Cold leg, warm heart.

You’re a survivor. I can read it in the way your skin sags from your bones, and your blood cultures grow almost pure bacteria like a bad lab experiment, and your heart just ticks away and you smile when I walk in the room.

“Mr. Verano! Good morning! How are you?!”

The medical student mutters to the other medical student, “Why does he always yell like that?”

Because you’re basically deaf. But you smile benignly. “It’s that time…” you say… You say that every morning. I have no idea if it is that time or not.

“You’ve still got a good pulse here!” I announce obnoxiously loud and then in a normal speaking voice, “Go ahead and take down those dressings, “ to the medical students.

One is disgusted. The other morbidly curious. They’ve never really seen your leg before, but they’ve seen wounds. Oh I made sure they saw some good ones. One of them, I can’t tell which one, moans quietly while they pull down your dressing revealing, honestly, some pretty good healthy beefy tissue.

“That looks good Mr. Verano, this thing is starting to heal,” to the med student, “Do you need to step out?”

“No… I think I’m fine.”

“That beefy red tissue is healthy, you should’ve seen it before his surgery, basically it was dry and yellowish black and more or less dead.”

“oh. That’s good.”

She has no idea. She is alarmed by the sound of my voice.

“I think I knew you in my old neighborhood,” you whisper. “You work at the grocery!” You tighten up your face which is a bundle of elastic that has lost it’s stretch, like sweat pants from the ‘80’s, sagging from the outlines of your skull, your skin, which is more liver spots, than that healthy tan you developed hanging out on the beach in Sarasota at your retirement community, is like some damaged papyrus that falls apart and wiggles away when we touch it.

“Close, we’re at a hospital. It’s Monday. You have bad blood flow to your foot, and we fixed it. You’re just a little confused, it’s okay.” So am I.

You look at me with a completely vacant stare, like a greek oracle, “This is it.”

“Alright Mr. Verano, We will see you later, I’m very happy with your leg.”

Outside the room the mediical students blink like they’re trying to forget the image of your foot, with its missing big toe, and beefy red wound across the side of your ankle.

“He had a nice pulse,” I explain, “that red wound, that’s healthy, overall this is a good progression for him.”

“He looks so sick.” One of them says

“Yeah, he is, he’s a 66 year old guy in a 90 year old’s body, he lived a hard life.” I spoke to your kids yesterday, they didn’t hide their anger or frustration.

I get it. They want you to get better. But no one can tell me what better looks like. From here, it looks liike your foot healing. Finally. From them, they want to see their Dad, as he was, 20 years ago, a white tanktop on, a cigarrete in his mouth, healthy pot-belly shaking with laughter, ambliing around the kitchen picking at Mom’s pre-dinner preparations and smiling innocently. Better is a matter of perspective. Today, your foot is healing. Last week, your foot was killing you. You’re delirious from being in the hospital. I can understand why your kids are mad. Better is a matter of perspective, but sometimes building a bridge from their perspective to mine feels impossible. I didn’t know you as you were. They don’t know you as you are. The tension between those visions is thin and tight, like a dream that could snap and recoil to either pole if anyone moves.

Residency Interviews

Interview season is here! I remember looking around the internet for advice, tips, thoughts, ways to save money, and realistic advice about what to ask, and what to look for in a surgical residency program. What are they looking for? What should I be looking for? What are some red flags?

Here’s just 5 pieces of reflection from my interview process last year.

1. Enjoy yourself

   You’ve worked hard. Really hard. As one senior surgeon advised me, this is one of the “breaks” in your career where you get to sort of kick back, relax, travel, make connections, and enjoy the fruits of your labor. Don’t worry about how you stack up. it doesn’t matter at this point and there’s not much you can do to change it. So just let go of that notion, and try to be present. Relax into your own skin, be yourself, try and make friends with the folks on the trail (they’ll be your colleagues, not really your competition) and see how well you fit with the programs you visit. Does their culture/vibe/attitude fit yours?

   • DO: Relax and have a beer/wine/coke product and be yourself.

   • DON’T: Get blitzed at the pre/post-interview events.

2. Travel Cheap, but Sleep Well

   By all means, use all the gift cards, points, promotions, free couches/futons/guest rooms etc., that you can. But don’t be afraid to ask the friends your crashing with if you’ll get a good nights sleep. It’s so clutch to feel rested the next morning because the days are kind of long, you’re walking all over these hospitals (which seem to be getting larger and larger), and if you’re like me, you’re a little bit tired at the end of the day from meeting so many people. Find a place you can get some sleep. I got hotels/airbnb’s for only 2 of my interviews, and the rest I crashed at a friend’s.

   • DO: Hit up friends and alumni- “hey I see you matched here, wondering if you had any advice and/or a couch?”

   • DO: get those credit cards that give you enough miles for a free flight (Chase was running a special that gave people 100K free miles for signing up and no cancellation fees when you ditched the card at the end of the interview circuit)

   • DO: Pack an extra suit

   • DON’T: Skimp on peace of mind.

3. Define Your Priorities/Philosophy

   It’s important to go to these places with some core self-knowledge.. When you go to these programs, they will tell you (nearly) all the same things. They’re awesome. They’ve got it all. Top notch research. The best fellowship match. The best surgical experiences. There will be some differences, but for the most part, they’re all great (and they actually are). How do you choose? Without a philosophy or pre-existing set of principles, you’ll be swayed by one presentation or another, influenced by your mood, a good meal, a good night’s sleep or a very persuasive faculty member. Know thyself. What’s important to you? Do you want a robust community surgery experience? Are you interested in research? Do you see yourself becoming a surgical educator, public health guru, or a community surgeon? This is the part where it helps to build an excel sheet (I usually don’t, I’m more of a gut-feeling person, but for this decision I succumbed to excelitis).

4. A human system with human failings

   Finally, you’ve got to make up your mind. You’re going to be in this thing for 5 years at least. Who knows where the match will land you. Try to be honest with folks. I personally never experienced what some people refer to as “the games” - basically programs lying to you about whether you were ranked or not, in an effort to get as many candidates to rank them highly. In my experience, people were straight shooters. If they liked me, they told me so, if they didn’t, I guess they didn’t really say much and I got the message. But some of my colleagues did report being told one thing, and come match day, things turned out differently. Therefore, go into the rankings with the understanding that no one owes you anything. It’s a human system with human failings. Furthermore, everyone will have an opinion about these programs - They’ll have stories from their experience with these institutions. Those stories change. Institutions evolve. Leadership changes. Try to gauge where the program is now, how the residents are now, because those are the folks you’re going to be learning from. You’re not going to match to bygone era of greatness, though there is something to be said about legacy. You’re matching to the environment at a particular point in time with a set of particular people - are you good with them?

   A note on the “malignant” program=

   A lot of folks will tell you horror stories about certain places being “malignant”. It’s important to understand what they mean by that - are there verbally or emotionally abusive faculty/residents? Are the residents scheduled to go over duty hours? Do the upper levels throw their juniors under the bus? Those things are actual malignant behaviors and you should watch out. If you hear about folks working long hours or having long patient lists, or if you hear that there are “tough” rotations, don’t take that to mean malignant. Seek to understand what the challenge is. Working hard isn’t malignant. Working under constant anxiety or fear brought on by leaders/faculty (and not a person’s own inborn anxious nature) is malignancy. This is sometimes hard to tease apart because residents are anxious creatures. We fret about what people think about us. We’ve done it since we were knee-high to a grasshopper. So don’t confuse a person’s anxiety and fear with a program that runs on anxiety and fear. Although if a program is filled with anxious fearful people you should think twice. That said, don’t judge an entire program by a single interaction. This is hard, especially if you have a particularly negative interaction.

   
   With the vagaries of the match system, you may or may not end up at your top choice. The good news is that great physicians come from all kinds of places. I’ve met amazing faculty and fellows from all kinds of programs including my own. Like most of your adult education, it’s more about your attitude and what you bring to the table, than it is to about the program. That being said, here are some red flags…

Warning: Do not Proceed

Residents speaking ill of each other and of faculty at the interview - Residents are tired, the interviews supply them with free beer, and before you know it, the truth comes out. Especially at the pre-interview events. If you hear residents disparage other members of their program, if you hear them disparage faculty systematically, be careful. If this is one resident, it’s probably them. One faculty member, same thing. But if there is a lot of this talk, proceed with caution.

Mass exodus: Are lot of folks leaving? Why? What is the plan to fill those positions?

Financial challenges: Is the hospital system or program in the red? This may mean they don’t have the resources to support you appropriately or hire help as needed. Much of this data is publicly available because most hospitals are non-profit and publish their financial reports each year. While you can’t drill into how the department is doing, being at a place that is financially healthy is important.

Good questions & Bad questions

1. Don’t use your questions to pander - most people will see through that

2. Try to see under the hood of the program, for what they’re about “What about this residency program are you most proud of?”

3. “What is an area of growth for this residency program” - this is an awesome question for a couple of reasons, first, if people balk at this question, be wary, every program has stuff they should be trying to improve, and they should be honest about it, because after all if you choose to rank them highly, they don’t want you to feel like you were sold a bill of goods. Second, this reveals a pain point in the program, and whatever it is, usually it reveals the part of the residency that is going to grow/develop most while you are there, because it’s something that’s on people’s minds.

4. Do ask hard questions, “Is the leadership changing,” “Your residents have said/I’ve heard X, what do you think|?” - obviously don’t be inappropriate or insulting, but if there’s an issue you need to get cleared up, by all means ask. Again, programs should try to be transparent with you. And you with them.

Becoming a Colleague

I’ve had a lot of time to think the last couple of days about this work, and residency broadly. I’m on vacation, and I’m listening to Viktor Frankl’s Man’s Search for Meaning. I’ve realized for myself that residency is hard, but it is an incredible gift. I get to take care of people. Yes, I often have to contend with the electronic medical record, I sometimes have no clue how to do a seemingly simple thing, or find something obvious, the hours are long. But this work is a privilege. My colleagues, co-residents, are the people who help remind me to care more deeply, and be more present with patients. Not by words, but by actions. They see the patients with me. They ask me what my assessment is and correct me as needed or tell me if I made a good save. They bluntly dress me down for poor decision making or inefficiency. But they also go out of their way to relieve me, to share their burdens and mine, and to help me become a better doctor. Find a place that isn’t as interested in who you are as in who you should become. The best version of yourself. When you match, you’ll feel very much like a medical student all over again. You’ll feel lost. Like a tourist. But the unimaginable will happen soon. You will become a colleague. You will be transformed by your experiences and the support and help of the people around you, particularly the senior residents. Hopefully, and I believe almost certainly, you will find yourself at a place where you become the kind of colleague the field needs to be filled with - thoughtful, dedicated, hard-working, humble & compassionate surgeons.