Absite Smackdown! · Episode 56: How Valuable Are Away Rotations During Surgical Residency?


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Dr. Kashmer: Welcome back to the Absite Smackdown podcast. And with us today is Dr. Carlos Palacio. Carlos is the residency site director at McAllen, for the Las Vegas Valley Health System GME consortium. He trained in General Surgery at the Michael DeBakey department of Surgery at the Baylor College of Medicine and completed Surgical Critical Care fellowship. Carlos has been great to work with for me on a personal level. He's part of the Absite Smackdown team for the upcoming release.

And of course also with us today, we have our host Jessica Rizzo who nicely let me do the intro today. So looking forward today to speaking with Dr. Carlos, who just has so much to share about a residency and ABSITE in the era of COVID. With that, Jessica, I'll get out of your way!

Jessica Rizzo: Thanks for that, Dr. David Kashmer. So like Dr. David said, we're here with Dr. Carlos. I'm just going to call him Dr. Carlos, if that's okay, because I don't have that Spanish tongue that you all do to propel that pronunciation correctly! So again Dr. Carlos, you're running the satellite for residents and I just kind of want to get into that because you have this task of being in charge of all these residents away from their mothership...their wellness, their education, everything that they have to do. And so I was just wanting to know a little bit about that. How do you educate them when they're away? How you take care of their wellness? What steps you do? If you wouldn't mind sharing that with us.

Dr. Palacio: I'm going to start by saying everything started by an accident, to be quite honest. We, wanted to improve, or give something back to the community. And, within our corporation, we found this general surgery residency program that was based in Vegas. So we sent an email. That's how everything has started...just with an email to the general surgery program director. We were four guys were interested in education. We're interested in educating the new generation. And they accepted us. They were very thrilled. They were very happy. And that's how everything has started. As far as, you know, getting the residents, getting the residents down here...that has been a little bit of a challenge. Especially culture, and the hospital. Because, as everybody knows, this is a community hospital. So nobody was used to having surgical residents in here.

Dr. Palacio: So since July, there has been quite a challenge with that part but they have been very well welcomed by the nurses and by the staff right now. They run 80% of the patient care to describe it like that. They talk to physicians, they talk to consultants, the consultants already know them. They have their cell phone and, and as is routine in general surgery residency, we are just watching them and making sure there is no mistake. We are also making sure they receive good education, review, and ABSITE prep. So talking about the ABSITE, our team includes four younger surgeons--recent graduates, five years, less than five years for most of us. So we're very ABSITE oriented. And the feedback that we have received from the residents is that our teaching during rounds is very, very oriented to that goal and also the surgery board exam. Like not only like get them to pass the surgery board exam and the ABSITE at the end of the residency.

Dr. Palacio: So the feedback that we have received from them has been very, very positive, because of the teachings during rounds that may help with ABSITE exam score and the surgery board exam. Now, technology has really helped us here because they have their weekly education from Las Vegas their mothership. Right. So we had to set up a room to allow review, and we'll have a Zoom meeting. So while they are here, they still don't lose that core curriculum that may help with ABSITE score. They don't fall out of track for the surgery board exam or ABSITE. So they keep going with every single lecture they are receiving there, and they will receive it here. They will also get those here. And it's protected time. Like they are not allowed to receive calls at that time. The phone gets forwarded to us, so we will get the calls. And it's just our education time basically. Sometimes what happens in some other places (and this is what I've been told) they go to other rotations and then they forget that they have to study and yada, yada, yada. But we have been very, very careful with that here for the sake of the surgical residents and their eventual board exam, clinical knowledge, and ABSITE. So, I think that zoom meetings has helped a lot for that.

Jessica Rizzo: I mean, I know just Zoom has been so helpful for everything that we do. And in education, like you said, just technology is changing everything. And I know that's part of what we had in mind when Absite Smackdown was created. So it sounds like you're running a really successful program with balance. And so again, with the balance of their education and then during their rotations and being in the hospital, what about their wellness? What about their self care and you know, what opportunities do you give them to make sure that they're rested?

Dr. Palacio: Yeah, absolutely. It's tough, in the sense that they are away from their friends and they're away from their families. They're in a town where they don't know anybody. At the beginning of the rotation, we created like a little pamphlet for them with places to go and eat, and places to go to the gym, places to do different things. The South Padre Island, which is an hour away from here. So on their day off, they tell me, yeah, I've driven there. It's very nice and some spend the whole day there and then they come back. So I think those are the kinds of activities that you have to encourage the residents to do, during their protected time off. It's also important. So for instance, if they have a long stay here in town, we like to give them a vacation. At least one week of vacation, so they can go back either to Vegas or visit the family. One of our residents went to Hawaii during that time because that's where his family is. So I was like, yeah, you can go the whole week if you want. That's fine. I mean, if you're spending three months in McAllen, then one week in Hawaii, I think that's really good right?

Jessica Rizzo: Right.

Dr. Palacio: Yeah. I mean, we definitely have to, we have to be very careful with that because why don't we don't want to burn them out. You know, we don't want them to get depressed. I mean, I think General Surgery as a whole or the surgical residency is very tough. And you have to have attention to details every day. You have to make sure that every patient makes it, I mean, within your capabilities. So wellness for us is very important. We have another resident, she has a family with little kids, so you have to accommodate those needs. If she has to come back to see their family now with COVID, it's a little bit difficult because of getting onto a plane and coming back. Again, you have to accommodate.

Jessica Rizzo: Correct. Right. So that's, I mean, that's super interesting about the fact that you started this program during COVID. You don't have a pre-COVID idea of what it's like...it's only been during COVID for you. And that's super fascinating.

Dr. Palacio: You know, at the beginning we thought about canceling, I'm going to be honest. We wondered whether we should we continue with this. And, you know, we had the conversation with the program director there and they said, no, no, let's go ahead and do it. We just have to take precautions. So far from the residents only one has gotten sick. We sent him home to the apartment and he stayed there for two weeks and then came back to work. So yeah, I don't know how this would have been before COVID. It has always been COVID times.

Dr. Kashmer: I did want to add in that one of the most interesting things from the mothership side is how valuable the away sites are for cases. The amount of cases residents get the for their clinical experience. It's just incredibly important to have those. And like Dr. Carlos said the challenge is how to kind of integrate them in a meaningful way into the didactic schedule for the residents from the mothership. And what I'm really curious about Carlos as I was listening to you is (when you have residents during ABSITE exam time) what are the specific things you guys do (if anything) around the time of the ABSITE exam to try to allow the residents to perform their best. Are there any tips or tricks or things you've learned early in the experience or things you do to help them do the best they canon the exam?

Dr. Palacio: Yes. So, what I created, and every month, at least before the ABSITE, I give them a questionnaire and it's based on the questions. The different questionnaires that we have. And I created a PowerPoint presentation. I gave them the test at the beginning. They have 20 minutes and then we go over each question. To me it's about having the knowledge, but it's also pattern recognition on how to answer questions. And that's the main thing that I teach them. You already have the knowledge and you just have to tune it a little bit here and there, but also remember you have to learn how to answer the question. You know, when I was studying the only thing I did the month before was questions, questions, questions, questions. And that's what I give them. That's what I give them a few weeks before. And during rounds, we ask them questions that are ABSITE exam pertinent, but I feel that, the few weeks before, it's just, you would just have to do questions and questions and repeat and repeat over and over and over again.

Dr. Kashmer: It's so interesting that you say that because, the podcast episodes we've done before really drive home that the available evidence is that the more questions you do, in general, the better your score on the exam. They're associated, and it's statistically significant in several series. So it's really interesting you hit on that. I think, like you said, the knowledge base and having that knowledge base is key, but then beyond that, doing a lot of questions, especially in the month or so ahead of time is important. It sounds to me like you really nailed it because that fits exactly with what the available evidence is and exactly what worked best for me when I was a resident along with the residents I've taught. So that, that makes really good sense to me.

Dr. Palacio: And for me it was the same way, you know, like there was one year that I didn't do well, and that was the year that I didn't do questions. You have to have the knowledge. But it's just pattern recognition, you know, most of it.

Jessica Rizzo: Yeah. So on the year you didn't do well, was that your first year to take it?

Dr. Palacio: No, it was actually a in the middle. It was, I think it was my third year. it was third year of my residency. It was very busy, very, very busy, busy year. A little bit about me: I was a preliminary resident and an international medical graduate. So I knew early on that I had to really do well, on the ABSITE exam. And, to me that was key my first two years. That's how I got the categorical spot because I did very well on my first two ABSITE tests. Third year was a very challenging year. And the fact that I was already a categorical maybe played a role out of that. I was just busy and busy and I just study, study, study, study. I didn't do many questions. And, you know, the next year I thought, nah, I need to do well this time. And it was just questions, questions all the time. Yeah.

Jessica Rizzo: Good. I think that's wonderful that you had at least some difficulty because I think that when we teach, having experience with not being perfect helps. Then you're able to take that experience and move it forward and help other people. And so without that, you would have just done amazing the whole time. You know, maybe you wouldn't know how important the questions are because you know, you didn't have that experience. So I think that's amazing. Dr. K, have anything to add to that?

Dr. Kashmer: I mean, I had a similar experience. Mine was my first year. And, we've talked about it in a previous episodes. I think, like you said, it can be tough for us as surgeons to talk about the years we didn't do as well as we want, but, like Carlos, I had the experience, although mine was early on where I just got shellacked by the test. And that was mostly due to all the things we've talked about in other episodes. You know, Jessica, it was a combination of maybe not having the knowledge base I should have had and being on call the night before, which I did not know enough to avoid. And I did the whole, you know, micro-sleep thing during the test. And that doesn't excuse it.

Dr. Kashmer: I think if I'd been better prepared I could have overcome that probably, but it was just too many hits. And so my experience (just to keep it brief) in many ways mirrors Carlos'. And I think, like you said, part of why I helped you guys out when you talked about the review book and part of why I'm so happy to participate in this and so energized about it in the podcast is because of that. I think it's the right thing to do: to share with residents and future colleagues so that they don't have the same experience that I had or that Carlos had one year. So just to help them do a little better...that's why I like doing this so much.

Jessica Rizzo: Yeah. Well, this is wonderful. It's so nice to have two guests on get different perspectives. Interesting to me how similar they are, but at the same different, because you know, we're not going to age shame anyone, but Dr. Kashmer is a lot older but much of the experience is the same. So I find that fascinating. Anything to add before we wrap up and say goodbye today?

Dr. Palacio: I, I would like to encourage the programs to do away rotations. I truly believe it brings value to the program. You know, the clinical experience is different. The patient population is different. I really think that the programs, especially at the PDs should consider sending the residents away to rural America. It would really improve that resident's background clinically and in Surgery. For instance, I'm going to tell you, I trained in Houston and in Houston we had gunshot wounds right and left. That's the way it was. Now here in McAllen that proportion of gunshot wounds is pretty small as it's mostly blunt trauma in our particular case. So those are the good things that the residents are going to see when they go away. And that brings value to a program.

Dr. Kashmer: Just to pick up on what Dr. Carlos said, that experience away from the mothership institution is so valuable. When I was in the program director role, it was something we encouraged for our resident staff. And the reason why is just as he said, excellent clinical experience. The challenge is how do you make sure that the didactics happen also. And just again, like Carlos said, the evolution of Zoom and the ability to use things like what you all have developed with Absite Smackdown review course as well as the SCORE curriculum are just fantastic. Of course, you know, Absite Smackdown! and the other products--they don't replace that SCORE. They're just complementary. I think all those things are key for this, that incredible away rotation experience, but it's not really a way it's still where Medicine is practiced and it's still part of the system often. But they get great cases. They get to see a whole new patient and demographic, and it's just so important. So it's been great hearing today about how Carlos and the team there at McAllen have maintained the didactics and even in some ways improved them with the questions and the PowerPoint focused in on the key things that help residents do well on the ABSITE. They even have specialized things there in McAllen to help general surgery residents do well and to support them for things like wellness. It's great to see Jessica.

Jessica Rizzo: All right. Well, wonderful. Thank you guys so much for being on today. I hope I have you back soon, Dr. Carlos. Just saying bye to everybody and remember...#AbsiteSmackdown!

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