Episode 10: Questioning The Assumptions To Advance Medical Education In Anesthesia w. Dr. Jed Wolpaw

Mar 1, 2019


This Episode

Interview w/ Dr. Jed Wolpaw

You Will Learn

  • Strategies for cultivating comprehensive wellbeing as a medical professional.
  • Advancements in residency program structures in the US.
  • Tips for overcoming imposter syndrome.

Resources & Links

Show Notes

In this episode Dr. Wolpaw discusses ways in which the residency format for today’s doctors doesn’t fully reflect current best-thinking in adult education.  We talk about his perspectives as a career-changer (he started off as a high school history teacher), his popular ACCRAC podcast, and the ways that he thinks residency programs need to continue to evolve to allow for optimal patient care while still giving residents a great learning experience and allowing them time to maintain sanity.

Show Transcript

Justin: [00:00] Hello everyone. Welcome to the Anesthesia Success Podcast. I’m your host, Justin Harvey. This week’s guest is joining us from Baltimore, Maryland is Dr Jed Wolpaw. Jed Is an assistant professor of anesthesiology and critical care at the Johns Hopkins University School of Medicine where he also serves as residency program director for anesthesia. In addition, he’s also the founder of the wildly popular ACCRAC podcast, which stands for anesthesia and critical care review and commentary. And this has expanded his pedagogy across the globe where he has 30,000 monthly listeners tuning in. So I’d love to start off by just hearing a little bit about your professional background, your clinical and educational focus at Hopkins.

Dr. Wolpaw: [00:41] Sure. My background is unusual. I started off as a high school history teacher, not everyone’s first job before going to medical school, but then did switch it up, went to medical school and also didn’t take the straight path into anesthesia. I actually matched into emergency medicine, which is what I thought I was going to do. It fell in love with critical care and back then you could not do a critical care through emergency medicine. So I knew that if I wanted to be an intensivist, I had to switch, obviously put a lot of hard thought into that, but ended up deciding to switch. So after my intern year I switched to anesthesia, went back to UCF where I did my anesthesia residency and then I came to Hopkins in 2014 for my ICU fellowship. Stayed on faculty. When I finished that one year fellowship, I got pretty quickly involved in the clerkships, just they kind of needed someone to help take over, the medical student clerkship and anesthesia.

Dr. Wolpaw: [01:33] And I was happy to do that, using my teaching background obviously and some organizational stuff. And then there was an opening about a year after that as an associate program director and the residency, which I took. And then about two years ago, when Dr Swingle, Deb Swingle, who was a fantastic program director, did this for 10 years before I did, moved on to do some other really interesting stuff. my chair asked me if I wanted to be the program director and it was not something I had imagined happening that early in my career, but was very exciting. I was able to do it knowing that I had a ton of great support and mentorship, not least of all, of course from Deb who was still very much around and, and helping me. And so took that opportunity and it’s been an absolutely amazing journey. I couldn’t be happier to get to do what I do.

Justin: [02:20] That’s awesome. So obviously in addition to your program, to a directorship, you’ve been running this on this, on the side, and I guess I could say this, a educational podcast helping clinicians, understand different types of procedures and different options for treatment and all that. Why don’t you unpack a little bit about what is accurate in the context of your current job and how did that come to be?

Dr. Wolpaw: [02:42] Yeah, Justin, that’s a great question. When I was in emergency medicine as an intern would listen to em rap, which is an incredibly done podcast. I believe it was one of the original medical podcasts. It was started, quite a while back and it is an emergency medicine focused podcast. And as far as I knew, every emergency medicine trainee certainly in my program maybe in the country would listen to that podcast. And so I did. And then when I switched to anesthesia, I kind of figured, oh, I’ll just now listen to the version of AMRAP that is anesthesia. And quickly found out there was no such thing. And I was really taken aback. I remember even as a resident thinking, wow, I wish this existed.

Dr. Wolpaw: [03:31] And Gee, I wonder if I could ever do this. I, I even thought about it as a resident, but the idea of trying to do that while doing residency training, especially with absolutely no technological skills whatsoever, seemed just out of the realm of possibility. So I had it in the back of my head, but didn’t do anything about it. And then when I finally finished training and had a little more time and got involved with the residency, I heard the residents asking, saying that they really wish they had some audio learning options and there wasn’t a lot out there. And so it kind of brought this back up and I thought, I don’t know how to do it, but I bet I could if I just spend some time. And so I think much like you did, I spent some time on youtube and reading blogs about how one might go about starting a podcast.

Dr. Wolpaw: [04:17] How do you record it, what kind of equipment do you need? And once I sort of pieced that together, I sat down one day. Of course I hadn’t had to learn to much. So I sat in front of my computer with no headphones, no microphone, no nothing. I pushed record on garage band and took what had been a lecture that I used to just give in person, turned it into the first episode. Of course there’s been a lot of podcasts that have come up in emergency medicine and elsewhere. Scott Weingard’s podcast is one I listen to regularly.

Dr. Wolpaw: [05:05] So I decided to go with ACCRAC instead and one of our medical students at the time designed a fun logo with a laryngoscope that looks slightly like a goose, his beak, which I thought was a lot of fun. So we use that. and it’s been a blast. We’re now is, as you said more, it’s sort of to my utter shock, above 30,000 listeners worldwide and with, over 105, I think we just posted the 106th episode. So it’s become in two years a a much bigger thing than I ever could have imagined. But it’s a lot of fun. I learned a ton from doing it and I feel blessed to be able to do it. Yeah, that’s excellent. And I did notice that you had recently rolled over your centennial episodes, so congratulations on that.

Dr. Wolpaw: [05:46] Thank you. Yes, that was a big milestone. Yeah. One of the challenges in podcasting is to literally just keep going, like in so many things in life. I was listening to episode 100, which was fun cause you were addressing some listener questions, which were both personal and professional. And I learned a couple of really interesting things about you and, and we did talk about this before, but whenever I first invited guest on, the first thing I do is usually Google, see what’s going on and what they’ve done in the press and all that. And, and I obviously stumbled upon the, the New York Times article, which you referenced in episode 100 which will link to in the show notes here and the story about how you met your wife and your wife at the time was an attending physician and you were an ms three. I’m sure there’s a lot of ms three and ms four is out there potentially wondering, wow, what’s the secret? How do I do it? So I’d love to hear a little bit about that story.

Dr. Wolpaw: [06:39] That’s right. So yes, it is available. I’ll tell you when I, the day I showed up for intern year, Justin, the senior residents in my er program in good fun had cut out that article from the New York Times wedding section and posted it on the board and the intern lounge or the resident lounge. I’ve had to learn to accept that the knowledge is out there. Yeah. So it was fun. I, the story is that I took part as a third year medical student in a longitudinal clerkship program.

Dr. Wolpaw: [07:11] So I did a variety of clerkships strung out over third year instead of all in chunks as they are traditionally done. And one of the things I did over the course of that year was a variety of shifts in the pediatric acute care clinic that was kind of part of the longitudinal pediatric part of this program. And as it turns out, my now wife, that’s where she worked for a chunk of her time. And so not every time, but maybe half of the time that I would do those shifts, she would be one of the attendings in that clinic. And so I got to know her a little and certainly knew who she was over the course of that year. Thought she was fantastic. She certainly was one of the best teachers that I had ever had and just a great person. and certainly, also very beautiful and so I was very, very interested and intrigued but knew that there was no way I could pursue it in any way while I was a medical student in that clinic.

Dr. Wolpaw: [08:03] So as it turns out, my very last shift ever in that clinic, at the end of my third year, she was one of the attendings on and I worked with her and I at the end of the day, had to go to a kind of end of year meeting that was required. And so we had seen a patient, but we’re waiting for some labs to come back. Didn’t yet know the outcome. And I told her, I’m so sorry but I have this required meeting I have to go to. And she said, no problem. if you want to know the outcome, if you want to know what happens with the kid, just shoot me an email. And then I left and I thought to myself, all right, this is it. and I can either do this now or never, but I know I’m never going to work with her again cause I’m not going into pediatrics.

Dr. Wolpaw: [08:39] I’m not doing any more pediatrics rotations even though I have another year of medical school to go. So I went home that evening and I sat there and I composed this email and I’ll never forget it because I wrote it in Gmail and I didn’t know, I knew nothing. I didn’t know if she was married and I knew she didn’t wear a wedding ring, but I didn’t know if she was married. I didn’t know if she was in a relationship. we had never had any kind of personal, discussions. And I wrote this whole email, I called it feedback and thoughts and the first half of it was telling her how grateful I was for all the teaching over the course of the year and how I just thought she had done such an amazing job. And then I said, additionally I have some thoughts I’d like to share.

Dr. Wolpaw: [09:19] I look, I don’t know if they are appropriate or not. I hope they are okay. I, I want to apologize in advance if in any way this comes off as inappropriate. but I just want to tell you that, and I think I said something like, you have one of the most astounding smiles I’ve ever seen and I really would love to take you out for a drink sometime. And I said, look, I know I’m a third year med student and you’re an attending. I told her I’m not as young as, I didn’t go straight through. I had another career first I was a teacher, so I’m not 26 but, and it may be that you wouldn’t even consider going out with a medical student if that’s the case. I completely get it. But I just thought I’d probably always regretted if I didn’t at least give this a shot.

Dr. Wolpaw: [09:57] And the funny part, Justin, is that I pushed send and then totally panicked and tried to unsend it. But this was before, this was before Gmail had the unsend option and so, or maybe I think they did, but it was only a very brief, maybe 10 or 15 seconds. And I remembered zooming up with my mouse to try to hit it and missed it and it went away and I couldn’t unsend it. I was terrified she was going to send it to the Dean and say, look at this medical student is being completely inappropriate. And I didn’t hear anything for a couple of days. So I didn’t know at the time later found out that what happened was she got it, had no idea what to do with this thing, sent it to all her friends and said, what should I do? So all the guys, all the, all the male friends who of course were physicians that had been male medical students at some point said to her, that must have taken so much courage for him to write to an attending.

Dr. Wolpaw: [10:46] You’ve got to give him at least one date, even if you don’t like him, even if you’re not interested, you cannot shoot down that kind of courage. So you got to give them at least one date. And so she checked, actually believe it or not, also sent it to her supervisor, to the clinic director or the division director to say, is this even, am I even allowed to do this? And they checked the bylaws. And it turned out that as long as she wasn’t going to be supervising or evaluating me anymore, that it was allowed by UCF rules. And so she said, okay. And she wrote me back. It was like a couple of days later and I’d been totally panicking for two days and she said, throw out some dates. So, it took us about nine days to, to arrange a date that we finally went out to dinner and we saw each other almost every day from that point on and got married 13 months after that first date.

Justin: [11:36] Wow. So take me to that moment when you’re walking into the restaurant. And so you’ve had these email exchanges, you pick a place to pick a time and you walk in and then you see her for the first time as no longer you were superior. You’re like probably having this out of body experience. What was that like?

Dr. Wolpaw: [11:50] I think like anything kind of like giving a, if you ever give a talk to a large group, I give grand rounds and various places and you’re going in and you got, a hundred or 200 people sitting in an auditorium and you’re walking in and no matter how much you’ve prepared, it’s always a little surreal. And you always kind of, as you’re walking in think, ah, this could be a total disaster and then the session starts, or in this case, the date starts and you, I think you’d just fall back on those conversational or in the case of the speech of those speaking skills that you’ve always used.

Dr. Wolpaw: [12:23] And so, I think as long as you don’t, as long as you don’t psych yourself out too much, I absolutely walking into that restaurant thought with, by the way, this bottle of a dry Riesling, we had had that as part of our email discussions about why types of wine. And she had never had a dry Riesling. And so I brought this and I remember thinking, what am I doing? this is what, but, but think, but then I sat down and we just talked and we talked until the restaurant kicked us out and then we went to a bar and talked to the bar closed. Do I mean, once, if you hit it off and you’re just talking, you’re just a real person, then that’s, you just be yourself and it’ll work out.

Justin: [12:56] I love that story. Thanks for sharing that that. I want to talk a little bit more about podcasting because I think it’s what you, you’ve, I mean it seems from my vantage point as a newer podcast or you’ve really caught lightening in a bottle here and there’s obviously this need out there that hasn’t been addressed in any other forum. And as far as, being able to educate not only at the Hopkins Program but, but people all across America, how, how does that impact kind of the way that you and I should say worldwide? How does that impact the way you think about content, the way you think about, what questions do we want to answer and how do we, how do we bring instruction to what’s going to be a very wide audience and does that, what does that mean to you?

Dr. Wolpaw: [13:35] Yeah. So I think you’ve really hit it, Justin, that there is a huge audience out there, one that we don’t reach it all when all we do is give a lecture to our local medical students or residents or fellows. And it’s part of, of course this FOME movement that’s really taken off. I should say stands for free, open access, medical education and really taken off in the world of emergency medicine in the world of kind of international critical care a lot more than it has in anesthesia or many other specialties in the United States. Now I think it’s happening, it’s just happening. We’re just behind. So it’s happening a little more slowly. But what you realize is that with today’s technology you have the ability to take that same talk that may be well received by your trainees locally and put it out there where anybody in the world can access it.

Dr. Wolpaw: [14:25] Not only does it make it accessible, but it also allows for some other things. So first of all, it allows for kind of continuous quality improvement or continuous peer review. When you write an article for a journal, you get peer reviewed. Eventually it gets accepted hopefully, and then it gets published and that’s it. It’s static. Nobody can change it, nobody can comment on it. but when you think about podcasts or blogs or anything like that that we have these days, they can be in your show notes for this episode a year from now, someone can say, Oh, Wolpaw said such and such the thing that’s completely wrong, or it’s changed since then, or whatever. Or I could go on there and say, I said this about the program, but now it’s changed and it’s this. And so people, you can have an up to date document, which is a really unique thing.

Dr. Wolpaw: [15:11] So that’s one aspect. And then on top of that, we know a lot more about education and the way adults learn than we ever did before. So spaced learning is key. The ability to not just get a lecture one time or learn something in a, you’re cramming for a test one time and then try to retain it. But to have that learning accessible to you in a staged and spaced way over the course of time, podcasts or any kind of asynchronous education, whether it’s an online video, whether it’s a blog that you write, allow for that learners can access those whenever they want. They can come back to them, they can break them up, they can fast forward, rewind anything they want to do and that we know isn’t only nice for learners, which of course it is. And I’ll touch on that again in a second.

Dr. Wolpaw: [15:55] But it also allows for that space to education. Now why do I say it’s nice? Because I actually think that this form of education, podcast, asynchronous learning in general is conducive to learn or wellbeing. Another huge, huge focus, becoming a huge focus is something we definitely need to focus on. Why? Because it puts the control back in the hands of the learner. So you at least if it’s an audio only podcast, you can listen while you’re working out. You can listen to while you’re commuting to and from work. So it doesn’t add time to your day. It allows you to do things that are conducive to your wellbeing, like go for a bike ride or a jog, but also do some learning. And so for all those reasons, I think that this form of education is really key. There’s actually some interesting studies on this one that I love to cite is a study that looked at anesthesia residents being taught to read reports, and they put one group got a traditional lecture introduction and the other got a podcast introduction, and then they did a bunch of practice and then they had an exam and a group that had the podcast introduction did significantly better on the exam.

Dr. Wolpaw: [16:59] Then the group that got the traditional lecture introduction and more so the group that within the group that had the podcast, the students or the residents who had had more exposure to podcasts in the past did even better than those who were newer to podcasts. So you can imagine in our current generation of learners, many of whom have grown up listening to podcasts who listened to podcasts all the time. This can be a real powerful tool. Yeah. You mentioned, getting feedback in real time as far as you put something out there and then listeners have an opportunity to respond. There are a variety of, of kind of, I’ll call them frequent commenters, people who clearly, not only listen regularly but, but listen and then participate in comments.

Dr. Wolpaw: [17:45] sometimes they will put a, just some additional information, things that they’ve done that are related to the topic that they want to share, which I think is fantastic. In fact, I say at the end of every episode, please, go out comments so that everybody can learn from what you have to say. I don’t in the least thing that I am the one and only expert or even an expert on this. I often am interviewing experts, but not being an expert myself on the specific topic. And, I would, I would say that no matter how expert the expert, I mean, I’ve interviewed Todd Dorman who was the society of critical care medicine president a few years ago about an area of critical care in terms of management of thinking about heart failure in the ICU that he is a world expert on. And yet, he’s not the only expert and it may be that there’s something that changes since we do that, that someone else could comment on.

Dr. Wolpaw: [18:32] So there are people who will put their own thoughts out there and then there are people who will ask questions and say, this isn’t what I thought or, I found this study that’s, that seems to contradict a part of what you said. Do you have any thoughts on that? And then I will either myself comment on what I think or I’ll go back to the person I interviewed if it was an interview episode and I’ll say, hey, I got this comment. You have any thoughts on this? And so it allows for a dialogue. And so there are some episodes where there’s absolutely three or four back and forth between me and a comment or where I think we produce some really good information that really adds to the content of the podcast.

Justin: [19:05] What would you say is the best or your favorite thing that has come out of this whole endeavor?

Dr. Wolpaw: [19:09] Oh, I mean I, it’s incredibly hard. I think that feeling like, I have been able to provide a resource that helps people not only with their learning but with their wellbeing I would say is probably my favorite thing. I have, for example, at ASRA every year, or at least for the past couple of years since I started the podcast I’ll have medical students and residents come up to me. It’s funny of course, because they’ll hear my voice and even if they’ve never seen me, they’ll, they’ll recognize me. Although my favorite is of course the spouses who come up and say, Oh, I recognize your voice. I was made to listen to it for 10 hours on our card trip last week. and of course, Justin, you may be one of those, a person outside of medicine who has been forced to listen to it. But what I love is the actual trainees who will say, I used to feel like I had to choose between going for a jog or going to the gym and reading a chapter at night.

Justin: [20:17] I think something you said earlier dovetails nicely with where I want to go in a minute, which is talking about the idea of putting the control for learning in the hands of the learner. I’m interested to hear how has that idea and that philosophy, impacted some of the programs that you’ve instituted in your, in the anesthesia residency program at Hopkins?

Dr. Wolpaw: [20:34] Yeah, that’s a great question. So I talk a lot about and think a lot about the fact that our system of medical education in this country, by which I mean a little, let’s put medical school side and talk from him about Graduate Medical Education. The way we train residents was designed with apps. Not only was the design without any knowledge of adult learning theory, it was, it almost feels like it was designed in direct opposition to adult learning theory. It was as if somebody sat down and said, how can we make something that is the opposite of what adult learners need? And a couple of examples of that are adult learners for example, are their strongest motivation is internal. So things like self esteem, job satisfaction, quality of life, those are the big motivators for adult learners. And yet residency traditionally was designed with the opposite, right? Did the worst possible. It’s quality of life. The word no self esteem. Self esteem has traditionally been beaten down by residency. And so adult learners also need to have some control and input into their own learning. And traditionally we didn’t do that at all.

Dr. Wolpaw: [21:37] Adult people showed up for a residency and they were treated like a blank slate. They knew nothing. They were just told, go where, go where I tell you, do what I tell you. Don’t complain, don’t ask questions. And as long as you don’t, challenge the authority here and you do what you’re told, then three years later, four years later, or whatever it is, will spit you out as a trained physician. and that’s led to, as rates of burnout and trainings in this country that are sky high, at least 50% depending on the study. And so it’s a big, big problem. So what we’ve tried to do is say, look, we may at some point need to completely redesign residency. As I said, it was not designed in any kind of comprehensive way. It was really designed as a labor system and as a byproduct of that Labor, the thought was you will learn.

Dr. Wolpaw: [22:20] So there may come a time. In fact, the AMA, the American Medical Association, just put out a call for proposals for $15 million in funding for a campaign called reimagine residency. So a really don’t just think big about how we could completely revamp it, but that aside until that kind of big change happens, residency is going to be hard. It’s going to be hard. We know that it’s a challenge. It’s a challenge. It’s challenging because it’s a lot of hours. It’s not 120 hours a week the way it used to be. And to be honest, in anesthesia it’s usually not even 80 hours anymore, but still 55 60 hours is still a lot of hours. It’s not actually the hours that make it difficult. It’s the lack of control, right? You take an adult and you put them in a situation where they have very little control over their life or their own learning, and that’s what’s really difficult.

Dr. Wolpaw: [23:09] So what we believe is that if we can give some control back, even if it’s not completely, even if it’s not the same as maybe a total reinvisioning of this, but if we can find ways to give some control back, then we can make a difference. And we have found that our burnout rates and our residents are about a third of the national average for anesthesia trainees. And so we’re very proud of that. Of course, I’m not happy where they are, I’d like them to be zero, but we’re always working on that. But, but the, there are about a third of the national average and I think it’s because of these initiatives to try to give some control back. So let me give you some specific examples. Obviously creating as many podcasts and podcasts like opportunities as possible is one to again give that control back to our learners.

Dr. Wolpaw: [23:51] But we also, for example, have taken a page out of the book of internal medicine and pediatrics programs who you may know have a jeopardy rotation and that jeopardy resident sits at home unless there’s a resident who calls out sick, in which case that jeopardy resident gets jeopardize to go fill in for that resident. But if they don’t, they just sit at home. Now what we’ve done is we have a resident every day who is nonclinical jeopardy resident, but instead of sitting at home, they come into the hospital. Now, I’ll tell you the feedback. The preference that I got from a lot of the faculty was, well, okay fine, but if that resident isn’t needed to fill in for a call out, sick from another resident, then of course we should just put them in an operating room and have them assigned to do a case just like they would anyway, and I fought back against that.

Dr. Wolpaw: [24:41] I said, no, we’re going to keep them nonclinical and we’re going to say to that resident, you’re an adult you can use this day however you think would be best for your own learning. If you are interested in cardiac and you want to go do some transesophogeal echo practice, go for it. If you’ve got a manuscript due when a couple of weeks and you’d want to spend some time working on that, go for it. If you want to spend some time doing a bunch of multiple choice questions to study for your upcoming and training exam, you can do that. This was a very hard concept for people to understand because traditionally it is just not even in the realm of what we would consider doing in a residency program to say to a resident, no, we’re not going to assign you to a role. We’re going to let you choose.

Dr. Wolpaw: [25:24] Even though that seems so obvious, if you think, how would I treat an adult? Of course that’s how you would treat an adult, but it’s not how you treat a kid. You wouldn’t tell a kindergartner who shows up to kindergarten, hey, you tell us what you want to do. Right. It seems crazy to think about that, but that is how we’ve traditionally treated people in medicine. You show up and it’s like, you know nothing and you are just like a kid. You need to be told where to go, what to do. We know best you don’t. And so we really have tried to move away from that. We have built in, we have two full protected education and wellbeing days every month that nobody else has anything like that. I shouldn’t say anything like that. There are places that are getting closer to having those kinds of things.

Justin: [26:01] Why don’t you tell us a little more about that? Because I was, I was sharing this with Sarah, my wife the other day, explaining. Yeah, they have two days a month and it’s all didactics and wellbeing and there’s a lot of flexibility for physicians. And she was, she was like, what? How does that work? who’s running the EORs? What’s going on? and so I’d love to hear you unpack a little bit about what that program looks like.

Dr. Wolpaw: [26:22] Yeah, exactly. That’s a lot of people’s reaction. A lot of programs questions, is it because they, they just can’t imagine doing it now. We’re very lucky that this was started. I take no credit for starting these. These were started by my predecessor 10 years ago. I think in response at the time, to some criticism from the residents about the balance of learning.

Dr. Wolpaw: [26:44] And so the residents at the time were a little unhappy were able to go to the then chair of the department and say, look, we’re going to be in trouble if we don’t address this. And so she came up with this plan and they signed off on it. And it’s become a really integral part of our program ever since. So we have these two full days. They used to be just all, teaching and learning all day. And they still are very much of that. But we’ve also, in the past couple of years since I took over, started building in some protected time for wellbeing during those days. And I, I really feel strongly that this is key. You can’t say that you think wellbeing is important and not dedicate time to it. That would be like saying, I think that learning anesthesia is important, but I’m not actually going to ever put you in the operating room to learn anesthesia.

Dr. Wolpaw: [27:28] So if you think it’s important, you have to have some time dedicated to it. And so we do that. We also are able to use those days to do a ton of simulation based education, flipped classroom education. We can bring in all kinds of really, really interesting additional stuff for our residents. So we do leadership training, we do communications training and teaching. So how to teaching to teach. We’ve brought in people to talk about financial planning, so right up your alley, Justin. So that our residents who as doctors are notoriously terrible at taking care of their finances. So we brought in some of our business school professors to talk to them about how to manage their finances, how to handle their loans and that kind of stuff. We brought in people to do some lean sigma quality improvement training, all kinds of stuff.

Dr. Wolpaw: [28:12] So it’s really, really, an opportunity that gives us the ability to say we’re not just teaching you how to perform anesthesia. We really think you need to be a well rounded leader and teacher and practitioner of this specialty in many, many ways. And if we believe that, which we do, then we have to have the time for it. And of course, again, adult learners need to have some control over their time and learning. And so we are constantly asking our residents, what do you want to see on these days? Do you want to see some changes? Is there anything new you’d like to see? Do you want to have this or that? The wellbeing time, we provide some options. We’ve brought in people to lead yoga, meditation. We have a mindfulness course, but we make all that stuff optional because it may be that, Justin, for you yoga may not be most conducive to your wellbeing.

Dr. Wolpaw: [28:57] Maybe you want to go to the gym during that time and get a workout in, in the middle of the day so you can spend the time in the evening instead of working out with your kids or maybe you want to go hang out with some colleagues and talk about a difficult case you had or had, they’ll have a lunch with them or whatever it may be. So again, we give that control back to our learners.

Justin: [29:15] Yeah, it makes sense. I’m curious, it sounds like you’re working to turn the ship to some extent of the institutional way it’s always been done and as you stated, it’s like a labor focused, this is the workforce to provide care to the patients, which is obviously true and, and will continue to be, but bringing in more of an educational awareness. I’m curious, was it, was it the work you did at Harvard for the masters of Ed or was it your anecdotal experience as a resident, that, that has been such a driving force in these programs?

Dr. Wolpaw: [29:43] Yeah, I think it’s a combination of things. So certainly as a teacher, while as someone studying education and then as a teacher of ninth graders, I learned very early on that you ha you cannot simply, I mean I was teaching the first year I taught, I taught at South Boston high school and I had some, some ninth graders teaching world history and they were wonderful but challenging kids. And I realized very early on that if I just wanted to, stick an outline up on the board of some world history topic and start talking, they’d all just leave. Yeah. So that was, you have to get to know your learners. You have to allow, even though even ninth graders, which you could argue or are not adult learners, but you have to have them play a role and take part in the education and in shaping it and figuring out what they need and want.

Dr. Wolpaw: [30:36] And that’s really key. And so I think part of it was that experience. And then part of it was my own experience as a resident, having not gone straight through having been out of the world of medicine, having had a job. and of course also having a family at the time. So I had a, my first daughter three days before I started ca one year and my second daughter halfway through my seed two year. So realizing, this structure is not really that conducive to adults. When residency started, it was almost all men and they had no responsibilities outside the hospital. I mean, I’m sure there are probably some rare, rare exceptions, but for the most part, I mean, yes, they spent an enormous amount of time in the hospital, but when they did leave, they didn’t have to take care of kids.

Dr. Wolpaw: [31:24] They didn’t have to cook, they didn’t have to clean the house. That was all done by someone else. All they had to do was go home, eat the food, someone handed them, go to sleep. Right. That was the only thing. And so it was an all, yes, it was all consuming, but you can, you can do an all consuming job when it’s your only job. So now I doubt that was conducive to their wellbeing either. No one was certainly measuring it back then, but, but I think that certainly today you cannot take adults, adults who have families and lives, adults who are, not, who have been, have been told their whole lives that they should have a role and thinking about what’s happening to them, which, some people may disparage, but I think is a much better approach and stick them in a, in a situation where they have no say or no control.

Dr. Wolpaw: [32:12] It’s that is of course going to produce burnout. And so I think my own experience, and I’ll say, I mean I, when I was a resident UCF, it was a great program and I think had had taken some steps. It was certainly not, stuck in the dark ages of, of training. But they’ve made a lot of strides since then as well. So I think as I went through residency, in fact, I specifically remember thinking, if I’m ever a program director, I want to make sure that I focus on the wellbeing and and support of the people as people, not just as as labor force. And so that was a real driver, not realizing that I would have an opportunity, so, so soon out of residency to put it into practice. But certainly glad that I have. Yeah, that’s great.

Dr. Wolpaw: [32:55] And as a physician spouse, thanks for doing the good work. Absolutely. No, I believe me. And there’s some really interesting stuff. So one of the programs at Boston, I’m pretty sure it’s maybe at Boston children’s that they’ve done this. there’s another, I’m blanking, but, there’s a couple of people out there who’ve done some really interesting stuff with families with actually bringing in the families of their residents to go through a little bit of a simulation, figure out what exactly is this thing that their loved one is going through, what’s it look like? And they’ve shown some interesting results with, being able to reduce the kind of burnout and bad feelings on the, on the part of the spouse and family.

Justin: [33:38] Yeah, that’s awesome. I would absolutely do something like that because I’ve been curious, what is it that my wife gives so much of her life too, that I really, I’ve never been at an OR except for when I was under the gown. so Jed, I know that mentorship is something that, is it an important value for you? I know that you’ve mentored and similarly have been mentored from some of the things you’ve shared in the podcast. I’d love to hear, your own personal experience with that. The way you think about that in your own career, the way you think about it with regards to strategically investing in others and perhaps an example of a way you’ve benefited from someone else pouring into you in that same way.

Dr. Wolpaw: [34:10] Yeah, mentorship is really key. Justin. I think you’ve hit it on the head. The most common perception of mentorship in medicine is a research mentor. So it’s somebody who helps you do some research or helps you with a project and that’s him. That’s fine. I mean I think that is important and if, especially for people who have not done a lot of research in the past, it’s important to find those mentors.

Dr. Wolpaw: [34:35] We certainly help our residents get set up with those kind of mentors. That’s important. However, in my opinion it is the less important of maybe the two major kinds of mentors and the other kind are what I’ll call life mentors. People who you really connect with, not because you’re doing the same research project, but because they are somebody who inspires you, who understands you, who is invested in you, who really wants to see you succeed in life and who has some unique perspective to offer that you feel really helps you be a better person. That is so, so key for success in life and, and medicine. Unfortunately it’s also a lot harder to help people find. It’s harder. part of it is if you know your people. So if I know my residents and I know my faculty, I can match, make and say, for putting aside research for a minute, I think this person would be a great person for you to kind of get to know and maybe I’m right so that is can be helpful.

Dr. Wolpaw: [35:37] But a lot of it really has to be the initiative of the individual person who’s willing to kind of get out there, put themselves out there, get to know some people, get to know some folks, so some faculty or whoever it may be, and then find those people who they really connect with. I did a workshop on mentorship at the Society for education and anesthesia and we had a group of residents who joined this workshop and that’s what we really emphasize to them is we’ll give you some tips and some pointers and some guidelines. But if you don’t put yourself out there, if you’re, too nervous to go up to that speaker after grand rounds and say, Hey, what you said really resonated with me, is there a time I could sit down and talk to you more about your career and my career and what you talked about.

Dr. Wolpaw: [36:18] If you’re too afraid to do that, then you’re going to miss out on some opportunities. So I’ve had the incredible luck and been just blessed to, to have several of those kind of mentors in my life. I’ll give you a couple examples. So I, I guess I’ll say first and foremost that I’ve been lucky enough to have my wife who, and that’s a unique kind of mentorship relationship I think. But I think that spouse has the opportunity to help you be a better person in ways that really no one else can because no one else has that close. And my wife and I are very, very different than a lot of ways and I’ve come to see that as such a strength because she will challenge me to look at things in a way I wouldn’t have. Inevitably, my first response is to be grouchy about it and then I will almost inevitably realize that of course she was right and we’ll try what she had suggested.

Dr. Wolpaw: [37:08] And there are so many times where I have found myself approaching things in a better way thanks to her. So, I think that’s a real fantastic mentorship. in a way when I was, believe it or not, my sixth grade teacher was a woman named Marcia Jaffe and she was a fantastic teacher. We got very close through a program I was involved in in high school later that she also ran, which was a race relations discussion group and then became really, really close ever since. And she is one of my all time just most important mentors. She is a mentor in the realm of teaching and in the realm of interpersonal communication. She is just a master of reading people and groups, facilitating discussion, facilitating groups and helping people deal with their own. If they’re having an issue with they’re having a problem, if they need help, kind of thinking clearly through something they’re struggling with.

Dr. Wolpaw: [38:03] All those skills that I’ve been able to I hope make a difference in my residents and students lives by utilizing. I really got from her and still talk to her regularly and value her advice immensely. So Marcia is one of those people in that kind of relationship I think can really make a my life has made my life richer and that kind of relationship can make your life anyone’s life richer and more successful. Another is Dan Lowenstein who I interviewed on my podcast, a, he’s now the executive Vice Chancellor and provost at UCF. Dan is just an amazing person and mentor and Teacher. But he is to me really in many ways a mentor around mindfulness and around the importance of taking a step back from the, sometimes the all consuming nature of the what we do and to think about finding balance and finding peace and finding time and space to think about the things that we do and to think about the people that we are and the kind of greater good of what we do.

Dr. Wolpaw: [39:00] So that’s been really key. And then I’m very lucky to have my current chair, Colleen Cook, Dr. Cook, who is just in the way that she is so supportive of me and of course of many, many of her faculty. But to feel that you have a chair, a or a boss of any kind who is invested in your success and really wants to support you and help you succeed is something I wish everybody could have. It’s really a special thing and makes me, if it was really, she was one of the major reasons I decided to stay on faculty when I finished my fellowship and is absolutely the reason that I think I’m able to do as much good as I do because she supports me.

Justin: [39:41] I really love those examples. And especially being a sixth grade teacher and having a lifelong mentorship. What a, what a wonderful testimony to the person that she is. And, and that’s got to be just so amazing for her to, have a relationship like the one she has with you.

Dr. Wolpaw: [39:56] Absolutely. Yeah. Marsha, Marsha Jaffe. Yes. She’s a real, a real special woman. And I’ll, I’ll tell you that she has touched so many lives and not only did she teach sixth grade for decades and decades, but she ran this group in the high school also for many decades and just a has affected the lives of so many, so many people. It’s that wonderful saying that’s always a, I think, the scribe to anonymous, but a teacher affects eternity. You never know where her influence stops. And so, I think that’s so true of Marcia.

Justin: [40:24] Yeah. Awesome. so imposter syndrome, this is something that affects professionals in any industry. Definitely mine in finance, and definitely yours in medicine, I’m sure. So I want, I’d be interested to hear your thoughts on, imagine a, I’m sure you don’t have to imagine an early career physician talking to you about, oh my gosh, I was on and then I just felt totally inadequate and the surgeon said this and I didn’t know what to do. And I was like, I don’t even belong here. I can’t remember anything. I read in Med school all in one moment. And it’s like everything’s crashing down. How do you equip someone to be able to continue to interact, grow in self confidence and self awareness as a professional, as a clinician in what can be a very high stress environment?

Dr. Wolpaw: [41:02] Yeah, great question. So imposter syndrome is something that I think happens to all of us as certainly has happened to me. In fact, I’d say it happens to me every step of the way. So, you get to medical school, you’re sitting there, I was sitting there at UCF thinking, what mistake did they make, I was a high school teacher a few years ago, right? I mean, what am I doing here? And then of course you get into a residency and you think the same thing. I became program director and just a few years out of residency and of course I thought, oh, for sure my chair, meant someone else, right? I mean, it’s only a matter of time until she realizes, oh yeah, no, well Paul, I didn’t mean walled law. Something would get me the other guy. Right? So it is a, I mean, that is absolutely, and I think that the key and what I really tried to emphasize to others who are feeling it is that you have to normalize it.

Dr. Wolpaw: [41:52] You have to realize that if you think you’re feeling that way and it’s just you feeling that way, then you’re going to feel it’s going to reinforce it. So it’s going to be a self fulfilling prophecy. What you have to realize is how common it is. It’s very much like when you have a bad patient outcome, and I talked to this about my residents before they even start on July 1st their first year with us. I have this conversation because it’s so key and that is that every single one of us will have a bad patient outcome. Some of us will have patients die. Oh there’s, they may not die, but they will have bad outcomes and some of the time it’s going to be because of something we did that we could have done better or didn’t do right. And what happens is the second victim effect, as you may have heard of where providers will, of course the patient suffered harm there, the first victim.

Dr. Wolpaw: [42:37] But then the provider will put so much stress and pressure on themselves thinking that they screwed this up, that some providers end up quitting medicine, they get a depression, PTSD. It’s a major, major issue. And I think the number one reason is that they think it’s just them that they screwed up. What they don’t realize is that, so has everyone else. And it’s a real powerful experience when you realize that there’s a really neat method of kind of communication called confession sessions. They were first described by Susie Karen back in 2015 in the journal, a journal, Graduate Medical Education. And we’ve adapted them and, and we use them. And what I do is I sit down with a group of my residents and they write down anything. They want a question, comment, concern on a note card anonymously. And then they drop it in a hat. And I then right there with all the red, with the, I’ll do it for example with all the ca ones, I pull out each one, I read it and I co I respond to it right there. So there one week in anesthesia and I sit down with them and I do this. And by the fourth or fifth or sixth one that says, oh my God, I haven’t successfully intubated without my attendings help this week. I, I’m a total failure. I don’t think I belong here. I think there was a mistake. You see the stress level in the room just come down because they realize, oh, everyone else is feeling the same thing. So that’s, I think the key is realizing that it’s normal to feel that somehow you squeaked through, you don’t belong. If someone’s gonna figure it out, sooner or later, every one of us has felt that way. And if we all realize that we’ll all do a lot better and being able to thrive anyway.

Justin: [44:20] Yeah, that’s great advice. I think realizing that you’re in good company and that so many other people feel the exact same way that can, that can really help. Cool. Well in closing Jed, I want to ask this question that I ask all of my MD guests and I want to, just take you to a place where you’ve, your profession is very demanding obviously and very important in training future physicians and the educational element of what you do. And I’d love to hear a brief anecdote or story about a time when you were particularly glad that you do what you do because you were able to witness the impact that your work has had.

Dr. Wolpaw: [44:56] Yeah, and I think one of the real wonderful things about medicine is that, and I don’t want to say it’s the only career, there may well be others, but it is one career where you really don’t, there may be crises, there may be struggles, but there really is one thing you don’t have to do is sit and think to yourself is there any meaning and what I do every day, right?

Dr. Wolpaw: [45:15] I mean, that is just not something that that happens in medicine. You if there, if nothing else, we know that we are actually caring for real people and making a difference in their lives every day. And that’s, that’s a huge, huge thing. We don’t want to forget that. I urge, my fellow physicians to remember that all in there are, again where our lives are not perfect, our jobs are not perfect, but it is a blessing to be able to feel like, no matter what else happened, I helped real people today. And so, so I think that’s really key thing to remember. And there are many, many instances of that. I think for me, some of the most powerful are around my time in the ICU, specifically around end of life. So one of the, one of the things I’ve mentioned at the very beginning that I will start it off in emergency medicine, but fell in love with critical care.

Dr. Wolpaw: [46:03] And one of the things that really drew me to it was not the excitement of putting in the lines or grabbing some high potency presser medications and are performing Cpr. And all of that happens in the ICU and certainly can be exciting. But what really drew me to it were some of those discussions around end of life, around the ethics with families. And I do a simulation every month with our medical students and nursing students and chaplain residents where we simulate some of these discussions. And I say to them, as much as it feels good to get that central line in smoothly, your ability to have these discussions and to help a family through these decisions, well we’ll have way more of an impact than how good you are at central lines. And so for me, I can, think of multiple times where I have had families who were really struggling.

Dr. Wolpaw: [46:57] They, for example, clearly we’re starting to comprehend that their loved one was not going to recover. And yet we’re feeling guilty and we know this, we know that families have a very hard time making the decision to withdraw support, to let their loved one go, even if they feel like it’s the right decision. And so having developed some expertise around how to have those discussions, I feel like I can think of many times where I have been able to sit down with a family and help them realize that this is not making a decision to end the life of their loved one. They’re making a decision to help stop the suffering of their loved one or they’re helping us understand what their loved one would want.

Dr. Wolpaw: [47:45] Sometimes the patient can’t tell us what they would want and so we need the help of the family too to get to know the patient better so we know what they would want to do and being able to have those discussions to listen carefully. Knowing when silence is important, not always feeling like you need to fill those silences or provide answers. Letting people have their emotions, letting people feel sad sometimes just being there for them. We learn a lot, for example, from our chaplain colleagues who know this very well, that sometimes just a presence, a silent presence can make more of an impact than any word could. So really being able to put that into practice and see the, the feeling of kind of release and relief on a families face when they realize that it’s okay that they are not there, they don’t need to feel guilty for this decision and that this is the right call.

Dr. Wolpaw: [48:39] to be honest, of course it’s rewarding when someone is very sick and we can help them turn the corner and recover. But in a way, it’s the harder task of helping a family feel okay about letting go and when a family can walk away saying this was unbelievably hard, but I feel like it was the right decision and I feel like I was supported in making this decision. That is probably the most rewarding experiences that I have.

Justin: [49:06] Wow. Well, thank you very much for sharing that. And Dr Wolpaw, I really appreciate you joining us today on the Anesthesia Success Podcast.

Dr. Wolpaw: [49:14] Justin has been an absolute pleasure. Thank you so much and good luck to you.

Show produced By: Dan Gummel & Justin Harvey Show Music: Great Scott:  Don’t Hold Back