate to attend the AOA Resident Leadership Forum. One key takeaway from that event was that leadership, like surgery, takes reps to get better. People aren’t naturally born orthopaedic leaders, just like they aren’t naturally born orthopaedic surgeons. I’ve logged thousands of cases in residency thus far. There’s no case log for leadership, but that doesn’t mean it’s any less important. My time as fracture chief was an important leadership experience and taught me a lot about my own leadership style, which was influenced more by parenting than I thought.

My wife, a proponent of Montessori parenting, reminds me when we’re with our daughter to “follow the child” (a tenet of the Montessori philosophy). In simple terms, it means observe your child, figure out his or her interests, and guide them. It means creating an environment that helps the child explore his or her interests, without dictating their every action or doing things for them. In other words, let them struggle a little. The full quote by Maria Montessori is more telling: “follow the child as his leader.”

Whether I intended to or not, I found myself embracing this philosophy as fracture chief. Leading the fracture team and parenting my own daughter are not the same thing, but there is some truth in the comparison. Every junior resident on the team was different. Some were vocal, others quiet. Some were comfortable with trauma, but for others, it was their first time on a trauma service. Given the different personalities, experience levels, and working styles on the team, I quickly realized that my goal was not to impose my own style on the team. Rather, I made it my goal to identify and bring out the best of each person’s personality and style.

To do this, I observed, listened, and guided. Some residents seemed to need more encouragement, and others proactively sought out criticism. Some residents asked for help, whereas others did not but accepted help if offered. Some residents felt comfortable in the OR, and others were just getting their bearings. These residents each required a different approach, and by observing their styles and figuring out how they would thrive, I tried to create an environment conducive to their development.