If I Knew Then What I Know Now

The following are short essays written by past SpineLine 20 Under 40 winners, on advice they would give current residents and fellows. With an overwhelming amount of responsibility on the plate of young physicians, the advice is intended to give residents and fellows some helpful pointers and tips to follow as they near the end of their training.

Jared Ament, MD

Ament I wish I knew then the magnitude of the responsibility our Attendings had for our training;

I wish I knew then the enormity of the risk our Attendings took each time we were in the OR;

I wish I knew then the boundless knowledge I could have still learned while in residency and fellowship;

I wish I knew then how complications can haunt you beyond the chastisement of faculty;

I wish I knew then that mistakes are inevitable; awful but certain, and when they happen, what matters most is how I respond to them;

I wish I knew then how much more I had to learn, even while in practice;

I wish I knew then the different dynamics and opportunities for different practice paradigms;

I wish I knew then how deleterious a bad partnership could be;

I wish I knew then how liberating a healthy partnership could be;

I wish I knew then how “ok” it would feel to ask for help when it was needed;

I wish I knew then how badly the insurance system has failed practitioners and patients alike;

I wish I knew then how little our service, commitment, sacrifice, and dedication matters to some;

I wish I knew then how much our service, commitment, sacrifice, and dedication matters to others;

I wish I knew then how much the practice of neurosurgery was not about actual neurosurgery;

I wish I knew then how grateful I would be to many of the people I resented the most;

I wish I knew then how scary being in practice can be;

I wish I knew then how nonsensical the medicolegal world actually was;

I wish I knew then how grateful I would be;

I wish I knew then how it wasn’t all about me;

Richard Menger, MD

The best advice is to talk less, smile more … and listen. Many young academic surgeons come out of top fellowships in systems that are capable of handling the most complex cases with efficiency and excellence. It takes time to develop that system and polish that skillset. It requires much more than just you. A spine surgeon can do a vertebral column resection with technical perfection but if the clinic, operating room, neuromonitoring, intensive care unit, floor, physical therapy outlook, clinical follow up, and patient education is not optimized then outcomes will fall short of expectation.

Menger You need to be a leader that maximizes everyone’s potential around you or you won’t maximize your own potential. You have to treat people like human beings and valuable members of the team because without them you cannot function. Listen to what they have to say and integrate the changes you can. It will provide better care and make you a better surgeon.

There are many people who have come before you that have allowed you to stand on their shoulders. There should be a great deal of deference to that. Their advice is so valuable. They have walked the walk. There is no substitute for practicing 10, 20 or even 30 years. Learning from the mistakes of other people and being honest about failure is incredibly necessary. This includes operative mistakes, systems issues, and even tactical and strategic issues.

“I wanted to understand how people outside of medicine thought, acted, interpreted, planned, and otherwise controlled the delivery of medicine,” he says. “To that effect, the year completely shifted my once siloed perspective on delivering surgical care.”

Creating that culture early both in yourself and those around you is important. Listen to the advice of other people and again be brutally honest with yourself. If you rationalize failure or complications, you give them power as you shield yourself from your responsibility and your learning moment. This is how you get to the next level. It’s a culture that needs to be created and nurtured. Failure needs to be discussed, not stigmatized. It’s what separates aviation from medicine. On a more pragmatic level, when there is a complication or a failure most people around you know it, and they realize it, and you will gain their respect by assertively and appropriately owning it. You are the captain of the ship.

At our institution, we set up a dedicated spine team. Certain complex surgeries are relatively new to our hospital. When I started I tried to provide direct attending sign out to the floor nurses for each patient they were about to receive. I personally couldn’t keep that up. It also pulled nurses from the floor. It didn’t add anything specific to care. Bluntly, it just wasn’t a good idea. This was a failure in tactics so we adapted and pivoted and we stopped doing it. We communicate directly in-person to the ICU team. We now communicate directly in other ways to the floor team. Saying it was a bad idea and owning that was important part of that process. We failed forward.

The absolute same holds true for intraoperative complications. It’s not just “bad bone” or a “bad fracture.” It’s more than just a closed loop.

The two best books in this space are Extreme Ownership by Jacko Willink and Leif Babin and Black Box Thinking by Matthew Syed.