Was Grey's Anatomy Lying About Residency?

It's cool. I like it, man. It's good. Yeah. Thank All right, guys. Welcome to uh two docs, one mic. This is our episode number three. Um I'm Adil and this is Hayo. How's it going, man? How's your week been? Hey guys. Uh yeah, doing good, man. Excited to be recording this again. Uh you know, it's been fun. You know, this podcasting thing is new but exciting. Uh we're having a good time. Maybe we just like our podcast and no one else listens, but uh you know, that's what we're doing.

We're just having fun here. Yeah. Audience of two. It's just us, dude. Yeah. But, you know, uh we're building our building our audience. I think I think it's I think it's good. Uh I've seen some new followers on on our social media accounts. So, it's been good. I've all of a sudden I checked the other day and it was just had, you know, eight new followers and I'm like, "Wait, we're not even marketing." But yeah, it's crazy. Crazy how stuff gets out there. Yeah. How was your week?

Week's been good, man. It's just been really busy. Um just a lot of surgeries. Uh which is good. Sometimes it feels a little too busy. Um, you know, when you're just working a lot and you know, cases come into clinic, uh, patients have bad injuries, fractures, um, you just got to get those cases in. You can't really let them wait and push them for a while. And so, you just add them onto an already busy schedule and just leads to late nights. So, I've had quite a few late nights in the last week.

I did I did 22 surgeries last week, which um, really was exhausting. So, so far this week has been a little slower, which is nice. Uh it's a it's a good little break. Uh what about yourself? Yeah, man. It's been Yeah, surprisingly it's been busy. You know, it's uh it's fun. When it's busy, you see your you know, business growing. I'm a business owner, so I see it in that way, too, because you know, it's something that I start I remember the days when I was not busy.

You know, whenever I get too busy, I get stressed out.

I think of the days uh three years ago when I started the practice and I had one patient and I remember uh my first one of the Fridays I had my echo tech came in I was like hey man sorry I don't have any echoes for you today to do you know just had one or two patients and used that was like that for a while just three four five patients a day and now I'm just like oh it's too many uh which is which is the testament to you know um and you know working hard in your business and but also Houston being a place of need for cardiology.

I mean, I was able to build a practice in 3 years. Uh, which is, you know, there's a lot of need for cardiologist. Yeah. No kidding, man. It's awesome. I mean, it makes you think, you know, when like back to when we were in training and, you know, you're so busy learning um, and just trying to absorb everything, you know, learn the surgical skills, get better at everything, you make mistakes, you you harp on them, you think about them, you want to impress whoever your attendings are.

you also want to keep, you know, keep growing and then keep your sanity while you're in there. You don't really think as much, at least I didn't um directly when I was going through training about how actually practice would be. You're kind of like so in your own head um about it in that moment, just one rotation to the next, one surgery to the next, one call shift to the next. You kind of don't take a step back and think like, okay, how am I going to actually grow and market this?

You're just like so focused on the day-to-day work. Yeah. And you know in in in residency you start residency as an intern year and I think at that point you're so overwhelmed you know uh we were talking about med school uh our last med school in college and our our last episode but you know in residency uh intern year is just crazy because you you're not a doctor yet. And I've said that to many people before graduating medical school doesn't mean you're a doctor. You don't know anything.

um you know uh I can I can put on a medical school graduate and maybe they can recognize a few things but they don't know how to treat a patient completely. I mean they're very new and interns are just like that. I used to I remember my first uh day when I was there and I was asking my uh my senior um you know uh can I order Tylenol on this patient? It's over-the-counter medication. I mean you know but I still was hesitant about giving that medication to a patient.

you know the way I don't know how is different we you did a surgical residency I did a medicine residency uh and they're very different in some ways but in some ways they're very similar in medicine we had teams you know we had a uh usually an upper level uh which was maybe a second year or third year maybe just one year ahead of us and there's two or three interns uh and that upper level was running the show that the the the two or three interns would be kind of doing a lot of the work, a lot of the note takingaking, a lot of the notew writing, seeing the patients early in the morning.

Um, but it was amazing that, you know, you'd look up to this upper level cuz you thought they knew everything. You know, they've gone through the intern year whereas now looking back, they were just second and third years. They were unsure, too. Uh, you know, um, and intern year, you're just so focused. All all you have to do is write the notes. You don't make any decisions. Yeah. You make day-to-day decisions here. you know, maybe can I give potassium to this patient or can I give alcohol?

Uh, but you ask everything, you know, your upper level and I think I was lucky to have uh really good ones. One of my first upper levels ended up being one of my really good friends. We ended up doing cardiology fellowship together. Oh, that's awesome. You know, we ended up being in the same program eventually down the line. But, uh, you know, they they they teach you the most. You learn the most from your co-residents and the the people leading the team.

um you know um would be your biggest teachers because sometimes you know let's be real you know uh there are good attendings and then there's not so good attendings then there there's attendings you have to manage as a resident you know was that was that weird to you know um and it might be different for you but I came across some attendings where they were more in the way than you know and these were board certified physicians that were there but they would just cause so much more stress and problems and their treatment plans would be all over the case where the residents were kind of managing these attendings sometimes.

Uh I don't know if you came across some of that. Yeah. You know, I mean it's almost like um you know, especially like in a surgical residency. Um you know, it really depended on like some of the attendings, they would be very very hands-off to the point that they would almost be disinterested and you would just I mean you would just be worried like am I doing the right thing? like I have I have no clue. Yes, the attending sometimes they don't respond. They don't answer their phone.

They're just totally out of the mix, right? And you and the team, right, as you're talking about the upper levels, you really really rely when you're a junior resident on your senior residents or even if there's fellows on the service like, "Hey, this patient has this injury. You know, they come in with a bad fracture. Like, does this need to go to the O right now? Can we do this in the morning? Can we post them for for when do we do this case? What implants do we need?" Right?

That's a huge factor, especially when you're a junior resident. and you don't really have the context and understanding of real surgery cuz you haven't done it. You're not the one doing the surgery. You're not making those decisions. A lot of times you're you're kind of just like an H&MP taking machine. You're just moving from one to the next, one to the next and teeing everything up. And now you have to make a decision.

It's like 1 in the morning a patient comes into the trauma bay and it's like I don't know what exact implant this patient needs to fix their femur fracture, but I know they need to go to the O. Do I wake someone up in the middle of the night right now just to ask them, do they need a plate and screws? Do they need a rod that goes inside the bone? Do they need both? Like you have no idea. I mean that was that was that was a big decision you had to make in in training if to call or not to call.

A huge decision. Yeah. I mean a game changer.

a game changer because you you could uh you know you could call for just some uh minor things and if you keep calling for something things your reputation gets the the person who just is is not very competent maybe you know maybe in your own mind or you know but people do get a bias where oh man this this intern he just calls for everything whereas if you don't call enough and don't call at the right times you can get in serious trouble because then the you know your attending will not be very happy they wanted to know about something something crucial that's their license is on the line.

Uh yeah, I mean that towing that line towing that line was really tough because kind of like you're saying it's almost a negative stigma. Like it's almost like a sense you have this unease when you're typing that text or about to make that phone call, you're like, "Oh man, they're going to chew me out. They're going to think I'm like a wuss. I can't handle it or I don't know my stuff. Like I I have to like wake someone up for this." It it's uh yeah, it's just weird.

I mean that whole part of training is u and I think it's gotten better for sure like the culture across the board in residency has improved in that there's not like it's not a sense of weakness as much as it used to be.

I mean in the past you know you hear stories from your attendings uh when they were in training themselves that I mean it was unheard of that they would call someone for help you know it was like that means you couldn't handle it yourself which that has changed right because patients suffer when you just kind of try to make it up on your own and hope it works. Yeah.

And that's when it's important to, you know, as an intern, it's always you're you're not the one that's getting in trouble much because you always have a upper level resident uh to kind of ask go to and look uh look to questions to and if the upper level resident doesn't doesn't know answer, they can always uh kind of go to the fellow.

So there there's this hierarchy that's built into academic medicine that allows you to kind of have a little bit of responsibility, but the consequences be a little bit more cushioned out uh by these other trainees that are above you in the hierarchy. Uh and and in the end um here's the thing, you know, if you call someone and even if it was not very important, you you told your attending who would have an answer for you and it's it's about someone's life and someone's health.

So that's important. Uh but you know um it's it it was hard because you know there there are some very good attendings that teach you a lot and and and and you know it's always good to call them and those are the ones you remember those the ones that were available for you and you always think uh you know you want to emulate that when you grow up and there's always good role models throughout training.

Um but you know now looking back um some of the things that I used to think were a big deal and I need to let someone know I need to do something about maybe it was not that big of a deal and as attending sometimes you know that and it's the you know some the things that I used to worry about as a resident as an intern like you know certain medications certain amount of blood pressure certain uh fevers as attending I'm just like yeah that's okay they'll be fine you know they this is something just we just have to wait and see and what happens and that's the mentality of most of the attendings and and they they as as now as an attending I I I can um be sympathetic to the fact that they maybe weren't always as involved or because it was a test as well for us to kind of be able to manage it because they know it's not that big of a deal.

Yeah. They've seen it, right? I mean they've lived it. You know, it's at some point it's a lot of it is pattern recognition.

you see stuff enough similar enough stuff and you just kind of understand that okay this clinical picture I've seen many many times this patient will be fine there's nothing urgent or emergent that needs to happen whereas conversely a little subtle difference you can be like oh my gosh that that really needs to go back now like that patient is on the cusp of crashing so I think that you know when you're early on you just don't have that you just haven't had enough reps you don't have the volume of experience from seeing enough patients Um, and you know, it's interesting when we would talk amongst each other during residency, like orthopedic residency was 5 years, and we would always ask each other like at what point do you really feel like you're pretty confident that you can handle it?

You understand? Basically, most of the patients that come in, you you have a good handle on what's going on. Not necessarily meaning we could execute every surgery, but at least diagnose the patient correctly, get the appropriate workup, the indications, you know, what surgery needs to be done and the basic steps and all that. And he's usually like third or fourth year.

I mean, it's it's it's well beyond the midpoint of residency until you really feel like you're solid and you have a good footing underneath you and you have enough of a foundation um where you can handle everything, at least the initial management of it. Yeah, definitely. I mean, it's it's a process, right? I think the the process is is not perfect, but it I think it's designed pretty well to the way it goes.

was, you know, I was I was talking about attendings and some of the attendings that um you know, you worked with that were way too involved and were micromanaging and that was not good for our training either. So, I can appreciate some attendings that gave the right amount of space, the right amount of um you know, autonomy versus someone who would constantly text, hey, what's going on with this? I checked the blood pressure. It's still high. What are you doing about that?

We we had attendees like that that would constantly micromanage and that was not a good thing for training either because the trainees need to know when to be able to make those decisions uh you know on their own.

Uh in terms of medicine residency you know um towards the end of second year and beginning of third year is when you start feeling like okay you got this you can take care of this cuz going through that second year of internal medicine residency is is the the big the the biggest year for your growth because that's the year you get a lot of independence. you have a team below you, medical students, interns, uh maybe some other uh health affiliated students and you're running a team.

You're the leader of the team. You're making decisions and your next point of contact a lot of time is attending. Uh so that year of of growth is is critical and by third year you you feel like okay now I got most of it. You are much more laxed.

you're much more ready and third year is usually a fun year because you're just kind of you know uh fixing the you know um fine-tuning your skills and then you get to fellowship man and then that's like whoa what just happened I thought I knew everything I thought I knew medicine I thought I could handle this but I became a first year cardiology fellow and oh my god this is stressful because now the whole resident team and other attendings are looking to you for answers and you have to and and cardiology is pretty is pretty critical for the sense that there could be minute-to-minute changes.

I mean, people could be crashing and you have to act and make the right decisions and the the decisions you make on spot can really have an effect and sometimes you don't have time to wait for the attending. Sometimes you have to do something right there and then to fix things. Yeah. The the responsibility really jumps up, huh? Yeah. It's it's crazy. There's, you know, you're you're one fellow, you know, um, as a fellow, you're covering the whole hospital.

Sometimes all of one big huge academic hospital. The ER's calling you, the internal medicine attendings are calling you, the the hospitalist from the hospital are calling you. Uh, you know, you're getting all these consoles, you know, you're going to the ER and this guy with heart rate of 25 and you're bedside doing a transvenous pacemaker at the same time and calling the cat lab.

uh you know while someone else is crashing upstairs that the residents are calling you hey this patient is you know their blood blood pressure is tanking they're going to cardiogenic shock so there's a lot of things you're juggling at the same time and you know you kind of learn those those skills but the first year of fellowship man that's that's I think one of the most stressful times I had uh but it was fun I mean you know because it's you know the I think in medicine residency or internal medicine per se the more you grow the less you're actively doing and more you're managing and making decisions So I wasn't writing too many notes.

I wasn't sitting in front of the computer and just writing H&MPs on H&MPs, but I was making the decisions. Sometimes those are the those are the hardest things to do. Yeah. You know, and that that's what's interesting like in from the surgical training side the um you know the first couple years especially second year is super busy and that's kind of the norm across the country in orthopedic training. You know I did my residency in Tampa and basically second year I mean you're loaded up on call.

you're taking so much night call 24-hour shifts. Um, and it's just kind of you. You're the one who's holding the page of your first call. You're answering all the trauma alerts. You're in the ER. You're reducing fractures, putting on splints, repairing lacerations, repairing tendons in the ER, um, getting people teed up and ready for the O, managing the floor. You're doing it all, you know, and we we usually had a census, like a 50 60 patient inpatient census that we would follow.

Um, and you're getting calls about all of them. And so second year was like I mean it's just a blur. You barely even remember that year of your life. Um I remember at one point um you know you have your personal pager, you have the service pager um and you have a separate pager uh legitimate lit real beepers like very old school um for the trauma alert. So you have three on there and you have your scrubs on and scrubs are loose. They're always little loose- fitting.

And I was just rushing back and forth consult after consult. And I I had to go to the bathroom so bad. I had to just I mean I was like, "Oh my gosh, I think my bladder is going to explode." And you know, they're all on your waistband of your scrubs. And I just I wasn't even thinking. I was just rushing. I was so tired. You're sleepd deprived. And I got in front of the toilet to go and I forgot that all the pages were still on my waistband.

As soon as I undid the the drawstring, all three of them fell into the toilet. And I was just like, "Oh my gosh." And my own my thought my first thought wasn't even like, "Oh my gosh, these are all going to be dirty now." My first thought was, "Oh my gosh, there's pages that were unanswered. I'm going to get written up for this." Like, and I was just like, "Oh my god." Pushed them out of there, cleaned them off, and just kept going. I mean, you just got to keep going. It was crazy.

But like that that year, that second year was just like a whirlwind. But, you know, your skills get up so much. I mean in that one year probably saw I'm not kidding like maybe 1,200500 patients like tons of consults. Um you just get so many repetitions in but then you know how you're talking about as you progress further into residency you kind of your role and the type of work you do changes is similarly like you start taking a lot less call as you become a senior resident.

Um a lot less primary call. So you're not the one responding immediately to every ER page, every consult, every trauma alert, but you're on backup. So it's a lot more decision-making role and guiding role and teaching role for the residents who are now on the trenches and then also doing the surgeries. Like now it's a much bigger role and responsibility.

You better be ready to go in and do the cases and take care of these patients and get them into the O, get them on the table, fix them, get them off the table. So, it's a and that's a totally different skill set really in the first couple years of residency. Um, you're not doing a lot of surgery or if you're in the O, you're you're just doing little amounts of it.

Um, every now and then you'll get to do more, but really the bulk of the operating comes in third and especially fourth and fifth year. And that's where every single case, I mean, that's a huge huge opportunity that this is your time, whether it sounds good or bad, this is your time to practice. this is your time to really learn how to do surgery because after this you're on your own.

You better be ready to go because if you do not come out of residency confident and well trained, you're not going to be up to par when you're in attending and there's no backup. There's no one to call on and be like, "Hey, can you come bail me out? I can't get this fracture reduced or I can't the joint replacement isn't balanced. It's dislocating." Like, you better know how to do it, you know? So the decisions and the roles change a lot and your responsibility just changes a lot.

It's not necessarily that it's more or less. It's just very different. Yeah. You know, it's uh that's that's so true. And I think medical training is designed to be um you know kind of like that where it's a slow transition from a lot more doing work seeing consult writing notes and then slowly going forward and then being the person making the decision leading a team doing those procedures and surgeries that are much more high stake.

you know, you you do a lot more high volume, low stakes work in the beginning, but then as you grow on, you're doing less volume, but high high stakes stuff and that's it's a beauty of the the the way the training is kind of been set up over years and over time um you know, but it's you realize that I mean as a as a first year um you know fellow in cardiology, you have to take those consults, you have to see those things so you get comfortable by your second and third year because you're now teaching ing a first year.

I mean, you know, you have to be in the cat lab, you know, in our cat lab. It was funny. I never understood it. You know, it was kind of annoying to we'd have to get early in the morning and we'd have to see all the all the cases that are that are set for that day and then our other fellows from other services would be texting us, hey, we need to add this cath uh cath or reinhardt cath or this procedure. Oh, and we'd be like, why why you keep adding stuff? Like, is this scary?

And then you and your co-fellow we had to like sit there and write the whole board and like you know and then be ready at like 8 a.m.

to present to the attendings of what cases are there that day and why are we doing it and a lot of times we'd be like hey I don't know why our fellow you know co-fellow is adding on this case and they' be like yeah this you know it kind of you just go back and forth like it's truly necessary I mean they could do this first instead or do that and you you learn a lot of decision- making in that because you're kind of triaging you know as well if this is truly necessary this is not necessary but writing the board knowing your patients well um knowing details about them cuz sometimes you know now as an attending um you know I do hard cats and I just go in I know the patient in the back of my head I know why I'm doing it but um you know um when you're a fellow you had to present it to the attendings that I'm sure had some a little bit of knowledge about why the case is happening but I think more of it was for your training and for you to be able to know why you're doing a case you're about to do because once you are on your own you have to explain it to not just your attending but you have to explain it if things go wrong uh to the the medical board sometimes or to uh the hospital administration or to the quality control people in the hospital why you did this case and why you think the complication happened.

So it's just training for this gruesome career that we have in the sense that you know there's a lot of a lot of checkpoints throughout the way through the training which is which is good. I think it's necessary. Oh for sure. I mean, it's the whole sense of graduated responsibility, right? And it's it's kind of like, um, you know, guilds back in the day in like medieval Europe, um, where you start as an apprentice and you slowly work your way up until you become the blacksmith.

A lot of steps along the way, a lot of check marks, a lot of checkpoints to hit and improving your skill slowly but surely. And a lot of it is just forced time. I mean, it just takes time to practice and hone a craft. Nothing happens easy. Yeah, I have nightmares. Like sometimes I just remember those days the first year you you we'd have this call that would start at like 6 5:00 p.m.

on a Friday and uh it would just you would be on call Friday, Friday night, new admissions, residents calling you, new residents be, hey, I have an admission, I have this. You're the fellow coming on. You have no idea what's been going on this whole week. They're texting you, hey, this patient might be crashing. Next Saturday morning, you go in to kind of round out all the patients and are taking new admissions.

You're still are supposed to learn the whole service and your pageent just keeps ringing. ER consults, er, consults. Uh, but now, you know, going through that going through that weekend that happened every couple of now the weekend just seems like a breeze to me as attending. I mean, it just, you know, I get a page and I know what to do, how to deal with it.

I I let the you know the hospital team triage it and I see them in the morning if something needs to be addressed right away right then I can make make those decisions. But going through that and getting bombarded by pages bombarded by other residents and and other services just just taught you how to deal with it and triage it.

Uh I think a lot of times a you know there's a lot of programs like towards my third year they were starting to have more protections and okay the fellow can only work this many hours and they have to go home otherwise and they cannot be contacted a new fellow has to come in whatot and sometimes that's not how real life is when I'm on call I'm on call all the time and you know if you're just creating this shift work mindset you know that's not good for how real life ends up being because real life is not shift work.

You know, my patient my patient panel as it grows for all my patients. You know, I over a thousand patients. Uh I'm in I'm in charge of their cardiac health and throughout the week something could happen. They might call and say, "Hey, my leg is swelling up like what does Dr. Naki recommend?" And the nurses reach out to me and now it's I've developed this skill set of remembering the patient, knowing the big picture about them, what we're doing, and kind of making suggestions on the go sometimes.

And if I need to look into their chart a little bit more, I'm able to do that. But a lot of times I I'm surprised at how I can remember a lot of my patients because I can make those decisions for them, give them answer right away, right then. But that came because because I went through that process because in the beginning when I started the fellowship, I couldn't keep 10 patients straight in my head when I'd be juggling a list of patients and I wouldn't know which patient is which.

I would get confused. But now I can I can have a list of uh thousands of patients in my head and kind of know what to do when when there's a question about them. Yeah. I mean it certainly teaches you a totally different way to think and and manage and compartmentalize and it builds a bit of a toughness, right? Like anytime you go through something that's grueling, um it may suck in the moment, but you know, we we all look fondly on it in the past.

Um and it kind of it kind of makes you who you are. Um and it lets you handle situations. That's why it doesn't seem really like a big deal when something happens now.

Um residents text you, you know, they're on call at the trauma center and hey, this guy came in, this car accident happened, this motorcycle car accident, um autoverse pedestrian injury, you're like, okay, let's just fix them up, just put them on the board, you know, it's just But when I was in their shoes as an intern uh many moons ago, you know, it's like that novelty of it, right? That excitement. Um a little bit of that excitement just goes away once you see things that often.

It's like a little bit of desensitization, which it's not that it dehumanizes you or the patients, but I think some of that is necessary to be able to think with a level head rather than get caught up in the moment um and the excitement of the situation around you.

Um, so I I think that's a big factor and it's important and that I I also think that's why, you know, with the duty hour limits and restrictions on training, which currently, you know, it sits at 80 hours is the cap, um, potentially restricting more than that, which there's talk of, I think, is dangerous because you're just going to have to lengthen training because there is just a certain amount of stuff you have to see. There's a certain amount of patterns you have to see again and again.

There's a certain amount of repetitions you need to have for you to be safe and consistent and reliable as a physician down the road to really take care of human beings unsupervised on your own. And you know, I I I saw that a lot when I was abroad. I I did quite a bit of my training uh whether elective or my second fellowship outside of the US. I did some of my training in in France in Odyssey, some in Norway and then my second fellowship was in Australia.

And the training environment is vastly different outside of the US. And I I you know, I'm not just saying it because I am American and trained mostly here. I I think the training is better here mainly because of how much work there is that the residents here across the board. They work like crazy. Really long hours and they work hard. Um in a lot of places in Europe, like the UK, there's like a 40hour limit. I mean, it's like a standard job.

You just cannot get the same amount of repetitions and volume. You're not going to see the same number of stuff in the same amount of time. And that's why people train for so much longer outside the US. I mean, so many of the residents when I was in Australia, they were in their early 40s, which is crazy. Like, they just have to train for so much longer to get the same amount the same amount of hands-on experience. Yeah.

It's about the repetition as well and being able to see so many different things but it's also about being able to make those decision when you're just dead tired you know learning how to make those decision cuz life is you know you will be tired you will be overworked I mean maybe it's the nature of our health care system where doctors are burnt out and overworked and our system is preparing us for that but uh you know I think some of it is also being able to make the decision under sometimes you have a 6-hour case or 8 hour case and you have to keep making the right decision for the patient and and then maybe after or on the day you might have a 4-hour case and after that you have an afternoon full of clinic and you're exhausted and you know you you have to keep making decisions.

The other day um I had a uh on on Monday uh you know I had a full clinic started in the morning I saw maybe you know 14 to 15 patients in the morning in 3 hours. Then at 12 to 1 right as my clinic ended I like said bye to my last patient I head straight to the cat lab and I had a case from 12 to 1. Um no time for lunch no time for anything else. Just went straight to the cat lab. Did the case from 12:00 to 1. ended up being a more complicated uh finding.

Had to talk to patients a little bit in more detail about their uh you know they're getting needing a surgery and a lot more um you know u extensive workup after that. So you know and then I was kind of running late for my 1:30 p.m. clinic start and then I had to rush back and see another good 15, you know, 10 15 or so patients in the afternoon time right after that. Uh which is back to back.

So it's like there's no breaks or sometimes and you have to you know you see 30 patients in the day plus you see uh you know you do procedure in the morning in the afternoon you round on your hospital patients and you know there's no way you could do that kind of work if you hadn't gone through the grueling training that you went through in internal medicine or you know surgery training or fellowship. Uh it's part of it I mean you know there's no way I could have done that.

You know, I used to I remember when I started fellowship, I would have seven patients in the VA clinic for the whole day and I would be complaining because that's too many, you know. Yeah, man. I mean, you know, like going through grueling stuff like that grit. It's the same thing like with athletics, right? I mean, practice has to be harder than the game. I mean, if you don't practice to the max, you're going to get destroyed when it comes to an actual competition, right?

I mean that that's such a such a common thing. Same thing with like the military, you know what I mean? Like the grueling training and the trials you put yourself through. Um there's a reason why training is so hard, why boot camp is so hard, why the selection pressure is so high for like elite special forces as an example. And um I'm not comparing myself to that. I would get immediately kicked out before I even finished the application.

But I'm just saying like that idea of going through a very grueling training process, I think it's really important and I think it it's critical whenever you're in a situation where you are going to be responsible for other human life, right? I mean that that's what it is. And so I think it's important and I think putting too many safeguards in place like too much time off, too much restriction of the hours, too many post call days or whatever. Yeah, there needs to be a balance.

But I think if you strike too much of a balance towards making training easy, you sacrifice a lot in an entire generation of trainees who are going to go out into practice that they're not going to be trained as well as the generation before. It doesn't have to be malignant. It doesn't have to be meanspirited, but it just needs to be timebased. It needs to have some amount of baseline number of reps, number of volume so that you can have great training and be confident in your training.

And you know in I don't know how how it is in surgery uh but in in medicine and cardiology there are programs that are very high clinical program where you see a lot of volumes high stress seeing bunch of patients doing a lot of work clinically and then there's some programs that are more academically inclined where you do have a lot less workload you know less procedure load you're more academically inclined you're maybe publishing a little bit more um but there's a vast difference in the trainees that come out of these programs I mean They're both one of them, one program produces more academically inclined uh uh physicians that are more uh you know focused on research and yeah they have a clinical side but their their main focus is research and then there's programs that produce clinicians that are very clinically strong but academically they just never learn how to promote and advance research in that sense and there's a role for both right there's a role for each and both types of physicians are needed.

We need research. We need advancement of medicine. We need those people to have labs and and and do research and do and maybe their clinical workload is less compared to the one someone like me who went to a clinically heavy program and now in a more clinically heavy setting even though I do research it's more it's it's more clinical uh industry sponsored research rather than uh you know um uh research that requires a lot more academic grit.

Uh so there are programs so you have a choice as a trainee you know what kind of lifestyle you want what kind of training you want uh and maybe some programs if you value your mental health a little bit more and and lifestyle maybe a program where there's a lot more focus on on research and and more academic heavy programs are than clinically heavy programs. There's always choices, right? Uh where you can go and interview, but in the end the match match decides it makes the decision for you.

Yeah. You just rank the list. I mean, do you think like one is better than the other? I mean, it depends like a so-called white collar versus bluecollar kind of that distinction of, you know, very white collar academic country club style versus bluecollar grueling hard work. Not really as focused on pumping out a bunch of papers and publications. I mean there's a need for both, right?

I mean the the I I do have a little bit of problem with the the new age academia uh in the sense that there's a lot more publishing for the sake of publishing rather than publishing for the sake of knowledge. A lot of people just want to pump out papers and volume of papers rather than the quality of papers and that's going on as well. And you know some people just truly enjoy that but we do need that.

I mean you sometimes you publish 20 papers and out of them one is can be a breakthrough right science is never science is never uh efficient you you have to do a lot of inefficient work to get one breakthrough and that breakthrough can save millions of lives so I I don't think one is better than the other I honestly as a trainee going in or you know you have to envision what your life is going to be like what kind of medicine you want to practice if you want to be in a clinical setting you want be in a private practice setting where you're seeing patients and and kind of interacting doing more clinical stuff.

Yeah. And you want a procedure heavy uh play where you want to have like very high skills in doing you know either surgeries or you want to have high skills in doing hard cats or PCIs which is you know coronary interventions you know you then you go to a clinically heavy program.

But if your clinical goals are to maybe be assistant professor or associate professor at a academic institution and maybe have a research lab also see some patients in your clinic which is more of a niche clinic sometimes. Um if that's your goal maybe go to a more academic program right um which uh what do you think about that? I mean I guess you kind of went to you did your residency at Baylor uh but I don't know about your other programs.

No, I did uh I did my med school at Baylor, but residency uh residency was in Tampa. I mean, you know, like this is my bias. Um obviously some people will think differently, but I think especially if you're doing a procedural field like surgery, um and even non-surgical fields that are very procedure heavy like some cardiology practices, GI things like that um you know, you really you train one time.

Um, you can always do research, you can always write papers, but your training experience and opportunity will not come again. And I I genuinely think if you're doing something procedural, a manual skill-based thing, which is simply improvement via practice over time, um, I think it's critical to be in a training program that allows you to do a lot of volume and autonomy to do that, too. Not just simply watching one of your attendings do the surgery again and again and again.

I mean, you have to watch and see how it's done the first handful of times and be guided through it, but you have to have the ability to do it. And you know, that really only happens in these so-called bluecollar programs. I mean, that that's simplifying it, right? Every program has a little bit of both. Um but there are certainly programs especially those that are associated with very like big county hospitals, trauma centers often that are places that take care of indigent patients.

Um those are the centers that just have a very high volume and volume drives everything. The number of patients you see, the number of cases you do, the variety of cases you do, all of that comes from volume. And I I strongly believe that if you are a surgeon or someone who is heavy heavily procedural in your clinical practice, I mean, you have to be good and you're not going to be good if you haven't done a lot of it.

And the only way to do a lot of it is to go to a program that allows you to do that. And so that that's my bias, right? But I I really think that if you want to be good as a surgeon, um you have to be in a place that allows you to practice and get good at surgery.

Yeah, that's very true because you know I I saw it firsthand uh you know in in my cardiology fellowship we had I had uh different types of attendings and I had an attending who had come out of a very clinical heavy program that you know you just could go to any for any procedure you could go to him and he was newly out of training but he could do advanced stuff I mean very complex procedures uh and another attendee who was just out of a more academic you know white collar program Uh and you could see the difference.

You could see the difference. I mean the the time it took for one guy to kind of just do the procedure, how nervous he was during one, his comfort level. Uh you could clearly see the difference in the procedure skills and uh you know ability uh maybe academically and clinically, maybe in terms of their knowledge.

one person from the that the so-called white collar program is much more advanced and they have a lot more they're more up to date on the new advances and and the new new therapies and maybe clinical knowledge wise they're they're ahead procedurally and how to get through complicated things and how to uh you know in our in our case fix complex coronary disease.

There's definitely a huge bias in the sense that go to a clinically clinically heavy program where you get to do a lot of the procedures independently. I mean in our in our VA cat lab, I mean we were the the fellows were in the case from beginning to end for the most part and it was amazing. Yeah. You just you ran the show, right? You ran the show. The kind of training you got there and there was attending supervision.

I mean he would he would be there if something was going down south he would just quickly scrub in but for the most part he just watched and it was amazing and you appreciate those those kind of trainings because that gave you confidence. Now I can go in and and know confidently go going knowing in that hey something comes through a problem happens you know I'll know what to do with it because because that's how I was trained. No for sure man.

I mean, I just remember like when I was in residency, um, you know, you have new attendees come in, get hired in the program. Um, and it was very evident when a fresh attendant came in year one or two of practice that had basically gone to a program that they really didn't do a lot of independent operating. Um, and we our our program in Tampa, it was a blessing. I mean, it was extremely trauma heavy.

We had a a lot of uh a very large catchment area uh at Tampa General Hospital and in the training program there and so we had we did a lot of surgery and we had a good amount of autonomy and our attendees really let us operate. I mean I remember I think I was a fourth year resident and this new attendant came in and they were doing a knee replacement. You know, by that time in residency, I'd maybe done 150, I don't know, maybe 200 almost knee replacement, like a lot.

We had a a lot of joint replacements. And this this attending uh he had only learned how to do it using a robot um because his robotic guided surgery is becoming a thing. It's becoming very popular. But we did them all freehand. I mean, only a couple of our attendings used the robot to do it.

We just learned how to do it the oldfashioned way by measuring by understanding the balancing of the joint, how tight or loose to make it so it was stable and didn't dislocate but still had fluid motion, right, to to treat the patient appropriately. And so on that day, the the robot wasn't working. It was the the software or something like and like the guy couldn't get through the ca like literally couldn't finish the case.

And like the nurse who was in the room came out in the into the hall, you know, cuz we had a bunch of rooms stacked back and forth that were just orthopedic rooms, orthopedic rooms for joint replacement, for trauma, for spine, for everything. And she came and she found me. She's like, hey, um the Makeo robot uh isn't working. Um we're kind of stuck. Can you come and help? And I was like, what? I mean, the robot's not working. Just do a knee replacement. She was like, yeah, he uh he can't.

And I was like, what? It's kind of awkward. You got to go in there and you have to kind of like tow the line a little bit because he was the attending and I was still a trainee and I was like, "Hey, I just wanted to check in. Is everything going okay?" You know, I didn't want to make it known that the nurse came and told me like, "Hey, he needs help." And he just looked at me. I was like, "Yeah, the robot's not working.

We can't figure it out." And, you know, you kind of offered like, "Do you want me to scrub in?" And I was and he was like, "Yeah, sure." And you know, we just we finished the whole case and just did the knee replacement like the oldfashioned way. But that's how we were trained to do it. Yeah. But that just shows like when you're so reliant on only technology or only the newest thing and you haven't had enough repetitions or enough experiences like that. I mean things are going to break things.

You need to troubleshoot stuff. Um and it wasn't just me like that. Like all of our residents they were trained very well. Yeah. And so we we were lucky in that sense. So that that's why, you know, experiences like that um it really makes you value the training you got and and the ability to to get your repetitions in.

And the last thing it kind of brings you to is being humble humble in in in you know uh medicine because and and knowing to ask for help because there will be times you will be stuck and there's no one no one uh you know higher or lower than you to ask for help. I mean, we're a lot of times now, you know, I ask for help. Uh, the cat lab texts, hey, what do you think? What do you see?

You know, um, because it's important to ask for help, ask for, you know, there's some people, I mean, there's some, you know, there's some texts in the cat lab that have been doing hard cats since before I was born. And just because I'm the physician and I'm the I'm the doctor that's leading the case doesn't mean I yeah medically my knowledge is there and I know but technically they've done so many cases and they've been doing it throughout the years that they know a lot too.

Knowing when to ask for help I mean you know you're attending agreeing for you to scrub in and kind of let you do the case because he was not comfortable. I mean, you know, that's that's knowing, okay, yeah, maybe let's let's right now let's let our ego go and let's uh do what's best for the patient. And sometime it's important to know when to let your ego go. I mean, the that's one thing I've learned through years of training is the ego sometime gets you in the most trouble.

And sometimes letting go of your ego and yeah, having the confidence in something in in your abilities and what you can do, but then um not letting your ego get in the way of when you need help. Oh, totally. I mean, yeah. You can't try to be a hero because that's how you get into trouble and you get your patient into trouble. For sure. I I mean, just like you said, I I ask my colleagues for help and assistance and advice all the time. All the time.

I sometimes you're just in a really hard case or you know ahead of time going in like, "Hey, I think this is going to be an issue or a problem and I'm going to either need an extra pair of hands or a different skill set, right? Like I I do cases every now and then combined with like vascular surgery, some complex upper extremity case or like a deformity case or something like that where they are by far better than I am at handling the vessels, the arteries, things like that.

I mean, I would be foolish to try to take that on on my own. You know, it's there there's no heroics there. It you you got to load the boat. And this it's a team sport. It's a team sport, man. For sure. I mean, we can we can keep talking about this stuff forever. There's so much to discuss. you know, there's so many things that to come in the future for us to talk about. Uh, you know, and not just about medicine, but more many other things.

So, I'm excited for this podcast to go on and, you know, let's see where it goes. Um, but, um, we'll hopefully meet next week and, uh, yeah. Yeah. Stay tuned. Episode three, guys, in the books. All right. See you guys. All right, man. See you. Heat. Heat.