Roads traveled and lessons learned: Keys for success at the 3 levels of residency
Residency: a simple word that many of us often consider in its totality. Residency training is the proverbial largest "box to check" on our pathway to becoming fully fledged, board-certified plastic surgeons. However, distilling it down in this manner vastly undervalues the sheer amount of nuanced technical skill, personal growth and professional development gained during a plastic surgery residency. The person who enters as a newly minted "MD" fresh out of medical school bears almost no resemblance to the person who exits a training program upon graduation. For this article, we asked three highly successful trainees at different stages of their plastic surgery journey to provide insights on the specific qualities that typify an outstanding resident at the level of training that they themselves just completed. Through this lens, we hope to demystify some of those "intangibles" and provide guidance to those looking ahead to excel and "level-up" in the next phase of their training.
Russell Ettinger, MD
PSR Editor
CHIEF RESIDENT: Roles and Responsibilities
By Sameer Shakir, MD
What are the primary roles of a chief resident?
A chief resident's roles involve the ability to manage a clinical service, operate (somewhat) independently and complete various administrative tasks. The successful transition from senior to chief resident requires proficiency in applying a fund of knowledge to make sound clinical decisions and utilize previously acquired technical skills to operate efficiently.
What personal qualities can help make someone successful at this level?
A chief resident should be a leader. Emotional intelligence, ability and leading by example may be critical attributes to demonstrate throughout residency, but they become even more important at this level. Emotional intelligence means demonstrating empathy, managing conflict, communicating effectively and relieving stress in a constructive manner. Ability means demonstrating proficiency, inspiring confidence and building trust within a team-setting. Leading by example means never asking someone else to do something you wouldn't do (or haven't done) yourself.
What are the greatest pitfalls an individual could encounter at this level?
Although service-related obligations continue to decrease in this role, it would be a mistake to simply coast through the year. There's always something to learn from every case – big or small. As the team leader, it's equally important to look after the well-being of others. Are you consistently assigning your co-residents late days? Are you considering the personal and educational desires of your colleagues in addition to your own? As a chief resident, it's better to be loved than to be feared.
What key intraoperative attributes or skills are required at this level?
The ability to execute the operation in its entirety; to identify and avoid common pitfalls, and to transition to an assistant role for junior residents in the appropriate circumstance. Every operation has a rhythm and cadence. Certain portions can be quickly executed, while others require slow attention to detail. Mastery of this nuance leads to operative efficiency.
What advice would you give someone entering this phase of their training?
The chief year serves as a unique opportunity to further hone operative skills, identify and remedy knowledge gaps, and function in a pseudo-autonomous role. Chief residents typically feel comfortable with the technical execution of most operations and procedures, but opportunities are available to learn case setups, transition to an assistant role to educate junior residents and develop clinical and operative efficiency.
What resources (textbooks, journal articles, lectures, etc.) would you use to prepare or study at this level?
Read daily for 30 minutes. Read anything. There are several excellent resources available – including comprehensive descriptive textbooks, operative atlases and journal articles. During my chief year, I read CME articles from Plastic and Reconstructive Surgery (and watched the accompanying videos), reviewed chapters published in Clinics and Seminars in Plastic Surgery and annotated operative atlases such as Operative Techniques in Plastic Surgery, written by Kevin Chung, MD, MS. Additionally, the references in these resources often include key publications, which are worth a review.
Dr. Shakir is PGY-7 and a craniofacial Fellow at the University of Washington, Seattle.
MID-LEVEL RESIDENT: Roles and responsibilities
By Yusha Katie Liu, MD, PhD
What's the primary role of a mid-level resident?
The middle years of residency have the steepest learning curve as residents transition from general surgery and other off-service rotations to full-time plastic surgery training. The primary focus should be on personal learning to understand fundamental surgical principles and to establish a solid fund of knowledge for the breadth of plastic surgery. It's never too early to think about future goals and explore opportunities for research and career development/committee positions – especially if planning for additional Fellowship training after residency. A mid-level resident should also be proficient at managing both acute care and critically ill patients, as well as the initial evaluation and treatment of new consults. The midlevel resident also can be a valuable mentor for interns and medical students.
What personal qualities can help make someone successful at this level?
Meticulous attention to detail and inquisitiveness is key. Noticing subtle differences and constantly asking "why" is crucial for learning – everything from positioning and draping to instruments to use and retractors to give the best exposure, to suture, implant and hardware choices, to postoperative rehabilitation protocols. Attendings have personal preferences for good reason, and listening to their rationale can help you figure out what makes the most sense. Then develop your own style.
What are the greatest pitfalls an individual could encounter at this level?
It's exciting to progress through the years and realize how far you've come, but overconfidence can be a barrier to continued learning. Even if you feel comfortable in your ability to perform certain procedures or steps of an operation independently, always be open to and actively elicit feedback, which will help you become more precise, efficient and dexterous. No matter your stage of training, you can always find ways to be better.
What key intraoperative attributes or skills are required at this level?
It's imperative that you develop technical skill with surgical approaches and exposure, as well as master closure techniques for different parts of the body.
What advice would you give someone entering this phase of their training?
Take advantage of this phase to soak-up knowledge. You don't have the day-to-day duties of an intern, and you don't have the administrative responsibilities of a chief resident. Read, question, explore, reflect, research.
What resources (textbooks, journal articles, lectures, etc.) would you use to prepare or study at this level?
The best resource may be your chief residents. When learning a new operation, it can be overwhelming to figure out the key elements from the variety of techniques described in textbooks. If senior residents share their notes – especially if it takes you through the exact steps of the operation – it can help you to focus your learning and often may include tips and tricks. This can be supplemented by anatomy atlases and online surgical videos.
Dr. Liu is PGY-6 and a chief resident at the University of Washington, Seattle.
JUNIOR RESIDENT: Roles and responsibilities
By Philip Tolley, MD
What's the primary role of a junior resident?
Simply put, an intern's primary role is to make the service run smoothly. This simple idea has profound, positive consequences. By constantly asking what needs to be done to further the care of your patients, multiple things occur: Patients benefit from more-effective care and are discharged sooner; other members of your team are then able to think about complex management; and you begin to develop your medical decision-making.
What personal qualities can help make someone successful at this level?
The most important attributes of a great intern include communicating effectively and taking responsibility for and ownership of patients. Communicating with your team is essential to ensure the medical decisions being made by the team are from an informed perspective. As an intern, you often have the most information about changes in patient status – and often you're the first to know, as well. Your upper-levels and attendings can't act on things they don't know. I always say that as an intern, you never want to be the only person who knows something. If you take a personal sense of responsibility for your patients, you'll be reliable – since you'll always ensure that whatever needs to be completed will be completed, no matter how tired or busy you feel.
What are the greatest pitfalls an individual could encounter at this level?
They say there are two types of interns: those who write things down, and those who forget. As an intern, you're juggling so many different tasks: notes to write, orders to place, patients to check on, consults to see, pages to respond to – and the list goes on. It becomes very easy for things to become forgotten. You're being relied upon to make sure all the tasks for the day get done – and if you forget, it often gets missed. Come up with a system that works for you and stick to it.
What key intraoperative attributes or skills are required at this level?
As an intern, you should be absorbing everything that you can whenever you're in the O.R. Specifically, you should really focus on mastering the fundamentals of surgery, such as proper instrument use and names, needle and tissue handling, suturing, etc. If you start out with bad habits, you'll only tend to exaggerate them over time.
What advice would you give someone entering this phase of their training?
Intern year is very busy, and it often feels like you're doing more "work" and less "learning." Trust that everything you do gains you experience. You may not feel like you become a better doctor day by day, but when you look back over the course of the year, you'll see the strides you've made. So don't get discouraged – just keep working hard and doing the right thing for your patients. Your knowledge and skill will subtly and steadily accumulate.
What resources (textbooks, journal articles, lectures, etc.) would you use to prepare or study at this level?
The sheer amount of information there is to learn, coupled with the paucity of time you have outside the hospital, can feel overwhelming. Just remember: Doing something is better than doing nothing. If you develop a habit of reading 10-15 minutes a day, you'll be better-served in the long run. The knowledge you gain from a single day of 15 minutes of reading may seem inconsequential, but when you add up the knowledge gained week after week, month after month and year after year throughout residency, the result is substantial. Specifically, I think CME articles from Plastic and Reconstructive Surgery (with the accompanying videos); The Plastic Surgery Series by Peter C. Neligan, MD, for specific topics; and Review of Plastic Surgery by Donald W. Buck II, MD, for In-Service Exam review are all great resources.
Dr. Tolley is PGY-4 in the University of Washington Plastic and Reconstructive Surgery Residency Program.