As a fourth-year orthopaedic surgery resident, we had some surgical autonomy.  Always at arm’s length from the attending oversight, this was just enough to push us past our comfort zones.

My problem was I loved my comfort zone.

The single most influential day in my career happened late one evening as a PGY-4.  I was about to start a complex ankle fracture by myself.  The ankle fracture involved the fibula and the tibia.  The surgical approach and fixation of the fibula was straight-forward; the tibia was not.  I remember having a conversation with my attending before the case – this was an attending who scared the living crap out of me.  He said, “start first on the tibia without me.”  I was not expecting this – this was out of my comfort zone and was an unusual sequence.  I really liked my comfort zone.   Even though I could recite every textbook step of the procedure, and I knew when to ask for help, I was scared.  I was uncomfortable.  I knew that he could do that part better than me, and I did not want to make a mistake.  I so desperately wanted to be perfect at every single thing I did, and if I could not be perfect, I preferred not to try.

So I didn’t.

I chose to start on the fibula – the easier part – the part well within my comfort zone.  When my attending came into the OR, he lost it.  He screamed, he cursed, and he yelled about how I hadn’t done what he had asked.

He broke me that day.

I remember standing at the window outside the OR that night thinking I had chosen wrong in my life – although this was just one example, this was a recurring theme in my life.  I was not cut out for surgery, and I needed to find something else to do.  My confidence was destroyed.  I remember curling up in a ball in the call room that night, strategizing how I would be able to pay off my loans when I quit.

The irony is that no one knew any of this about me – I was a “star” resident.  I published a lot of research, and was well-liked by my attendings, peers, and staff.   I was soon to be appointed administrative chief resident for our department – a position elected by the faculty and residents.  On the outside, I was thriving.  On the inside, I was paralyzed by perfectionism, and I had no confidence in my surgical skills.   I was also extremely and pathologically concerned about my image – I needed to maintain my “golden child” image, and to do that, I could never make a mistake.

Over the next week, I became very introspective. Thinking I was the only person who had ever felt this way in surgical residency, I did not seek help.  I knew, though, that I only had two options for self-sanity: leave residency, or solve my current predicament.  I refused to stay scared, unconfident, and technically sub-par forever, and I knew the decision needed to be made right then.

After some serious consideration, I chose to stay and solve my predicament.

Because I did not seek help, I wrote down skills that I needed to work on.  Beyond “fixing an ankle fracture,” I self-identified “confidence,” “perfectionism,” and “imposter syndrome” as things I needed to learn about.  At a time when most of my classmates were reading about orthopaedic surgery, I was learning things on my own that would be forever impactful.  I read Harvard Business Review and other similar articles, and several books, including Lean In and The Confidence Code.  I learned how truly common this feeling of inadequacy is, particularly in women, and I armed myself with a strategy to strengthen these intangible skills.  This really worked – with the intangible skills came the tangibles.

In my current position as an attending physician at a major teaching hospital, I have identified some themes that seem to cross medical specialties and training levels.  First, one problem with surgical residency is that it is a finite time period to learn a technical skill at a relatively old age.  If you do not go through the normal process of trial and error within the boundary of patient safety, and you are scared to show that you are not perfect, you will hit a ceiling.  I see surgeons in practice every day who still struggle with confidence – and confidence is a problem that can be solved – but it needs to be taught – and it needs to be recognized early.  Another problem with surgical residency is that no one talks about any of this.  Faculty teach the knowledge you need for in-training and board examinations, but a very select few teach “intangible” skills.

Every year for my faculty grand rounds at Emory University, I have the pleasure of putting myself out there – I am a teacher of the intangibles for our department.  I use myself as an example.  I let my trainees know that they are not alone.  I have come a very long way since that day as a PGY-4 – I actively avoid my comfort zone, and I no longer struggle at all with confidence or technical skills.  I challenge my generation of surgical educators to openly discuss how unbelievably difficult it is to learn how to be a surgeon.  I challenge you to openly discuss your struggles – because every single one of us has had them.  Take the time to understand and help a trainee who may be labeled as “lazy,” or you may think has “bad surgical hands”… because I promise you, they care.  They want to be better.  They do not want to be curled up in a ball in a call room, contemplating non-medical careers.  Our trainees may not know how to fix these problems – and they probably think they are the first surgical resident in the history of surgical residencies to ever feel that way.

Mara L. Schenker is an orthopedic surgeon.

Image credit: Shutterstock.com