WEBVTT 00:00:10.000 --> 00:00:12.439 anesthesia enthusiasts, and possibly people who 00:00:12.439 --> 00:00:14.800 are pretending to be anesthesia enthusiasts. 00:00:15.419 --> 00:00:17.640 My name is John Crow, and you're listening to 00:00:17.640 --> 00:00:20.760 Style Points. Today on the podcast, I have special 00:00:20.760 --> 00:00:23.420 guest Dr. Ben Fidelis, who will be chatting with 00:00:23.420 --> 00:00:26.559 us about imposter syndrome. Before that, I'll 00:00:26.559 --> 00:00:28.820 hand it over to my co -host, Nate Moore, to talk 00:00:28.820 --> 00:00:32.820 about this month's RSI. Thanks, John. I'm really 00:00:32.820 --> 00:00:35.560 excited to introduce Dr. Veronica Takugang today. 00:00:35.799 --> 00:00:38.579 She is an anesthesia intern here at UC, but she's 00:00:38.579 --> 00:00:40.939 not new to Cincinnati. She grew up in the city 00:00:40.939 --> 00:00:43.439 and her first job was at Graders. So we'll be 00:00:43.439 --> 00:00:45.299 seeing if she still has any free ice cream connections 00:00:45.299 --> 00:00:47.939 after the show. Veronica will be teaching us 00:00:47.939 --> 00:00:49.899 about inhaled anesthetics. Welcome, Veronica. 00:00:50.880 --> 00:00:53.899 Thanks, Nate. So the course of general anesthesia 00:00:53.899 --> 00:00:56.219 can be divided into three phases, induction, 00:00:56.600 --> 00:00:59.240 maintenance, and emergence. The majority of general 00:00:59.240 --> 00:01:01.740 anesthetics administered today use inhaled agents 00:01:01.740 --> 00:01:04.640 during the maintenance phase. And while most 00:01:04.640 --> 00:01:08.180 adult cases use IV agents for induction, pediatric 00:01:08.180 --> 00:01:10.799 patients commonly receive inhalation inductions 00:01:10.799 --> 00:01:14.340 to avoid awake IV placement. For these reasons, 00:01:14.400 --> 00:01:16.879 it is important to understand how inhaled anesthetics 00:01:16.879 --> 00:01:19.060 work. Let's first think about how these agents 00:01:19.060 --> 00:01:21.390 get into the body. Inhaled agents start as a 00:01:21.390 --> 00:01:23.689 liquid but are turned into a gas by a vaporizer, 00:01:23.829 --> 00:01:26.430 then are swept into the lungs along with the 00:01:26.430 --> 00:01:28.950 fresh gas flow from the ventilator. Note that 00:01:28.950 --> 00:01:30.930 the patient does not necessarily receive the 00:01:30.930 --> 00:01:33.150 concentration set on the vaporizer of inhaled 00:01:33.150 --> 00:01:35.689 anesthetic. The actual composition of the gas 00:01:35.689 --> 00:01:38.810 mixture depends on three factors, fresh gas flow 00:01:38.810 --> 00:01:41.489 rate, the volume of the breathing system, and 00:01:41.489 --> 00:01:43.569 any absorption by the machine or breathing circuit. 00:01:44.400 --> 00:01:47.859 So the greater the fresh gas flow rate, the smaller 00:01:47.859 --> 00:01:50.260 the breathing system volume, and the lower circuit 00:01:50.260 --> 00:01:52.939 absorption, the closer the inspired gas concentration 00:01:52.939 --> 00:01:55.579 will be compared to the fresh gas concentration. 00:01:56.459 --> 00:01:59.079 Things that affect the uptake of inhaled anesthetics 00:01:59.079 --> 00:02:02.040 include solubility in the blood, alveolar blood 00:02:02.040 --> 00:02:04.099 flow, and the difference in partial pressure 00:02:04.099 --> 00:02:07.379 between alveolar gas and venous blood. So how 00:02:07.379 --> 00:02:09.139 do we know that our patients are getting enough 00:02:09.139 --> 00:02:11.159 inhaled anesthetic to keep them deep enough through 00:02:11.159 --> 00:02:14.009 surgery? One factor we use to ensure our patients 00:02:14.009 --> 00:02:17.310 are adequately anesthetized is the MAC, or mean 00:02:17.310 --> 00:02:20.349 alveolar concentration. MAC values are standardized 00:02:20.349 --> 00:02:23.189 such that getting one MAC of a given agent prevents 00:02:23.189 --> 00:02:25.870 movement in about 50 % of patients. The amount 00:02:25.870 --> 00:02:28.909 of each agent needed to achieve one MAC is different, 00:02:28.969 --> 00:02:31.770 and these values decrease with age. For example, 00:02:32.069 --> 00:02:35.090 a healthy 40 -year -old needs to receive 2 .1 00:02:35.090 --> 00:02:38.080 % of sevoflurane to achieve one of MAC. However, 00:02:38.319 --> 00:02:40.939 the MAC decreases about 6 % with each decade 00:02:40.939 --> 00:02:43.699 of age, so the same patient at 50 will only need 00:02:43.699 --> 00:02:47.900 1 .97 % of sevoflurane to achieve one MAC. Modern 00:02:47.900 --> 00:02:50.120 OR monitors will automatically calculate the 00:02:50.120 --> 00:02:52.819 patient's current MAC percentage based on the 00:02:52.819 --> 00:02:55.400 amount of anesthetic agent the patient exhales, 00:02:55.400 --> 00:02:57.819 but not all will automatically adjust the MAC 00:02:57.819 --> 00:03:00.979 based on the patient's age. So be mindful of 00:03:00.979 --> 00:03:03.280 what one MAC really means for the patient in 00:03:03.280 --> 00:03:06.139 front of you. Inhalation anesthetics include 00:03:06.139 --> 00:03:10.340 nitrous oxide, halothane, isoflurane, desflurane, 00:03:10.500 --> 00:03:13.159 xenon, and the most commonly used in the developed 00:03:13.159 --> 00:03:16.719 world, sevoflurane. Each agent has its own unique 00:03:16.719 --> 00:03:18.680 properties that cause variable effects on each 00:03:18.680 --> 00:03:20.960 organ system, so it is important to take that 00:03:20.960 --> 00:03:23.240 into consideration when formulating an anesthetic 00:03:23.240 --> 00:03:27.319 plan for a patient. Nitrous oxide is an NMDA 00:03:27.319 --> 00:03:29.460 receptor antagonist that is relatively inexpensive. 00:03:30.120 --> 00:03:33.460 It rapidly diffuses from the blood into air -filled 00:03:33.460 --> 00:03:35.439 cavities, which can be dangerous in instances 00:03:35.439 --> 00:03:38.699 such as air embolisms or pneumothorax. Nitrous 00:03:38.699 --> 00:03:40.719 oxide can even diffuse into the tracheal tube 00:03:40.719 --> 00:03:42.840 cuff itself, increasing the pressure against 00:03:42.840 --> 00:03:45.919 the tracheal mucosa. However, it has very fast 00:03:45.919 --> 00:03:48.580 onset and offset, which can help with quick wake 00:03:48.580 --> 00:03:51.340 -ups. Halothane used to be a common anesthetic, 00:03:51.360 --> 00:03:53.870 but has fallen out of favor. It has been associated 00:03:53.870 --> 00:03:56.509 with liver damage and can cause direct myocardial 00:03:56.509 --> 00:03:58.990 depression leading to low blood pressure, which 00:03:58.990 --> 00:04:01.409 can be exacerbated in patients taking beta blockers 00:04:01.409 --> 00:04:04.169 or calcium channel blockers. Halothane can cause 00:04:04.169 --> 00:04:06.669 hepatic dysfunction and in extremely rare cases 00:04:06.669 --> 00:04:11.099 cause halothane hepatitis. Isoflurane is a pungent 00:04:11.099 --> 00:04:13.099 agent that is relatively soluble in the blood, 00:04:13.219 --> 00:04:16.160 resulting in slightly slower onset and offset 00:04:16.160 --> 00:04:18.879 compared to Sivoflurane. At higher concentrations, 00:04:19.220 --> 00:04:21.920 it can dilate coronary arteries, leading to a 00:04:21.920 --> 00:04:24.500 theoretical coronary steal of blood away from 00:04:24.500 --> 00:04:27.620 maximally dilated ischemic lesions. However, 00:04:27.839 --> 00:04:30.560 this has not been observed to result in clinically 00:04:30.560 --> 00:04:33.810 significant effects. Sivoflurane is relatively 00:04:33.810 --> 00:04:36.689 insoluble in blood, making it an excellent choice 00:04:36.689 --> 00:04:39.050 for smooth and relatively rapid induction and 00:04:39.050 --> 00:04:41.930 emergence in both kids and adults. It is the 00:04:41.930 --> 00:04:43.949 most commonly used inhaled agent in the developed 00:04:43.949 --> 00:04:46.930 world and has a good safety profile and is inexpensive. 00:04:47.709 --> 00:04:50.329 Desflurane has very low solubility in the blood, 00:04:50.470 --> 00:04:52.670 causing very rapid induction and emergence from 00:04:52.670 --> 00:04:55.589 anesthesia. However, it is also an extremely 00:04:55.589 --> 00:04:58.449 potent greenhouse gas. For this reason, many 00:04:58.449 --> 00:05:00.550 centers have moved away from desflurane use. 00:05:01.399 --> 00:05:03.680 It's also extremely pungent and can cause airway 00:05:03.680 --> 00:05:06.480 irritation, making it a poorer choice for inhalation 00:05:06.480 --> 00:05:09.699 inductions. Xenon is an odorless noble gas that 00:05:09.699 --> 00:05:11.959 has very fast onset and emergence parameters. 00:05:12.420 --> 00:05:15.500 Like nitrous oxide, it is an NMDA inhibitor. 00:05:15.620 --> 00:05:18.199 It has very little effect on cardiovascular, 00:05:18.660 --> 00:05:21.420 hepatic, or renal systems and may actually be 00:05:21.420 --> 00:05:24.269 protective against neuronal ischemia. Unfortunately, 00:05:24.529 --> 00:05:26.649 cost and limited availability have prevented 00:05:26.649 --> 00:05:29.670 its widespread use, so the use of xenon is mostly 00:05:29.670 --> 00:05:32.629 limited to test questions currently. I hope this 00:05:32.629 --> 00:05:35.110 brief overview of inhaled anesthetics helps you 00:05:35.110 --> 00:05:36.990 breathe easier next time you are faced with a 00:05:36.990 --> 00:05:46.120 problem on a test or in the OR. It's not like 00:05:46.120 --> 00:05:49.339 I'm talking national secrets. This is my opinion 00:05:49.339 --> 00:05:52.199 about a topic that you approached me about. Yeah, 00:05:52.300 --> 00:05:56.079 that's true. And interestingly, I get to see 00:05:56.079 --> 00:05:59.680 where the downloads come from for my podcast. 00:05:59.920 --> 00:06:03.939 Oh, use the metrics. And one of the places that 00:06:03.939 --> 00:06:06.610 has. i would say an abnormally high amount of 00:06:06.610 --> 00:06:10.029 downloads is washington dc i don't know why hmm 00:06:10.029 --> 00:06:12.970 all right maybe it's the fbi yeah i don't know 00:06:12.970 --> 00:06:15.889 yeah exactly or maybe there's just maybe it's 00:06:15.889 --> 00:06:18.470 just the podcast culture and and uh traffic sucks 00:06:18.470 --> 00:06:21.230 and dmv oh yeah that's that's cool you know it's 00:06:21.230 --> 00:06:24.250 it's just hey we we are progressive young listeners 00:06:24.250 --> 00:06:27.389 who you know this is how we consume our information 00:06:27.389 --> 00:06:30.610 because we're stuck on the metro or the traffic 00:06:30.610 --> 00:06:34.009 for 90 minutes. Yeah, that's great. For the five 00:06:34.009 --> 00:06:37.430 -mile commute. I imagine I could probably sort 00:06:37.430 --> 00:06:39.829 all of my listeners by where the traffic is the 00:06:39.829 --> 00:06:45.189 worst. Oh, that's interesting. Yeah. Well, Ben, 00:06:45.269 --> 00:06:47.689 thank you so much for joining us. Thank you for 00:06:47.689 --> 00:06:49.949 having me. I really appreciate it. I feel honored 00:06:49.949 --> 00:06:53.329 to be offered this opportunity. I knew that you 00:06:53.329 --> 00:06:56.170 wanted to give your little spiel right up front 00:06:56.170 --> 00:06:57.889 since you are a very important person. Oh, I 00:06:57.889 --> 00:06:59.709 don't know about important, but I am a person. 00:07:01.700 --> 00:07:04.259 Similarly, all of the views expressed are my 00:07:04.259 --> 00:07:09.019 own. Nothing here that I state reflects any endorsement 00:07:09.019 --> 00:07:11.300 from the Department of Defense, Department of 00:07:11.300 --> 00:07:14.779 State, United States Air Force, United States 00:07:14.779 --> 00:07:16.860 Air Force, School of Aerospace Medicine, or any 00:07:16.860 --> 00:07:20.699 of the alike. This is my opinion as a student, 00:07:21.000 --> 00:07:23.980 as a scholar, as a, you know, I call myself a 00:07:23.980 --> 00:07:29.480 professional. Someday I would hope to have. A 00:07:29.480 --> 00:07:31.500 similar disclaimer. I'm one of those people that 00:07:31.500 --> 00:07:33.480 gets up in front of people and says, well, I 00:07:33.480 --> 00:07:35.899 have no disclosures, but if anybody is willing 00:07:35.899 --> 00:07:38.939 to pay me, then that would be great. Yeah. Here's 00:07:38.939 --> 00:07:41.360 my bank account. Although I guess I could add 00:07:41.360 --> 00:07:43.120 advertisements to the podcast, but I haven't 00:07:43.120 --> 00:07:44.980 done that yet. So I don't, I don't have any sponsors. 00:07:45.839 --> 00:07:48.399 That's okay. If you want to be a sponsor on the 00:07:48.399 --> 00:07:51.680 podcast, please contact me at styleboyspodcasts 00:07:51.680 --> 00:07:56.259 at gmail .com and we would be happy to be paid 00:07:56.259 --> 00:08:01.060 by you. That's a great plug. So I want to start 00:08:01.060 --> 00:08:03.339 with one of my get to know you questions. Great. 00:08:03.459 --> 00:08:07.379 Which is my dinner question that I asked during 00:08:07.379 --> 00:08:10.160 my residency interviews. I asked it to a lot 00:08:10.160 --> 00:08:11.740 of people yesterday when they were coming in 00:08:11.740 --> 00:08:14.139 to interview for our program. If you could have 00:08:14.139 --> 00:08:16.279 dinner with anyone in the world, could be somebody 00:08:16.279 --> 00:08:18.800 from the past or even from fiction, who would 00:08:18.800 --> 00:08:23.319 you have dinner with and why? So my initial reaction 00:08:23.319 --> 00:08:28.350 would be. if I could have a dinner party, it 00:08:28.350 --> 00:08:32.090 would be both sets of my grandparents. I, some 00:08:32.090 --> 00:08:34.669 of them passed when I was young and some of them, 00:08:34.690 --> 00:08:38.409 uh, unfortunately had, um, you know, just decline 00:08:38.409 --> 00:08:41.750 in the mental capacity as I got older. And I 00:08:41.750 --> 00:08:46.129 think I would just have such a lovely dinner 00:08:46.129 --> 00:08:49.649 getting to know them now that I have kids now 00:08:49.649 --> 00:08:54.789 that I had some military experience that I have 00:08:54.789 --> 00:08:58.980 had. time in this world and been able to to learn 00:08:58.980 --> 00:09:01.460 a little bit more about them you know as growing 00:09:01.460 --> 00:09:04.299 up as a kid i i love my grandparents but you 00:09:04.299 --> 00:09:08.019 appreciate people differently as as you pay you 00:09:08.019 --> 00:09:09.799 know you pass through different phases of life 00:09:09.799 --> 00:09:12.860 so i think that would be my my dinner party um 00:09:12.860 --> 00:09:18.370 from my personal level And if I'm going to get 00:09:18.370 --> 00:09:22.029 a bonus separate, maybe a lunch, I would probably 00:09:22.029 --> 00:09:25.710 say Dolly Parton. Thank Dolly Parton. Just a 00:09:25.710 --> 00:09:31.090 wonderful, kind soul. Who's, you know, that's 00:09:31.090 --> 00:09:34.169 perhaps the safest answer. Oh, OK. All right. 00:09:34.269 --> 00:09:39.210 All right. She's just she's just, you know, an 00:09:39.210 --> 00:09:42.750 amazing individual, a philanthropist who has, 00:09:42.970 --> 00:09:46.149 you know. broken ground and barriers over time 00:09:46.149 --> 00:09:49.710 and has been you know with us so dolly parton 00:09:49.710 --> 00:09:54.169 man i i think that i would leave lunch with dolly 00:09:54.169 --> 00:09:58.789 parton feeling like inspired and hopeful that's 00:09:58.789 --> 00:10:03.210 right she's just wonderful and um in so many 00:10:03.210 --> 00:10:06.929 ways so i don't know anyone actually i probably 00:10:06.929 --> 00:10:08.710 don't know anyone who who couldn't get behind 00:10:08.710 --> 00:10:12.149 that answer and if yeah if um if you do then 00:10:12.539 --> 00:10:14.100 You know, we can throw it on later. Yeah, right. 00:10:14.360 --> 00:10:18.039 Exactly. The reason why we're here today is to 00:10:18.039 --> 00:10:21.360 talk about something that is near and dear to 00:10:21.360 --> 00:10:24.259 you, which is talking about imposter syndrome. 00:10:25.139 --> 00:10:29.919 What about imposter syndrome drew you in? Why 00:10:29.919 --> 00:10:32.259 are you interested to talk about it? Absolutely. 00:10:32.779 --> 00:10:37.460 Great question. imposter syndrome is is especially 00:10:37.460 --> 00:10:39.879 prevalent in medical training we're in a high 00:10:39.879 --> 00:10:43.000 stakes environment where we all want to do well 00:10:43.000 --> 00:10:46.480 we have a passion a calling i hope to take care 00:10:46.480 --> 00:10:49.919 of our patients and our decisions our management 00:10:49.919 --> 00:10:54.980 our job day -to -day has very dire consequences 00:10:54.980 --> 00:10:58.519 and impact also on conversely on the positive 00:10:58.519 --> 00:11:05.940 side through that we often have quite a bit of 00:11:05.940 --> 00:11:08.960 pressure on our shoulders. That's, you know, 00:11:08.980 --> 00:11:11.620 some of it is self -imposed and certainly some 00:11:11.620 --> 00:11:15.419 of it is external. Talking about imposter syndrome 00:11:15.419 --> 00:11:18.419 is important because of the prevalence in this 00:11:18.419 --> 00:11:24.100 environment and the impact it has on us. I believe 00:11:24.100 --> 00:11:29.000 that, you know, at some point in almost everyone's 00:11:29.000 --> 00:11:33.919 medical career, they'll have some symptoms, some 00:11:33.919 --> 00:11:36.840 signs of imposter syndrome, whether it's full 00:11:36.840 --> 00:11:41.279 -blown feelings of fraud or just inadequacy, 00:11:41.360 --> 00:11:45.820 you know, it's certainly, you know, if it hasn't 00:11:45.820 --> 00:11:47.460 hit you yet, it probably will at some point. 00:11:49.000 --> 00:11:52.399 Whenever I saw that you were giving a talk about 00:11:52.399 --> 00:11:56.159 imposter syndrome at the Ohio Society of Anesthesiologists 00:11:56.159 --> 00:11:59.240 meeting, which is where I first saw that this 00:11:59.240 --> 00:12:01.819 was something that you were interested in, I 00:12:01.819 --> 00:12:04.159 have to admit, I thought that you were probably 00:12:04.159 --> 00:12:09.620 the least likely person that I know that I would 00:12:09.620 --> 00:12:11.639 imagine would have imposter syndrome, which is 00:12:11.639 --> 00:12:13.580 why I was excited to talk to you about it partially. 00:12:15.000 --> 00:12:17.059 I remember when you first came to the department 00:12:17.059 --> 00:12:20.919 a few years ago, and the way that you were described 00:12:20.919 --> 00:12:24.759 to me was sort of as the opposite of somebody 00:12:24.759 --> 00:12:26.659 who might be struggling with imposter syndrome, 00:12:26.779 --> 00:12:30.909 just as a... superb clinician and somebody who 00:12:30.909 --> 00:12:34.809 always has a good head on shoulders, very professional, 00:12:35.009 --> 00:12:43.049 solid guy. So tell me, what is it about that 00:12:43.049 --> 00:12:45.570 description that you don't feel applies to you 00:12:45.570 --> 00:12:49.669 or that you struggle with? Great. First of all, 00:12:49.669 --> 00:12:53.029 thank you. I feel honored that people perceive 00:12:53.029 --> 00:12:56.299 and describe me that way. I think it's really 00:12:56.299 --> 00:13:00.320 through some self -discovery and my own vulnerability 00:13:00.320 --> 00:13:04.899 that I've discovered. Sometimes I feel like I 00:13:04.899 --> 00:13:07.480 don't know the answer and the truth is a lot 00:13:07.480 --> 00:13:09.259 of people don't have all the answers all the 00:13:09.259 --> 00:13:14.759 time. It's not until we have this self -reflection 00:13:14.759 --> 00:13:18.980 and this acceptance of who we are and we're all 00:13:18.980 --> 00:13:21.179 human, we're all striving to be the best versions 00:13:21.179 --> 00:13:26.870 of ourselves. If we fail to recognize and we 00:13:26.870 --> 00:13:31.690 fail to normalize and label it, I think we do 00:13:31.690 --> 00:13:35.110 all ourselves, we do each other a disfavor. We're 00:13:35.110 --> 00:13:36.870 all professionals and we all suffer from these 00:13:36.870 --> 00:13:40.250 things. And it is, I think, you know, one of 00:13:40.250 --> 00:13:43.230 my jobs is to normalize this and say, hey, you 00:13:43.230 --> 00:13:46.450 may, this is your perception of me. And I do 00:13:46.450 --> 00:13:49.629 feel like I've had wonderful training. I show 00:13:49.629 --> 00:13:52.149 up every day ready to work. I do all the things 00:13:52.149 --> 00:13:55.139 that. you know, we should do. But at the same 00:13:55.139 --> 00:13:59.480 time, I still am far from where I want to be 00:13:59.480 --> 00:14:01.500 and we're all striving for it. But if I'm doing 00:14:01.500 --> 00:14:04.840 it, certainly everyone else is too. So let's 00:14:04.840 --> 00:14:07.399 back up a little bit. I'd love to hear more about 00:14:07.399 --> 00:14:12.639 your background, your intro to medicine, your 00:14:12.639 --> 00:14:16.879 pathway to being part of the Seastars. Tell me 00:14:16.879 --> 00:14:19.940 more about all that. Absolutely. So I took a 00:14:22.090 --> 00:14:24.309 non -straightforward approach to medicine. I 00:14:24.309 --> 00:14:26.110 always knew I wanted to go in the medical field. 00:14:28.210 --> 00:14:30.690 But when I graduated from undergrad, I knew I 00:14:30.690 --> 00:14:33.769 wasn't quite ready yet. The decision to commit 00:14:33.769 --> 00:14:37.169 to medicine was, it's a big one, right? You put 00:14:37.169 --> 00:14:40.370 that as your priority. You know, I feel that 00:14:40.370 --> 00:14:42.409 our profession is not one to be taken lightly 00:14:42.409 --> 00:14:45.769 and it's not just, oh, it's the next path because 00:14:45.769 --> 00:14:47.690 I don't know what else to do. That shouldn't 00:14:47.690 --> 00:14:53.539 be the answer in my book. I took a few years 00:14:53.539 --> 00:14:57.440 off, didn't know quite what I wanted to do in 00:14:57.440 --> 00:15:00.320 the interim. I did a little bit of business consulting. 00:15:01.039 --> 00:15:05.000 I spent some time actually working in the agricultural 00:15:05.000 --> 00:15:09.720 industry. One of my great grandfathers was a 00:15:09.720 --> 00:15:14.100 farrier in the cavalry. And I was like, oh man, 00:15:14.179 --> 00:15:15.639 that's a pretty cool piece of family history. 00:15:16.419 --> 00:15:22.440 So I went to... the West, went to fair school, 00:15:22.620 --> 00:15:26.139 learned how to shoe horses, moved back to Florida, 00:15:26.200 --> 00:15:28.039 did that for a little while, realized it was 00:15:28.039 --> 00:15:33.539 backbreaking work. And then I managed a show 00:15:33.539 --> 00:15:37.899 horse barn, did some importing and sales and 00:15:37.899 --> 00:15:43.340 management of in that arena, you would say. And 00:15:43.340 --> 00:15:45.299 then I was like, okay, I'm ready. I'm ready to 00:15:45.299 --> 00:15:47.120 go back, ready to hit the books, ready to hit 00:15:47.120 --> 00:15:50.769 the lab. You know, let's continue this on. So 00:15:50.769 --> 00:15:55.210 that was about a four -year hiatus. Did some 00:15:55.210 --> 00:15:57.389 post -bac work where I was down in Florida at 00:15:57.389 --> 00:16:01.450 the University of Florida. And applied for medical 00:16:01.450 --> 00:16:03.850 school. I did not get in the first time, which 00:16:03.850 --> 00:16:07.889 is not an uncommon thing. Neither did I. And 00:16:07.889 --> 00:16:13.590 here we are. And got in on the second round. 00:16:15.610 --> 00:16:17.549 Did my training at University of South Florida 00:16:17.549 --> 00:16:22.250 in Tampa, Florida. Went on to do residency. Joined 00:16:22.250 --> 00:16:24.210 the military during medical school because this 00:16:24.210 --> 00:16:26.169 was also something near and dear to my heart. 00:16:26.309 --> 00:16:30.289 Come from both grandfathers were in the Army 00:16:30.289 --> 00:16:33.850 Air Corps. And I also wanted to continue on that 00:16:33.850 --> 00:16:37.789 tradition. I think at that point we were solidly 00:16:37.789 --> 00:16:42.970 almost into a decade of our overseas involvement. 00:16:44.360 --> 00:16:46.500 again another discussion whether right or wrong 00:16:46.500 --> 00:16:48.200 but that was the state of affairs and i felt 00:16:48.200 --> 00:16:52.460 a calling to help those who were doing work to 00:16:52.460 --> 00:16:54.799 try to make the world a better place or at least 00:16:54.799 --> 00:16:57.659 you know that was all of our where our heart 00:16:57.659 --> 00:17:04.539 was went through the hpsb program managed to 00:17:04.539 --> 00:17:06.700 get civilian training all the way through. So 00:17:06.700 --> 00:17:08.759 did residency at University of Maryland Medical 00:17:08.759 --> 00:17:11.000 Center in shock trauma in Baltimore, and then 00:17:11.000 --> 00:17:13.299 did a critical care fellowship at Vanderbilt 00:17:13.299 --> 00:17:16.119 University and had an outstanding group of mentors 00:17:16.119 --> 00:17:20.980 at both places, especially Vanderbilt. Graduated 00:17:20.980 --> 00:17:24.759 in the midst of COVID, towards the end of COVID 00:17:24.759 --> 00:17:28.180 from fellowship. Came here as my first duty station. 00:17:28.420 --> 00:17:31.940 Again, very, very lucky to come to an institution 00:17:31.940 --> 00:17:37.819 with a heritage. and a high volume of sick patients 00:17:37.819 --> 00:17:41.960 to work in the OR, to work in the ICUs, to continue 00:17:41.960 --> 00:17:45.660 to do ECMO management, retrieval, transport, 00:17:46.019 --> 00:17:52.119 and so do my Air Force job, which is to work 00:17:52.119 --> 00:17:55.720 at our C -STAR Cincinnati Center for Sustainment 00:17:55.720 --> 00:17:59.519 Training and Readiness, where our job here is 00:17:59.519 --> 00:18:05.390 to prepare and validate. members of our CCAT, 00:18:05.450 --> 00:18:08.390 Critical Care Air Transport Team. That's the 00:18:08.390 --> 00:18:11.190 final portion of their pipeline. It's a two -week 00:18:11.190 --> 00:18:13.869 course, which is both instructional, but it's 00:18:13.869 --> 00:18:16.849 really assessment validation in order to take 00:18:16.849 --> 00:18:20.170 care of critically ill patients downrange and 00:18:20.170 --> 00:18:23.369 transport them basically a flying ICU. Sometimes 00:18:23.369 --> 00:18:26.089 it's back of pickup trucks. Sometimes it's rotor 00:18:26.089 --> 00:18:28.450 wings. Sometimes it's fixed wing and just preparing 00:18:28.450 --> 00:18:33.200 for what's next. All sounds really amazing. And 00:18:33.200 --> 00:18:36.539 I fortunately had the opportunity to go see some 00:18:36.539 --> 00:18:39.559 of the Seastar simulation stuff with Jesse when 00:18:39.559 --> 00:18:43.019 I had him on the podcast too. And I had no idea 00:18:43.019 --> 00:18:46.660 how much really cool stuff you guys have. Oh, 00:18:46.660 --> 00:18:50.880 it's amazing. I really feel lucky to be part 00:18:50.880 --> 00:18:54.680 of it. And that's what my job also is when I 00:18:54.680 --> 00:18:58.559 deploy as well. So what deployments have you 00:18:58.559 --> 00:19:03.549 been on? Managed to have a deployment that was 00:19:03.549 --> 00:19:05.789 supposed to be six months and turned into a seven 00:19:05.789 --> 00:19:09.730 and a half month deployment in East Africa. It's 00:19:09.730 --> 00:19:12.569 part of a special operations team out there. 00:19:12.710 --> 00:19:15.670 And without getting into details, we had a really 00:19:15.670 --> 00:19:20.410 large area of the continent to cover and provide 00:19:20.410 --> 00:19:24.289 medical support. We were the asset to mitigate 00:19:24.289 --> 00:19:27.849 risk and to take care of, you know, our brothers 00:19:27.849 --> 00:19:31.000 and sisters and our... partner nations that were 00:19:31.000 --> 00:19:36.519 doing the work mostly anti -terrorism work okay 00:19:36.519 --> 00:19:42.460 so through all that uh you're clearly have an 00:19:42.460 --> 00:19:44.960 incredible cv uh everyone around you respects 00:19:44.960 --> 00:19:48.299 you very much when did you first start to recognize 00:19:48.299 --> 00:19:52.559 imposter syndrome in yourself absolutely and 00:19:52.559 --> 00:19:55.559 the way i think of imposter syndrome too is is 00:19:55.559 --> 00:20:00.220 a spectrum right there's people that certainly 00:20:00.220 --> 00:20:02.759 have full -blown imposter syndrome where they 00:20:02.759 --> 00:20:06.500 feel despite objective evidence of their knowledge 00:20:06.500 --> 00:20:10.660 and performance that they are a fraud and that's 00:20:10.660 --> 00:20:12.500 really really tough to be in that position because 00:20:12.500 --> 00:20:15.680 in my mind or thinking about a fraud is someone 00:20:15.680 --> 00:20:18.720 who does who isn't something who doesn't have 00:20:18.720 --> 00:20:22.220 the skills that they they actually have in their 00:20:22.220 --> 00:20:28.480 armamentarium i feel that most of us manifest 00:20:28.480 --> 00:20:34.859 imposter syndrome in inadequacy or underpreparation 00:20:34.859 --> 00:20:37.799 or feelings of underpreparation despite adequate 00:20:37.799 --> 00:20:40.380 preparation or data that we've done the job, 00:20:40.460 --> 00:20:44.019 done the work, and we're capable. And that's 00:20:44.019 --> 00:20:46.400 really where it was for me. It's like, hey, you 00:20:46.400 --> 00:20:52.900 know, I am the line. I am responsible for these 00:20:52.900 --> 00:20:57.240 patients, for this job, and... Am I good enough? 00:20:57.400 --> 00:20:59.380 Is this, you know, so many people are looking 00:20:59.380 --> 00:21:03.480 at me. Do I have what it takes? Was this something 00:21:03.480 --> 00:21:07.220 that you started to feel in medical school or 00:21:07.220 --> 00:21:09.920 residency or more as an attending? What do you 00:21:09.920 --> 00:21:12.720 think? Sure. I believe it was towards the end 00:21:12.720 --> 00:21:16.480 of residency until to being a junior attending. 00:21:16.619 --> 00:21:20.940 I think for me, it was more the reality of the. 00:21:21.559 --> 00:21:24.319 application. And we're lucky enough not to work 00:21:24.319 --> 00:21:26.000 in silos. We have a great group of colleagues 00:21:26.000 --> 00:21:27.799 here that always back each other. You ask for 00:21:27.799 --> 00:21:29.980 help and you end up having to kick people away 00:21:29.980 --> 00:21:32.900 because you have so much help. But for me, it 00:21:32.900 --> 00:21:36.960 was towards that period where I'm the one making 00:21:36.960 --> 00:21:41.819 decisions. And again, this is the impact of these 00:21:41.819 --> 00:21:45.559 decisions, the nature of our job. We see those 00:21:45.559 --> 00:21:48.720 decisions and the downstream effects of those 00:21:48.720 --> 00:21:52.710 pretty quickly compared to other areas of medicine 00:21:52.710 --> 00:21:55.410 where you're seeing someone every four months 00:21:55.410 --> 00:21:57.930 for titration outpatient blood pressure medication 00:21:57.930 --> 00:22:01.430 right where we have a dangerous job or make critical 00:22:01.430 --> 00:22:06.170 decisions and we do it in a very very short amount 00:22:06.170 --> 00:22:08.750 of time with sometimes limited data points and 00:22:08.750 --> 00:22:11.049 that's that's high stakes that's a lot riding 00:22:11.049 --> 00:22:15.880 on that i feel some of my Self -reflection is 00:22:15.880 --> 00:22:19.160 healthy concern and respect for that responsibility. 00:22:19.740 --> 00:22:21.759 And I think part of it too is making sure that, 00:22:21.819 --> 00:22:25.299 you know, some other people you can show up and 00:22:25.299 --> 00:22:27.019 have a bad day and it doesn't have much consequence. 00:22:27.119 --> 00:22:29.359 But if one of us shows up and has a bad day, 00:22:29.420 --> 00:22:32.039 well, it's a bad day not only for you, but some 00:22:32.039 --> 00:22:36.319 other folks too. This is really true. You know, 00:22:36.400 --> 00:22:39.579 when you think about other areas of medicine, 00:22:39.799 --> 00:22:43.900 when an internal medicine doctor sees a patient, 00:22:45.360 --> 00:22:49.220 and decides to prescribe a medication, the pathway 00:22:49.220 --> 00:22:51.700 for the medication getting to the patient is 00:22:51.700 --> 00:22:54.460 very different. For that internal medicine doctor, 00:22:54.700 --> 00:22:58.779 he will go back to his computer, he will type 00:22:58.779 --> 00:23:02.359 in an order, or he will tell one of his residents 00:23:02.359 --> 00:23:05.700 to type in an order, one of his APPs. That order 00:23:05.700 --> 00:23:09.519 goes in, and it goes to the pharmacy, who double 00:23:09.519 --> 00:23:12.779 -checks it, makes sure that it's correct. And 00:23:12.779 --> 00:23:16.640 then after the pharmacy, it will typically be 00:23:16.640 --> 00:23:19.440 dispensed by a nurse. And if it's a high -alert 00:23:19.440 --> 00:23:22.779 medication, then that gets double -checked again 00:23:22.779 --> 00:23:28.759 by the nurse and it's given to the patient. For 00:23:28.759 --> 00:23:31.500 us, it's very different. We see something on 00:23:31.500 --> 00:23:33.440 the monitor that we don't like and we have to 00:23:33.440 --> 00:23:38.319 push a medicine. We open the OmniCell, pull out 00:23:38.319 --> 00:23:40.380 the medicine, draw it up, and give it immediately 00:23:40.380 --> 00:23:44.210 into the patient's IV. There's not... Usually 00:23:44.210 --> 00:23:46.970 you need double checking. You're right. I think 00:23:46.970 --> 00:23:52.750 that that sort of dramatic responsibility is 00:23:52.750 --> 00:23:55.970 a weighty thing that we have to deal with. I 00:23:55.970 --> 00:23:58.890 agree. You hit the nail on the head and we can 00:23:58.890 --> 00:24:00.650 talk all about the safety systems and everything, 00:24:00.769 --> 00:24:04.150 but I think the emphasis today is really on how 00:24:04.150 --> 00:24:09.049 do we handle those pressures, those stressors, 00:24:09.049 --> 00:24:13.980 and still have the confidence. in our skills 00:24:13.980 --> 00:24:18.420 in our knowledge in our training in our previous 00:24:18.420 --> 00:24:23.660 repetitions in order to provide the best care 00:24:23.660 --> 00:24:26.140 and not let that stand in the way of thinking 00:24:26.140 --> 00:24:30.500 as clearly as we can in those situations did 00:24:30.500 --> 00:24:34.319 you have any sort of event that made you say 00:24:34.319 --> 00:24:37.279 to yourself you know imposter syndrome is something 00:24:37.279 --> 00:24:40.750 that i want to talk about To my colleagues, I 00:24:40.750 --> 00:24:42.490 want to share my experience because that's a 00:24:42.490 --> 00:24:46.549 vulnerable thing that you're doing to put yourself 00:24:46.549 --> 00:24:51.609 out there and say, look, this is who I am. I 00:24:51.609 --> 00:24:54.650 mean, spoiler alert, I think everybody has some 00:24:54.650 --> 00:24:57.410 degree of this. I certainly do myself. I feel 00:24:57.410 --> 00:25:03.289 that way all the time. But what event or mindset 00:25:03.289 --> 00:25:06.250 change pushed you over to the idea of, you know, 00:25:06.329 --> 00:25:08.529 I'm going to put together a talk about this? 00:25:08.920 --> 00:25:13.839 Absolutely. I think two things. One, in my personal 00:25:13.839 --> 00:25:19.579 life, I've realized that I struggle to be vulnerable, 00:25:19.680 --> 00:25:24.980 whether that's with my wife, with my friends, 00:25:25.059 --> 00:25:29.299 my family. And I realized this also extends to 00:25:29.299 --> 00:25:34.359 my professional life. So in this personal sort 00:25:34.359 --> 00:25:38.980 of quest to be more me or at least get in touch 00:25:38.980 --> 00:25:43.559 with myself and connect with those around me 00:25:43.559 --> 00:25:48.859 people I love my colleagues my patients that 00:25:48.859 --> 00:25:52.720 that's this is a critical portion of that is 00:25:52.720 --> 00:25:55.839 is having the self -awareness that hey I have 00:25:55.839 --> 00:25:57.900 these feelings too and you know what you probably 00:25:57.900 --> 00:26:02.819 do too but let me go first let me let me share 00:26:02.819 --> 00:26:05.380 with you my story let me share with you my feelings 00:26:05.380 --> 00:26:09.569 and maybe then you won't feel as alone either. 00:26:11.789 --> 00:26:16.809 When residents ask me questions that I don't 00:26:16.809 --> 00:26:19.450 know the answer to, which is more often than 00:26:19.450 --> 00:26:25.029 I'd like to admit, I think, in the beginning 00:26:25.029 --> 00:26:28.049 when I was a junior attending, I very much felt 00:26:28.049 --> 00:26:32.009 like, oh, I have to know the answer to this, 00:26:32.109 --> 00:26:36.680 and I would feel very terrible. if i didn't know 00:26:36.680 --> 00:26:39.980 and so i would often deflect or say something 00:26:39.980 --> 00:26:43.000 like well why don't you look that up yeah right 00:26:43.000 --> 00:26:47.099 something like that but i've started trying to 00:26:47.099 --> 00:26:51.160 say you know i don't remember let's look it up 00:26:51.160 --> 00:26:54.099 together let's let's both learn and i think that 00:26:54.099 --> 00:26:57.119 that's a little bit freeing it's it's helped 00:26:57.119 --> 00:27:00.900 me be a better teacher and probably be a better 00:27:00.900 --> 00:27:03.859 person to be more vulnerable like that even though 00:27:03.859 --> 00:27:07.109 it's hard It is hard, but you also realize that 00:27:07.109 --> 00:27:09.369 when you can be honest with yourself and honest 00:27:09.369 --> 00:27:14.369 with others, it feels so much better. That weight 00:27:14.369 --> 00:27:17.410 is lifted off your shoulders and it's okay not 00:27:17.410 --> 00:27:19.710 to know the answer. And I think part of my critical 00:27:19.710 --> 00:27:23.170 care training made that easier because, you know, 00:27:23.170 --> 00:27:27.529 in the ICU, the patients are so heterogeneous. 00:27:27.769 --> 00:27:30.470 They don't read the studies. We're like extrapolating 00:27:30.470 --> 00:27:32.789 information. You have all these people and you're 00:27:32.789 --> 00:27:36.420 trying to Make assessments, integrate information, 00:27:36.539 --> 00:27:38.420 make the best decision. And then, of course, 00:27:38.480 --> 00:27:43.660 it's a dynamic environment. So it's the ICU training 00:27:43.660 --> 00:27:47.059 and fellowship helped me in the OR, not just 00:27:47.059 --> 00:27:49.079 from a clinical standpoint, but from the fact 00:27:49.079 --> 00:27:52.039 that it's OK to say you don't know. And that's 00:27:52.039 --> 00:27:54.819 why you have a team or you have resources in 00:27:54.819 --> 00:27:58.859 order to, you know, arrive at the right answer. 00:27:58.900 --> 00:28:02.660 And sometimes it's. Not knowing it on the tip 00:28:02.660 --> 00:28:05.859 of your tongue is an okay thing. Do you think 00:28:05.859 --> 00:28:09.720 that being in the military helped you with your 00:28:09.720 --> 00:28:13.079 mindset in terms of imposter syndrome? Did it 00:28:13.079 --> 00:28:14.519 make it more challenging? What do you think? 00:28:17.420 --> 00:28:19.279 That's a good one. I think it's a mixed bag. 00:28:19.460 --> 00:28:24.519 I think the environment in which I practice medicine 00:28:24.519 --> 00:28:29.759 certainly... amplified those feelings at times 00:28:29.759 --> 00:28:33.240 when you're the sole three -member medical team 00:28:33.240 --> 00:28:39.559 in this area relied on by you know layers and 00:28:39.559 --> 00:28:42.440 layers of folks you feel that pressure for sure 00:28:42.440 --> 00:28:45.779 and I think that drives you to to train to prepare 00:28:45.779 --> 00:28:48.819 and to know these things and through the training 00:28:48.819 --> 00:28:54.140 preparation the reps you realize that you actually 00:28:54.140 --> 00:28:58.099 do have it I think also in the military, there's 00:28:58.099 --> 00:29:02.920 quite a bit of experience, inexperience. There's 00:29:02.920 --> 00:29:07.839 quite a bit of variety in levels of intelligence, 00:29:08.160 --> 00:29:10.960 application of that intelligence, right, and 00:29:10.960 --> 00:29:16.259 skill set. And seeing that variety, I think, 00:29:16.259 --> 00:29:19.680 was helpful. In medical school, everyone is a 00:29:19.680 --> 00:29:22.720 super achiever of some sorts. We've made it to 00:29:22.720 --> 00:29:26.630 this level. You know, everyone is. board certified 00:29:26.630 --> 00:29:29.529 in the pursuit of board certification. They're 00:29:29.529 --> 00:29:35.049 well read, they're well published. And I think 00:29:35.049 --> 00:29:38.250 that is not necessarily a true representation 00:29:38.250 --> 00:29:40.829 of life in general, right? We surround ourselves, 00:29:40.869 --> 00:29:43.769 we spend most of the time working hours at work 00:29:43.769 --> 00:29:46.829 around these, you know, super smart people. And 00:29:46.829 --> 00:29:50.859 that sometimes can be challenging. that comparison 00:29:50.859 --> 00:29:52.579 and those things that can also be very supportive 00:29:52.579 --> 00:29:55.119 if you have a resilient culture. But I think 00:29:55.119 --> 00:29:58.700 it also sets yourself up to, you know, feeling 00:29:58.700 --> 00:30:00.700 that way a little bit more different, a little 00:30:00.700 --> 00:30:03.160 bit more frequently than maybe in other settings. 00:30:05.259 --> 00:30:09.380 So what do you think we need to do to have a 00:30:09.380 --> 00:30:11.759 culture that's a little bit more resilient, that 00:30:11.759 --> 00:30:16.160 supports people like both of us who struggle 00:30:16.160 --> 00:30:20.869 with these feelings? So, of course, you know, 00:30:20.890 --> 00:30:22.230 you and I were at the Grand Rounds yesterday 00:30:22.230 --> 00:30:24.650 with Dr. Amy Henson out of Boston Children's, 00:30:24.670 --> 00:30:28.670 who's wonderful. Yes, absolutely. Who primarily 00:30:28.670 --> 00:30:31.930 spoke to us in this joint Grand Rounds about 00:30:31.930 --> 00:30:37.509 burnout and resilient culture at the divisional 00:30:37.509 --> 00:30:41.950 and department levels. So plug for her. But imposter 00:30:41.950 --> 00:30:45.329 syndrome is a part of that. And I look at that. 00:30:47.509 --> 00:30:53.180 I look at the. burnout and the resiliency in 00:30:53.180 --> 00:30:56.359 culture of an institution or a divisional level 00:30:56.359 --> 00:31:00.119 as kind of like the strategic overarching framework. 00:31:00.700 --> 00:31:05.900 The things that I try to share with my residents, 00:31:06.000 --> 00:31:08.980 my colleagues are more on the tactical or individual 00:31:08.980 --> 00:31:13.039 level, like how can I own this? And I think the 00:31:13.039 --> 00:31:18.339 change starts when we, as teachers who are responsible 00:31:18.339 --> 00:31:22.400 for residents, who interact with nursing anesthetists, 00:31:22.500 --> 00:31:25.740 who work with fellows, with all sorts of different 00:31:25.740 --> 00:31:29.460 levels of folks. If we demonstrate this vulnerability 00:31:29.460 --> 00:31:34.480 and we provide our trainees and those around 00:31:34.480 --> 00:31:38.099 us with a safe space to share their feelings 00:31:38.099 --> 00:31:41.700 or to come to us with questions, concerns, challenges, 00:31:41.900 --> 00:31:44.259 I think that's where we build it from the ground 00:31:44.259 --> 00:31:46.160 up. So I think there's two ways of doing it from 00:31:46.160 --> 00:31:48.950 the top down. Super important, but also it is 00:31:48.950 --> 00:31:51.250 our responsibility to own a piece of it. And 00:31:51.250 --> 00:31:55.470 that starts with yourself. One thing that helps 00:31:55.470 --> 00:31:58.670 me to understand things better is specific examples. 00:31:58.869 --> 00:32:01.589 I wonder if you'd be willing to tell a story 00:32:01.589 --> 00:32:06.690 or two about situations where you felt like you 00:32:06.690 --> 00:32:10.569 did right by our trainees or by somebody else 00:32:10.569 --> 00:32:13.289 you were with and being vulnerable, talking about 00:32:13.289 --> 00:32:21.599 a situation. where you might have felt like you 00:32:21.599 --> 00:32:26.660 did it right. Absolutely. The example that comes 00:32:26.660 --> 00:32:29.640 to mind was in the ICU, which is a perfect place 00:32:29.640 --> 00:32:32.059 to not know the answer and still be okay with 00:32:32.059 --> 00:32:34.160 not knowing the answer. And it was a complex 00:32:34.160 --> 00:32:37.660 patient who had multisystem organ failure and 00:32:37.660 --> 00:32:44.109 some complex things going on with the... social 00:32:44.109 --> 00:32:47.710 aspects of his life. And at this point, it's 00:32:47.710 --> 00:32:50.930 pretty straightforward, challenging, but pretty 00:32:50.930 --> 00:32:53.170 straightforward what we needed to do from a medical 00:32:53.170 --> 00:32:56.789 standpoint. But when I said, I don't know if 00:32:56.789 --> 00:32:59.109 this is the right thing to do for the patient, 00:32:59.329 --> 00:33:03.490 this bristled the hair of some of my consulting 00:33:03.490 --> 00:33:08.099 colleagues. We're discussing about mechanical 00:33:08.099 --> 00:33:12.079 support devices and durable options for a patient 00:33:12.079 --> 00:33:14.819 and multi -system organ failure that started 00:33:14.819 --> 00:33:19.019 as heart failure. And I think having a discussion 00:33:19.019 --> 00:33:23.980 in front of everyone, meaning trainees, medical 00:33:23.980 --> 00:33:27.700 students, multidisciplinary team, and saying, 00:33:27.740 --> 00:33:32.539 hey, there's more to this. We need to not make 00:33:32.539 --> 00:33:34.940 decisions for someone else, which we can. Talk 00:33:34.940 --> 00:33:37.440 about paternalism another time. But to really 00:33:37.440 --> 00:33:39.880 say, hey, there's a lot of conflicting data and 00:33:39.880 --> 00:33:42.880 I don't know what to do with it. It's real easy 00:33:42.880 --> 00:33:45.299 to look at endpoints and target endpoints of 00:33:45.299 --> 00:33:48.359 certain things, organ function or what have you. 00:33:48.740 --> 00:33:53.240 But it's different to look at the big picture 00:33:53.240 --> 00:33:55.279 and say, I'm not sure what's right or wrong. 00:33:56.539 --> 00:33:58.720 And we need to figure this out together as a 00:33:58.720 --> 00:34:00.859 team because I don't know the right answer. And 00:34:00.859 --> 00:34:03.809 just being saying, you know, this decision. my 00:34:03.809 --> 00:34:07.650 feelings in front of surgeons in front of you 00:34:07.650 --> 00:34:13.849 know several other attending teams i think showed 00:34:13.849 --> 00:34:17.110 you know my colors to my team that it's okay 00:34:17.110 --> 00:34:19.809 that you know when the person in charge of my 00:34:19.809 --> 00:34:22.130 team doesn't know the answer and just owns it 00:34:22.130 --> 00:34:24.269 and that's okay i don't need to fake it or or 00:34:24.269 --> 00:34:28.489 make these decisions quickly or without without 00:34:28.489 --> 00:34:33.250 deep thought I have been in situations before 00:34:33.250 --> 00:34:38.389 with some of my senior residents, and they will 00:34:38.389 --> 00:34:41.130 ask me a question about a plan that we have for 00:34:41.130 --> 00:34:48.809 a patient. And I'll say something like, well, 00:34:48.949 --> 00:34:52.070 I don't really know. What do you think we should 00:34:52.070 --> 00:34:55.090 do? But I've noticed that they don't actually 00:34:55.090 --> 00:34:59.789 believe me when I say that. Oftentimes, I say, 00:35:00.329 --> 00:35:02.170 yeah yeah okay but what what do you actually 00:35:02.170 --> 00:35:05.670 want to do it's like no what i'm telling you 00:35:05.670 --> 00:35:09.110 the truth i i don't actually know what the right 00:35:09.110 --> 00:35:13.110 thing to do is here and i am seeking your input 00:35:13.110 --> 00:35:16.949 as somebody who's also done this before you know 00:35:16.949 --> 00:35:22.289 that's a great way of doing it i think we often 00:35:22.289 --> 00:35:25.510 you know as a trainee you have this great advantage 00:35:25.510 --> 00:35:29.230 of working with different attendings on a daily 00:35:29.230 --> 00:35:31.630 basis see how different things are done you you 00:35:31.630 --> 00:35:33.710 are in a unique position where you're collecting 00:35:33.710 --> 00:35:35.570 all this data collecting different approaches 00:35:35.570 --> 00:35:40.530 you have the ability and then graduate from training 00:35:40.530 --> 00:35:44.690 and you're practicing an or on your own or overseeing 00:35:44.690 --> 00:35:47.949 two three rooms sometimes four running together 00:35:47.949 --> 00:35:54.869 and unless you actively seek out colleagues actively 00:35:54.869 --> 00:35:58.070 talk to your surgeons about his or her approach 00:35:58.070 --> 00:36:02.329 and have these discussions the further you get 00:36:02.329 --> 00:36:05.570 out the more alone you might end up feeling and 00:36:05.570 --> 00:36:07.769 then the harder it is to reach out so having 00:36:07.769 --> 00:36:11.269 uh i think it's a very valid question not to 00:36:11.269 --> 00:36:13.650 flip it on the learner saying oh well teach me 00:36:13.650 --> 00:36:16.150 what you know where this is part of your mock 00:36:16.150 --> 00:36:19.150 oral exam but rather like what have you seen 00:36:19.150 --> 00:36:21.489 has worked in the past oh you're on your neuro 00:36:21.489 --> 00:36:25.130 rotation and it's month two it's been three months 00:36:25.130 --> 00:36:29.039 since i've done this beach chair position? What 00:36:29.039 --> 00:36:32.420 are your thoughts? And having that as an honest 00:36:32.420 --> 00:36:39.840 conversation is great. One thing that I've found 00:36:39.840 --> 00:36:44.760 is that patients really want you to be confident 00:36:44.760 --> 00:36:49.440 in whatever you do. But you also have to balance 00:36:49.440 --> 00:36:53.320 that with the humility of knowing that you don't 00:36:53.320 --> 00:36:56.150 know everything and that you might not. be right 00:36:56.150 --> 00:36:58.429 all the time what do you think the best way is 00:36:58.429 --> 00:37:08.269 to balance the confidence and the humility i 00:37:08.269 --> 00:37:11.690 believe that the answer when a patient asks me 00:37:11.690 --> 00:37:15.989 about these things is to promise them or to impart 00:37:15.989 --> 00:37:19.289 in them that i will do everything i can to take 00:37:19.289 --> 00:37:23.449 care of you the way you deserve the way the dynamic 00:37:24.509 --> 00:37:28.050 situation calls for. That's not to say I may 00:37:28.050 --> 00:37:30.909 not know an answer to along the way, or it might 00:37:30.909 --> 00:37:36.750 be a real time dynamic decision. But I can clearly 00:37:36.750 --> 00:37:39.949 say when I wake up, you know, I'm prepared, and 00:37:39.949 --> 00:37:42.670 I'm confident that I will do my best to take 00:37:42.670 --> 00:37:45.650 care of you the way you deserve. Some of those 00:37:45.650 --> 00:37:47.250 other things you can figure out along the way, 00:37:47.369 --> 00:37:51.530 you can look up, you can speak to expert colleagues 00:37:51.530 --> 00:37:54.059 who've done this, you know, longer. who are smarter 00:37:54.059 --> 00:37:58.000 than me but i i have no problem telling a patient 00:37:58.000 --> 00:38:01.119 i'm confident in being prepared to take care 00:38:01.119 --> 00:38:04.159 of you the way i'd take care of any family member 00:38:04.159 --> 00:38:06.679 so it makes sense separating the the intent from 00:38:06.679 --> 00:38:13.039 the actual individual minutia of the medical 00:38:13.039 --> 00:38:16.980 decision making that is actually something that 00:38:16.980 --> 00:38:20.300 i like to share with patients a lot as a way 00:38:20.300 --> 00:38:24.340 to build rapport but it's also part of my actual 00:38:24.340 --> 00:38:27.119 underlying philosophy, which is helpful. I say, 00:38:27.179 --> 00:38:31.360 well, I'm telling you this information or I'm 00:38:31.360 --> 00:38:33.360 presenting you with this plan, but this is the 00:38:33.360 --> 00:38:35.480 exact same thing that I would do for my family 00:38:35.480 --> 00:38:39.360 member because I treat my patients as if I were 00:38:39.360 --> 00:38:42.039 treating my family member. That's just my underlying 00:38:42.039 --> 00:38:45.239 ethos about treating patients generally. And 00:38:45.239 --> 00:38:48.280 so I find that that can sometimes help patients 00:38:48.280 --> 00:38:52.130 buy into your plan. Like I really am. doing the 00:38:52.130 --> 00:38:53.989 best thing i can think of for you and this is 00:38:53.989 --> 00:38:56.750 this is the best thing that we can do i'm sorry 00:38:56.750 --> 00:38:59.489 we do have to start that arterial line while 00:38:59.489 --> 00:39:03.530 you're awake that's i i know that's not going 00:39:03.530 --> 00:39:06.150 to be fun or comfortable for you but i would 00:39:06.150 --> 00:39:08.690 also be doing this if it was my family member 00:39:08.690 --> 00:39:12.170 in the same situation 100 and i think two things 00:39:12.170 --> 00:39:14.269 kind of came into my mind as you were sharing 00:39:14.269 --> 00:39:20.639 this and one is this is not a substitution for 00:39:20.639 --> 00:39:24.300 training, preparation, reading, and doing all 00:39:24.300 --> 00:39:26.860 the things we need to do in order to deliver 00:39:26.860 --> 00:39:29.280 the best evidence -based care to that patient 00:39:29.280 --> 00:39:31.920 in that situation. But it's layering it saying, 00:39:32.079 --> 00:39:38.300 I can't possibly know the thousand permeations 00:39:38.300 --> 00:39:40.960 of what may happen, but I have the training to 00:39:40.960 --> 00:39:44.719 fall back on how to assess and intervene appropriately. 00:39:45.519 --> 00:39:49.110 So let's say that you could go, back in time 00:39:49.110 --> 00:39:53.289 and talk to a previous version of yourself give 00:39:53.289 --> 00:39:56.469 him advice when you're struggling with feeling 00:39:56.469 --> 00:39:59.210 like a fraud or that you don't belong what what 00:39:59.210 --> 00:40:02.769 would you tell the past version of yourself what 00:40:02.769 --> 00:40:07.130 would you say to make him feel better it's a 00:40:07.130 --> 00:40:10.889 great question i wish i could i would say the 00:40:10.889 --> 00:40:17.170 stress about not having what it takes is inappropriately 00:40:17.579 --> 00:40:21.619 placed meaning you work hard you read you prepare 00:40:21.619 --> 00:40:27.139 trust in that process trust in yourself and reach 00:40:27.139 --> 00:40:31.320 out because everyone else is you know having 00:40:31.320 --> 00:40:34.860 some permeation of these feelings along the way 00:40:34.860 --> 00:40:39.519 and reaching out for assistance for help for 00:40:39.519 --> 00:40:41.960 knowledge for support is never a sign of weakness 00:40:41.960 --> 00:40:45.139 it's a sign of strength to know what you need 00:40:45.610 --> 00:40:50.090 and how to get it and whom to get it from. How 00:40:50.090 --> 00:40:52.650 do you think that your perspective on imposter 00:40:52.650 --> 00:40:58.190 syndrome has changed over time? I think that 00:40:58.190 --> 00:41:01.469 over time, my perspective has changed to this 00:41:01.469 --> 00:41:05.489 is not a me problem, but this is a problem common 00:41:05.489 --> 00:41:08.829 to folks in the medical field, to medical trainees. 00:41:09.090 --> 00:41:15.010 And part of my job is... to support those around 00:41:15.010 --> 00:41:21.610 me who may have challenges who may have intermittent 00:41:21.610 --> 00:41:24.389 periods where they feel like they don't belong 00:41:24.389 --> 00:41:30.590 or despite evidence of high performance and well 00:41:30.590 --> 00:41:33.550 thought out plans and preparations you know struggle 00:41:33.550 --> 00:41:38.619 lastly I want to go over what you feel like your 00:41:38.619 --> 00:41:40.780 style points are, whether or not it has to do 00:41:40.780 --> 00:41:44.400 with imposter syndrome specifically. What style 00:41:44.400 --> 00:41:46.260 points or points of personal preference have 00:41:46.260 --> 00:41:48.920 brought you success both in and out of the OR? 00:41:52.099 --> 00:41:56.019 Good question. I'll tie this one into imposter 00:41:56.019 --> 00:41:58.219 syndrome. And I think more about vulnerability 00:41:58.219 --> 00:42:03.940 is over time, especially like over the past, 00:42:04.019 --> 00:42:07.230 you know, six, eight. you know 10 years we've 00:42:07.230 --> 00:42:12.829 spent so much time on the focus of others in 00:42:12.829 --> 00:42:18.090 medicine and for many of us that was still informant 00:42:18.090 --> 00:42:20.349 you know formative years of your life from a 00:42:20.349 --> 00:42:25.489 mental and emotional development position i feel 00:42:25.489 --> 00:42:28.309 like it's important for everyone and this is 00:42:28.309 --> 00:42:33.530 sojourn that i'm on myself is to to become re 00:42:33.530 --> 00:42:36.469 -acclimated with yourself you know what makes 00:42:36.469 --> 00:42:41.150 me me what are what are my important values that 00:42:41.150 --> 00:42:44.170 i hold near and dear that i'm willing to you 00:42:44.170 --> 00:42:49.889 know my hill to die on right and you know if 00:42:49.889 --> 00:42:53.530 you haven't had those that insight and that self 00:42:53.530 --> 00:42:55.349 -reflection over the past years because you've 00:42:55.349 --> 00:43:00.730 been busy reading you know bearish and critical 00:43:00.730 --> 00:43:03.730 care medicine and everything else that in order 00:43:03.730 --> 00:43:07.449 to provide the care and the calling that we all 00:43:07.449 --> 00:43:10.130 feel or else we wouldn't be here. Sometimes we 00:43:10.130 --> 00:43:13.130 forget that, you know, we're people behind that. 00:43:13.889 --> 00:43:16.309 And it's critical to focus on that. And I think 00:43:16.309 --> 00:43:19.070 that's, you know, whether it's five minutes here 00:43:19.070 --> 00:43:23.650 or there, long weekends, self -reflection, self 00:43:23.650 --> 00:43:27.170 -exploration, getting into a meditation practice, 00:43:27.289 --> 00:43:32.300 however that works for you. You know, time will 00:43:32.300 --> 00:43:35.179 turn, you know, whether or not you're ready for 00:43:35.179 --> 00:43:38.000 it. And don't miss out on the opportunity to 00:43:38.000 --> 00:43:41.039 know yourself. And I think that's, I think that 00:43:41.039 --> 00:43:43.559 ties in. And it's probably one of the other parts 00:43:43.559 --> 00:43:46.739 about imposter syndrome is just being vulnerable 00:43:46.739 --> 00:43:49.559 and being self -aware. And then you realize the 00:43:49.559 --> 00:43:52.440 feelings I have maybe aren't truly imposter syndrome. 00:43:52.500 --> 00:43:57.009 It's just pressure, right? And expectation. But, 00:43:57.009 --> 00:43:58.949 you know, we're people at the end of the day 00:43:58.949 --> 00:44:02.010 and humanism is a real thing. And we owe it to 00:44:02.010 --> 00:44:04.250 ourselves to not only know ourselves, but to 00:44:04.250 --> 00:44:07.469 connect and support and love one another. But 00:44:07.469 --> 00:44:08.829 if you don't know yourself, it's really hard 00:44:08.829 --> 00:44:12.429 to do that for someone else. Well, personally, 00:44:12.650 --> 00:44:15.170 I've had a really nice time connecting with you. 00:44:15.289 --> 00:44:17.690 Thank you so much for joining us, Ben. I feel 00:44:17.690 --> 00:44:23.150 honored. Thanks for being here. That's it for 00:44:23.150 --> 00:44:26.490 this month's episode of Style Points. Anecdotally, 00:44:26.490 --> 00:44:28.889 I've heard that the immediate and permanent cure 00:44:28.889 --> 00:44:31.429 for imposter syndrome is leaving a five -star 00:44:31.429 --> 00:44:34.570 rating or review for this podcast. It can also 00:44:34.570 --> 00:44:37.809 help other people find the show. Genuinely, though, 00:44:37.929 --> 00:44:41.110 I appreciate everyone who listens. I also want 00:44:41.110 --> 00:44:43.670 to share that with the last episode, this podcast 00:44:43.670 --> 00:44:46.530 has been downloaded over 10 ,000 times in total 00:44:46.530 --> 00:44:49.369 over the last couple of years. Not really sure 00:44:49.369 --> 00:44:51.889 what that means, but at least my mom thinks that 00:44:51.889 --> 00:44:55.369 that's pretty neat. Lastly. Take a deep breath. 00:44:55.929 --> 00:44:59.110 Open your eyes. We are all done.