Returning from the lab

[thedrjojo]

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After 2 years of research (2 podium presentations, 4 poster presentations, 1 first author pub (two if you count the module I wrote for SCORE), 1 MPH degree, another 5 first author manuscripts written and waiting for advisers to edit/approve before submitting, potential for a bunch of other 1st and 2nd author manuscripts once we finish up the RCT in the coming months), tomorrow I return to clinical world. Enjoyed myself in lab, hopefully seems to be very productive (pending when/if these manuscripts get submitted/published)... I am concerned going back that I will be super rusty, since we don't moonlight while doing research.... I was doing research on organ donors so would on occasion help out the transplant coordinators and put in a central line (maybe 3-4), A-line (maybe 5), or get to scrub the procurement (maybe 5 times), and had to cover the ICU/trauma service a few times... Woo, get to take call day 1 back too (but it is the VA...).

So, anyone have any pointers for a PGY3 coming back out of the lab? Any tips to brush off the rust? I mean, I took a trauma call last week and a lot of it was like riding a bike (ran a few trauma ABC's, pulled a chest tube, updated the trauma list and presented at morning report) but I know about a year ago when I was covering a trauma call I covered a case and felt like a total noob and was definitely rusty when things when a little awry.

 

[SLUser11]

After 2 years of research (2 podium presentations, 4 poster presentations, 1 first author pub (two if you count the module I wrote for SCORE), 1 MPH degree, another 5 first author manuscripts written and waiting for advisers to edit/approve before submitting, potential for a bunch of other 1st and 2nd author manuscripts once we finish up the RCT in the coming months), tomorrow I return to clinical world. Enjoyed myself in lab, hopefully seems to be very productive (pending when/if these manuscripts get submitted/published)... I am concerned going back that I will be super rusty, since we don't moonlight while doing research.... I was doing research on organ donors so would on occasion help out the transplant coordinators and put in a central line (maybe 3-4), A-line (maybe 5), or get to scrub the procurement (maybe 5 times), and had to cover the ICU/trauma service a few times... Woo, get to take call day 1 back too (but it is the VA...).

So, anyone have any pointers for a PGY3 coming back out of the lab? Any tips to brush off the rust? I mean, I took a trauma call last week and a lot of it was like riding a bike (ran a few trauma ABC's, pulled a chest tube, updated the trauma list and presented at morning report) but I know about a year ago when I was covering a trauma call I covered a case and felt like a total noob and was definitely rusty when things when a little awry.

Some people jump right back in without much difficulty, while some others tend to suffer "skill decay" while in the lab. One thing that can be a major issue is juggling some of your unfinished projects/pending manuscripts with your busy clinical workload, especially if you have a very intense mentor.

If you have fears that you will be rusty from a technical standpoint, then simply spending some time in the sim lab throwing knots and sutures will help you out. Most likely you are fine, but it's possible that such an exercise will improve your confidence, which is important.

I think most residents coming out of the lab feel rusty on the patient management side of things, as they haven't had to manage patients and make tough clinical decisions for a while. How to adjust for this would depend on the setup of your teams over the next 6 months. Will you be the senior-most resident, or will you have a chief above you? If you'll have more senior resident leadership, you can always bounce things off them for a little while to gain confidence, but this can obviously be sticky if your chief was your previous classmate...sort of embarassing to ask that person for help.

I think the difficulty of transitioning back to clinical work depends on the level of autonomy, etc that is expected of a PGY-3. If the PGY-2s are button men, and the PGY-3 is expected to do big operations and manage complex patients, then the transition is harder than if you already got a taste of advanced training during your second year.

I think my advice is vague and not overly-helpful. In the end, you simply need repetitions to get back in the swing. 6 months from now, you will feel normal again. I wish you the best of luck.

 

[thedrjojo]

Some people jump right back in without much difficulty, while some others tend to suffer "skill decay" while in the lab. One thing that can be a major issue is juggling some of your unfinished projects/pending manuscripts with your busy clinical workload, especially if you have a very intense mentor.

If you have fears that you will be rusty from a technical standpoint, then simply spending some time in the sim lab throwing knots and sutures will help you out. Most likely you are fine, but it's possible that such an exercise will improve your confidence, which is important.

I think most residents coming out of the lab feel rusty on the patient management side of things, as they haven't had to manage patients and make tough clinical decisions for a while. How to adjust for this would depend on the setup of your teams over the next 6 months. Will you be the senior-most resident, or will you have a chief above you? If you'll have more senior resident leadership, you can always bounce things off them for a little while to gain confidence, but this can obviously be sticky if your chief was your previous classmate...sort of embarassing to ask that person for help.

I think the difficulty of transitioning back to clinical work depends on the level of autonomy, etc that is expected of a PGY-3. If the PGY-2s are button men, and the PGY-3 is expected to do big operations and manage complex patients, then the transition is harder than if you already got a taste of advanced training during your second year.

I think my advice is vague and not overly-helpful. In the end, you simply need repetitions to get back in the swing. 6 months from now, you will feel normal again. I wish you the best of luck.

Thanks for the advice. Yeah, I made it a point to get as much written of my manuscripts as I could before returning, and think i did a good job with it. Also, my PI is very good about knowing to manage the clinical and research (he is in transplant, so always gets the research schedule messed up due to clinical work. I have a resident that left the lab the year last year and have seen the expectations, but I also have seen how little work he has been able to get taken care of during his PGY3 year, which I don't want to be my situation, having all this work sitting there waiting to get finished/published... he will get there, and I'll get 2nd/3rd author out of his stuff)

We don't have much in the way of a sim lab, and I think knots won't be the big area that throws me off, its going to be A) more complex operative stuff and B) like you said, the management stuff. If we had a better sim lab I would have loved to get in there and play around and practice. Our sim lab is hopefully growing in the coming months/years, which will help going forward.

Overnight in the VA i will be the only surgical resident in house, with the senior resident on phone backup and an attending on call. We are getting rid of interns overnight at the VA because the work load is too low to justify two in house people overnight, so I'll be managing floor and ICU patients, and seeing any consults. I'll have a 4 and 5 above me (the 4 was my intern when I was a 2, the 5 above me went into the lab herself, so she was always senior to me, so that won't be THAT awkward). There is a ton of autonomy here and my second rotation (where I have a chief resident who was classmates of mine and on a bunch of side research with me, I just got 3rd author on a paper he is first author on, I'm trying to get published a 1st author paper where he is 2nd author, and we have another paper where he is 2nd and i'm 3rd... he will be applying surg onc so he might be abandoning me with the team for a bit of the rotation, but hopefully the interviews are later on after I move on).

As PGY2's we definitely did a ton of real management of complex patients (especially at the VA, we run the ICU overnight, and I had a few train wrecks dropped at my feet and told, resuscitate them overnight and we will take them back in the morning... essentially an MTP later (18U prbc, 17ffp, 2 10packs of platelets, just ozzing from everywhere on a guy with a spontaneous bleed while supratherapeutic on coumadin), 3 pressors, all night pain...) so i've been there, done that, but it was 2 years ago.

I won't be the chief of a team (well, we have a fellow on the team, but I dunno how involved they will be) until October, so I hope to be back in the swing there.

It's gonna be the little stupid things that I'm going to miss. Like, I just renewed my ACLS and was fine with all of it except for stable SVT, i was blanking out on using a Calcium channel blocker/beta blocker for pharmacological management, however the second it was mentioned I remember the first time I dealt with that on call overnight as an intern, and remember several other instances where I had to deal with that or walk an intern through dealing with that.

 

[SLUser11]

Thanks for the advice. Yeah, I made it a point to get as much written of my manuscripts as I could before returning, and think i did a good job with it. Also, my PI is very good about knowing to manage the clinical and research (he is in transplant, so always gets the research schedule messed up due to clinical work. I have a resident that left the lab the year last year and have seen the expectations, but I also have seen how little work he has been able to get taken care of during his PGY3 year, which I don't want to be my situation, having all this work sitting there waiting to get finished/published... he will get there, and I'll get 2nd/3rd author out of his stuff)

We don't have much in the way of a sim lab, and I think knots won't be the big area that throws me off, its going to be A) more complex operative stuff and B) like you said, the management stuff. If we had a better sim lab I would have loved to get in there and play around and practice. Our sim lab is hopefully growing in the coming months/years, which will help going forward.

Overnight in the VA i will be the only surgical resident in house, with the senior resident on phone backup and an attending on call. We are getting rid of interns overnight at the VA because the work load is too low to justify two in house people overnight, so I'll be managing floor and ICU patients, and seeing any consults. I'll have a 4 and 5 above me (the 4 was my intern when I was a 2, the 5 above me went into the lab herself, so she was always senior to me, so that won't be THAT awkward). There is a ton of autonomy here and my second rotation (where I have a chief resident who was classmates of mine and on a bunch of side research with me, I just got 3rd author on a paper he is first author on, I'm trying to get published a 1st author paper where he is 2nd author, and we have another paper where he is 2nd and i'm 3rd... he will be applying surg onc so he might be abandoning me with the team for a bit of the rotation, but hopefully the interviews are later on after I move on).

As PGY2's we definitely did a ton of real management of complex patients (especially at the VA, we run the ICU overnight, and I had a few train wrecks dropped at my feet and told, resuscitate them overnight and we will take them back in the morning... essentially an MTP later (18U prbc, 17ffp, 2 10packs of platelets, just ozzing from everywhere on a guy with a spontaneous bleed while supratherapeutic on coumadin), 3 pressors, all night pain...) so i've been there, done that, but it was 2 years ago.

I won't be the chief of a team (well, we have a fellow on the team, but I dunno how involved they will be) until October, so I hope to be back in the swing there.

It's gonna be the little stupid things that I'm going to miss. Like, I just renewed my ACLS and was fine with all of it except for stable SVT, i was blanking out on using a Calcium channel blocker/beta blocker for pharmacological management, however the second it was mentioned I remember the first time I dealt with that on call overnight as an intern, and remember several other instances where I had to deal with that or walk an intern through dealing with that.

I wasn't doubting your ability to tie knots, but just saying that some repetition of simple surgical tasks might improve your confidence. I think some laparoscopic box training (knot tying, sewing, etc) might be a nice way to do it.

Honestly, it sounds like you are sitting pretty. The VA rotation you've described seems like an excellent way to get back into the swing of things. You will be kicking @$$ in a couple months. Until then, just be humble and work hard. Also, use your chief as a resource since it sounds like she had to adjust to the same thing a couple years ago.

 

[thedrjojo]

I wasn't doubting your ability to tie knots, but just saying that some repetition of simple surgical tasks might improve your confidence. I think some laparoscopic box training (knot tying, sewing, etc) might be a nice way to do it.

Honestly, it sounds like you are sitting pretty. The VA rotation you've described seems like an excellent way to get back into the swing of things. You will be kicking @$$ in a couple months. Until then, just be humble and work hard. Also, use your chief as a resource since it sounds like she had to adjust to the same thing a couple years ago.

thnx. Considering I never did any lap knot tying as a PGY2 (I did maybe 20 appys, 20 choles, and a few other random lap cases, but otherwise not too complex of laparoscopy). It's interesting that so many of our residents go into MIS (we just matched 3 of our chiefs into MIS, including one staying here) despite what I would

yeah, my buddy who left the lab last year recommended I try to start at the VA, he went there first and it helped him get back into the swing of things.

I think its more jitters than anything else.

 

[ThoracicGuy]

Overnight in the VA i will be the only surgical resident in house, with the senior resident on phone backup and an attending on call. We are getting rid of interns overnight at the VA because the work load is too low to justify two in house people overnight, so I'll be managing floor and ICU patients, and seeing any consults. I'll have a 4 and 5 above me (the 4 was my intern when I was a 2, the 5 above me went into the lab herself, so she was always senior to me, so that won't be THAT awkward). There is a ton of autonomy here and my second rotation (where I have a chief resident who was classmates of mine and on a bunch of side research with me, I just got 3rd author on a paper he is first author on, I'm trying to get published a 1st author paper where he is 2nd author, and we have another paper where he is 2nd and i'm 3rd... he will be applying surg onc so he might be abandoning me with the team for a bit of the rotation, but hopefully the interviews are later on after I move on).

The VA is a fantastic rotation to start back on. Not quite as uptight as the university hospitals and enough pathology and autonomy to get back into it. Sometimes I miss my VA days...

 

[thedrjojo]

The VA is a fantastic rotation to start back on. Not quite as uptight as the university hospitals and enough pathology and autonomy to get back into it. Sometimes I miss my VA days...

yeah, so far so good... arguing with medicine over an admission for a vasculopath that we will never operate on... glad my attending has my back though

 

[ThoracicGuy]

yeah, so far so good... arguing with medicine over an admission for a vasculopath that we will never operate on... glad my attending has my back though

But can't you just operate on him? He needs surgery!!!

 

[thedrjojo]

But can't you just operate on him? He needs surgery!!!

I won this battle... for now.

even if the patient is on the SICU side of the ICU as a telemetry bed, I'm still claiming victory since its not on my service... which means the interns can see him in the morning

 

[thedrjojo]

Put scalpel to skin for the first time in a while. Felt good to be back, even if it was a gallbag in a guy with 45 bmi, fatty liver, and the attending stole much of the case and almost converted to open