#152 Dare to Lead: Becoming a PGY2

May 29, 2019 | By Matthew Watto, MD

ACP’s Resident Transition Series w/doctors Abby Spencer & Shreya Trivedi

Dare to lead. Master the transition to becoming a PGY2 with tips from expert educator Abby Spencer MD, MS, FACP, IM Residency Program Director and Vice Chair for Education for the Medicine Institute at Cleveland Clinic and Shreya Trivedi MD, GIM Fellow at NYU School of Medicine. Topics include: how to run work rounds, preparing your team for attendings rounds, how to teach on the fly, finding your leadership style, and what to read during residency. This is the first of three episodes that we’re co-developing with the American College of Physicians for their Resident Transitions Series.

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Credits

Written and produced by: Shreya Trivedi MD

Graphics and Show Notes by: Hannah R Abrams

Hosts: Paul Williams MD, FACP; Stuart Brigham MD; Matthew Watto MD, FACP; Shreya Trivedi MD

Guest: Abby Spencer MD, MS, FACP

Sponsor

The Resident Transitions Series is brought to you by The American College of Physicians with support from its Council of Resident/Fellow Members. Visit acponline.org/resident to learn more about the benefits of Resident/Fellow Membership and join our proud internal medicine community today!

Time Stamps

• 00:00 ACP’s Resident Transitions Series – Sponsor
• 01:50 Disclaimer, intro and guest bio
• 06:05 Guest one liner, book recommendations, favorite failure, advice for learners
• 14:10 Stuart’s tale of struggle from residency
• 18:05 New PGY2 resident thinks she has nothing to teach her learners
• 20:20 How to run work rounds and set expectations
• 31:55 How, when and where to teach as a resident
• 46:09 Leadership skills, understanding your learners, and giving difficult feedback
• 60:08 What to read during residency, how to find time, and some strategies to achieve your learning goals
• 71:30 Take home points
• 75:28 Outro
• 77:10 End credit sequence

Dare to Lead: Becoming a PGY2 Pearls

You’re not alone. It’s incredibly common to get to the end of intern year and feel like you’ve focused so much on getting things done that you haven’t read or prepared to teach. “As soon as you meet your July 1 intern, though, you’ll know how much you’ve learned and how much you have to teach.” -Dr. Spencer

Beware the curse of competence! Identify what your interns are able and willing to do, and help them do it. It’s easy for residents to do everything (themselves) because they know they can do it more efficiently, but resident leadership is about building that capacity in your team.

Prepared teaching or teach on the fly? Yes. Be ready to find teaching points during the day, but build a bank of 3-5 ‘canned’ talks during your PGY2 year that can serve you for the rest of your teaching career. Be creative– teaching moments can be physical exam, difficult conversations, or even reflecting on your own mistakes.

“Your job is to make the team look excellent.” Savvy attendings know that the best residents are the ones stepping back and letting the intern and students look good. Boost the intern’s confidence by thinking through the key nuances of the case with them; as a bonus, it will make them look great on rounds!

Leadership style isn’t about who we want to be, it’s about what our learners need from us. You likely have ideas of what leader you want to be like, or what styles you want to avoid. That said, the best team leaders will adapt their style to what their learners need in this point of their training. Our job is to see their potential and nurture it.

Studying after hours: The age old wisdom is true: read about your patients. Find a specific, answerable question that came up during the day. Or, do the MKSAP questions related to your patient’s diagnosis.

Dare to Lead Show Notes

Running Rounds: Day 1 Checklist

Big Picture

Day 1 is all about expectations and introductions, both from yourself and from your learners. Use these questions as a guide to find out what your team needs from you and make it clear what you expect from your team.

Introductions

In the first day bustle, be purposeful about getting to know your learners as people and helping them set goals. A short amount of time on this will set your tone for the month.

1. Have each team member set one teaching goal and one wellness/curiosity goal for the month. It can be something little– taking the stairs, or even having the team do ins & outs for an intern who’s not drinking enough water.
2. Show them you’re interested not just in their learning, but in them. Find out—what are they going home to? What’s important to them about medicine?

Expectations

Give clear and specific expectations to each team member upfront. It’s unfair and frustrating for students and interns when they fail to meet unspoken expectations.

Yourself:

First, pay attention to yourself during the day. What does ideal look like for you, and why? What needs to happen to get there?

Interns:

Ask your interns: what’s worked for them in the past? Without telling any names, which seniors did they get the most from in the past? What are their pet peeves?

1. Negotiate the ‘nitty gritty’ in person to avoid miscommunication.
2. Avoid the ‘curse of competence’: Not letting other people do it because you’re good at it and you know you can do it. (See the ‘Leading & Understanding Your Learners’ section for how to know when it’s appropriate to let your interns fly solo)

Interns and Students:

Have an explicit conversation around what you expect. No need for residents to hand out papers with their expectations, but be honest about what details you’re particular about.

Reframing your Role:

“You’re getting your show ready. Your job is to make the team look excellent.” Remember, everybody’s job on the team is to set each other up for success. The best thing the intern can do is prep the student so that they can anticipate what the attending/resident is going to ask them. As a resident, boost the intern’s confidence by thinking through with the plan for each patient. Savvy attendings know that a resident who sits back and is quiet while the student and intern shine has worked really hard to prepare their team. A well run team provides excellent patient care, and everyone benefits.

Teaching as a Resident

Big Picture:

It’s easy to feel pressure to have polished teaching modules or give talks on the fly, but really, good resident teaching is about understanding your learners and seizing the organic opportunities in the day, even if they don’t seem like traditional ‘teaching points.’

Prepare or teach on the fly?

Yes. You can do both at the same time by building 3-5 ‘canned’ talks you have ready to go on something you’ve read a million times, or are really interested in (e.g. narrow complex tachycardia). When there’s a patient who fits that, you’ll be able to teach both ‘on the fly’ and smoothly. These talks will last you your whole teaching career!

Be deliberate about teaching moments.

Before you go into each room, think about why the team is going in and set a goal. It could be point out an interesting exam finding, have a difficult conversation, or elicit a piece of the history. Help your learners develop the skill of knowing what to focus on in each room.

Don’t forget you can teach physical exam skills.

There’s so much more than just the medical facts to teach—you can read Bates the night before and show them new parts of the physical exam. As Dr. Spencer points out, “you’re becoming better at your craft because you’re preparing to teach.” You can even set up your teammates e.g. empower your intern to teach and wow the med student: “Tomorrow you’re going to walk us through Ms. Smith’s lung exam.”

“Where’s my feedback?”

We teach and give feedback all day, but learners don’t always recognize those moments. Label the teaching point as it’s happening, and label feedback with “I’m going to give you feedback now” so that they know to pay attention.

“I’m a generalist.”

Sometimes the best teaching you can do is create an environment that facilitates learning by admitting your own limitations. This instills the safety to be curious and not know, to ‘put their nickel down’ and be safe doing so. As Dr. Watto quotes, “Education is something that other people do to you, learning is something that you do to yourself”— inspiring them to learn is everything.

Don’t be afraid to offload the morning.

If there are four admissions in the morning, don’t be afraid to say “we can do a little more teaching in the afternoon,” or “I’ll send you an email with some teaching points.”

Creative tips for teaching on rounds:

1. Teach from your mistakes! Do a diagnostic post-mortem with your learners.
2. Have med students summarize the teaching points that the intern missed when they get called away from rounds.
3. If you don’t know the answer to a question? “Great question, why don’t you look it up for tomorrow’s rounds?”
4. If they don’t know the answer to a question? Rescue them with a “rhymes with” of the answer (e.g. ‘schmendo-carditis’)– it’s goofy and they won’t forget it!

Leading & Understanding Your Learners

Big Picture:

As a resident, it’s not about who you want to be, it’s about what your learners need from you. A lot of people come in to second year wanting to be like certain people, or not like other people. The best leadership, though, responds to where your learners are.

The Willing/Able Spectrum

When tasks come up, understand where your learners are in terms of willingness and ability. Identify:

Able and willing

Let them do it! Always trust but verify.

Absolutely able, not willing

Build confidence! Trust but verify.

Unable, willing

Find what’s meaningful to them—“I really appreciate how much you care about patients and I know you wouldn’t want to hurt them”

1. Set specific triggers to be called, i.e. “I like to be called for… [x/y/z]”
2. Trust but verify: pay close attention to their notes.
3. I’m not gonna let you hurt anybody, but I’m gonna let you get pretty close.

Unable, unwilling

Explore what’s meaningful to them.

How to help a struggling intern:

“A leader is anybody who takes the responsibility to recognize the potential in people and processes and has the courage to nurture those processes.” (Brené Brown) Look for people’s potential and build it up in them.

Don’t label:

Don’t label: A ‘good’ or ‘bad’ intern or colleague is situational. The all-star on Cardiology may be a nervous wreck on Nephrology. Our job is not to label them, but to see their potential, meet them where they are.

Check in

Dr Spencer’s recommends checking their insight. They may seen their own deficiencies and be praying for someone to bring them up…or they may have no idea.

1. Ask: What do you think went well? Was there anywhere where you think we didn’t give the patient everything they should get from us? Bring it back to the patient, use “we”, and ask—how would you do it differently next time?
2. Look at the problem together with them and frame it in terms of their motivation to get better.
3. Give direct feedback and a “Next time try…” Also ask them what you can do better and share your own mistakes.

Studying as a PGY2

Big Picture

Tie your daily reading to what you see clinically. Learn the basics before you try to keep up with the latest primary literature. That’s for attendings and fellows.

Learning from your patients

Have a specific, answerable question that came up during the day. Dr. Trivedi recommends keeping a notecard with your questions during the day— for example, don’t just look up bullous pemphigoid, look up “what are the medications we can use for pemphigoid?”

Bring your learners in

Push yourself and your team. Formulate clinical questions from the day and decide who is going to look them up. Caution: ALWAYS close the loop and ask them what they learned. They won’t do it next time if not held accountable .

It’s easy to say you’ll study, but how can you make it happen?

A few tips to try out from Doctors Spencer and Trivedi:

1. Set a low bar for daily reading goals (e.g. 5 minutes).
2. Keep a notecard with clinical questions
3. Do all the MKSAP questions related to your patient’s diagnosis.
4. Try to find a review article on the topic—Annals’ ‘In the Clinics’, or NEJM reviews are high level evidence that’s digested for you!
5. Uncle Bob Centor’s #KashlakChief #5goodminutes, and #medtwitter in general are great bite-size sources of information!
6. Prioritize reading the basics over reading to stay up to date.

The magic can happen when you can acknowledge what you don’t know.

Dr. Spencer’s Quote Corner

Take-home points from Dr. Spencer’s favorite quotations:

“If your troops stop bringing you their problems, it means they think you don’t care or you can’t help” (Colin Powell): One of the most important things any resident can do is communicate effectively with their attendings, interns, and patients. You have to be approachable with problems. Struggling to show it? Try starting responses with, “Thank you, I’m so glad you brought this up.”

“You can’t go into battle if you think you look silly on a horse” (Attributed to Napoleon) You’re ready to lead– embrace it!

“Don’t worry about the efficiency or what you can do or you can’t do; just take care of the patients, and if you care deeply, you’re going to work even harder, and the rest will come.” (Dr. Spencer’s Residents) The transition to second year is really hard; remember to care and connect. Don’t lose the joy, and make sure you find meaning in the privileges and interactions you get to have.

Goals and Learning Objectives

Goals

Listeners will learn skills for learning, teaching and leading as they transition from the PGY1 to PGY2 year.

Learning objectives

After listening to this episode listeners will…

1. Explore options for how to run resident work rounds
2. Learn strategies to prepare their team for attending (teaching) rounds
3. Develop an approach to teaching on the fly
4. Diagnose their learners
5. Provide feedback to struggling learners
6. Analyze the benefits and risks of various leadership styles
7. Develop a plan for learning outside of the hospital

Disclosures

Dr. Spencer reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Links

Links from the show are included above.

Citation

Spencer, Abby. Guest expert. “Dare to Lead: Navigating the PGY1-2 Transition.” The Curbsiders Internal Medicine Podcasthttp://thecurbsiders.com. May 29, 2019.