EPISODE 66
How Responsibility Turns Students Into Surgeons | Jacob Steffen Pt. 1
Episode Transcript
Dr. Randy Lehman (00:00):
Welcome back to the Rural American surgeon. Today is a little different, and for some of you a very practical episode. I sat down with medical student Jacob Steffan to answer his questions on how to succeed on a sub eye. We went long, but I felt like so much of it was gold that I just split it into two parts. So if you are a med student heading into a subi, this is going to be perfect for you. Let's get into part one. Jacob. Stefan. Jacob, welcome to show. Thank
Jacob Steffen (00:35):
You Dr. Lehman. I appreciate the warm introduction. Ever since I did my rural surgery rotation with you and heard about the podcast, I was super interested and hopeful that someday I'd get to be a part of an episode at some point. So I appreciate it.
Dr. Randy Lehman (00:51):
Yep, that's how life goes. You just have these connections and I'm super glad I got to meet you too and I think you just have a very bright future. So I'm very happy to make your acquaintance and see how things go for you. And I think basically what happened is you were asking me some questions like from a mentor mentee sort of perspective about how to do a sub-I that you have upcoming in your fourth year. And I said, Hey, would you be willing to ask me all those questions on a Saturday morning and let's put it on the show because if you have questions then somebody else does too and you're the most helpful to yourself five years ago. And so let's just throw this out there and let people find it in addition to answering your questions. So this episode is going to be basically you asking me the questions that you want to know about your upcoming sub-I. And I would tell you, go ahead and take it away.
Jacob Steffen (01:48):
Yeah, thank you. So I have my step exam at the end of this month and two, three days after that I start my subi. So the first question I have for you Dr. Layman, is what is a subi for somebody who maybe is in their first two years of medical school or somebody else who is not sure? What is the subi and why does it matter?
Dr. Randy Lehman (02:08):
Yeah, so a SUBI stands for sub internship or AI acting internship or basically it's a fourth year rotation in medicine or surgery where you are supposed to be pretending to be an intern and getting yourself ready to be an intern. And many times this is done as an away, sometimes you do them at your home institution, but they're kind of like a month long interview in a way as well. Sometimes you might do them at a program where you really want to go and then you want to impress them. And I know some programs in the past that I've heard that they only take people that have done a sub eye at their place if they're more competitive. But then you and I were talking and you said that may not be true, maybe the opposite, you might actually decrease your chances of kidding accepted at the place that you want to go if you do the subi there.
(03:02):
But I think that that depends on who you are. And probably most people, it sounds like the average person shows their true colors when they show up for their subi and doesn't impress, and then the program would rather have nameless aless chance than that person, which I think says more honestly about the, I don't really think that that's true if you're outstanding and if you put your time into it. So I think that just shows that a lot of people could be doing better. That would be my take on it. So basically something you do as a fourth year, probably one month rotation, and it really helps you in a couple ways. Number one, getting into a place potentially, and number two, preparing you to be a resident. And number three, if I've trained, when I trained, I went to so many different locations like Cincinnati, university of Cincinnati, Christ Hospitals, good Sam, Jewish Community Hospitals down there, the va, and then I had rotations in Campbellsville, Kentucky.
(04:11):
Then I went to Mayo and I went to Owatonna in Mankato and Eau Claire and La Crosse Methodist and St. Mary's. I've almost blanked on the main hospital in Rochester. And then even it was after I've gotten out, even doing a little bit of locums, kind of floating around to a couple little hospitals and then now several hospitals in this general area you really, and then also international missions. So I've been to many different settings, literally dozens and I think it's really bad to train at one institution, go to med school residency and work at one institution and not see much more of the world and not see other systems. And I think some people do that and they get really siloed and it's like they think that that's the way that it is, but there's actually a lot of different ways to get safe surgery done and you can cross train and by doing that cross-training, you come in and now multiple ways to achieve an outcome and it definitely makes you a better surgeon. So that's kind of the third way that a subi sort of helps you is you won't forget a couple cases from that rotation that you just won't forget and you'll remember. And it's like anything with surgery, just showing up as half the battle and don't hide and then everything else you get out of it, what you put into it. What else as far as specific questions do you have about the sub-I?
Jacob Steffen (05:49):
Yeah, so first of all, it's interesting that you say that and from what I understand it's kind of a new trend for medical students tend not do away rotations, which is kind of what Dr. Lehman was describing for our listeners is something that it's kind of like a subi or a month rotation that you do at a different institution and it's kind of a new trend now where people aren't doing those anymore. So it's kind of interesting and the fact that general surgery is the only specialty as far as I understand that has that data, that it actually hurts your chance of the matching. So I don't know, definitely something to keep an eye out for and as a medical student, something to think about. So my next question for you I think is more related to your application as far as letters of recommendation and communication with the attendings that you're working with. I understand that a lot of people say you should ask for letters and things at the beginning. So what are your thoughts on that and how should you approach that?
Dr. Randy Lehman (06:54):
Who told you that?
Jacob Steffen (06:57):
I've heard it from, I just went to a new or to a different kind of a session for aspiring medical students for general surgery at IU or not aspiring medical students, aspiring general surgery residents, surgery
Dr. Randy Lehman (07:15):
Residents. Yeah, I don't know. I never did that. I would ask at the end,
(07:20):
But you could in the first time meeting somebody the first day, if you have a little gap where you could get a little one-on-one and shake your hand and say, here's who I am and what I want to do and I want to make the most of this rotation, you could add that you would like to ask for a letter of recommendation at the end, but I think everybody already knows that. So you don't have to say that and I think it kind of cheapens your experience. But if you could ask them for their advice on how to get the most out of the rotation and tell them that you would like to get the most out of the rotation and then follow it up with four weeks of showing up and trying to get everything, trying to actually do that, then you ask them for the letter on the last day and then it's going to be a no brainer. But if you lead with I want to get a letter from you at the end of this rotation, I mean how good your letter is or whether you get a letter has a lot more to do with how you did for the four weeks than it does on if you asked on the first day. And it seems weird to me mean, but if that's what your advisors are telling you to do, you could take their
Jacob Steffen (08:46):
Advice
Dr. Randy Lehman (08:46):
Or
Jacob Steffen (08:46):
That was from one session from I think one or two people doing the session. So it'd be interesting to see what other people think about that too. So I like that communication of how can I get the most out of this rotation? I think that is a good way to set forth that you're really interested in doing surgery and want to do well in the rotation. So as far as the actual day-to-day life, what is it like on a sub-I?
Dr. Randy Lehman (09:18):
Yeah, it's going to depend greatly on the place that you are doing the sub-I and whatever their culture is, whatever their rounding time is, their typical. So what I would not do is I would not take just because you did a rotation at your home institution say, and this is how they did it there or because you saw something online that said I should be doing this or that. I would just ask upfront and take notes and then pay very close attention the first couple days on because they probably have it set up where they round with the staff at a certain time and then everything that you do is based off of that T minus one hour, two hours, three hours. So if they're going to round with the staff at seven, then you need to find out what the expectations are for you.
(10:22):
If you're with a senior resident or even an intern, you could tell them, I want to pretend to be an intern and I like this to be a great rotation and just tell me what I need to do. And then when they tell you don't forget it, take notes and then don't ask again and then do it. So if for example, getting the numbers, so maintaining the list, so the list is all the patients and sometimes it'll be computer generated and you can just print the list and it will have certain numbers with it, but then some numbers will always be missing and then it will be the intern's job to write those specific numbers or specific things down. Or maybe they want you to write post-op day to laparoscopic lysis adhesions for small bowel obstruction or there's something specific that the computer won't pull in.
(11:22):
If they're using Epic, they might want to use an epic report, but then it's not going to be the same as other places might be using an Excel document where they put all the patients in and then you have to maintain. And so then every day, usually twice a day, probably at least morning and night you're going to come in and punch in different things. So you just need to learn what, and it's going to be a printed paper list most likely that everybody's going to have in their pocket every day and it's probably your job to prepare that. Most of the times when I did sub or not, but even just straight rotations, most but not all, we would round as a resident team one time and usually nowadays the chief or the senior resident was involved in those rounds, but not always. So sometimes I would go round as an intern by myself with the patients with the list that I had already made.
(12:16):
I would ask them all the questions and be ready to make all the decisions as if I was the only person in the world. And then I would go present that to my chief resident and we would go round. So if we were going to round with the staff at seven, maybe I'm going to round with the chief resident at six, I'd be rounding at five, which means I'm in there at four printing the list out, writing the numbers down, going, and then I would go at five and see all the patients and then I would come and at six usually we would do walk rounds, so we would walk to the patient's room and then I would tell them, here's the deal, this is post-op day one, lap sigmoid colectomy, patient's not passing gas yet and they're walking their pain's controlled, their AFib brow vitals are stable, white blood counts 13, otherwise labs unremarkable. Plan is weight return to bowel function. By that time I say a weight return to bowel function, we're like walking into the room already.
(13:16):
Maybe you would say the patient's on a clear liquid diet. I think we just stay on a clear liquid diet until they're passing gas or whatever. So then we would go in, poke on a belly, get out, and sometimes if there's wound dressing changes that need to be done, there's a particular way to do it and so that might be something very helpful. You can stay and do the dressing change, the team goes on to the next patient and then you catch up with 'em as soon as possible. So you just have to feel out those things and then we'll come back around with the staff and usually with the staff, the intern doesn't present. Now the senior resident would usually present at the door in that scenario, sometimes you'll want to present in front of staff on your rotation. You're not getting a letter from the resident, you're getting a letter from the staff, but they might just say, we're going to have you follow these two patients and if they do, that means own those patients with everything you have.
(14:22):
You need to know what their kids' names are and where they live and what job they did and everything about them in addition to their surgical history before this time, everything that went on during this operation. Usually they'll make it a patient that you operated on, which is great, you can remember and if they have drains, you want to know exactly what those drains are doing and where they're going and then how they're doing on any given day and see them usually multiple times. So don't be scared of doing PM rounds. The PM rounds are very powerful if you can just come back around at three o'clock or something, find a little gap and just walk around and see the patients and before you go in and see the patients run the list. So run the list means look at their chart in the computer, see if there's any new notes from nursing, how are their vitals doing?
(15:15):
Are there any new labs? And then stop by and see them. You'll pick something up probably doing that. If nothing, you'll pick up education for yourself, but if you pick up a fever spike or something and then you bring it to someone's attention or somebody starts passing gas and you are waiting on that and then now you can advance the diet rather than wait until the next morning. Those are ways that you can practically be helpful, but then other times they might, I had some rotations where the chief resident said, don't go round by yourself. We will do discovery rounds and so just get the list ready, we'll all meet and then we'll just go and we'll go in together. And it's kind of duplication work. It literally adds an hour to your life. And the other problem is sometimes you go in there, you're waking the patient up at five o'clock, they really don't want to be woken up and then they tell you a different story than they say one hour later. And so it's kind of like why don't we just all go together, let the patient give us one story, it's more towards six instead of five.
Jacob Steffen (16:18):
That's like the classic medical student story. Somebody says something completely different and you walk into the room with the attending and they say something completely different and you're like, oh, okay.
Dr. Randy Lehman (16:32):
Yeah. And you don't have to be defensive about that. Everybody knows the patient's lie and misrepresent things all the time. And so as long as that's the, you're probably going to ask me this, but what's your biggest tip? My biggest tip is don't lie. Now that might seem weird that I have to say that. Okay, but this is what I say with my kids. I say, how many times do you have to lie to be a liar? One. Okay. And so if you ever lie, that calls into question everything that you have ever said. But if you never lie and I get the sense that you're a person that just always tells the truth, then I am always going to believe you. I mean I'm the kind of person to believe until you give me a reason not to believe. And I don't think everybody's like that. Some people don't believe you from the start and you have to prove, but I hope that there's more people that at least give you the benefit of that upfront. I think there are, but how might you be tempted to lie?
Jacob Steffen (17:51):
I actually like this because I was just part of a panel for incoming third year students just got done with second year. This was the end kind of the ending of what we were talking about and probably the most important thing do not lie. And like you said, it seems kind of silly that you have to say that, but at the same time it's so tempting to make it look like you did something that you didn't and maybe should have, but lying is not the correct answer for that. So I'll let you continue.
Dr. Randy Lehman (18:28):
So the way you'd be tempted to lie is something that's probably a certain way that you should know, but you don't really but you think it's probably fine. Are the patient's vitals fine? You should know that you're the AI and probably they are, but if you don't know, don't say yes. It's embarrassing to say, I don't know. You can always say I will check. That's a very standard. You're going to say that for the next forever, the rest of your life. I'm not sure, but I'll check.
Jacob Steffen (19:14):
That was going to be my next question is what's the correct way to handle that situation to something that you don't know that you probably should?
Dr. Randy Lehman (19:23):
Yep, I will read about that. If it's a question about something that is medical and it's like a textbook type question. If it's a patient type question, I should know that, but I don't, I'm not sure, but I'll find out. Those are good ways to answer it. But not to say that it's fine when it's not or to say the thing that you think that it might be rather than talk about not doing bad things, not lying on your rotation. How do you eliminate the temptation to lie by doing the right thing in the first place? So I would say the most effective way is for me, and I'm not sure, you might be more on tech or something like that, but for me is keeping a written list in my pocket of the things I need to do that I can quickly pull out and write down if it's going to be my responsibility to do something after rounds, maybe that's powwow with the discharge planner or change a wound dressing or talk to a nurse or follow up on a lab or we're ordering a lab during rounds that needs followed up on.
(20:39):
I just write that down under that patient on the list and then every hour or so I got that paper open and I'm running the list. Anything that I can do now and then I try to go work on those and I put little check boxes and check 'em off as they're done. And if it's a lab that needs followed up on, I write it right there so that when the staff asks me about it, I can pull the list out of my paper pocket and I can say, yeah, we did check that PM hemoglobin on that trauma patient and it was 9.2 which is stable from 9.16 hours prior. And I write that little bit down too. It's going to be overwhelming, but the more you write things down and if even just showing the fact that you have a list and you're trying, that's what a good AI does, put it that way.
Jacob Steffen (21:30):
Yeah, that's great. I think adding a running checklist, some other things I thought about when you're talking about that is I've heard some advice where you're writing a lot of other things down sometimes. Sometimes you're writing down special labs and things like that, but to highlight an actual to-do list, draw in there like an actual open box next to whatever you wrote that's a to-do item or a task item, then you can check it off whenever it's done and then you're not confusing maybe a patient presentation or something you wrote down from a physical exam with an actual to do item and they kind of stand out to you. That's something that you need to do later. So I want to ask you another question I thought about when you said actual the list like running the list. What are some examples of some numbers or some things that commonly change that a medical student should be looking out for that they need to update the list? Does that include labs, room numbers, something about imaging or something like that?
Dr. Randy Lehman (22:33):
Yeah, it just depends how they're going to do the list. I would say more and more the list is coming from the EMR and so sometimes it's got a lot of garbage on it, but at least it will have their name and date of birth and room number, unit, things like that. But if they're still running a list in a separate Excel for example or some file like that, then yeah, you're going to have to be checking multiple times a day and that's where you would put in a little checkbox to come in earlier. The better stay later the better and do it in the middle, then you'll just have to update those things. Yeah, if you want to talk about what are the important things on a patient, like the actual numbers that change for the patient, I was told before of all the stuff that you know about the patient, there's a percentage of it and I don't really know the right percentage.
(23:37):
I can't remember what I was told, but I'll make my own up right now. I'll say maybe 60, 70% of it. It makes it into the note of all the things you know about the patient. You don't need to know their kid's name and put it in the note, but be rest assured that the staff will be reading your notes and it is good if you read the notes. It is good if you come in early and get it all teed up for yourself and write it in the computer and pin the note and then you can quickly get your notes signed after rounds.
(24:21):
You can go to breakfast with the team if that's what they're doing. But you got to figure out a way to get back to the computer, get your note in because if that note is there and it's really good and really reliable because the staff still has to dictate their own note most of the time. I mean don't always just co-sign and if your note is signed, they can get their note done or they can rely on your note to dictate from they're going to love you. And if at minimum they're going to be reading your note and that's going to be showing them what's in your mind. So that's why you want your note to be really high quality. So say 67% of the stuff goes into the note that then into your presentation, there's a much smaller percent of the things that are in the note. It's probably only six to 7% of the things from the note that makes it into the presentation. It depends. If it's medicine then it's 67% and if it's surgery it's six to 7%.
(25:28):
As soon as you say this patient is a, we already lost interest, get to the point. And if you can treat it sort of like a very, very, very abbreviated presentation where you know how the rules are, tell 'em what you're going to tell 'em, tell 'em and then tell 'em what you told 'em for any presentation. If you can lead with a punchline, that's fine. So this is a cholecystectomy or it's a cholecystitis consultation from the ER and then tell 'em what's going on. And sometimes I get calls from the ER now as a staff and there's a few doctors that just they want to say this is a 67-year-old female who's had abdominal pain for six to seven hours and then they start saying, well, even before that they say the patient has these comorbidities and this happened and oh man, literally I'll interrupt them. I'll say, what's the CT show?
(26:36):
That is such a waste of everybody's time to do a presentation like that. We're trying to get the job done here. If they would call me and say hi, I have a patient I believe has cholecystitis, they are 63, it's a female history of diabetes, no prior abdominal operations pain for the last eight hours cur after eating hasn't gone away, came in here, I gave morphine. It kind of got better but didn't completely go away and it's in the right upper quadrant radiates to the back. Is there anything relevant? Right it does it matter if their sister got their gallbladder out? No, don't worry. Put it in your note. It needs to be in your note, but you do not need to say like three other family members have had their gallbladder out or whatever. So you say that and then you say mildly tachycardic, heart rate 110 other vitals, normal last PO intake. Don't forget to put that in your note, ask it when you go talk to 'em and then present it. That will be a shining star moment. And then on physical exam, she has an equivocal Murphy sign, white counts 13 ASTs 70, all other LFTs are within normal limits and ultrasound shows peric cystic fluid and gallbladder wall thickening consistent with acute cholecystitis.
(28:11):
My impression is if you want to say that and lead into it, that will anchor and they will not interrupt you for a split second. You'll capture their, because they know I'm a med student and I'm just trying to say the thing that I'm supposed to say for my ai. Okay, so if you just say, my impression is acute cholecystitis, the patient has no major contraindications for surgery. That's thoughtful. I believe we should offer laparoscopic cholecystectomy done. So being a surgeon is more about managing complications and deciding who does and doesn't get an operation. Then it is about the cutting and sewing and what you want to do is you want to give them a glimpse that you're a safe person with good judgment to be able to do those things.
Jacob Steffen (29:06):
Yeah, that's really great advice. I think something that maybe especially earlier in med school, you fantasize the cutting and the sewing like you were talking about, and the actual technical skills of surgery, which is really fun. And then you get on the floor and you're like, oh, this is very medicine heavy complication management, patients on blood thinners, what should I do next? All those type of things you don't think about until you have to deal with it and then you're like, oh, this is actually a lot different compared to what you're doing in the actual or
Dr. Randy Lehman (29:44):
Yeah, I would also say limit your presentation on the HPI to maybe three or four points. So I'll give you a couple of tips for your note and for your medical interview. These are the sections that should be in your note. Chief complaint, history of present illness, past medical history, meds, allergies, past surgical history, family history, social history, review systems if you want, which I always write otherwise negative, but you can do it. Then if it's a patient that's admitted ins and outs, everybody, vitals, people forget vitals, then physical exam, then labs, then imaging, then any other objective ancillary tests like for example, EKG or if there's a cardiac stress test and then impression, which should be a numbered list of diagnoses that roughly match something on the ICD 10.
(30:54):
And then plan, you can write your plan under each diagnoses or you could put your number listed and just write your plan. That is your note and you're going to present in that format because that's how we expect to see it. The only thing is you could just drop drop the diagnosis at the very beginning. If you want to capture our attention a little bit more, I will give you one tip for your note, which is in your HPI actually two tips. Most of the time the patient is having a symptom and the chief complaint is like abdominal pain or vomiting. So you expand on that symptom and the acronym I use is L-O-P-Q-R-S-T. So location, onset provocation, radiation, severity, timing. So location, where is it onset, when did it start provocation, anything make it better or worse. Aggravating or alleviating factors. Radiation. Does it travel or radiate anywhere?
(31:59):
Severity you could say mild, moderate, severe. You could say on a scale of one to 10 timing. So that can be a lot of different things, but mainly if it occurs at particular when you wake up in the morning or it always, and it's kind of ties to aggravating or alleviating factors, but it's a little different. You put all those things in there and for anything that is pain that you can always ask those questions. Now sometimes it is not quite as relevant, but you usually can use that. And then at the end of my HPI section I always put, and this is for my real life, if they're on anticoagulation or not, even though it's going to be right down there in their med list. And if so when their last dose, I also will put, if it's an ER consult when their last PO intake was, if you do that, I'm telling you you'll shine.
(32:53):
And then third, obviously don't do that for a clinic patient unless you're considering taking them from clinic and going to the, and then the third thing is any relevant surgery. So for most of my notes, the patient has not had surgery in this area before. So even if that's like a skin cancer or a lump or bump, but it's not saying they've never had surgery, it's just they haven't had surgery right where you're going to cut. That's what matters. And so if they've had belly surgery, and of course you always ask the patient, have you had belly surgery? No. And you're like, how many kids do you have? Three of 'em. Oh, they're born vaginally. Oh no, they're all born C-section that all the time they have to going to do that. So you have to read through the lines. You don't have to fill in the patient. That counts as an abdominal surgery when their abdomen was opened and their kid was scooped out. But those are the three things that I would put anticoagulation prior surgery in the area. And then if it's an ER consult, last PO intake,
Jacob Steffen (33:48):
I get
Dr. Randy Lehman (33:49):
To
Jacob Steffen (33:49):
Last. I like those last three things because there's a lot of stuff on surgery that maybe is unique to surgery and some other people don't think about. On my family medicine rotation, it's important to ask if the patient's taking their anticoagulation but you're not expecting that they stopped it in surgery, you should expect that they stopped it and nowhere else should you expect that they're stopping their anticoagulation. So that's really good.
Dr. Randy Lehman (34:19):
And the diet thing, it's usually like the ER or the floor, not the er. So much the floor, I feel like general surgery, the clicky button for general surgery must be very close to general diet because often they click both of them at the same time. It's like don't feed the patient and then call me, but what are you going to do?
Jacob Steffen (34:41):
Yeah. So specifically for, you mentioned your physical exam obviously goes in your note. Are there anything, any physical exam maneuvers that you think you see people miss out on or something that you maybe don't do outside of general surgery? Obviously the abdomen is very important for general surgery doing an abdominal exam, but is there any other specific things that you can think of?
Dr. Randy Lehman (35:09):
What I really care about is what's coming out of the tubes.
(35:13):
If they have an Inge tube and you can't tell me whether it's green or brown or clear or red coming out the Inge tube, that's a problem. I personally think bowel sounds are a complete waste of time and I hate it when nurses tell me what the bowel sounds are because first off, they don't really know what to listen for and it tells you nothing. All that matters for return of bowel function is whether they're passing gas or not. And if they haven't had a bowel movement for a day, that doesn't mean anything. What matters is if they're passing gas for bowel obstruction, return of bowel function after bowel surgery, the character and volume of the two bowel puts. So urine, if they have a Foley, you should be looking at the Foley and seeing how dark the urine is and you should know the volume that's coming out because the best marker of perfusion is really urine output in a person with normal kidneys.
(36:09):
So know that. And then if it's dark and low volume, probably there might still be third spacing. We need to be doing something about it. Physical exam findings for appendicitis, whether or not you say they have a positive Murphy's I think is good for appendicitis ing sign, ator sign, sos sign. So lemme talk about just rosing and Murphy's. Okay, so Murphy's is inspiratory arrest on deep palpation of the right upper quadrant. All those words matter. So I have them breathe all the way out, breathe all the way in, breathe all the way out again, and then have them breathe all the way in. And on the second breath I push. And the thing is, if you push hard enough on a normal person that doesn't have acute cholecystitis, you can make 'em stop breathing. So it's a bit of a, ultimately you're probably not going to be presenting on a patient that doesn't have imaging already. So use that to your advantage. Don't say somebody has a really Frank Murphy sign when really they don't have acute cholecystitis. It is just kind of building your own case. These are signs that existed before we had good imaging. By the way, I had a great success today using point of care ultrasound. You were talking about that.
Jacob Steffen (37:34):
Oh yeah,
Dr. Randy Lehman (37:36):
The other day. Side note. So yeah, I sold a pig to my buddy and we had castrated him and immediately after we castrated he had this, what looked like a testicle, kind of about the same size. But I made two cuts and I took two testicles out. So I knew that it was a seroma and that was a month before I sold it to my buddy and he's over there, man, I know this is a nut and you can't be getting one of my other pigs pregnant. And so I took my ultrasound over there and threw it on and it's a hematoma decision made to leave it situ you and not introduce bacteria don't cut. He's like, we got to cut into it, we got to cut. And I'm like, no, look, this is what a testicle looks like on ultrasound and this ain't it.
Jacob Steffen (38:27):
That's a focus success story. And another great example of your classic rural American surgeon story,
Dr. Randy Lehman (38:35):
That's a classic rural surgery story happened this morning.
Jacob Steffen (38:38):
That's awesome. I don't know if I've ever heard of anybody using ultrasound on a pig before, which is great.
Dr. Randy Lehman (38:44):
Yeah, I got this little portable unit when I was seeing patients in my own, actually it's not little, it's like, I mean it's like a $30,000 terra on full flip up thing.
Jacob Steffen (38:56):
Oh, it comes on a little cart. Yeah,
Dr. Randy Lehman (38:58):
But I just carried an ENC case out there. Just got to triple sanitize it afterwards. Alright, next question.
Jacob Steffen (39:08):
So what are some things you notice that sub eyes do that an excellent subi does versus an average subi?
Dr. Randy Lehman (39:16):
Yes, before I do that, let me remember to do the ING sign. So ING
(39:22):
Is for appendicitis, which is occurring in the right lower quadrant. So if you push on the left lower quadrant and it hurts in the right, that's a positive ING sign. So what a average subi would do is they wouldn't know what a robing sign is, never heard of it or they would say the patient has it, but then they would be wrong about what it actually is. And an outstanding subi would know what it is, would actually do it and then would report it correctly. So you got to start, the best time to plant a tree was 20 years ago, the second best time is today. So it would be great if you could go back in time and study more, but you are where you are right now. So I think getting up in the morning, cracking open a book, getting yourself to your recliner with your coffee, however you want to do it.
(40:18):
But that was what would work for me doing question banks to increase your fund of knowledge and understand that everybody, I don't think people talk about it enough, but everybody was there where they didn't know anything and it felt like it was overwhelming the amount. But there is an end to the diseases. Yeah, there's changes that are happening and stuff, but there comes a point where you pretty much know what you're looking at and the quicker you can get there, the quicker you'll start feeling comfortable. But be careful obviously of being comfortable because there's the Dunning Kruger effect, you're familiar with that.
(41:04):
The confidence increases greatly when you have a little bit of experience. And then that is the confidence as if you graft it on a line on the X axis being experience and you put confidence on the Y axis. As you get more experience, your confidence increases greatly and there's a peak of stupidity or a mountaintop of stupidity and then you get enough experience to realize, oh, I don't actually know anything. And then you have a huge valley where confidence drops lower than it was before you ever started medical school. And that's called a valley of despair. And you have to keep getting experience and keep learning and eventually you climb up a, I don't know, slope of sustainability I think it's called or something like that where your confidence will be appropriate to what you actually know. And so you can blunt that mountaintop and valley by understanding that the Dunning Kruger effect is a thing.
(42:18):
And just understanding you only know what, and I'll tell you one interesting or funny story, I mean about myself. So I remember being an intern Mayo Clinic. I'll give it two stories. I'll tell a good story about myself to offset this bad story that I'm about to tell about myself. So the bad story is it is just talking about fund of knowledge. We're sitting there a few months into intern year rounding and we did table rounds. That's another thing that maybe they do that too, maybe they do walk rounds and then they do table rounds with the staff and then they do walk arounds with the staff after different people scattered to different places. You just ask where you're supposed to go, but we're doing table rounds. And so then they would always make it a little learning opportunity and ask questions. So someone was talking about appendic appendic mucus, which is usually a low grade neoplasm that is a tumor that secretes mucin in the appendix and it causes the appendix to be dilated. And if it ruptures, then the mucin goes out into the abdomen and it's not a cancerous thing, it's not invasive, but people still die from it and it still can be very devastating and terminal. And the treatment, if it's ruptured and they have mucin in their belly, it's kind of a reddish color kind of gelatinous. And that's called lay term is jelly belly or the official term is pseudo peritoneal.
(43:49):
And the treatment is hip, which is hyperthermic, isolated hypothermic, peritoneal intraperitoneal, chemotherapy, I'm sorry, hypothermic, intraperitoneal chemotherapy. So that means they're going to open the abdomen and then put hot chemotherapy in it and agitate the belly for whatever the protocol is, 45 minutes or an hour and then suck that back out and strip everything out that looks like peritoneal studying or O might do an ectomy. And that's the way to treat that among other certain types of disseminated intraperitoneal cancers. I didn't know any of that at this time. And I was an intern and the staff turned to me and said, Randy, what is pseudo peritoneum? And I said, I know what an atrial mix is and that's the best I could do on that moment. Atrial max is a tumor in the heart in the atrium that's like a smooth muscle tumor.
(45:04):
And I had read about that because I was studying, but I hadn't done any practice questions or I didn't know what pseudo peritoneal I was or Jelly Belly and I should have because I was a surgical intern, but I didn't lie and I tried to offer something and then he was just kind of like, okay, well we'll read about it. And then just quickly moved on. And if you can build some rapport, if you always get every question wrong, it's going to be a hard road, but everybody gets that. You're not going to always understand everything.
(45:46):
Also, as an intern, I was in the ICU on my very first rotation and the patient developed contraction alkalosis. And so I had just studied for step two and took step two. And I never learned, I don't remember learning anything about this in any rotation. I hadn't come across it anywhere besides in my UWorld Q Bank. And little did I know that there's always a language. And I think sometimes people learn the language and they don't really understand the concept. So even the apps, they'll say, oh, the patient has developed a contraction alkalosis and they need diamox. And it's like, okay, so diamox is a trade name. And I hadn't heard anybody say that since I had been up there in the ICU and I am just like your nurse practitioners are very useful and helpful and they can do a lot of things, but when they look at the patient, they're looking at it like a nurse and they're seeing the patient as a human being, which is great, and they're looking at the outside of them. When you look at the patient, you're looking at a medical textbook and you're seeing an h and e slide of a glomerulus and you're seeing diagrams of pumps and receptors.
(47:32):
When a nurse gives a patient a medicine, they see a pill and they're thinking about whether or not they can swallow this pill and whether it's been six hours since they got the last one. But when you give it, you're seeing the receptors inside that it's going and hitting. And I would say that a PA training program different than a nurse practitioner in that the training kind of comes, you can still come to the same conclusion, but generally that's what separates the doctor from everybody else is that they're looking at things on a molecular level in their head. And so they asked me what the bicarb was and I told 'em and they said, what do you think we should do about it? And now, I mean, after a couple months in the ICU, literally this question gets asked every day. And I think that my 9-year-old could sit in there and give the right answer, which is I think we should give diamox, but I never heard of diamox and neither should you honestly, because it's a trade name and it was dead silent.
(48:45):
And he's just staring at me for it was probably five straight seconds silent. And I go, I think we should give acetazolamide. And everybody knew that that came from my head and not from just being there. And so the only way to know that I had a similar experience given magnesium for torsos, it just came from a question. And so we're all walking around and nobody knows the answer and then they ask a question and I say, so you have these types of questions where they can only come from you studying and it will come out. And it's not that you're trying to look good, you're trying to do the right thing, but then you just naturally do look good. So I went on this humongous rant because your question was how do you do a good job as an ai? What separates good from great?
(49:46):
And I think preparation, I guess is preparation and honesty, and then also being a human being. Understand everybody else is a human being also to a certain degree, being quiet and just be there, but you don't have to talk all the time. You shouldn't make small talk with people, let them make small talk with you and say a few things and then shut up. Nobody really cares what you think as you're not their colleague. You're only going to be there for, they're not trying to create a long-term relationship with you. They're just, you should show up, try to do your job, try to learn. And if you do that, they want to help you learn. Nobody wants to keep you from that, but the staff surgeon is going to be operating with their tech for years. They've already been operating with them for years. They're going to be operating with them for years. So when they're talking about their kids or their concert they went to or whatever, just don't say anything. Just focus on the surgery and do your thing.
(50:58):
Somebody might say something to you and then just respond and then wrap it up. But nobody cares about your kids and your thing because they can't hang on to all of it. And you're kind of like a person that comes in and out. You're part of it. They're used to people like you. There's a role. Everybody kind of has their appropriate level of respect for you, which is low. And then you move on and you're going to have your own team and your own colleagues, and the people that you have those conversations with are your fellow med students for the most part. Does that make sense?
Jacob Steffen (51:30):
Yeah, I like that advice. I think there's a lot to be said about just listening, just being quiet and listening and just watching how people interact with each other. But the main reason you're there is to understand the surgical process. So it's always good to not overshare things and just pay attention and do what you need to do and get what you need to get done.
Dr. Randy Lehman (51:54):
We're going to pause there. That's part one of this conversation and we've got a lot more to cover or performance, technical skills, how to stand out without being annoying, and the biggest mistakes sub eyes make. If this has been helpful so far, part two, we're going to bring it home for you and I'll see you there.
