Words of advice from a chief resident [PODCAST]

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“Chiefs, remember, one of those interns is going to fill your shoes in a few years. They may model you in that role, so you want to raise them well! As a former chief resident, I have lots of pearls for those entering residency. However, what I will tell you now is different from what I would have told you then. I have since learned that there are possibilities to create the results that we want and not just follow the path we are told to take.

Recently, a former intern of mine — who went on to be a chief resident and subsequently a program director — tweeted that he received advice from another chief: “If you are unhappy in residency, you need to adjust your expectations.” He pondered that this suggestion was a mixed bag. Can you see both sides?

Residents, who is responsible for your happiness? Is it the institution, the program, the program director, the chief resident — or you?”

Marion McCrary is an internal medicine physician and can be reached at Marion McCrary Wellness.

She shares her story and discusses her KevinMD article, “A word of advice from one chief resident to another.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we welcome back on the show Marion McCrary. She is an internal medicine physician and a physician coach, and she wrote the KevinMD article “A word of advice from one chief resident to another.” Marion, welcome back to the show.

Marion McCrary: Thanks, Kevin, for having me back and for letting me talk about my former life as a chief resident.

Kevin Pho: We’ll get into that story and article in a little bit. But for those who didn’t get a chance to listen to our first episode, can you just briefly share your story and journey to where you are today?

Marion McCrary: I’d be happy to. As Kevin said, I am an internal medicine physician in North Carolina. My practice is primary care outpatient, and I take care of folks from 18 to as old as you want to be, so there are lots of opportunities to have conversations about expectations and different things. I am now practicing full time and also doing coaching for physicians through AMWA, the American College of Physicians, and working in a role as a well-being champion for physicians. So it’s been really nice to be able to do both of those.

Kevin Pho: Now, I’m an internal medicine primary care physician myself, and some would say that is an all-consuming job, doing primary care. But you’re also finding time to be a physician coach as well. So why take on that added burden?

Marion McCrary: I think it’s really important for all of us to help each other and to create this community where it’s OK to talk about some of the things that may be challenging to us, whether that is in our home life or in our careers, and really just having people hold space to be able to have those conversations. For me, I started thinking about it in a role with the American College of Physicians, and I see it as a service to other physicians, just like some may be involved with advocacy in their societies or their local community. So for me, it’s my way of giving back, I would say, and of helping other physicians when they need it.

Kevin Pho: I know a lot of physicians are interested in getting into the coaching space. So give us a sense of what a typical week would be, and how your responsibilities both as a coach and as a primary care physician intertwine during the week.

Marion McCrary: Yeah, it can be very different for different individuals. I practice full time, and so the time that I work on some of my coaching work and the things that I do with the societies is usually time that I spend in the evening or on the weekends. Sometimes there are days that I have administrative time that I’m able to do that as well, like we’re recording in the morning during the work week.

But again, it’s something I’m passionate about, and so it would be time that I would possibly be spending doing other things that I enjoy. So I don’t see it as something that takes away my time. It’s something that’s very valuable. There are some physicians who work in medicine part time and then do their coaching part time, and there are some physicians who have transitioned and are coaches full time. So it really just depends on what works for them.

Kevin Pho: All right, so let’s transition now into the recent KevinMD article that you wrote. It’s titled “A word of advice from one chief resident to another.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Marion McCrary: Yeah, it actually kind of came up based on a Twitter conversation I was having with a former intern, who went on to be a chief resident in the program that we were in and is now a program director. As people were kind of thinking, “Oh gosh, the new residents are coming,” there were lots of tweets about that time. He said, “I had a memory that one of my chief residents had said to me, ‘If you’re unhappy in residency, you just need to adjust your expectations.'” And he was saying, “Well, that’s kind of a mixed bag of advice.” I put a little tweet back and said, “That wasn’t me, was it?” I didn’t think I said that. He said no, and he gave the other name.

But it made me start thinking: Is that good advice, or bad advice, or both? So I started writing it out and thinking, what would I say to myself now, and what would I have said back when I was a chief resident years ago? Because my mindset’s very different.

My first thought is that if somebody had said to me, “Gosh, you just have to change your expectations if you’re not happy here,” it sounds like I’ve done something wrong, that I haven’t shown up the way that I was supposed to. It just felt really bad. But then, as I started to think about it now, kind of in the mindset I have, it’s like, well, who’s really responsible for my happiness? So is that my program, if I was a resident? My program director, are they in charge of my happiness? Or does it really come down to me, and can I adjust how I think about things, my mindset, my expectations, and really see things a little bit differently, so that I can create a space with whatever I’m doing in my life that makes me feel that I’m happier, or that I’m in charge of this space?

When you come into residency, there are some things that you feel like you don’t have control over. I remember as a chief resident, before my interns came in and before the year started, it was our job to make the full schedule for the whole year. So we were telling these interns when they came in, “Here’s your week of vacation, here’s your next week of vacation, here’s where you’re going to be on call.” It was already mapped out. So it was like coming into, we’ll say, the military. Some people compare residency and military training. You don’t have any control over this.

Coming into a space like that, you really can start to feel, “Oh my gosh, I just have to kind of fall in line and do what they tell me. They really do have all this control over me.” And I wanted folks to maybe think about it a little bit differently. So in the article, I brought up four scenarios and just talked about them in ways that people could have different expectations of the time they spent in residency, to see if it would help serve them a little bit better.

Kevin Pho: All right, so why don’t we go into those four scenarios that some people go into residency with, and what’s your response to each of those scenarios?

Marion McCrary: Yeah, I would love to. The first one is we think we need to be the absolute best. We have these expectations of ourselves that we have to be perfect all the time, and that’s part of how we got to where we were in residency. We were the folks that showed up, did the hard work, and went through everything. So as you start to think about all the different responsibilities that you have, I challenged the expectation and said, well, maybe you don’t have to be getting an A-plus-plus in everything that you do. How do you actually say, “This is going to be the priority that I want to put the most effort into, but this one maybe not as much”?

People will talk about doing B-plus or B-minus work but actually doing a good job. It may be something that you can put less effort into and not have to feel like you’re overwhelmed with it. I left folks with the caveat that it’s probably not patient care that you want to spend B-minus work on, but maybe you don’t have to write the best note every time you write a note. And I think people start to realize there’s a little bit of room there for getting things done. What do they say? “Perfection is the enemy of done,” or something like that, and maybe I’m messing up the quote. But it’s really just getting things done that’s important during that time.

The second piece goes back to this arrival fallacy, or heaven’s fallacy: that you’re going to sacrifice during this time to get to whatever is beyond residency graduation, so when you get to be an attending, it’ll all be better. “So I can spend three years, or four years, or however long your residency is, and just grind through it, plow through it, and not enjoy any of it, and it’ll be all worth it when it’s over.” I really wanted to change that expectation and say, you know what, this is a large chunk of your life. Enjoy the journey as you go. Find what makes you happy during this time, because you want to be able to look back on it and remember it in a positive way, and not have it just be the time that you spend in the hospital or in the clinic.

The third and the fourth are a little bit different. The third one goes back to that sense of not having control over anything and how you spend your time. I think that does get better the more experience you have in residency and the comfort level that you have with the system and what you’re doing day to day. But I would encourage folks to not give up on all the things that make them happy. The example I used in the article was that some people feel like, “I can’t go to the gym. I can’t get in my exercise routine.” But if you’re able to change that expectation, you know, what used to be, for me to feel like I exercised, it needed to be five hours a day, for an extreme, but maybe I could still feel like I’m getting exercise that’s valuable for me if I get in 20 minutes three times a week. So it’s kind of changing that expectation of what your upper limit or your lower limit might be, for you to be able to do all the things that you want to do, whether that’s spending time with your kids while you’re in residency or traveling to see friends. You can get those things done. You may just not be doing them at the frequency that you’ve been used to before you headed into med school and residency.

The last one is that my expectation when I went into residency was that I would kind of follow the rules. I would do it in the time allowed. I would just kind of follow the plan. For a lot of people, that’s not what they need. There may need to be some more exploration in residency. There may need to be some time where you do something else in the middle of it and then come back to it. So I wanted to leave people with the thought that you can change it up. You can make it what you want.

I thought about this. I heard on a podcast an interview with a physician who had actually taken some time off to train to be in the Olympics. They were talking about how what normally took four years to get through med school took them like seven, but they had all these different things they did in their life in between, and here they were in the same place, in residency now. So it’s just to think you can be creative during this time. You can get out of it what you want.

So those were four expectations that I realized may be valuable for folks to think about differently as they’re in their residency time, and for chief residents, possibly, to have these words of wisdom that they could give their trainees as they work through their training.

Kevin Pho: We’re talking to Marion McCrary. She’s an internal medicine physician and a physician coach, and she wrote the KevinMD article “A word of advice from one chief resident to another.” Marion, the concept, of course, of physician burnout and resident burnout has been at the forefront over the last few years, and residency programs have responded by limiting work hours and paying more attention to burnout in their medical trainees. After reflecting over the last few years, do you think that enough has been done? Is it simply more resiliency classes, more yoga classes, reducing work hours? And if not, what more needs to be done to help the behavioral health aspects of our medical trainees today?

Marion McCrary: Well, there are a lot of great points there. Someone said to me, “We don’t want to hear about yoga anymore. Yoga is great, but you can’t yoga your way out of burnout.” And I’m putting together a presentation on resiliency, and I’m afraid people might throw tomatoes at me. You know, that type of thinking of, “We’ve heard this. I don’t know if this is going down the right path.”

I actually was a chief resident the year the work hours change happened, so I’m dating myself now. My co-chief resident and I were in charge of figuring out how we were going to revamp this program to be able to put the work hours in, and we could see the positives and negatives behind it. I think there have been some things that have been valuable for that, and then it may not have been fully what we wanted it to be.

I know there’s been a lot of emphasis in graduate medical education on having a wellness piece. It’s mandated. And how that looks in different programs, in terms of what that support is: Is it a pizza lunch once a month where you talk about your resiliency, or what you’re doing for mindfulness? Or does it go beyond that, and does it involve more conversation about day to day and how to do this in real time, in real life? And coaching, I think, has been a piece that has started to make its way into that. A lot of programs are using coaches for their residents in different capacities, to really help them through some of these processes.

I think we start talking about it now with our med students and our residency trainees, and then hopefully, if we can do it right, it’s going to change the culture of medicine as we go. As those folks from this program start to go out into all the places that they go, they’re going to build on this and kind of mentor and teach this to the folks underneath them. And in the program I’m in, it’s really interesting that there are attendings who are trained in some coaching skills who work with residents. So they’re learning some of these different ways of thinking about things, these expectations, these skills, these tools, a little bit, and then they’re helping the residents. So we’re actually kind of catching the attendings and teaching them some of these things as well.

And I think just, again, changing the way we think about how we train doctors, what works and what doesn’t work. This is something that is in flux right now, and I think that we’re heading in the right direction. COVID has been so devastating for trainees and how they’re learning, and the community has been different. And so I know that with what we’re seeing now, with the rise in physicians leaving medicine and the rise in physician suicide, it’s really a time to focus on this.

Coming up in September, depending on when this comes out, before or after, September 17 is National Physician Suicide Awareness Day. So it’s just really a time to think about where you are in that space, in your community, in your programs, your institution, and how you’re supporting physicians and their wellness, to try to avoid the ultimate loss of physicians, the loss of physician life.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Marion McCrary: You can change your expectations. You can do different things and have different thoughts. Figure out what serves you and really try to make that happen, and not just stay in the plan the way you think it should be. You don’t always have to follow the rules.

Kevin Pho: Marion, thank you again for coming back on our show and sharing your time and insight. We’ll see you soon.

Marion McCrary: Thank you for having me again.

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