Episode 67
Why Great Surgical Residents Prepare Before They Feel Ready | Jacob Steffen Pt. 2
Episode Transcript
Dr. Randy Lehman (00:00):
Welcome back to the Rural American Surgeon. I'm your host, Dr. Randy Lehman. This is part two of my conversation with Jacob Stefan on how to succeed during your surgical sub-I. In part one, we covered the foundation, how to think, how to prepare, how to function as a team. And now we're getting into more of the practical side or expectations, technical skills, the little things that separate average from exceptional, not just sub eyes, but residents and surgeons. Let's jump back in.
Jacob Steffen (00:34):
What types of technical skills should you have? And this can go over into the OR as well, but when you show up your first day as far as dressing changes, wound vacs, NG tubes, all chest tubes, everything that you can think of, what should a sub eye know how to do for their patients when they come on the first day?
Dr. Randy Lehman (00:58):
So on the floor, if you haven't done something before, don't just do it. So tell somebody that you would like to do it, but you've never done it before and then they'll do it with you or they'll tell you how to do it and then you can do it or whatever. But placing an NG tube is a great skill to have, I'll tell you that. So I always have the patient sit. A lot of times the nurses will not get an NG tube and then I'll get to go and do it. Now, the one trick that I use is I give them some hurricane spray in their nose and in the back of their throat, and then I can always be the hero that way, but almost, I mean actually I don't think I've ever not got an NNG tube. And many times the nurses call and say that it's impossible.
(01:43):
So it's not true. Sit at the side of the bed, get them up to your level. So their shoulders are at your level. Give them a cup of water with a straw in it. Have them tuck their chin to their chest loosely. Hold the straw, say don't start drinking until I tell you. But then when I tell you, swallow hard, so they're loosely holding the straw in their mouth. If you can, you get hurricane spray their nose. You may not be allowed to do that as a student, but maybe you can ask the resident to order it for you. And then if you do that, then pick which side. And if they've ever had an NNG tube before, ask 'em that so that if they've ever broken their nose or whatever and try to get the one that's a straight shot back. Take the NNG tube, get it all opened up and everything.
(02:31):
Make sure you have suction already set up with a tube that comes over to you but not hooked up to the tube yet. It's just sitting there ready to go. And then use the biggest tube that you can and the stiffest tube that you can. People always try to use the smaller flexible tube is going to make it much harder for you. Use the big stiff one and then you get yourself some lube and you can really lubricate the tip of the tube and then get them in that position and put the tube straight on the bottom of their nose and push it straight backwards. Do not point it up as it can go into their brain. So point it straight back and understand that there's going to be about five inches or so until it hits the back of their nasopharynx where it dumps into their posterior and it's got to make that turn and go down.
(03:36):
So it's going straight back in their nose and it's going to hit and turn and go down and you want them to swallow as you're making that turn. So I will often very carefully slide it straight back until I'm kind of almost there. And then because they're about to start gagging, and then I'll say, okay, now swallow hard. And then I push hard and then it goes right down into the esophagus. And as long as it's feeding just easy, it feels, I don't know, something feels like you're pushing an NG tube down, what? And it goes easy, then just drop it. And I'm talking like take it down to like 60 centimeters. And if they're coughing, that's a problem.
(04:23):
But if they swallowed hard, then their epiglottis will flip and cover their trachea and you won't go into their trachea. But if there's bloody and coughing, then don't keep pushing. And if there's pressure, you can go down to the trachea. That's the hard part. And then it goes down and tickles the corona and starts bleeding and everything. And as long as it drops, then just hold it and make sure you don't lose it at that point. And then that's the other thing is if you can at the beginning have something to tape it with, whether you're using tape and you're splitting it, twisting it around the tube, or sometimes they have bridals and that's a little magnetic thing. You'll have to have somebody show you how to do it or there's a specific tape device that tapes on their nose and then you tape it to the tube.
(05:10):
And I would use a little alcohol prep swab and wipe their nose to get all because they're going to be sweating and everything and get it cleaned off and dried off so that it sticks and adheres, then stick it to the tube and then hook it straight to suction. And nurses will say, always, you can't have it to suction because we don't know where it is. Well, if it went down like that, it's in the stomach Now you can push a little air in, listen on the stomach, fine, and then hear for bowel sounds or the air rushing in, that's probably a good move. But if you hook it up and you get a thousand ccs of bill output, it's in the stomach, it's not going to be anywhere else. And then you get your x-ray to confirm placement. So that's NG tube placement 1 0 1, but what we're talking about are things that you should know how to, do you have any questions about that I guess?
Jacob Steffen (06:02):
No. I mean the specific NG tube, that makes sense, but I think your summary makes sense is if you don't know how to do something, just ask someone to teach you to do it.
Dr. Randy Lehman (06:13):
But other things that you should know how to do besides an tube, okay, pulling an NG tube, a lot of times they might want you to take the dressings out of a wound in preparation for rounds. So maybe you run ahead a patient and you pull the wound out. Don't do this without being asked, but you could offer or if they want you to take it, clean it all out and then you'll stay and you'll repack the wound so wet to dry dressings and then just ask 'em how to do it. I can't tell you on this particular episode or else it'll be all afternoon how to do each one. But those are the med student type things. I mean, when I was a medical student as a four, I got everything ready to do an IND of a breast overnight resident showed up and had other things to do and looked me in the eye and said, are you comfortable doing this?
(07:08):
And I said Yes. And he said, all right, sounds good. Call me if there's any problems. And he went back to the OR and I drained the abscess on my own on the floor and everything went great so you can get to a point and then other people are not going to have that level of comfort with you, and I probably wouldn't do that with somebody that I just met, but that's towards the end of your rotation. You've already done a lot. So are you going to be prepared to do that? Just try to think you're the only surgeon, the only person in the world and you're going to need to take care of this. And then so all the stuff that you need, get it at the bedside, be ready, say, I like to try. If someone's trying to elbow you out of the way, whether that's a central line or whatever, but you shouldn't be putting a central line just on day one.
(07:58):
Never proved it to anybody by yourself, but you should be allowed to try to access the vein. And if you come in prepared, they shouldn't have to set it up for you. And the only part that you get to do is the access needle. That's not at all how it should be. You should set it all up and be ready to do it and then they should then give you the right to do it once you've done all that and you can kind of defend yourself just a little bit. And then also don't be offended if somebody takes over because different people have different levels of things and you'll learn who the person is that will let you do the most and you have gravitate towards them. And so that's kind of on the floor and the I-C-U-I-N-D in the clinic, maybe biopsies and suturing, things like that. But the first thing that you're going to get to do in the OR is probably drive camera. So learn about that. You can ask the techs for a little bit of advice and when you ask for people for advice, so here's a little trick on dealing with people from the master at dealing with people that I apparently am right?
(09:14):
If you can get somebody, ask somebody a favor, a small favor, can you give me some advice on how to run the camera? They're now invested in you and they want you to be successful because now if you ask them for a big favor, you're going to irritate them and so you'll push them away. But everybody that you meet I would say is willing to give you the littlest favor. And if you ask for a lot of those favors, now you have a bunch of people that are actually interested in your success. Obviously you want to not abuse it and everything can be taken to an extreme. So don't do that.
(10:06):
But when there's a quiet moment, and then also just be willing to give back and if you're going to ask for a favor from a tech, well maybe you stay until the dressings are on and bring the bed in for them and help them move the patient over from the or bed to the cart and that shows that you're a team player and you're just trying to help out and don't push them and try not to be underfoot, but at the same time try to be available. So the or the first thing you're going to get to do is probably drive the camera. Then the other thing is hold the retractor. So hold it still and tow in and don't slip out. And also the other thing people, residents do a lot of the times, I'm trying to look at this thing, okay, so you pull the point of the retraction is to create exposure.
(11:01):
It's not to pull as hard as you can. So sometimes you got one person pulling over here, the other person pulling real hard and it moves the whole view over and I can't even see the thing. So if you can retract to the point where the thing that we're trying to see is actually in view and understanding that, and it doesn't take a lot of pressure, it just takes tension from both sides. So then next thing is you're either going to be able to stitch skin or you're going to be able to tie a knot. So you should know how to tie a knot.
(11:39):
And if you only know how to tie one knot, a two-handed throw is the best, but it would be best if you knew how to do a two-handed throw with your right hand and your left hand and a one-handed throw with your right hand and your left hand, and you can practice on one of those Ethicon braided things that's large so you can see your knots and if you can tie your knots going down square, if you can find videos about it or talk to residents that are willing to teach you, learn how to tie a knot because if you get a chance to tie a knot, you're golden if you can do it. And I think nobody is going to teach you, nor should they teach you how to tie a knot in the operating room with a patient asleep. I think some people think that they think that's the time to learn. No, it is not. The time to learn is on a pig's foot or on some silk stitches. And you also want to take on your
Jacob Steffen (12:43):
Water
Dr. Randy Lehman (12:44):
Bottle,
(12:45):
On your water bottle, on your steering wheel, on your pants, on your belt loop. You can tie it on your scrub strings and you can just tie it on every thing in your office and you shoulding, I would say, I mean you should be, maybe you tie 400 knots a day, and so that would be a hundred right-handed, two hand ties, a hundred left-handed, two hand ties, and a hundred right-handed and left-handed, one-handed ties. If you do that by the end of a month, you are going to have thrown thousands of knots and you'll be able to shine. And what you realize is a two-handed throw brings the opposite tail in from the tan that you're tying, whereas a one-handed brings the same side through. And so why that's relevant is a lot of times there will be a needle on one of the two, and so you should not be bringing the needle through the hole.
(13:54):
So you want to do the throw that brings the free tail through, not the needle. Obviously know how to do instrument ties as well. And then most of our skin we're closing with a subcuticular four oh Monocryl or you'll do a deep, just a single deep buried for a port site. So I'll give you one tip about that. Right in the middle of a five millimeter port site, you go deep to superficial, superficial to deep with a four oh monocryl bring the tails out both toward you because if one tail goes this way and the needle strand goes the opposite, then you tie, you're tying on top of the string that's going across, so you're bringing your knot to the surface. I think sometimes this is why knot spit out and then you have both the tails out towards you, throw your first throw and then this is the big tip, pull one side and then the other.
(14:59):
So you have to give slack and pull the other. And what that does is it slams the tissue together and it takes out the slack and then your knot will be tight and the skin will be closed and it will look like it's closed just perfectly in a straight line and it will eliminate that gaos that sometimes you have if you just went ahead and tied afterwards. So pull one side, then give slack and pull the other side and feel it slide through, slams the tissue together. Then tie your usually four throws and then cut your knot. Another thing is cutting suture. They're going to ask you to do that, so you don't want to have your scissors big and wide and come swooping in like your crop dusting and then get out of there. You want to be cutting, undo most surgery just with your wrists and your fingers.
(15:48):
So you have your elbows braced and sometimes I put my hand down and have my scissor in my hand and my wrist is braced on my other hand so that I can be real stable. You just crack the scissors just a little bit. Go into the string and slide down with the V of your scissors on the string so you can kind of feel it slide down until you hit the knot and you feel a hard stop. It's tactile. Then turn your hand and your scissors 90 degrees clockwise if you're using your right hand and a right-handed scissors. And then cut with a little bit of tension down. And in that will people are trying to gnaw through Vicryl with the scissors and they're blaming the scissors. If you do that, it applies enough tension on the string and the cutting edge so that the 90 degree clockwise rotation gets you off the knot so you won't cut the knot out and then the pressure on the string cuts that way. Even if it's a bit dull of the scissors, it'll still cut quickly and easily and don't have to look like a fool kind of gnawing through it. Yeah,
Jacob Steffen (17:02):
I still remember the day I had the gap os like you were talking about the first day I was with you and you asked me to close the port site, you were over my shoulder watching me like a hawk like you should be on my first day. And you taught me that though, one, two. And ever since then that solved my gaos problem. So speaking of nostalgia, I don't think I'll ever forget that day.
Dr. Randy Lehman (17:28):
Nice thing about this is if anybody ever does my rotation ever again, they better watch this beforehand then I won't have to say it so many times. So anyway, that's what you're going to do in the or and you're not going to be stitching on valve, don't expect it. You're probably not going to be dissecting the gallbladder. Don't expect it. If you ever get the opportunity to do things close scarpa fascia, just be glad for it. But you can put yourself in a position where no one is going to give you an opportunity to do something when you haven't proven that you can do the level one. They're not going to put you on the level two task, but if you come in and you're just blowing everything out of the water because clearly you prepared and you tried to stitch it home and you had a hemostat in your pocket and you're popping it all day long with your hands so that you can figure out a way to not have to put your fingers into the instrument and you can throw a stitch, you can do those basic things, that's how you're going to get to do more.
(18:32):
And the funny part about it is your reputation is going to proceed you and in surgery is kind of like the rich get richer. So if you can come into intern year, you can come into your AI then intern year with the skills that are kind of expected at the end of your intern year, but you have 'em at the beginning, it won't take long and you'll be doing the second year level things, which doesn't seem groundbreaking when it happens. I mean it's kind of cool, but what will end up happening is things will feed on itself over and over and over again and you don't need to be in competition with the person next to you, okay? You're not doing it because you're trying to be the best resident in your year. Everybody can be awesome in your year. They probably won't be, but that's not your problem and it's not that you're trying to be better than them, so don't worry about that.
(19:24):
You just be the best that you can be and just understand that by the time you're a chief, if you do those things consistently, you stay late for the case. You prepare at home on the textbook and on your tying and you get good at tying, you tie on the pop tab of a can of pop for a long time, get good at it, drink the pop so you can stay awake, then tie on an empty pop can and then that's hard and try to do that without the pop can moving. So now you got nice good tension, but the pop can's not moving and then you put the pop can inside of a big coffee can that you also drank all the coffee because you had to stay awake. And then you put that coffee can, the pop can inside it down inside your washing machine and you get down in there and if you can tie on that pop can without moving it and still have good tension on a 3.0 silk inside of the coffee can inside of the washing machine, now you can tie on a tiny pancreatic branch of a pancreatic artery or you can tie doing the pancreatic ostomy on a Whipple without the stitches pulling through.
(20:49):
And that's where you want to end up and you don't need to be there as a four, but you want to end up there. I mean as an MS four, you want to end up there by a three by a resident level three, and then you can actually have quality operating during your third, fourth and fifth years and you want to be that person that the other staff will then have a hard case and they'll say, where's Jacob? And then you'll come and you'll get an opportunity to get even better. So it's like the rich get richer because of just that whatever you put in as a third year med student, as a fourth year med student as an intern, it compounds.
Jacob Steffen (21:40):
Yeah, that's great advice. I like the rich get richer thing. If you can come in proving yourself that you're already past where they expect you to be, then you get a little bit more responsibility and then that builds on itself. That's great advice. Speaking of technical skills and being in the or, is there anything that are big screaming no-nos in the OR that med students should not be doing?
Dr. Randy Lehman (22:10):
Don't talk. Don't contaminate the sterile field. Those are probably the most important, but be present and don't avoid the or either. So you need to understand sterile field, talk to the techs about it, know how to scrub before you get there. Don't make people teach you how to scrub that are not techs. The techs would love to teach you how to scrub and that's a great way to give them respect. And then come in, don't stand just how do I describe this? Stand with your body against the patient and your hands on the patient. If your hands are all out here, it scares us because at any given moment they might itch your nose or they might, your phone might ring and you might reach back here or you might touch somebody on the back. So just get up to the patient in the place you're supposed to be.
(23:17):
Put your hands on the patient and wait for instructions. I'll make everybody feel comfortable. And then after the case is over, if you can help the staff out by moving the patient over, just understand what you're supposed to do. It's not like you are a ai, you're not going to the surgeon's lounge to get a coffee as soon as the glue is on the patient, you are continuing the work until your part of the work is done. So stay with the patient. I would say that's something I didn't necessarily appreciate as much. I was like, well, these people are actually, that's their job and they're being paid to do it and I'm paying to be here. That's a bit of a hard pill to swallow, but if you can get over yourself and understand that we all kind of went through it, part of your tuition is a little bit of grunt work, so yeah, you got to pay the money too, but you also got to pay the sweat equity as well.
Jacob Steffen (24:31):
Yeah, I love that. Great advice. And I think a lot of people, I think do a good job of helping patients move, but it's little things like that just helping out that I think can help a lot of people shine and I don't know, do attendings and stuff. Notice when medical students do small things like that,
Dr. Randy Lehman (24:54):
What's going to happen is the staff, when you're not around, they're going to say, oh man, Jacob, he's a real dweeb. Or Man, we really like Jacob. That's what they'll say and they're going to say it. They're going to say something and it's when you're not there that they're going to say it. And so again, why do you do the right thing? There's selfish reasons to do the right thing. The other thing is I got to tell you another story about myself. I followed a fellow resident who's in my class, Michelle Junta up there. Michelle was the nicest person and she was the hardest worker.
(25:38):
And I had just come off of, they were super against residents at Eau Claire for the longest time. And then they were taking me because I was the rural track, but one resident went before me and it was Michelle Junker and I had just, this is going to be my, let's think here, fourth year rotation had to be, I think it was my second or third rotation of fourth year. And I just came off of an HBB rotation with the man at the Mayo Clinic who completed Whipples in 90 minutes. I had done, I mean when he retired, it took more than two surgeons to replace his clinical output and I just loved it. And I finished a case where I got to be alone on a Whipple until 10 o'clock in the morning. And I mean not alone, there was a tech with me who's his tech, so they would sound the alarm bells if something was going bad.
(26:51):
But I mean I had the portal vein, I dissected off the pancreas by myself, and that came from a month of showing up and even before that, showing up as an intern on the same service and proving myself, that's insane. And then I go to this other rotation and now I'm the second resident ever to come there. So they're not used to working with residents, they're not used to giving up their operation. And the person before me was Michelle, and she baked them cakes and came in and was so nice and I'm sure she just showed up to everything and showed up early and did all the work and was happy to write the notes and do the easy stuff.
(27:47):
And she's so likable and I showed up and the level of cases were basic cases and I wanted to do them, but I'm, my perspective was you guys already have a way that all this is working out and you have an a PP on the clinic on the wards at all times, and it doesn't really make a lot of sense for me to come in and round on patients that I didn't have anything to do with. When you already have the pieces in place, I'm like more or less getting in the way. So I said something, I guess I said this early on to one of the apps that I'm just here to operate.
(28:30):
And then that got back to me because it was repeated in a bad way. It's not really what I meant. I like, I'm happy to help out, but at the same time what I meant was, let me stay out of your way. You do things the way you've been doing. Let me get to the OR and I'll operate. But they weren't even really ready for me to operate with them because you just have to understand the context of where you are and what's going on. Then I did not have a very good rotation and I left early.
(29:04):
And the ironic part is I go to other rotations and have a very different experience and people have a very different experience of me, but then I was going to the OR and it was like, okay, I'm going to do this inguinal hernia. You watch me do this one and then I'll let you do the next one as a four, right? When I just got done doing major parts of a Whipple by myself. And so it didn't really, but if I had that to do over again, I would had better situational awareness and I would've just learned who to operate with and who not to, and I would've just not been, it's easy to get cocky in surgery. It's hard to stay that way. I would've checked my ego at the door in a better way. I don't have to bake the cakes. You don't have to do that. You don't have to suck up. You just have to get good rest yourself, get good nutrition, show up a little earlier than you think you should need to do a little more work than you think. You should need to be a little more humble. And if not, surgery is a very humbling profession and it will humble you.
(30:23):
I can't remember why I started rambling on that, but that's kind of just reality. That's my reality. So hopefully you can learn something from it. And guess what?
Jacob Steffen (30:34):
I think
Dr. Randy Lehman (30:35):
Michelle Junker got a job there
Jacob Steffen (30:39):
That's hilarious
Dr. Randy Lehman (30:41):
And she's awesome and she's loving it and they love her and she's a great surgeon. The perception becomes reality.
Jacob Steffen (30:51):
Yeah, I think a lot of medical students could take something away from that. And there's the hierarchy a little bit in the hospital, whether people will admit it or not, a little bit of a hierarchy and you are pretty much on the bottom of it and it's okay to be on the bottom of it. So that's where you're supposed to be and sometimes you just got to roll with the punches whether or not you agree with it. So there's something to be learned from that. For sure. So the next topic I want to talk about is what are the top three mistakes outside of the or that you see sub eyes make
Dr. Randy Lehman (31:33):
I top three mistakes outside the, or not being prepared, which could be showing up late, kind of goes into that. I'm not sure if I've said this before, I have talking too much. No situational awareness of what the context is doing small talk. Just say what you need to say about your patients and then lock it in and not being prepared too much chatter. I mean I could think of more than just one more, but I'll say entitlement for the number three. So coming in and thinking that you're owed something, I mean, it's kind of sickening that you may be paying like 50, 60, $80,000 for a year if you sit down and you calculate the per day and per hour and per minute cost of you actually being there. Somebody should be spoonfeeding you the information and catering to your every whim. And you should have an army of people coming around you and wiping your butt, but it is actually not the fault of anybody immediately around you, and it is actually not their responsibility to do that.
(32:59):
And so you could be mad at the system. I would suggest not being mad at the system because the thing is the system, once you're in to the level that you are, the system is set up for your success and you will ultimately be quite successful. And so easier said than done, okay, if there are people that know me across my whole life and across many things and then they come and find this podcast and they say what he treated me with disrespect or who's he to say that they would be right to say that. Okay, so I'm just telling you that if I had it to do over again and I'm telling you that I'm not perfect. And so as I say it, it's easier said than done. And if you can just try to understand that you can get the most out of your experience if you kind of check all that baggage at the door and show up and understand that anything that the people around you are giving you, it's not the resident's job to teach you, but they will teach you, but they'll teach you if you'll help them and help yourself.
(34:06):
And same thing with the staff to a degree, if there's a didactic and they're coming and they're giving a lecture, yeah, that's part of their job, but they don't have to give you anything in the or, but most of them want to, but they don't want to if you're attitude style. So entitlement and then maybe let me throw a fourth one on there, which is disengagement too. And it's hard. You got to go rotation after rotation for years and years, but your ai, it's going to be easy I think to stay engaged, but it is hard to stay engaged on rotations that you're not going to do. But cutting out early and those kind of things, it makes it hard, but at the same time you got to pace yourself. So the AI though is not the time to take the foot off the gas.
Jacob Steffen (35:11):
Yeah, that makes sense. I think a lot of times that actually brings me to another point, just a little sidetrack. A lot of times people will say, you can go home if you want to. And it really depends on how they phrase it. And I've heard people say, if they offer you to go home then you should because that means that they want you to go home. But I've also heard people say that you should stay. What are your thoughts on that?
Dr. Randy Lehman (35:40):
I think if they say you should go home, then you should go home. If they say you can go home, then you can go home at that time, then I would make it more about what's going on. So if there's an opportunity for learning and operating, then I would stay. If they say, they say, you can go home if you want to, that probably means stay,
Jacob Steffen (36:07):
Right? Yeah.
Dr. Randy Lehman (36:09):
So you just read the situation and I tried, I still do too much. So it's like there's a curve for boredom and activity is on the x axis and intensity is on the Y axis, and then there's a curve for overwhelmed. And you would like to have those two curves be very far apart on the X axis so that there's this big space in between where you have the right amount of activity where you are simultaneously not bored and also not overwhelmed. But I think for me, those two curves actually overlap. And I usually live in an area where I am simultaneously bored and overwhelmed at the same time. And I did that when I was a med student resident too. So I was like, I always had other things going on and I don't know, just analyze all the time that you're spending doing other things in your life.
(37:20):
And if you're spending too much time playing Clash Royale or if you're definitely things that are not actually helping you, I think that the stability for me, my life really came together when I changed some things in my life. And really Brittany was a big help. So my wife, and actually when I pursued the more traditional moral lifestyle, then my life got a lot easier and better and enhanced. And so if you're spending a lot of time chasing vices, eliminate those because why I'm saying this is what are you going to go do when you leave? So if you're going to go sleep and study and work out and do some healthy things that are good for you and get into the sunshine, or if you're going to go drink or get on Tinder or go to the casino or binge watch TV or binge play video games, what am I missing from this list?
Jacob Steffen (39:01):
I feel like you've covered all the major ones for today's society.
Dr. Randy Lehman (39:05):
So if you're going to go do those things, you're going to be more tired the next day and it's going to take energy out of you. I mean, I'm presenting it again, like a selfish reason for not doing those things. But I think that there's a better reason for not doing those things as well. I think if you can have a balanced life outside doing some diversion things, some healthy things and some family things get depth and meaning some faith-based things that you can kind of understand. The two most important days in a person's life is the day they were born and the day they figured out why you get that alignment and you chase being that true person. And again, every day I'm not preaching to you, I'm preaching myself and this is what I'm trying to be. But once you kind of do that a little bit more, then it gets a little more clear.
(40:07):
I had a time where I was in med school and I was teaching for Kaplan and I had a guy who was in my little focus group and he literally couldn't talk without shutting his eyes. It was very strange. He got, at that time, our MCAT was out of 45 and there's 15 is a perfect score in each section. Is that right? I think that's right. It's something like that. Say that I'm right. Okay. He got perfect score on the two sciences perfect score and the verbal reasoning was the third. So there's physical sciences and chemical sciences maybe, or something like biological sciences and then perfect score. And then on the verbal reasoning, he got a six or a seven, which was obviously terrible. So it's just like a person that is extremely smart but has no idea how to use words or talk to other people and stuff.
(41:12):
So anyway, this is the person that's telling me this advice, so take it for a grain of salt, but he told me that I should not be teaching for Kaplan because now I am a student doctor and I should be focused. And he could go and he could be working bartending, and he could make $350 a night bartending. And obviously he could do that, but he knows now that he's a doctor, and so you need to realize he needs to be studying and doing these other doctorly things rather than meanwhile, same guy is at every med school party leading the charge, pushing hard on the bro stuff that needs to be done on the med school fraternity or whatever.
(42:06):
I think it's fine to work a little bit and have some other thing if you can handle it, but it's probably actually best if you don't. But definitely the Kaplan thing was great because you're drilling in the basic science further by teaching it. So I was doing that. I also did some real estate things while I was a resident that really paved the way for me to be in many other ways, and I do not regret any of that. And I don't think that you can only study so much, so only you know and how much energy you have and the resources around you and stuff. So don't overdo it, but a little balance is helpful.
Jacob Steffen (42:51):
Yeah. I think you touched a little bit on this by talking about some of the stuff that you went through and your journey and teaching through Kaplan and things like that. Let's pretend for a second. You are a third year medical student about to start your sub-I. What is the most important piece of advice that you can give to your younger self?
Dr. Randy Lehman (43:21):
It's like when my grandpa went up to my cousin at their reception line of their wedding, and he said to my new cousin-in-law Bjorn, he said, I just have one word of advice for you, run. No, it is just like I'm feeling in my body as you're saying. Imagine you're a third year med student about to, I don't know if I had to, I don't know if I would go through it all again. So it's like I just talked actually to my daughter and did a little episode with her and I told her, you're going to have enough strength to handle every day, but if you knew all the things that you were going to have to handle for your whole life today, you would be crushed. And so as I think back to being a third year med student, I'm thinking of all the things that I handled and I made it through and there are some touch and go moments, but I'm thinking about handling it all at once. So my advice to myself, is that what you asked? Yeah, is take it one day at a time, but plan for the long haul, try to grow every day in some way, try to get through every day from a third year midstream. I'm thinking about who I was and what I was thinking about at that time.
(45:13):
I would also tell myself that, try to see everybody around you. God sees them and try to behave like Jesus showed you how to behave and read the book because it will speak to you every day. And now when I think about, I would say, oh yes, I love everybody. What's very easy for me to do is still not just when I was in training, but still, and I think it's common is everybody rallies around the patient. Everybody is there for the patient and wants the right thing to be done, but they forget about these people beside them or they feel, or even worse, they feel like these people beside them or out to get them or they're actually trying to hold them back. It really feels that way sometimes. What I mean is that the nurse that's not getting the patient ready in the pre-op bay or the nurse that has a question and so therefore doesn't move forward with the thing that needs to be done, and now the case is delayed and that's going to stack up all these other things behind you that are bad for the day or the texts, the attending leaves the room and they just all start talking and not paying attention and not helping you.
(46:41):
And you feel very disrespected. And sometimes it is intentional and sometimes it is disrespectful and sometimes they hate you because they're not you. And there's an element of that that is real, but you don't really do anybody any favors by buying into that.
(47:02):
And so if you can treat those other people around you like they're a person, yes, they're not as good of a person as you are, they're not as driven as you are, they haven't done the things, they don't have the iq, they don't have the aptitude, they don't have the ability, they don't have the drive that you do. It's going to be true for every single person that's listening to this podcast still at this point. That's just true. So what do you do? You're not going to make them you. So you have to figure out some way to deal with it. And where I was going with this is I used to say, yeah, I love everybody, but right after love is joy and peace. And then shortly after that is kindness and patience. So if you really want to have the full spectrum of the things, are you bringing joy to the room when you walk in?
(47:56):
Are you bringing peace? And again, preaching to myself big time, because many times I have not done that. And many times I have been silently toxic and I don't want to be that way. And I think it's helpful to talk about it a little bit and try to do a little bit better. So if I had it to do over, if I was giving myself advice, that's what it would be about. I would say get to sleep, limit the phone time, get up in the morning and be a little prepared spiritually. But also on the textbook, I would say you're not spending too much money on textbooks. I spend a lot of money on textbooks. I love books, love that. Just in time learning. There's nothing wrong with it. Hiding in the bathroom for three minutes on Medscape, reading the steps of an operation does not mean that you're a bad resident.
(48:58):
It means you're a good resident, okay? You want to prep, prepare at home. You can't always prepare at home for everything. And actually, I have one more thing for you, Jacob. This is the longest episode I think I've ever done, but it actually might be the best I would recommend for your AI to get one resource, one comprehensive surgery review resource. It could be a review resource or it could be a textbook, something like that. And I would recommend before you start your rotation, and you might be able to do this in a weekend or in a single day, but before you start, review everything about surgery. What I mean by that is at least go from the very beginning of the table of contents and read through the table of contents until you get to the end or flip through the book very rapid fire and just look at the headlines and the bolded words and don't read anything about the body because getting entirely through something gives you now a framework where now you're going to have a case that's about something and you're going to know where to place it.
(50:28):
At least I heard that that operation is in the esophagus part of the textbook or whatever. Then you're going to know a few things about it. Then that's when you can go back and throughout the rest of your course, you're going to want to learn about the things that you're currently doing, but you have to learn about everything as well. So just, I actually, I don't think I've ever done a pseudo peritoneal case. I have done some appendectomies for mucosal. Matter of fact, the very first case I had was an appendix for mucosal. But even just because I haven't done that case doesn't mean I'm not responsible for knowing about it. And when the patient shows up with a CT, finding what I'm looking at and what to do. The hard part is you want to learn about the specific things that you're doing and you want to get really good at lap choline and inguinal hernia and the things that you're repeating. But if you don't stay in the textbook as well, then you won't know those fraction things on the side. Qbanks are very good. Trying to get through an entire Q bank every year as a resident is a very good goal. And then you will know where to plug those, the stuff, but you have to balance it. And so if you try to get better every day, balance it with your technical skills, your people skills, your book knowledge, best way to be rounded, AI and resident and surgeon for life.
Jacob Steffen (52:00):
Yeah, I'm really glad you brought that up because sometimes you go into the textbook front to back thing. You go into some of these situations in medical school and you're expected to understand the complicated processes of something that you have never heard of before. And this happened to me when I went to Riley. I did my rotation there and I did a rotation in pediatric pulmonology the first day I walked in. I tried to learn as much as I could about it with the resources that they gave me and everything, and I had no idea what was going on. It was so frustrating and it was scary because I had to present these patients and make plans for problems that I've never had before. I'm in Terre Haute doing my rotations here, and a lot of the complex, especially pediatric cases, they do handle a lot of things here, but especially pediatric cases they send to Riley, it's only an hour away.
(53:00):
So people go to Riley, but then the end result of that is that you don't hear or see a lot of the complex things. So I get to Riley and I was trying to learn kind of case by case every detail that I needed to know about this specific problem. And then about a week into the rotation, I was frustrated. I had no idea what was going on a lot of the times. And then I took a step back and said, okay, I need to understand first the basics of things. I need to understand what a trach is. I need to understand vent settings and how they work before I go into all these other complicated things, and I need to know the terminology of what stuff is. And that flipped my rotation. And finally now I'm saying, okay, this kid has BPD, I know what that is.
(53:50):
And instead of understanding every little detail about BPD going into it, I knew what A BPD was. Then once it popped up and I needed to know something about it, then I could at least be able to ask the right questions. So understanding something like that where you can go through a textbook really quickly and at least you've seen it before, I think that that plays a huge difference in how your experience can go. Because if you have never heard of something, then it's impossible to learn about it. You don't even know what to ask.
Dr. Randy Lehman (54:24):
I do. That is exactly the crux of being a med student, so spoken with experience.
Jacob Steffen (54:33):
Oh yeah.
Dr. Randy Lehman (54:36):
Awesome. Anything else that you'd like to know before your rotation?
Jacob Steffen (54:40):
I think we covered a lot of the basic things. It was really helpful to hear from the man about all the things that you need to do and the overall arching themes of the wards and some tips in the or. And then we also got a couple of awesome kind of how-tos on some of the technical skills, which is great. So I think anybody watching this would appreciate the advice that you gave 'em, and it would help 'em a lot, for sure.
Dr. Randy Lehman (55:09):
Cool. Well, thanks for doing this with me. It's just been, I think it'll help a lot of people hopefully for years here, and hopefully it stays relevant. So you can take the time to say it once, and then if you got feedback, feel free to interact with us, a listener on the Rural American Surgeon channels. So there's a YouTube channel, there's a Facebook, and you can definitely reach out to us. There's also a website and you can submit things to me there. And I do get all of the emails that are sent to me. And so thank you guys for your support as well, and if you've hung with us this long, thanks for listening.
Jacob Steffen (55:49):
Yeah, thanks for having me, Dr. Lehman. I appreciate it.
Dr. Randy Lehman (55:53):
Yes, it's been my pleasure, Jacob, and I hope to see you soon. And by the way, we have an upcoming mini series that Jacob is helping me as a co-host basically for the students for training programs that specifically train a rural surgeon. And so if you are interested in that, we're going to try to do a few programs per day for several episodes, and you can continue to follow us there. And if you're a practicing surgeon that's not relevant, then feel free to tune out and skip ahead. But you may find it interesting when some of these programs are actually bringing to the table as far as training a rural surgeon. And you may even find a place where you may want to pursue your future partner from as well when you hear about some of the programs that are actually out there. So we look forward to that. Thank you Jacob, very much for joining me. Thanks to the listener, this has been the Rural American Surgeon, and we will see you on the next episode of the show.
