Reflections on Residency

(soft music) - This is Lab Medicine Rounds, a curated podcast for physicians, laboratory professionals and students. I'm your host, Justin Justin Kreuter, the Bow Tie Bandit of Blood Transfusion Medicine pathologist at Mayo Clinic. Today we're rounding with Dr. Isabella Holmes, a first year pathology resident at Michigan State, to discuss her residency trading experience so far. Thanks for joining us today, Dr. Holmes. - Thank you so much for having me Dr. Kreuter.

- So, this actually ties back a little bit to an earlier podcast that we had, which was really talking about , how is this initial introduction to pathology going, advice for those that are coming into the field. And we wanted to do kind of this follow up and you know, now that you have this first year almost behind you, we're recording this

on May 31st, 2023. Maybe let's kick off and let's start by telling our audience your story and maybe why you decided to become a pathologist. - Yeah, so I feel like my story is, everyone's journey to pathology is a little bit different, but it's kind of all the same in that pathology sort of found us. And so I feel like my story echoes that. So I grew up in Arizona.

I went to Northern Arizona University for undergrad and then I went to Lake Erie College of Osteopathic Medicine in Florida for medical school. And when I was in medical school, I found myself a lot of the time asking a lot of super detailed questions. And most of the time I would get a response of, "Oh well that doesn't matter. We don't care about that."

And so then I'd be like, oh, okay, well, I was kind of hoping for a little bit more and I noticed that I was asking a lot of my questions based off of pathophysiology. So I was like venting to a friend one day and I was like, "I don't know what I'm gonna do. I really just enjoy reading Robbins and then I just wanna read Robbins all day." And she was like, "Wow, well you should be a pathologist then." And then I was like, "That's actually a really good idea. I think I will be a pathologist."

And it kind of made sense that I ended up in pathology because between med school and college, I was a faculty laboratory instructor in chemistry labs. So I taught organic chemistry and general chemistry labs. So when I left that job I didn't think I would ever be going back to the lab. And I was kind of disappointed, even though med school was still my dream and everything, but that's how far like pathology wasn't even a career I had in mind. So I'm really glad that pathology found me.

And you know, as soon as I set up a rotation in pathology, I knew within like the first, I don't know, it's like love at first sight. It's like as soon as I walked into that lab I was like yep, this is definitely for me. So I never looked back. I'd like to thank my friend Katarina Kosheri. She's the one who told me to do pathology.

- I know, friends help friends find pathology. - They see things in you that you don't see yourself, right? - Yeah, yeah, so true. So maybe can you then with that kind of tell us kind of maybe the what, like what has this first year sort of been for you in terms of what's that rotation look like and then, how has has that experience been? - So I feel like the first word that comes to mind is fast.

I feel like this year has gone by so fast and I really can't even believe that I'm about to be a second year pathology resident. I kind of, I feel like a lot of first year pathology residents feel this way that I kind of feel like I'm not ready to be a second year. It's like everything went by in such a blur and you know, in pathology a lot of the time.

I mean we all have varying experiences of what we get exposed to in med school, so it's kind of like, I feel like I still have my training wheels on and I'm not really sure what I'm gonna be able to let those go. And thankfully my program is like so nice and so supportive and so they're like totally okay with us, walking us through the field of pathology step-by-step. And I'm kind of, I don't know, I feel like our rotations too, they're only two weeks long.

So you're there for the first week and you're like, what's happening? Where do I show up? And then by the second week you sort of start to know what's going on and then it is time to start a different rotation again. So it's been a whirlwind, but I feel like I have gotten a little bit better at certain things. So I feel like that's progress.

But yeah. - As you talk about this experience of going through these rotations, that's one of the things that I've also kind of reflected on for learners and how you're really doing this kind of rapid sequencing through these different facets of pathology. Given that it's like really an apprenticeship, right? It's a cognitive apprenticeship you're learning as well as skills.

Do you have any advice for listeners who might be going into pathology residency as far as how they can set themselves up for a success during that and I guess, try to start to take a little bit of ownership for things? I know that's kind of a classic challenge, but. - Yeah, so, and I was kind of thinking about this question a lot 'cause I was thinking about what I've actually done myself and then, what I feel like general advice is. So there's kinda like two different answers there.

For me, what has helped me take ownership of my cases, and this is kind of, I don't know if other people do this, but when I'm reading through the clinical history of the patient, sometimes if I'm looking at slides I'll look at it blind and then I'll go through the history. But a lot of the time I start off with the history the most.

I spend like 20 minutes digging through the chart and what really helps me connect with the patients 'cause even though you're not there face-to-face is I actually read the social work notes because those kind of give me like a good idea of like a picture of that human that's on the slide or that I'm calling for over the phone.

And I haven't really heard that a lot, but for me that's what really makes me motivated to, not only get them, help get the correct answer, but also to see the case all the way through. And I've noticed that the patients that I do look into their personal history a little bit more, I actually remember them and I write them down in my notebook and I actually follow up on them later because you get that little bit of personal touch that sometimes is lacking in pathology.

And so that's what I like to do. I know that like other people take ownership in cases, the general advice is, you need to learn from these cases 'cause they're pertinent to future cases in your board. So this is a good, it's always like, this is a good example for this. And so I know that's how some people take ownership too. So I've kind of, I do like a little bit of mix of both, but for me it's really like the personal history that keeps me invested in the case.

- This really resonates with me. I was just at a noon conference where somebody was presenting a case of something where, there's only been 20 describes in the world literature, but there were, it was a great example for several different things in the transfusion medicine world.

And it was like, okay, even though this is this very rare case, there are these, this is a great examples for X, Y, and Z. I tend to get the most out of that by kind of, I know for me at the end of the day kind of reflecting back. I usually just take about 15 minutes before going home and just kind of jot down notes on, what did we learn or discuss today and is there something where I was like, geez, I bet I need to read a little bit more on that.

What's your process look like for kind of capturing the learning? - Yeah, I do the same thing. I have a notebook, just a standard composition notebook that I, it's basically attached to me with every rotation and I try to remember it as much as I can. Sometimes I forget it but I usually bring it down to sign

out and every time I hear a word or something I'll just like jot it down really quick and then look it up as soon as I get the chance back at my desk. I try to not leave the day without having at least looked up everything in the notebook because I feel like in the beginning I got into the mindset of oh I'll write it down and I'll look it up later. Later never comes, it's like today or never.

And so I feel like I've really learned to seize the day in pathology residency, but that's what I do and it's been working a lot better actually committing to that. And also not like worrying so much about writing down every single thing that the attending is saying, because I'm also very much an auditory learner. So if I'm too busy writing things down, I'm not gonna actually learn from that person who's trying to teach me in that moment.

So you don't need to copy everything, just write down a couple of like key like memory joggers. Yeah. - Yeah, I can see that. I also wanna applaud and highlight, right, that this skill that you just articulated right of you, you started one thing and that was, you're gonna jot things down that you need to look up, but then you discovered or recognized for yourself that you weren't following, you're writing this stuff down but not capitalizing on it the way I think you intended.

How did you catch yourself? Because that's something that all of us, I continue to work on catching myself. How did you do that? - That's a good question. I don't know. I feel like it was just, when you're doing something for so long and you're not, I guess for me maybe it goes back to like exercise and like staying committed to something and I feel like I have learned what it means to show up for myself in terms of like exercise and eating right and sleeping well.

And so when I started to notice like, okay,

well I keep not doing this and that list and that notebook just kept getting longer and then at a certain point you get anxious because you're like, well now you know, it's like giant laundry pile, it becomes too much to tackle. And so then I'm like, okay, well obviously what I'm doing isn't working. And this did take me a couple, like a few months, probably like three or four months to be totally honest, to figure it out. So it's not like I recognized it right away.

- Good, you're a human like the rest of us. - Yeah, yeah. But I think it comes back to like exercise and just being healthy and like learning. Like that's how I learned how to show up for myself if that makes sense. And so I knew that like education wise and academically, I was not doing what I needed to do for success for me.

- So this reminds me another podcast that we did earlier about no excuses where we had somebody, they were also tying it into kind of that physical exercise and how does that translate into their clinical practice. One of the things I'm curious about, we're kind of been talking about how you and yourself have been developing, navigating residency, wonderful words of wisdom for our listeners, especially those that are going into the field.

But I think for us that are educators to reflect on how we're setting our students up for success, helping 'em make that transition, what does that look like as far as that that culture, that interprofessionalism of, you're a physician now in Michigan and there's other, and there's residents who are surgeons, residents who are internal medicine. I imagine you're interacting with them professionally, but how is that kind of going or how is that working?

Is it working the way you imagined it would work, those kind of connections? Is that happening by, I don't know. Is there kind of a, what's that community like? - So I think it's really fun actually and I think, I don't know at Michigan I feel, I'm sure it's like this in a lot of places, but everyone is just so nice and I do it, we connect the most I feel like, well, cause I'm a first year anyway, on autopsy and micro and then on transfusion.

I feel like that's when I am doing that interprofessional house officer to other house officer type of communication. And since I'm on autopsy right now, I feel like that is like the easiest thing to speak about. Basically we had a case where we've had some unexpected findings and I usually page the clinician in the morning to ask, hey, like is there any specific questions? And the house officer called me and he just, it was just like a very relaxed conversation.

It kind of felt like in med school when I'm just talking to my fellow med students, just like very casual, giving the information that we need to know and you're not worried about sounding silly or saying the wrong thing just because it's just like that. I don't know that open vibe. And so I feel like we had a really good discussion that morning and then later he actually called me and texted me again. He was like, "Hey, I'm just really curious about that case."

And for me like I was like, this is awesome because like someone's interested in autopsy, like that's great, 'cause I feel like, sometimes you don't get like that participation as much as you would want. So then it felt like my work was really, really valued then. And so then I called him back and we had a great discussion and that's just happened like recently. So that's why it's fresh in my mind.

But I don't know, I feel like it's very casual here and a lot of people go by first name basis, which I think also kind of helps when,

he answers the phone, he's like, "Hey, it's Chris." And I'm like, "Hey, it's Izzy, what's up?" And I don't know. So that's how it's been as the house officer communication. As far as the attending to house officer relationship, I feel like, I don't know, they do a good, I'm a very anxious and nervous person. So when I don't know something I feel like a lot of pressure to answer a certain way.

But I feel like Michigan has done a really good job at like calming me down and not making me as nervous to the point where I feel pretty comfortable majorly messing up and saying silly things in front of most of my attendings. Which I feel like is a really good and kind of necessary comfortable learning environment because especially for someone like me, like I'll just not say anything if I'm nervous, I'll just be quiet the entire time, so.

- Absolutely, actually if I can underline that for the listeners, I think that is a profound realization and one that I recognize myself all too late. There was a lot of quiet just in, during trading and it really wasn't until I was more senior where I was like, this is the time that I need to make mistakes. And then by making mistakes, my attendings understand how to correct me and coach me to do better going forward. And that escaped me for a while. So kudos for appreciating that.

And do you have any kind of advice for people? 'Cause I imagine, you've seen others kind of struggle with this and how do you help them to realize to speak up and making mistakes is okay when you're training? - Yeah, so let's see, how should I word this? I feel like I have gotten to a point now for the most part.

I'm like 70% there where I'm basically shameless at this point because it's like, it's a good way to think of it or a good metaphor is you know how you're studying for a test and you don't necessarily understand a topic and so you're kind of like, ah, I just don't wanna deal with that topic right now. I'll focus on this other stuff and take the test. And then that topic that you avoided is all over the test and then you're kind of just like, that's embarrassing.

I should have just like asked and then I would've gotten a good grade or something like that. I kind of take that approach to residency now because I have noticed that when I try to avoid something that I don't

understand because it's either conceptually very difficult or it's something that I should feel like I should already know by now. And so it's kind of like that embarrassment, I'm just afraid of being like, wait, can you explain this to me? It's really just hurting myself because the further I get into residency it's gonna just affect me more and more and then at a certain point it's gonna be even harder to come and ask for help.

So I just have been like, okay, wait, I'm sorry, I don't know anything. Can you please explain this to me? And I feel like taking that approach of kind of subtly humbling myself, which I feel like I came into this process pretty humble, but man I have been humbled a lot more since then.

I feel like, I don't know, I don't really think anyone is like, don't think that people are judging you because we all started in different spots and I know that some more senior attendings may have, their beginning residency days are long behind them. But I don't know, for me talking to the fellows also really helps because they're in some subspecialty training, but they're pretty close to you as far as where they were at in residency. And especially at Michigan.

We have a lot of our fellows, like most residency programs that also did residency here. So when you know I'm talking to this heen path fellow that I think is a total genius and I'm like, oh this is awful, I suck. And he's all like, "Oh, when I was a resident, I didn't even know this until my third year. So like, you're way ahead." And then I'm like, "Okay, okay." You know? So I don't know, I guess just be open and shameless. I don't know if that's good advice, but that's what I'm doing.

- Right on. As we're kinda hitting on advice, I'm kind of curious, what do you think for you has been kind of the biggest surprise of residency training? I kind of got an eye for, something that you didn't expect, but wow, this, this was really a surprise this year.

- I think that the biggest surprise for me actually is and I feel like this shouldn't be a surprise, this should be kind of, I guess expected, but is just how supportive the attendings are with us. I mean they really value, like they actually care whether or not I'm understanding a concept. It's not just like a nine to five job, they're just getting it done and leaving for the day. They actually care and get, are gratified from me learning something.

And so to me that makes me feel like just so good and just like so cared for I guess. So I'm just, I'm surprised at how cared for I feel. Like in my program I could tell them that I'm having the worst day of my life and they would be like, okay, yeah. How can we support you and like what do you need from us to like help you? And they're not judgmental about it.

They, I don't know, it's like, it's kind of like we're all like friends which isn't like, I know there's like a hierarchy and like a respect thing, but it really doesn't feel like that a lot of the time. So it's pretty cool. I just got married for example, right? And so I had all these attendings emailing me like being how was the wedding? We wanna see pictures. And it's just like, I don't know, that sense of community is just like not something I was expecting to find. So it's great.

- Yeah, just to highlight that for the listeners. I mean I think in any program you go to there's obviously gonna be a spectrum, but I think overall faculty are very dedicated to training, to the residents and I think being upfront and communicating, that helps us not only with learning stuff,

but helps to support us each other during challenging times. I wonder if I could kind of ask you to look into the future now as we close out this particular episode. And so, I hope we can grab you again in the future, Dr. Holmes, and do another check-in. So you're headed into your second year of residency training. I'm kind of curious of kind of what do you think is gonna be your biggest challenge for the year ahead? How are you thinking about being successful?

What kind of tactic approach are you kind of thinking about for that challenge? - I feel like my biggest challenge going into second year is not really, I guess it, I don't know, I would say it's a challenge but, so my husband is technically living in New York right now, so when I come home I don't have anything else to do besides go work out, work on research, do things for residency, whether that be studying, presentation, whatever.

So I think it's gonna be challenging for me 'cause he's moving here in a couple of weeks, which is awesome, 'cause long distance is not fun. But when I get home I feel like I'm gonna really want to just be home. And so a lot of the time I'm in this habit of coming home and doing my work at home because I like to hang out with my cats and stuff like that. So I'm gonna have a lot of like work life balance adjustments that I'm not really sure how to navigate yet.

But I'm hoping that I'll just navigate it the same way I did in med school. But residency is a lot more time commitment than med school, I feel like. I feel in med school you have a lot more autonomy of your free time versus in residencies. So that's I feel like my biggest challenge. And then, sorry, there was a follow up question, I don't remember.

- Well and I was curious about does that, do you think it's fair to say that because I agree with you, like it seems like each stage of training there, there's potentially, I mean there's more of a demand on our time but also, 'cause you've been successful with the previous step, it's kind of an incremental and survivable is that kind,

do you think that's fair to say? I don't want to be sending inappropriate sunshines and rainbows, but you know, I think also to say that, you know, if you find that you struggle with something, I think it sounds like speaking up and talking to colleagues, it sounds like you have an awesome support network there in your residency. And I think, for any residency somebody goes to, I'd say that same piece of advice and I don't know, does that seem to resonate with you?

- Definitely, and what I've noticed from talking to my colleagues about my struggles that I've been having, 99% of the time you're not the only person that's currently experiencing that. I feel like I can always find like one to two other people that are also experiencing the same emotion that I am about, whatever it is that's going on. So you're never alone.

And then also, talking to your more senior residents, they really, I don't know my, the senior residents here I feel like are very chill and really like bring you back down to the ground. So I feel like that support has also been helpful. Yeah. And as far as your a whole adaptability thing and sunshine and rainbows and stuff, I totally, I do agree with you.

I do think that, every time that you've made it through something that you didn't think you were gonna get through, and not to sound so dramatic, and you still made it through, I mean that, you, it's not like that experience just happened and you survived and you left like you learned and grew from that experience to become the person that you are now.

So I feel like, especially for me, like looking back and thinking about who the person I was like 10 years ago when I was in college, I couldn't even imagine like the stuff that I'm doing today, I would've never imagined that I was capable of doing these things and you know, being at such a great pathology program.

I mean, I remember like I just wanted a job at one point in my life and I was like a maid for a long time and so, you just never know what's gonna happen and you know, I feel like you do get stronger and that's not to like harp on the whole resilience term, 'cause I know that's kind of a hot topic, but you do get stronger and you do build a strong foundation of how to get through problems and you get faster at, getting solutions to those problems, if that makes any sense.

- We've been rounding with Dr. Holmes talking about her residency training experience. Thank you for taking the time to share your words of wisdom with us. - Thank you so much for having me. Hope you have a great day. - It's all of our listeners, thank you for joining us today. We invite you to share your thoughts and suggestions via email. Please direct any suggestions to mcleducation@mayo.edu. If you've enjoyed Lab Medicine Rounds podcast, please follow or subscribe.

Until our next rounds together, we encourage you to continue to connect lab medicine and the clinical practice through insightful conversations. (soft music)