S3E8: Residency and the Making of a Leader (feat. Alexa Lisevick MD, Samuel Oduwole MD, & Salvatore Falisi MD)
Brooke:
Welcome to Learning to Lead, a podcast about leadership, teamwork, and reimagining healthcare. This podcast is for learners, educators, and healthcare professionals interested in building leadership skills in a supportive community.
We are your hosts Rahul Anand, Maya Doyle, Peter Longley, Amber Vargas, and Brooklynn Weber.
Together we bring you conversations with emerging and established leaders, deep dives and hacks to help you become the best leader you can be.
Rahul:
Welcome to this episode of Learning to Lead. I'm your host, Rahul, and with me our co-host, Amber and Pete.
Pete:
Hello.
Amber:
Hello. Happy to be here.
Rahul:
Today's show is a special one. We're reconnecting with three Quinnipiac alumni who sat in the same leadership class as medical students just a few years ago now, seven years later, they're in their third year of residency out in the field, living and leading at the front lines of healthcare. We are here to reflect on their journeys, what's shaped them, what's challenged them, and how they've become the leaders and team members they are today. Alexa, Sam and Sal. Welcome to the show. Let's talk about the transition to residency. So how did you end up deciding what you're going to pursue for your specialty career and what role did leadership training do in that?
Sal:
This is Sal. So I ultimately decided on pursuing anesthesiology as my specialty and I'll kind of tell the story of how I got there and then leadership is kind of integrated into that. So I came into medical school assuming I was going to be some kind of surgeon, and then doing third year rotations. I found myself on my surgery rotation, more interested in what was going on. On the other side, I was really interested in the hemodynamic management and the procedural, doing airways, doing lines, pressors kind of ACL S. All of that stuff was more interesting to me than the actual surgery stuff, more of the physiology than the anatomy. Basically, leadership didn't factor so much into that decision for me in terms of specialty, but coming into medical school I accepted an Army HPSP scholarship, so I knew I was going to do a military residency and then owe a few years as an attending as a medical officer.
So I was more interested in applying leadership in that aspect of my career. The military loves to stress that all officers, all soldiers are leaders, all officers are kind of leaders amongst leaders and certainly all physicians are leaders on their healthcare teams. So I had no prior military experience in medical school, so I was viewing it more as a preparation for that aspect of my future career. That said, I use a lot of it clinically often, so obviously most of my time is spent in the OR is a very high intensity, very high performing team environment. A lot of the things we learn about apply. And the interesting thing about the OR is that who's wearing the leader hat can change at the drop of a hat. When we're doing our pre-safe checks, the circulator is kind of running that show at our hospital when it's induction time and we're doing the airway, we're kind of running the room when surgery's underway. It's a surgeon patient codes. When we start ACL S, it's kind of back to us and it's a very fluid situation. Sometimes there's multiple surgical teams and we're shuffling even amongst that end. So being able to kind of turn on and off the leader button and switch between different styles and is more or less a daily occurrence in anesthesia. And that's not even getting into the labor and delivery floor, which we could probably do a whole episode on the dynamics of that, but I'll leave it there.
Alexa:
Ironically, Sal, I think we were on the same surgery rotation and I, prior to that rotation really did not have aspirations of becoming a surgeon. And then I after that rotation very strongly felt like, oh, I think I'm going to be a surgeon. And it's funny how that happens, but I think a lot of the things that you've spoken about I also love and as it relates back to leadership training, earlier I had mentioned that part of the way I was leading teams was related to the way I thought that the world sort of wanted me to behave, particularly as a woman, as a young woman, I think there is something to be said for that. And on our surgery rotation, it was one of the first times where I saw women surgeons bounce very dynamically between leadership styles, whether that was leading rounds, whether that was leading teaching sessions in the operating room, in the trauma bay. And I think I just fell in love with it. I mean I thought it was the greatest thing and it's interesting how that all came full circle and I can tell you now as a surgery resident, it takes so much time and energy in learning to try to get to that level of functionality. I mean every day is kind of extremely humbling.
Sam:
Wow, this is Sam here. Those are great responses. My colleagues, I don't know if I can match up, but my choice of specialty was decided before I got into medical school. I knew that I wanted to be a surgeon in the musculo cell system, so I chose orthopedic surgery. They knew me as the ortho person in medical school. It's kind of funny that I've changed my career paths now to physical medicine and rehab. I think that was a fixed decision for me going in. I knew that that's what I wanted to do at that time and medical school, me, pre-medical school, me wanted to do that. But as I learned more about myself and my leadership styles and as I went into residency and prioritized what was important for me, I recognized that a different field, one that still prioritized the musculoskeletal system because I really liked that system and want to help people gain the mobility, be able to live life to the best that they can.
Switching to physical medicine really allowed me to accomplish those goals and also kind of balance my life. What's important to me as far life being able to see my 2-year-old who was an infant when I started a residency, see my wife, engage in my hobbies and better have the bandwidth to be a leader better be able to have the impact that I had mentioned earlier. I was doing a few of that for me, a lot more time and more longitude of care of patients where I can, an individual will have that impact and have the bandwidth impact teams and systems. And so been quite a bit of a change, but I'm so much better for it. I can be a better leader as I have the bandwidth to meet those needs at this time.
Rahul:
Wow. What great stories as you made your transition from medical school to residency, what surprised you or challenged you?
Alexa:
This is Alexa speaking. I would echo what Sam has alluded to. I think the challenge from being a medical student to being a intern and then later a resident can be really challenging. And I think similar to Sam in medical school, I spent a lot of time becoming a well-rounded person, whether that was goals, hobbies, taking care of myself, focusing on my own health and wellness and all of those things require time. And then you transition to residency in very abruptly. You go to working approximately 80 hours a week in a hospital where you are expected to be the best version of yourself as much as possible. And the time that you have outside of the hospital then becomes smaller and you are tired and sometimes you're hungry and then trying to reconcile that you can't do all of the things that you once did that you previously took a lot of pride in or invested a lot of yourself into. For me, it changed a lot of the way that I saw myself and I think it really impacted my resiliency, especially at the beginning. And so I think you have to learn to take care of yourself in a different way to give yourself grace and flexibility and rebuild some of those expectations. I think it's challenging
Rahul:
And what makes it even more challenging is how little control you have over your schedule and over the expectations that are set for you plus changing into a new organization, a new town a lot of the time.
Alexa:
Yeah, absolutely. No, also that's a great point. It can be isolating and there can be moments where you are away from family friends and that support system that was physically there previously.
Sal:
Yeah, completely agree. I remember vividly as a med student, how could a resident possibly forget they have a student or something? How could, no freaking way what? And then you're like, oh yeah, now I see. Okay. But the flip side that I will say surprised me how kind of early on in intern year was having real responsibility and an actual role. I feel like as a med student you're generally pretty superfluous. Maybe on a subi you're pretty useful, but especially early M three, you're there to learn. You're not there to accomplish tasks. So that is basically an overnight change. Like day one of intern year, you have things that need to get done to take care of patients. And yes, the hours were exponentially worse and everything, but I got infinitely more satisfaction out of actually having a well-defined role than checking tasks off. So much worse for all the reasons Alexa kind of already mentioned, but also far, far more rewarding than being a med student
Rahul:
And that matches up with who you are. So much s you love doing things.
Sal:
Yeah.
Amber:
I love hearing all of your stories. It's so meaningful to hear your lived experience and what's going on in health systems and your roles on teams because as a medical student, yes, I'm exposed, but it's still kind of an abstract way of thinking of how I'm going to be a leader in these systems soon. So thank you for picking out the stories and how they relate to leadership because yeah, I'm so passionate about leadership development, but when I hear these stories it just confirms why it's so relevant, so important to pick up these skills on my way there. So thank you guys.
Rahul:
Let's talk a little bit more about teamwork then. Can you think of a first experience when you felt you were the leader of a team? And if it's an interprofessional team, then tell us who all are on this team when you have this moment.
Sal:
So the way my particular program is structured, we do a little bit of ICU kind of every year. So you do some as an intern at PGY2, and then when you're a PGY3, you were the senior for your month and you make the schedule for all the interns and residents and you're kind of overseeing the team. There's a fellow and an attending above you, but the ground level leadership is your role. So that was kind of early on this past year for me. And that's particularly interesting because we get interns coming through from every different surgical service, anesthesia, the transition year interns, people going into fields that are never going to be anywhere near an ICU presumably for the rest of their career after intern year. So just navigating all of that and the different dynamics and some programs, even when they're on the ICU, they're still, they have other responsibilities for the call pool on the weekend or what have you.
So that was really, really challenging and trying to make it a fruitful experience for everyone trying to assign patients in a way that it was at least somewhat relevant to their field or make sure that my surgical interns weren't getting completely slammed because they were also on call for 72 hours straight on the weekend because that's a thing that people still do in certain fields. So it was kind of taking a peek behind the curtain at all these different places people were coming from was challenging, rewarding. And that was probably the first time I was getting a significant amount of feedback, kind of bottom up feedback. People that I was responsible for were telling me I'm pissed about the schedule or great lecture today or can I swap this? So I like to think I did a good job that month, but that was probably the most interdisciplinary crazy team that I've had to lead during residency so far.
Alexa:
I think being an intern is very interesting in that as you said, it is the first time when you become an intern, at least at my institution, you are responsible for the medical students. A large part of their experience is driven by, as you said, their assignments to cases and you help them get onboarded and oriented. They need to be in the right places and what to do in the operating room, how to prepare for the cases, how to behave in the operating room. There's a lot of things that you have to do. And it is coupled at the same time with a time period where you start receiving a lot of feedback, constant feedback from everyone, from people that are senior to you, from people that are junior to you. And I think it can be really somewhat overwhelming to the senses because certainly there can be good feedback, but a lot of times when you do something right, it's kind of like a checkbox like okay, you did it. Whereas when you do something wrong or you don't do something right, it's like, okay, you did not do that right. We can't have this again. And so also the balance of what is considered to be positive versus negative also shifts as well when you become a trainee. So it's an interesting time.
Sam:
Yeah, this is same here. I agreed with what my colleagues have said, thinking of times when I've been a leader on a team, when I was the PGY two and the trauma service, there's the leader PGY three, the four or five, they were above you, but they're usually in the operating room and you're the two and you're taking care of the intern. So we are responsible for everything that's going on the floor. So making sure the intern's doing their job, doing it well, while also getting consults from the trauma bay, the ED all over the hospital. And for me, providing guidance for the intern was critical for me to make sure that they felt comfortable in their role and that they could come to me and I was always open to them to just stopping and saying, Hey, how can I help? And making them know that no question was a dumb question and creating that environment of psychological safety was critical for me.
So I really liked being a senior to the junior residents because seeing them grow and seeing them feel comfortable coming to me because I know sometimes in residency it's hard. You don't want to feel silly about asking a question, that's a dumb question. But I learned that with my style of making my juniors feel welcome to ask a question and feeling safe, they asked more and they felt more comfortable and more confident and did better. Same with the medical students. When I had medical students on the service, I really try to nurture 'em and say, Hey, I'm near the talk. I can answer any question you like. I'll walk you through a scrub machine. And so I noticed that because as a medical student you do have this fear that you're doing something wrong, so you're always being evaluated. And so I was really big on making the interns and the medical students feel comfortable and they really very appreciative. And I was actually inducted into the Penn Gold Human Society by the medical students. So the rising fourth years induc me or nominated me that was inducted into the gold humanist society or how I interacted with the medical students. So I feel very proud about that and it makes me know that I'm doing the right thing with the students and that in large part is being a good leader and how I learned that from this class and trying to lead of kindness.
Rahul:
Woo-hoo. Cheering for you, Sam. That's fantastic. Congratulations.
Sam:
Thank you.
Pete:
I thank all of you for providing that construct around feedback. How did you handle critical feedback and then how did it improve you providing critical feedback?
Alexa:
I think so I will say we get a fair bit of particularly grand round speakers who come and speak about feedback in the context of surgical education. And one of the more helpful things that I have found is asking the person how did they think that something went first? And allowing them, whoever you're going to be delivering the feedback to, allowing them the opportunity to speak because it can help to set the tone and the context for where they are mentally and emotionally and then help you to deliver more impactful feedback or sometimes to even recognize, okay, now is not the best possible time to do so. And sometimes a lot of learners are really self-aware and so they can tell you what they thought went well, what they thought didn't go well, or what they feel like they want to improve on next time before you even say it. And so I think giving some credit to the learner and trying to give some credit to yourself when you are the learner can help to reduce the stress of giving and receiving critical feedback.
Pete:
Thank you. Sam, how about you?
Sam:
Yeah, I think specific feedback is very helpful. So when I had a medical student going rounds and we do dressing changes, and so I wanted the medical students to found a feel empowered and help the chief resident, so lot of 'em to go and the chief resident one, the medicals, see how the medical sit would do on rounds. And one of my students wasn't prepared, didn't have some of the dressing stuff and so I pulled 'em aside, Hey, give 'em good feedback on what they've done already. And I know there's some theory about how to go about doing it, but then I said, for this next patient you'll need this, this and this. I will get this for you and show you where they are. And then the chief would really like it shows that you take initiative on the next patient if you have all these ready by your side.
She had her pockets, her saline syringes, her AB pads, galls, I made sure she all that ready for the next time and the chief resident commented on and said, Hey student, that was great. I liked that you were prepared and had that. And so just giving that specific feedback for things that could improve the experience and then go to the next step, helping them accomplish that, showing them where to get those things and how much sooner to go to get those things and to create a platform and system for them to make that change happen. That's when the change happen.
Pete:
Great. Sal, you got any examples?
Sal:
Yeah, what Alexa said about kind of assessing the receiver of feedback's perception is always the first thing I do. I think that's so key because it's very, very rare where someone kind of doesn't know that they're not meeting expectations or whatever you're kind of doing generally people know it's pretty rare where you're like, oh, I need to really tell them something and they're like, Nope, crushed it. It's usually you're kind of on the same page. But if it is different, that's a wildly different conversation. So I always like to start there and agree with what Sam said. I've definitely, as an intern, I had a few med students who we would go through before rounds on a medicine rotation and this is what we're going to talk about, this is your plan. We're going to give these values here, really go over it. And then they would go to present and you could see just the anxiety of presenting itself.
So we would just do practice presentations beforehand, just like the reps of doing it once through would be more to help overcome that. But again, I think assessing perception, getting on the same page in that regard and then just setting someone up for success. People will be more receptive to your feedback if they feel you're invested in the first place. If you have a med student and you're like, yeah, you got it, you wing it on rounds and then they bomb it and then you go try to give them feedback, it comes off as kind of hollow to me like, well, it would've been nice to have a conversation before and maybe so setting people up for success in the first place and showing them you're invested will make them trust your feedback more.
Rahul:
Great. I love those pearls. And I'd say just to build on that, giving and receiving feedback is certainly a muscle that can be strengthened. And a couple of things that I'm picking up from what you're saying is ask the person first how it went from your perspective and then you can share what you think might be helping them grow. And a couple of things I've realized is giving positive specific feedback is a great way to build this skill. So I'll often ask someone I'm working with, how did that go for you? And once they say what they say, which as you said, Sal is rarely I crushed it, I might actually tell them this is where you crushed it, you did so good there. And where leaders are in the business of not just seeing people for who they are but who they can become.
And so that positive feedback can really help someone build confidence and identity. And typically leaders need to try to have a four or five is to one ratio of positive to negative feedback. So people should not be hearing from you just when you have something critical to say, they should be hearing from you all the time. And that's one way of building the muscle. And it can happen in expected roles, but it can also happen in unexpected situations or across professions too, where I think it can really break boundaries. I want to come back to interprofessional teams. So tell us a little bit about the interprofessional teams that you're a part of and how you're navigating that. What's working well for you, and then what are areas where you wish you could be doing better?
Sam:
Hey, it's Sam, I can pitch into this. I think I mentioned earlier, intern year when you have AL rounds and social work rounds, PT rounds at the rehab, there's a lot of overlap and conversation between the occupational physical therapist and speech and language therapist because often people who have strokes may need one or all three of those specialists to help get them back to their baseline or somewhere near it. And so there's a lot of conversation between doctors and the therapist at rehab. I'll start first of what I want to learn and get better at. What I've been trying to do is understand the language of the therapist. So for example, P-T-U-S-A men assist, guard assist or full assist, all this language, you don't really learn in medical school what that means. And so trying to partner with the therapist and help the patients and help families understand where they are means I need to go and learn more from the therapist.
What I did was an elective just where I shadowed the therapist and saw what they did on a day-to-day basis. Understand, okay, what do you mean when you say this? Tell me the language. 25 oh men assist miny like 25% or less moderate cyst, 50 full cyst where you're basically doing work and what types of aphasia you're seeing and how you're helping patients improve. Just really understanding the language that's used really allows me to then come back to the patients and families and tell 'em how their family is doing in rehab and where their sheer goals are for discharge. And so I'm still an intern now in physical in rehab, but as I go into my PG two year where I'll be rotating at the rehab, I want to go in knowing that I can understand the basic language of the therapist. And so when we talk about we do rounds and say, all right, this patient's being discharged on this date, they'll need this DME, why they need a rolling walker because they need this much assistance. I think understanding the basic language of the therapist will allow me to then come to terms and say, okay, this is an appropriate discharge date we can get, I'll sign the DME and we will get this patient to the next stage, to the next level. So that's something in a professional team, especially for rehab physicians understanding the basic language.
Alexa:
Yes, I think that is a really excellent point. I think that especially when you first start off, something that you have highlighted is that there's a huge external cognitive load. You are trying to learn the languages of different providers. You're trying to learn how to do your job effectively. And so I think as it comes to working in an interprofessional team, I think it has gotten easier as time has gone on because as that sort of external cognitive load has gone down a little bit, and I've learned more about how each of the team members functions as you highlighted, the pharmacist, the physical therapist, the nurses, the medical students, the other residents, the occupational therapists, the nutritionists, and then also all of your senior people as well. You start to have a more bird's eye view of things and you can orient in a timeline in a patient's hospital visit, what things need to be managed more quickly or prioritized. They are acute and which things will naturally take some time and that is okay. But I think when you first start out, that can be completely overwhelming to the system. And I think at the very beginning a lot of it is trying to identify expectations of people around you and recognize where you fit into that mold.
Sam:
I would say Pete being our senior person, you're in the nursing field. I have, it's funny, in medical school you're taught your nurses are the backbone. They see the patient, they the patient very well, always have respect for them and listen. And I've really taken that the heart, as I've gone to residency, I find that residency kind of can bog people now a little bit and sort of that's lost not by the nature of anyone being selfish or whatnot, but there's sometimes be an adversarial nature between the providers and the nursing about types of questions. And I have found that I, ICU nurses are special because everyone, and they're amazing and they're essentially the residents listen to ICU nurses. But I think where you have some conflict elsewhere, I tend to always listen with empathy when the nurses present something to me and if a nurse says something's wrong, I would take the extra time to go and see the patient.
And this year there's been time where the nurses were concerned about something and other people were like, I don't know. And I went to see the patient and something was clinically wrong and something changed and needed an intervention. And so that as a lesson to Amber and other students that the nurses are the eyes and ears and so when they say something, listen some of empathy and go check it out. That's something that has been important. And I know Sal and Alexa comment on that because there's a push and pull with the providers in nursing and how to best optimize that relationship.
Rahul:
Yeah, that makes me think of the charge nurse who trained me when I was a first year resident in India, in Delhi, India. And I will not forget her and could not be more grateful to her until my dying day. Because here I am joining the first year of medicine residency in the largest tertiary care hospital in Delhi. And she had all the knowledge about workflow, about how patients would come in and out. She had been there for more than a decade and I learned so much from her, whether that's interacting with the patient or family, getting procedures set up and done discharging patients, simple things like making time to eat, getting a breather in the middle of a night shift. I mean, I think that when across professions we can have each other's back, we can lift each other so much. It's incredible. Now, Alexa, you mentioned bird's eye view.
So I want to have us look at a bird's eye view at the systems level. In medical school you were building foundations of leadership and learning a lot about yourself and others. And then as you came to residency, you really hit the playing field on how to interact across professions within professions, inpatient care. Talk about systems a little bit. So what are the kind of systems exposure you are getting? What are the roles and experiences, whether that's in your organization or outside your organization, in your specialty or with the healthcare delivery system? Where are you learning about systems and how are you growing that muscle?
Alexa:
Yeah, I will say that it is not uncommon that opportunities arise to get involved in systems level discussions. I think when you are a resident, I think you're limited by time. But for instance, one particular, I was a member of a work group focused on interdisciplinary communication on the acute care floors, so the surgical patients and then medical acute care as well. And it was a very interesting experience because it was one of the very first times where I had a significant amount of time listening to particularly the nurses and the mid-level providers and apps about where do we as residents and as fellows and as attendings fall short. And the whole focus was how do we communicate care better to the patient? So it wasn't even focused so much as to how do we communicate better between providers. That was part of it. But a lot of it was, as you said, Sam, the people who are directly in front of the patient who interact most closely with the patient's family, where are the places that communication from the acute care medical or acute care surgical team, where is that communication falling short? And I mean, it was really interesting and it was really challenging to try to find a time that we could promise to be at the bedside when the family was also at the bedside to have a conversation. It was surprising how difficult that was to try to find maybe five to 10 minutes in a day. And so, yeah, no, the medical healthcare system is very interesting.
Sal:
Yeah, one little one-liner, Dr. Anand that I remember from you from when we were medical students was every system is designed to get the outcome it gets,
Which I think about all the time. So my residency is kind of unique. Well, most military residencies bounce to many civilian hospitals just because the nature of our patient population to get the numbers required. We don't take care of many kids certainly don't have enough babies for L and d numbers, things like that. So we bounce around to a lot of civilian hospitals. So one of the benefits of that is we see how similar things are done in multiple different institutions with different incentives, big academic centers, military hospitals, more of the private practice kind of environment. So from a passive exposure setting, we definitely can see the different practices and different practice environments, which I think is really, really beneficial. And then in a more formal setting, so we're recording this in April, so I recently found out I'll be a chief resident for this coming academic year. So seeing behind the curtain of coordinating with all these different hospitals and the two states and DC and coordinating the training licenses and the training agreements and is a herculean task that our program directors and admin staff do a tremendous amount of work for. So just getting a little bit of the behind the scenes of just the amount of coordination stuff like that requires is eyeopening.
Rahul:
Congratulations, Sal. Yeah, being a chief resident is a great stepping stone to systems level experiences.
Sal:
Yeah, I'm looking forward to it a lot. Thank you for the congratulations.
Rahul:
Well, thank you for sharing your journey as a medical student first and now as a resident with us. What's the one greatest thing you've learned about leadership and teamwork as a resident?
Alexa:
Ask help and advice from people who have done it before you. If you are in a new situation, you don't know what to do, ask your senior resident, call your administrative chief. They have an abundance of very applicable knowledge and are tremendously helpful.
Sam:
Yes, and I'll second that as well. And I'll say being a good leader to others first comes by being a strong leader yourself, meaning being a good leader of your own self. There's a reason we have the domain self teams and systems. Find out how you can optimize the way you interact with your teammates and your systems and that will then help you better lead others within the team in systems.
Sal:
Yeah, I would say along those lines, the one piece of advice I would give anyone who's anywhere in this process, I think is kind of lead by example. So I think everyone can think of an example of the leader who is the first one to leave early or give themselves the favorable call schedule or not. There's plenty of examples, but you can start from day one of intern year, be the person that helps out your co-interns, be the person that embraces challenge, has those interprofessional conversations we talked about. And people will look to you as a leader even when you're not in a formal position of leadership.
Rahul:
Such a wonderful message. Yeah, it does compound over time. Well, Alexa, Sam Sal, thank you so much for being here. It's been a privilege and a joy. And listeners, if you're thinking about your own leadership journey, we'd love to hear from you too. Thanks for tuning in. Until next time, take care and keep leading and learning.
Brooke:
Thank you for listening to our show. Learning to Lead is a production of the Quinnipiac University podcast studio, in partnership with the Schools of Medicine, Nursing and Health Sciences.
Creators of this show are Rahul Anand, Maya Doyle, Peter Longley, Amber Vargas and Brooklynn Weber.
The student producer is Brooklynn Weber, and the executive producer is David DesRoches.
Connect with us on social media @LearningToLeadPod or email us at LearningToLeadPod@quinnipiac.edu.